Vedolizumab, Adalimumab, and Methotrexate Combination Therapy in Crohn's Disease (EXPLORER)

BACKGROUND & AIMS

Although biologics have revolutionized the treatment of Crohn's disease (CD), an efficacy ceiling has been reached. Combining biologic therapies may improve remission rates.

METHODS

EXPLORER, a phase 4, single-arm, open-label study, evaluated triple combination therapy with vedolizumab (300 mg on day 1, weeks 2 and 6, and then every 8 weeks), adalimumab (160 mg on day 2, 80 mg at week 2, then 40 mg every 2 weeks), and methotrexate (15 mg weekly) in biologic-naïve patients with newly diagnosed, moderate- to high-risk CD. Endoscopic remission at week 26 (primary end point; Simple Endoscopic Score for CD ≤2), clinical remission at weeks 10 and 26 (secondary end point; Crohn's Disease Activity Index <150), and incidences of adverse events and serious adverse events were evaluated.

RESULTS

Among 55 enrolled patients, the mean CD duration was 0.4 years, the mean baseline Simple Endoscopic Score for CD was 12.6, and the mean baseline Crohn's Disease Activity Index was 265.5. At week 26, 19 patients (34.5%) were in endoscopic remission. At weeks 10 and 26, 34 (61.8%) and 30 patients (54.5%), respectively, were in clinical remission. Post hoc Bayesian analysis showed that the probabilities that triple combination therapy produced a higher endoscopic remission rate (33.5%; 95% credible interval, 22.4-45.7) than placebo (14%), vedolizumab monotherapy (27%), or adalimumab monotherapy (30%) were 99.9% or higher, 86.3%, and 71.4%, respectively. Six patients had serious adverse events.

CONCLUSIONS

Combination therapy resulted in endoscopic and clinical remission at week 26 in 34.5% and 54.5% of patients, respectively, with no safety signal related to the treatment regimen. This supports further evaluation of combination therapy in CD.

CLINICALTRIALS

gov number: NCT02764762.

And the survey said.... evaluating rationale for participation in gun buybacks as a tool to encourage higher yields

BACKGROUND

Gun buyback programs represent one arm of a multipronged approach to raise awareness and education about gun safety.

METHODS

The city of Worcester, MA has conducted an annual gun buyback at the Police Department Headquarters since 2002. We analyzed survey responses from a voluntary, 18-question, face-to-face structured interview from December 2009 to June 2015 using descriptive statistics to determine participant demographics and motivations for participation.

RESULTS

A total of 943 guns were collected, and 273 individuals completed surveys. The majority of participants were white males older than 55years (42.4%). Participants represented 61 zip codes across Worcester County, with 68% having prior gun safety training and 61% with weapons remaining in the home (27% of which children could potentially access). The top reasons for turning in guns were "no longer needed" (48%) and "fear of children accessing the gun" (14%). About 1 in 3 respondents knew someone injured/killed by gun violence. Almost all (96%) respondents claimed the program raised community awareness of firearm risk.

CONCLUSION

The Worcester Goods for Guns Buyback has collected more than 900 guns between 2009 and 2015. The buyback removes unwanted guns from homes and raises community awareness about firearm safety.

A prospective study of safety and satisfaction with same-day discharge after laparoscopic appendectomy for acute appendicitis

BACKGROUND/PURPOSE

This study examines the safety and patient satisfaction in discharging children undergoing laparoscopic appendectomy (LapAppy) for acute appendicitis on the day of surgery.

METHODS

After institutional review board approval, data were collected prospectively for 158 consecutive patients undergoing LapAppy for simple appendicitis. Time from operation to discharge and complications were analyzed. At follow-up, parents completed a satisfaction survey. The Student t test was used for statistical analysis.

RESULTS

Laparoscopic appendectomy was performed in 158 children ranging from age 2 to 19 years (mean, 12 years) over a 6-month period. Single-port, single-instrument LapAppy was possible in 152 patients (96%). Eighty percent of patients (n = 126) were discharged on the day of surgery, a mean of 4.8 hours postoperatively (range, 1-12 hours). Of the remaining 32, 24 (75%) were admitted because the operation ended too late for postoperative discharge; 3 (9%), for medical reasons; and 5 (16%), when the families declined to leave. One hundred nine parents (87%) whose children went home postoperatively stated that they were happy with the expeditious discharge, whereas 17 (13%) felt nervous. In addition, 116 parents (92%) stated that, in retrospect, same-day discharge was preferable, whereas 10 parents (8%) were not sure that it was the best decision. None, however, would insist on admission if faced with the situation again. There were no major complications and no significant difference in the rate of umbilical wound infections for same-day discharge patients (2%) and admitted patients (3%).

CONCLUSION

Routine same-day discharge after pediatric LapAppy for acute appendicitis is safe, with good parent satisfaction.

Laparoscopic staging and tumor ablation for hepatocellular carcinoma in Child C cirrhotics evaluated for orthotopic liver transplantation

BACKGROUND

Surgical resection and liver transplantation remain the only treatments that offer cure for hepatoma, but are limited to those with early stage disease. Prelisting radiological staging is not always definitive. In this study, we sought to delineate the role of laparoscopy for clarification of staging in advanced cirrhotic patients when radiological assessment during evaluation for orthotopic liver transplants (OLTx) is equivocal.

METHODS

Over a 3-year period, 18 patients with advanced liver insufficiency being evaluated for OLTx listing underwent laparoscopic staging when the following criteria were met: (1) lesion(s) with indeterminate size/borders, (2) an indeterminate number of lesions, or (3) lesion(s) and alpha-fero protein (AFP) less than 100 ng/ml. Patients underwent exploratory laparoscopy and laparoscopic ultrasound with biopsy, with or without ablation of lesion(s).

RESULTS

Laparoscopic staging was initiated in 18 patients; four of the first six patients were converted to open procedures. Twelve patients were restaged as a result of the procedure: six down-staged and six up-staged. Stage changes were based on laparoscopic visualization of advanced disease in two, ultrasonographic clarification of tumor size/number in seven, and biopsy in three. Twelve of the 14 laparoscopic procedures included laparoscopic radiofrequency ablation while one received ethanol ablation. One patient required 2 units of red blood cells. One patient died on postoperative day 7 because of gastrointestinal bleeding. Four of the six down-staged patients underwent liver transplant, and pathological staging of the explants agreed with laparoscopic staging in all cases.

CONCLUSION

Laparoscopic staging for HCC in advanced cirrhosis can clearly characterize tumor burden when preoperative radiological assessment is equivocal.