Recently listed Stockholm convention POPs: Analytical methodology, occurrence in food and dietary exposure

In recent years, the Stockholm Convention has listed an additional set of persistent organic pollutants (POPs) for elimination or restricted use/release. Data on the occurrence of these contaminants in food is scarce. Validated analytical methodology was developed to investigate the occurrence of hexachlorobutadiene (HCBD), pentachlorobenzene (PCBz), hexachlorobenzene (HCB) pentachlorophenol (PCP) and polychlorinated naphthalenes (PCNs) in 120 retail foods and 19 total diet study samples. The foods covered the range of commonly consumed dietary items including dairy products, eggs (hen and other species), poultry, meat, fish, vegetables, etc. HCBD showed a low frequency of detection, whereas PCBz, HCB and PCNs occurred in most samples (ranges: <0.01 to 0.19 μg/kg; <0.01 to 3.16 μg/kg and 0.1 to 166 ng ΣPCNs/kg respectively). PCP (<0.01 to 1.9 μg/kg) was detected more frequently in meat products, offal and eggs. Fish, shellfish, eggs from all species, animal fats, meat, offal and meat products showed higher contamination levels, which is normal when investigating lipophilic POPs. These levels of occurrence are similar to more recently reported literature levels but perhaps lower, relative to historic data. This is not unexpected, given the restrictions/limitations on these chemicals within the UK and Western Europe. The estimated human exposure to population groups through dietary intake is correspondingly low and based on current toxicological knowledge, the levels in the examined samples do not suggest a cause for health concern. The data also provide a current baseline for HCBD, PCBz and PCP, and update existing data for PCN and HCB occurrence in foods.

Outcomes and outcome measures used in evaluation of communication training in oncology - a systematic literature review, an expert workshop, and recommendations for future research

BACKGROUND

Communication between health care provider and patients in oncology presents challenges. Communication skills training have been frequently developed to address those. Given the complexity of communication training, the choice of outcomes and outcome measures to assess its effectiveness is important. The aim of this paper is to 1) perform a systematic review on outcomes and outcome measures used in evaluations of communication training, 2) discuss specific challenges and 3) provide recommendations for the selection of outcomes in future studies.

METHODS

To identify studies and reviews reporting on the evaluation of communication training for health care professionals in oncology, we searched seven databases (Ovid MEDLINE, CENTRAL, CINAHL, EMBASE, PsychINFO, PsychARTICLES and Web of Science). We extracted outcomes assessed and the respective assessment methods. We held a two-day workshop with experts (n = 16) in communication theory, development and evaluation of generic or cancer-specific communication training and/or outcome measure development to identify and address challenges in the evaluation of communication training in oncology. After the workshop, participants contributed to the development of recommendations addressing those challenges.

RESULTS

Out of 2181 references, we included 96 publications (33 RCTs, 2 RCT protocols, 4 controlled trials, 36 uncontrolled studies, 21 reviews) in the review. Most frequently used outcomes were participants' training evaluation, their communication confidence, observed communication skills and patients' overall satisfaction and anxiety. Outcomes were assessed using questionnaires for participants (57.3%), patients (36.0%) and observations of real (34.7%) and simulated (30.7%) patient encounters. Outcomes and outcome measures varied widely across studies. Experts agreed that outcomes need to be precisely defined and linked with explicit learning objectives of the training. Furthermore, outcomes should be assessed as broadly as possible on different levels (health care professional, patient and interaction level).

CONCLUSIONS

Measuring the effects of training programmes aimed at improving health care professionals' communication skills presents considerable challenges. Outcomes as well as outcome measures differ widely across studies. We recommended to link outcome assessment to specific learning objectives and to assess outcomes as broadly as possible.

The potential of recycled materials used in agriculture to contaminate food through uptake by livestock

The potential for contaminant uptake from recycled materials used in livestock farming, to animal tissues and organs, was investigated in three practical modular studies involving broiler chickens, laying chickens and pigs. Six types of commercially available recycled materials were used either as bedding material for chickens or as fertilizer for cropland that later housed outdoor reared pigs. The contaminants studied included regulated contaminants e.g. polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/Fs, dioxins) and polychlorinated biphenyls (PCBs), but related contaminants such as polybrominated diphenylethers (PBDEs), hexabrominated cyclododecane (HBCDD), polychlorinated naphthalenes (PCNs), polybrominated dioxins (PBDD/Fs) and perfluoroalkyl substances (PFAS) were also investigated. Contaminant occurrence in the recycled materials was verified prior to the studies and the relationship to tissue and egg concentrations in market ready animals was investigated using a weights of evidence approach. Contaminant uptake to animal tissues and eggs was observed in all the studies but the extent varied depending on the species and the recycled material. PCBs, PBDEs, PCDD/Fs, PCNs and PFAS showed the highest potential to transfer, with laying chickens showing the most pronounced effects. PBDD/Fs showed low concentrations in the recycled materials, making it difficult to evaluate potential transfer. Higher resulting occurrence levels in laying chickens relative to broilers suggests that period of contact with the materials may influence the extent of uptake in chickens. Bio-transfer factors (BTFs) estimated for PCDD/F and PCBs showed a greater magnitude for chicken muscle tissue relative to pigs with the highest values observed for PCBs in laying chickens. There were no significant differences between BTFs for the different chicken tissues which contrasted with the high BTF values for pigs liver relative to muscle. The study raises further questions which require investigation such as the effects of repeated or yearly application of recycled materials as fertilizers, and the batch homogeneity/consistency of available recycled materials.

Survey of antimicrobial susceptibility of bacterial pathogens isolated from dogs and cats with respiratory tract infections in Europe: ComPath results

AIMS

To present antimicrobial susceptibilities for bacteria from dogs and cats with respiratory tract infection (RTI) across Europe in 2013-2014 and compare with data from 2008-2010.

METHODS AND RESULTS

Minimal inhibitory concentrations were determined for 464 isolates following Clinical and Laboratory Standards Institute standards using antibiotics approved for RTI treatment. Where possible, susceptibility was calculated using predominantly human-derived breakpoints whilst some antibiotics had no breakpoints. The main pathogen from dogs was Staphylococcus pseudintermedius which was > 90% susceptible to fluoroquinolones and oxacillin (92·5%; six isolates confirmed mecA-positive) and 53·8, 80·0 and 88·8% susceptible to tetracycline, penicillin and trimethoprim/sulfamethoxazole. Streptococci, Escherichia coli, Bordetella bronchiseptica, Staphylococcus aureus and Pseudomonas aeruginosa were also present in dog RTI. Streptococci were fully susceptible to penicillin, ampicillin and pradofloxacin. None were enrofloxacin-resistant but 31·4% had intermediate susceptibility. The least active agent against streptococci was tetracycline (51·4% susceptible). For E. coli, 90·9% were amoxicillin/clavulanic acid-susceptible; susceptibility to other compounds ranged from 63·6 to 81·8%. There are no breakpoints for B. bronchiseptica and Ps. aeruginosa. For Staph. aureus, penicillin susceptibility was low (34·8%); for other compounds 87·0-100%. The main RTI pathogen from cats was Pasteurella multocida, where only pradofloxacin has breakpoints (100% susceptible). Susceptibility of coagulase-negative staphylococci ranged from 66·7% (penicillin) to 97·2% (pradofloxacin). Streptococci from cats were 100% susceptible to all antibiotics except enrofloxacin and tetracycline (both 65·2% susceptible).

CONCLUSIONS

Overall, antimicrobial resistance was low to medium in RTI in dogs and cats, although susceptibility varied widely among pathogens studied.

SIGNIFICANCE AND IMPACT OF THE STUDY

Responsible use of antibiotics is crucial to maintain susceptibility and continued resistance monitoring is important to support this goal. These findings support the need for the setting of RTI-specific breakpoints for pathogens of dogs and cats.

P97 Utility of computer technology in management of non-syndromic craniosynostosis- is it cost effective?

Objectives

To discuss the utility of Computer technology for non-syndromic craniosynostosis (Metopic craniosynostosis) in the form of 3D printed models that could be utilised intraoperatively to aid fronto-orbital remodelling.

Design

Prospective study form 2015–2017.

Subjects

Paediatric non-syndromic metopic craniosynostosis cohort.

Methods

We present a series of 7 patients with non-syndromic metopic craniosynostosis operated on by the craniofacial team Edinburgh over a three year period. The Edinburgh Craniofacial service is supported by the Managed Service Network (MSN) for Neurosurgery, Scotland as a part of nationally delivered Craniofacial service. We utilised 3D printing models of the orbital bar to plan a fronto-orbital advancement technique. The models were then subsequently sterilised and used intra operatively. 3D printer utility is available to us as a part of the NHS Lothian craniomaxillofacial and plastics surgery service.

Results

No intra-operative or post operative complications were noted in our series. All patients undergo standardised pre and post operative 3D CT and photography follow up to objectively measure the outcome.

Conclusions

The utility of Computer technology is a useful and safe adjunct for non-syndromic craniosynostosis, particularly metopic craniosynostosis. A careful pre-operative planning and 3D printed model is helpful to achieve the desired bespoke surgical outcome and to reduce operative time. Post operative 3D CT and 3D photography were utilised to objectively measure the outcome. No extra costs were incurred to our service. We believe that this could be incorporated in preoperative planning as an essential tool.

Virtual chromoendoscopy for the real-time assessment of colorectal polyps in vivo: a systematic review and economic evaluation

BACKGROUND

Current clinical practice is to remove a colorectal polyp detected during colonoscopy and determine whether it is an adenoma or hyperplastic by histopathology. Identifying adenomas is important because they may eventually become cancerous if untreated, whereas hyperplastic polyps do not usually develop into cancer, and a surveillance interval is set based on the number and size of adenomas found. Virtual chromoendoscopy (VCE) (an electronic endoscopic imaging technique) could be used by the endoscopist under strictly controlled conditions for real-time optical diagnosis of diminutive (≤ 5 mm) colorectal polyps to replace histopathological diagnosis.

OBJECTIVE

To assess the clinical effectiveness and cost-effectiveness of the VCE technologies narrow-band imaging (NBI), flexible spectral imaging colour enhancement (FICE) and i-scan for the characterisation and management of diminutive (≤ 5 mm) colorectal polyps using high-definition (HD) systems without magnification.

DESIGN

Systematic review and economic analysis.

PARTICIPANTS

People undergoing colonoscopy for screening or surveillance or to investigate symptoms suggestive of colorectal cancer.

INTERVENTIONS

NBI, FICE and i-scan.

MAIN OUTCOME MEASURES

Diagnostic accuracy, recommended surveillance intervals, health-related quality of life (HRQoL), adverse effects, incidence of colorectal cancer, mortality and cost-effectiveness of VCE compared with histopathology.

DATA SOURCES

Electronic bibliographic databases including MEDLINE, EMBASE, The Cochrane Library and Database of Abstracts of Reviews of Effects were searched for published English-language studies from inception to June 2016. Bibliographies of related papers, systematic reviews and company information were screened and experts were contacted to identify additional evidence.

REVIEW METHODS

Systematic reviews of test accuracy and economic evaluations were undertaken in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Meta-analyses were conducted, where possible, to inform the independent economic model. A cost-utility decision-analytic model was developed to estimate the cost-effectiveness of VCE compared with histopathology. The model used a decision tree for patients undergoing endoscopy, combined with estimates of long-term outcomes (e.g. incidence of colorectal cancer and subsequent morbidity and mortality) derived from University of Sheffield School of Health and Related Research's bowel cancer screening model. The model took a NHS perspective, with costs and benefits discounted at 3.5% over a lifetime horizon. There were limitations in the data on the distribution of adenomas across risk categories and recurrence rates post polypectomy.

RESULTS

Thirty test accuracy studies were included: 24 for NBI, five for i-scan and three for FICE (two studies assessed two interventions). Polyp assessments made with high confidence were associated with higher sensitivity and endoscopists experienced in VCE achieved better results than those without experience. Two economic evaluations were included. NBI, i-scan and FICE are cost-saving strategies compared with histopathology and the number of quality-adjusted life-years gained was similar for histopathology and VCE. The correct surveillance interval would be given to 95% of patients with NBI, 94% of patients with FICE and 97% of patients with i-scan.

LIMITATIONS

Limited evidence was available for i-scan and FICE and there was heterogeneity among the NBI studies. There is a lack of data on longer-term health outcomes of patients undergoing VCE for assessment of diminutive colorectal polyps.

CONCLUSIONS

VCE technologies, using HD systems without magnification, could potentially be used for the real-time assessment of diminutive colorectal polyps, if endoscopists have adequate experience and training.

FUTURE WORK

Future research priorities include head-to-head randomised controlled trials of all three VCE technologies; more research on the diagnostic accuracy of FICE and i-scan (when used without magnification); further studies evaluating the impact of endoscopist experience and training on outcomes; studies measuring adverse effects, HRQoL and anxiety; and longitudinal data on colorectal cancer incidence, HRQoL and mortality.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016037767.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

[Empirical health services research in emergency and acute medicine : Preliminary results of concomitant monitoring of patient recruitment and sample quality]

BACKGROUND

Up until now, research data on the implementation of empirical health services research in emergency departments in Germany are scarce.

STUDY AIM

A monitoring instrument applied in a multicenter prospective cohort study in emergency departments (EDs) is described and discussed regarding requirements for the control and supervision of data collection.

MATERIALS AND METHODS

Patients with cardiac diseases, respiratory tract infections, and hip fractures were recruited in eight EDs located in a central district of Berlin. Enrolment figures and nonresponder reasons were analyzed through descriptive statistics. Potential sample bias was examined in terms of response rates as well as the distribution of age and sex in the group of participants and nonresponders. Qualitative content analysis was applied to data from routine supervisory and feedback meetings with study nurses.

RESULTS

Within the first 8 months of data collection, 61.1% of the aimed 1104 patients were recruited. Most frequently stated nonresponder reasons were the dense work and care processes in EDs (41.9%) and patients' disease burden (24.7%). Moreover, qualitative results revealed problems with identifying potentially eligible participants and difficulties because of missing research infrastructure in study centers. The response rate of 50.7% and approximately equal distribution of age and sex in participants and nonresponders do not indicate sample biases.

DISCUSSION

The monitoring instrument has proven to be suited for empirical research in EDs and revealed optimization potential. We recommend using qualitative and quantitative data systematically.

General population normative data for the EORTC QLQ-C30 health-related quality of life questionnaire based on 15,386 persons across 13 European countries, Canada and the Unites States

OBJECTIVE

The European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 health-related quality of life questionnaire is one of the most widely used cancer-specific health-related quality of life questionnaires worldwide. General population norm data can facilitate the interpretation of QLQ-C30 data obtained from cancer patients. This study aimed at systematically collecting norm data from the general population to develop European QLQ-C30 norm scores and to generate comparable norm data for individual countries in Europe and North America.

METHODS

We collected QLQ-C30 data from the general population across 11 European Union (EU) countries, Russia, Turkey, Canada and United States (n ≥ 1000/country). Representative samples were stratified by sex and age groups (18-39, 40-49, 50-59, 60-69 and ≥ 70 years). After applying weights based on the United Nations population distribution statistics, we calculated QLQ-C30 domain scores to generate a 'European QLQ-C30 Norm' based on the EU countries. Further, we calculated QLQ-C30 norm scores for all 15 individual countries.

RESULTS

A total of 15,386 respondents completed the online survey. For the EU sample, most QLQ-C30 domains showed differences by sex/age, with men scoring somewhat better health than women, while age effects varied across domains. Substantially larger differences were seen in inter-country comparisons, with Austrian and Dutch respondents reporting consistently better health compared with British and Polish respondents.

CONCLUSIONS

This study is the first to systematically collect EORTC QLQ-C30 general population norm data across Europe and North America applying a consistent data collection method across 15 countries. These new norm data facilitate valid intra-country as well as inter-country comparisons and QLQ-C30 score interpretation.

Etelcalcetide for Treating Secondary Hyperparathyroidism: An Evidence Review Group Evaluation of a NICE Single Technology Appraisal

The manufacturer of the calcimimetic drug etelcalcetide was invited to make an evidence submission as part of the National Institute for Health and Care Excellence (NICE) Single Technology Appraisal (STA) programme. Within this submission, they reported evidence on the clinical and cost effectiveness of etelcalcetide for the treatment of secondary hyperparathyroidism (SHPT) in patients with chronic kidney disease (CKD) on haemodialysis. The Southampton Health Technology Assessments Centre (SHTAC), part of the Wessex Institute at the University of Southampton, was the independent Evidence Review Group (ERG) commissioned to appraise the company's submission. This article describes the ERG's review and critique of the company's submission and summarises the NICE Appraisal Committee's subsequent guidance (issued in June 2017). The clinical-effectiveness evidence submitted by the company consisted of two double-blind, randomised controlled trials (RCTs) comparing etelcalcetide with placebo, one RCT comparing etelcalcetide with cinacalcet, two single-arm extension studies of the above trials, and one single-arm study evaluating the effect of switching from cinacalcet to etelcalcetide. No study specifically examined the population specified in the NICE appraisal scope: patients refractory to standard therapy with phosphate binders and vitamin D (PBVD). None of these trials were designed to collect long-term efficacy data for outcomes such as mortality, bone fractures, cardiovascular events, or parathyroidectomies. Instead, biomarker data from the trials were mapped to long-term outcomes by an assumed linear relationship between the trial outcome, reduction of parathyroid hormone (PTH) by > 30%, and the log-hazard ratios for the occurrence of clinical events derived from a large, long-term RCT of cinacalcet (the EVOLVE trial). After submission of a confidential Patient Access Scheme (PAS) discount reducing etelcalcetide drug costs, the incremental cost-effectiveness ratio (ICER) for etelcalcetide versus cinacalcet was £14,778 per quality-adjusted life-year (QALY) gained in the company's base case. While this value is lower than the NICE threshold range of £20,000 and £30,000 per QALY gained, it was the opinion of the ERG that the ICER was highly uncertain due to efficacy data limitations for etelcalcetide, inadequate synthesis of clinical-effectiveness evidence, and strong assumptions connecting short-term biomarker data with long-term clinical outcomes. The ERG produced an alternative base case for etelcalcetide versus cinacalcet, with an ICER of £22,400 per QALY gained, also subject to uncertainty. The NICE Appraisal Committee recommended etelcalcetide as an option for the treatment of SHPT in adults with CKD only if treatment with a calcimimetic is indicated and cinacalcet is not suitable, subject to the company's provision of the agreed PAS discount.

Ein einfaches und spezifisches Verfahren zur Entfernung von Heparin aus Zitratplasma

Heparin hat einen signifikanten Einfluß auf eine ganze Reihe von Laboruntersuchungen in der Hämostase. Häufig gelingt daher unter Heparintherapie nicht mehr der Nachweis von bestimmten Gerinnungsstörungen, deren Kenntnis jedoch für die weitere Therapie von Bedeutung wäre. Durch Einsatz eines spezifischen heparinabbauenden Enzyms (Heparinase 1) gelingt eine einfache und schnelle enzymatische Depolymerisierung von sowohl unfraktionierten als auch niedermolekularen Heparinen.

Bei insgesamt 34 Gesunden wurden die aPTT vor und nach Behandlung mit Heparinase gemessen. Der Mittelwert betrug vor Heparinase 25,6 und nach Heparinase 25,2 sec. Offensichtlich wird lediglich das Heparin abgebaut, ohne daß es zum Verlust von Gerinnungsfaktoren kommt. Die Analyse der Einzelfaktoren in einem Plasmapool zeigte praktisch identische Werte vor und nach der Enzymbehandlung. Auch die Thromboplastinzeit wird durch das enzymatische Verfahren nicht verändert. Nach Zusatz von verschiedenen Heparinen zu Plasma wurde durch Heparinasebehandlung nahezu der Ausgangswert der aPTT wieder erreicht, solange die Konzentration unter 2 E/ml lag.

Diese Ergebnisse zeigen, daß die enzymatische Behandlung mit Heparinase 1 ein einfaches und spezifisches Verfahren zur. Entfernung von Heparin darstellt.

Does Methodological Guidance Produce Consistency? A Review of Methodological Consistency in Breast Cancer Utility Value Measurement in NICE Single Technology Appraisals

Since 2004, National Institute for Health and Care Excellence (NICE) methodological guidance for technology appraisals has emphasised a strong preference for using the validated EuroQol 5-Dimensions (EQ-5D) quality-of-life instrument, measuring patient health status from patients or carers, and using the general public's preference-based valuation of different health states when assessing health benefits in economic evaluations. The aim of this study was to review all NICE single technology appraisals (STAs) for breast cancer treatments to explore consistency in the use of utility scores in light of NICE methodological guidance. A review of all published breast cancer STAs was undertaken using all publicly available STA documents for each included assessment. Utility scores were assessed for consistency with NICE-preferred methods and original data sources. Furthermore, academic assessment group work undertaken during the STA process was examined to evaluate the emphasis of NICE-preferred quality-of-life measurement methods. Twelve breast cancer STAs were identified, and many STAs used evidence that did not follow NICE's preferred utility score measurement methods. Recent STA submissions show companies using EQ-5D and mapping. Academic assessment groups rarely emphasized NICE-preferred methods, and queries about preferred methods were rare. While there appears to be a trend in recent STA submissions towards following NICE methodological guidance, historically STA guidance in breast cancer has generally not used NICE's preferred methods. Future STAs in breast cancer and reviews of older guidance should ensure that utility measurement methods are consistent with the NICE reference case to help produce consistent, equitable decision making.

Defective trophoblast invasion underlies fetal growth restriction and preeclampsia-like symptoms in the stroke-prone spontaneously hypertensive rat

STUDY QUESTION

What is the impact of chronic hypertension on placental development, fetal growth and maternal outcome in the stroke-prone spontaneously hypertensive rat (SHRSP)?

SUMMARY ANSWER

SHRSP showed an impaired remodeling of the spiral arteries and abnormal pattern of trophoblast invasion during placentation, which were associated with subsequent maternal glomerular injury and increased baseline hypertension as well as placental insufficiency and asymmetric fetal growth restriction (FGR).

WHAT IS KNOWN ALREADY

A hallmark in the pathogenesis of preeclampsia (PE) is abnormal placentation with defective remodeling of the spiral arteries preceding the onset of the maternal syndrome. Pregnancies affected by chronic hypertension display an increased risk for PE, often associated with poor maternal and fetal outcomes. However, the impact of chronic hypertension on the placentation process as well as the nature of the factors promoting the development of PE in pregnant hypertensive women remain elusive.

STUDY DESIGN, SIZE, DURATION

Timed pregnancies [n = 5] were established by mating 10-12-week-old SHRSP and Wistar Kyoto (WKY, normotensive controls) females with congenic males. Maternal systolic blood pressures (SBPs) were recorded pre-mating, throughout pregnancy (GD1-19) and post-partum by the tail-cuff method. On selected dates, 24 h urine- and blood samples were collected, and animals were euthanized for isolation of implantation sites and kidneys for morphometrical analyses.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The 24 h proteinuria and the albumin:creatinine ratio were used for evaluation of maternal renal function. Renal injury was assessed on periodic acid Schiff, Masson's trichrome and Sirius red stainings. Placental and fetal weights were recorded on gestation day (GD)18 and GD20, followed by determination of fetal cephalization indexes and developmental stage, according to the Witschi scale. Morphometric analyses of placental development were conducted on hematoxylin-eosin stained tissue sections collected on GD14 and GD18, and complemented with immunohistochemical evaluation of isolectin B4 binding for assessment of placental vascularization. Analyses of vascular wall alpha actin content, perforin-positive natural killer (NK) cells and cytokeratin expression by immunohistochemistry were used for evaluation of spiral artery remodeling and trophoblast invasion.

MAIN RESULTS AND THE ROLE OF CHANCE

SHRSP females presented significantly increased SBP records from GD13 to GD17 (SBPGD13 = 183.9 ± 3.9 mmHg, P < 0.005 versus baseline) and increased proteinuria at GD18 (P < 0.01 versus WKY). Histological examination of GD18 kidneys revealed glomerular enlargement and mesangial matrix expansion, which were not evident in pregnant WKY or age-matched virgin SHRSP. At GD20, SHRSP displayed a significant reduction of placental mass (P < 0.01 versus WKY) and signs of placental insufficiency (i.e. hypertrophy and reduced branching morphogenesis of the labyrinth layer), associated with decreased offspring weights and increased cephalization index (both P < 0.001 versus WKY) indicating asymmetric FGR. Notably, SHRSP placentas displayed an incomplete remodeling of spiral arteries starting as early as GD14, with luminal narrowing and reduced densities of perivascular NK cells followed by decreased infiltration of endovascular trophoblasts at GD18.

LARGE SCALE DATA

n/a.

LIMITATIONS, REASONS FOR CAUTION

A pitfall of the present study is the differences in the blood pressure profiles between rats and humans (i.e. unlike pregnancies affected by PE, blood pressure in SHRSP and other hypertensive rat models decreases pre-delivery), which limits extrapolation of the results.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings provide new insights on the role of chronic hypertension as a risk factor for PE by interfering with early events during the placentation process. The SHRSP strain represents an attractive model for further studies aimed at addressing the relative contribution of intrinsic (i.e. placental) and extrinsic (i.e. decidual/vascular) factors to defective spiral artery remodeling in pregnancies affected by PE.

STUDY FUNDING AND COMPETING INTEREST(S)

This work was supported by research grants from Fundación Florencio Fiorini to G.B., from Charité Stiftung to S.M.B. and University of Buenos Aires (UBACyt) to J.T. The authors have no competing interests to declare.

Reslizumab for Treating Asthma with Elevated Blood Eosinophils Inadequately Controlled by Inhaled Corticosteroids: An Evidence Review Group Perspective of a NICE Single Technology Appraisal

As part of the National Institute for Health and Care Excellence (NICE) Single Technology Appraisal (STA) process, the manufacturer of reslizumab (Teva) submitted evidence for its clinical and cost effectiveness for the treatment of eosinophilic asthma inadequately controlled by inhaled corticosteroids. NICE commissioned Southampton Health Technology Assessments Centre (SHTAC) as an independent Evidence Review Group (ERG) to provide a critique of the manufacturer's submitted evidence. Reslizumab is compared with best standard of care and omalizumab, for a small 'overlap' population of patients who have both eosinophilic and IgE-mediated severe asthma. This paper provides a summary of the ERG's review of the manufacturer's submission, and summarises the NICE Appraisal Committee's subsequent guidance (issued in August 2017). The ERG considered that there were limitations in the approach proposed by the manufacturer for the exacerbation rate and the utility for severe exacerbation. The company amended their initial analysis, following comments from the ERG and the NICE committee, whereby the incremental cost effectiveness ratio was £29,870 per QALY gained for reslizumab compared with best standard care. The NICE Appraisal Committee (AC) concluded that reslizumab was recommended as an option for the treatment of severe eosinophilic asthma that is inadequately controlled in adults despite maintenance therapy with high-dose inhaled corticosteroids plus another drug, only if (1) the blood eosinophil count has been recorded as 400 cells per microlitre or more and (2) the patient has had three or more asthma exacerbations in the past 12 months, and (3) the company provides reslizumab with the discount agreed in the patient access scheme.

Occurrence and spatial distribution of chemical contaminants in edible fish species collected from UK and proximate marine waters

The occurrence of a range of regulated and emerging organic environmental contaminants was investigated in 182 samples of edible marine fish sampled mainly from UK marine regions, but extending northerly to the coast of Norway and south to the Algarve. These species (sprats, mackerel, turbot, halibut, herring, grey mullet, sea bass, grey mullet, sardines, etc.) are among those considered to be at the highest risk of contamination with regulated contaminants such as polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/Fs, dioxins), and polychlorinated biphenyls (PCBs), but the occurrence of polybrominated diphenylethers (PBDEs) and polybrominated biphenyls (PBBs) was also investigated. Sub-sets of samples (50-75) were also analysed for emerging contaminants: polychlorinated naphthalenes (PCNs), polybrominated and mixed halogenated dibenzo-p-dioxins, dibenzofurans and biphenyls (PBDD/Fs, PXDD/Fs and PXBs) and perfluoroalkyl substances (PFAS). Contaminant occurrence varied with species and location, but all measured contaminants were detected, with sprats, sea bass, sardines, mackerel, and herring showing higher tissue concentrations. The concentrations of the different contaminants in the various samples were mapped utilising the GPS coordinate data of the capture locations to visualise spatial distribution levels. In terms of catch location, fish sampled from the coasts of southern Britain, north-western France and the Irish Sea appeared to contain proportionately higher levels of some contaminants - e.g. samples from the Irish Sea tended to show higher PCN concentrations, whereas higher levels of PCBs were observed in some fish sampled off the coasts of northern France. Similarly, samples of mullet from the southeast coast of UK showed much higher concentrations of BDE-99 than the other regions. In terms of occurrence trends, PCDD/F and PCB concentrations show a modest decline over the last decade but where limited background data is available for emerging contaminants, there is no evidence of downward trends.

The clinical effectiveness and cost-effectiveness of abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis: a systematic review and economic evaluation

BACKGROUND

Juvenile idiopathic arthritis (JIA) is characterised by joint pain, swelling and a limitation of movement caused by inflammation. Subsequent joint damage can lead to disability and growth restriction. Treatment commonly includes disease-modifying antirheumatic drugs (DMARDs), such as methotrexate. Clinical practice now favours newer drugs termed biologic DMARDs where indicated.

OBJECTIVE

To assess the clinical effectiveness and cost-effectiveness of four biologic DMARDs [etanercept (Enbrel(®), Pfizer), abatacept (Orencia(®), Bristol-Myers Squibb), adalimumab (Humira(®), AbbVie) and tocilizumab (RoActemra(®), Roche) - with or without methotrexate where indicated] for the treatment of JIA (systemic or oligoarticular JIA are excluded).

DATA SOURCES

Electronic bibliographic databases including MEDLINE, EMBASE, The Cochrane Library and the Database of Abstracts of Reviews of Effects were searched for published studies from inception to May 2015 for English-language articles. Bibliographies of related papers, systematic reviews and company submissions were screened and experts were contacted to identify additional evidence.

REVIEW METHODS

Systematic reviews of clinical effectiveness, health-related quality of life and cost-effectiveness were undertaken in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. A cost-utility decision-analytic model was developed to compare the estimated cost-effectiveness of biologic DMARDs versus methotrexate. The base-case time horizon was 30 years and the model took a NHS perspective, with costs and benefits discounted at 3.5%.

RESULTS

Four placebo-controlled randomised controlled trials (RCTs) met the inclusion criteria for the clinical effectiveness review (one RCT evaluating each biologic DMARD). Only one RCT included UK participants. Participants had to achieve an American College of Rheumatology Pediatric (ACR Pedi)-30 response to open-label lead-in treatment in order to be randomised. An exploratory adjusted indirect comparison suggests that the four biologic DMARDs are similar, with fewer disease flares and greater proportions of ACR Pedi-50 and -70 responses among participants randomised to continued biologic DMARDs. However, confidence intervals were wide, the number of trials was low and there was clinical heterogeneity between trials. Open-label extensions of the trials showed that, generally, ACR responses remained constant or even increased after the double-blind phase. The proportions of adverse events and serious adverse events were generally similar between the treatment and placebo groups. Four economic evaluations of biologic DMARDs for patients with JIA were identified but all had limitations. Two quality-of-life studies were included, one of which informed the cost-utility model. The incremental cost-effectiveness ratios (ICERs) for adalimumab, etanercept and tocilizumab versus methotrexate were £38,127, £32,526 and £38,656 per quality-adjusted life year (QALY), respectively. The ICER for abatacept versus methotrexate as a second-line biologic was £39,536 per QALY.

LIMITATIONS

The model does not incorporate the natural history of JIA in terms of long-term disease progression, as the current evidence is limited. There are no head-to-head trials of biologic DMARDs, and clinical evidence for specific JIA subtypes is limited.

CONCLUSIONS

Biologic DMARDs are superior to placebo (with methotrexate where permitted) in children with (predominantly) polyarticular course JIA who have had an insufficient response to previous treatment. Randomised comparisons of biologic DMARDs with long-term efficacy and safety follow-up are needed to establish comparative effectiveness. RCTs for JIA subtypes for which evidence is lacking are also required.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015016459.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.