Patient-reported outcomes in RA patients treated with tofacitinib or bDMARDs in real-life conditions in two Latin American countries

OBJECTIVE

To describe efficacy, safety, and patient-reported outcomes (PROs) in patients with rheumatoid arthritis (RA) with an inadequate response to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) treated with tofacitinib or biological DMARDs (bDMARDs) in real-life conditions.

METHODS

A noninterventional study was performed between March 2017 and September 2019 at 13 sites in Colombia and Peru. Outcomes measured at baseline and at the 6-month follow-up were disease activity (RAPID3 [Routine Assessment of Patients Index Data] score), functional status (HAQ-DI [Health Assessment Questionnaire] score), and quality of life (EQ-5D-3L [EuroQol Questionnaire]). The Disease Activity Score-28 (DAS28-ESR) and frequency of adverse events (AEs) were also reported. Unadjusted and adjusted differences from baseline were estimated and expressed as the least squares mean difference (LSMD).

RESULTS

Data from 100 patients treated with tofacitinib and 70 patients with bDMARDs were collected. At baseline, the patients' mean age was 53.53 years (SD 13.77), the mean disease duration was 6.31 years (SD 7.01). The change from baseline at month 6 was not statistically significant different in the adjusted LSMD [SD] for tofacitinib vs. bDMARDs for RAPID3 score (-2.55[.30] vs. -2.52[.26]), HAQ-DI score (-.56[.07] vs. -.50[.08]), EQ-5D-3L score (.39[.04] vs. .37[.04]) and DAS28-ESR (-2.37[.22] vs. -2.77[.20]). Patients from both groups presented similar proportions of nonserious and serious AEs. No deaths were reported.

CONCLUSION

Changes from baseline were not statistically significantly different between tofacitinib and bDMARDs in terms of RAPID3 scores and secondary outcomes. Patients from both groups presented similar proportions of nonserious and serious AEs.

CLINICAL TRIAL NUMBER

NCT03073109.

Cost-utility analysis of ceftazidime-avibactam versus colistin-meropenem in the treatment of infections due to Carbapenem-resistant Klebsiella pneumoniae in Colombia

BACKGROUND

Ceftazidime-Avibactam (CAZ-AVI) is a new antimicrobial against carbapenem-resistant Klebsiella pneumoniae. The aim of the study is to examine the cost-effectiveness of CAZ-AVI compared to colistin-meropenem (COL+MEM) in Colombia.

METHODS

A decision tree model was developed from health-care system perspective assuming a 30-day time horizon. The clinical course was simulated based on treatment response between 48 and 72 hours, and the duration of the treatment was 7-14 days. Cost inputs were extracted from a published Colombian manual tariffs and official databases, expressed in 2019 dollars (USD).

RESULTS

In the base case analysis, CAZ-AVI was associated with reduced mortality, length of hospital stay and fewer add-on antibiotics, resulting in an increase of 1.76 QALYs per patient versus COL+MEM and incremental costs associated in CAZ-AVI were $2,521 higher per patient compared to COL+MEM ($755 versus $3,276). The incremental costs were partially increased due to the lower mortality rate observed with CAZ-AVI. The incremental cost-effectiveness ratio was estimated to be $3,317 per QALY. In the probabilistic sensitivity analysis, with a willingness to pay above $2,438, CAZ-AVI has higher probability of being cost-effective.

CONCLUSION

CAZ-AVI demonstrates cost-effectiveness as a treatment for Carbapenem-resistant Klepsiella pneumoniae infections by reducing the number of deaths and increasing QALYs.

EXPERT COMMENTARY

Previous studies and surveillance programs from Colombia have reported prevalence of pathogens and the antimicrobial susceptibility of infections caused by multidrug-resistant Gram-negative bacteria. The health authorities have to consider and plan adequate surveillance systems in order to predict the resistance type and in choose the optimal antibiotics when infections occur.

Stakeholder Perceptions and Experiences of a College Live Mascot Program: a Study of Higher Education Ad Hoc Change

Organizational change is a complex and critical issue in higher education today. Changes experienced across institutional systems have both short-term and long-term impact, making this phenomenon ripe for educational leadership research. Many universities and colleges have applied Kotter's (1995) eight-step change model prescriptively to implement academic initiatives, curriculum revisions, and strategic vision. However, Kotter's (1995) model has not previously explored ad hoc changes over time and has not been used to study a college live mascot program. Although a decreasing campus tradition, college live mascots have a relationship and impact on a student's experience and college identification, as well as university engagement with alumni and the public. Therefore, understanding how change is identified and experienced by campus stakeholders of a college live mascot program describe the various complexities and issues that initiate a climate for institutional change. To explain the evolution of a college live mascot program, oral histories across twenty years of campus stakeholders, including student trainers, campus administrators, and external consultants were analyzed using Kotter's (1995) model. The findings of this study affirmed that the steps associated with Kotter's (1995) change model, with a specific focus on the first three steps, are relevant for ad hoc changes, and offer implications for higher education change.

Differing molecular response of young and advanced maternal age human oocytes to IVM

STUDY QUESTION

What effect does maternal age have on the human oocyte's molecular response to in vitro oocyte maturation?

SUMMARY ANSWER

Although polyadenylated transcript abundance is similar between young and advanced maternal age (AMA) germinal vesicle (GV) oocytes, metaphase II (MII) oocytes exhibit a divergent transcriptome resulting from a differential response to in vitro oocyte maturation.

WHAT IS KNOWN ALREADY

Microarray studies considering maternal age or maturation stage have shown that either of these factors will affect oocyte polyadenylated transcript abundance in human oocytes. However, studies considering both human oocyte age and multiple stages simultaneously are limited to a single study that examined transcript levels for two genes by qPCR. Thus, polyadenylated RNA sequencing (RNA-Seq) could provide novel insight into age-associated aberrations in gene expression in GV and MII oocytes.

STUDY DESIGN, SIZE, DURATION

The effect of maternal age (longitudinal analysis) on polyadenylated transcript abundance at different stages was analyzed by examining single GV and single in vitro matured MII oocytes derived from five young (YNG; < 30 years; average age 26.8; range 20-29) and five advanced maternal age (AMA; ≥40 years; average age 41.6 years; range 40-43 years) patients. Thus, a total of 10 YNG (5 GV and 5 MII) and 10 AMA (5 GV and 5 MII) oocytes were individually processed for RNA-Seq analysis.

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

Patients undergoing infertility treatment at the Colorado Center for Reproductive Medicine (Lone Tree, CO, USA) underwent ovarian stimulation with FSH and received hCG for final follicular maturation prior to ultrasound guided oocyte retrieval. Unused GV oocytes obtained at retrieval were donated for transcriptome analysis. Single oocytes were stored (at -80°C in PicoPure RNA Extraction Buffer; Thermo Fisher Scientific, USA) immediately upon verification of immaturity or after undergoing in vitro oocyte maturation (24 h incubation), representing GV and MII samples, respectively. After isolating RNA and generating single oocyte RNA-Seq libraries (SMARTer Ultra Low Input RNA HV kit; Clontech, USA), Illumina sequencing (100 bp paired-end reads on HiSeq 2500) and bioinformatics analysis (CLC Genomics Workbench, DESeq2, weighted gene correlation network analysis (WGCNA), Ingenuity Pathway Analysis) were performed.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 12 770 genes were determined to be expressed in human oocytes (reads per kilobase per million mapped reads (RPKM) > 0.4 in at least three of five replicates for a minimum of one sample type). Differential gene expression analysis between YNG and AMA oocytes (within stage) identified 1 and 255 genes that significantly differed (adjusted P < 0.1 and log2 fold change >1) in polyadenylated transcript abundance for GV and MII oocytes, respectively. These genes included CDK1, NLRP5 and PRDX1, which have been reported to affect oocyte developmental potential. Despite the similarity in transcript abundance between GV oocytes irrespective of age, divergent expression patterns emerged during oocyte maturation. These age-specific differentially expressed genes were enriched (FDR < 0.05) for functions and pathways associated with mitochondria, cell cycle and cytoskeleton. Gene modules generated by WGCNA (based on gene expression) and patient traits related to oocyte quality (e.g. age and blastocyst development) were correlated (P < 0.05) and enriched (FDR < 0.05) for functions and pathways associated with oocyte maturation.

LARGE SCALE DATA

Raw data from this study can be accessed through GSE95477.

LIMITATIONS, REASONS FOR CAUTION

The human oocytes used in the current study were obtained from patients with varying causes of infertility (e.g. decreased oocyte quality and oocyte quality-independent factors), possibly affecting oocyte gene expression. Oocytes in this study were retrieved at the GV stage following hCG administration and the MII oocytes were derived by IVM of patient oocytes. Although the approach has the benefit of identifying intrinsic differences between samples, it may not be completely representative of in vivo matured oocytes.

WIDER IMPLICATIONS OF THE FINDINGS

Transcriptome profiles of YNG and AMA oocytes, particularly at the MII stage, suggest that aberrant transcript abundance may contribute to the age-associated decline in fertility.

STUDY FUNDING/COMPETING INTEREST(S)

J.M.R. was supported by an Austin Eugene Lyons Fellowship awarded by the University of California, Davis. The Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health (awarded to P.J.R.; R01HD070044) and the Fertility Laboratories of Colorado partly supported the research presented in this manuscript.

Impact of milk fish farming in the tropics on potentially pathogenic vibrios

Ratios of sucrose-negative to sucrose-positive vibrios on TCBS agar (suc-/suc+) indicate the abundance of potential human pathogenic non-cholera vibrios in coastal mariculture environments of the Lingayen Gulf (Philippines. In guts of adult maricultured milkfish (Chanos chanos) of suc- vibrios reached extreme peak values ranging between 2 and 545 million per g wet weight. Suc- vibrios outnumbered suc+ vibrios in anoxic sediments, too, and were rarely predominant in coastal waters or in oxidized sediments. Suc-/suc+ ratios in sediments increased toward the mariculture areas with distance from the open sea at decreasing redox potentials. There is circumstantial evidence that suc- vibrios can be dispersed from mariculture areas to adjacent environments including coral reefs. An immediate human health risk by pathogenic Vibrio species is discounted, since milkfish guts contained mainly members of the Enterovibrio group. A representative isolate of these contained proteolytic and other virulence factors, but no genes encoding toxins characteristic of clinical Vibrio species.

[Delay in diagnosis of HIV infection]

Late presentation of HIV is common. It has been associated with greater risk of AIDS, death, lower immunological response, greater toxicity and a higher probability of transmission. In this study we review the impact of different definitions in terms of mortality and morbidity, associated factors, economic implications, as well as strategies for increasing diagnosis.

Topical corticosteroids as adjunctive therapy for bacterial keratitis

BACKGROUND

Bacterial keratitis is a serious ocular infectious disease that can lead to severe visual disability. Risk factors for bacterial corneal infection include contact lens wear, ocular surface disease, corneal trauma and previous ocular or eyelid surgery. Topical antibiotics constitute the mainstay of treatment in cases of bacterial keratitis where as the use of topical corticosteroids remains controversial. Topical corticosteroids are usually used to control inflammation using the smallest amount of the drug. Their use requires optimal timing, concomitant antibiotics and careful follow up.

OBJECTIVES

The objective of the review was to assess the clinical effectiveness and adverse effects of corticosteroids as adjunctive therapy for bacterial keratitis.

SEARCH STRATEGY

We searched CENTRAL, MEDLINE, EMBASE, and LILACS up to 15 January 2007. We also searched the Science Citation Index to identify additional studies that had cited the included trial, an online database of ongoing trials (www.clinicaltrials.gov), reference lists of included trials, earlier reviews and the American Academy of Ophthalmology guidelines. We also contacted experts to identify any unpublished and ongoing randomized trials.

SELECTION CRITERIA

We included randomized controlled trials evaluating adjunctive therapy with topical corticosteroids in people with bacterial keratitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all the retrieved articles. Methodological quality of the one included trial was assessed using forms developed using pre-specified criteria by at least two review authors. We planned to extract data on outcomes using forms developed for the purpose. We planned to report risk ratios for dichotomous outcomes and mean differences for continuous outcomes.

MAIN RESULTS

A single trial was eligible for inclusion in the review. Participants in the trial were randomized using a random numbers table. Allocation concealment was not attempted. Masking of participants, and care-providers was also not attempted. Outcome assessment was conducted independently by two physicians. Neither was masked to the treatment allocation. The trial reported the healing rate of epithelial defects and improvement in visual acuity.

AUTHORS' CONCLUSIONS

There are no good quality randomized trials evaluating the effects of adjunct use of topical corticosteroids in bacterial keratitis. The only randomized trial we identified in the literature suffered from major methodological inadequacies.

Phase III randomized pilot study comparing interferon alpha-2b in combination with radiation therapy versus radiation therapy alone in patients with stage III-B carcinoma of the cervix

This randomized pilot study was designed to determine whether the addition of interferon alpha-2b to standard radiation therapy offered an advantage in loco-regional control and survival over radiation therapy alone in a homogeneous group of patients with stage IIIB carcinoma of the cervix. Thirty-six patients were treated with a combination of interferon alpha-2b plus radiation therapy, and 38 patients were treated with radiation therapy alone. Patients with evidence of ureteral obstruction were excluded from the study. Evaluation of loco-regional response was determined by pelvic examination, cervical cytology, biopsies and CT scans when indicated. Survival time was measured from initiation of treatment to date of death or last follow-up. Patient characteristics were comparable between both study arms. The objective complete response rate was 67% in the combined therapy group and 55% in the radiation alone group (P = 0.454). With a median follow-up of 17 months for all patients and 31 months for live patients, 50% of the combined group survived vs. 39.5% of the radiation alone group (P = 0.424). We conclude that the addition of interferon alpha-2b to standard radiation therapy did not significantly improve loco-regional response or survival, although such a trend was noted. We encourage the design of a larger randomized study with sufficient power to detect meaningful differences to prove whether the tendency observed in the present investigation holds any promise to improve the outcome of these patients.

[Comparison of computed tomography and ultrasonic studies of the brain in newborns and infants. Correlation in 40 cases]

We correlate the cases of forty neonates and nursing infants whose brains were studied using ultrasound and CT scan. The indications for the aforementioned studies were: 15 cases of dysmorphism, 16 cases with significant neurological signs and 9 cases of preterm neonates with body weight less than 1,500 g. The results of the correlations were as follows: 24 cases demonstrated similar images (60%), 14 cases showed a better resolution of the images by ultrasound (35%), better resolution of the images by CT scan in 2.5% and non-coincidental images in one case (2.5%). We conclude that in the specialty of neonatology, using ultrasound has more advantages than the CT scan method.

Phase II study of orally and rectally administered Tegafur in liver metastases from gastric carcinoma

Twenty-four eligible and evaluable patients with measurable liver metastases from gastric cancer were treated with oral or rectal Tegafur. Objective responses were seen in 8 of the patients (33.3%), lasting between 1.5 and 15 months. The median survival period was 10 months for the responders and 2.6 months for non-responders. No complete response was observed. The survival of responders was significantly longer than that of non-responders (p less than 0.01). Toxicity was mild and consisted principally of gastrointestinal and hematological side effects. No central nervous system toxicity was seen.

Specific red cell adherence: immunologic evaluation of random mucosal biopsies in carcinoma of the bladder

We studied 103 random biopsies from patients with overt transitional cell carcinoma of the bladder for specific red cell adherence. We evaluated 62 random biopsies from patients whose primary tumors were positive for specific red cell adherence and 100 per cent of the biopsies in these patients also were positive for specific red cell adherence regardless of the pathologic finding in the random biopsy. We evaluated 41 random biopsies from patients whose primary bladder tumors were negative for specific red cell adherence and only 27 per cent of all biopsies in this group of patients were positive for specific red cell adherence. Thus, we found that in 92 of the 103 random biopsies (89 per cent) and specific red cell adherence of the biopsy agreed with that of the primary tumor. The loss of red cell antigens in random biopsies that are histologically normal may prove to be the earliest measureable changes of the malignant potential of the urothelium.

Specific red cell adherence testing and benign prostatic hyperplasia

Specific red cell adherence testing has established itself as a valuable means of predicting the behavior of non-invasive bladder carcinoma. In an attempt to determine whether specific red cell adherence testing could have a similar role in low grade, low stage prostatic carcinoma we first attempted to detect its presence in benign prostatic diseases. We tested 36 consecutive prostatectomy specimens of benign disease for the presence of specific red cell adherence in the prostatic acini. We were able to detect the presence of specific red cell adherence in only 36 per cent of the cases with benign prostatic hyperplasia. Thus, we believe that specific red cell adherence testing is not present in a sufficient percentage of patients with benign disease to allow its usefulness in determining the aggressive behavior of prostatic cancer.

Osteogenic sarcoma of the tongue

A 45-year-old woman had a mass in the left side of the tongue. Histologic examination of the tumor revealed it to be an extraskeletal osteogenic sarcoma. Pulmonary metastases were seen on admission. The patient had a rapid downhill course and died. Extraskeletal osteogenic sarcomas are well-recognized albeit rare neoplasms. In a search of the literature we were unable to find a single case arising in the tongue. The electron microscopic findings are also presented.

Intracellular spiral inclusions in cerebral cell processes in Creutzfeldt-Jakob disease

Electron microscopic examination of brain biopsy specimens from two patients with Creutzfeldt-Jakob disease revealed the presence of intracellular membranous spiral inclusions in the processes of cortical cells. These inclusions, 375 nm to 660 nm in length and 50 nm to 88 nm in width, resemble similar structures reported in a patient with the same disease by Bastian and, more recently, in a second patient by Gray et al. These inclusions bear close morphologic resemblance to spiroplasma organisms, a wall-free prokaryote known to cause a "slow-virus"-like disorder in mice.

Retroperitoneal neurofibromatosis and venous anomalies

A 45-year-old woman had abdominal pain, azotemia, and hypertension. Intravenous pyelography revealed bilateral ureteral compression by extrinsic tumor masses that proved to be neurofibromata by histologic examination. After surgical removal of the tumors, she became normotensive and asymptomatic. In addition, severe medial hypertrophy of veins was seen in the tissue examined. We believe that the latter is most probably related to the neurofibromatosis and is analogous to the hypertrophic arterial changes known to occur in patients with von Recklinghausen's disease.

Association of pulmonary alveolar lipoproteinosis with mycobacterial infection

A case of pulmonary alveolar proteinosis associated with tuberculosis of the lung is reported. The patient had fever, cough, and pulmonary cavities. Sputum cultures for Mycobacterium tuberculosis were positive on three occasions. Thirty-three months later, diffuse bilateral lower lobe infiltrates developed. An open lung biopsy revealed filling of the alveoli by a periodic-acid-Schiff-positive amorphous granular material. There is a significant association between this disease and various infectious and fungal agents, but its association with tuberculosis is rare. It has been reported only three times before in the English literature. This appears to be the fourth documented case with this association. A review of the literature with special emphasis on tuberculosis associated with alveolar lipoproteinosis is presented. The electron-microscopic findings are also described.