Prothrombin complex concentrate vs. fresh frozen plasma in adult patients undergoing heart surgery - a pilot randomised controlled trial (PROPHESY trial)

There is equipoise regarding the use of prothrombin complex concentrate vs. fresh frozen plasma in bleeding patients undergoing cardiac surgery. We performed a pilot randomised controlled trial to determine the recruitment rate for a large trial, comparing the impact of prothrombin complex concentrate vs. fresh frozen plasma on haemostasis (1 h and 24 h post-intervention), and assessing safety. Adult patients who developed bleeding within 24 h of cardiac surgery that required coagulation factor replacement were randomly allocated to receive prothrombin complex concentrate (15 IU.kg^-1 based on factor IX) or fresh frozen plasma (15 ml.kg^-1 ). If bleeding continued after the first administration of prothrombin complex concentrate or fresh frozen plasma administration, standard care was administered. From February 2019 to October 2019, 180 patients were screened, of which 134 (74.4% (95%CI 67-81%)) consented, 59 bled excessively and 50 were randomly allocated; 25 in each arm, recruitment rate 35% (95%CI 27-44%). There were 23 trial protocol deviations, 137 adverse events (75 prothrombin complex concentrate vs. 62 fresh frozen plasma) and 18 serious adverse events (5 prothrombin complex concentrate vs. 13 fresh frozen plasma). There was no increase in thromboembolic events with prothrombin complex concentrate. No patient withdrew from the study, four were lost to follow-up and two died. At 1 h after administration of the intervention there was a significant increase in fibrinogen, Factor V, Factor XII, Factor XIII, α₂ -antiplasmin and antithrombin levels in the fresh frozen plasma arm, while Factor II and Factor X were significantly higher in the prothrombin complex concentrate group. At 24 h, there were no significant differences in clotting factor levels. We conclude that recruitment to a larger study is feasible. Haemostatic tests have provided useful insight into the haemostatic changes following prothrombin complex concentrate or fresh frozen plasma administration. A definitive trial is needed to ascertain the benefits and safety for each.

Steroid-sparing effects of benralizumab in patients with eosinophilic granulomatosis with polyangiitis

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare, anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis characterised by asthma, chronic rhinosinusitis and blood eosinophilia, which may be accompanied by neurological, cardiac, cutaneous and renal involvement [1]. Oral corticosteroids (OCS) are the most frequently used drugs to control eosinophilic inflammation and symptoms. Persistent symptoms or relapses are common, however, and many patients are at risk of developing long-term complications from systemic steroid therapy [2]. The ability of other immunosuppressant agents to achieve consistent disease control or to reduce maintenance OCS (mOCS) requirements appears to be limited [3].

Benralizumab reduces oral corticosteroid requirements in patients with EGPA and leads to improved patient-reported outcome measureshttps://bit.ly/2GI0vhf

Adding value to the use of Health Impact Assessment and social return on investment technologies

Health Impact Assessment (HIA) and Social Return on Investment (SROI) are beneficial public health methodologies that assess potential effects on health including social, economic and environmental factors and have synergies in their approaches. This paper explores how HIA and SROI can complement each other to capture and account for the impact and social value of an assessed intervention or policy.

A scoping review of academic and grey literature was undertaken to identify case studies published between January 1996 and April 2019 where HIA and SROI methods have been used to complement each other. Semi-structured interviews were carried out with nine international experts from a range of regulatory/legislative contexts to gain a better understanding of past experiences and expertise of both HIA and SROI. A thematic analysis was undertaken on the data collected. The review identified two published reports which outline when HIA and SROI have both been used to assess the same intervention. Interview results suggest that both methods have strengths as standalone processes i.e. HIAs are well-structured in their approach, assessing health in its broadest context and SROI can add value by monetizing social value as well as capturing social/environmental impact. Similarities of the two methods were identified i.e. a strong emphasis on stakeholder engagement and common shared principles. When questioned how the two methods could complement each other in practice, the results indicate the benefits of using HIA to explore initial impact, and as a platform on which to build SROI to monetarize social value.

HIA and SROI methodologies have cross-over. The research suggests potential benefits when used in tandem or combining the methods to assess impact and account for health and social value. Innovative work is now being carried out in Wales to understand the implications of this in practice and to understand how the results of the two methods could be used by decision-makers.

Key messages

HIA and SROI methods can be used in tandem to capture both the health impact and social value of policies and proposed interventions. HIA and SROI when used together can provide valuable information to inform decision makers around the health impact and social value of proposed policies and interventions.

Assessing the public health impact of climate change in Wales

In April 2019, Wales declared a climate emergency. Public Health Wales commissioned a Health Impact Assessment (HIA) to assess the potential impact of Climate Change on the population of Wales to be carried out to inform key strategic decision makers to understand/plan for the potential differential health impacts that may occur in Wales from climate change.

A comprehensive mixed-method HIA was conducted over a 6-month period in 2019/20. A review of peer-reviewed evidence on the potential impact of climate change/climate change events on health and population groups and a review of grey literature on direct impacts such as the environment, mental wellbeing and health care settings was conducted. The search was undertaken using MEDLINE, Embase, Proquest. 2 stakeholder workshops, qualitative interviews, a community health profile utilising recognised data sources (i.e. The National Survey for Wales) and a survey to identify the publics' views on climate change were also carried out. All findings were analysed, synthesized and collated into a report.

The HIA initial findings indicate significant potential impacts across the wider determinants of health and mental well-being i.e. Air quality, excess heat/cold; flooding; economic productivity; working conditions; access to services; infrastructure; and community resilience. A range of impacts were identified across population groups, settings, geographical areas including urban and rural contexts; outdoor workers; children and young people; older people; schools; hospitals/care homes and workplaces.

The impacts identified are both confirmed and potential. Undertaken in a short timeframe, the findings have been beneficial to inform decision-makers to prepare for Climate Change plans/policies using an evidence-informed approach. The work has demonstrated the value of a HIA approach for significant, complex policies by mobilising a range of evidence through a transparent process, resulting in transferrable learning for others.

Real-World Effectiveness of Benralizumab in Severe Eosinophilic Asthma

BACKGROUND

Benralizumab is an IL5-receptor monoclonal antibody licensed for the treatment of severe eosinophilic asthma (SEA). It has demonstrated efficacy in clinical trials in reducing asthma exacerbation rates and maintenance oral corticosteroids (mOCSs).

RESEARCH QUESTION

What is the real-world effectiveness of benralizumab and what baseline characteristics are associated with response to therapy?

STUDY DESIGN AND METHODS

We assessed outcomes in all SEA patients who began benralizumab treatment at our specialist center. At each dosing visit, exacerbation history, mOCS dose, spirometry, and Asthma Control Questionnaire (ACQ6) and Mini-Asthma Quality of Life Questionnaire (mAQLQ) scores were recorded. Response to treatment was defined as a reduction of ≥ 50% in annualized exacerbation rate (AER) or in mOCS dose after 48 weeks of treatment. Super response was defined as zero exacerbations and no mOCSs for asthma.

RESULTS

One hundred thirty patients were included in the analysis. At 48 weeks, a 72.8% reduction in AER was noted, from 4.92 ± 3.35 per year in the year preceding biologic treatment to 1.34 ± 1.71 per year (P < .001), including 57 patients (43.8%) who were exacerbation-free with benralizumab. In those receiving mOCSs (n = 74 [56.9%]), the median daily prednisolone dose fell from 10 mg (interquartile range, 5-20 mg) to 0 mg (interquartile range, 0-5 mg; P < .001), and 38 of 74 patients (51.4%) were able to discontinue mOCS therapy. Clinically and statistically significant improvements were found in ACQ6 scores, mAQLQ scores, and FEV₁. Overall, 51 patients (39%) met the super responder definition and 112 patients (86%) met the responder definition. The optimal regression model of super responders vs other responders included baseline characteristics associated with a strongly eosinophilic phenotype and less severe disease. Eighteen patients (13.8%) were nonresponders to benralizumab. Evidence of chronic airway infection was observed in 6 of 18 patients, and an increase in the blood eosinophil count consistent with the development of anti-drug antibodies was observed in 5 of 18 patients.

INTERPRETATION

In a large real-world SEA cohort, benralizumab led to significant improvements in all clinical outcome measures. A lack of response was seen in a minority of patients and should be a focus for future investigation.

Adherence to corticosteroids and clinical outcomes in mepolizumab therapy for severe asthma

INTRODUCTION

Inhaled corticosteroids (ICS) achieve disease control in the majority of asthmatic patients, although adherence to prescribed ICS is often poor. Patients with severe eosinophilic asthma may require treatment with oral corticosteroids (OCS) and/or biologic agents such as mepolizumab. It is unknown if ICS adherence changes on, or alters clinical response to, biologic therapy.

METHODS

We examined ICS adherence and clinical outcomes in OCS-dependent severe eosinophilic asthma patients who completed 1 year of mepolizumab therapy. The ICS medicines possession ratio (MPR) was calculated (the number of doses of ICS issued on prescription/expected number) for the year before and the year after biologic initiation. Good adherence was defined as MPR >0.75, intermediate 0.74-0.51 and poor <0.5. We examined outcomes after 12 months of biologic therapy, including OCS reduction and annualised exacerbation rate (AER), stratified by adherence to ICS on mepolizumab.

RESULTS

Out of 109 patients commencing mepolizumab, 91 who had completed 12 months of treatment were included in the final analysis. While receiving mepolizumab, 68% had good ICS adherence, with 16 (18%) having poor ICS adherence. ICS use within the cohort remained similar before (MPR 0.81±0.32) and during mepolizumab treatment (0.82±0.32; p=0.78). Patients with good adherence had greater reductions in OCS dose (median (interquartile range) OCS reduction 100 (74-100)% versus 60 (27-100)%; p=0.031) and exacerbations (AER change -2.1±3.1 versus 0.3±2.5; p=0.011) than those with poor adherence. Good ICS adherence predicted the likelihood of stopping maintenance OCS (adjusted OR 3.19, 95% CI 1.02-9.94; p=0.045).

CONCLUSION

ICS nonadherence is common in severe eosinophilic asthma patients receiving mepolizumab, and is associated with a lesser reduction in OCS requirements and AER.

Rescue of degenerating neurons and cells by stem cell released molecules: using a physiological renormalization strategy

Evidence suggests that adult stem cell types and progenitor cells act collectively in a given tissue to maintain and heal organs, such as muscle, through a release of a multitude of molecules packaged into exosomes from the different cell types. Using this principle for the development of bioinspired therapeutics that induces homeostatic renormalization, here we show that the collection of molecules released from four cell types, including mesenchymal stem cells, fibroblast, neural stem cells, and astrocytes, rescues degenerating neurons and cells. Specifically, oxidative stress induced in a human recombinant TDP‐43‐ or FUS‐tGFP U2OS cell line by exposure to sodium arsenite was shown to be significantly reduced by our collection of molecules using in vitro imaging of FUS and TDP‐43 stress granules. Furthermore, we also show that the collective secretome rescues cortical neurons from glutamate toxicity as evidenced by increased neurite outgrowth, reduced LDH release, and reduced caspase 3/7 activity. These data are the first in a series supporting the development of stem cell‐based exosome systems therapeutics that uses a physiological renormalization strategy to treat neurodegenerative diseases.

Real-World Effectiveness and the Characteristics of a "Super-Responder" to Mepolizumab in Severe Eosinophilic Asthma

BACKGROUND

Mepolizumab was the first licensed anti-IL5 monoclonal antibody for severe eosinophilic asthma (SEA). To date there are few data to confirm its efficacy in the real-world setting or assessment of baseline characteristics associated with response.

RESEARCH QUESTION

How do patients with severe eosinophilic asthma respond to mepolizumab in the real world setting and which characteristics are associated with a super-response to this therapy?

STUDY DESIGN AND METHODS

We conducted a retrospective review of all patients who received at least 16 weeks of treatment with mepolizumab (100 mg subcutaneously) for SEA at our regional asthma center in the United Kingdom. Clinical data were collected at each 4-week visit. At 16, 24, and 52 weeks, patients were classified as "responders" or "nonresponders." A response was defined as ≥50% reduction in exacerbations; for patients whose condition requires maintenance oral corticosteroids (mOCS), a response was defined as ≥50% reduction in prednisolone dose. Super responders were defined as exacerbation-free and off mOCS at one year.

RESULTS

Ninety-nine patients were included in the analysis. Asthma exacerbations decreased from a baseline of 4.04 ± 2.57 to 1.86 ± 2.17 per year at one year (54% reduction; P < .001). Sixty-eight patients were receiving mOCS at the time of commencing mepolizumab. By one year, the daily median dose fell from 10 mg (interquartile range, 10 to 15) to 0 mg (interquartile range, 0 to 10; P < .001). Fifty-seven percent of them were able to discontinue mOCS; 72.7% (95% CI, 63.0 to 80.7) of the patients were classified as responders, and 28.3% (95% CI, 20.2 to 38.0) of the patients were classified as super responders. Baseline characteristics associated with responder and super responder status included the presence of nasal polyposis (P = .012), lower baseline Asthma Control Questionnaire 6 (P = .006), a lower BMI (P = .014), and, in those patients receiving mOCS, a significantly lower prednisolone dose at baseline (P = .005). At 16 weeks, the one-year responder status was correctly identified in 80.8% patients; by 24 weeks, this status rose to 92.9%.

INTERPRETATION

In a real-world SEA cohort, treatment with mepolizumab reduced exacerbation frequency and mOCS requirements. Nasal polyposis, a lower BMI, and a lower maintenance prednisolone requirement at baseline were associated with better outcomes. Twelve-month response was identifiable in >90% of patients by week 24.

Oral corticosteroid-sparing effects of reslizumab in the treatment of eosinophilic granulomatosis with polyangiitis

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare but devastating vasculitis characterised by perivascular eosinophilic inflammation, severe asthma, peripheral eosinophilia and sinonasal disease, frequently complicated by cardiac, neurological or renal involvement [1, 2]. The mainstay of therapy for EGPA is use of systemic corticosteroids (OCS), with or without concomitant immunosuppression with methotrexate, azathioprine, cyclophosphamide or rituximab [3, 4]. The long-term use of these agents is associated with significant drug-related morbidity and the risk of relapse in EGPA patients remains significant despite treatment [1, 5]. Interleukin (IL)-5 is a critical cytokine regulating eosinophil development, migration and activation [2]. In EGPA, high doses of the IL-5 neutralising antibody mepolizumab lead to improved disease control and reduced requirement for OCS therapy, with an excellent safety profile [6, 7]. Reslizumab is another IL-5 neutralising antibody currently licensed for the treatment of severe eosinophilic asthma [8]; however, there are – to our knowledge – no published data exploring the utility of reslizumab in the management of EGPA. Here, we report clinical and patient-reported outcomes in a cohort of treatment-refractory, OCS-dependent EGPA patients with severe asthma commenced on reslizumab.

Blockade of interleukin-5 with reslizumab appears to have significant oral corticosteroid sparing effects in patients with eosinophilic granulomatosis with polyangiitis and severe eosinophilic asthmahttp://bit.ly/2D2yYSK

Skills and knowledge to facilitate competence for health and wellbeing in Environmental Impact Assessment

Findings

This paper describes a clear set of expected skills and knowledge outcomes that competent practitioners and multi-disciplinary teams need to exhibit; which policy makers and commissioners need to seek; and which reviewers should expect see applied, in order to ensure that high quality, fit for purpose EIAs are carried out which include the widest interpretation of health, wellbeing and inequalities. It discusses the work of the Wales HIA Support Unit to train and mentor practitioners and organisations and presents resources to enable this such as its Skills and Knowledge Development Framework, which provides a pathway to develop and support competence in practice, and the Quality Assurance Review Framework for HIA.

Conclusions

To enable competent broad holistic assessments to be carried out a clear set of criteria, tools, resources and training opportunities are needed in order to enable and facilitate a wide range of personnel to deliver a wide and inclusive health appraisal as part of EIA.

The Public Health Implications of Brexit: A Health Impact Assessment Approach

Key messages

HIA can inform and influence action in response to important strategic decisions. The Brexit HIA is a unique example which can inform international HIA practice.

The Public Health Implications of Brexit in Wales: A Health Impact Assessment (HIA) approach

Key messages

Brexit is a major policy change with major health impacts. HIA is an informative and influencing process to support planning and future policy making.

An Attempt to Quantitate "Value" In Medical Oncologic Therapy

Objective

We wanted to examine the incremental cost-effective ratio (ICER) for a variety of Food and Drug Administration (FDA) approved oncology drugs in the adjuvant or curative setting to determine the value provided.

Design

We examined the annualized incremental drug costs of a variety of FDA approved chemotherapeutic drugs used in an adjuvant or curative setting based on National Comprehensive Cancer Network (NCCN) category 1 practice guidelines for melanoma, Her2/neu over-expressive breast cancer, renal cell carcinoma, stage IIIA non-small cell lung cancer, myeloma, B cell lymphoma, and Hodgkin lymphoma. The studies we examined were randomized clinical trials on which the NCCN guidelines are based; we solely examined the incremental cost-effectiveness of the trial drug as we assumed that the costs of the health care provided were equivalent between the two treatment arms. We used a formula to determine the incremental cost-effectiveness ratio (ICER). The ICER compares a new intervention (C new) with its alternate (C alt) divided by the quality-adjusted life-years (QALY) that results from the new intervention (QALY new) versus the alternate (QALY alt) and is expressed as ICER = (C new-C alt)/(QALY new-QALY alt). The QALY’s were derived from what was reported in the study and based on the incremental disease-free survival.

Results

Drugs such as rituximab provide high value in the curative therapy for lymphoma. Drugs such as adjuvant dabrafenib and trametinib provide intermediate value in the treatment of melanoma, and similarly with maintenance lenalidomide in myeloma and adjuvant trastuzumab in breast cancer. Oncologic drugs that provide low value include adjuvant ipilimumab in melanoma, adjuvant sunitinib in renal cell carcinoma, adjuvant neratinib in breast cancer, adjuvant durvalumab in lung cancer, and brentuximab in the curative therapy for Hodgkin’s lymphoma.

Conclusion

The ICER needs to be evaluated for newly approved FDA oncology chemotherapeutic drugs before incorporating them into routine clinical practice.

Overcoming suvivorship care planning implementation challenges through decentralization

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Background: To meet Commission on Cancer accreditation requirements, cancer programs must implement processes to monitor the dissemination of survivorship care plans (SCP) for patients with Stages I-III cancers who were treated with curative intent and completed active therapy. Challenges of SCP delivery across disease sites include lack of designated/trained staff, time burden, knowledge of current evidence-based guidelines, and sustainability. We describe the challenges NorthShore University HealthSystem Kellogg Cancer Center (NKCC) and their Living in the Future (LIFE) Cancer Survivorship Program faced in meeting this standard and how evolving the SCP delivery process has resulted in a sustainable model. Methods: LIFE implemented a technology-based SCP tool using a centralized consultative model led by a nurse practitioner (NP) with specialized survivorship training. Physicians referred eligible patients to the survivorship clinic for an education visit where they received a SCP from the NP. Since the centralized model was dependent on one person for delivery, a more sustainable model was needed. NKCC transitioned to a decentralized process, moving SCP creation and delivery responsibility to all oncology care providers (OCPs). Although not all OCPs had specialized survivorship training, care quality was supported by automated SCP creation based on evidence-based care recommendations embedded in the technology. Results: To date, 143 evidence-based SCPs have been delivered since tool implementation in April 2017. During the centralized model (April 25– June 30) 67 SCPs were created by the lead LIFE NP; 76 were created during the decentralized process while the lead NP was on leave (July 3 – Oct 1). By using a technology-based SCP, OCPs incorporated SCP delivery into their workflow and no longer had to refer patients to a separate clinic. Conclusions: This project demonstrates the feasibility of a sustainable, decentralized process using a technology-based SCP as an option for augmenting centralized SCP delivery. A comparable number of patients received a SCP during both processes with an equivalent number of SCPs being delivered via the decentralized model by OCPs supported by evidence-based technology.

Abstract OT3-05-10: A single arm phase II study of palbociclib in combination with tamoxifen as first line therapy for metastatic hormone receptor positive breast cancer

Background: Hormone receptor positive breast cancer is the most commonly diagnosed subset of breast cancer (60-65%). Endocrine therapy is effective for this subset of breast cancer, in both the adjuvant and metastatic settings. Despite advances in endocrine therapy, many patients relapse during or after completing adjuvant therapy and metastatic breast cancer remains incurable. Palbociclib is a reversible, oral, small molecule inhibitor of cyclin dependent kinases 4 and 6 (CDK4/6). CDK4 and CDK6 together with cyclin D have important roles in regulation of the G1/S transition via regulation of the phosphorylation state of retinoblastomaprotein (Rb). Palbociclib showed significantly improved progression-free survival taken together with endocrine agents in treatment of metastatic breast cancer. Preclinical data showed that in combination with tamoxifen, palbociclib had synergistic growth inhibitory activity as well as efficacy in a model of acquired tamoxifen resistance. Combining palbociclib with tamoxifen in first line treatment of metastatic hormone receptor positive breast cancer may offers an appealing alternative to other endocrine combinations. Methods: This is a non-randomized, open-label, single-arm, multicenter, phase II study of palbociclib in combination with tamoxifen in patients with hormone receptor positive/HER2 negative advanced breast cancer. The primary objective is to determine the objective response rate (complete or partial response) based on RECIST 1.1 or MDA Criteria (for patients with bone only disease). Secondary objectives are: safety and tolerability, progression-free survival, clinical benefit rate, 2-year overall survival. Correlative objectives will explore alterations in circulating tumor DNA and changes in gene expression pattern at the time of progression. Eligibility criteria: women or men with diagnosis of hormone receptor positive/ HER2 negative locally advanced or metastatic breast cancer, not amenable to curative surgery; no prior systemic anti-cancer therapy for advanced hormone receptor positive breast cancer; adequate organ function; pre and post menopausal women are allowed. Drug administration: palbociclib dose will be 125 mg orally once daily on days 1-21 of each 28-day cycle; tamoxifen dose will be 20 mg orally once daily for every day of the 28-day cycle. As of June 2017, the study enrolled 10/71 patients and it is still open to enrollment. NCT 02668666; ocdanciu@uic.edu

Citation Format: Danciu OC, Hoskins K, Tamkus D, Truica C, Blaes A, Green L, Liu L, Toppmeyer D, Wisinski K. A single arm phase II study of palbociclib in combination with tamoxifen as first line therapy for metastatic hormone receptor positive breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT3-05-10.