End of an era of administering erythropoiesis stimulating agents among Veterans Administration cancer patients with chemotherapy-induced anemia

Erythropoisis stimulating agent (ESA) use was addressed in Food and Drug Administration (FDA) Oncology Drug Advisory Committee (ODAC) meetings between 2004 and 2008. FDA safety-focused regulatory actions occurred in 2007 and 2008. In 2007, black box warnings advised of early death and venous thromboembolism (VTE) risks with ESAs in oncology. In 2010, a Risk Evaluation Strategies (REMS) was initiated, with cancer patient consent that mortality and VTE risks were noted with ESAs. We report warnings and REMS impacts on ESA utilization among Veterans Administration (VA) cancer patients with chemotherapy-induced anemia (CIA). Data were from Veterans Affairs database (2003–2012). Epoetin and darbepoetin use were primary outcomes. Segmented linear regression was used to estimate changes in ESA use levels and trends, clinical appropriateness, and adverse events (VTEs) among chemotherapy-treated cancer patients. To estimate changes in level of drug prescription rate after policy actions, model-specific indicator variables as covariates based on specific actions were included. ESA use fell by 95% and 90% from 2005, for epoetin and darbepoetin, from 22% and 11%, respectively, to 1% and 1%, respectively, among cancer patients with CIA, respectively (p<0.01). Following REMS in 2010, mean hematocrit levels at ESA initiation decreased from 30% to 21% (p<0.01). Black box warnings preceded decreased ESA use among VA cancer patients with CIA. REMS was followed by reduced hematocrit levels at ESA initiation. Our findings contrast with privately- insured and Medicaid insured cancer patient data on chemotherapy-induced anemia where ESA use decreased to 3% to 7% by 2010–2012. By 2012, the era of ESA administration to VA to cancer patients had ended but the warnings remain relevant and significant. In 2019, oncology/hematology national guidelines (ASCO/ASH) recommend that cancer patients with chemotherapy-induced anemia should receive ESAs or red blood cell transfusions after risk-benefit evaluation.

Ebola, Zika, Corona…What Is Next for Our World?

In the past century, there have been several pandemics. Within the context of global health, these pandemics have often been viewed from the lens of determinants such as population, poverty, and pollution. With an ever-changing world and the COVID-19 pandemic, the current global determinants of public health need to be expanded. In this editorial, we explore and redefine the major determinants of global public health to prevent future pandemics. Policymakers and global leaders should keep at heart the determinants suggested hereby in any planning, implementation, and evaluation of efforts to improve global public health and prevent pandemics.

[Clinical effectiveness of super pulsed carbon dioxide fractional laser debridement surgery in treating chronic wounds]

Objective: To investigate the clinical effectiveness of super pulsed carbon dioxide fractional laser debridement surgery on the treatment of chronic wounds. Methods: From December 2018 to May 2019, 37 patients with chronic wounds who met the inclusion criteria were admitted to the Affiliated Hospital of Southwest Medical University for a prospective randomized controlled study. Using the random number table, the patients were divided into surgical debridement group (19 patients, 4 males and 15 females, aged (58±16) years, 25 wounds) and laser debridement group (18 patients, 9 males and 9 females, aged (58±10) years, 23 wounds). In patients of surgical debridement group, oedematous and aging granulation tissue was scraped from the wound by scalpel handle or curet, and the residual necrotic tissue was removed by sharp surgical instruments. In patients of laser debridement group, oedematous and aging granulation tissue and necrotic tissue was removed by super pulsed carbon dioxide fractional laser therapeutic machine, laser gasification debridement was performed repeatedly till fresh normal tissue layer observed. In patients of the two groups, according to the wound in the first 3 d after the first debridement, debridement dressing was performed twice at least as before, then wound debridement dressing was performed once every 1 to 4 days as before according to the wound conditions. The wound healing rates on 7, 14, 21, and 28 d after the first debridement were calculated. The positive rates of bacterial culture of wounds before and after the first debridement were calculated. The color and texture of the wound granulation tissue before the first debridement and on 7, 14, and 28 d after the first debridement were observed and scored. The pain scores before every debridement, during every debridement, and after every debridement dressing change were evaluated by visual analogue scale. The times of debridement dressing change were recorded. Data were statistically analyzed with two independent sample t test, analysis of variance for repeated measurement, Fisher's exact probability test, Mann-Whitney U test, and Bonferroni correction. Results: (1) On 7, 14, 21, and 28 d after the first debridement, the wound healing rates of patients in laser debridement group (29.5% (24.1%, 36.0%), 47.1% (42.7%, 62.4%), 71.4% (62.2%, 76.8%), and 88.6% (79.2%, 96.3%) were significantly higher than those of surgical debridement group (1.6% (1.0%, 12.8%), 12.7% (2.0%, 16.6%), 24.5% (8.9%, 45.5%), 43.9% (23.2%, 70.8%), Z=3.477, 3.553, 2.721, 2.193, P<0.05 or P<0.01). (2) Before the first debridement, the positive rates of bacterial culture of wounds in patients of laser debridement group and surgical debridement group were 92% (23/25) and 91% (21/23), respectively, which were similar (P>0.05). After the first debridement, the positive rate of bacterial culture of wounds of patients in surgical debridement group was 64% (16/25), which was significantly higher than 13% (3/23) of laser debridement group (P<0.01). (3) On 7, 14, and 28 d after the first debridement, the scores of color and texture of wound granulation tissue of patients in laser debridement group were significantly higher than those of surgical debridement group (Z=3.420, 5.682, 6.142, 4.461, 5.337, 4.458, P<0.01). (4) The pain scores during every debridement and after every debridement dressing change in patients of laser debridement group were significantly lower than those of surgical debridement group (t=2.847, 5.046, P<0.05 or P<0.01). (5) The time of debridement dressing change in laser debridement group was 8.0 (7.0, 10.0) times, which was significantly less than 10.0 (9.5, 12.5) times in surgical debridement group (Z=2.261, P<0.05). Conclusions: Compared with traditional surgical debridement method, super pulsed carbon dioxide fractional laser debridement surgery is more effective in treating patients with chronic wounds. Laser debridement makes the wound healing more efficiently with reduced pain and better infection control; significantly reduces the number of dressing changes, and is especially suitable for the wound treatment in outpatients.

End of an era for erythropoiesis-stimulating agents in oncology

Erythropoiesis-stimulating agents (ESAs) are available to treat chemotherapy-induced anemia (CIA). In 2007-2008, regulatory notifications advised of venous thromboembolism and mortality risks while the Center for Medicare and Medicaid Services' restricted ESA initiation to patients with hemoglobin <10 g/dl. In 2010, a Risk Evaluation and Mitigation Strategies required consent prior to administration. We evaluated ESA utilization from 2003 to 2012 and obtained private health insurer claims data for persons with lung, colorectal, or breast cancer from 2001 to 2012. ESA use for CIA was determined by an ESA claim after chemotherapy, up to 6 months after treatment. We identified 839,948 commercially insured patients, including 24,785 patients with ESA-treated CIA (3.2%). Darbepoetin use increased 3.9-fold from 2003 to 2007 (12.3% to 48.7%) and then decreased 95% to 2.6% by 2012. Epoetin use decreased 90% from 2003 to 2012 (30.3% to 3.1%). Between 2003 and 2012, mean epoetin dosing decreased 0.8-fold (244,979 in 2003 vs. 196,216 units in 2012), but increased 1.8-fold for darbepoetin-treated CIA (262 in 2003 to 467 μg in 2012). Among CIA patients, transfusions were low (4.5%) in 2002-2007, then increased 2.2-fold between 2008 and 2012. Safety initiatives between 2007 and 2010 facilitated reductions in ESA use combined with changes in coverage. These data show the efficacy of regulatory efforts, publication of adverse events and changes in reimbursement in reducing use of ESAs. Future studies are warranted to optimize deimplementation strategies to improve patient safety.

Intestinal dysbacteriosis mediates the reference memory deficit induced by anaesthesia/surgery in aged mice

BACKGROUND

Postoperative cognitive dysfunction (POCD) is associated with increased morbidity and mortality and has become a major concern for patients and caregivers. POCD is most common in older patients. Previous studies demonstrated that the gut microbiome affects cognitive function and behaviour, and perioperative factors, including the operation itself, antibiotics, opioids or acid-inducing drugs, affect the gut microbiome. Thus, we hypothesised that intestinal dysbacteriosis caused by anaesthesia/surgery induces POCD.

METHODS

Tibial fracture internal fixation was performed in 18-month-old C57BL/6 mice under isoflurane anaesthesia to establish the POCD model. The Morris water maze was used to measure reference memory after anaesthesia/surgery. High-throughput sequencing of 16S rRNA from faecal samples was used to investigate changes in the abundance of intestinal bacteria after anaesthesia/surgery. To confirm the role of the gut microbiome in POCD, we pretreated mice with compound antibiotics or mixed probiotics (VSL#3). Anaesthesia/surgery impaired reference memory and induced intestinal dysbacteriosis in aged mice.

RESULTS

The 16S rRNA sequencing data revealed 37 genera (18 families) of bacteria that changed in abundance after anaesthesia/surgery. Pretreating mice with compound antibiotics or mixed probiotics (VSL#3) prevented the learning and memory deficits induced by anaesthesia/surgery. We further conducted quantitative real-time polymerase chain reaction (qRT-PCR) of 22 common types of bacteria among the 37 total types to verify the results of bacterial flora changes after anaesthesia/surgery. Numbers of 8 types of bacteria changed after anaesthesia/surgery but returned to normal after treatment with a mix of probiotics.

CONCLUSIONS

Our data suggest that deficits in reference memory induced by anaesthesia/surgery are mediated by intestinal dysbacteriosis.

Caveat Medicus: Clinician experiences in publishing reports of serious oncology-associated adverse drug reactions

Oncology-associated adverse drug/device reactions can be fatal. Some clinicians who treat single patients with severe oncology-associated toxicities have researched case series and published this information. We investigated motivations and experiences of select individuals leading such efforts. Clinicians treating individual patients who developed oncology-associated serious adverse drug events were asked to participate. Inclusion criteria included having index patient information, reporting case series, and being collaborative with investigators from two National Institutes of Health funded pharmacovigilance networks. Thirty-minute interviews addressed investigational motivation, feedback from pharmaceutical manufacturers, FDA personnel, and academic leadership, and recommendations for improving pharmacovigilance. Responses were analyzed using constant comparative methods of qualitative analysis. Overall, 18 clinicians met inclusion criteria and 14 interviewees are included. Primary motivations were scientific curiosity, expressed by six clinicians. A less common theme was public health related (three clinicians). Six clinicians received feedback characterized as supportive from academic leaders, while four clinicians received feedback characterized as negative. Three clinicians reported that following the case series publication they were invited to speak at academic institutions worldwide. Responses from pharmaceutical manufacturers were characterized as negative by 12 clinicians. One clinician’s wife called the post-reporting time the “Maalox month,” while another clinician reported that the manufacturer collaboratively offered to identify additional cases of the toxicity. Responses from FDA employees were characterized as collaborative for two clinicians, neutral for five clinicians, unresponsive for negative by six clinicians. Three clinicians endorsed developing improved reporting mechanisms for individual physicians, while 11 clinicians endorsed safety activities that should be undertaken by persons other than a motivated clinician who personally treats a patient with a severe adverse drug/device reaction. Our study provides some of the first reports of clinician motivations and experiences with reporting serious or potentially fatal oncology-associated adverse drug or device reactions. Overall, it appears that negative feedback from pharmaceutical manufacturers and mixed feedback from the academic community and/or the FDA were reported. Big data, registries, Data Safety Monitoring Boards, and pharmacogenetic studies may facilitate improved pharmacovigilance efforts for oncology-associated adverse drug reactions. These initiatives overcome concerns related to complacency, indifference, ignorance, and system-level problems as barriers to documenting and reporting adverse drug events- barriers that have been previously reported for clinician reporting of serious adverse drug reactions.

Complexity of the Basic Reproduction Number (R0)

The basic reproduction number (R₀), also called the basic reproduction ratio or rate or the basic reproductive rate, is an epidemiologic metric used to describe the contagiousness or transmissibility of infectious agents. R₀ is affected by numerous biological, sociobehavioral, and environmental factors that govern pathogen transmission and, therefore, is usually estimated with various types of complex mathematical models, which make R₀ easily misrepresented, misinterpreted, and misapplied. R₀ is not a biological constant for a pathogen, a rate over time, or a measure of disease severity, and R₀ cannot be modified through vaccination campaigns. R₀ is rarely measured directly, and modeled R₀ values are dependent on model structures and assumptions. Some R₀ values reported in the scientific literature are likely obsolete. R₀ must be estimated, reported, and applied with great caution because this basic metric is far from simple.

Comparison of vaccination coverage of four childhood vaccines in New Zealand and New York State

AIM

To ensure that children are vaccinated, different national governments use diverse strategies. We compared childhood vaccination coverage rates between New York State (NYS) and New Zealand (NZ) as the vaccination strategies are different.

METHODS

We used vaccination records from the NYS Immunisation Information System and the National Immunisation Register of NZ to measure (i) vaccination coverage by school entry and by age six; (ii) coverage of different socio-demographic groups; and (iii) trend in vaccination coverage between 2011 and 2015.

RESULTS

We analysed the records of 583 767 NYS children and 269 800 NZ children 7 years of age. NZ children were 3.3-21.5% more likely than NYS children to receive each of the vaccines. Compared to NYS, NZ children were 39.6% more likely to be up-to-date by the start of school and 28.1% more likely to be up-to-date by age 6 years. Both NYS and NZ had statistically significant increases in the proportion of children who were up to date on each vaccine and all vaccines by the start of school and by 6 years of age (P < 0.001).

CONCLUSIONS

We identified under-vaccinated groups and examined the point in the vaccine series where children were most vulnerable to being under-vaccinated. This information is useful in targeting future investigations and interventions aimed at mitigating disparities in vaccine coverage. This comparison of regions with different vaccination programmes and policies is important when considering whether the particular vaccination coverage strategies of one region could be adapted and applied for the benefit of another.

[Analysis on prognosis and influencing factors of postoperative low anterior resection syndrome for rectal cancer patients undergoing laparoscopic anus-preserving radical resection]

Objective: To investigate the prognosis and influencing factors of postoperative low anterior resection syndrome (LARS) for rectal cancer patients undergoing laparoscopic sphincter-preserving radical resection. Methods: A retrospective case-control study was used in this study. Clinical data of 268 rectal cancer patients undergoing laparoscopic sphincter-preserving radical resection at Department of Gastrointestinal Surgery of The First Affiliated Hospital of Bengbu Medical College from January 2016 to January 2018 were retrospectively collected. Inclusion criteria: (1) operation procedure was total mesorectal excision (TME) and sphincter-preserving radical resection; (2) rectal cancer was confirmed by postoperative pathology; (3) age of patient was ≥ 18 years old. Exclusion criteria: (1) patient who had history of pelvic surgery and pelvic fractures, which would affect the anorectal function; (2) patient who had history of preoperative chronic constipation and irritable bowel syndrome, which would affect defecation; (3) patient who developed postoperative complications, such as anastomotic leakage, which would affect defecation function; (4) patient who received long-term use of drugs, which would affect the function of gastrointestinal tract or anus; (5) patient suffered from mental illness, who was unable to communicate properly; (6) patient who was lack of clinical data or had incomplete clinical data. Patients were followed up at 3, 6 and 12 months postoperatively, and LARS was diagnosed and graded according to the LARS score scale. The LARS score ranged from 0 to 42 points, and 0 to 20 was difined as no LARS, 21 to 29 was mild LARS, and 30 to 42 was severe LARS. LARS score >20 points at any time point was defined as postoperative LARS. Severe LARS transferring into mild LARS and mild LARS transferring into no LARS was defined as symptom improvement. Incidence and outcomes of LARS were evaluated. The factors associated with LARS outcomes were analyzed using χ(2) test and logistic regression model. Results: A total of 268 patients were enrolled. The incidence of LARS was 42.9% (115/268), 32.5% (87/268) and 20.1% (54/268) at 3, 6, and 12 months postoperatively respectively, and no new case of LARS was found after 3 months postoperatively. The incidence of mild LARS was 25.7% (69/268), 17.2% (46/268) and 8.6% (23/268) at 3, 6, and 12 months postoperatively respectively, and mild LARS incidence at 6 months was significantly lower than that at 3 months (χ(2)=5.857, P=0.016), and was significantly higher than that at 12 months (χ(2)=8.799, P=0.003). The incidence of severe LARS was 17.2% (46/268), 15.3% (41/268) and 11.6% (31/268) at 3, 6, and 12 months postoperatively respectively, without significant difference among 3 time points (all P>0.05). The improvement rate within one year after surgery in patients with mild LARS diagnosed at 3 months was significantly higher than that in patients with severe LARS (88.4% vs. 32.6%, χ(2)=38.340, P<0.001). Univariate analysis showed that female, distance from anastomosis to anal verge < 5 cm and tumor diameter ≥ 5 cm were associated with unsatisfied LARS outcomes (all P<0.05). Logistic regression analysis showed that distance from anastomosis to anal verge <5 cm was an independent risk factor for LARS outcome (OR=3.589, 95% CI: 1.163 to 2.198, P<0.001). Conclusions: The incidence of LARS after laparoscopic sphincter-preserving radical resection decreases with time. The improvement rate within postoperative 1-year of severe LARS is lower than that of mild LARS. Low anastomotic position may lead to impaired improvement of LARS.

[Retrospective cohort study on the correlation between high value of lactic acid and risk of death in 127 patients with extensive burn during shock stage]

Objective: To analyze the relationship between serum lactic acid value and risk of death in patients with extensive burn during shock stage and the related influencing factors. Methods: Clinical data of 127 patients (111 males and 16 females) with extensive burn admitted to Institute of Burn Research of the First Affiliated Hospital of Army Medical University from January 2009 to December 2013 and Department of Plastic Surgery and Burns of the Affiliated Hospital of Southwest Medical University from January 2016 to December 2018, who met the admission criteria, were retrospectively analyzed. The patients aged 21 to 62 years, with total burn area more than 50% total body surface area. All patients were treated with antishock therapy after admission. (1) According to the treatment outcome, the patients were divided into survival group (n=98) and death group (n=29). The gender, age, total burn area, partial-thickness burn area, full-thickness burn area, abbreviated burn severity index (ABSI), admission time after injury, number of patients with inhalation injury, number of patients with acute renal failure, and serum lactic acid values on admission and at post admission hour (PAH) 12, 24, 36, and 48 were recorded. (2) According to the optimal positive cut-off value of serum lactic acid 48 hours after admission, the patients were divided into high lactic acid group and normal lactic acid group. Age, gender, total burn area, indexes at PAH 48 including urea nitrogen, creatinine, alanine aminotransferase (ALT), aspartate aminotransferase (AST), total serum bilirubin, alkaline phosphatase (ALP), albumin, white blood cell count, platelet count, lymphocyte count, prothrombin time (PT), hematocrit value, oxygenation index, respiratory index (RI), the alveolar-arterial oxygen partial pressure difference, mean arterial pressure (MAP) at PAH 48, the average urine volume within 48 hours after admission, the total volume of intravenous fluid infusion within 48 hours after admission, the volume of fluid infusion per kilogram of body mass within the first 24 hours after admission, the volume of fluid infusion per one percent of body surface area per kilogram of body mass within the first 24 hours after admission, the volume of urine per kilogram of body mass per hour within the first 24 hours after admission, and the percentage of hospital death were recorded. Data were processed with t test, chi-square test, and Fisher's exact probability test. Cox regression analysis was used to screen independent risk factors affecting the prognosis of patients. Receiver operating characteristic curve (ROC) of serum lactic acid value at PAH 48 of 127 patients was drawn to predict patients' death and determine the optimal positive cut-off value. Multivariate logistic regression analysis was used to screen independent risk factors causing increase of serum lactic acid. Results: (1) There were significantly statistical differences in total burn area, full-thickness burn area, and ABSI of patients between survival group and death group (t=6.257, 4.476, 5.727, P<0.01), while other indexes between the two groups were close. (2) The serum values of lactic acid of patients in death group on admission and at PAH 12, 24, 36, and 48 were (4.00±0.28), (4.50±0.26), (4.02±0.31), (3.48±0.22), (3.40±0.19) mmol/L, respectively, which were significantly higher than those in survival group [(3.30±0.21), (3.20±0.19), (2.33±0.17), (1.85±0.18), (1.50±0.09) mmol/L, t=14.552, 29.603, 38.133, 40.648, 74.973, P<0.05 or P<0.01]. (3) Cox regression analysis showed that the serum value of lactic acid at PAH 48 was the independent risk factor affecting the prognosis of patients, with risk ratio of 1.853 and 95% confidence interval of 1.342-2.559, P<0.01. (4) The total area under ROC of serum value of lactic acid at PAH 48 to predict death of 127 patients was 0.811, with 95% confidence interval of 0.699-0.924, P<0.01. The optimal positive cut-off value of serum value of lactic acid was 1.75 mmol/L, with sensitivity of 75.0% and specificity of 79.5% for predicting death. (5) There were significantly statistical differences in total burn area, ALT, AST, ALP, PT, total serum bilirubin, total volume of intravenous fluid infusion within 48 hours after admission, volume of fluid infusion per kilogram of body mass within the first 24 hours after admission, and percentage of hospital deaths of patients between high lactic acid group (n=34) and normal lactic acid group (n=93), t=3.592, 6.797, 10.367, 2.089, 2.880, 4.517, 2.984, 4.044, χ(2)=58.498, P<0.05 or P<0.01, while other indexes were close between the two groups. (6) Multivariate logistic regression analysis showed that AST and total serum bilirubin were independent risk factors for increase of serum lactic acid, with odds ratios of 1.021 and 1.064 and 95% confidence intervals of 1.001-1.040 and 1.001-1.132, P<0.05. Conclusions: Serum value of lactic acid at PAH 48 can independently predict the death of patients with extensive burns. Liver injury is an important risk factor causing hyperlacticemia during burn shock stage. Widespread increase of vascular permeability and large amount of fluid resuscitation are the core factors leading to aggravation of abdominal organ injury.

Recent progress in children's meals law in restaurants in Baltimore City and California State: Making a healthy beverage option the default choice

In July 2018, Baltimore became the largest US city to prohibit restaurants from including sugar-sweetened beverages on kids' menus. In September 2018, California made history by becoming the first US state to require either water or milk as the default beverage with children's meals at all restaurants. Supporters of children's meals laws view them as helping to change the culture of health on beverage preferences and subtly influencing the choices of patrons. Using subtle methods of influencing children's beverage choices at restaurants, or nudges, will not on its own eradicate childhood obesity. However, the law aims to make healthier choices easier options and to influence people's choices in predictable ways without restricting their options. Evidence from a wide range of fields shows that people tend to stick with defaults and that setting beneficial defaults has high rates of acceptability. The laws in Baltimore and California, along with the other jurisdictions that have passed similar legislation, reflect a growing understanding - among restaurant owners, community members and policymakers alike - of the importance of feeding children healthy meals. They also signal that making healthier beverages the default option on children's menus is gaining strength in the US. Cities and states across the country should consider enacting similar laws as part of a greater public health initiative to combat the childhood obesity epidemic.

How does the Cox maze procedure compare? Cost-effectiveness analysis of alternative treatments of atrial fibrillation

OBJECTIVES

Data related to the cost effectiveness of surgical interventions and catheter ablation is sparse. This model-based analysis assessed the clinical and economic trade-offs involved in using catheter ablation or the Cox maze procedure in treating patients with atrial fibrillation.

METHODS

A deterministic model was developed to project 1 year and lifetime health-related outcomes, costs, quality-adjusted life years (QALYs) and cost effectiveness of each treatment in patients with atrial fibrillation. Using previously unpublished Inova Heart and Vascular Institute (IHVI) data for patients undergoing either procedure, 1 year cost and clinical efficacy inputs were estimated. This data was supplemented with published literature and used to estimate costs, utilities, mortality and likelihood of patient improvement. Results were reported as cost-effectiveness ratios in $/QALY. Sensitivity analyses were conducted to assess the robustness of results.

RESULTS

Patients initially treated with a Cox maze procedure were estimated to have higher costs than those treated with catheter ablation, both after 1 year and over the lifetime. However, patients undergoing the Cox maze procedure also had lower rates of 1 year mortality than catheter ablation patients (3.5% vs. 8.5%) and the highest rate of improvement following treatment, resulting in higher QALYs (12.4 vs. 10.2). Compared to catheter ablation, the lifetime incremental cost-effectiveness ratio for the Cox maze surgical procedure was $12,794 per QALY gained. Without quality adjustment, the ratio was $11,315. Results were most sensitive to the likelihood of improvement following each intervention and the cost of the initial procedure.

CONCLUSIONS

At a societal willingness to pay of $100,000/QALY, Cox maze procedure was found to both increase overall and quality-adjusted survival and constitute an effective use of resources in patients with atrial fibrillation.

Regulatory and Clinical Experiences with Biosimilar Filgrastim in the U.S., the European Union, Japan, and Canada

Biosimilar filgrastims are primarily indicated for chemotherapy-induced neutropenia prevention. They are less expensive formulations of branded filgrastim, and biosimilar filgrastim was the first biosimilar oncology drug administered in European Union (EU) countries, Japan, and the U.S. Fourteen biosimilar filgrastims have been marketed in EU countries, Japan, the U.S., and Canada since 2008, 2012, 2015, and 2016, respectively. We reviewed experiences and policies for biosimilar filgrastim markets in EU countries and Japan, where uptake has been rapid, and in the U.S. and Canada, where experience is rapidly emerging. U.S. regulations for designating biosimilar interchangeability are under development, and such regulations have not been developed in most other countries. Pharmaceutical substitution is allowed for new filgrastim starts in some EU countries and in Canada, but not Japan and the U.S. In EU countries, biosimilar adoption is facilitated with favorable hospital tender offers. U.S. adoption is reportedly 24%, while the second filgrastim biosimilar is priced 30% lower than branded filgrastim and 20% lower than the first biosimilar filgrastim approved by the U.S. Food and Drug Administration. Utilization is about 60% in EU countries, where biosimilar filgrastim is marketed at a 30%-40% discount. In Japan, biosimilar filgrastim utilization is 45%, primarily because of 35% discounts negotiated by Central Insurance and hospital-only markets. Overall, biosimilar filgrastim adoption barriers are small in many EU countries and Japan and are diminishing in Canada in the U.S. Policies facilitating improved U.S. adoption of biosimilar filgrastim, based on positive experiences in EU countries and Japan, including favorable insurance coverage; larger price discount relative to reference filgrastim pricing; closing of the "rebate trap" with transparent pricing information; formal educational efforts of patients, physicians, caregivers, and providers; and allowance of pharmaceutical substitution of biosimilar versus reference filgrastim, should be considered. IMPLICATIONS FOR PRACTICE: We reviewed experiences and policies for biosimilar filgrastims in Europe, Japan, Canada, and the U.S. Postmarketing harmonization of regulatory policies for biosimilar filgrastims has not occurred. Acceptance of biosimilar filgrastims for branded filgrastim, increasing in the U.S. and in Canada, is commonplace in Japan and Europe. In the U.S., some factors, accepted in Europe or Japan, could improve uptake, including acceptance of biosimilars as safe and effective; larger cost savings, decreasing "rebate traps" where pharmaceutical benefit managers support branded filgrastim, decreased use of patent litigation/challenges, and allowing pharmacists to routinely substitute biosimilar for branded filgrastim.

[Evaluation of bioceramic putty repairment in primary molars pulpotomy]

OBJECTIVE

To evaluate the clinical characteristics and effectiveness of bioceramic putty repairment (iroot BP Plus) used as pulp capping agents on pulpotomy in primary molars.

METHODS

Forty primary molars were treated by pulpotomy with bioceramic putty repairmen as the pulp capping agents at the Third Clinical Division of Peking University School and Hospital of Stomatology, from September 2016 to September 2017. The children who were followed up over one year were selected as the subjects of this study. The teeth were checked clinically and radiographically during fixed intervals, and classified into one of five outcomes: N, H, P₀, P_X, P_Y. N, absence of clinical symptoms, and absence of apical radiolucency; H, absence of clinical symptoms, and nonpathologic radiographic change present; P₀, absence of clinical symptoms, and pathologic change present, no need for treatment; P_X, present or absence of clinical symptoms, pathologic change present treatment or extract immediately; P_Y, premature loss of deciduous tooth. Molars classified into N and H were regarded as successful, classified into P₀, P_X and P_Y were regarded as failed.

RESULTS

Followed up for 12-24 months (the average follow up time was 16months), thirty four children were finally included, aged from 3.1 years to 8.5 yaers (the average age was 4.3 years), forty primary molars were included. Thirty four primary molars were included into N group, with absence of clinical symptoms, absence of apical radiolucency. Two molars were included into H group with physiological root absorption. One molar was included into P₀group with absence of clinical symptoms butinternal absorption of the root. Three molars were included into P_X group, with gingival fistula and apical radiolucency. None was included into P_Y group. Thirty six teeth got successful treatment, four molars failed. One year success rate of pulpotomy of primary molars using bioceramic putty repairment was 95%.

CONCLUSION

Current evidence suggests that bioceramic putty repairment as a pulpotomy medicament showed satisfied clinical and radiographic result in pulpotomy of primary molars. Bioceramic putty repairment is an acceptable material when used in pulpotomy of primary molars.