Intravenous pegylated liposomal prednisolone outperforms intramuscular methylprednisolone in treating rheumatoid arthritis flares: A randomized controlled clinical trial.

Glucocorticoids (GCs) are potent anti-inflammatory drugs but their use is limited by systemic exposure leading to toxicity. Targeted GC delivery to sites of inflammation via encapsulation in long-circulating liposomes may improve the therapeutic index. We performed a randomized, double-blind, active-controlled, multi-center study in which intravenously (i.v.) administered pegylated liposomal prednisolone sodium phosphate (Nanocort) was compared to equipotent intramuscular (i.m.) methylprednisolone acetate (Depo-Medrol®; i.e. a current standards-of-care for treating flares in rheumatoid arthritis patients). We enrolled 172 patients with active arthritis who met all eligibility criteria, eventually resulting in 150 patients randomized in three groups: (1) Nanocort 75 mg i.v. infusion plus i.m. saline injection; (2) Nanocort 150 mg i.v. infusion plus i.m. saline injection; and (3) Depo-Medrol® 120 mg i.m. injection plus i.v. saline infusion. Dosing in each group occurred at baseline and on day 15 (week 2). Study visits occurred at week 1, 2, 3, 4, 6, 8 and 12, to assess both efficacy and safety. The primary endpoint was the "European League Against Rheumatism" (EULAR) responder rate at week 1. Safety was determined by the occurrence of adverse events during treatment and 12 weeks of follow-up. Treatment with Nanocort was found to be superior to Depo-Medrol® in terms of EULAR response at week 1, with p-values of 0.007 (good response) and 0.018 (moderate response). Treatments were well tolerated with a comparable pattern of adverse events in the three treatment groups. However, the Nanocort groups had a higher incidence of hypersensitivity reactions during liposome infusion. Our results show that liposomal Nanocort is more effective than Depo-Medrol® in treating patients with rheumatoid arthritis flares and has similar safety. This is the first clinical study in a large patient population showing that i.v. administered targeted drug delivery with a nanomedicine formulation improves the therapeutic index of glucocorticoids.

FIGO Classification 2018: Validation Study in Patients With Locally Advanced Cervix Cancer Treated With Chemoradiation.

PURPOSE: In 2018, the International Federation of Gynecology and Obstetrics (FIGO) proposed a new staging for cervical cancer. The present study was designed to reclassify patients with locally advanced cervix cancer and perform a comparative evaluation with FIGO 2009. METHODS AND MATERIALS: Patients with locally advanced cervical cancer (stage IB2-IVA) who had baseline cross-sectional imaging and received (chemo-) radiation and brachytherapy were included. Survival outcomes were analyzed according to FIGO 2009. Patients were then reclassified according to FIGO 2018, and TNM classification outcomes were analyzed. FIGO stage and known prognostic factors were included in univariate analysis, and multivariate analysis was performed to investigate the prognostic value of clinical stage. RESULTS: Six hundred thirty-two patients were included. Overall, 185 (29.3%) patients had pelvic adenopathy, and 51 (8.2%) had positive paraortic nodes. At a median follow-up of 33 months, 116 (18.3%) patients had recurrence. Three-year disease-free survival (DFS) according to FIGO 2009 for stage IB, IIA, IIB, IIIA, IIIB, and IVA was 86%, 91%, 76%, 57%, 65%, and 61%, respectively. The 3-year DFS after restaging according to FIGO 2018 for stage IB, IIA, IIB, IIIA, IIIB, IIIC1, IIIC2, and IVA was 100%, 93%, 84%, 53%, 77%, 74%, 61%, and 61%, respectively. Patients with clinically significant lymphadenopathy had inferior outcomes compared with node-negative patients (62.9% vs 77.8%; P = .002). Patients with ≥3 paraortic nodes had poorer DFS than patients with <3 paraortic lymphadenopathy (13.6% vs 56.3%; P = .001). Furthermore, patients with primary tumor volume >30 cm3 had worse 3-year DFS than those with primary tumor volume ≤30 cm3 (67.4% vs 78.5%; P = .002). CONCLUSIONS: FIGO 2018 modification is associated with heterogenous outcomes in node-positive patients that are affected by primary tumor and nodal volume. We propose a modification to the existing TNM staging system to allow more robust classification of outcomes.

Efficacy of the novel nasal steroid S0597 tested in an environmental exposure unit.

BACKGROUND: S0597 is a novel glucocorticosteroid that was formulated as an intranasal spray to treat seasonal allergic rhinitis (SAR). In a previous phase 2 study, doses of 100 to 400 µg twice daily were well tolerated and more effective than placebo for improving nasal symptoms induced by grass pollen. OBJECTIVE: To assess the clinical efficacy and safety of a once-daily S0597 nasal spray for treatment of SAR induced by ragweed pollen in an environmental exposure unit (EEU). METHODS: A single-center, phase 2, randomized, double-blind study in 222 adults with SAR and a positive skin prick test result to short ragweed. Participants underwent ragweed pollen challenge in the EEU at the screening or priming visit and on days 1, 7, and 14 and received 50, 200, or 400 µg of S0597 or placebo in the evening for 13 days. The primary efficacy end point was change in total nasal symptom score (TNSS) from baseline to day 14. RESULTS: Improvement in TNSS from baseline to day 14 was statistically significant in all S0597 groups compared with placebo. Least-squares mean differences in change from baseline between active treatment and placebo were 1.18, 1.84, and 1.17 for the 50-, 200-, and 400-µg/d S0597 groups, respectively (P < .05). The 200-µg group demonstrated statistically significant improvements in all TNSS subscales (rhinorrhea, nasal congestion, sneezing, nasal itching) compared with placebo at days 7 and 14. CONCLUSION: Treatment with 50 to 400 µg of S0597 once daily was well tolerated and significantly more effective than placebo in relieving nasal symptoms of SAR associated with ragweed pollen. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01940146.

Effect of benzalkonium chloride-free latanoprost ophthalmic solution on ocular surface in patients with glaucoma.

INTRODUCTION: Benzalkonium chloride (BAK), included as a preservative in many topical treatments for glaucoma, induces significant toxicity and alters tear breakup time (TBUT). BAK-containing latanoprost, an ester prodrug of prostaglandin F2α, can cause ocular adverse events (AEs) associated with BAK. The purpose of this study was to evaluate the efficacy and safety of BAK-free latanoprost. PATIENTS AND METHODS: A prospective, open-label, single-arm, multicenter, 8-week study in patients with primary open-angle glaucoma or ocular hypertension taking BAK-containing latanoprost for ≥12 months was performed. Patients were switched to BAK-free latanoprost ophthalmic solution 0.005% administered once daily, and eyes were assessed after 28 and 56 days. Primary efficacy and safety variables were TBUT and treatment-emergent AEs, respectively. RESULTS: At day 56, 40 eyes were evaluable. Mean TBUT increased significantly from baseline (3.67±1.60 seconds) to 5.03±2.64 and 6.06±3.39 seconds after 28 and 56 days of treatment with BAK-free latanoprost (P<0.0001). Ocular Surface Disease Index(©) (OSDI(©)) score also decreased significantly to 12.06±13.40 and 7.06±10.75 at 28 and 56 days, respectively, versus baseline (18.09±18.61, P<0.0001). In addition, inferior corneal staining score decreased significantly to 0.53 from baseline (0.85, P=0.0033). A reduction in conjunctival hyperemia and intraocular pressure was observed at both time points. No treatment-related serious AEs were evident and 12 (26.08%) treatment-emergent AEs occurred in seven patients, with eye pain and irritation being the most frequent. No clinically significant changes in vital signs or slit lamp examinations were observed. CONCLUSION: Results indicate that switching from BAK-containing latanoprost to BAK-free latanoprost resulted in significant improvements in TBUT, OSDI(©) score, and inferior corneal staining score, and measurable reductions in conjunctival hyperemia score. Furthermore, BAK-free latanoprost was well tolerated with only mild-to-moderate and self-limiting AEs. BAK-free latanoprost appears to be effective in protecting ocular surface integrity in glaucoma patients but further studies are needed to confirm this beneficial effect.

Efficacy and safety of a novel nasal steroid, S0597, in patients with seasonal allergic rhinitis.

BACKGROUND: Allergic rhinitis (AR) poses a significant global burden with increasing prevalence. Although intranasal glucocorticosteroids are effective, older agents can have limiting side effects. S0597, a novel intranasal glucocorticosteroid, has demonstrated good safety and tolerability during preclinical and phase 1 studies. OBJECTIVE: To assess the clinical efficacy, safety, and tolerability of different doses of S0597 nasal spray vs placebo in patients with seasonal AR. METHODS: This phase 2, randomized, double-blinded, placebo-controlled, parallel-group, single-center study randomized 159 patients 18 to 65 years old (mean age 37.8 years) with a positive skin prick test reaction for Dactylis glomerata to receive S0597 at 200, 400, or 800 µg/d or placebo for 15 days. On days 1 (baseline), 15, and 16, patients underwent a 4-hour pollen challenge to evaluate treatment efficacy measured by the change in total nasal symptom score (TNSS) from baseline to days 15 and 16 and changes in TNSS subscales and nasal secretion. RESULTS: Statistically significant improvements in TNSS from baseline to days 15 and 16 were observed with all S0597 doses vs placebo (P = .0005 overall), with the greatest improvements observed in the highest-dose group (P < .0001). Significant decreases were observed in each S0597 dose group vs placebo for TNSS subscales and nasal secretion. Improvements in nasal secretion were related to dose, with the greatest decreases from baseline in the 800-µg/d group on days 15 and 16 (P < .0001). CONCLUSION: Treatment with S0597 at 200, 400, and 800 µg/d by 2 divided doses for 2 weeks was safe and significantly more effective than placebo for improving nasal symptoms associated with grass pollen-induced seasonal AR in adults. TRIAL REGISTRATION: ClinicalTrials.gov, identifier NCT01614691.

Efficacy and safety of benzalkonium chloride-free fixed-dose combination of latanoprost and timolol in patients with open-angle glaucoma or ocular hypertension.

BACKGROUND: Benzalkonium chloride (BAK) is a common preservative in topical ocular preparations; however, prolonged use may lead to deleterious effects on the ocular surface, affecting quality of life and reducing adherence to treatment and overall outcomes. This study compared the intraocular pressure (IOP)-lowering efficacy and safety of a novel once-daily, BAK-free, fixed-dose combination of latanoprost plus timolol with latanoprost or timolol administered as monotherapy or concomitantly. METHODS: This was a 6-week, randomized, open-label, parallel-group, active-controlled study in patients aged ≥18 years with open-angle glaucoma or ocular hypertension. A total of 227 patients were randomized to either a once-daily, BAK-free, fixed-dose combination of latanoprost 0.005%/timolol 0.5% ophthalmic solution or concomitant administration of once-daily latanoprost 0.005% plus twice-daily timolol 0.5% or once-daily latanoprost 0.005% monotherapy, or twice-daily timolol 0.5% monotherapy. Efficacy end points were assessed at three time points on visits at weeks 1, 2, 4, and 6 versus baseline. RESULTS: The IOP-lowering efficacy of the fixed-dose combination of latanoprost/timolol was similar to that of latanoprost plus timolol administered concomitantly at all time points (mean IOP difference and 95% confidence interval within ±1.5 mmHg; P=0.4223 to P=0.9981). The fixed-dose combination of latanoprost/timolol demonstrated significantly better IOP-lowering efficacy than timolol monotherapy at all time points (P=0.001 to P<0.0001) and significantly better IOP-lowering efficacy than latanoprost monotherapy at all time points. Responder rates on at least one time point and on at least two time points with fixed-dose combination latanoprost/timolol were similar to those with concomitant latanoprost plus timolol (85.5% versus 82.1%, P=0.6360; 78.2% versus 75%, P=0.6923), but significantly better than either latanoprost or timolol monotherapy (68.5%, P=0.0355; 55.4%, P=0.0005; 57.4%, P=0.0202; and 46.4%, P=0.0006, respectively). No significant differences in ocular and nonocular treatment-emergent adverse events were found between the treatment groups. CONCLUSION: A BAK-free, fixed-dose combination of latanoprost 0.005%/timolol 0.5% was as effective and well tolerated as concomitant latanoprost and timolol for treatment of elevated IOP in patients with open-angle glaucoma or ocular hypertension.

Assessment of awareness regarding climate change and its health hazards among the medical students.

BACKGROUND: Climate change has emerged as one of the most devastating environmental threat and there is overwhelming evidence of wide range of implications for human health. To mitigate this, well-prepared medical man power is required. OBJECTIVES: The objectives of this study were (1) to assess the awareness regarding climate change and its health hazards among the medical students and (2) to recommend the awareness campaigns regarding climate change and its health hazards for students based on the results. SETTINGS AND DESIGN: This observational study was conducted at the Medical College in Pune city. MATERIALS AND METHODS: Medical students from all years of M.B.B.S. (Bachelor of Medicine and Bachelor of Surgery) who had given the written consent were included in this study. A self-administered, pre-tested, questionnaire was used. Responses were evaluated. STATISTICAL ANALYSIS USED: Proportions, percentage, and Chi-square test. RESULTS: A total of 250 medical students were included in this study. In all, 246 (98.40%) students commented that global climate is changing, while 245 (98%) students opined that human activities are contributing to climate change. The commonest source of information about climate change was newspaper and magazines (78.20%). Majority commented that deforestation and industrial and vehicular pollution contribute most to climate change. According to 47.50% of the students, health-related issues are priority for climate change prevention strategy. According to 65.10% students, direct physical hazards of extreme climatic events are most important health-related impact of climate change, followed by natural disaster-related health hazards (43.50%), waterborne diseases (27.60%), vector-borne diseases (17.60%), and malnutrition (10%). There was statistically significant difference found between year of MBBS of the students and the awareness regarding United Nations Federation on Climate Change, Kyoto protocol (χ(2) = 7.85, P = 0.02), and Intergovernmental Panel on Climate Change (χ(2) = 12.77, P = 0.002). A significant difference was found between the awareness about health impact of climate change at different places (χ(2) = 11.25, P = 0.001). CONCLUSION: Students had awareness regarding health hazards of the climate change, but improvement for mitigation is required. It is suggested that a large nation-wide awareness survey regarding climate change and its health hazards is necessary to determine the preparedness of medical students and also to suggest any changes in the current curriculum.

Oxidative damage and sensitivity to nociceptive stimulus and opioids in aging rats.

Oxidative stress contributes to aging and may cause alterations in pain and analgesia. Knowledge about effects of oxidative stress on the opioid system is very limited. This project was designed to determine the relationship between age-related oxidative damage and opioid antinociception. Three age groups of male Fischer 344 rats were tested for pain sensitivity and responses to morphine and fentanyl using the hot plate method. Oxidative stress markers in various brain regions were measured. With advancing age, nociceptive threshold and antinociceptive effects of opioids decreased significantly. There was a significant negative correlation between morphine antinociception and protein oxidation in cortex, striatum, and midbrain (r(2)=0.73, 0.87, and 0.77, respectively), and lipid peroxidation in cerebral cortex, hippocampus, and striatum (r(2)=0.73, 0.61, and 0.71, respectively). Similar correlation was observed between oxidative stress markers and fentanyl antinociception. These findings demonstrate that the age-related increase in oxidative damage in brain is associated with a significant decrease in the antinociceptive effects of opioids.

Changes in opioid receptor proteins during mitochondrial impairment in differentiated SK-N-SH cells.

Aging and neurodegenerative diseases are associated with oxidative damage that may contribute to changes in neurosensory processing, including pain. The effects of neuronal oxidation on the opioid receptor system are poorly understood. Earlier, we have reported that 3-nitroproprionic acid (3-NPA)-induced oxidative stress and impairment of mitochondrial energy metabolism significantly reduced the function of mu but not delta opioid receptors [A. Raut, M. Iglewski, A. Ratka, Differential effects of impaired mitochondrial energy production on the function of mu and delta opioid receptors in neuronal SK-N-SH cells, Neurosci. Lett. 404 (2006) 242-246]. In the present study, we studied the effects of 3-NPA-induced oxidative stress on protein levels of the mu, delta, and kappa opioid receptors (MOR, DOR, and KOR, respectively). The opioid-responsive differentiated SK-N-SH neuronal cells were used as an in vitro model. Cells were exposed to 0, 5, 10, and 20mM of 3-NPA for 0, 1, 2, 12, and 24h. After the 3-NPA treatments, plasma membrane preparations were made and used for the Western blot assay. There was a significant reduction in the level of the MOR protein while levels of DOR and KOR proteins remained unaffected after exposure to 3-NPA. These findings demonstrate for the first time that there is a selective impairment of the MOR protein under conditions of mitochondrial oxidative damage at the neuronal level. The reduction in the level of the MOR protein may contribute to the impairment of MOR function under oxidative damage conditions shown in our previous study.

Differential effects of impaired mitochondrial energy production on the function of mu and delta opioid receptors in neuronal SK-N-SH cells.

Oxidative stress contributes to changes in neurosensory processing, including pain, that occur during aging and neurodegeneration. The effects of neuronal oxidation on the opioid system are poorly understood. In this in vitro study, oxidative stress was induced by 3-nitroproprionic acid (3-NPA) in opioid-responsive differentiated SK-N-SH cells. Changes in the inhibitory effects of opioid receptor agonists on intracellular cAMP were used as a marker of the function of mu and delta opioid receptors (MOR and DOR, respectively). Cells were treated with morphine and selective MOR and DOR agonists and antagonists to characterize the function of each receptor subtype. Cyclic AMP (cAMP) was measured by enzyme immunoassay. Levels of reactive oxygen species (ROS) were assessed using the 2',7'-dichlorofluorescin diacetate assay. Exposure of cells to 3-NPA resulted in an increase in ROS. After 3-NPA exposure, there was a significant attenuation of the inhibitory effect of morphine and DAMGO but not of DPDPE on cAMP. In cells pretreated with CTOP, 3-NPA did not change the inhibitory effect on cAMP. These findings demonstrate for the first time that under conditions of mitochondrial damage, the function of MOR is significantly decreased, while the function of DOR does not change, suggesting that the effect of 3-NPA on opioid receptors is subtype-specific.

Menopausal Vasomotor Symptoms (MVS) survey for assessment of hot flashes.

OBJECTIVES: During the menopause, 65%-80% of women experience hot flashes. Hot flashes can also occur after hysterectomy and may be experienced during cancer therapy. A very limited assessment of hot flashes is provided by currently available menopausal instruments. This study was performed to evaluate a new Menopausal Vasomotor Symptoms (MVS) survey as an instrument for a comprehensive and subjective assessment of hot flashes. METHODS: The MVS survey was designed to assess multiple dimensions of hot flashes and to be simple and easy to administer. Hot flashes and associated conditions were addressed with 39 closed-ended questions. Sixty-one qualified women, 40-58 years old, from the Dallas, Fort Worth Metroplex area were enrolled. Women experiencing hot flashes took the survey at baseline and then 14 days, 2 months, and 6 months later. Factor analysis was performed. Face and content validity, internal consistency, test-retest reliability, and sensitivity to changes were evaluated. RESULTS: Fifty-two women (85.2%) completed all study sessions. The MVS survey was found to have good face and content validity and good internal consistency (rhoKR = 0.87). Spearman rank-order correlation coefficients at the 14-day retest varied from 0.58 to 1.00. As a result of these analyses, the MVS survey was further refined. CONCLUSIONS: The MVS survey was found to be comprehensive, simple, valid, reliable, sensitive, and a convenient instrument for subjective assessment of various characteristics of hot flashes. The MVS survey may serve as a valuable clinical and research tool for measurement of hot flashes.