Comparative Efficacy (DAS28 Remission) of Targeted Immune Modulators for Rheumatoid Arthritis: A Network Meta-Analysis.

INTRODUCTION: The objective of this study was to evaluate the relative efficacy of targeted immune modulators (TIMs) in TIM-naïve/mixed populations (≤ 20% TIM-experienced) and TIM-experienced (> 20% TIM-experienced) adults with moderate-to-severe rheumatoid arthritis with an inadequate response to or intolerance of conventional disease-modifying antirheumatic drugs (cDMARDs). METHODS: A fixed-effects Bayesian network meta-analysis (NMA) was performed using published study-level data from 41 randomized controlled trials (RCTs) identified from two recent systematic literature reviews conducted by the Institute for Clinical and Economic Review, and two additional phase III trials for filgotinib (FINCH-1, FINCH-2). RCTs that compared TIMs with each other, cDMARD therapy, or placebo were included. Treatments included Janus kinase (JAK) inhibitors, tumor necrosis factor α inhibitors (TNFi), and other non-TNFi therapies. Efficacy was defined as achieving remission with a DAS28 score < 2.6 at 12 and 24 weeks. RESULTS: In the 12-week analysis for the TIM-naïve/mixed population, all TIMs combined with cDMARD therapy were significantly more likely to achieve remission compared with a cDMARD alone, with intravenous tocilizumab showing a substantially greater magnitude of effect (odds ratio 19.36; 95% credible interval 11.01-38.16). Similarly, in the 24-week analysis, intravenous and subcutaneous tocilizumab showed the highest odds ratio of achieving DAS28 remission compared with cDMARD therapy. Similar trends were observed for the analyses on monotherapy or TIM-experienced population. CONCLUSIONS: This NMA demonstrated that tocilizumab is associated with a greater likelihood of remission (DAS28 < 2.6) at 12 and 24 weeks compared with most other TIMs, including new JAK inhibitors, when used in combination with a cDMARD or as monotherapy among TIM-naïve/mixed or TIM-experienced populations.

Criticality of a conserved tyrosine residue in the SpeG protein from Escherichia coli.

The SpeG spermidine/spermine N-acetyltransferase (SSAT) from Escherichia coli belongs to the Gcn5-related N-acetyltransferase (GNAT) superfamily of proteins. In vitro characterization of this enzyme shows it acetylates the polyamines spermine and spermidine, with a preference toward spermine. This enzyme has a conserved tyrosine residue (Y135) that is found in all SSAT proteins and many GNAT functional subfamilies. It is located near acetyl coenzyme A in the active center of these proteins and has been suggested to act as a general acid in a general acid/base chemical mechanism. In contrast, a previous study showed this residue was not critical for E. coli SpeG enzymatic activity when mutated to phenylalanine. This result was quite different from previous studies with a comparable residue in the human and mouse SSAT proteins, which also acetylate spermine and spermidine. Therefore, we constructed several mutants of the E. coli SpeG Y135 residue and tested their enzymatic activity. We found this conserved residue was indeed critical for E. coli SpeG enzyme activity and may behave similarly in other SSAT proteins.

A Cost-Effectiveness Framework for COVID-19 Treatments for Hospitalized Patients in the United States.

INTRODUCTION: The COVID-19 pandemic is a global crisis impacting population health and the economy. We describe a cost-effectiveness framework for evaluating acute treatments for hospitalized patients with COVID-19, considering a broad spectrum of potential treatment profiles and perspectives within the US healthcare system to ensure incorporation of the most relevant clinical parameters, given evidence currently available. METHODS: A lifetime model, with a short-term acute care decision tree followed by a post-discharge three-state Markov cohort model, was developed to estimate the impact of a potential treatment relative to best supportive care (BSC) for patients hospitalized with COVID-19. The model included information on costs and resources across inpatient levels of care, use of mechanical ventilation, post-discharge morbidity from ventilation, and lifetime healthcare and societal costs. Published literature informed clinical and treatment inputs, healthcare resource use, unit costs, and utilities. The potential health impacts and cost-effectiveness outcomes were assessed from US health payer, societal, and fee-for-service (FFS) payment model perspectives. RESULTS: Viewing results in aggregate, treatments that conferred at least a mortality benefit were likely to be cost-effective, as all deterministic and sensitivity analyses results fell far below willingness-to-pay thresholds using both a US health payer and FFS payment perspective, with and without societal costs included. In the base case, incremental cost-effectiveness ratios (ICER) ranged from $22,933 from a health payer perspective using bundled payments to $8028 from a societal perspective using a FFS payment model. Even with conservative assumptions on societal impact, inclusion of societal costs consistently produced ICERs 40-60% lower than ICERs for the payer perspective. CONCLUSION: Effective COVID-19 treatments for hospitalized patients may not only reduce disease burden but also represent good value for the health system and society. Though data limitations remain, this cost-effectiveness framework expands beyond current models to include societal costs and post-discharge ventilation morbidity effects of potential COVID-19 treatments.

Cost-effectiveness of omalizumab for the treatment of moderate-to-severe uncontrolled allergic asthma in the United States.

Objective: Uncontrolled asthma is associated with considerable clinical burden and costs to payers and patients. US economic models evaluating biologics using data from clinical trials demonstrate high incremental cost-effectiveness ratios (ICERs), but the cost-effectiveness based on real-world treatment patterns is unknown. This analysis used real-world evidence to assess the cost-effectiveness of adding omalizumab to standard of care (SOC).Methods: A Markov model was applied to track patients' health states in 2-week cycles, comparing costs and treatment effects of SOC alone versus SOC + omalizumab over a lifetime (US payer perspective). Outcomes included exacerbation events, life years, quality-adjusted life years (QALYs), total costs, and an ICER. Patient characteristics, exacerbations, patient-reported outcomes, and work productivity were derived from the real-world PROSPERO (Prospective Study to Evaluate Predictors of Clinical Effectiveness in Response to Omalizumab) study. Published literature informed mortality, exacerbation-related disutility, and unit costs. Sensitivity analyses assessed model robustness.Results: Over a lifetime horizon, omalizumab was associated with an increase of 2.0 QALYs at a cost of $US 148,319 in patients with uncontrolled asthma (ICER of $75,319/QALY gained) and a reduction in exacerbations of 6.0 events/patient. Accounting for responder status improved the ICER ($70,505/QALY); incorporating indirect costs further reduced the ICER. One-way and multivariate sensitivity analyses confirmed that the base case outcome was robust to variation in inputs.Conclusions: Based on real-world outcomes, omalizumab may be cost-effective for uncontrolled asthma from the US payer perspective. Including broader evidence on treatment discontinuation, caregiver burden, and oral corticosteroid reduction from real-world studies may better reflect the effects and value of omalizumab for all healthcare stakeholders.

The spermidine acetyltransferase SpeG regulates transcription of the small RNA rprA.

Spermidine N-acetyltransferase (SpeG) acetylates and thus neutralizes toxic polyamines. Studies indicate that SpeG plays an important role in virulence and pathogenicity of many bacteria, which have evolved SpeG-dependent strategies to control polyamine concentrations and survive in their hosts. In Escherichia coli, the two-component response regulator RcsB is reported to be subject to Nε-acetylation on several lysine residues, resulting in reduced DNA binding affinity and reduced transcription of the small RNA rprA; however, the physiological acetylation mechanism responsible for this behavior has not been fully determined. Here, we performed an acetyltransferase screen and found that SpeG inhibits rprA promoter activity in an acetylation-independent manner. Surface plasmon resonance analysis revealed that SpeG can physically interact with the DNA-binding carboxyl domain of RcsB. We hypothesize that SpeG interacts with the DNA-binding domain of RcsB and that this interaction might be responsible for SpeG-dependent inhibition of RcsB-dependent rprA transcription. This work provides a model for SpeG as a modulator of E. coli transcription through its ability to interact with the transcription factor RcsB. This is the first study to provide evidence that an enzyme involved in polyamine metabolism can influence the function of the global regulator RcsB, which integrates information concerning envelope stresses and central metabolic status to regulate diverse behaviors.

Generating enzyme and radical-mediated bisubstrates as tools for investigating Gcn5-related N-acetyltransferases.

Gcn5-related N-acetyltransferases (GNATs) are found in all kingdoms of life and catalyze important acyl transfer reactions in diverse cellular processes. While many 3D structures of GNATs have been determined, most do not contain acceptor substrates in their active sites. To expand upon existing crystallographic strategies for improving acceptor-bound GNAT structures, we synthesized peptide substrate analogs and reacted them with CoA in PA4794 protein crystals. We found two separate mechanisms for bisubstrate formation: (a) a novel X-ray induced radical-mediated alkylation of CoA with an alkene peptide and (b) direct alkylation of CoA with a halogenated peptide. Our approach is widely applicable across the GNAT superfamily and can be used to improve the success rate of obtaining liganded structures of other acyltransferases.

Endoscopically assisted decompression for pronator syndrome.

PURPOSE: Traditional surgical management for pronator syndrome results in a relatively long and possibly disfiguring scar across the antecubital fossa. The purposes of this study were to present an endoscopic technique that facilitates the decompression of the proximal median nerve without extensile incisions, and to evaluate whether this minimally invasive procedure could adequately and safely treat the condition to improve outcome scores. METHODS: We treated 13 patients (14 cases) with isolated pronator syndrome with endoscopically assisted decompression and retrospectively reviewed them. We excluded patients with concomitant carpal tunnel syndrome or other compression neuropathies. The average age of the patient at presentation was 41 years. Final follow-up averaged 22 months. We asked all patients to rate their preoperative and postoperative condition and functional capabilities using the validated Disabilities of the Shoulder, Arm, and Hand (DASH) scoring protocol. RESULTS: All 13 patients improved symptomatically as reflected in the DASH score assessment. The preoperative scores averaged 56 and the postoperative scores were significantly reduced and averaged 6. There were 3 minor complications, which resolved spontaneously. CONCLUSIONS: The endoscopically assisted, minimally invasive approach to treat pronator syndrome adequately and safely decompressed all anatomical points of compression and improved DASH scores. This may reduce morbidity and facilitate a quicker recovery compared with the traditional open incision techniques. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

A 12-year experience using the Brown two-portal endoscopic procedure of transverse carpal ligament release in 14,722 patients: defining a new paradigm in the treatment of carpal tunnel syndrome.

BACKGROUND: Compared with the open technique, endoscopic carpal tunnel release has a shorter postoperative recovery period but has been associated with an increased risk of iatrogenic injury. Because of morbidity of the open method, including painful scars, pillar pain, tendon adhesions, scar entrapment of the median nerve, chronic regional pain syndrome, and a longer postoperative recovery period, many patients have been treated nonoperatively to circumvent or forestall surgery, resulting in unrelieved median nerve compression and an increased risk of permanent nerve injury. METHODS: Inclusion criteria included a diagnosis of carpal tunnel syndrome based on history and physical examination and electrodiagnostic studies; failure of a short trial of conservative therapy; and advanced disease as evidenced by sensory, motor, or atrophic changes in the median nerve distribution. Exclusion criteria included prior surgery, wrist extension of less [corrected] than 40 degrees, mass within the carpal tunnel, Guyon's syndrome, and bony carpal tunnel abnormalities. Patients meeting these criteria were treated by the Brown two-portal endoscopic technique. RESULTS: A total of 14,722 patients were treated with the Brown endoscopic procedure. Eleven patients (0.07 percent) required conversion to an open procedure. There was one iatrogenic injury. Postoperative results were inversely related to the severity of the preoperative electrodiagnostic studies and the duration of symptoms regardless of the method of nonoperative treatment given. CONCLUSIONS: Operative decompression should be carried out promptly if symptoms have been present for 2 months or longer, as the occurrence of permanent nerve damage has been noted within this time frame. The authors advocate use of the two-portal endoscopic technique as previously described by Brown et al. for this purpose.