The Use of Semi-Absorbable Mesh and its Impact on Donor-Site Morbidity and Patient-Reported Outcomes in DIEP Flap Breast Reconstruction

BACKGROUND

This study aimed to evaluate the impact of semi-absorbable mesh on donor-site morbidity and patient-reported outcomes in deep inferior epigastric perforator (DIEP) flap breast reconstruction.

METHODS

We conducted a retrospective cohort study of all patients who had DIEP flap breast reconstruction in our department from July 2007 to March 2019. Patients were invited to a comparative follow-up visit and grouped according to donor-site closure: primary fascial closure (the no-mesh group) and fascial reinforcement with semi-absorbable mesh in a subfascial position (the mesh group). The primary outcome of interest was donor-site morbidity, including bulging, hernia formation and rectus abdominis muscle strength. We also surveyed, surgical site complications and patient-reported outcomes using Patient and Observer Scar Assessment Scale v2.0 and BREAST-Q^© version 2.0.

RESULTS

A total of 191 patients had received DIEP flap breast reconstruction. Eighty-five patients (44.5%) with 108 DIEP flaps (53 patients in the mesh group and 32 patients in the no-mesh group) were included in the study. The mean BMI of the patients was significantly higher in the mesh group (mesh group, 26.9 vs. no-mesh group, 25.0, with p = 0.03). The incidence of hernia was significantly reduced in the mesh group (mesh group, 2.8% vs. no-mesh group, 13.5%, with p = 0.03). The incidence of bulging and the extent of rectus abdominis muscle strength were similar for both groups. Operative surgical site complications were reduced in the mesh group (mesh group, 7.5% vs. no-mesh group, 18.8%). There was no difference in patients' physical well-being and satisfaction with the donor site between groups. Patient-reported scar outcome was significantly better in the no-mesh group (p < 0.001).

CONCLUSION

Our novel method of donor-site closure with semi-absorbable mesh in a subfascial position for reinforcement of the anterior rectus fascia on the DIEP donor site is safe. It has no negative impact on surgical site complications and patient-reported outcomes, while reducing the incidence of hernias on the donor-site in DIEP flap breast reconstruction.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Caregiver-guided pain coping skills training for patients with advanced cancer: Results from a randomized clinical trial

BACKGROUND

Pain is a major concern among patients with advanced cancer and their family caregivers. Evidence suggests that pain coping skills training interventions can improve outcomes, however they have rarely been tested in this population.

AIM

To test the efficacy of a caregiver-guided pain coping skills training intervention. The primary outcome was caregiver self-efficacy for helping the patient manage pain.

DESIGN

A randomized controlled trial compared the intervention to an enhanced treatment-as-usual control. Dyads in both conditions received pain education, and those in the intervention received three sessions of pain coping skills training. Caregiver outcomes (self-efficacy; caregiver strain, caregiving satisfaction, psychological distress) and patient outcomes (self-efficacy, pain intensity and interference, psychological distress) were collected at baseline and post-intervention.

SETTING/PARTICIPANTS

Two hundred two patients with stage III-IV cancer and pain and their family caregivers were enrolled from four outpatient oncology clinics and a free-standing hospice/palliative care organization.

RESULTS

Compared to those in the control arm, caregivers in the intervention reported significant increases in caregiving satisfaction (p < 0.01) and decreased anxiety (p = 0.04). In both conditions, caregivers reported improvements in self-efficacy, and patients reported improvements in self-efficacy, pain severity and interference, and psychological distress.

CONCLUSIONS

This is the first study to test a pain coping skills intervention targeted to patients and caregivers facing advanced cancer. Findings suggest that pain education provides benefits for patients and caregivers, and coping skills training may be beneficial for caregivers. Further research is needed to optimize the benefits of education and pain coping skills training for improving cancer pain outcomes.Trial registration: ClinicalTrials.gov NCT02430467, Caregiver-Guided Pain Management Training in Palliative Care.

A214 BARIATRIC SURGERY PATIENTS WITH NON-ALCOHOLIC FATTY LIVER DISEASE HAVE DIFFERENT VISCERAL ADIPOSE TISSUE GENE EXPRESSION COMPARED TO THOSE WITH NORMAL LIVER

Background

Non-alcoholic fatty liver disease (NAFLD) includes simple steatosis (SS) and nonalcoholic steatohepatitis (NASH). It affects 74–98% of individuals with morbid obesity undergoing bariatric surgery (BSX). Among several factors contributing to NAFLD pathogenesis, adipokines secreted by visceral adipose tissue (VAT) can play a role by regulating glucose/lipid metabolism and inflammation.

Aims

This study aims to determine if visceral adipose tissue adipokine and cytokine gene expression are associated with NAFLD (SS and NASH) at the time of BSX.

Methods

Patients were recruited from the Toronto Western Hospital Bariatric Clinic. Demographic data was recorded. The VAT and liver biopsies were collected at the time of bariatric surgery. VAT adipokines and other mediators were assessed by RT-PCR and included markers of thermogenic capacity, inflammation, fibrosis, adipokines, and others. Liver histology was assessed by a pathologist using the Brunt system and individuals were diagnosed as either SS, NASH, or having a healthy liver (HL). Blood samples were collected pre-BSX to measure liver and metabolic syndrome related parameters, including HOMA-IR, HbA1c, liver enzymes, and lipid profile. Anthropometry was also assessed. Groups were compared using Kruskal-Wallis test followed by Wilcoxon ranked sum, or chi-square and Fisher’s exact test as necessary. Data was considered to be statistically significant with a p-value less than 0.05.

Results

We are presenting data on 126 patients, 80.2% females with a median age of 49 and a body mass index (BMI) of 46.9. Fifty-seven patients had SS, 34 had NASH and 35 had a healthy liver (HL). BMI, age, and sex did not differ between the three groups. First, we found that those with NASH had significantly higher VAT expression of fibrosis (Loxl2), inflammation (CCL4 and TGFb1) and proliferation markers (E2F1) and significantly lower expression of adipokines (TNFa and resistin) compared to HL. Also, we found that SS had significantly higher fibrosis (Col3a1, Col6a1, Loxl2, CD9 and Acta2), inflammation (Nox2, TGFb1, IFNg and Clec10a), browning (PPARa, PPARg and Glut1) and proliferation (E2F1) marker expression compared to HL.

Conclusions

Results show that there is a significant difference in the expression pattern of VAT fibrotic and inflammatory markers between HL, SS and NASH patients. The observed increase of inflammatory markers in NAFLD is in line with prior research outlining the ability of inflammatory mediators from VAT to contribute to liver pathology via portal circulation. The relationship between VAT characteristics and NAFLD are important in understanding the widespread metabolic effects of obesity.

Funding Agencies

CIHRCanadian Liver foundation

A48 USE OF ENDOSCOPIC ULTRASOUND FINE NEEDLE ASPIRATE AND ENDOSCOPIC ULTRASOUND FINE NEEDLE BIOPSY FOR DETECTION OF GATA6 EXPRESSON IN PANCREATIC DUCTAL ADENOCARINCOMA

Background

GATA6 is a transcription factor that can be used to distinguish between the basal-like and classical subtypes of pancreatic ductal adenocarcinoma (PDAC). The basal-like subtype has been demonstrated to be less responsive to modified FOLFIRINOX chemotherapy and thus can be used to predict response to specific chemotherapies. To date, GATA6 expression has only been evaluated in surgically resected PDAC specimens. Less than 15% of patients with PDAC are eligible for surgery. Endoscopic ultrasound guided fine-needle aspirate (EUS-FNA) and biopsy (EUS-FNB) can potentially help assess GATA6 expression in PDAC and in turn, help guide personalized treatment selection in all cases of PDAC.

Aims

The primary objective of this study was to explore the yield of EUS-FNA and EUS-FNB for the detection of GATA6 among patients with PDAC. The study also aimed to explore the impact of lesion location on sample adequacy and type of fixative on validity of GATA6 staining.

Methods

This study was conducted from November 2017 to October 2019. Consecutive patients with a diagnosis of PDAC confirmed by biopsy were included. Patients underwent either EUS-FNB or EUS-FNA to obtain tissues samples. Samples were fixed in either neutral buffered formalin (NBF) or a methanol based buffered solution (Cytolyt) and evaluated by a specialized cytopathology team. Fisher’s exact test was used and a p-value ≤0.05 was considered to indicate statistical significance.

Results

Forty-four patients were included in the study. Twenty-three (52%) patients were male and the median age of patients was 67.5 years. Twenty-five lesions were located in the head and neck of the pancreas, 14 were located in the body, and 4 were located in the tail. One patient was found to have a local recurrence of PDAC at the surgical bed of a previous Whipple procedure.

Eighteen lesions were sampled by EUS-FNA and 26 were sampled using EUS-FNB. Thirty-eight (86%) samples were adequate for assessment of GATA6. Sampling technique (p=0.68) and fixative type (p=1.00) did not appear to affect sample adequacy. Compared to pancreatic body or tail specimens, samples obtained from the head or neck of the pancreas were more likely to be inadequate for analysis (p=0.03).

Conclusions

EUS-FNA and EUS-FNB samples are efficacious methods of assessing GATA6 expression in PDAC. This is the first predictor of treatment response that has been demonstrated to be obtained without surgical resection. Neither EUS needle type or alcohol fixation before cell block preparation appear to impact GATA6 detection. Lesions in the pancreatic head or neck appear to be associated with higher rates of sample inadequacy. Larger, prospective studies are required to confirm our findings.

Funding Agencies

None

A209 NON-INVASIVE ASSESSMENT OF LIVER FIBROSIS USING APRI, FIB-4, AND TRANSIENT ELASTOGRAPHY IN CHRONIC HEPATITIS B PATIENTS

Background

Accurate assessment of liver fibrosis is important to identify patients with chronic hepatitis B (CHB) who require antiviral therapy. As liver biopsy is invasive and costly, non-invasive tests of liver fibrosis are increasingly being used.

Aims

We aimed to evaluate the performance of the aspartate aminotransferase-to-platelet ratio index (APRI), Fibrosis 4 index (FIB-4), and transient elastography (TE) in predicting fibrosis in patients with CHB.

Methods

We retrospectively analyzed a prospectively enrolled cohort of consecutive adults with CHB who underwent liver biopsy for routine clinical indications (ALT &gt; ULN and HBV DNA &gt; 2,000 IU/ml) from January 2018 to December 2019. Demographic information, routine biochemistry, HBV serology including HBV DNA, abdominal ultrasound, fibrosis stage by liver biopsy and TE data were collected. Positive predictive values (PPV) and negative predictive values (NPV) were calculated using published cut-off values with liver biopsy as the reference standard.

Results

Fifty-five patients of Asian ethnicity (mean age 46 years, 65% male) were included. Most patients were HBeAg-negative (67%) and treatment-naïve (80%). Eleven (20%) patients had advanced fibrosis (F3-F4 METAVIR) and 4 (7%) patients had cirrhosis (F4). APRI &lt;0.50 had a NPV of 73% for significant fibrosis (F2-F4) and APRI &gt;1.50 had a PPV of 33% for significant. All 4 patients with cirrhosis were misclassified as having no cirrhosis with an APRI &lt;1. FIB-4 &lt;1.45 had a NPV of 90% for advanced fibrosis (F3-F4). No patient, including 11 patients with advanced fibrosis, had a FIB-4 above the cut-off value to detect advanced fibrosis (&gt;3.25). TE data was available for 38 patients. TE &lt;7.25 kPa had a NPV of 78% for significant fibrosis and TE &gt;12.4 kPa had a PPV of 50% for cirrhosis.

Conclusions

In Asian patients with CHB and a low prevalence of advanced fibrosis or cirrhosis, APRI, FIB-4, and TE performed well in excluding those with advanced fibrosis but were unable to accurately identify those with significant/advanced fibrosis and cirrhosis. Further studies with larger numbers of CHB patients are needed to confirm our results.

Funding Agencies

None

Widening the Indications for Intrasaccular Flow Disruption: WEB 17 in the Treatment of Aneurysm Locations Different from Those in the Good Clinical Practice Trials

BACKGROUND AND PURPOSE

The safety and efficacy of the Woven EndoBridge (WEB) device has been shown in multiple good clinical practice trials, whereas aneurysm locations in these trials were restricted to bifurcation aneurysms located at the circle of Willis (MCA bifurcation, ICA bifurcation, anterior communicating artery, basilar artery tip). Our aim was to evaluate angiographic and clinical results with the WEB 17 in aneurysm locations that were excluded from the good clinical practice trials, assuming that the angiographic and clinical results are similar to those of the good clinical practice trials for aneurysms in traditional locations.

MATERIALS AND METHODS

We performed retrospective analysis of immediate and follow-up results of aneurysms in locations outside the good clinical practice trials in which the WEB 17 was used on an intention-to-treat approach.

RESULTS

Between June 2017 and May 2020, forty-seven aneurysms in 44 patients met the inclusion criteria. Aneurysm locations were the ICA posterior communicating artery in 19 (40.3%), the ICA paraophthalmic or choroidal locations in 4 (8.6%), anterior cerebral artery A2 segment in 13 (27.7%), MCA M1 segment in 2 (4.3%), posterior cerebral artery P2 segment in 2 (4.3%), PICA in 3 (6.4%), and the superior cerebellar artery in 4 (8.4%) cases. The procedure-related morbidity and mortality rates in the entire series were 0.0%. The early and late (<12 and >12 months) complete occlusion rates were 63.9% (23/36) and 77.8% (14/18), respectively.

CONCLUSIONS

The WEB 17 is safe and effective in aneurysm locations different from the traditional bifurcation aneurysms included in the good clinical practice trials. Further studies will help to define the entire spectrum of aneurysm morphologies and locations suitable for the WEB 17.

[Successful treatment of a geriatric COVID-19 patient with severe chest trauma : An interdisciplinary case report]

Die Coronaviruserkrankung 2019 (COVID-19) ist eine neu auftretende Infektionskrankheit, die sich weltweit rasch ausgebreitet hat und zu einer hohen Morbidität und Mortalität führt. Klinische Erfahrungen bezüglich des chirurgischen Managements bei COVID-19-Patienten mit schwerem Thoraxtrauma sind limitiert. Hier wird über das interdisziplinäre Management einer geriatrischen COVID-19-Patientin nach schwerem Thoraxtrauma mit pulmonaler Symptomatik bei traumatisch instabiler Rippenserienfraktur und begleitendem Hämatothorax berichtet.

[Extracorporeal Lung Support in Thoracic Surgery: Basics and Pathophysiology]

Extracorporeal lung support (ECLS) is of increasing importance in general thoracic surgery. Different modes of ECLS may be applied in several situations throughout the perioperative phase and are adapted to the individual patient's needs and the planned surgical procedures. ECLS is not a static procedure and should be always evaluated according to the present condition of the patient. Therefore, it is essential to understand the pathophysiology of the disease and the different ECLS modes, as well as the different cannulation options, in order to be able to use the different escalation and de-escalation techniques in accordance with the clinical situation.

Periprocedural Safety and Feasibility of the New LVIS EVO Device for Stent-Assisted Coiling of Intracranial Aneurysms: An Observational Multicenter Study

BACKGROUND AND PURPOSE

Stent-assisted treatment techniques can be an effective treatment option for intracranial aneurysms. The aim of this study was to evaluate the periprocedural feasibility and safety of the new LVIS EVO stent for the treatment of intracranial aneurysms.

MATERIALS AND METHODS

Patients with intracranial aneurysms treated with the LVIS EVO in 11 European neurovascular centers were retrospectively reviewed. Patient and aneurysm characteristics, procedural parameters, immediate grade of occlusion, and technical and clinical complications were assessed.

RESULTS

Fifty-seven patients with 59 aneurysms were treated with the LVIS EVO device; 57.6% of the aneurysms were incidental; 15.3% were acutely ruptured; 15.3% were recanalized or residual aneurysms; and 11.9% were treated for symptoms other than acute hemorrhage. The most frequent aneurysm locations were the middle cerebral artery (25.4%) and the anterior communicating artery (22.0%). The rate of immediate successful deployment was 93.2%. In 6.8% (n = 4) of cases, additional in-stent angioplasty was needed. The immediate complete occlusion rate was 54.2%, while there was a residual aneurysm in 35.6% and a residual neck in 10.2%. Periprocedural technical complications occurred in 7/59 treatments (11.9%; the most frequent technical complication [n = 3] was thrombus formation), which all resolved completely without clinical sequelae. Postprocedural neurologic complications occurred after 4/59 treatments (6.8%; 2 transient ischemic attacks, 1 minor stroke, 1 major stroke), of which only 1 persistent complication was directly related to the procedure (minor stroke in the vascular territory distal to the stent).

CONCLUSIONS

The LVIS EVO stent is a safe, feasible device for the treatment of intracranial aneurysms.

ICF-based multidisciplinary rehabilitation program for complex regional pain syndrome of the hand: efficacy, long-term outcomes, and impact of therapy duration

Background

Complex regional pain syndrome (CRPS) is a rare but feared complication in hand surgery. Although multimodal therapy concepts are recommended, there is only low evidence on efficacy of such approaches. Furthermore, recommendations regarding therapy duration are lacking. Aim of this study was to validate the efficacy of an International Classification of Functioning, Disability and Health (ICF)-based multidisciplinary rehabilitation concept for treatment of CRPS of the hand and to find correlations between therapy duration and outcome measures.

Methods

Patients with CRPS of the hand after occupational trauma that underwent an ICF-based rehabilitation program between 2010 and 2014 were included in this retrospective study. Besides demographic data, outcomes included pain (VAS), range of motion assessed by fingertip-to-palm-distance (PTPD) and fingernail-to-table-distance (FTTD) as well as strength in grip, 3-point pinch and lateral pinch. All measures were gathered at admission to and discharge from inpatient rehabilitation therapy as well as at follow-up. Statistical analysis included paired t-test, ANOVA and Pearson's correlation analysis.

Results

Eighty-nine patients with a mean age of 45 years were included in this study. Duration of rehabilitation therapy was 53 days on average. All outcomes improved significantly during rehabilitation therapy. Pain decreased from 6.4 to 2.2. PTPD of digit 2 to 5 improved from 2.5, 2.8, 2.6, and 2.3 cm to 1.3, 1.4, 1.2, and 1.1 cm, respectively. FTTD of digit 2 to 5 decreased from 1.5, 1.7, 1.5, and 1.6 cm to 0.6, 0.8, 0.7, and 0.7 cm, respectively. Strength ameliorated from 9.5, 3.7, 2.7 kg to 17.9, 5.6, 5.0 kg in grip, lateral pinch, and 3-point pinch, respectively. Improvement in range of motion significantly correlated with therapy duration. 54% of patients participated at follow-up after a mean of 7.5 months. Outcome measures at follow-up remained stable compared to discharge values without significant differences.

Conclusion

The ICF-based rehabilitation concept is a reliable and durable treatment option for CRPS of the hand. Range of motion improved continuously with therapy duration and thus may serve as an indicator for optimum length of therapy.

Susceptibility of the floodwater mosquito Aedes albifasciatus from eggs of different dormancy times to the nematode parasite Strelkovimermis spiculatus

This study aimed to evaluate the effects of egg dormancy times on susceptibility of larvae of the floodwater mosquito Aedes albifasciatus (Diptera: Culicidae) to parasitism by their natural enemy Strelkovimermis spiculatus (Nematoda: Mermithidae) and on their life history traits. Aedes albifasciatus eggs stored for 2, 4, 6, 8 and 10 months were hatched, and the larvae either exposed to S. spiculatus (treatment group) or not exposed (control group). Egg dormancy time had a negative effect on the retention of parasites, but no effect on the prevalence and intensity of parasitism or the melanization of nematodes. The survival to adulthood of control individuals decreased as dormancy time increased, whereas that of exposed individuals that remained uninfected was constant and low. A trend towards increasing development times with longer dormancy times was detected in the control group, but not in the exposed noninfected group. The results suggest nonconsumptive effects of parasites in exposed but not infected larvae from eggs with short dormancy times. In contrast, the relatively low fitness of larvae from eggs with long dormancy times regardless of their contact with the nematodes may be the result of the nutritional deprivation during the egg stage.

Random-pattern versus perforator-based adipocutaneous skin paddles for postoperative monitoring of free muscle flaps-a comparative retrospective cohort study

INTRODUCTION

Free microvascular muscle flaps represent well-established reconstructive options for complex soft tissue defects. However, due to their lack of cutaneous capillary beds, they are difficult to monitor postoperatively. To this end, random and axial-pattern adipocutaneous skin paddles are often included. The objective of the study was to compare the impact of random-pattern versus perforator-based adipocutaneous skin paddles on operative efficacy and muscle flap safety.

METHODS

Between August 2014 and July 2016, a total of 120 free muscle flaps were included in this retrospective monocentric cohort study. Based on their skin-paddle type, they were either grouped into a 'perforator-based' (group Pb) or 'random-pattern' (group Rp) cohort. The electronic medical records and operative reports of all patients were subsequently reviewed and patient, defect, and flap characteristics of both groups were compared. The effect of the competing skin paddle types on the overall operative time, incidences of flap loss or microvascular complications, and total length of hospital stay were then assessed.

RESULTS

Group Pb comprised 72 flaps, whereas 48 flaps constituted group Rp. Patient, defect, and flap characteristics were similar between both groups. Groups Pb and Rp were comparable regarding patient age (group Pb: 61 (10-90) vs. Rp: 59 (13-81), p = 0.556), ASA (American Society of Anesthesiologists) class (group Pb: 3 (1-4) vs. Rp 3 (1-3), p = 0.977), and comorbidities, summarized by the Charlson comorbidity index (CCI; group Pb: 1 (0-4 vs. Rp: 1 (0-5), p = 0.295). Both types of monitoring skin paddles were equally reliable. There was no significant difference in the mean operation time between both groups (group Pb: 373 ± 122 min vs. Rp: 342 ± 84 min, p = 0.124). In-patient treatment after flap surgery and total length of hospital stay were significantly shorter in group Pb (group Pb: 24 ± 10 days vs. Rp: 32 ± 17 days, p = 0.002 and group Pb: 39 ± 15 vs. Rp: 48 ± 24, p = 0.022).

CONCLUSION

Perforator-based skin paddles are a reliable tool for postoperative perfusion monitoring of free muscle flaps and help avoid additional surgical interventions as opposed to their random-pattern counterparts. Thus, the overall and postoperative length of hospital stay is significantly reduced.

[Chemical peeling for treatment of Melasma, pigmentary disorders and hyperpigmentation : Indications, effectivity and risks]

Pigmentary disorders and hyperpigmentation are widespread. Dark skin types in particular show a tendency to formation of melasmas and to hyperpigmentation. Light skin types have a tendency to ephelides and solar lentigines. In addition to topical treatment with lightening substances, superficial chemical peeling as well as combined procedures of topical treatment with chemical peeling play an important role in the treatment of hyperpigmentation. A strict avoidance of UV light and consequent daily application of sun protectíon factor 50+ are mandatory for successful treatment.

Early Integrated Telehealth versus In-Person Palliative Care for Patients with Advanced Lung Cancer: A Study Protocol

Introduction: Early palliative care (PC) integrated with oncology care improves quality of life (QOL), depression symptoms, illness understanding, and end-of-life (EOL) care for patients with advanced lung cancer. The aims of this trial are to compare the effect of delivering early integrated PC through telehealth versus in-person on patient and caregiver outcomes. We hypothesize that both modalities for delivering early PC would be equivalent for improving patient QOL, communication about EOL care preferences with their oncologist, and length of stay in hospice. Methods: For this comparative effectiveness trial, we will enroll and randomize 1250 adult patients with advanced nonsmall cell lung cancer (NSCLC), who are not being treated with curative intent, to receive either early integrated telehealth or in-person PC at 20 cancer centers throughout the United States. Patients may also invite a family caregiver to participate in the study. Patients and their caregivers in both study groups meet at least every four weeks with a PC clinician from within 12 weeks of patient diagnosis of advanced NSCLC until death. Participants complete measures of QOL, mood, and quality of communication with oncologists at baseline before randomization and at 12, 24, 36, and 48 weeks. Information on health care utilization, including length of stay in hospice, will be collected from patients' health records. To test equivalence in outcomes between study groups, we will compute analysis of covariance and mixed linear models, controlling for baseline scores and study site. Study Implementation and Stakeholder Engagement: To ensure that this comparative effectiveness trial and findings are as patient centered and meaningful as possible, we have incorporated a robust patient and stakeholder engagement plan. Our stakeholder partners include (1) patients/families, (2) PC clinicians, (3) telehealth experts and clinician users, (4) representatives from health care systems and medical insurance providers, and (5) health care policy makers and advocates. These stakeholders will inform and provide feedback about every phase of study implementation.

Measures to manage, reduce and prevent medicines shortages in European countries in 2020

Background

Several countries have seen an increase in medicines shortages that constitute a major public health threat as they can negatively impact the health outcomes of patients. The study aims to survey measures that European countries apply or consider introducing to address medicines shortages.

Methods

A questionnaire was sent to the public authorities, as involved in the Pharmaceutical Pricing and Reimbursement Information (PPRI) network, in 47 countries, thereof 44 countries of the WHO European region. Respondents were asked to report measures in place or being discussed as of the first quarter of 2020.

Results

Preliminary data from 8 countries (Albania, Austria, Finland, Germany, Italy, the Netherlands, Romania, Sweden; further responses are expected) show that national registers to which manufacturers notify, usually on a mandatory basis, upcoming and existing shortages (including end dates and causes in some countries) are common (all countries but Albania). Medicine reserve supplies that have to be kept for defined medicines exist in Albania and Finland; they are being established the Netherlands and are under discussion in Germany and Sweden. Finland and Italy allow issuing export bans for targeted medicines; this possibility is before implementation in Austria, was planned and then withdrawn in Romania and is under discussion in the other countries (except Albania). Further measures include simplified import permits (with patient information leaflets in foreign language), working groups with relevant stakeholders and financial sanctions for manufacturers in case of non-supply.

Conclusions

Governments have been reacting to shortages by implementing appropriate measures and adapting existing ones. Actions taken differ with regard to stakeholders addressed, the degree of obligation and the focus (optimising the management of existing shortages vs. prevention of future supply limitations).

Key messages

A mix of measures to address medicine shortages is applied in European countries. Recently, the number of measures increased, and actions requested from stakeholders tend to have become mandatory.

Combination of the PI3K inhibitor Idelalisib with the conventional cytostatics cytarabine and dexamethasone leads to changes in pathway activation that induce anti-proliferative effects in B lymphoblastic leukaemia cell lines

BACKGROUND

The introduction of combined conventional cytostatics and pathway-specific inhibitors has opened new treatment options for several cancer types including hematologic neoplasia such as leukaemias. As the detailed understanding of the combination-induced molecular effects is often lacking, the identification of combination-induced molecular mechanisms bears significant value for the further development of interventional approaches.

METHODS

Combined application of conventional cytostatic agents (cytarabine and dexamethasone) with the PI3K-inhibitor Idelalisib was analysed on cell-biologic parameters in two acute pro-B lymphoblastic leukaemia (B-ALL) cell lines. In particular, for comparative characterisation of the molecular signatures induced by the combined and mono application, whole transcriptome sequencing was performed. Emphasis was placed on pathways and genes exclusively regulated by drug combinations.

RESULTS

Idelalisib + cytostatics combinations changed pathway activation for, e.g., "Retinoblastoma in cancer", "TGF-b signalling", "Cell cycle" and "DNA-damage response" to a greater extent than the two cytostatics alone. Analyses of the top-20 regulated genes revealed that both combinations induce characteristic gene expression changes.

CONCLUSION

A specific set of genes was exclusively deregulated by the drug combinations, matching the combination-specific anti-proliferative cell-biologic effects. The addition of Idelalisib suggests minor synergistic effects which are rather to be classified as additive.

Outcomes of Patients With Cancer Discharged to a Skilled Nursing Facility After Acute Care Hospitalization

BACKGROUND

After discharge from an acute care hospitalization, patients with cancer may choose to pursue rehabilitative care in a skilled nursing facility (SNF). The objective of this study was to examine receipt of anticancer therapy, death, readmission, and hospice use among patients with cancer who discharge to an SNF compared with those who are functionally able to discharge to home or home with home healthcare in the 6 months after an acute care hospitalization.

METHODS

A population-based cohort study was conducted using the SEER-Medicare database of patients with stage II-IV colorectal, pancreatic, bladder, or lung cancer who had an acute care hospitalization between 2010 and 2013. A total of 58,770 cases were identified and patient groups of interest were compared descriptively using means and standard deviations for continuous variables and frequencies and percentages for categorical variables. Logistic regression was used to compare patient groups, adjusting for covariates.

RESULTS

Of patients discharged to an SNF, 21%, 17%, and 2% went on to receive chemotherapy, radiotherapy, and targeted chemotherapy, respectively, compared with 54%, 28%, and 6%, respectively, among patients discharged home. Fifty-six percent of patients discharged to an SNF died within 6 months of their hospitalization compared with 36% discharged home. Thirty-day readmission rates were 29% and 28% for patients discharged to an SNF and home, respectively, and 12% of patients in hospice received <3 days of hospice care before death regardless of their discharge location.

CONCLUSIONS

Patients with cancer who discharge to an SNF are significantly less likely to receive subsequent oncologic treatment of any kind and have higher mortality compared with patients who discharge to home after an acute care hospitalization. Further research is needed to understand and address patient goals of care before discharge to an SNF.

Two-Center Experience in the Endovascular Treatment of Intracranial Aneurysms Using the Woven EndoBridge 17 Device Including Midterm Follow-Up Results: A Retrospective Analysis

BACKGROUND AND PURPOSE

The Woven EndoBridge device proved its effectiveness in the treatment of ruptured and unruptured intracranial aneurysms as a stand-alone device. Before 2016, Woven EndoBridge deployment required at least a 0.021-inch microcatheter. In 2016, a smaller device, the Woven EndoBridge 17 with finer size increments that used a 0.017-inch microcatheter, was introduced. We retrospectively analyzed our initial and follow-up results with the Woven EndoBridge 17 in ruptured and unruptured aneurysms.

MATERIALS AND METHODS

One hundred twenty-seven intracranial aneurysms in 117 patients were scheduled for treatment with the Woven EndoBridge 17 between June 2017 and February 2019. Twenty-nine aneurysms were ruptured.

RESULTS

Treatment was performed as intended in 124 of 127 cases (97.6%). Additional devices such as stents or coils were used in 12 cases (9.7%). Five thromboembolic complications and 1 hemorrhagic complication were encountered, resulting in clinical deterioration in 2 patients. The overall morbidity and mortality in the entire series have been 1.7% and 0.0% to date, respectively. The follow-up results at 3 and 12 months revealed complete occlusion in 76.1% (70/92) and 78.0% (32/41).

CONCLUSIONS

The Woven EndoBridge 17 device is safe in the treatment of small broad-based aneurysms without the general need for additional devices. The low complication rate and the promising follow-up results underline the value of this technique in a growing range of endovascular treatment options for intracranial aneurysms.

Mechanical Thrombectomy in Acute Ischemic Stroke Using a Manually Expandable Stent Retriever (Tigertriever) : Preliminary Single Center Experience

OBJECTIVE

The aim of this study was to evaluate the safety and efficacy of a manually expandable stent retriever (Tigertriever, Rapid Medical, Yoqneam, Israel) in the treatment of acute ischemic stroke caused by intracranial large vessel occlusions (LVO).

METHODS

We performed a single center retrospective analysis of all patients treated by mechanical thrombectomy due to LVO using the Tigertriever. The angiographic and clinical success was evaluated by the modified thrombolysis in cerebral infarction score (mTICI) and the modified Rankin score (mRS).

RESULTS

A total of 68 acute intracranial arterial occlusions in 61 patients (42 female, median age 77 years, range 43-92 years) were treated by mechanical thrombectomy using the Tigertriever. The overall successful reperfusion rate (mTICI 2b-3) was 85.3% (58/68 occlusions) with a first pass effect (mTICI 3) of 23.5% (16/68 occlusions). In 57 of the 68 occlusions the Tigertriever was used on an intention to treat approach with a success rate of 86.0% and in the 11 remaining occlusions where the Tigertriever was used as a bail-out device the success rate was 81.9%. In seven patients a mild subarachnoid hemorrhage occurred (11.5%) and one symptomatic intracerebral hemorrhage was observed (1.6%). At discharge 39.3% of the patients (24/61) had a favorable outcome (mRS 0-2).

CONCLUSION

The Tigertriever offers a safe and effective treatment option in ischemic stroke due to LVOs with reperfusion rates and a safety profile similar to alternative devices. The Tigertriever is a promising bail-out tool in complex cases. Its role as a first line device has to be evaluated in further prospective studies.

Endovascular Thrombectomy of Calcified Emboli in Acute Ischemic Stroke: A Multicenter Study

BACKGROUND AND PURPOSE

Large intracranial vessel occlusion due to calcified emboli is a rare cause of major stroke. We assessed the prevalence, imaging appearance, the effectiveness of mechanical thrombectomy, and clinical outcome of patients with large-vessel occlusion due to calcified emboli.

MATERIALS AND METHODS

We performed a retrospective analysis of clinical and procedural data of consecutive patients who underwent mechanical thrombectomy due to calcified emboli in 7 European stroke centers.

RESULTS

We screened 2969 patients, and 40 patients matched the inclusion criteria, accounting for a prevalence of 1.3%. The mean maximal density of the thrombus was 327 HU (range, 150-1200 HU), and the mean thrombus length was 9.2 mm (range, 4-20 mm). Four patients had multiple calcified emboli, and 2 patients had an embolic event during an endovascular intervention. A modified TICI score of ≥2b was achieved in 57.5% (23/40), with minimal-to-no reperfusion (modified TICI 0-1) in 32.5% (13/40) and incomplete reperfusion (modified TICI 2a) in 10% (4/40). Excellent outcome (mRS 0-1) was achieved in only 20.6%, functional independence (mRS 0-2) in 26.5% and 90-day mortality was 55.9%.

CONCLUSIONS

Acute ischemic stroke with large-vessel occlusion due to calcified emboli is a rare entity in patients undergoing thrombectomy, with considerably worse angiographic outcome and a higher mortality compared with patients with noncalcified thrombi. Good functional recovery at 3 months can still be achieved in about a quarter of patients.