An Introduction to Biosimilars for the Treatment of Retinal Diseases: A Narrative Review.

Biological therapies have revolutionized the treatment of disease across a number of therapeutic areas including retinal diseases. However, on occasion, such treatments may be relatively more expensive compared to small molecule therapies. This can restrict patient access and treatment length leading to suboptimal clinical outcomes. Several biosimilar candidates of ranibizumab and aflibercept are currently in development and the first biosimilar of ranibizumab received EMA approval in August and FDA approval in September 2021. Biosimilars are biological medicines that are highly similar to an already-approved biological medicine (reference product). The physicochemical and clinical similarity of a biosimilar is determined by a rigorous analytical and clinical program, including extensive pharmacokinetic and pharmacodynamic analysis with phase III equivalence studies where appropriate. These phase III studies are carried out in a patient population that is representative of all of the potential approved therapeutic indications of the originator product and the most sensitive for detecting potential differences between the biosimilar and the reference product. Biosimilars have been used successfully across a wide range of therapeutic areas for the past 15 years where they have achieved substantial cost savings that can be reinvested into healthcare systems without affecting the quality of patient care. The current review provides an introduction to biosimilars with the aim of preparing retinal specialists for discussing these products with their patients.

The Effects of Iron Rust on the Ageing of Woods and Their Derived Pulp Paper.

The accelerated ageing of wood in terms of heating or iron rusting has a potential effect on the physio-mechanical, chemical and biological properties of wood. The effects of accelerated ageing on the mechanical, physical and fungal activity properties of some wood materials (Schinus terebinthifolius, Erythrina humeana, Tectona grandis, Pinus rigida and Juglans nigra) were studied after several cycles of heating and iron rusting. The fungal activity was assayed against the growth of Aspergillus terreus, Aspergillus niger, Fusarium culmorum and Stemphylium solani. In addition, the mechanical and optical properties of paper sheets produced from those wood pulps by means of Kraft cooking were evaluated. The mechanical and chemical properties of the studied wood species were affected significantly (p < 0.05) by the accelerated ageing, compared to control woods. With Fourier transform infrared (FTIR) spectroscopy, we detected an increase in the intensity of the spectra of the functional groups of cellulose in the heated samples, which indicates an increase in cellulose content and decrease in lignin content, compared to other chemical compounds. For pulp properties, woods treated by heating showed a decrease in the pulp yield. The highest significant values of tensile strength were observed in pulp paper produced from untreated, heated and iron-rusted P. rigida wood and they were 69.66, 65.66 and 68.33 N·m/g, respectively; we calculated the tear resistance from pulp paper of untreated P. rigida (8.68 mN·m2/g) and T. grandis (7.83 mN·m2/g) and rusted P. rigida (7.56 mN·m2/g) wood; we obtained the values of the burst strength of the pulp paper of untreated woods of P. rigida (8.19 kPa·m2/g) and T. grandis (7.49 kPa·m2/g), as well as the fold number of the pulp paper of untreated, heated and rusted woods from P. rigida, with values of 195.66, 186.33 and 185.66, respectively. After 14 days from the incubation, no fungal inhibition zones were observed. Accelerated ageing (heated or iron-rusted) produced significant effects on the mechanical and chemical properties of the studied wood species and affected the properties of the produced pulp paper.

Low back pain among Italian runners: A cross-sectional survey.

BACKGROUND: Low Back Pain (LBP) is commonly reported as a very frequent disorder in sports, but its prevalence in runners remains unclear. OBJECTIVES: To determine the prevalence of LBP in a wide sample of Italian runners. DESIGN: A cross-sectional online survey. SETTING: A national survey, according to the CHERRIES and STROBE guidelines, was performed in 2019. PARTICIPANTS: 2539 Italian runners. METHODS: A sample of Italian runners registered with national running associations was recruited. The survey was conducted using an online survey development platform. The questionnaire was self-reported and included 38 questions. MAIN OUTCOME MEASURES: Descriptive statistics and frequencies were used to analyze results. Relationships between demographics, daily habits and running characteristics and the responses given was calculated with Cramer's V. Only correlation values higher >0.60 were deemed of interest. RESULTS: 2539 questionnaires (63.5%) were valid for analysis. In total, 22.6% of runners reported having experienced LBP in the past year. Most participants (77.0%) reporting episodes of LBP believed it was not caused by running. No significant correlations (Cramer's V < 0.60) were found between LBP and demographics, training characteristics or lifestyle habits. CONCLUSION: The prevalence of LBP among Italian runners was 22,57%. LBP was not associated with training, equipment or lifestyle.

Correction to: Unlocking the Value of Anti-TNF Biosimilars: Reducing Disease Burden and Improving Outcomes in Chronic Immune-Mediated Inflammatory Diseases: A Narrative Review.

In the original article, under the "Access to treatment" heading.

Unlocking the Value of Anti-TNF Biosimilars: Reducing Disease Burden and Improving Outcomes in Chronic Immune-Mediated Inflammatory Diseases: A Narrative Review.

Immune-mediated inflammatory diseases (IMIDs) are chronic conditions that create a significant disease burden on millions of patients while adding a major financial burden to societies and healthcare systems. The introduction of biologic medicines has contributed majorly to improving the clinical outcomes of IMIDs and as such these modalities have gained first- or second-line positions in a wide range of treatment guidelines from different international clinical societies. However, the high cost of these biologics traditionally limited their accessibility and delayed their initiation, leaving millions of patients with unmet medical needs for a more affordable and sustainable solution. The introduction of cost-efficient biosimilar anti-TNFs within Europe since 2013 has allowed more patients with IMIDs to access biologic therapies earlier and for longer, potentially altering the course of the disease into a milder phenotype and reducing the long-term disease burden. This review provides the latest evidence for the impact of biosimilars on patient outcomes and demonstrates their clinical value beyond a reduction in price.

Real-World Evidence on Etanercept Biosimilar SB4 in Etanercept-Naïve or Switching Patients: A Systematic Review.

INTRODUCTION: In 2016, SB4 (Benepali®) became the first etanercept (ETN) biosimilar to obtain marketing authorisation in Europe. Despite robust analytical and clinical comparisons, outstanding questions remain on SB4 use in routine practice. METHODS: A systematic search for publications on real-world evidence of SB4 effectiveness, safety and drug survival was undertaken using search terms (SB4 OR Benepali OR biosimilar etanercept OR innovator etanercept) in the BIOSIS® Toxicology, BIOSIS Previews®, Embase® and MEDLINE® databases up to 17 January 2019. RESULTS: Of 959 articles identified, eight journal articles, two journal letters and 23 congress abstracts were selected on criteria of original real-world evidence with a clinical focus. As expected with real-world evidence, quality scoring showed that the evidence had high external validity but lower internal validity. A total of 13,552 patients were described across nine European countries and all approved SB4 indications: 2499 were ETN-naïve and 11,053 switched from reference ETN to SB4 (switchers). Switch acceptance rates (a combination of clinicians offering and patients accepting initiation on SB4) ranged between 51.6% and 99.0%; patient support programmes positively contributed to acceptance. Disease activity was generally similar pre- and post-switch (typically 3-month timeframe). Retention rates across studies were at least 75% (up to 12 months follow-up). No new safety signals were identified. Differences in discontinuation rates versus historic controls reported in some studies may have been influenced by differences in treatment practices, lack of clinician confidence and nocebo effects. CONCLUSION: Nearly 2500 ETN-naïve patients have been initiated on SB4 and outcomes are similar to those patients receiving reference ETN. Overall this systematic review of real-world evidence provides additional reassurance that SB4 is as effective and safe as reference ETN in both switched and naïve patients. FUNDING: Biogen International GmbH.

Correction to: To See or NOsee: The Debate on the Nocebo Effect and Optimizing the Use of Biosimilars.

The article "To See or NOsee: The Debate on the Nocebo Effect and Optimizing the Use of Biosimilars", written by Mourad F. Rezk and Burkhard Pieper was originally published electronically on the publisher's internet portal (currently SpringerLink) on June 5, 2018 without open access.

To See or NOsee: The Debate on the Nocebo Effect and Optimizing the Use of Biosimilars.

In addition to the general clinical benefit offered, biosimilars may not only generate savings for healthcare budgets but also improve patient access to biologic products. Since the first biosimilar was approved in Europe in 2006, a further 36 different biosimilar drugs have been approved for several indications. Despite the wealth of experience gained and the reported data supporting the use of biosimilars, both in naïve and biologic-experienced patients, some healthcare professionals continue to express doubt regarding the rigorous approval process for biosimilars and uncertainty with how to incorporate them into daily clinical practice. These opinions can be transferred to patients through poor or lack of communication, meaning that patients may lack confidence in treatment quality and, as a result, be susceptible to the nocebo effect. At the 2017 American College of Rheumatology/Association of Rheumatology Health Professionals annual meeting, during a debate the question was asked as to whether the nocebo effect was in fact being used to describe "any result you don't agree with". Here, we detail that the nocebo effect has been demonstrated in a number of clinical trials, and that this effect may negatively affect acceptance in patients switching from an originator product to a biosimilar. Awareness of the potential for the nocebo effect and adoption of enhanced communication techniques may be useful in mitigating the nocebo effect. Effective healthcare professional-patient dialogue is key in transferring confidence to the patient, and has been shown to reduce nocebo effects in patients when switching from an originator to a biosimilar. FUNDING: Biogen International GmbH.

Treatment Outcomes with Biosimilars: Be Aware of the Nocebo Effect.

Over the years, biologic agents have proven their importance in the management of chronic autoimmune diseases, such as rheumatoid arthritis, psoriasis, and inflammatory bowel disease. Biosimilars, which are biologic medicines, are highly similar to approved biologic medicines, and are comprehensively developed and rigorously tested to ensure efficacy and safety are similar to the reference product. A broader armamentarium of biosimilars is expected to improve patients' access to safe and effective biologic medicines, thus offering benefits to healthcare systems around the globe. Here we consider the factors that may compromise the benefits of biosimilars being realized, including patient and physician perception of biosimilars, and an often overlooked factor, the nocebo effect, which is re-emerging with the widespread adoption of biosimilar medicines. We have also described a variety of strategies and recommendations that could help limit the nocebo effect. FUNDING: Biogen.

A randomized single-blind trial of standard diet versus fiber-free diet with polyethylene glycol electrolyte solution for colonoscopy preparation.

BACKGROUND AND STUDY AIMS: Colonoscopy preparation usually involves the intake of large volumes of polyethylene glycol electrolyte solution (PEG-ES) in combination with a clear-liquid diet (CLD). Liberalization of the diet might enhance the tolerance to PEG-ES without compromising the quality of the preparation. The primary aims of this study were to evaluate the efficacy and tolerability of PEG-ES given with a CLD compared with a fiber-free diet (FFD) for colonoscopy preparation. The incidence of adverse events among patients in the two diet groups was also assessed as a secondary outcome. METHODS: This was a single-center randomized, prospective, single-blind study. A total of 200 patients undergoing colonoscopy were randomized to either CLD or FFD in addition to PEG-ES. RESULTS: Patients in the FFD group were able to drink more PEG-ES (mean +/- SD, 3.9 +/- 0.3 L) compared with those in the CLD group (3.3 +/- 0.7 L) ( P < 0.01). The quality of the preparation was significantly better in the FFD group, with more patients having satisfactory preparations than those in the CLD group (81.4 % vs. 52.0 %; P < 0.001). Tolerance to the preparation was higher in the FFD group compared with the CLD group, with significantly more patients adhering to the FFD regimen ( P < 0.001). There were more adverse events experienced in the CLD group, with odds ratios of 1.9 for nausea (95 % confidence interval [CI] 1.0 - 3.6), 3.8 for vomiting (95 % CI 1.3 - 11.3), and 3.0 for headache (95 % CI 1.5 - 5.9). CONCLUSION: FFD given with PEG-ES on the day before colonoscopy is a more effective regimen than the standard CLD regimen, and is better tolerated by patients.

A short case of a splenic arteriovenous fistula coexisting with portal hypertension secondary to hepatitis C: Radiologic diagnosis and treatment.

Summary Splenic arteriovenous fistula (SAVF) is a rare but potentially curable condition. Only a few cases have been reported in the English literature. SAVF can cause portal hypertension, ascites, gastrointestinal bleeding, and heart failure. An early diagnosis is essential to avoid life threatening complications. We hereby present a case of SAVF in a young female patient, with hepatitis C liver cirrhosis who presented with recurrent severe upper gastrointestinal bleeding. Such an association of liver cirrhosis and SAVF has not been previously reported.

Troubleshooting in animal models of colitis: The use of a novel electrocautery model.

INTRODUCTION: Experimental colitis induced by chemical agents leads to upregulation of inflammatory cytokines in distant unaffected small intestine and to a decrease in nutrient absorption. To preclude any possible proximal diffusion of these chemicals, we designed a novel method for ulcer induction in the colon by electrocautery. METHODS: Under light anesthesia, a colonic ulcer was induced in rats by a special electrocautery probe introduced in the descending colon through the rectum allowing the injection of a controlled electrolytic current. A direct current (3-7 mA) was delivered through the electrodes for 30s and then for another 30s after reversing the polarity of the electrodes. Then, the probe was moved for a distance of +/-0.5 cm and the current injection was repeated. Rats were sacrificed at various time intervals after ulcer induction (3-96 h). Samples from colon and jejunum were taken for histological assessment and determination, by ELISA, of the levels of interleukin-1beta (IL-1beta) and tumor necrosis factor alpha (TNF-alpha). In other groups of animals, jejunal amino acid absorption was determined in vivo at 24 and 48 h post electrocautery. RESULTS: A colonic ulcer persisted for 72 h after cauterization. A significant upregulation of the levels of different cytokines was observed in the colon and jejunum post cauterization and persisted for at least 48 h. In the jejunum, IL-1beta increased from 81+/-9 to 652+/-110 (p<0.01) and 243+/-47 (p<0.05) pg/mg protein at 24 and 48 h, respectively. Similarly, jejunal TNF-alpha levels increased by approximately 2 folds at 24 and 48 h post ulcer induction (p<0.05). A similar but higher increase in cytokines was observed in the colon. Jejunal alanine absorption (0.2+/-0.02 micromol/20 min/cm) decreased significantly at 24 and 48 h after colitis induction (0.12+/-0.01 and 0.14+/-0.02, respectively; p<0.01). DISCUSSION: This model may be used as an alternative or a complement to chemical models of colitis.

Infección diseminada por Mycobacterium bovis tras instilación endovesical de BCG / Disseminated infection due to Mycobacterium bovis alter intravesical instillation of BCG

No disponible

Use of the six-shooter ligation device in the management of bleeding esophageal varices: a developing-country experience.

Endoscopic variceal ligation has emerged as a superior alternative to endoscopic injection sclerotherapy, however, the "single-shot" mechanism of the generally used Stiegman-Goff ligator made the procedure tedious and time-consuming and required overtube placement, associated with discomfort and potentially life-threatening complications. In this study we describe our experience with the Saeed Six-Shooter (multiple-ligation device). Fifty consecutive patients with variceal bleeding were prospectively studied. After initial endoscopic ligation, subsequent sessions were every 2 weeks. Study outcomes were: the ability to control active bleeding, the frequencies of rebleeding, the number of treatment sessions and time required for irradication, the percentage eradication of varices, complications, and mortality. Active bleeding was controlled in all eight (100%) patients. Four (8%) patients rebled, three from esophageal varices, and one from portal hypertensive gastropathy. Esophageal varices were eradicated in 47 (94%) patients (3.1 +/- 1.3 sessions). Time needed till eradication was 6.2 +/- 1.9 weeks. Chest pain was reported in two (4%), low, grade pyrexia in two (4%), and pneumonia in one (2%) patient. There were three deaths, none due to exsanguination. The Six-Shooter is a safe and efficient device for the endoscopic ligation of esophageal varices which has overcome the limitations of the single-shot ligator: (1) Visualization is better (the endoscopic "tunnel vision" and internal light reflection from the stainless-steel banding cylinder of the single-shot device are avoided); and (2) the use of an overtube is no longer necessary and serious complications can be avoided.

Five-year trial of deferiprone chelation therapy in thalassaemia major patients.

Twelve thalassaemia major patients have been given deferiprone 75 mg/kg body weight daily as iron chelation therapy for 5 years. Their ages ranged from 18 to 34 years (mean 24.2) at the end of the study. Two patients were hepatitis C virus (HCV) mRNA positive and a further 5 were positive for HCV antibody. The mean serum ferritin level fell significantly from 4,302 +/- 2,245 microg/l SD at baseline to 3,032 +/- 1,155 microg/l at 2 years (p = 0.037) and 2,229 +/- 1,070 microg/l (p = 0.007) at 5 years. At the end of the study, liver iron ranged from 3.59 to 23.7 mg/g dry weight (mean 11.9 +/- 5.4), 3 patients having levels >15 mg/g. There was no significant change in serum AST levels, but ALT levels fell significantly at 2 years (p = 0.019) and 5 years (p = 0.001). Liver biopsy at the end of the study showed no evidence of hepatic fibrosis caused by deferiprone. Cardiac studies showed no overall change in left ventricular ejection fraction but a significant improvement in isovolumic relaxation time (p = 0.045). We conclude that in this albeit small group of thalassaemia major patients, deferiprone was a safe long-term method of iron chelation. In a minority, higher doses of deferiprone or a combination with desferrioxamine would be needed to lower liver iron below 15 mg/g.

Interplay between nitric oxide and vasoactive intestinal polypeptide in inducing fluid secretion in rat jejunum.

Nitric oxide (NO) and vasoactive intestinal polypeptide (VIP) interact in the regulation of neuromuscular function in the gut. They are also potent intestinal secretogogues that coexist in the enteric nervous system. The aims of this study were: (1) to investigate the interaction between NO and VIP in inducing fluid secretion in the rat jejunum, and (2) to determine whether the NO effect on intestinal fluid movement is neurally mediated. The single pass perfusion technique was used to study fluid movement in a 25 cm segment of rat jejunum in vivo. A solution containing 20 mM L-arginine, a NO precursor, was perfused into the segment. The effect of the NO synthase inhibitors (L-NAME and L-nitroindazole (L-NI)) and the VIP antagonist ([4Cl-D-Phe6,Leu17]VIP (VIPa)) on L-arginine-induced changes in fluid movement, expressed as microl min(-1) (g dry intestinal weight)(-1), was determined. In addition, the effect of neuronal blockade by tetrodotoxin (TTX) and ablation of the myenteric plexus by benzalkonium chloride (BAC) was studied. In parallel groups of rats, the effect of L-NAME and L-NI on VIP-induced intestinal fluid secretion was also examined. Basal fluid absorption in control rats was (median (interquartile range)) 65 (45-78). L-Arginine induced a significant fluid secretion (-14 (-20 to -5); P<0.01). This effect was reversed completely by L-NAME (60 (36-65); P<0.01) and L-NI (46 (39-75); P<0.01) and partially by VIPa (37 (14-47); P<0.01). TTX and BAC partially inhibited the effect of L-arginine (22 (15-32) and 15 (10-26), respectively; P<0.05). The effect of VIP on fluid movement (-23 (-26 to -14)) was partially reversed by L-NAME (24 (8.4-35.5); P<0.01) and L-NI (29 (4-44); P<0.01). The inhibition of VIP or NO synthase prevented L-arginine- and VIP-induced intestinal fluid secretion through a neural mechanism. The data suggest that NO enhances the release of VIP from nerve terminals and vice versa. Subsequently, each potentiates the other's effect in inducing intestinal fluid secretion.

Effect of oral iron chelation therapy with deferiprone (L1) on the psychosocial status of thalassaemia patients.

Beta-thalassemia requires life-long treatment, including regular blood transfusion and daily iron chelation by desferrioxamine, which places considerable burden on the social and psychological life of patients. It is expected that oral chelation therapy, which is easier to administer, would improve their psychosocial status. In this sutdy, interviews were conducted with a series of 44 patients recently placed on oral chelation therapy to evaluate their reactions to the new treatment. Eighty-six per cent of patients complied better with the oral chelation therapy. Fifty per cent of patients mentioned that relief from the desferrioxamine pump was the major improvement, while 47% felt psychologically better. Fifty per cent of patients noted improvements in their relationships, while 63% noted increased social activities. Evaluation of a larger sample of patients over a longer period of time is needed in order to confirm the favourable results obtained in this study.

Regulated expression of GRP78 during vasopressin-induced hypertrophy of heart-derived myocytes.

Although the development of cellular hypertrophy is widely believed to involve Ca(2+) signaling, potential supporting roles for sequestered Ca(2+) in this process have not been explored. H9c2 cardiomyocytes respond to arginine vasopressin with an initial mobilization of Ca(2+) stores and reduced rates of mRNA translation followed by repletion of Ca(2+) stores, up-regulation of translation beyond initial rates, and the development of hypertrophy. Rates of synthesis of the endoplasmic reticulum (ER) chaperones, GRP78 and GRP94, were found to increase preferentially at early times of vasopressin treatment. Total GRP78 content increased 2- to 3-fold within 8 h after which the chaperone was subject to post-translational modification. Preferential synthesis of GRP78 and the increase in chaperone content both occurred at pM vasopressin concentrations and were abolished at supraphysiologic Ca(2+) concentrations. Co-treatment with phorbol myristate acetate decreased vasopressin-dependent Ca(2+) mobilization and slowed appearance of new GRP78 molecules in response to the hormone, whereas 24 h pretreatment with phorbol ester prolonged vasopressin-dependent Ca(2+) mobilization and further increased rates of GRP78 synthesis in response to the hormone. Findings did not support a role for newly synthesized GRP78 in translational up-regulation by vasopressin. However up-regulation, which does not depend on Ca(2+) sequestration, appeared to expedite chaperone expression. This report provides the first evidence that a Ca(2+)-mobilizing hormone at physiologic concentrations signals increased expression of GRP78. Translational tolerance to depletion of ER Ca(2+) stores, typifying a robust ER stress response, did not accompany vasopressin-induced hypertrophy.

Comparison between deferoxamine and deferiprone (L1) in iron-loaded thalassemia patients.

INTRODUCTION: Iron-chelating therapy with deferoxamine in patients with thalassemia major has dramatically improved the prognosis of this disease. However, the limitations of this treatment have stimulated the design of alternative orally active iron chelators. OBJECTIVE: To compare the effectiveness and safety of, and compliance with, oral deferiprone (L1), and deferoxamine, in thalassemia major patients. METHODS: All patients were followed up in one center in Lebanon. Sixteen patients were on L1 (75 mg/kg/d), and 40 patients on subcutaneous deferoxamine (20-50 mg/kg/d). Serum ferritin level, urinary iron excretion (UIE) and side effects were monitored over a two year period. RESULTS: Patients on L1 had an initial serum ferritin concentration of 3663+/-566 microg/l (mean+/-SEM), that dropped to 2599+/-314 at 6 months (p<0.02; paired t-test), and stabilised at that level over the 24 months follow up. Patients on deferoxamine had an initial mean serum ferritin concentration of 3480+/-417 (NS compared to the L1 group), which dropped gradually to 3143+/-417 (p<0.05) and 2819+/-292 (p<0.02) at 6 and 24 months, respectively. The most common adverse reactions associated with L1 were arthralgia and nausea, but they did not necessitate stopping the drug. CONCLUSION: L1 had comparable efficacy as deferoxamine with minimal side effects and better compliance. Provided long term side effects are not encountered, L1 seems to be a valuable alternative iron chelator for patients unable or unwilling to use deferoxamine effectively.