Intravenous ferric derisomaltose for the treatment of iron deficiency anemia

Intravenous (IV) iron is the therapy of choice when oral iron is ineffective or poorly tolerated, yet use has been limited by fears of hypersensitivity reactions (HSRs). Newer formulations that bind iron more tightly and release it more slowly have made the risk of serious or severe HSRs very low. One such formulation, ferric derisomaltose, has been approved in the United States for delivery of 1000 mg iron in a single IV infusion. Ferric derisomaltose rapidly repletes iron parameters with low rates of serious or severe HSRs. Single-infusion iron repletion offers convenience, eliminates adherence concerns, and reduces healthcare resource utilization.

On the synthesis of a sliding-mode-observer-based adaptive fault-tolerant flight control scheme

This paper presents an active Fault-Tolerant Control (FTC) framework to accommodate the actuator faults by using a Fault Estimation (FE) module fitted with an adaptive control law. It focuses on the problem of fault estimation based fault tolerant control for linear uncertain system with mitigation of the reconfiguration transients. In this work, a second-order sliding mode observer is designed to reconstruct the Loss of Effectiveness (LoE) of the actuators. The use of a bumpless strategy to cleverly manage the transient behavior where fault estimation is different from the real one due to an abrupt fault occurrence. Signals provided by the FE module are next used by an augmented fault-tolerant control allocation scheme to accommodate the fault. More precisely, the flight state tracking problem has been addressed with a robust adaptive model-reference Integral Sliding Mode (ISM) control law in a state feedback setting. Next, the problem of stability and performance of the overall FTC scheme with taking into account both FE performance and control law is rigorously considered. At the end, simulation examples on an aircraft from a European program are used to illustrate the effectiveness of the proposed approach.

Maternal and Neonatal Outcomes Associated with Psychostimulant Use in Pregnancy

IntroductionRecent evidence from the USA and Nordic countries suggests a possible association between psychostimulant use during gestation and adverse pregnancy and birth outcomes. Objectives and ApproachWe employed a distributed cohort analysis using linked administrative data for women who gave birth in New South Wales (NSW; Australia) and Ontario (Canada), whereby a common protocol was implemented separately in each jurisdiction. The study population comprised women who were hospitalized for a singleton delivery over an 8 (NSW) and 4 (Ontario) year period, respectively, with the NSW cohort restricted to social security beneficiaries. Psychostimulant exposure was defined as at least one dispensing of methylphenidate, amphetamine, dextroamphetamine or lisdexamfetamine during pregnancy. We examined the risk of maternal and neonatal outcomes among psychostimulant exposed mothers compared with unexposed mothers. ResultsThere were 140,356 eligible deliveries in NSW and 449,499 in Ontario during the respective study periods. Fewer than 1% of these pregnancies were exposed to psychostimulants during gestation, although use was higher in Ontario (0.30% vs 0.11% in NSW). Preliminary unadjusted analyses indicated possible associations between psychostimulant use in pregnancy and higher risks of pre-term birth (relative risk [RR] 1.7, 95% confidence interval [CI] 1.4-2.0 (Ontario); RR 1.8, 95% CI 1.2-2.6 (NSW)) and pre-eclampsia (RR 2.0, 95% CI 1.5-2.6 (Ontario); RR 2.0, 95% CI 1.2-3.5 (NSW)). Similarly, psychostimulant use was associated with higher risks of low birthweight (RR 1.6, 95% CI 1.3-1.9 (Ontario); RR 2.0, 95% CI 1.3-3.0 (NSW)) and admission to neonatal intensive care (RR 2.1, 95% CI 1.9-2.3 (Ontario); RR 1.5, 95% CI 1.1-1.9 (NSW)). Conclusion / ImplicationsUnadjusted analyses indicate an increased risk of adverse maternal and birth outcomes associated with psychostimulant exposure during pregnancy, potentially representing a placental effect. We are currently refining the analyses, employing propensity score methods to adjust for confounding.

Supporting Drug Regulators Through Simple Rapid Cycle Analyses

IntroductionDrug regulators require timely, relevant information to address questions about the safety of prescribed medicines. Some questions can be informed by initial rapid and simple analyses of linked exposure/outcome data. These analyses will establish how many individuals have received the drug, their characteristics, the availability of follow up time and the frequency of the event of interest in the exposed cohort. This approach does not enable causal inferences but establishes the need for, and feasibility of, more complex controlled analyses. Discovery that the exposure or outcome are uncommon can allay initial fears about the extent of a problem. Objectives and ApproachA pilot network to support the Australian drug regulator (TGA, Department of Health) was established among three research institutions in Australia and Canada. Initial queries were identified and prioritised by staff at the TGA. Academic staff at the partner institutions performed a rapid feasibility assessment based on existing knowledge and expertise. Following this, initial exposure/outcome analyses were undertaken on selected queries using routinely collected data from Canada and Australia. Updates were provided to the TGA at each stage to ensure that decision-makers were fully informed and participated in decision making. ResultsTo date, the network has assessed 20 queries. Seven were deemed infeasible and 4 queries were being addressed by studies that were already planned or underway; in these cases, arrangements were made to provide early results directly to the regulator. The final four queries progressed to an initial exposure/outcome analysis, and one such study was expanded to a fully adjusted controlled analysis. Conclusion / ImplicationsThis framework has proven to be agile and responsive and has strengthened the relationship between academia and the TGA. It may serve as a model for others who wish to engage more closely with governments or other decision makers.

Tuning of an Artificial Pancreas Controller: an in silico methodology based on clinically-relevant criteria

This paper presents a methodology to tune an artificial pancreas controller by minimizing the time spent in endangering glycaemic ranges (hypo- and hyperglycaemia). The risk associated to the patient's glycaemia is evaluated with an objective metric (the blood glucose risk index), which has an established clinical relevance. The tuned controller is validated in the UVA/Padova environment where the resulting artificial pancreas achieves minimal glucose risk index in realistic 24-hour long scenarios with unannounced glucose intake.

Tolerancing and characterization of curved image sensor systems

Curved image sensors, not having to correct the field curvature, are considered a relevant solution for improving the vast majority of optical systems. They offer the possibility of designing compact aberration-free optical systems. In this work, we explain the advantage of the curved sensor system using the aberration theory. A complete procedure was developed to produce functional curved sensors and functional prototypes were carried out. This paper focuses on the tolerancing process of curved sensors and its inclusion in optical design. A compact objective prototype designed and produced demonstrates the advantage of curvature and the impact of tolerancing.

The Longitudinal Relation Between Community Violence Exposure and Academic Engagement During Adolescence: Exploring Families' Protective Role

Few published studies have examined the interaction between community violence exposure, academic engagement, and parental involvement, despite theory suggesting that these three domains of development are interrelated during adolescence. This study had two related objectives: (a) to assess the temporal ordering of the relation between community violence exposure and academic engagement over the course of mid-adolescence and (b) to examine whether the pattern of these relations varies by level of parental involvement. The study sample included 273 ethnic minority males (33.4% Latino and 65.6% African American) and their caregivers living in impoverished urban neighborhoods. The present study drew on data collected through in-home surveys on violence exposure, school experiences, and family functioning at three time points during mid-adolescence. Cross-lagged model results suggest that at Time 1 (M age = 13.5), community violence exposure predicted lower academic engagement at Time 2 (M age = 14.8). Between Time 2 and Time 3 (M age = 15.8), it was academic engagement that predicted lower community violence. Parental involvement moderated these relations such that academic engagement at Time 2 only reduced the risk of violence exposure at Time 3 in the presence of families with high levels of involvement relative to others in the sample. Findings suggest that practitioners might seek to promote positive school experiences as youth move into high school to reduce risk of violence exposure. Results also indicate the importance of designing interventions that target both positive family and school functioning.

Variations in hospitalization and emergency department/observation stays using the oncology care model methodology in Medicare data

OBJECTIVE

To assess variations in hospitalizations, emergency department/observational (ED/OB) stays not resulting in hospitalization, reasons for hospitalization, and hospitalization discharge destinations after chemotherapy, information not provided as part of Oncology Care Model (OCM) baseline data.

METHODS

OCM methodology was applied to the Medicare 20% sample data to identify 6-month patient episodes triggered by chemotherapy in 2012-2015. Proportions of episodes with hospitalization or ED/OB stays, reasons for hospitalization, and discharge destinations were summarized.

RESULTS

Of 485,186 6-month episodes for 255,229 patients in 13,823 practices, 25% of episodes led to ≥1 hospitalization (from 14% in breast cancer to 56% in acute leukemia), and 23% to ED/OB stays (from 18% in breast cancer to 36% in liver cancer). In 2995 practices with ≥20 total episodes, practice-level proportions of episodes with hospitalization ranged from 14% to 31% (20th-80th percentile) and with ED/OB stays from 17% to 29%. For all cancers combined, the most frequent reasons for hospitalization were infection (13%), anemia (7%), dehydration (5%), and congestive heart failure (3%); the most common discharge destinations were home (71%) followed by a skilled nursing facility (13%), death (6%), and hospice (5%). Reasons for hospitalization and discharge destinations varied by cancer type; acute leukemia episodes led to the highest rates of infection and anemia, and central nervous system tumor episodes to the highest proportions of death or hospice discharge.

CONCLUSION

The variations in frequency of and reasons for hospitalization, ED/OB stays, and hospitalization discharge destinations across cancer types should be considered when evaluating OCM practice performance.

Association between the regional variation in premature mortality and immigration in Ontario, Canada

Objectives

Health region differences in immigration patterns and premature mortality rates exist in Ontario, Canada. This study used linked population-based databases to describe the regional proportion of immigrants in the context of provincial health region variation in premature mortality.

Methods

We analyzed all adult premature deaths in Ontario from 1992 to 2012 using linked population files, Canadian census, and death registry databases. Geographic boundaries were analyzed according to 14 health service regions, known as Local Health Integration Networks (LHINs). We assessed the role of immigrant status and regional proportion of immigrants in the context of these health region variations and assessed the contribution using sex-specific multilevel negative binomial models, accounting for age, individual- and area-level immigration, and area-level material deprivation.

Results

We observed significant premature mortality variation among health service regions in Ontario between 1992 and 2012. Average annual rates ranged across LHINs from 3.03 to 6.40 per 1000 among males and 2.04 to 3.98 per 1000 among females. The median rate ratio (RR) decreased for men from 1.14 (95% CI 1.06, 1.19) to 1.07 (95% CI 1.00, 1.11) after adjusting for year, age, area-based material deprivation, and individual- and area-level immigration, and among females reduced from 1.13 (95% CI 1.05, 1.18) to 1.04 (95% CI 1.00, 1.05). These adjustments explained 84.1% and 94.4% of the LHIN-level variation in males and females respectively. Reduced premature mortality rates were associated with immigrants compared with those for long-term residents in the fully adjusted models for both males 0.43 (95% CI 0.42, 0.44) and females 0.45 (0.44, 0.46).

Conclusion

The findings demonstrate that health region differences in premature mortality in Ontario are in part explained by individual-level effects associated with the health advantage of immigrants, as well as contextual area-level effects that are associated with regional differences in the immigrant population. These factors should be considered in addition to health system factors when looking at health region variation in premature deaths.

Electronic supplementary material

The online version of this article (10.17269/s41997-020-00330-5) contains supplementary material, which is available to authorized users.

How do trainee doctors learn about research? Content analysis of Australian specialist colleges' intended research curricula

OBJECTIVES

Patients do better in research-intense environments. The importance of research is reflected in the accreditation requirements of Australian clinical specialist colleges. The nature of college-mandated research training has not been systematically explored. We examined the intended research curricula of Australian trainee doctors described by specialist colleges, their constructive alignment and the nature of scholarly project requirements.

DESIGN

We undertook content analysis of publicly available documents to characterise college research training curricula.

SETTING

We reviewed all publicly accessible information from the websites of Australian specialist colleges and their subspecialty divisions. We retrieved curricula, handbooks and assessment-related documents.

PARTICIPANTS

Fifty-eight Australian specialist colleges and their subspecialty divisions.

PRIMARY AND SECONDARY OUTCOME MEASURES

Two reviewers extracted and coded research-related activities as learning outcomes, activities or assessments, by research stage (using, participating in or leading research) and competency based on Bloom's taxonomy (remembering, understanding, applying, analysing, evaluating, creating). We coded learning and assessment activities by type (eg, formal research training, publication) and whether it was linked to a scholarly project. Requirements related to project supervisors' research experience were noted.

RESULTS

Fifty-five of 58 Australian college subspecialty divisions had a scholarly project requirement. Only 11 required formal research training; two required an experienced research supervisor. Colleges emphasised a role for trainees in leading research in their learning outcomes and assessments, but not learning activities. Less emphasis was placed on using research, and almost no emphasis on participation. Most learning activities and assessments mapped to the 'creating' domain of Bloom's taxonomy, whereas most learning outcomes mapped to the 'evaluating' domain. Overall, most research learning and assessment activities were related to leading a scholarly project.

CONCLUSIONS

Australian specialist college research curricula appear to emphasise a role for trainees in leading research and producing research deliverables, but do not mandate formal research training and supervision by experienced researchers.

Identifying the most effective essential medicines policies for quality use of medicines: A replicability study using three World Health Organisation data-sets

Background

Poor quality use of medicines (QUM) has adverse outcomes. Governments’ implementation of essential medicines (EM) policies is often suboptimal and there is limited information on which policies are most effective.

Methods

We analysed data on policy implementation from World Health Organisation (WHO) surveys in 2007 and 2011, and QUM data from surveys during 2006–2012 in developing and transitional countries. We compared QUM scores in countries that did or did not implement specific policies and regressed QUM composite scores on the numbers of policies implemented. We compared the ranking of policies in this and two previous studies, one from the same WHO databases (2003–2007) the other from data obtained during country visits in South-East Asia (2010–2015). The rankings of a common set of 17 policies were correlated and we identified those that were consistently highly ranked.

Findings

Fifty-three countries had data on both QUM and policy implementation. Forty policies were associated with effect sizes ranging from +13% to -5%. There was positive correlation between the composite QUM indicator and the number of policies reported implemented: (r) = 0.437 (95% CI 0.188 to 0.632). Comparison of policy rankings between the present and previous studies showed positive correlation with the WHO 2003–7 study: Spearman’s rank correlation coefficient 0.498 (95% CI 0.022 to 0.789). Across the three studies, five policies were in the top five ranked positions 11 out of a possible 15 times: drugs available free at the point of care; a government QUM unit; undergraduate training of prescribers in standard treatment guidelines, antibiotics not available without prescription and generic substitution in the public sector.

Interpretation

Certain EM policies are associated with better QUM and impact increases with co-implementation. Analysis across three datasets provides a policy short-list as a minimum investment by countries trying to improve QUM and reduce antimicrobial drug misuse.

Intraperitoneal paclitaxel and cisplatin compared with dose-dense paclitaxel and carboplatin for patients with stage III ovarian cancer

Introduction

Patients diagnosed with stage III ovarian cancer are at high risk of recurrence and optimal adjuvant therapy is often debated. There is limited literature that directly compares intraperitoneal paclitaxel and cisplatin with dose-dense paclitaxel and carboplatin.

Objectives

The primary objective was to compare progression-free survival, overall survival, and tolerability of adjuvant intraperitoneal paclitaxel and cisplatin to dose-dense paclitaxel and carboplatin in stage III ovarian cancer patients.

Methods

A retrospective, IRB-approved, single center chart review was conducted reviewing adult patients with stage III ovarian cancer undergoing adjuvant intraperitoneal therapy or dose-dense therapy between 2010 and 2018.

Results

Eighty-two patients were included in the final analysis; 44 in the intraperitoneal group and 38 in the dose-dense group. Intraperitoneal therapy was not associated with a longer progression-free survival (35.4 vs. 31.1 months; P = 0.97). The duration of overall survival did not differ between intraperitoneal and dose-dense (56.3 vs. 54.5 months; P = 0.55). Dose reductions were less frequent with intraperitoneal than dose-dense (11.36% vs. 31.58%; P = 0.02). No difference in treatment delays (45.5% vs. 65.8%; P = 0.07), dose cancellations (59.1% vs. 57.9%; P = 0.91), supportive care additions (95.5% vs. 84.2%; P = 0.09), or therapy discontinuation (59.1% vs. 39.5%; P = 0.07) between groups was noted.

Conclusions

Intraperitoneal therapy with paclitaxel and cisplatin, as compared with dose-dense paclitaxel and carboplatin, did not prolong progression-free or overall survival in the adjuvant setting among stage III ovarian cancer patients. A trend towards decreased tolerability was noted with intraperitoneal therapy.

Determination of Fat in Olestra-Containing Savory Snack Products by Capillary Gas Chromatography

A quantitative method to determine fat in olestra-containing savory snack products was validated within the AOAC Peer-Verified Methods Program. The method may be used to demonstrate compliance with the guidelines of the U.S. Nutrition Labeling and Education Act for labeling products as "fat free" or "low fat." The method can measure total and saturated fat in savory snacks when present at levels of 0.2-10 g total fat and 0.1-3 g saturated fat per 30 g serving. The method is standardized to measure C6- C24 fatty acids. Extraction of olestra-containing savory snack samples with chloroform-methanol (modified AOAC Official Method 983.23) yields a lipid extract containing the total fat and olestra. The extracted lipid is hydrolyzed by lipase, yielding fatty acids and unreacted olestra. The fatty acids are precipitated as calcium soaps. Olestra is extracted from insoluble soaps with hexane and then discarded. The isolated soaps are converted back into fatty acids with hydrochloric acid and extracted with hexane. The isolated fatty acids are converted to methyl esters with boron trifluoride-methanol and quantitated by capillary gas chromatography using internal standard. Test samples were prepared by blending olestra-containing and full-fat (triglyceride) snacks to obtain 6 levels of spiking (0-10 g total fat added/30 g serving) in potato chips, potato crisps, cheese puffs, and nacho cheese-flavored corn chips. Results were linear (r2 > 0.997) between 0 and 10 g fat/30 g serving for each product matrix. Mean recovery was 101 6% standard deviation (SD) for total fat and 104 ± 6% SD for saturated fat. Mean recovery by peer laboratory was 88 ± 5% SD for total fat and 95 ± 4% SD for saturated fat in potato chips (0-3 g total fat added/30 g serving). Two sets of 10 replicates of potato chips (0.5 g total fat/30 g serving and 0.16 g saturated fat/30 g serving) and potato crisps (0.5 g total fat/30 g serving and 0.16 g saturated fat/30 g serving) were analyzed by submitting and peer laboratories. Repeatability relative standard deviations ranged from 3.90 to 7.33% for total fat and from 4.01 to 11.53% for saturated fat. Reproducibility relative standard deviations were 7.33% (total fat, potato chips), 7.15% (total fat, potato crisps), 11.36% (saturated fat, potato chips), and 13.50% (saturated fat, potato crisps)

Patterns of granulocyte colony-stimulating factor prophylaxis in patients with cancer receiving myelosuppressive chemotherapy

Purpose

To evaluate patterns of primary prophylactic (PP) granulocyte colony–stimulating factor (G-CSF) use following chemotherapy by cancer type and febrile neutropenia (FN) risk.

Methods

Using a commercial administrative database, we identified adult patients diagnosed with breast, colorectal, lung, ovarian cancer, or non-Hodgkin lymphoma (NHL) who initiated chemotherapy with high risk (HR) or intermediate risk (IR) for FN between January 1, 2013, and August 31, 2017. We describe use of PP-G-CSF, proportion completing all their cycles with pegfilgrastim, timing of pegfilgrastim, and duration of short-acting G-CSF.

Results

Among 22,868 patients (breast 11,513; colorectal 3765; lung 4273; ovarian 1287; and NHL 2030), 36.8% received HR and 63.2% received IR (64.4% of whom had ≥ 1 risk factor [RF] for FN). Proportions of patients receiving PP-G-CSF in the first cycle were 76.1%, 28.2%, and 26.4% among patients receiving HR, IR, and IR plus ≥ 1 RF, respectively. Among breast cancer patients receiving HR regimens and initiating PP-pegfilgrastim, 60.4% (95% confidence interval [CI] 57.2–63.6%) initiating via on-body injector (OBI) and 51.9% (95% CI 48.0–55.8%) initiating via prefilled syringe (PFS) completed all their cycles with OBI and PFS, respectively. Among all cycles with PP-PFS, 8.5% received PFS on the same day as chemotherapy completion. Mean administrations/cycle were 3.2 (standard deviation [SD] 2.3) for filgrastim, 3.0 (SD 1.6) for filgrastim-sndz, and 4.3 (SD 2.5) for tbo-filgrastim.

Conclusions

There is under- and mistimed use of PP-G-CSF among patients at HR for FN. Novel pegfilgrastim delivery devices could help breast cancer patients at HR for FN complete all their cycles with timely prophylaxis.

Electronic supplementary material

The online version of this article (10.1007/s00520-020-05295-2) contains supplementary material, which is available to authorized users.

Family Support and Connection Groups: Long-Term Benefits for Inner-City Children?

Relatively few prevention trials have had long-term follow-up to determine if immediate impact translates to and explains long-term impact. The present report summarizes the long-term influence (measured when students are near the end of high school) of the SAFEChildren preventive intervention, which was applied during first grade. This program aims to facilitate and support developmental management, school-family connection, and social support among neigbhors through family groups and student tutoring and is focused on familes raising children in inner-city neighborhoods. Of the 424 families randomly assigned prior to first grade to intervention or no-intervention control, outcome data on at least one outcome was obtained for 375 (88.4%). Results indicate no long-term direct effects and a single mediated effect, with those in the intervention less likely to engage in risky sexual practices. Similar but non-significant trends were found for alcohol use and violence. These mixed results may suggest that family focused intervention that is relatively brief is not adequate to protect against multiple and ongoing developmental risk that arises in such communities. The limited impact is discussed in light of the uncertainty of subsequent condition on initial preventive benefits and the developmental ecology of the inner city. Implications for preventive intervention programming and for long-term evaluation are also addressed.

Identification of Actionable Fusions as an Anti-EGFR Resistance Mechanism Using a Circulating Tumor DNA Assay

PURPOSE

Gene fusions are established oncogenic drivers and emerging therapeutic targets in advanced colorectal cancer. This study aimed to detail the frequencies and clinicopathological features of gene fusions in colorectal cancer using a circulating tumor DNA assay.

METHODS

Circulating tumor DNA samples in patients with advanced colorectal cancer were analyzed at 4,581 unique time points using a validated plasma-based multigene assay that includes assessment of fusions in FGFR2, FGFR3, RET, ALK, NTRK1, and ROS1. Associations between fusions and clinicopathological features were measured using Fisher's exact test. Relative frequencies of genomic alterations were compared between fusion-present and fusion-absent cases using an unpaired t test.

RESULTS

Forty-four unique fusions were identified in 40 (1.1%) of the 3,808 patients with circulating tumor DNA detected: RET (n = 6; 36% of all fusions detected), FGFR3 (n = 2; 27%), ALK (n = 10, 23%), NTRK1 (n = 3; 7%), ROS1 (n = 2; 5%), and FGFR2 (n = 1; 2%). Relative to nonfusion variants detected, fusions were more likely to be subclonal (odds ratio, 8.2; 95% CI, 2.94 to 23.00; P < .001). Mutations associated with a previously reported anti-epidermal growth factor receptor (anti-EGFR) therapy resistance signature (subclonal RAS and EGFR mutations) were found with fusions in FGFR3 (10 of 12 patients), RET (nine of 16 patients), and ALK (seven of 10 patients). For the 27 patients with available clinical histories, 21 (78%) had EGFR monoclonal antibody treatment before fusion detection.

CONCLUSION

Diverse and potentially actionable fusions can be detected using a circulating tumor DNA assay in patients with advanced colorectal cancer. Distribution of coexisting subclonal mutations in EGFR, KRAS, and NRAS in a subset of the patients with fusion-present colorectal cancer suggests that these fusions may arise as a novel mechanism of resistance to anti-EGFR therapies in patients with metastatic colorectal cancer.