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Ørnbjerg LM, Brahe CH, Linde L, Jacobsson L, Nissen MJ, Kristianslund EK, Santos MJ, Nordström D, Rotar Z, Gudbjornsson B, Onen F, Codreanu C, Lindström U, Möller B, Kvien TK, Barcelos A, Eklund KK, Tomšič M, Love TJ, Can G, Ionescu R, Loft AG, Mann H, Pavelka K, van de Sande M, van der Horst-Bruinsma IE, Suarez MP, Sánchez-Piedra C, Macfarlane GJ, Iannone F, Michelsen B, Hyldstrup LH, Krogh NS, Østergaard M, Hetland ML. Drug effectiveness of 2nd and 3rd TNF inhibitors in psoriatic arthritis - relationship with the reason for withdrawal from the previous treatment. Joint Bone Spine 2024; 91:105729. [PMID: 38582359 DOI: 10.1016/j.jbspin.2024.105729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 03/01/2024] [Accepted: 03/06/2024] [Indexed: 04/08/2024]
Abstract
OBJECTIVE To investigate real-world retention and remission rates in PsA patients initiating a 2nd or 3rd TNFi and the association with reason for discontinuation from the previous TNFi-treatment. METHODS Prospectively collected routine care data from 12 European registries were pooled. Retention rates (Kaplan-Meier estimation) and crude/LUNDEX-adjusted rates of Disease Activity Score 28 and Disease Activity index for PSoriatic Arthritis (DAS28 and DAPSA28) remission were calculated and compared with adjusted Cox regression analyses and Chi-squared test, respectively). RESULTS We included 5233 (2nd TNFi) and 1906 (3rd TNFi) patients. Twelve-month retention rates for the 2nd and 3rd TNFi were 68% (95%CI: 67-70%) and 66% (64-68%), respectively. Patients who stopped the previous TNFi due to AE/LOE had 12-month retention rates of 66%/65% (2nd TNFi), and 65%/63% (3rd TNFi), respectively. Patients who stopped the previous TNFi due to LOE after less vs more than 24 weeks had 12-month retention rates of 54%/69% (2nd TNFi), and 58%/65% (3rd TNFi). Six-month crude/LUNDEX-adjusted DAS28 remission rates were 48%/35% and 38%/27%, and DAPSA28 remission rates were 19%/14% and 14%/10%, for the 2nd and 3rd TNFi. CONCLUSION Two-thirds of patients remained on TNFi at 12months for both the 2nd and 3rd TNFi, while one-third and one-quarter of patients were in DAS28 remission after 6months on the 2nd and 3rd TNFi. While drug effectiveness was similar in patients who stopped the previous TNFi due to AE compared to overall LOE, drug effectiveness was better in patients who had stopped the previous TNF due to secondary LOE compared to primary LOE.
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Affiliation(s)
- Lykke Midtbøll Ørnbjerg
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark.
| | - Cecilie Heegaard Brahe
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark
| | - Louise Linde
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark
| | - Lennart Jacobsson
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Michael J Nissen
- Department of Rheumatology, Geneva University Hospital, Geneva, Switzerland
| | - Eirik Klami Kristianslund
- Center for treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway and Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Maria José Santos
- Reuma.pt registry; Department of Rheumatology-Hospital Garcia de Orta, Almada and Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Dan Nordström
- ROB-FIN Registry, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Ziga Rotar
- biorx.si and the Department of Rheumatology, University Medical Centre Ljubljana, Slovenia and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Bjorn Gudbjornsson
- Centre for Rheumatology Research (ICEBIO), University Hospital and Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Fatos Onen
- TURKBIO Registry and Division of Rheumatology, School of Medicine Dokuz Eylul University, Izmir, Turkey
| | - Catalin Codreanu
- Center of Rheumatic Diseases, University of Medicine and Pharmacy, Bucharest, Romania
| | - Ulf Lindström
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Burkhard Möller
- Leitender Arzt der Universitätsklinik für Rheumatologie, Immunologie und Allergologie Inselspital, Bern, Switzerland
| | - Tore K Kvien
- Center for treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway and Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Anabela Barcelos
- Reuma.pt registry, Rheumatology Department - Centro Hospitalar do Baixo Vouga, Aveiro and Comprehensive Health Research Center (CHRC), NOVA University of Lisbon, Lisboa, Portugal
| | - Kari K Eklund
- Inflammation Center, Department of Rheumatology, Helsinki University Hospital, Helsinki, Finland
| | - Matija Tomšič
- biorx.si and the Department of Rheumatology, University Medical Centre Ljubljana, Slovenia and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Thorvardur Jon Love
- University of Iceland, Faculty of Medicine, and Landspitali University Hospital, Reykjavik, Iceland
| | - Gercek Can
- TURKBIO Registry and Division of Rheumatology, School of Medicine Dokuz Eylul University, Izmir, Turkey
| | - Ruxandra Ionescu
- Center of Rheumatic Diseases, University of Medicine and Pharmacy, Bucharest, Romania
| | - Anne Gitte Loft
- DANBIO Registry, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark; Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - Herman Mann
- Institute of Rheumatology and Department of Rheumatology, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Karel Pavelka
- Institute of Rheumatology and Department of Rheumatology, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Marleen van de Sande
- Amsterdam UMC, University of Amsterdam, Department of Clinical Immunology and Rheumatology, Amsterdam, The Netherlands; Amsterdam Rheumatology & immunology Center (ARC), Academic Medical Center, Amsterdam, The Netherlands
| | | | - Manuel Pombo Suarez
- Rheumatology Department, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Santiago, Spain
| | | | - Gary J Macfarlane
- Aberdeen Centre for Arthritis and Musculoskeletal Health (Epidemiology Group) University of Aberdeen, Aberdeen, United Kingdom
| | - Florenzo Iannone
- GISEA registry, Rheumatology Unit-DETO, University of Bari, Bari, Italy
| | - Brigitte Michelsen
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark; Department of Rheumatology, Geneva University Hospital, Geneva, Switzerland; Research Unit, Sørlandet Hospital, Kristianssand, Norway
| | - Lise Hejl Hyldstrup
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark
| | | | - Mikkel Østergaard
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Merete Lund Hetland
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Wu H, Zhao B, Yao Q, Kang J. Dehydroepiandrosterone-induced polycystic ovary syndrome mouse model requires continous treatments to maintain reproductive phenotypes. J Ovarian Res 2023; 16:207. [PMID: 37880784 PMCID: PMC10599050 DOI: 10.1186/s13048-023-01299-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 10/16/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Polycystic ovary syndrome (PCOS) is the most common endocrinopathy associated with infertility and metabolic disorder in women of reproductive age. Animal models have been developed and used as tools to unravel the pathogenesis of PCOS, among which most postnatal models employ continuing experimental manipulations. However, the persistence and stability of these animals after modeling is unknown. Dehydroepiandrosterone (DHEA)-induced PCOS mouse model is commonly used in PCOS studies. Thus the aim of the present study was to investigate the reproductive features of DHEA-induced PCOS mice fed a normal chow or an high-fat diet (HFD) with treatment withdrawal or consecutive treatments after PCOS mouse models were established. METHODS Prepubertal C57BL/6 J mice (age 25 days) were injected (s.c.) daily with DHEA on a normal chow or a 60% HFD for 20 consecutive days to induce PCOS mouse models. Mice injected with the vehicle sesame oil were used as controls. After 20 days, mice were divided into 2 groups, namely "Continue dosing group" and "Stop dosing group". The animals were consecutively treated with DHEA or DHEA + HFD, or housed without any treatment for 2 or 4 weeks. Estrous cycles were evaluated during this period. At the end of the experiment, serum testosterone (T) levels were measured and the morphology of ovaries was evaluated. RESULTS The mice in Continue dosing groups maintained reproductive phenotypes of PCOS mouse models. In contrast, 2 or 4 weeks after PCOS models were established, the mice with treatment withdrawal in Stop dosing groups exhibited normal serum testosterone levels, regular estrous cycle, and relatively normal ovarian morphology. In addition, even with consecutive treatments, there was no marked difference in body weight between DHEA mice on the normal chow or an HFD in Continue dosing groups and the control animals 3 weeks after modeling. CONCLUSIONS After PCOS mice were induced with DHEA or DHEA + HFD, the mice still need consecutive treatments to maintain reproductive phenotypes to be regarded as PCOS mice that meet the diagnostic criteria of PCOS defined by the 2003 Rotterdam criteria.
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Affiliation(s)
- Haowen Wu
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Peking University Health Science Center, No.38 Xueyuan Rd, Haidian District, Beijing, 100191, China
| | - Bining Zhao
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Peking University Health Science Center, No.38 Xueyuan Rd, Haidian District, Beijing, 100191, China
| | - Qiyang Yao
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Peking University Health Science Center, No.38 Xueyuan Rd, Haidian District, Beijing, 100191, China
| | - Jihong Kang
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Peking University Health Science Center, No.38 Xueyuan Rd, Haidian District, Beijing, 100191, China.
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van Til JA, Kip MMA, Schatorjé EJH, Currie G, Twilt M, Benseler SM, Swart JF, Vastert SJ, Wulffraat N, Yeung RSM, Groothuis-Oudshoorn CGMK, Warta S, Marshall DA, IJzerman MJ. Withdrawing biologics in non-systemic JIA: what matters to pediatric rheumatologists? Pediatr Rheumatol Online J 2023; 21:69. [PMID: 37434157 DOI: 10.1186/s12969-023-00845-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/15/2023] [Indexed: 07/13/2023] Open
Abstract
OBJECTIVE Approximately one third of children with JIA receive biologic therapy, but evidence on biologic therapy withdrawal is lacking. This study aims to increase our understanding of whether and when pediatric rheumatologists postpone a decision to withdraw biologic therapy in children with clinically inactive non-systemic JIA. METHODS A survey containing questions about background characteristics, treatment patterns, minimum treatment time with biologic therapy, and 16 different patient vignettes, was distributed among 83 pediatric rheumatologists in Canada and the Netherlands. For each vignette, respondents were asked whether they would withdraw biologic therapy at their minimum treatment time, and if not, how long they would continue biologic therapy. Statistical analysis included descriptive statistics, logistic and interval regression analysis. RESULTS Thirty-three pediatric rheumatologists completed the survey (40% response rate). Pediatric rheumatologists are most likely to postpone the decision to withdraw biologic therapy when the child and/or parents express a preference for continuation (OR 6.3; p < 0.001), in case of a flare in the current treatment period (OR 3.9; p = 0.001), and in case of uveitis in the current treatment period (OR 3.9; p < 0.001). On average, biologic therapy withdrawal is initiated 6.7 months later when the child or parent prefer to continue treatment. CONCLUSION Patient's and parents' preferences were the strongest driver of a decision to postpone biologic therapy withdrawal in children with clinically inactive non-systemic JIA and prolongs treatment duration. These findings highlight the potential benefit of a tool to support pediatric rheumatologists, patients and parents in decision making, and can help inform its design.
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Affiliation(s)
- Janine A van Til
- Department of Health Technology & Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, P.O. Box 217, Enschede, AE, The Netherlands
| | - Michelle M A Kip
- Department of Health Technology & Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, P.O. Box 217, Enschede, AE, The Netherlands
- Department of Pediatric Rheumatology, Division of Paediatrics, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Ellen J H Schatorjé
- Department of Paediatric Rheumatology, St. Maartenskliniek, Nijmegen, the Netherlands
- Department of Paediatric Rheumatology and Immunology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Gillian Currie
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Marinka Twilt
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Division of Rheumatology, Department of Pediatrics, Cumming School of Medicine, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
| | - Susanne M Benseler
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Division of Rheumatology, Department of Pediatrics, Cumming School of Medicine, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
| | - Joost F Swart
- Department of Pediatric Rheumatology, Division of Paediatrics, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
- Faculty of Medicine, Utrecht University, Utrecht, The Netherlands
- European Reference Network RITA (rare immunodeficiency autoinflammatory and autoimmune diseases network), Utrecht, The Netherlands
| | - Sebastiaan J Vastert
- Department of Pediatric Rheumatology, Division of Paediatrics, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
- Faculty of Medicine, Utrecht University, Utrecht, The Netherlands
- European Reference Network RITA (rare immunodeficiency autoinflammatory and autoimmune diseases network), Utrecht, The Netherlands
| | - Nico Wulffraat
- Department of Pediatric Rheumatology, Division of Paediatrics, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
- Faculty of Medicine, Utrecht University, Utrecht, The Netherlands
- European Reference Network RITA (rare immunodeficiency autoinflammatory and autoimmune diseases network), Utrecht, The Netherlands
| | - Rae S M Yeung
- Division of Rheumatology, The Hospital for Sick Children, Department of Paediatrics, Immunology and Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - C G M Karin Groothuis-Oudshoorn
- Department of Health Technology & Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, P.O. Box 217, Enschede, AE, The Netherlands
| | - Sanne Warta
- Department of Health Technology & Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, P.O. Box 217, Enschede, AE, The Netherlands
| | - Deborah A Marshall
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Division of Rheumatology, Department of Pediatrics, Cumming School of Medicine, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Maarten J IJzerman
- Department of Health Technology & Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, P.O. Box 217, Enschede, AE, The Netherlands.
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Jalilian H, Heydari S, Mir N, Fehresti S, Khodayari-Zarnaq R. Forgone care in patients with type 2 diabetes: a cross-sectional study. BMC Public Health 2021; 21:1588. [PMID: 34429093 PMCID: PMC8386068 DOI: 10.1186/s12889-021-11639-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 08/17/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Diabetes mellitus is a complex chronic disease requiring appropriate continuous medical care and delayed, or forgone care may exacerbate the severity of the disease. This study aimed to investigate the factors affecting forgone care in patients with type2 diabetes. MATERIALS AND METHODS This was a cross-sectional study involving 1139 patients with type 2 diabetes aged> 18 years in 2019 in Tabriz, Iran. The researcher-made questionnaire was used for data collection. Data were analyzed using IBM SPSS software version 22 and IBM AMOS 22. Exploratory Factor Analysis (EFA) was performed for dimension reduction of the questionnaire, and Confirmatory Factor Analysis (CFA) used to verify the result of EFA. We applied the binary logistic regression model to assess the factors affecting forgone care. RESULTS Of the 1139 patients, 510 patients (45%) reported forgone care during the last year. The percentage of forgoing care was higher in patients without supplementary insurance coverage (P = 0.01), those with complications (P = 0.01) and those with a history of hospitalization (P = 0.006). The majority of patients (41.5%) reported that the most important reason for forgoing care is financial barriers resulting from disease treatment costs. Of the main four factors affecting, quality of care had the highest impact on forgone care at 61.28 (of 100), followed by accessibility (37.01 of 100), awareness and attitude towards disease (18.52 of 100) and social support (17.22 of 100). CONCLUSION The results showed that, despite the implementation of the Islamic Republic of Iran on a fast-track to beating non-communicable diseases (IraPEN), a considerable number of patients with type2 diabetes had a history of forgoing care, and the most important reasons for forgoing care were related to the financial pressure and dissatisfaction with the quality of care. Therefore, not only more financial support programs should be carried out, but the quality of care should be improved.
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Affiliation(s)
- Habib Jalilian
- Department of Health Services Management, School of Public Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Somayeh Heydari
- Iranian Center of Excellence in Health Management, Department of Health Services Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Nazanin Mir
- Student Research Committee, School of Management and Medical Informatics, Iran University of Medical Sciences, Tehran, Iran
| | - Saeedeh Fehresti
- Department of Health Economics and Management, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Rahim Khodayari-Zarnaq
- Department of Health Policy and Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
- Tabriz Health Services Management Research Center, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
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van den Brand FF, Snijders RJALM, de Boer YS, Verwer BJ, van Nieuwkerk CMJ, Bloemena E, Kuiken SD, Drenth JPH, Bouma G. Drug withdrawal in patients with autoimmune hepatitis in long-term histological remission: A prospective observational study. Eur J Intern Med 2021; 90:30-36. [PMID: 33865679 DOI: 10.1016/j.ejim.2021.03.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 02/24/2021] [Accepted: 03/15/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Recommendations for drug withdrawal in patients with autoimmune hepatitis (AIH) in longstanding remission are conflicting and rely on retrospective data. We prospectively investigated the predictive value of histological normalisation for successful treatment withdrawal in AIH patients. METHODS Non-cirrhotic patients with established AIH and complete biochemical remission (normalisation of serum alanine aminotransferase [ALT] or aspartate aminotransferase [AST] and immunoglobulin G [IgG]) of at least 2 years were biopsied. Immunosuppressive therapy was only withdrawn in patients with histological normalisation (histological activity index [HAI] ≤3) with a minimum follow-up of 12 months. RESULTS A total of 17 patients in biochemical remission for at least 2 years were included. Persistent histological inflammatory activity (HAI >3) precluded drug withdrawal in five patients. These had higher values of ALT (25 vs. 16 U/L; p = 0.01) and AST (26 vs. 22 U/L; p = 0.01) compared with patients in histological remission. Immunosuppressive medication was withdrawn in 12 patients; eight (67%, C.I. 40-93% p = 0.4) remained in remission during a median follow-up of 62 months (range: 13-75 months); and four (33%, C.I. 7-60% p = 0.4) required reinstitution of therapy after 1, 6, 11, and 40 months, all without clinical signs of disease progression or hepatic decompensation. No predictors of relapse were identified. CONCLUSION Two-thirds of the patients who prove to have histological normalisation after at least 2 years of biochemical remission achieve treatment-free remission. Although patient numbers were small and results should be interpreted with caution, these findings support a liver biopsy prior to drug withdrawal.
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Affiliation(s)
- Floris F van den Brand
- Amsterdam UMC, Vrije Universiteit Amsterdam, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, de Boelelaan 1117, Amsterdam, the Netherlands.
| | - Romée J A L M Snijders
- Amsterdam UMC, Vrije Universiteit Amsterdam, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, de Boelelaan 1117, Amsterdam, the Netherlands; Department of Gastroenterology and Hepatology, Radboudumc, Nijmegen, the Netherlands
| | - Ynto S de Boer
- Amsterdam UMC, Vrije Universiteit Amsterdam, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, de Boelelaan 1117, Amsterdam, the Netherlands
| | - Bart J Verwer
- Department of Gastroenterology and Hepatology, Spaarne Hospital, Haarlem, the Netherlands
| | - Carin M J van Nieuwkerk
- Amsterdam UMC, Vrije Universiteit Amsterdam, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, de Boelelaan 1117, Amsterdam, the Netherlands
| | - Elisabeth Bloemena
- Amsterdam UMC, Vrije Universiteit Amsterdam, Pathology, Amsterdam, the Netherlands
| | - Sjoerd D Kuiken
- Department of Gastroenterology and Hepatology, OLVG, Amsterdam, the Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboudumc, Nijmegen, the Netherlands
| | - Gerd Bouma
- Amsterdam UMC, Vrije Universiteit Amsterdam, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, de Boelelaan 1117, Amsterdam, the Netherlands
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Rey JR, Merino Llorens JL, Iniesta Manjavacas ÁM, Rodríguez SOR, Castrejón-Castrejón S, Arbas-Redondo E, Poveda-Pinedo ID, Tebar-Márquez D, Severo-Sánchez A, Rivero-Santana B, Juárez-Olmos V, Martínez-Cossiani M, Buño-Soto A, Gonzalez-Valle L, Herrero-Ambrosio A, López-de-Sá E, Caro-Codón J. Influence of statin treatment in a cohort of patients admitted for COVID-19. Med Clin (Barc) 2021; 158:586-595. [PMID: 34511251 PMCID: PMC8302844 DOI: 10.1016/j.medcli.2021.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 07/03/2021] [Accepted: 07/05/2021] [Indexed: 01/08/2023]
Abstract
Antecedentes y objetivos Se ha especulado que las estatinas pueden ser de utilidad en el tratamiento de pacientes con COVID-19, pero no existen evidencias clínicas sólidas. El objetivo de este trabajo es conocer su utilidad en una cohorte de gran tamaño de pacientes hospitalizados por COVID-19, así como si su retirada se asocia con un peor pronóstico. Material y métodos Estudio retrospectivo observacional. Se incluyeron 2.191 pacientes hospitalizados con infección confirmada con SARS-CoV-2. Resultados La edad media fue de 68,0 ± 17,8 años y fallecieron un total de 597 (27,3%) pacientes. Un total de 827 pacientes (37,7% de la muestra) estaban tratados previamente con estatinas. Aunque precisaron con mayor frecuencia de ingreso en camas de críticos, dicho grupo terapéutico no resultó un factor predictor independiente de muerte en el seguimiento [HR 0,95 (0,72-1,25)]. Un total de 371 pacientes (16,9%) recibió al menos una dosis de estatina durante el ingreso. A pesar de ser una población con un perfil clínico más desfavorable, tanto su uso [HR 1,03 (0,78-1,35)] como la suspensión durante el ingreso en pacientes que las recibían crónicamente [HR 1,01 (0,78-1,30)] presentaron un efecto neutro en la mortalidad. No obstante, el grupo con estatinas desarrolló con mayor frecuencia datos de citolisis hepática, rabdomiolisis y más eventos trombóticos y hemorrágicos. Conclusiones En nuestra muestra, las estatinas no se asociaron de forma independiente a una menor mortalidad en pacientes con COVID-19. En aquellos pacientes que tengan indicación de recibirlas por su patología previa es necesario monitorizar estrechamente sus potenciales efectos adversos durante el ingreso hospitalario.
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Affiliation(s)
- Juan R Rey
- Servicio de Cardiología, Hospital Universitario La Paz, Madrid, España.
| | | | | | | | | | | | | | | | | | | | | | | | - Antonio Buño-Soto
- Servicio de Análisis Clínicos, Hospital Universitario La Paz, Madrid, España
| | - Luis Gonzalez-Valle
- Servicio de Farmacia Hospitalaria, Hospital Universitario La Paz, Madrid, España
| | | | | | - Juan Caro-Codón
- Servicio de Cardiología, Hospital Universitario La Paz, Madrid, España
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Lin Y, Long-Sutehall T, Myall M. Transferring home to die from critical care units: A scoping review of international practices. J Crit Care 2021; 65:205-215. [PMID: 34243069 DOI: 10.1016/j.jcrc.2021.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/17/2021] [Accepted: 06/18/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE To identify and characterise the international practices of transferring a dying patient home to die from critical care units. MATERIALS AND METHODS A systematic scoping review following the Joanne Briggs Institute methodology was applied searching fifteen data sources to identify papers published in English and Chinese from 1970 to 2019. RESULTS Of the 28 papers meeting eligibility criteria 19 were published in the West and seven in China. The number of patients being transferred home to die was larger in China (74/184-96/159) than in the West (1-7). Clinical characteristics of patients transferred included: consciousness, with or without intubation and ventilation, and clinical stability. Reported key barriers to transfer included: Lack of evidence guiding transfer practice, the CCU environment and culture, Practical and logistical factors and Family members expectations and reactions. Key facilitators of transfer were reported as: Engagement with the multidisciplinary team and Personal patient and family wishes. CONCLUSIONS Transferring patients home to die from critical care is a complex practice varying significantly across countries. Further research to address current knowledge gaps is important to inform policy and practice.
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Affiliation(s)
- Yanxia Lin
- School of Health Sciences, University of Southampton, Highfield, Southampton SO17 1BJ, UK.
| | - Tracy Long-Sutehall
- School of Health Sciences, University of Southampton, Highfield, Southampton SO17 1BJ, UK
| | - Michelle Myall
- School of Health Sciences, University of Southampton, Highfield, Southampton SO17 1BJ, UK
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8
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Cremer R, de Saint Blanquat L, Birsan S, Bordet F, Botte A, Brissaud O, Guilbert J, Le Roux B, Le Reun C, Michel F, Millasseau F, Sinet M, Hubert P. Withholding and withdrawing treatment in pediatric intensive care. Update of the GFRUP recommendations. Arch Pediatr 2021; 28:325-337. [PMID: 33875345 DOI: 10.1016/j.arcped.2021.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/15/2021] [Indexed: 11/29/2022]
Abstract
In 2005, the French-speaking task force on pediatric critical and emergency care [Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP)] issued recommendations on withholding and withdrawing treatments in pediatric critical care. Since then, the French Public Health Code, modified by the laws passed in 2005 and 2016 and by their enactment decrees, has established a legal framework for practice. Now, 15 years later, an update of these recommendations was needed to factor in the experience acquired by healthcare teams, new questions raised by practice surveys, the recommendations issued in the interval, the changes in legislation, and a few legal precedents. The objective of this article is to help pediatric critical care teams find the closest possible compromise between the ethical principles guiding the care offered to the child and the family and compliance with current regulations and laws.
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Affiliation(s)
- R Cremer
- Réanimation et soins continus pédiatriques, hôpital Jeanne-de-Flandre, ERER des Hauts-de-France, CHU de Lille, 59037 Lille, France.
| | - L de Saint Blanquat
- Réanimation pédiatrique, hôpital Necker-Enfants-malades, 149, rue de Sèvres, 75015 Paris, France
| | - S Birsan
- Unité de soins continus et réanimation néonatale et pédiatrique, hôpital des enfants, CHU Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - F Bordet
- Réanimation pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, 59, boulevard Pinel, 69500 Lyon-Bron, France
| | - A Botte
- Unité de soins continus et réanimation néonatale et pédiatrique, hôpital des enfants, CHU Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - O Brissaud
- Unité de soins continus et réanimation néonatale et pédiatrique, hôpital des enfants, CHU Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - J Guilbert
- Réanimation néonatale pédiatrique, hôpital Armand-Trousseau, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - B Le Roux
- Réanimation pédiatrique, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - C Le Reun
- Réanimation pédiatrique, hôpital Clocheville, CHU de Tours, 2, boulevard Tonnelle, 37000 Tours, France
| | - F Michel
- Anesthésie et réanimation pédiatrique, hôpital de la Timone, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France
| | - F Millasseau
- Réanimation pédiatrique, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - M Sinet
- Réanimation néonatale pédiatrique, hôpital Armand-Trousseau, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France; Réanimation et surveillance continue pédiatriques, hôpital Robert-Debré, 48, boulevard Sérurier, 75019 Paris, France
| | - P Hubert
- Réanimation pédiatrique, hôpital Necker-Enfants-malades, 149, rue de Sèvres, 75015 Paris, France
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9
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Pan CX, Costa BA, Yushuvayev EK, Gross L, Kawai F. Can Orthodox Jewish Patients Undergo Palliative Extubation? A Challenging Ethics Case Study. J Pain Symptom Manage 2020; 60:1260-1265. [PMID: 32882359 DOI: 10.1016/j.jpainsymman.2020.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 08/10/2020] [Accepted: 08/25/2020] [Indexed: 11/16/2022]
Abstract
According to Jewish law/ethics, continuous life-sustaining therapy may not be withdrawn after its introduction, unless the patient has improved and no longer has a medical indication for the treatment. We report the case of an 88-year-old Orthodox Jewish patient, on invasive mechanical ventilation, with severe anoxic brain injury after multiple cardiac arrests. Although the patient's son informed the palliative care team that his father did not want to be in pain or to linger in a vegetative state when terminally ill, the mechanical ventilation was keeping him alive with a poor neurological prognosis. Additionally, the patient had previously stated his wish to observe Orthodox Jewish principles regarding end-of-life care. After extensive discussion, the family Rabbi clarified that it would be acceptable to withdraw mechanical ventilation if there were a "reasonable expectation" he would breathe on his own for a "reasonable amount of time." Thus, if the patient's death were to occur, it would not be an immediate consequence the normal ventilator weaning process. Following intermediation by the hospital Rabbi, the definition of what would be a "reasonable expectation" and "reasonable amount of time" was established by the family Rabbi as "over 50%" and "on the order of hours," respectively. Following pulmonary consultation, the patient underwent palliative extubation and, 12 hours after the procedure, died comfortably surrounded by the family. In conclusion, the collaborative and interdisciplinary work among the family Rabbi, hospital Rabbi, and the various medical teams allowed the development of a plan that met all of the patient's personal and religious wishes and beliefs.
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Affiliation(s)
- Cynthia X Pan
- Division of Geriatrics and Palliative Care Medicine, New York-Presbyterian Queens, Flushing, New York, USA.
| | - Bruno Almeida Costa
- Department of Internal Medicine, Walter Cantidio University Hospital, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - Elina K Yushuvayev
- Division of Geriatrics and Palliative Care Medicine, New York-Presbyterian Queens, Flushing, New York, USA
| | - Liam Gross
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, NewYork-Presbyterian Brooklyn Methodist, Brooklyn, New York, USA
| | - Fernando Kawai
- Division of Geriatrics and Palliative Care Medicine, New York-Presbyterian Queens, Flushing, New York, USA
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10
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Jung SM, Pyo JY, Lee SW, Song JJ, Lee SK, Park YB. Clinical characteristics associated with drug-free sustained remission in patients with rheumatoid arthritis: Data from Korean Intensive Management of Early Rheumatoid Arthritis (KIMERA). Semin Arthritis Rheum 2020; 50:1414-20. [PMID: 32241617 DOI: 10.1016/j.semarthrit.2020.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 02/14/2020] [Accepted: 02/25/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES There is limited information on treatment withdrawal in patients with rheumatoid arthritis (RA). This study investigated the clinical course after stopping disease-modifying anti-rheumatic drugs (DMARDs) in patients with well-controlled RA and the clinical features associated with disease flare. METHODS Among patients in the Korean Intensive Management of Early Rheumatoid Arthritis (KIMERA) cohort, discontinuation of DMARDs was determined by a shared decision between patient and rheumatologist. Drug-free remission was defined as (1) non-use of DMARDs and corticosteroids, (2) Disease Activity Score in 28 joints (DAS28) <2.6, and (3) no evidence of synovitis. The maintenance rate of drug-free remission and the predictors for flare were evaluated using Cox proportional hazard models. RESULTS Of 234 patients, 50 patients discontinued DMARDs. All but one using etanercept were treated with conventional synthetic DMARDs. The median follow-up duration was 30 months, and 31 patients (62%) experienced disease flare after stopping DMARDs. The maintenance rate of drug-free remission was 94.0%, 86.7%, and 46.1% at 12, 24, and 48 months, respectively. Disease flare was correlated with longer time to remission, failure of initial DMARDs, and longer duration of disease and higher disease activity at DMARD withdrawal (P = 0.001, 0.022, 0.010 and 0.037, respectively). In multivariate analyses, longer duration of disease (>24 months) and higher disease activity (DAS28 >2.26) at DMARD withdrawal was independently associated with disease flare. CONCLUSION Drug-free remission was feasible in selected patients with well-controlled RA. Patients with early RA and lower disease activity at DMARD withdrawal are more likely to maintain the drug-free remission.
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11
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de Jong HMY, van Mens LJJ, Nurmohamed MT, Kok MR, van Kuijk AWR, Baeten DLP, van de Sande MGH. Sustained remission with methotrexate monotherapy after 22-week induction treatment with TNF-alpha inhibitor and methotrexate in early psoriatic arthritis: an open-label extension of a randomized placebo-controlled trial. Arthritis Res Ther 2019; 21:208. [PMID: 31521192 PMCID: PMC6744710 DOI: 10.1186/s13075-019-1998-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 09/05/2019] [Indexed: 11/10/2022] Open
Abstract
Background If TNF inhibitors are initiated in the early stages of psoriatic arthritis, this could potentially modulate disease and therefore allow us to discontinue the TNF inhibitor after achieving remission. Objective To investigate whether remission induced by tumour necrosis factor alpha inhibitor (TNFi) and methotrexate in patients with early psoriatic arthritis is sustained after withdrawal of TNFi. Methods Open-label extension of a recently published double-blind, randomized placebo-controlled trial. Patients with psoriatic arthritis fulfilling the CASPAR criteria and with active disease at baseline (swollen and tender joint count ≥ 3) were randomized to either golimumab and methotrexate or matched placebo and methotrexate. Patients in Disease Activity Score (DAS) remission at week 22 continued in the open-label extension on methotrexate monotherapy. The primary end point was the percentage of patients in DAS-CRP remission (DAS < 1.6) at week 50. Results Eight patients from the original placebo group and 18 patients from the original TNFi group continued in the extension phase. At week 50, 6 out of 8 (75%) patients from the original MTX (methotrexate) group versus 10 out of 18 (56%) patients from the original MTX+TNFi group were in DAS-CRP remission (p = 0.347). Considering the total study population, 6 out of 24 (25%) of the original MTX group versus 10 out of 26 (38.5%) of the original MTX+TNFi group were in DAS remission at week 50 (p = 0.308). Conclusions Remission achieved by initial combination treatment with TNFi and methotrexate in early psoriatic arthritis is maintained on methotrexate monotherapy in approximately half of the patients. Trial registration Registered at Clinicaltrials.gov with number NCT01871649 on June 7, 2013.
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Affiliation(s)
- Henriëtte M Y de Jong
- Department of Clinical Immunology and Rheumatology, Infection & Immunity Institute, Amsterdam UMC, AMC/University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.,Amsterdam Rheumatology & Immunology Center (ARC), Amsterdam, the Netherlands
| | - Leonieke J J van Mens
- Department of Clinical Immunology and Rheumatology, Infection & Immunity Institute, Amsterdam UMC, AMC/University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.,Amsterdam Rheumatology & Immunology Center (ARC), Amsterdam, the Netherlands
| | - Michael T Nurmohamed
- Amsterdam Rheumatology & Immunology Center (ARC), Amsterdam, the Netherlands.,Department of Rheumatology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Department of Rheumatology, Reade, Amsterdam, the Netherlands
| | - Marc R Kok
- Department of Rheumatology and Clinical Immunology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Arno W R van Kuijk
- Amsterdam Rheumatology & Immunology Center (ARC), Amsterdam, the Netherlands.,Department of Rheumatology, Reade, Amsterdam, the Netherlands
| | - Dominique L P Baeten
- Department of Clinical Immunology and Rheumatology, Infection & Immunity Institute, Amsterdam UMC, AMC/University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.,Amsterdam Rheumatology & Immunology Center (ARC), Amsterdam, the Netherlands
| | - Marleen G H van de Sande
- Department of Clinical Immunology and Rheumatology, Infection & Immunity Institute, Amsterdam UMC, AMC/University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands. .,Amsterdam Rheumatology & Immunology Center (ARC), Amsterdam, the Netherlands.
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12
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Moreno M, Gratacós J, Torrente-Segarra V, Sanmarti R, Morlà R, Pontes C, Llop M, Juanola X. Withdrawal of infliximab therapy in ankylosing spondylitis in persistent clinical remission, results from the REMINEA study. Arthritis Res Ther 2019; 21:88. [PMID: 30953541 PMCID: PMC6451276 DOI: 10.1186/s13075-019-1873-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 03/22/2019] [Indexed: 12/16/2022] Open
Abstract
Background Recent data suggest that anti-TNF doses can be reduced in ankylosing spondylitis (AS) patients. Some authors even propose withdrawing treatment in patients in clinical remission; however, at present there is no evidence to support this. Objective To assess how long AS patients with persistent clinical remission remained free of flares after anti-TNF withdrawal and to evaluate the effects of treatment reintroduction. We also analyze the characteristics of patients who did not present clinical relapse. Methods Multicenter, prospective, observational study of a cohort of patients with active AS who had received infliximab as a first anti-TNF treatment and who presented persistent remission (more than 6 months). We recorded at baseline and every 6–8 weeks over the 12-month period the age, gender, disease duration, peripheral arthritis or enthesitis, HLA-B27 status, BASDAI, CRP, ESR, BASFI, and three visual analogue scales, spine global pain, spinal night time pain, and patient’s global assessment. Results Thirty-six out of 107 patients (34%) presented persistent remission and were included in our study. After treatment withdrawal, 21 of these 36 patients (58%) presented clinical relapse during follow-up. Infliximab therapy was reintroduced and only 52% achieved clinical remission, as they had before the discontinuation of infliximab; in an additional 10%, reintroduction of infliximab was ineffective, obliging us to change the anti-TNF therapy. No clinical or biological factors were associated with the occurrence of relapse during the follow-up. Conclusions Two thirds of patients in clinical remission presented clinical relapse shortly after infliximab withdrawal. Although the reintroduction of infliximab treatment was safe, half of the patients did not present the same clinical response that they had achieved prior to treatment withdrawal.
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Affiliation(s)
- Mireia Moreno
- Rheumatology Department, Parc Taulí Hospital Universitari, I3PT, Universitat Autònoma de Barcelona, 08208, Sabadell, Barcelona, Spain
| | - Jordi Gratacós
- Rheumatology Department, Parc Taulí Hospital Universitari, I3PT, Universitat Autònoma de Barcelona, 08208, Sabadell, Barcelona, Spain.
| | | | - Raimon Sanmarti
- Rheumatology Department, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Rosa Morlà
- Rheumatology Department, Hospital del Vendrell, Tarragona, Spain
| | - Caridad Pontes
- Clinical Pharmacology Department, ParcTaulí Hospital Universitari, I3PT, Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain
| | - Maria Llop
- Rheumatology Department, Parc Taulí Hospital Universitari, I3PT, Universitat Autònoma de Barcelona, 08208, Sabadell, Barcelona, Spain
| | - Xavier Juanola
- Rheumatology Department, Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
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13
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Sedano Muñoz R, Quera Pino R, Lubascher Correa J, Pizarro Jofré G, Simian Marín D. Evaluation of de-escalation of anti-TNF-α therapy in inflammatory bowel disease. Gastroenterol Hepatol 2019; 42:133-140. [PMID: 30595227 DOI: 10.1016/j.gastrohep.2018.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 10/15/2018] [Indexed: 06/09/2023]
Abstract
Anti-tumour necrosis factor α therapy in inflammatory bowel disease has been shown to be effective in clinical practice. After more than a decade using these therapies the question arises about whether there is an appropriate time to suspend these therapies, and how this should be done. This review aims to evaluate the current evidence on these topics concerning anti-tumour necrosis factor α therapies, and eventually identify conditions and subgroups of patients that could potentially be candidates for withdrawal.
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Affiliation(s)
- Rocío Sedano Muñoz
- Servicio de Gastroenterología, Hospital Clínico de la Universidad de Chile, Santiago, Chile.
| | - Rodrigo Quera Pino
- Programa Enfermedad Inflamatoria Intestinal, Clínica Las Condes, Santiago, Chile; Departamento de Gastroenterología, Clínica Las Condes, Santiago, Chile
| | - Jaime Lubascher Correa
- Programa Enfermedad Inflamatoria Intestinal, Clínica Las Condes, Santiago, Chile; Departamento de Gastroenterología, Clínica Las Condes, Santiago, Chile
| | - Gonzalo Pizarro Jofré
- Programa Enfermedad Inflamatoria Intestinal, Clínica Las Condes, Santiago, Chile; Departamento de Gastroenterología, Clínica Las Condes, Santiago, Chile
| | - Daniela Simian Marín
- Programa Enfermedad Inflamatoria Intestinal, Clínica Las Condes, Santiago, Chile; Sub-Dirección Académica, Clínica Las Condes, Santiago, Chile
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14
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Danel-Brunaud V, Touzet L, Chevalier L, Moreau C, Devos D, Vandoolaeghe S, Defebvre L. Ethical considerations and palliative care in patients with amyotrophic lateral sclerosis: A review. Rev Neurol (Paris) 2017; 173:300-307. [PMID: 28479121 DOI: 10.1016/j.neurol.2017.03.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 03/15/2017] [Accepted: 03/28/2017] [Indexed: 12/12/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is not a curable disease, but it is treatable. By definition, much of the care provided to ALS patients is palliative, even though active life-sustaining strategies are available to prolong survival. Healthcare professionals must develop communication skills that help patients cope with the inexorable progression of the disease and the inevitability of death. Symptomatic treatments as well as respiratory insufficiency and nutritional life-sustaining therapies must be regularly evaluated as the disease progresses, without losing sight of the burden placed on the patient's non-professional caregivers. The decision-making process regarding tracheostomy with invasive ventilation (TIV) is of greater complexity. Providing full information is crucial. Several long interviews are necessary to explain, discuss and allow assimilation of the information. Also, physicians should be careful not to focus exclusively on the biomedical aspects of disease, as ALS patients generally welcome the opportunity to discuss end-of-life issues with their physicians. Psychological factors, education level and cognitive status (especially the level of executive dysfunction) have a major influence on their decisions. However, as many patients do not complete advance directives with regard to TIV, advance care planning may instead be suggested in anticipation of emergency interventions. This should be discussed by healthcare professionals and the patient, and based on the wishes of the patient and caregiver(s), and communicated to all healthcare professionals. Many healthcare professionals are involved in the management of an ALS patient: they include not only those at ALS centers who provide diagnosis, follow-up and treatment initiation (particularly for respiratory and nutritional care), but also the medical and social care networks involved in disability support and home care. Specialist palliative care teams can work in partnership with ALS centers early in the course of the disease, with the center coordinating information-sharing and collaborative discussions.
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Affiliation(s)
- V Danel-Brunaud
- Université de Lille, Faculté de Médecine, Lille, France; Service de Neurologie et Pathologie du Mouvement, CHRU de Lille, Avenue du Professeur Emile Laine, 59037 Lille, France; Espace Éthique Hospitalier et Universitaire, CHRU de Lille, Avenue du Professeur Emile Laine, 59037 Lille, France.
| | - L Touzet
- Service de Soins Palliatifs, CHRU de Lille, Avenue du Professeur Emile Laine, 59037 Lille, France
| | - L Chevalier
- Service de Soins Palliatifs, CHRU de Lille, Avenue du Professeur Emile Laine, 59037 Lille, France
| | - C Moreau
- Université de Lille, Faculté de Médecine, Lille, France; Service de Neurologie et Pathologie du Mouvement, CHRU de Lille, Avenue du Professeur Emile Laine, 59037 Lille, France; Troubles cognitifs, dégénératifs et vasculaires, INSERM U1171, Lille, France
| | - D Devos
- Université de Lille, Faculté de Médecine, Lille, France; Troubles cognitifs, dégénératifs et vasculaires, INSERM U1171, Lille, France; Service de Pharmacologie Médicale, CHU de Lille, Avenue du Professeur Emile Laine, 59037 Lille, France
| | - S Vandoolaeghe
- Espace Éthique Hospitalier et Universitaire, CHRU de Lille, Avenue du Professeur Emile Laine, 59037 Lille, France
| | - L Defebvre
- Université de Lille, Faculté de Médecine, Lille, France; Service de Neurologie et Pathologie du Mouvement, CHRU de Lille, Avenue du Professeur Emile Laine, 59037 Lille, France; Troubles cognitifs, dégénératifs et vasculaires, INSERM U1171, Lille, France
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15
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Chao YS, Boivin A, Marcoux I, Garnon G, Mays N, Lehoux P, Prémont MC, Leeuwen EV, Pineault R. International changes in end-of-life practices over time: a systematic review. BMC Health Serv Res 2016; 16:539. [PMID: 27716238 PMCID: PMC5048435 DOI: 10.1186/s12913-016-1749-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 06/29/2016] [Indexed: 11/10/2022] Open
Abstract
Background End-of-life policies are hotly debated in many countries, with international evidence frequently used to support or oppose legal reforms. Existing reviews are limited by their focus on specific practices or selected jurisdictions. The objective is to review international time trends in end-of-life practices. Methods We conducted a systematic review of empirical studies on medical end-of-life practices, including treatment withdrawal, the use of drugs for symptom management, and the intentional use of lethal drugs. A search strategy was conducted in MEDLINE, EMBASE, Web of Science, Sociological Abstracts, PAIS International, Worldwide Political Science Abstracts, International Bibliography of the Social Sciences and CINAHL. We included studies that described physicians’ actual practices and estimated annual frequency at the jurisdictional level. End-of-life practice frequencies were analyzed for variations over time, using logit regression. Results Among 8183 references, 39 jurisdiction-wide surveys conducted between 1990 and 2010 were identified. Of those, 22 surveys used sufficiently similar research methods to allow further statistical analysis. Significant differences were found across surveys in the frequency of treatment withdrawal, use of opiates or sedatives and the intentional use of lethal drugs (X2 > 1000, p < 0.001 for all). Regression analyses showed increased use of opiates and sedatives over time (p < 0.001), which could reflect more intense symptom management at the end of life, or increase in these drugs to intentionally cause patients’ death. Conclusion The use of opiates and sedatives appears to have significantly increased over time between 1990 and 2010. Better distinction between practices with different legal status is required to properly interpret the policy significance of these changes. Research on the effects of public policies should take a comprehensive look at trends in end-of-life practice patterns and their associations with policy changes.
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Affiliation(s)
- Yi-Sheng Chao
- University of Montreal Hospital Centre Research Centre (CRCHUM), Montreal, Canada
| | - Antoine Boivin
- University of Montreal Hospital Centre Research Centre (CRCHUM), Montreal, Canada. .,Institut de recherche en santé publique de l'Université de Montréal, Montréal, Canada.
| | - Isabelle Marcoux
- Interdisciplinary School of Health Science, University of Ottawa, Ottawa, Canada
| | | | - Nicholas Mays
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Pascale Lehoux
- Département d'administration de la santé, Université de Montréal, Montreal, Canada
| | | | - Evert van Leeuwen
- Scientific Institute for Quality of Healthcare, Radboud University Nijmegen, Nijmegen, The Netherlands
| | - Raynald Pineault
- Département de santé publique de Montréal, Institut National de Santé Publique du Québec, Montreal, Canada
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16
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Sinclair R, Turner GA, Jones DAR, Luo S. Clinical studies in dermatology require a post-treatment observation phase to define the impact of the intervention on the natural history of the complaint. Arch Dermatol Res 2016; 308:379-87. [PMID: 27025208 DOI: 10.1007/s00403-016-1636-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 01/26/2016] [Accepted: 02/22/2016] [Indexed: 11/29/2022]
Abstract
The use of a post-treatment period of observation or "regression phase" is common in pharmaceutical and cosmetic clinical dermatology studies. Regression phases can be incorporated into a variety of study designs, ranging from simple post-treatment observation for a defined period, as has been used for moisturizers, antidandruff formulations, and treatments for acne, to more complex randomized intermittent-treatment designs, as used in studies of psoriasis pharmacotherapies. Extensive information can be derived from a regression phase. Notably, it can provide useful data on the persistence of effect and time to relapse after treatment cessation, which are particularly relevant to skin conditions in which consumer or patient adherence to treatment is suboptimal. By incorporating a regression phase, a clinical study can more closely reflect "real-world" behavior, e.g., the switching by consumers from antidandruff to beauty shampoos. The regression phase can also help to differentiate between products that show similar effectiveness during the treatment phase, and monitoring post-treatment physiological end points can provide valuable evidence on the safety and mechanism of action of the therapy.
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Affiliation(s)
- Rodney Sinclair
- Epworth Hospital, Melbourne, VIC, Australia.,University of Melbourne, Melbourne, VIC, Australia
| | - Graham A Turner
- Unilever Research & Development, Port Sunlight, Quarry Road East, Wirral, Merseyside, CH63 3JW, UK.
| | - D Andrew R Jones
- Unilever Research & Development, Port Sunlight, Quarry Road East, Wirral, Merseyside, CH63 3JW, UK
| | - Shengjun Luo
- Unilever Research & Development, Shanghai, People's Republic of China
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17
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Graftieaux JP, Bollaert PE, Haddad L, Kentish-Barnes N, Nitenberg G, Robert R, Villers D, Dreyfuss D. Contribution of the ethics committee of the French society of intensive care medicine to a scenario for the implementation of organ donation after Maastricht III-type cardiac death in France. ACTA ACUST UNITED AC 2014; 33:128-34. [PMID: 24462574 DOI: 10.1016/j.annfar.2014.01.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
French law allows organ donation after death due to cardiocirculatory arrest. In the Maastricht classification, type III non-heart-beating donors are those who experience cardiocirculatory arrest after the withdrawal of life-sustaining treatments. French authorities in charge of regulating organ donation (Agence de la Biomédecine, ABM) are considering organ collection from Maastricht type III donors. We describe a scenario for Maastricht type III organ donation that fully complies with the ethical norms governing care to dying patients. That organ donation may occur after death should have no impact on the care given to the patient and family. The dead-donor rule must be followed scrupulously: the organ retrieval procedure must neither cause nor hasten death. The decision to withdraw life-sustaining treatments, withdrawal modalities, and care provided to the patient and family must adhere strictly to the requirements set forth in patient-rights legislation (the 2005 Léonetti law in France) and should not be influenced in any way by the possibility of organ donation. A major ethical issue regarding the family is how best to transition from discussing treatment-withdrawal decisions to discussing possible organ retrieval for donation should the patient die rapidly after treatment withdrawal. Close cooperation between the healthcare team and the organ retrieval team is crucial to minimize the distress of family members during this transition. Modalities for implementing Maastricht type III organ donation are discussed here, including the best location for withdrawing life-sustaining treatments (operating room or intensive care unit).
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Affiliation(s)
- J-P Graftieaux
- Département d'anesthésie-réanimation, CHU de Reims, hôpital Robert-Debré, avenue du Général-Koenig, 51100 Reims, France.
| | - P-E Bollaert
- Service de réanimation médicale, CHU de Nancy, hôpital central, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54035 Nancy cedex, France
| | - L Haddad
- Consultation douleur, CHU Saint-Louis, avenue Claude-Vellefaux, 75010 Paris, France
| | - N Kentish-Barnes
- Service de réanimation médicale, CHU Saint-Louis, avenue Claude-Vellefaux, 75010 Paris, France
| | - G Nitenberg
- Service de réanimation médicochirurgicale, institut Gustave-Roussy, 39, rue Camille-Desmoulins, 94805 Villejuif cedex, France
| | - R Robert
- Service de réanimation médicale, CHU de Poitiers, hôpital Jean-Bernard, 2, rue de la Milétrie, 86021 Poitiers cedex, France
| | - D Villers
- Service de réanimation médicale, CHU de Nantes, Hôtel-Dieu, place Alexis-Ricordeau, 44093 Nantes cedex 01, France
| | - D Dreyfuss
- Service de réanimation médicochirurgicale, CHU Louis-Mourier, 92700 Colombes, France
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18
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Adams JA, Bailey DE, Anderson RA, Thygeson M. Finding your way through EOL challenges in the ICU using Adaptive Leadership behaviours: A qualitative descriptive case study. Intensive Crit Care Nurs 2013; 29:329-36. [PMID: 23879936 DOI: 10.1016/j.iccn.2013.05.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Revised: 05/28/2013] [Accepted: 05/29/2013] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Using the Adaptive Leadership framework, we describe behaviours that providers used while interacting with family members facing the challenges of recognising that their loved one was dying in the ICU. RESEARCH METHODOLOGY In this prospective pilot case study, we selected one ICU patient with end-stage illness who lacked decision-making capacity. Participants included four family members, one nurse and two physicians. The principle investigator observed and recorded three family conferences and conducted one in-depth interview with the family. Three members of the research team independently coded the transcripts using a priori codes to describe the Adaptive Leadership behaviours that providers used to facilitate the family's adaptive work, met to compare and discuss the codes and resolved all discrepancies. FINDINGS We identified behaviours used by nurses and physicians that facilitated the family's ability to adapt to the impending death of a loved one. Examples of these behaviours include defining the adaptive challenges for families and foreshadowing a poor prognosis. CONCLUSIONS Nurse and physician Adaptive Leadership behaviours can facilitate the transition from curative to palliative care by helping family members do the adaptive work of letting go. Further research is warranted to create knowledge for providers to help family members adapt.
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Affiliation(s)
- Judith A Adams
- Duke University School of Nursing (DUSON), Durham, NC, United States.
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