Safety Analysis of Four Randomized Controlled Studies of Ibrutinib in Patients With Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma or Mantle Cell Lymphoma

Background

Multiple studies have demonstrated the efficacy and safety of ibrutinib for chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) and mantle cell lymphoma (MCL). This first-in-class inhibitor of Bruton's tyrosine kinase has become a standard treatment for patients with CLL and MCL.

Prognosis communication with older patients with multimorbidity: Assessment after an educational intervention

ABSTRACT

This study aimed to assess how internal medicine residents incorporated prognosis to inform clinical decisions and communicated prognosis in primary care visits with older patients with multimorbidity after an educational intervention, and resident and patient perspectives regarding these visits. Assessment used mixed-methods. The authors assessed the frequency and content of prognosis discussions through residents’ self-report and qualitative content analysis of audio-recorded clinic visits. The authors assessed the residents’ perceived effect of incorporating prognosis on patient care and patient relationship through a resident survey. The authors assessed the patients’ perceived quality of communication and trust in physicians through a patient survey. The study included 21 clinic visits that involved 12 first-year residents and 21 patients. Residents reported incorporating patients’ prognoses to inform clinical decisions in 13/21 visits and perceived positive effects on patient care (in 11/13 visits) and patient relationship (in 7/13 visits). Prognosis communication occurred in 9/21 visits by self-report, but only in six of these nine visits by content analysis of audio-recordings. Patient ratings were high regardless of whether or not prognosis was communicated. In summary, after training, residents often incorporated patients’ prognoses to inform clinical decisions, but sometimes did so without communicating prognosis to the patients. Residents and patients reported positive perceptions regarding the visits.     

The Effect of Resident Duty-Hours Restrictions on Internal Medicine Clerkship Experiences: Surveys of Medical Students and Clerkship Directors

Phenomenon: Medical students receive much of their inpatient teaching from residents who now experience restructured teaching services to accommodate the 2011 duty-hour regulations (DHR). The effect of DHR on medical student educational experiences is unknown. We examined medical students’ and clerkship directors’ perceptions of the effects of the 2011 DHR on internal medicine clerkship students’ experiences with teaching, feedback and evaluation, and patient care. Approach: Students at 14 institutions responded to surveys after their medicine clerkship or subinternship. Students who completed their clerkship (n = 839) and subinternship (n = 228) March to June 2011 (pre-DHR historical controls) were compared to clerkship students (n = 895) and subinterns (n = 377) completing these rotations March to June 2012 (post-DHR). Z tests for proportions correcting for multiple comparisons were performed to assess attitude changes. The Clerkship Directors in Internal Medicine annual survey queried institutional members about the 2011 DHR just after implementation. Findings: Survey response rates were 64% and 50% for clerkship students and 60% and 48% for subinterns in 2011 and 2012 respectively, and 82% (99/121) for clerkship directors. Post-DHR, more clerkship students agreed that attendings (p =.011) and interns (p =.044) provided effective teaching. Clerkship students (p =.013) and subinterns (p =.001) believed patient care became more fragmented. The percentage of holdover patients clerkship students (p =.001) and subinterns (p =.012) admitted increased. Clerkship directors perceived negative effects of DHR for students on all survey items. Most disagreed that interns (63.1%), residents (67.8%), or attendings (71.1%) had more time to teach. Most disagreed that students received more feedback from interns (56.0%) or residents (58.2%). Fifty-nine percent felt that students participated in more patient handoffs. Insights: Students perceive few adverse consequences of the 2011 DHR on their internal medicine experiences, whereas their clerkship director educators have negative perceptions. Future research should explore the impact of fragmented patient care on the student–patient relationship and students’ clinical skills acquisition.     

Anti-prion activity generated by a novel vaccine formulation

Chronic wasting disease (CWD) is a transmissible spongiform encephalopathy (TSE) of domestic and wild cervids in North America. To address possible prevention regimens for CWD, we have used a mouse model system and the Rocky Mountain Laboratory (RML) mouse-adapted scrapie prion strain to screen efficacy of potential vaccine candidates. Three peptides derived from the primary amino acid sequence of the prion protein were conjugated to blue carrier protein (BCP) and formulated in an adjuvant containing M. avium subsp. avium. CL57/BL6 mice were vaccinated and boosted with 50 microg of the carrier protein-peptide conjugate formulation; all vaccines produced a humoral immune response as measured by ELISA. Disease challenge with the RML scrapie prion strain revealed anti-prion activity was generated by the vaccine formulations as measured by a delay in clinical disease onset and prolonged survivorship.     

Reliability and validity of severity dimensions of psychopathology assessed using the Structured Clinical Interview for DSM‐5 (SCID)

This study examined whether the Structured Clinical Interview for DSM (SCID), a widely used semistructured interview designed to assess psychopathology categorically, can be adapted to identify reliable and valid severity dimensions of psychopathology. The present study also examined whether these severity dimensions have better psychometric properties (internal consistency, test–retest reliability, and concurrent and predictive validity) than categorical diagnoses. Participants (N = 234) were recruited from the community and clinics. Retest reliability and prospective predictive validity (symptoms and functioning 1 year later) were examined in subsamples of participants. Dimensional severity scales were created from an adapted version of the SCID for both current and lifetime major depression, alcohol, substance, post‐traumatic stress disorder, panic, agoraphobia, social anxiety, specific phobia, obsessive–compulsive disorder, and generalized anxiety disorder. The SCID's severity scales demonstrated substantial internal consistency (all Cronbach's αs >.80), test–retest reliability, and concurrent and predictive validity. Symptom severity scales demonstrated significant incremental validity over and above categorical diagnoses for both current and prospective outcomes. The psychometric properties of SCID‐identified symptom scales were far superior to the psychometrics of categorical diagnoses for both current and lifetime psychopathology. These results highlight the feasibility and utility of the SCID to assess reliable and valid symptom severity dimensions of both current and lifetime psychopathology.     

The Indirect Effect of Ethnic Identity on Marijuana Use Through School Engagement: An African American High School Sample

Background: African American marijuana use is associated with many negative social, emotional, and health-related consequences. Of significance, over recent years this population has shown an increase in use. In the literature, ethnic identity and school engagement are prominent protective factors against substance use. Objective: This study will examine how these protective factors are related, specifically whether ethnic identity mitigates risk through school engagement to reduce marijuana use. Method: A path analysis was conducted with 437 African American high school students (41% male) from Midwestern schools to examine the role of school engagement in the relationship between ethnic identity and marijuana use. Results: The results revealed that students high in ethnic identity have higher school engagement, which lessens their frequency of marijuana use. Therefore, ethnic identity reduces marijuana use by increasing student's school engagement. Conclusions/Importance: The results offer a clearer picture of how ethnic identity and school engagement protect against marijuana use. The results also present insight into how to protect students who are low in ethnic identity.     

Cross-linking influences the impact of quantitative changes in myocardial collagen on cardiac stiffness and remodelling in hypertension in rats

OBJECTIVE: To assess whether the variable impact of quantitative changes in myocardial collagen on left ventricular (LV) diastolic myocardial stiffness (myocardial k) and remodelling (increased volume intercept of diastolic pressure-volume relations) in LV hypertrophy (LVH) is associated with alterations in myocardial collagen cross-linking. METHODS: We evaluated myocardial collagen content (hydroxyproline concentrations [HPRO]) and the degree of myocardial collagen cross-linking (solubility to cyanogen bromide digestion) in 14-15- and 21-22-month-old spontaneously hypertensive rats (SHRs), and in aortic-banded rats with pressure overload hypertrophy (POH). RESULTS: In rats with POH and in SHRs irrespective of age, increases in myocardial [HPRO] were noted. However, hypertensive rats differed in the material and geometric properties of the myocardium, and in qualitative aspects of fibrosis. In 14-15-month-old SHRs myocardial k (determined from diastolic stress-strain relations) and insoluble (cross-linked) [HPRO] were increased, but no LV remodelling or increases in myocardial soluble (non-cross-linked) [HPRO] were noted. In rats with POH, LV remodelling and increases in soluble myocardial [HPRO] occurred, but no increase in k or insoluble myocardial [HPRO] were observed. In 21-22-month-old SHRs, increases in k, soluble and insoluble myocardial [HPRO], as well as LV remodelling occurred. CONCLUSIONS: Collagen cross-linking may determine the diverse relation that exists between increases in myocardial collagen concentrations and either myocardial stiffness or chamber remodelling in hypertension. These findings support the notion that fibrosis contributes to myocardial stiffness as well as LV dilatation in LVH, albeit an effect that is modulated by collagen quality.