Cryptosporidiosis after treatment with fingolimod: a case report and pharmacovigilance review

Background

Cryptosporidium sp. are common intracellular parasites responsible of severe diarrhea in T-cell-immunocompromised patients. We report the first case of a woman who contracted cryptosporidiosis after treatment with fingolimod, a drug labeled for multiple sclerosis and responsible for marked lymphopenia.

Case presentation

A 60-year-old woman was admitted for abdominal pain diarrhea and fever. The patient suffered from multiple sclerosis and had been treated with fingolimod from august 2017 to september 2018 time of occurrence of the first digestive symptoms. Stool culture was negative but parasitological examination was positive for Cryptosporidium sp. Blood biological examination profound lymphopenia of 240/mm³ [17 CD4/mm³ (7%) and 32 CD8/mm³ (14%)]. Fingolimod was stopped, and the patient was put on nitazoxanide 500 mg bid for 7 days. The diarrhea resolved and no relapse was observed. Six other cases were found in the Pharmacovigilance database.

Conclusion

Physicians should be aware of this association and screen for Cryptosporidium in cases of diarrhea in patients treated with fingolimod. Patients should be aware of this risk and advise to take appropriate measures to avoid such contamination.

Developing professional caregivers' empathy and emotional competencies through mindfulness-based stress reduction (MBSR): results of two proof-of-concept studies

OBJECTIVES

To assess the feasibility and acceptability of a mindfulness-based stress reduction (MBSR)-based intervention and determine if the intervention is associated with a significant signal on empathy and emotional competencies.

DESIGN

Two pre-post proof-of-concept studies.

SETTING

Participants were recruited at the University of Montreal's Psychology Department (Study 1) and the CHU Sainte-Justine Department of Hematology-Oncology (Study 2).

PARTICIPANTS

Study 1: 12 students completed the 8-week programme (mean age 24, range 18-34). Study 2: 25 professionals completed the 8-week programme (mean age 48, range 27-63).

INTERVENTION

Standard MBSR programme including 8-week mindfulness programme consisting of 8 consecutive weekly 2-hour sessions and a full-day silent retreat.

OUTCOMES MEASURES

Mindfulness as measured by the Mindful Attention Awareness Scale; empathy as measured by the Interpersonal Reactivity Index (IRI)'s Perspective Taking and Empathic Concern subscales; identification of one's own emotions and those of others as measured by the Profile of Emotional Competence (PEC)'s Identify my Emotions and Identify Others' Emotions subscales; emotional acceptance as measured by the Acceptance and Action Questionnaire-II (AAQ-II) and the Emotion Regulation Scale (ERQ)'s Expressive Suppression subscale; and recognition of emotions in others as measured by the Geneva Emotion Recognition Test (GERT).

RESULTS

In both studies, retention rates (80%-81%) were acceptable. Participants who completed the programme improved on all measures except the PEC's Identify Others' Emotions and the IRI's Empathic Concern (Cohen's d median=0.92, range 45-1.72). In Study 2, favourable effects associated with the programme were maintained over 3 months on the PEC's Identify my Emotions, the AAQ-II, the ERQ's Expressive Suppression and the GERT.

CONCLUSIONS

The programme was feasible and acceptable. It was associated with a significant signal on the following outcomes: perspective taking, the identification of one's own emotions and emotional acceptance, thus, justifying moving towards efficacy trials using these outcomes.

Outcomes of MBSR or MBSR-based interventions in health care providers: A systematic review with a focus on empathy and emotional competencies

BACKGROUND

Emotional competencies are extremely important for healthcare providers exposed to patients' suffering. The effect of mindfulness-based stress reduction (MBSR) has been studied in this population. However, it is unclear whether capacities identified as core for care are modified favourably by this intervention.

OBJECTIVES

(1) To identify outcomes in studies on the effect of MBSR in healthcare providers. (2) To evaluate the impact of MBSR on these outcomes. (3) To assess current knowledge on whether capacities central to care are positively impacted by MBSR: empathy, identification of one's own emotions, identification of other's emotions and emotional acceptance.

METHODS

We performed a systematic review on interventional studies published up to 2015 evaluating the effect of MBSR in healthcare professionals. A subset of studies including empathy and emotional competencies was assessed for bias following current methodological standards.

RESULTS

Thirty nine studies were identified. 14/39 studies measured empathy or some form of emotional competence in healthcare providers. Evidence regarding the effects of MBSR in professionals suggests this intervention is associated with improvements in burnout, stress, anxiety and depression. Improvements in empathy are also suggested but no clear evidence is currently available on emotional competencies.

CONCLUSIONS

High quality evidence is available on the effect of MBSR on professionals' mental health. However, while some emotional competencies have been identified as being of major importance for high quality care, they are still scarcely studied. Studying these outcomes is important, as it may help explain how mindfulness contributes to professionals' mental health and thus help develop targeted interventions.

To be or not to be empathic: the combined role of empathic concern and perspective taking in understanding burnout in general practice

Background

General practice is stressful and burnout is common among family physicians. A growing body of evidence suggests that the way physicians relate to their patients could be linked to burnout. The goal of this study was to examine how patterns of empathy explained physicians’ burnout.

Methods

We surveyed 294 French general practitioners (response rate 39%), measured burnout, empathic concern (EC) and perspective taking (PT) using self-reported questionnaires, and modeled burnout levels and frequencies with EC, PT and their interaction in linear and logistic regression analyses.

Results

Multivariate linear models for burnout prediction were associated with lower PT (β = −0.21, p < 0.001) and lower EC (β = −0.17, p < 0.05). Interestingly, the interaction (EC x PT) also predicted burnout levels (β = 0.11, p < 0.05). The investigation of interactions revealed that high scores on PT predicted lower levels of burnout independent from EC (odd ratios (OR) 0.37; 95% confidence interval (95% CI) 0.21–0.65 p < 0.001), and high scores on both EC and PT were protective against burnout: OR 0.31; 95% CI 0.15–0.63, p < 0.001).

Conclusions

Deficits in PT alone might be a risk factor for burnout, whereas higher PT and EC might be protective. Educators should take into account how the various components of empathy are potentially associated with emotional outcomes in physicians.

Concepts and approaches to in situ luminescence dating of Martian sediments

In this paper we present the concept of a robotic instrument for in situ luminescence dating of near-surface sediments on Mars. The scientific objectives and advantages to be gained from the development of such an instrument are described, and the challenges presented by the Mars surface environment to the design and operation of the instrument are outlined.

Recent progress in protein farnesyltransferase inhibition

This review aims to provide a recent update on protein farnesyltransferase inhibition, covering the period 1999 to mid 2000. A brief overview of the project rationale and its most recent evolution is also presented. For each inhibitor series, the most advanced molecules are presented along with a short description of the patent environment, focusing on second generation patents that cover new applications for protein farnesyltransferase inhibitors (PFTIs).

Characterization of endoglin on mouse uterine stromal cells

During the oestrous cycle and early pregnancy, the uterus undergoes a variety of morphological and physiological modifications involving uterine cell proliferation and differentiation as well as extensive tissue remodelling. Transforming growth factor beta (TGF-beta) has powerful effects on these events and thus is thought to have a critical role in uterine physiology. Endoglin is a transmembrane glycoprotein that binds TGF-beta 1 and -beta 3 and interacts with TGF-beta signalling receptors to modulate many effects of this growth factor in different types of cell. Studies in mice revealed the highest concentrations of endoglin in the reproductive tract, notably on stromal cells of cyclic and pregnant uteri. The objective of the present study was to investigate the role of endoglin expressed on uterine stromal cells in binding TGF-beta and in the cellular responses induced by this growth factor. Highly purified populations of uterine stromal cells were isolated by cell affinity to the monoclonal antibody MJ7/18, which is specific to mouse endoglin. Affinity labelling of these cells with 125I-labelled TGF-beta followed by immunoprecipitation with endoglin-specific polyclonal 1256:4b antiserum indicated that endoglin expressed at the surface of uterine stromal cells binds TGF-beta 1 and interacts with TGF-beta signalling receptors. Treatment of uterine stromal cells with different concentrations of TGF-beta 1 induced a biphasic proliferative response and addition of MJ7/18 as well as neutralizing TGF-beta antibodies showed endoglin to be a modulator of TGF-beta-induced stromal cell proliferation. Given the importance of TGF-beta in the regulation of uterine physiology, these results indicate a role for endoglin during uterine tissue remodelling and decidualization.

Differentiation between partial agonists and neutral 5-HT1B antagonists by chemical modulation of 3-[3-(N,N-dimethylamino)propyl]-4-hydroxy- N-[4-(pyridin-4-yl)phenyl]benzamide (GR-55562)

The synthesis and binding affinity at cloned h5-HT1D, h5-HT1D, and h5-HT1A receptors of 3-[3-(N,N-dimethylamino)propyl]-4-hydroxy- N-[4-(pyridin-4-yl)phenyl]benzamide (2, GR-55562) and four O-methylated analogs are described. The functional activity of these compounds was determined at the h5-HT1B receptor using a [35S]GTP gamma S binding assay. The four analogs have been prepared in order to evaluate the influence of the alkylamino side chain conformation on binding and intrinsic activity. Whereas 2 and its derivatives display a similar binding affinity profile, major differences arise from analysis of the intrinsic activity data at h5-HT1B receptors. The O-methylated analog of 2, 3-[3-(N,N-dimethylamino)propyl]-4-methoxy- N-[4-(pyridin-4-yl)phenyl]benzamide (3a), and the (1Z)-3-(N,N-dimethylamino)prop-1-enyl derivative (3c) act as neutral and potent antagonists (in a similar way to 2), while the 3-(N,N-dimethylamino)-prop-1-ynyl (3b) and (1E)-3-(N,N-dimethylamino)prop-1-enyl (3d) analogs display nonnegligible agonist activity. Molecular modeling studies show that, when the common triaryl portions of the molecules are overlapped, the partial agonists and the neutral antagonists differ by a near-orthogonal orientation of the NH+ projection to the hydrogen-bond receptor site.

Suggestive linkages between markers on human 1p32-p22 and body fat and insulin levels in the Quebec Family Study

A single-gene rodent mutation (diabetes) and a quantitative trait locus (dietary obese 1) mapped to the mid portion of mouse chromosome 4 have been related to obesity and/or insulin levels. Synteny relationships place their putative human homologs on 1p31 and 1p35-p31, respectively. In 137 sibships of adult brothers and sisters from the Québec Family Study, genetic linkages between seven microsatellite markers from 1p32-p22 and various obesity- and diabetes-related quantitative phenotypes were examined using single locus sibpair linkage analysis. Suggestive linkages were observed between markers D1S476 and body mass index (p = 0.05), fat mass (p = 0.02), the sum of six skinfolds (p = 0.02), the insulin area after an oral glucose tolerance test (p = 0.02), and between the neighboring marker D1S200 and body mass index (p = 0.03), and fat mass (p = 0.009). Suggestive linkages were also observed between the more telomeric markers D1S193 and body mass index (p = 0.03), and between the neighboring marker D1S197 and fasting insulin level (p = 0.05). No linkage was observed with the trunk to extremity skinfolds ratio. These linkages suggest that human homologs of the mouse diabetes or dietary obese 1 and/or other genes in this interval on chromosome 1 play a role in the regulation of body mass, body composition, and insulin levels, but not of subcutaneous fat distribution.

Dapsone in rheumatoid arthritis

Dapsone, a synthetic sulfone with chemical similarities to sulfapyridine, has been used for a number of years to treat leprosy and dermatitis herpetiformis. Recently, a number of prospective, randomized, double-blind trials have shown their success in the management of rheumatoid arthritis, with dapsone being superior to placebo and comparable to chloroquine and hydroxychloroquine. Its mode of anti-inflammatory actions in rheumatoid arthritis is not clearly understood, but modulation of neutrophil activity or inhibition of neutrophil inflammatory product formation or release appear to play a role. The major limiting side effect is hemolytic anemia, which may be mitigated through careful patient selection, conservative drug dosing, close monitoring, and possibly, concurrent administration of antioxidants or cytochrome P450 inhibitors. Methemoglobinemia is another common finding among patients receiving dapsone therapy, but rarely does it result in prominent symptoms other than transient pallor. Less common adverse events to dapsone include the idiosyncratic reactions of leukopenia and agranulocytosis, cutaneous eruptions, peripheral neuropathy, psychosis, toxic hepatitis, cholestatic jaundice, nephrotic syndrome, renal papillary necrosis, severe hypoalbuminemia without proteinuria, an infectious mononucleosis-like syndrome, and minor neurological and gastrointestinal complaints. In this report, two patients with advanced rheumatoid arthritis, who were safely and effectively treated with dapsone after failure with other second-line agents, are described and the literature is reviewed. We suggest that dapsone is an effective second-line agent in the treatment of rheumatoid arthritis.

Listeria monocytogenes causing endovascular infection

Listeria monocytogenes is an uncommon cause of mycotic aneurysms, endocarditis, and other endovascular infections. When they occur, these infections usually involve patients with relatively normal host defenses, but with abnormal vascular intima or cardiac valves. We have reported a Listeria monocytogenes infection at the site of a posttraumatic aortic aneurysm.

[Delayed hemolytic transfusion reaction caused by an anti-U]

Delayed hemolytic transfusion reactions due to anti-U are rare, only two (2) cases having been reported in the literature. We now report a third case: a multiparous black woman without any transfusion history was admitted to hospital for severe microlytic anemia (31 g/l). The patient was group AB negative, the direct antiglobulin test was negative and an anti P1 cold allo-antibody was present in her serum. Five A, Rh negative, P2 packed red cells were cross-marched with the sample obtained at admission on January 8, 1988. She was transfused on January 8, 9, 10, 11 and 12. On the 12th of January her hemoglobin level reached 125 g/l. On January 13, the patient presented clinical signs of hemolysis and her hemoglobin fell to 60 g/l within 24 hours. On January 15, the direct antiglobulin test was positive and an antibody found in her serum was reactive with all the red cells of the commercial panel. The sample was referred to our red cell serology reference laboratory. The phenotype of the pre-transfusion sample was found to be Fy(a-b-) M, N, S-s-U-. An anti-U was detected in the eluate and the serum. The patient was transfused with two (2) units of O-P2, U-red cells obtained from the American Red Cross, Syracuse, and her hemoglobin reached 90 g/l within 48 hours. This is the third reported case of a delayed hemolytic transfusion reaction due to anti-U. This case illustrates the need to perform cross-matches with samples obtained within 48 hours of the scheduled transfusion for patients who have been transfused with blood in the preceding 3 months. Also, this case emphasises the need to recruit U negative blood donors for the Canadian rare donor file.