Health state utility estimates for value assessments of novel treatments in Huntington's disease: a systematic literature review

BACKGROUND

Huntington's disease (HD) is a progressive neurodegenerative disease with a devastating impact on patients and their families. Quantifying how treatments affect patient outcomes is critical for informing reimbursement decisions. Many countries mandate a formal value assessment in which the treatment benefit is measured as quality-adjusted life-years, calculated with the use of utility estimates that reflect respondents' preferences for health states.

OBJECTIVE

To summarize published health state utility data in HD and identify gaps and uncertainties in the data available that could be used to inform value assessments.

METHODS

We conducted a systematic literature review of studies that used preference-based instruments (e.g., EQ-5D and SF-6D) to estimate utility values for people with HD. The studies were published between January 2012 and December 2022.

RESULTS

Of 383 articles screened, 16 articles reported utility values estimated in 11 distinct studies. The utility measure most frequently reported was EQ-5D (9/11 studies). Two studies reported SF-6D data; one used time trade-off methods to value health state descriptions (vignettes). Although utility scores generally worsened to a lower value with increased HD severity, the estimates varied considerably across studies. The EQ-5D index range was 0.89 - 0.72 for mild/prodromal HD and 0.71 - 0.37 for severe/late-stage disease.

CONCLUSIONS

This study uncovered high variability in published utility estimates, indicating substantial uncertainty in existing data. Further research is needed to better understand preferences and valuation across all stages and domains of HD symptoms and the degree to which generic utility measures capture the impact of cognitive changes on quality of life.

Lewy body dementia: Overcoming barriers and identifying solutions

Despite its high prevalence among dementias, Lewy body dementia (LBD) remains poorly understood with a limited, albeit growing, evidence base. The public-health burden that LBD imposes is worsened by overlapping pathologies, which contribute to misdiagnosis, and lack of treatments. For this report, we gathered and analyzed public-domain information on advocacy, funding, research outputs, and the therapeutic pipeline to identify gaps in each of these key elements. To further understand the current gaps, we also conducted interviews with leading experts in regulatory/governmental agencies, LBD advocacy, academic research, and biopharmaceutical research, as well as with funding sources. We identified wide gaps across the entire landscape, the most critical being in research. Many of the experts participated in a workshop to discuss the prioritization of research areas with a view to accelerating therapeutic development and improving patient care. This white paper outlines the opportunities for bridging the major LBD gaps and creates the framework for collaboration in that endeavor. HIGHLIGHTS: A group representing academia, government, industry, and consulting expertise was convened to discuss current progress in Dementia with Lewy Body care and research. Consideration of expert opinion,natural language processing of the literature as well as publicly available data bases, and Delphi inspired discussion led to a proposed consensus document of priorities for the field.

CYP46A1 activation by low-dose efavirenz enhances brain cholesterol metabolism in subjects with early Alzheimer's disease

BACKGROUND

Efavirenz is an anti-HIV drug, and cytochrome P450 46A1 (CYP46A1) is a CNS-specific enzyme that metabolizes cholesterol to 24-hydroxycholesterol (24HC). We have previously shown that allosteric CYP46A1 activation by low-dose efavirenz in a transgenic mouse model of Alzheimer's disease (AD) enhanced both cholesterol elimination and turnover in the brain and improved animal performance in memory tests. Here, we sought to determine whether CYP46A1 could be similarly activated by a low-dose efavirenz in human subjects.  METHODS: This pilot study enrolled 5 subjects with early AD. Participants were randomized to placebo (n = 1) or two daily efavirenz doses (50 mg and 200 mg, n = 2 for each) for 20 weeks and evaluated for safety and CYP46A1 target engagement (plasma 24HC levels). A longitudinal mixed model was used to ascertain the statistical significance of target engagement. We also measured 24HC in CSF and conducted a unique stable isotope labeling kinetics (SILK) study with deuterated water to directly measure CYP46A1 activity changes in the brain.

RESULTS

In subjects receiving efavirenz, there was a statistically significant within-group increase (P ≤ 0.001) in the levels of plasma 24HC from baseline. The levels of 24HC in the CSF of subjects on the 200-mg dose of efavirenz were also increased. Target engagement was further supported by the labeling kinetics of 24HC by deuterated water in the SILK study. There were no serious adverse effects in any subjects.

CONCLUSIONS

Our findings suggest efavirenz target engagement in human subjects with early AD. This supports the pursuit of a larger trial for further determination and confirmation of the efavirenz dose that exerts maximal enzyme activation, as well as evaluation of this drug's effects on AD biomarkers and clinical symptomatology.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03706885.

Comparison of endovascular infrapopliteal revascularization strategies based on the angiosome model in diabetic patients within critical limb ischemia

Background

The relevance of an angiosome model for infrapopliteal endovascular interventions (EVT) in diabetic patients is still in debate because the lesions are more likely to be diffuse with a different pattern of collateral arteries ranging from reduced to normal caliber. The aim of this study was to analyse the outcome of two different endovascular infrapopliteal interventional strategies (Group I: angiosome-based direct revascularization -DR- vs. Group II: complete (direct + indirect) revascularization strategy -CR-) in diabetic patients with critical limb ischemia. Furthermore we analyzed the outcome if DR or CR failed and only indirect revascularization (IR) or no revascularization was possible. Both groups were differentiated in patients with collaterals, defined as an intact pedal arch (immediate or after pedal PTA).

Patients and methods

We performed a prospective cohort study in routine angiologic patients. The database includes 91 consecutive EVT with two intrapopliteal interventional strategies performed in 68 diabetic patients (pts.; 24 female, 44 male, mean age 73±10 years) between 2013–2015 and 2016–2019. The study included only patients with CLI (Rutherford class 4 or greater) with a critical subtotal stenosis or occlusion of at least one artery below the knee. EVT were performed mainly by an antegrade approach and with the use of 5F sheaths. In case of failure to recanalise, a retrograde approach was attempted. Positive clinical outcome was defined as wound healing without amputation or wound healing after minor amputation, combined with a symptom improvement to Rutherford category 0 or 1 after 6 months. The clinical outcome proportions were compared using the Fisher's exact test.

Results

An angiosome-based direct reperfusion (DR) of the artery supplying the ischemic tissue and a complete (both direct and indirect, CR) revascularization strategy demonstrated a similar positive clinical outcome (92,6% vs. 90,5%; p=0.594). Indirect revascularization showed a significantly lower positive outcome in comparison to a successful DR as well as CR strategy (33,3% vs 92,6%, p=0.0003; 40% vs 90,5%, p=0.001). IR outcome improved by the presence of collaterals (66,7% vs. 30,8%).

Conclusions

In case of successful intervention, both strategies (DR and CR) yielded a similarly high proportion of positive clinical outcome. The role of collaterals and the pedal arch are important for the clinical outcome in patients in whom only indirect revascularization was possible, because of unsuccessful CR or DR. The time of the procedure/radiation, the risk to reopen more than one vessel, the necessary amount of contrast medium and final the costs of the procedure should also be considered for an individually based decision process to perform an angiosome-based direct or a complete revascularization.

Funding Acknowledgement

Type of funding source: None

Ivory vs. osseous ivory substitutes-Non-invasive diffractometric discrimination

A new discrimination method for the bioapatite materials bone, antler and ivory was developed using X-ray diffractometry and comprises non-invasive measurements in order to take valuable objects into account. Our approach deals with the analysis of peak intensity ratios resulting from several measurements on each object. For instance, the intensity ratio of the apatite reflections 002 and 310 has been described in the literature as representing the degree of apatite crystal orientation and varies depending on the sample orientation. The decisive factor for the material identification is the value dispersion of intensity ratios resulting from the total of all measurements on one object. This pattern of data points, visualised via kernel density estimation (KDE), is characteristic for ivory, bone and antler, respectively, and enables the discrimination of these materials. The observation is justifiable since apatite crystal orientation adapts to the collagen fibre arrangement which shows major differences between different sorts of bioapatite materials. The patterns of data points were received via analysis of 88 objects made of bone (n = 30), antler (n = 27) and ivory (n = 31). In order to verify several identifications X-ray computer tomography was supplemented. The presented method usefully supplements already existing approaches concerning microscopic, elementary and biochemical analyses.

P223 Cat bite with unexpected consequences

A 25 y/o female patient with corrected tetralogy of Fallot (1995), pulmonary valve bio-prosthesis (1999) with consequent stenosis, and finally implantation of a pulmonary valve Hancock-conduit (2005), presented to our department with night sweats, shortness of breath, and fever for the past three weeks. Leukocytes and CRP were elevated, transthoracic echocardiography revealed a large vegetation on the pulmonary valve prosthesis with relevant stenosis (peak gradient 70 mmHg). The patient reported to have an 18-year-old cat as a pet, which had bit her shortly before onset of symptoms.

Blood cultures remained negative, bacterial broad spectrum PCR revealed Bartonella species. PET-CT was ordered and confirmed pulmonary valve endocarditis.

The patient was treated with antibiotics and eventually transferred to cardiac surgery due to persistently high gradients over the valve in combination with exertional dyspnea.

Bartonella is a well-known cause of blood culture negative infective endocarditis, which must be tested for specifically. This case underlines the importance of taking complete patient history, including presence of pets and especially recent bites. Comprehensive imaging must be performed timely in every patient with known valve disease and unexplained symptoms.

Abstract P223 figure 1

P1706 Trilogy of stroke

A 53 y/o female patient presented with clinical signs of stroke. Substantial cardiovascular risk factors were present with arterial hypertension, hyperlipidemia, impaired glucose tolerance, and a history of smoking. Transthoracic echocardiography revealed a suspicious structure on the aortic valve. Consequently, transesophageal echocardiography (TEE) was ordered.

In TEE, the structure proved to be highly suspicious for fibroelastoma. In addition, significant plaque of the aortic arch, and a persistent foramen ovale (PFO) were diagnosed in this examination.

The patient was referred to cardiac surgery for excision of the mass on the aortic valve and for PFO closure.

This case stresses the importance of echo in patients presenting with stroke. Apart from left atrial thrombus, several other possible embolic substrates can be diagnosed.

Abstract P1706 figure 1

Thermomechanical method for cement extraction in revision arthroplasty

BACKGROUND

In joint revision surgery, bone cement extraction remains a major challenge which even today has not seen a satisfactory solution yet. We studied in an experimental setting the impact of heat sources on the mechanical properties and microstructure of bone cement and determined the glass transition temperature (T _G) of bone cement. As a result, it would be possible to establish a thermomechanical method which makes use of the structural and material-specific property changes inherent in bone cement at elevated temperatures.

METHODS

Prepared samples of polymerized bone cement were thermoanalyzed with a Netzsch STA 409 C thermal analyzer. Samples weighing approx. 55 mg were heated to 390 °C at a rate of 5 K/min. Both simultaneous differential thermal analysis and thermogravimetry were employed. The thermomechanically induced changes in the microstructure of the material were analyzed with a computed tomography scanner specifically developed for materials testing (3D-μXCT).

RESULTS

The bone cement changed from a firm elastic state over entropy-plastic (air atmosphere 60-155 °C) to a plastic viscosity state (air atmosphere >155 °C). Between 290 and 390 °C, the molten mass disintegrated (decomposition temperature).

CONCLUSION

Our study was able to determine the glass transition temperature (T _G) of bone cement which was about 60 and 65 °C under air and nitrogen, respectively. Heating the dry bone cement up to at least 65 °C would be more than halve the strength needed to detach it. Bone cement extraction would then be easy and swift.

Current complications and challenges in nonalcoholic steatohepatitis screening and diagnosis

Nonalcoholic steatohepatitis (NASH) can lead to complications such as liver failure, cirrhosis and hepatocellular carcinoma. The diagnostic gold standard for NASH is liver biopsy; however, other noninvasive methods have been developed. In this article, the authors evaluate current methods in NASH screening and diagnosis. Routine radiologic modalities were found to detect hepatic steatosis accurately, but were unable to establish the diagnosis of NASH or stage of fibrosis. Newly developed elastography based techniques seem promising to estimate liver fibrosis. Other noninvasive tests such as FibroTest, ELF, Hepascore, FIB-4, NFS, FLI and ION (biochemical panels) have AUROCs ranging between 0.80-0.98 for detecting advanced fibrosis but lack specificity for detecting mild fibrosis. Noninvasive tools, especially elastography, identify NASH associated advanced fibrosis potentially reducing liver biopsies. More research is needed to validate the clinical utility of these tests.

Vaccination against hepatitis A and B in patients with chronic liver disease and type 2 diabetes: has anything changed?

BACKGROUND & AIMS

Given the severity of acute hepatitis in patients with chronic liver diseases (CLD) and patients with type 2 diabetes (DM), most of these patients are recommended to be vaccinated. The aim is to assess the recent changes in HAV and HBV vaccination rates in patients with CLD and DM in the U.S. using the most recent population data.

METHODS

We used the National Health and Nutrition Examination Surveys (NHANES) cycles 2009-2012 and 2013-2014, and compared those to previous cycles (1999-2004 and 2005-2008).

RESULTS

In general U.S. population, the rates of quality measure (QM, serologic immunity or history of vaccination) for HBV increased from 31.9% in 1999-2004 to 49.5% in 2013-2014 (P < 0.0001), synchronously with an increase in self-reported HBV vaccination: from 24.4% to 41.3% (P < 0.0001). A similar increase was noted for HAV: 12.0% in 1999-2004 to 33.4% in 2013-2014 in vaccination, 44.0% to 52.4% in HAV QM (all P < 0.0001). Greater recent increases in HBV QM were noted in non-HBV CLD patients: 34.7% to 56.8% in HBV QM and 22.7% to 51.1% in HBV vaccination (all P < 0.0001), while the changes in patients with diabetes were similar to those in general U.S. population despite the recent CDC recommendation (for the age 19-59): 31.0% to 45.1% (P = 0.007) in HBV QM, and 22.3% to 39.0% (P = 0.0004) in HBV vaccination.

CONCLUSIONS

Despite recommendations, HAV and HBV vaccination rates in patients with CLD and DM remain relatively low. Better vaccination strategies for these high risk patients should be undertaken.

Long-term outcomes of lung transplant recipients with hepatitis C infection: a retrospective study of the U.S. transplant registry

BACKGROUND

Chronic hepatitis C patients in need of a lung transplant are often considered ineligible due to their infection.

AIM

To assess the association of hepatitis C virus (HCV) infection with long-term outcomes of lung transplants.

METHODS

From the Scientific Registry of Transplant Recipients (1995-2011), we selected all adults with and without HCV infection who underwent lung transplantation.

RESULTS

A total of 17 762 lung transplant recipients were included (55.5% bilateral). Of those, 319 (1.83%) had positive HCV serology. The HCV-positive recipients were 1.6 years younger, less Caucasian and more African-American, and had a significantly higher rate of co-infection with hepatitis B virus (all P < 0.001). Post-transplant patients were discharged alive at similar rates regardless of HCV status: 88.4% in HCV+ vs. 90.3% in HCV- (P = 0.25). The mortality rates were also similar at 1 and 2 years after transplantation (20.7% in HCV+ vs. 19.2% in HCV- and 31.6% in HCV+ vs. 28.9% in HCV-, respectively; both P > 0.05), but at post-transplant year 3 year, mortality rate in HCV+ became significantly higher (42.5% vs. 36.4%, P = 0.04) and remained higher for the duration of the follow-up (mean 9.1 years, max 18.4 years). In multivariate survival analysis, after adjustment for confounders, being HCV+ was associated with higher mortality: adjusted hazard ratio 1.24 (1.04-1.46), P = 0.01. No association of HCV infection with time to graft loss was found (P = 0.92).

CONCLUSIONS

Chronic HCV infection is associated with a moderate increase in post-lung transplant mortality. Treatment of HCV in lung transplant recipients may, therefore, result in improvement of post-transplant outcomes.

Non-alcoholic Fatty Liver Disease (NAFLD) is associated with impairment of Health Related Quality of Life (HRQOL)

BACKGROUND

NAFLD impacts patient reported outcomes (PROs). Our aim was to assess the impact of NAFLD on patients' HRQOL.

METHODS

National Health and Nutrition Examination Survey (NHANES) 2001-2011 data were used to identify adult patients with NAFLD [Fatty Liver Index (FLI) > 60 in absence of other liver disease and excessive alcohol >20 g/day for men, >10 g/day for women]. Patients with other chronic diseases (ex. HIV, cancer, end-stage kidney disease) were excluded. Subjects without any of these conditions were healthy controls. HCV RNA (+) patients were HCV-controls. All patients completed NHANES HRQOL-4 questionnaire. Linear regression determined the association between NAFLD and HRQOL components adjusting for age, gender, race, and BMI.

RESULTS

Participants with complete data were included (n = 9661); 3333 NAFLD (age 51 years and BMI 34 kg/m(2)); 346 HCV+ (age 49 years; BMI 27 kg/m(2)) and 5982 healthy controls (age 48 years and BMI 26 kg/m(2)). The proportion of subjects rating their health as "fair" or "poor" in descending order were HCV controls (30 %) NAFLD (20 %) and healthy controls (10 %) (p < 0.001). HRQOL-4 components scores 2-4 were lowest for HCV, followed by NAFLD and then healthy controls (p-values p = 0.011 to < .0001). After adjustment for age, gender, race, and BMI, NAFLD patients were 18-20 % more likely to report days when their physical health wasn't good or were unable to perform daily activities as a result (p < .0001).

CONCLUSIONS

NAFLD causes impairment of HRQOL. As NAFLD is becoming the most important cause of CLD, its clinical and PRO impact must be assessed.

A wireless patch for sleep respiratory disorders applications

This paper presents a conformable wireless patch and its mobile application for physical activity, spO2 and pCO2 recording associated to digital biomarkers that aim at providing the clinicians with a reliable computer-aided diagnosis tool for rapid and continuous monitoring of sleep respiratory disorders. Each part of the system is described and results are presented and discussed. The reflectance sp02 sensor has been tested in vivo on several body sites and several subjects then compared to a reference device. The electrochemical tcpO2 sensor has been validated in vitro. Based on these physiological parameters, the proposed algorithms to automatically identifying sleep respiratory events are compared to a reference index.

Real-world evaluation of TNF-inhibitor utilization in rheumatoid arthritis

OBJECTIVES

To evaluate 12-month treatment patterns, healthcare resource use (HCRU), and costs for patients with rheumatoid arthritis (RA), following initiation of index TNF inhibitors (TNFi) and subsequent biologic DMARDs (bDMARDs).

METHODS

This was a retrospective cohort analysis of adults with RA newly initiating TNFi in the Truven Marketscan Commercial Claims and Encounters and Medicare Supplemental Databases during 2010-2013. A sub-group of patients who switched to a bDMARD within 12 months post-index and within 180 days of last index TNFi were subsequently evaluated over 12 months. TNFi/bDMARD treatment patterns were characterized as: continuers, no gap >180 days in prescription/administration of index TNFi; discontinuers, gap >180 days; switchers, initiated new bDMARD. Concomitant conventional synthetic DMARD use, co-morbid chronic illnesses, and RA severity were assessed. All-cause/RA-related HCRU and costs were evaluated 12 months post-index.

RESULTS

Of 9567 identified patients, 67.2%, 17.3%, and 15.4% were continuers, discontinuers, and switchers, respectively. Switchers had the highest 12-month unadjusted mean all-cause costs of $34,585 vs $33,051 for continuers (p = 0.1158) and $24,915 for discontinuers (p < 0.0001; discontinuers vs continuers, p < 0.0001). RA-related costs comprised 82.8%, 31.4%, and 85.7% of total costs for continuers, discontinuers, and switchers, respectively. Of 764 switchers, 68.2% switched to alternative TNFi (cyclers), the rest to non-TNFi bDMARDs; 36.7% of patients who switched to TNFi switched again (to third-line bDMARD) vs 27.6% (p = 0.0313) of those who switched to non-TNFi bDMARDs. Switchers to non-TNFi bDMARDs had higher mean 12-month all-cause costs of $76,580 compared with $50,689 for switchers to alternative TNFi (p < 0.0001); biologic-administration visits comprised 78.8% of the greater total RA-related costs of switchers to non-TNFi bDMARDs.

CONCLUSIONS

Real-world TNFi discontinuation/switching rates correspond to randomized controlled trial non-response rates. TNFi cycling is common and associated with an increased likelihood of switching to third-line bDMARD. Switching to non-TNFi bDMARDs was associated with higher costs, mostly attributed to in-office administrations.

Well-differentiated neuroendocrine neoplasia: relapse-free survival and predictors of recurrence after curative intended resections

BACKGROUND

Resection with curative intention is the cornerstone of treatment in patients with neuroendocrine tumors. A proportion of patients will relapse after R0 resection, but the factors predictive of recurrence are not well understood.

METHODS

A database established 1998 at the University Hospital Marburg was queried for all patients with documented R0 resection. Recurrence-free survival and overall survival were estimated using the Kaplan-Meier method. Uni- and multivariate analyses were performed.

RESULTS

180 patients with a median age of 52 years entered the analysis. We observed 77 recurrences after a median time of 2.9 years. 24% of the recurrences occurred later than 5 years after operation. Median recurrence-free survival of the whole cohort was 101 months. In univariate analysis grade by Ki-67, stage, high lymph node ratio and microangioinvasion were significant predictors of recurrence. On multivariate analysis these parameters were confirmed as independent prognostic parameters with stage and microangioinvasion being the most important predictors.

CONCLUSIONS

After R0 resection of neuroendocrine tumors, postoperative surveillance should be extended to at least 10 years. Patients with distant metastases and microangioinvasion are at high risk of recurrence. Clinical trials of adjuvant treatment protocols are indicated in these patients.

SOX2 promotes dedifferentiation and imparts stem cell-like features to pancreatic cancer cells

SOX2 (Sex-determining region Y (SRY)-Box2) has important functions during embryonic development and is involved in cancer stem cell (CSC) maintenance, in which it impairs cell growth and tumorigenicity. However, the function of SOX2 in pancreatic cancer cells is unclear. The objective of this study was to analyze SOX2 expression in human pancreatic tumors and determine the role of SOX2 in pancreatic cancer cells regulating CSC properties. In this report, we show that SOX2 is not expressed in normal pancreatic acinar or ductal cells. However, ectopic expression of SOX2 is observed in 19.3% of human pancreatic tumors. SOX2 knockdown in pancreatic cancer cells results in cell growth inhibition via cell cycle arrest associated with p21^Cip1 and p27^Kip1 induction, whereas SOX2 overexpression promotes S-phase entry and cell proliferation associated with cyclin D3 induction. SOX2 expression is associated with increased levels of the pancreatic CSC markers ALDH1, ESA and CD44. Importantly, we show that SOX2 is enriched in the ESA⁺/CD44⁺ CSC population from two different patient samples. Moreover, we show that SOX2 directly binds to the Snail, Slug and Twist promoters, leading to a loss of E-Cadherin and ZO-1 expression. Taken together, our findings show that SOX2 is aberrantly expressed in pancreatic cancer and contributes to cell proliferation and stemness/dedifferentiation through the regulation of a set of genes controlling G1/S transition and epithelial-to-mesenchymal transition (EMT) phenotype, suggesting that targeting SOX2-positive cancer cells could be a promising therapeutic strategy.

A gut feeling about insular seizures

A 43-year-old man presented to the Prince of Wales Hospital, Sydney, New South Wales, Australia, after experiencing his first tonic-clonic seizure. For the previous 2 years he had undergone gastroenterological investigation of episodes of gagging associated with hypersalivation and lachrymation, occurring three or four times per week. EEG showed epileptiform discharges in the right anterior temporal region; brain MRI revealed a lesion in the right insular cortex. Video-EEG telemetry demonstrated that the episodes of gagging were focal seizures. Antiepileptic drug therapy resulted in no further episodes occurring over the next 10 months.