Assessing patient readiness for the clinical adoption of personalized medicine

BACKGROUND/AIMS

Although pharmacogenomics-based diagnostics and therapeutics are increasingly being translated into personalized medicine applications, relatively little evidence exists about how novel pharmacogenomics-based technologies will be accepted and adopted by patients. It is important to understand the characteristics of genomic diagnostics and targeted therapeutics that might impact utilization or serve as barriers to adoption of these novel technologies in order to formulate appropriate policies and procedures. The objective of this study was to investigate patients' understanding and knowledge of personalized medicine and the process of decision-making regarding pharmacogenomics testing and targeted therapeutics and to better understand how patients value receiving pharmacogenomics-based care.

METHODS

We conducted 4 focus groups with 8-10 individuals in each group with patients recruited from out-patient clinics at The Methodist Hospital in Houston, Tex., USA.

RESULTS

The use of genomic diagnostics and targeted therapeutics to facilitate personalized medicine has considerable support from patients. However, our data revealed that participants were concerned with issues surrounding privacy and confidentiality of genetic test results, particularly with respect to access of information by insurers, with potential costs of testing and issues related to accuracy of test results. Questions regarding willingness to pay revealed that patients would be more willing to pay out-of-pocket if the disease associated with pharmacogenomic testing for treatment was perceived to be high risk (e.g., colorectal cancer) versus a chronic condition that was perceived as lower risk (e.g., high cholesterol).

CONCLUSION

As the personalized medicine approach is increasingly incorporated into health care, understanding patients' needs and their readiness to adopt these novel technologies will become progressively more important for the development of appropriate health policies.

Synthesis and characterization of ultra-small superparamagnetic iron oxide nanoparticles thinly coated with silica

Ultra-small superparamagnetic iron oxide nanoparticles (SPIOs) were synthesized by co-precipitation of iron chloride salts with ammonia and then encapsulated with thin (~2nm) layers of silica. The particles have been characterized for size, diffraction pattern, surface charge, and magnetic properties. This rapid and economical synthesis has a number of industrial applications; however, the silica-coated particles have been optimized for use in medical applications as MR contrast agents, biosensors, DNA capturing, bioseparation and enzyme immobilization.

Poor outcome in adolescents with high-risk Hodgkin lymphoma

This retrospective study looks at the differences between adolescents (15-19 years) and young adults (20-25 years), diagnosed with Hodgkin lymphoma and treated at the same adult institution. Outcome according to risk category was evaluated, and although there were no significant differences in the whole cohort, or low and intermediate-risk categories, high-risk adolescent patients had a significantly worse outcome compared to that of young adults. In these high-risk patients, 5-year event free survival was 43.6% in adolescents compared to 58.7% in young adults (log-rank survival p=0.03), and the 5-year overall survival in adolescents was 66.7% compared to 84.4% in the young adults (p=0.04). Possible contributing factors to this inferior outcome in these high-risk patients were explored. The difference could not be explained in terms of differences in histological subtype (p=0.5), proportion of patients with bulky (p=0.6) or extranodal disease (p=0.6), initial treatment received (chemotherapy alone compared to combination therapy, p=0.2), or proportion proceeding to high-dose treatment after initial treatment failure (p=0.6). There was no difference in the documented number of delays, dose reductions or episodes of non-compliance during initial treatment in the two high-risk age groups. A significantly greater proportion of high-risk adolescents had primary progressive disease (PPD) [eight high-risk adolescents (33.3%) compared to two high-risk young adults (7.7%), p=0.02].

The clinical and cost-effectiveness of left ventricular assist devices for end-stage heart failure: a systematic review and economic evaluation

OBJECTIVES

To assess the clinical and cost-effectiveness of left ventricular assist devices (LVADs) as a bridge to heart transplantation (BTT), as a bridge to myocardial recovery (BTR) or as a long-term chronic support (LTCS) for people with end-stage heart failure (ESHF).

DATA SOURCES

For the systematic review, electronic databases and bibliographies of related publications plus experts and manufacturers. For the economic evaluations, data originated from the systematic review of clinical and cost-effectiveness, UK hospitals, device manufacturers and expert opinion.

REVIEW METHODS

For the systematic review, studies were selected and assessed against a set of rigorous criteria; data were then synthesised using a narrative approach through subgroup analysis based on the indication for treatment, type of LVAD and quality of studies. The economic evaluation developed two models to evaluate the use of LVADs, first as a BTT and second as LTCS for patients suffering from ESHF.

RESULTS

Sixteen studies assessed the clinical effectiveness of LVADs as a BTT. Despite the poor methodological quality of the evidence, LVADs appeared beneficial compared to other treatment options (i.e. inotropic agents or usual care) or to no care (i.e. the natural history of ESHF) improving the survival of people with ESHF during the period of support and following heart transplantation. Patients supported by an LVAD appeared to have an improved functional status compared with those on usual care and experienced an improvement in their quality of life from before device implantation to the period during support. Serious adverse events are a risk for patients with an LVAD. With a scarcity of evidence directly comparing different devices, it is difficult to identify specific devices as the most clinically effective. The HeartMate LVAD is the only device that has evidence comparing it with the different alternatives, appearing to be more clinically effective than inotropic agents and usual care and as clinically effective as the Novacor device. Second generation devices, such as Jarvik 2000 and MicroMed Debakey LVADs, are early in their development but show considerable promise that should be assessed through long-term studies. Evidence of the clinical effectiveness of LVADs as a BTR was limited to seven non-comparative observational studies that appeared to show that the LVADs were beneficial in providing support until myocardial recovery. It was not possible to assess whether the LVADs are more effective than other alternatives or specific devices. No evidence was found on the quality of life or functional status of patients and limited information on adverse events was reported. Six studies assessed the clinical effectiveness of LVADs as an LTCS and from these it was evident that LVADs provided benefits in terms of improved survival, functional status and quality of life. Nineteen studies assessed the costs and cost-effectiveness of LVADS for people with ESHF, with the majority being simple costing studies and very few studies of the cost-effectiveness of LVADs. With no relevant cost-effectiveness studies available, an economic evaluation for BTT and LTCS was developed. The economic evaluation has shown that neither LVAD indication considered, that is, BTT and LTCS, is a cost-effective use. For the HeartMate LVAD used as a BTT the cost per QALY was pound 65,242. In the less restrictive indication, LTCS, where LVADs are not just given to patients awaiting transplantation, the analysis has shown that LTCS is not cost-effective. The baseline cost per QALY of the first-generation HeartMate LVAD was pound 170,616. One- and multi-way sensitivity analysis had limited effect on the cost per QALY. A hypothetical scenario based on the cost of a second-generation MicroMed DeBakey device illustrated that a 60% improvement in survival over first-generation devices was necessary before the incremental cost-effectiveness approached pound 40,000 per QALY.

CONCLUSIONS

Although the review showed that LVADs are clinically effective as a BTT with ESHF, the economic evaluation indicated that they are not cost-effective. With the limited and declining availability of donor hearts for transplantation, it appears that the future of the technology is in its use as an LTCS. Further research is needed to examine the clinical effectiveness of LVADs for people with ESHF, assessing patient survival, functional ability, quality of life and adverse events. Evaluations of the clinical effectiveness of LVADs should include economic evaluations, as well as data on quality of life, utilities, resources and costs. A systematic review of the epidemiology of ESHF should be undertaken to assess its potential impact.

Guidelines for clinical studies with compression devices in patients with venous disorders of the lower limb

OBJECTIVES

The scientific quality of published clinical trials is generally poor in studies where compression devices have been assessed in the management of venous disease. The authors' aim was to establish a set of guidelines which could be used in the design of future clinical trials of compression treatments for venous diseases.

DESIGN

Consensus conference leading to a consensus statement.

METHODS

The authors form a expert consensus group known as the International Compression Club (ICC). This group obtained published medical literature in the field of compression treatment in venous disease by searching medical literature databases. The literature was studied by the group which attended a consensus meeting. A draft document was circulated to ICC members and revised until agreement between contributors was reached.

RESULTS

The authors have prepared a set of guidelines which should be given consideration when conducting studies to assess the efficacy of compression in venous disease.

CONCLUSIONS

The form of compression therapy including the comparators used in the clinical study must be clearly characterised. In future studies the characteristics of the material provided by the manufacturer should be described including in vivo data on pressure and stiffness of the final compression system. The pressure exerted on the distal lower leg should be stated in mmHg and the method of pressure determination must be quoted.

The quest for Factor VIIa exosite inhibitors

Coagulation proteases are involved in a highly orchestrated proteolytic cascade which is essential for haemostasis and blood clotting. In particular, the initiator of the coagulation cascade, Factor VIIa, binds to its cofactor, tissue factor, and its substrate, Factor X, via exosite interactions to form a ternary catalytic complex named extrinsic Xase. These exosite interactions have also been shown to allosterically induce the active conformation of the catalytic site of Factor VIIa. We have developed a direct continuous fluorescence polarization-based extrinsic Xase assay, which has been used to screen in excess of 1 million structurally diverse low-molecular-mass compounds as a potential starting point for the development of anticoagulants. The primary screen hits were categorized with deconvolution assays into either active-site or exosite inhibitors. The latter category of hits displayed both competitive and uncompetitive modalities of inhibition with respect to Factor X activation. An uncompetitive mechanism of action is of particular interest as it offers a hypothetical inhibitory advantage in the context of inhibiting a proteolytic cascade such as the blood coagulation pathway.

Prenatal predictors of mortality in very preterm infants cared for in the Australian and New Zealand Neonatal Network

AIM

To identify antenatal and perinatal risk factors for in-hospital mortality of babies born within the Australian and New Zealand Neonatal Network (ANZNN).

METHODS

Data were collected prospectively as part of the ongoing audit of high-risk infants (birth weight <1500 g or gestation <32 weeks) admitted to all level III neonatal units in Australia and New Zealand. Antenatal and intrapartum factors to 1 min of age were examined in 11 498 infants with gestational age >24 weeks. Risk and protective factors for mortality were derived from logistic regression models fitted to 1998-9 data and validated on 2000-1 data.

RESULTS

For the whole cohort of infants born between 1998 and 2001, prematurity was the dominant risk factor, infants born at 25 weeks having 32 times greater odds of death than infants born at 31 weeks. Low birth weight for gestational age also had a dose-response effect: the more growth restricted the infant the greater the risk of mortality; infants below the 3rd centile had eight times greater odds of death than those between the 25th and 75th centiles. Male sex was also a significant risk factor (odds ratio (OR) 1.55, 95% confidence interval (CI) 1.31 to 1.82). Maternal hypertension in pregnancy was protective (OR 0.46, 95% CI 0.36 to 0.50). The predictive model for mortality had an area under the receiver operating characteristic curve of 0.82.

CONCLUSIONS

Risk of mortality can be predicted with good accuracy with factors up to the 1 min Apgar score. By using gestation rather than birth weight as the main indicator of maturity, these data confirm that weight for gestational age is an independent risk factor for mortality.

Sexual health care of HIV-positive patients: an audit of a local service

The sexual health care of 175 HIV-positive patients attending the two HIV clinics at Barts and the London NHS Trust was audited for the first time. The audit standard was that 100% of patients should be in receipt of a sexual health screen within six months of their first HIV out-patient appointment. Overall, 44.5% of patients had a sexual health screen, of which 46 (60.5%) were diagnosed with a sexually transmitted infection. Those screened were younger than those who were not. Five factors were identified which were significantly associated with not having a genitourinary screen performed; site of HIV care, setting of HIV diagnosis, stage of HIV disease, specialty of HIV physician and whether a screen was recommended by the HIV physician. A number of recommendations have been implemented to improve the uptake of sexual health screening amongst HIV-positive patients.

Pathways to care: help seeking behaviour in first episode psychosis

OBJECTIVE

To determine the number of attempts it took before patients with a first episode of psychosis received adequate help, the signs or symptoms that led them to seek help and the people from whom they attempted to seek help.

METHOD

Subjects were 86 individuals with a schizophrenia spectrum disorder, mainly schizophrenia, who were attending a comprehensive program for early psychosis treatment.

RESULTS

Help-seeking attempts began in the prodromal phase of the illness and continued into the psychotic phase. Concerning behaviours ranged from more general symptoms to psychotic symptoms. A range of contacts were made early on but emergency services were most often the contact that helped individuals obtain appropriate treatment for psychosis.

CONCLUSION

Improved public education and gatekeeper education might reduce the time required for individuals developing a psychosis to receive timely and adequate care.

Cost-effectiveness of eformoterol Turbohaler versus salmeterol Accuhaler in children with symptomatic asthma

We conducted an economic evaluation in a UK setting based on a 12-week prospective randomized open-label parallel-group comparison of eformoterol Turbohaler 12 microg b. i.d. with salmeterol Accuhaler 50 microg b. i.d. in children aged 6-17 with symptomatic asthma receiving inhaled corticosteroids and short-acting beta2-agonists. The principal effectiveness measure was percentage of symptom-free days with no short-acting beta2-agonist use during the study period. Asthma-related medication, unscheduled physician contacts and hospitalizations were collected prospectively and cost to the UK NHS calculated using year 2,000 prices. The economic evaluation included 73 patients in the eformoterol group and 72 patients in the salmeterol group. The mean age of patients was 11.6 years (eformoterol) and 11.8 years (salmeterol). The mean percentage of symptom-free days with no short-acting beta2-agonist use was 39% in the eformoterol group and 30% in the salmeterol group. Mean per patient daily cost was 1.15 pounds in the eformoterol group and 1.39 pounds in the salmeterol group. Both cost and effectiveness differences favoured eformoterol (P < 0.05; one-sided). Sensitivity analysis confirmed the results to be robust to changes in effectiveness, price and resource utilisation parameters. Eformoterol delivered by Turbohaler was found to be significantly more effective and less expensive than salmeterol Accuhaler in this study.

Abnormalities of molecular regulators of proliferation and apoptosis in carcinoma of the oral cavity and oropharynx

OBJECTIVE

Abnormalities in genes regulating cell proliferation and death may affect disease outcome in squamous cell carcinoma (SCC) of the head and neck.

METHODS

Proliferative activity (Histone H3 in-situ-hybridization (HISH) labeling index (LI)) and the genes and/or gene products of Cyclin D-1, c-erbB-2, Bcl-2, p21, and p53, were investigated in 35 patients with SCC of the oral cavity and oropharynx, previously studied for p27 expression.

RESULTS

Overexpression or very low expression of Cyclin D-1 was associated with unfavorable disease outcome and shorter time-to-recurrence. High c-erbB-2 expression was significantly associated with shorter overall survival and was synergistic with low p27 expression. Bcl-2, HISH LI, p21 expression, and p53 mutation and protein analysis were not significantly predictive, but there were trends suggesting shorter disease-free/overall survival for patients with undetectable Bcl-2, high HISH, and mutant p53.

CONCLUSIONS

Several cell proliferation and death regulators appeared to predict disease outcome. Limited evidence of cooperativeness among regulators was also seen.

Delayed transient sciatic nerve palsy after total hip arthroplasty

Sciatic nerve palsy after total hip arthroplasty is a well-known complication, but delayed sciatic nerve palsy is rare. We report such a case with profound clinical manifestations and well-documented electrophysiologic changes. We found no helpful guidance to managing delayed palsy in the literature. We also are unaware of any previous cases reported in which nearly full recovery has occurred.