Patient preferences and experiences regarding thrombopoietin-receptor agonists for immune thrombocytopenia in the United Kingdom and Ireland (TRAPeze UK & IE study)

OBJECTIVES

To establish the experiences with and preferences towards existing thrombopoietin-receptor agonist (TPO-RA) treatments of individuals with immune thrombocytopenia (ITP) in the UK and Ireland, based on treatment attributes.

METHODS

Responses from UK and Ireland individuals with ITP were collected in a pan-European online survey (TRAPeze, [Thrombopoietin-Receptor Agonist Patient experience survey]) from 18 September 2020 to 18 February 2021. TRAPeze was a survey of treatment preference regarding TPO-RAs (using a discrete choice experiment design), participant demographics, disease characteristics, treatment history, overall satisfaction with therapy, direct healthcare resource utilization and wider social impact.

RESULTS

The survey was completed by 32 UK respondents. Characteristics with the greatest influence on preference towards TPO-RA treatments were method of administration (odds ratio (OR) 5.6, 95% confidence interval (CI) 3.2-10.1) and drug-food interactions (OR 3.2, 95% CI 1.8-5.7). Particularly, participants were more likely to select an oral tablet over a subcutaneous injection (OR 7.4, 95% CI 3.6-15.1) and a treatment without food restrictions rather than with food restrictions (OR 3.6, 95% CI 1.8-6.8).

CONCLUSION

This is the first study to quantify the preference of individuals with ITP towards TPO-RA treatment attributes and demonstrates preference for orally administered treatments, without drug-food interactions.

Differences in obstetrical care and outcomes associated with the proportion of the obstetrician's shift completed

BACKGROUND

Understanding and improving obstetrical quality and safety is an important goal of professional societies, and many interventions such as checklists, safety bundles, educational interventions, or other culture changes have been implemented to improve the quality of care provided to obstetrical patients. Although many factors contribute to delivery decisions, a reduced workload has addressed how provider issues such as fatigue or behaviors surrounding impending shift changes may influence the delivery mode and outcomes.

OBJECTIVE

The objective was to assess whether intrapartum obstetrical interventions and adverse outcomes differ based on the temporal proximity of the delivery to the attending's shift change.

STUDY DESIGN

This was a secondary analysis from a multicenter obstetrical cohort in which all patients with cephalic, singleton gestations who attempted vaginal birth were eligible for inclusion. The primary exposure used to quantify the relationship between the proximity of the provider to their shift change and a delivery intervention was the ratio of time from the most recent attending shift change to vaginal delivery or decision for cesarean delivery to the total length of the shift. Ratios were used to represent the proportion of time completed in the shift by normalizing for varying shift lengths. A sensitivity analysis restricted to patients who were delivered by physicians working 12-hour shifts was performed. Outcomes chosen included cesarean delivery, episiotomy, third- or fourth-degree perineal laceration, 5-minute Apgar score of <4, and neonatal intensive care unit admission. Chi-squared tests were used to evaluate outcomes based on the proportion of the attending's shift completed. Adjusted and unadjusted logistic models fitting a cubic spline (when indicated) were used to determine whether the frequency of outcomes throughout the shift occurred in a statistically significant, nonlinear pattern RESULTS: Of the 82,851 patients eligible for inclusion, 47,262 (57%) had ratio data available and constituted the analyzable sample. Deliveries were evenly distributed throughout shifts, with 50.6% taking place in the first half of shifts. There were no statistically significant differences in the frequency of cesarean delivery, episiotomy, third- or fourth-degree perineal lacerations, or 5-minute Apgar scores of <4 based on the proportion of the shift completed. The findings were unchanged when evaluated with a cubic spline in unadjusted and adjusted logistic models. Sensitivity analyses performed on the 22.2% of patients who were delivered by a physician completing a 12-hour shift showed similar findings. There was a small increase in the frequency of neonatal intensive care unit admissions with a greater proportion of the shift completed (adjusted P=.009), but the findings did not persist in the sensitivity analysis.

CONCLUSION

Clinically significant differences in obstetrical interventions and outcomes do not seem to exist based on the temporal proximity to the attending physician's shift change. Future work should attempt to directly study unit culture and provider fatigue to further investigate opportunities to improve obstetrical quality of care, and additional studies are needed to corroborate these findings in community settings.

COVID-19 stressors, wellbeing and health behaviours: a cross-sectional study

BACKGROUND

Following the implementation of pandemic response measures, concerns arose regarding the impact for population health and wellbeing.

METHODS

This study reports findings from a survey (N = 2510) conducted in Warwickshire (UK) during August and September 2020, and for the first time investigates behaviours which may worsen or mitigate the association between COVID-19-related stressors and wellbeing.

RESULTS

Increased stressors were associated with lower mental wellbeing and higher loneliness. Participants with a mental health condition reported lower wellbeing, as did younger groups, women and participants not in employment. To cope with restrictions, more participants engaged in healthier behaviours over unhealthy behaviours, and relaxing reduced the association between stressors and poor wellbeing. Some participants reported increasing alcohol and unhealthy dietary behaviours to cope with restrictions, however, these behaviours did not mitigate the impact of COVID-19 stressors and were instead negatively associated with wellbeing. Around half of participants helped neighbours during the pandemic, a behaviour positively associated with wellbeing particularly among older adults.

CONCLUSION

These findings contribute understanding about how various positive and negative health behaviours may mitigate or worsen the impact of COVID-19 on wellbeing, and how public health interventions may effectively target behaviours and groups in similar populations.

Efficacy and Safety of Avatrombopag in Patients with Chronic Immune Thrombocytopenia: A Systematic Literature Review and Network Meta-Analysis

INTRODUCTION

A network meta-analysis (NMA) was performed to assess the efficacy and safety of avatrombopag, relative to eltrombopag, romiplostim, and fostamatinib, for patients with chronic immune thrombocytopenia (ITP) not responding adequately to corticosteroids.

METHODS

A systematic search of publication and clinical trial databases was conducted to identify relevant randomized controlled trials (RCTs) and observational studies. Data from eligible studies were extracted and analyzed in a Bayesian framework using relative effect sizes vs placebo. Outcomes included durable platelet response; need for rescue therapy; reduction in use of concomitant ITP medication; incidence of any or World Health Organization (WHO) grade 2-4 bleeding events, and any adverse events. Results were reported as odds ratios or incidence rate ratios (IRR) with 95% credible intervals (CrIs).

RESULTS

The NMA included seven phase 3 RCTs. Compared with placebo, avatrombopag was associated with statistically significant improvements in durable platelet response, reduction in use of concomitant ITP medication, and incidence of any bleeding events. Statistically significant differences vs placebo were also observed for durable platelet response and need for rescue therapy (eltrombopag, romiplostim, and fostamatinib); reduction in use of concomitant ITP medication (eltrombopag and romiplostim); incidence of any bleeding events (fostamatinib); and incidence of WHO grade 2-4 bleeding events (romiplostim and fostamatinib). No statistically significant differences were observed for any adverse events. Avatrombopag was associated with a statistically significant lower incidence of any bleeding events vs eltrombopag (IRR 0.38 [95% CrI 0.19, 0.75]) and romiplostim (IRR 0.38 [95% Crl 0.17, 0.86]); no other between-treatment differences were observed.

CONCLUSION

In this NMA, avatrombopag significantly increased the chance of achieving durable platelet response and reducing the use of concomitant ITP medication vs placebo, and significantly reduced the incidence of any bleeding events compared with placebo, eltrombopag, and romiplostim. The study aims to help guide clinicians managing patients with chronic ITP and insufficient response to previous treatment.

Measurement of the 2νββ Decay Half-Life of ^{130}Te with CUORE

We measured two-neutrino double beta decay of ^{130}Te using an exposure of 300.7 kg yr accumulated with the CUORE detector. Using a Bayesian analysis to fit simulated spectra to experimental data, it was possible to disentangle all the major background sources and precisely measure the two-neutrino contribution. The half-life is in agreement with past measurements with a strongly reduced uncertainty: T_{1/2}^{2ν}=7.71_{-0.06}^{+0.08}(stat)_{-0.15}^{+0.12}(syst)×10^{20}  yr. This measurement is the most precise determination of the ^{130}Te 2νββ decay half-life to date.

Complete pathological response in rectal cancer utilising novel treatment strategies for neo-adjuvant therapy: A systematic review

BACKGROUND

Locally advanced rectal cancer is routinely treated with neo-adjuvant long course chemoradiotherapy or short course radiotherapy, followed by total mesorectal excision. Not all patients respond to this treatment and there has been an emergence of novel treatment strategies designed to improve outcomes for these patients. This systematic review aims to assess the current novel neo-adjuvant treatment strategies being utilised in the treatment of patients with rectal cancer and how these impact pathological complete response (pCR) rates.

METHODS

A systematic review of the literature was performed to evaluate pathological response in patients with rectal cancer receiving novel neo-adjuvant therapy. EMBASE and Medline electronic databases were searched for relevant articles. Articles published between January 2008 and February 2019 were retrieved. Included studies underwent critical appraisal and complete pathological response rates were recorded.

RESULTS

Of the initial 1074 articles identified, 217 articles fulfilled the inclusion criteria, of these 60 articles (4359 patients) were included. Neo-adjuvant therapy delivered included novel long course chemoradiation therapy, neoadjuvant chemotherapy alone, addition of a biological agent, total neo-adjuvant therapy, novel short course radiation therapy and studies utilising biomarkers to select patients for therapy. Complete pathological response rates ranged from 0 to 60%.

CONCLUSION

A validated novel neo-adjuvant therapy that significantly increases pCR rates in patients with rectal cancer has not been identified.

A systematic review of cellular therapies for the treatment of limbal stem cell deficiency affecting one or both eyes

PURPOSE

This systematic review (SR) assessed the efficacy, safety and cost-effectiveness of cell-based therapy to manage limbal stem cell deficiency (LSCD), a sight-threatening orphan condition most frequently associated with severe chemical or thermal burns. LSCD has historically been treated by transplanting limbal tissue. In 1997, a new treatment, cultured limbal epithelial autografts, was described for unilateral LSCD. In cases of bilateral disease cultured autologous oral mucosa stem cells have been used. The relative efficacy of different cultured tissue procedures is unknown.

METHODS

A protocol was registered with PROSPERO (CRD42017081117). Searches were conducted in 14 databases and 6 conference websites. Two reviewers independently selected studies, conducted data extraction and assessed risk of bias. One reviewer extracted individual patient data (IPD); a second checked extracted data. Data were assessed to determine the feasibility of statistical analysis, with Bayesian synthesis used to estimate improvement achieved by different treatments.

RESULTS

Fifty-two studies were eligible for inclusion (1113 eyes); 41 studies (716 eyes) reported IPD. No evidence was identified on cost-effectiveness. This SR was unable to confirm that any of the types of ex vivo cultured stem cell transplants identified for LSCD treatment were statistically superior when assessed against the outcomes of interest.

CONCLUSIONS

We believe this SR is the first to include IPD analysis of LSCD data. There is no evidence for the superiority of any method of limbal stem cell transplant. Confirmation of the safety and efficacy of this treatment modality is challenging due to heterogeneity within and between the studies identified. Therefore, recommendations for future research are proposed.

Improved Limit on Neutrinoless Double-Beta Decay in ^{130} Te with CUORE

We report new results from the search for neutrinoless double-beta decay in ^{130} Te with the CUORE detector. This search benefits from a fourfold increase in exposure, lower trigger thresholds, and analysis improvements relative to our previous results. We observe a background of (1.38±0.07)×10^{-2}  counts/(keV kg yr)) in the 0νββ decay region of interest and, with a total exposure of 372.5 kg yr, we attain a median exclusion sensitivity of 1.7×10^{25}  yr. We find no evidence for 0νββ decay and set a 90% credibility interval Bayesian lower limit of 3.2×10^{25}  yr on the ^{130} Te half-life for this process. In the hypothesis that 0νββ decay is mediated by light Majorana neutrinos, this results in an upper limit on the effective Majorana mass of 75-350 meV, depending on the nuclear matrix elements used.

Cost-Effectiveness Analysis of Recombinant Factor VIII Fc-Fusion Protein (rFVIIIFc) for the Treatment of Severe Hemophilia A in Italy Incorporating Real-World Dosing and Joint Health Data

BACKGROUND

Patients with severe hemophilia A (SHA) in Italy are routinely treated with standard half-life recombinant factor VIII (rFVIII) products. rFVIII Fc-fusion protein (rFVIIIFc) is an extended half-life rFVIII product that enables less frequent administration than rFVIII, which may support improved adherence. Available data indicate low breakthrough bleed rates and potentially improved long-term joint health for patients treated with rFVIIIFc prophylaxis.

OBJECTIVE

This study assessed the cost effectiveness of rFVIIIFc versus rFVIII from an Italian healthcare perspective.

METHODS

A Semi-Markov model was constructed to assess the lifetime costs and benefits of rFVIII and rFVIIIFc prophylaxis. rFVIII product acquisition costs from a published Italian database were included for both prophylaxis and the resolution of breakthrough bleeding. Clinical outcomes within the model were determined based on published annualized bleeding rates and literature regarding the development of target joints (TJs) as the incidence of bleeds and TJs is associated with impaired health-related quality of life. Cost effectiveness was assessed using cost per quality-adjusted life-year (QALY) gained.

RESULTS

Compared with rFVIII, rFVIIIFc was associated with a per-patient cost saving of approximately €1.3 million and QALY gains of 0.39 over a lifetime horizon. Sensitivity analyses considering alternative efficacy, dosing, and structural assumptions each showed that rFVIIIFc dominated rFVIII (i.e., provided more QALYs at a reduced cost).

CONCLUSIONS

This cost-effectiveness analysis demonstrated that rFVIIIFc may offer a cost-effective treatment option for patients with SHA in Italy.

Positive adaptation of HPA axis function in women during 44 weeks of infantry-based military training

BACKGROUND

Basic military training (BMT) is a useful model of prolonged exposure to multiple stressors. 8-12 week BMT is associated with perturbations in the hypothalamic-pituitary-adrenal (HPA) axis which could predispose recruits to injury and psychological strain. However, characterisations of HPA axis adaptations during BMT have not been comprehensive and most studies included few if any women.

METHODS

We studied women undertaking an arduous, 44-week BMT programme in the UK. Anxiety, depression and resilience questionnaires, average hair cortisol concentration (HCC), morning and evening saliva cortisol and morning plasma cortisol were assessed at regular intervals throughout. A 1-h dynamic cortisol response to 1 μg adrenocorticotrophic hormone-1-24 was performed during weeks 1 and 29.

RESULTS

Fifty-three women (aged 24 ± 2.5 years) completed the study. Questionnaires demonstrated increased depression and reduced resilience during training (F 6.93 and F 7.24, respectively, both p < 0.001). HCC increased from 3 months before training to the final 3 months of training (median (IQR) 9.63 (5.38, 16.26) versus 11.56 (6.2, 22.45) pg/mg, p = 0.003). Morning saliva cortisol increased during the first 7 weeks of training (0.44 ± 0.23 versus 0.59 ± 0.24 μg/dl p < 0.001) and decreased thereafter, with no difference between the first and final weeks (0.44 ± 0.23 versus 0.38 ± 0.21 μg/dl, p = 0.2). Evening saliva cortisol did not change. Fasting cortisol decreased during training (beginning, mid and end-training concentrations: 701 ± 134, 671 ± 158 and 561 ± 177 nmol/l, respectively, p < 0.001). Afternoon basal cortisol increased during training while there was a trend towards increased peak stimulated cortisol (177 ± 92 versus 259 ± 13 nmol/l, p = 0.003, and 589 ± 164 versus 656 ± 135, p = 0.058, respectively).

DISCUSSION

These results suggest a normal stress response in early training was followed quickly by habituation, despite psychological and physical stress evidenced by questionnaire scores and HCC, respectively. There was no evidence of HPA axis maladaptation. These observations are reassuring for women undertaking arduous employment.

Evaluation of the BAX® System for Detection of Listeria monocytogenes in Foods: Collaborative Study

A multilaboratory study was conducted to compare the automated BAX® system and the standard cultural methods for detection of Listeria monocytogenes in foods. Six food types (frankfurters, soft cheese, smoked salmon, raw, ground beef, fresh radishes, and frozen peas) were analyzed by each method. For each food type, 3 inoculation levels were tested: high (average of 2 CFU/g), low (average of 0.2 CFU/g) and uninoculated controls. A total of 25 laboratories representing government and industry participated. Of the 2335 samples analyzed, 1109 were positive by the BAX system and 1115 were positive by the standard method. A Chi square analysis of each of the 6 food types, at the 3 inoculation levels tested, was performed. For all foods, except radishes, the BAX system performed as well as or better than the standard reference methods based on the Chi square results.

Evaluation of the BAX® System for Detection of Salmonella in Selected Foods: Collaborative Study

A multilaboratory study was conducted to compare the automated BAX® System to the standard cultural methods for detection of Salmonella in selected foods. Five food types—frankfurters, raw ground beef, mozzarella cheese, raw frozen tilapia fish, and orange juice—at 3 inoculation levels, were analyzed by each method. A sixth food type, raw ground chicken, was tested using 3 naturally contaminated lots. A total of 16 laboratories representing government and industry participated. In this study, 1386 samples were analyzed, of which 1188 were paired samples and 198 were unpaired samples. Of the 1188 paired samples, 461 were positive by both methods and 404 were negative by both methods. Thirty-seven samples were positive by the BAX System but negative by the standard reference method, and 11 samples were positive by standard cultural method and negative by the BAX System. Of the 198 unpaired samples, 106 were positive by the BAX System and 60 were positive by the standard cultural method. A Chi square analysis of each of the 6 food types, at the 3 inoculation levels tested, was performed. For all foods, the BAX System demonstrated results comparable to those of the standard reference methods based on the Chi square results.

Using electronic patient records: defining learning outcomes for undergraduate education

BACKGROUND

Healthcare professionals are required to access, interpret and generate patient data in the digital environment, and use this information to deliver and optimise patient care. Healthcare students are rarely exposed to the technology, or given the opportunity to use this during their training, which can impact on the digital competence of the graduating workforce. In this study we set out to develop and define domains of competence and associated learning outcomes needed by healthcare graduates to commence working in a digital healthcare environment.

METHOD

A National Working Group was established in the UK to integrate Electronic Patient Records (EPRs) into undergraduate education for healthcare students studying medicine, pharmacy, nursing and midwifery. The working group, comprising 12 academic institutions and representatives from NHS England, NHS Digital and EPR system providers, met to discuss and document key learning outcomes required for using EPRs in the healthcare environment. Outcomes were grouped into six key domains and refined by the group prior to external review by experts working in medical education or with EPRs.

RESULTS

Six key domains of competence and associated learning outcomes were identified and defined. External expert review provided iterative refinement and amendment. The agreed domains were: 1) Digital Health: work as a practitioner in the digital healthcare environment; 2) Accessing Data: access and interpret patient data to inform clinical decision-making; 3) Communication: communicate effectively with healthcare professionals and patients in the digital environment; 4) Generating data: generate data for and about patients within the EPR; 5) Multidisciplinary working: work with healthcare professionals with and alongside EPRs; and 6) Monitoring and audit: monitor and improve the quality and safety of healthcare.

CONCLUSION

The six domains of competence and associated learning outcomes can be used by academics to guide the integration of EPRs into undergraduate healthcare programmes. This is key to ensuring that the future healthcare workforce can work with and alongside EPRs.

Abdominal volume computed tomography assessment of body composition in dogs

Background

Computed tomography (CT) has been used to estimate body composition and determine tissue distribution in dogs, despite limited validation. This may introduce error into estimates of body composition studies and its effect on health in dogs. Further, the modality has not been validated against dual-energy X-ray absorptiometry (DXA) or over a wide range of dog breeds, ages and sexes. The objective of this study was to validate the use of semi-automated, abdominal volume CT for estimating total body composition of dogs relative to DXA. Twenty-two staff-owned dogs (weighing between 5.1-60 kg) were sedated and underwent full body DXA scan and abdominal CT. Abdominal tissue composition was estimated by CT using semi-automated volume segmentation, over predetermined tissue Hounsfield threshold values. Abdominal tissue composition determined by the various CT threshold ranges was compared to total body composition determined by DXA.

Results

Abdominal tissue composition estimated by CT strongly correlated with the estimates derived from DXA with a small Bland-Altman mean percentage differences in values: total body mass (− 250/2000HU: r² = 0.985; − 1.10%); total fat mass (− 250/-25HU: r² = 0.981; − 1.90%); total lean tissue mass (− 25/150HU: r² = 0.972; 3.47%); and total bone mineral content (150/2000HU: r² = 0.900; − 0.87%). Although averaged CT values compared well to DXA analysis, there was moderate variation in the individual predicted values. There was near perfect inter- and intra-observer agreement in segmentation volumes for abdominal fat.

Conclusions

Abdominal volume computed tomography (CT) accurately and reliably estimates total body composition in dogs, but greater variations may be observed in dogs weighing less than 10 kg.

Monitoring of tidal ventilation by electrical impedance tomography in anaesthetised horses

BACKGROUND

Electrical impedance tomography (EIT) is a method to measure regional impedance changes within the thorax. The total tidal impedance variation has been used to measure changes in tidal volumes in pigs, dogs and men.

OBJECTIVES

To assess the ability of EIT to quantify changes in tidal volume in anaesthetised mechanically ventilated horses.

STUDY DESIGN

In vivo experimental study.

METHODS

Six horses (mean ± s.d.: age 11.5 ± 7.5 years and body weight 491 ± 40 kg) were anaesthetised using isoflurane in oxygen. The lungs were mechanically ventilated using a volume-controlled mode. With an end-tidal carbon dioxide tension in the physiological range, and a set tidal volume (VT_vent ) of 11-16 mL/kg (baseline volume), EIT data and VT measured by conventional spirometry were collected over 1 min. Thereafter, VT_vent was changed in 1 L steps until reaching 10 L. After, VT_vent was reduced to 1 L below the baseline volume and then further reduced in 1 L steps until 4 L. On each VT step data were recorded for 1 min after allowing 1 min of stabilisation. Impedance changes within the predefined two lung regions of interest (EIT_ROI ) and the whole image (EIT_thorax ) were calculated. Linear regression analysis was used to assess the relationship between spirometry data and EIT_ROI and EIT_thorax for individual horses and pooled data.

RESULTS

Both EIT_ROI and EIT_thorax significantly predicted spirometry data for individual horses with R² ranging from 0.937 to 0.999 and from 0.954 to 0.997 respectively. This was similar for pooled data from all six horses with EIT_ROI (R² = 0.799; P<0.001) and EIT_thorax (R² = 0.841; P<0.001).

MAIN LIMITATIONS

The method was only tested in healthy mechanically ventilated horses.

CONCLUSIONS

The EIT can be used to quantify changes in tidal volume.