Interpreting Inclusion for Sanitation Perspectives from India: A Contextual Approach to Universal Design

Access to water, sanitation, and hygiene (WASH) for all is fundamental for sustenance. Goal 6 of the UN's Sustainable Development Goals urges that 'universal access to drinking water, sanitation and hygiene' is fundamental as a response in the current post-COVID scenario. Despite Government of India's efforts through programs like Swachh Bharat (Clean India) Mission, there is a long way to go to integrate equity and inclusion in the sanitation facilities of the public realm. This paper is an attempt to understand the aspect of inclusion in sanitation systems of urban public spaces of India, limiting the study to Delhi and Noida, which are in the National Capital Region (NCR). The aim is to explore the contextual challenges of universal design in public sanitation and develop an understanding of what makes a public toilet inclusive in the urban Indian context. A field-based, mixed methods approach is followed which begins with a literature review of government policies & schemes and theoretical understanding of inclusion as well as the role of universal design as an approach to achieve inclusion. This is followed by on-ground studies involving ethnographic surveys, analysis of imagery and field observations. The results show an analysis of the inclusive aspects of sanitation under the thematic domains of public perception, usage preferences and issues in the public toilet experience. The sanitation facilities in urban public spaces are used by a diverse population and the results showcase a collection of the qualitative experiences of a varied set of user groups. The subjective challenges of inclusive sanitation are highlighted through the various stages and components of the entire sanitation system - the design & infrastructure, operations & maintenance, and behavioural patterns. This paper tries to raise new grounded questions to further explore the highlighted marginal distinctions between inclusion and accessibility in the urban public sanitation experience of India.

Abstract P6-18-25: First-line treatment with ribociclib and letrozole in advanced breast cancer: First interim data from US patients enrolled in the phase 3b CompLEEment-1 clinical trial

Background: Addition of ribociclib to aromatase inhibitors significantly increased median progression-free survival in postmenopausal women in the MONALEESA-2 trial and premenopausal women in the MONALEESA-7 trial with hormone receptor–positive (HR+), human epidermal growth factor 2–negative (HER2−) advanced breast cancer (ABC). The global phase 3b CompLEEment-1 trial (Clinicaltrials.gov, NCT02941926) was designed to assess this treatment approach in a cohort of patients with HR+/HER2− ABC that was larger and more diverse than that of the MONALEESA program, particularly in the United States where underrepresented/underserved patient groups were targeted. Here we present the first interim safety analysis of the subset of US patients in the CompLEEment-1 trial.

Methods: Women (premenopausal and postmenopausal) and men with HR+/HER2− ABC, ≤1 line of prior chemotherapy, Eastern Cooperative Oncology Group performance status ≤2, and no prior endocrine therapy for ABC received open-label treatment with ribociclib (600 mg/d, 3 weeks on/1 week off) and letrozole (2.5 mg/d). Men and premenopausal women were required to use concomitant goserelin (3.6-mg subcutaneous implant every 28 days). Targeted enrollment in the overall study is ˜3000 patients. Patients with ≥56 days of follow-up at the data cutoff (October 3, 2017) were included in the first interim analysis (n=1008). The primary endpoint is safety and tolerability.

Results: In the first interim analysis, the US cohort of CompLEEment-1 included 128 patients, 94% of whom were continuing to receive treatment in the study. This cohort included 4 male patients (3%) and 18 patients not identified as white (14%); median age was 62.0 years (Table). The most common adverse events (AEs; >30%) were neutropenia (48%), nausea (45%), and fatigue (36%). The most common grade ≥3 AEs were neutropenia (30%) and leukopenia (6%); all other grade ≥3 AEs occurred in <5% of patients. Rates of AEs leading to discontinuation and dose interruption/adjustment were 5% and 52%, respectively. Four patients experienced at least 1 postbaseline QTcF >480 ms by local assessment. Grade ≥3 increases in alanine aminotransferase and aspartate aminotransferase levels occurred in 3 (2%) and 4 (3%) patients, respectively. There was 1 on-treatment death resulting from a serious AE, bradycardia, that was considered by the investigator to be treatment related.

Conclusions: The first interim safety data for ribociclib + letrozole from US patients in the CompLEEment-1 study, which included a broader population reflective of real-world clinical practice, are consistent with the global study population and previously reported safety profiles from the MONALEESA trials.

Table:Baseline CharacteristicsDemographicsPatients, %a (n=128)Age, median, y62.0Female96.9Postmenopausal86.7Premenopausal10.2Male3.1Race White82.8Black5.5Asian4.7Other3.1Unknown3.1Native American0.8ECOG Performance Status 0/1/250.0/45.3/4.7Stage at study entry II/III/IV2.3/3.1/94.5Current extent of disease Bone only28.1Central nervous system0.8Visceral53.1Liver20.3Lung38.3Other8.6Number of metastatic sites ≤261.73 or 424.2≥514.1aUnless otherwise noted.

Citation Format: Lu J, Shtivelband MI, Mitri Z, Chap L, Purkayastha D, Sawhney AG, Beck JT. First-line treatment with ribociclib and letrozole in advanced breast cancer: First interim data from US patients enrolled in the phase 3b CompLEEment-1 clinical trial [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-18-25.

Abstract PD5-11: Not presented

This abstract was not presented at the symposium.

Abstract P4-10-07: Patient-centered initiatives for improving trial participation of diverse patient populations in the open-label phase 3b compLEEment-1 study of ribociclib plus letrozole in the treatment of HR+/HER2- advanced breast cancer

Background: Reported 10-year survival rates in Caucasian, black, and Hispanic women with breast cancer are 80%, 66%, and 78%, respectively. One barrier to understanding disparities in these survival rates is the lack of data due to underrepresentation in clinical trials (including black, Hispanic, Native American, and Pacific Islander populations). US physicians at sites that treat minority patients with breast cancer identified lack of access to and financial burden of clinical trials as 2 key barriers to enrollment. Insufficient knowledge of genetic mutations specific to breast cancer is also a key barrier to identifying ideal treatment to extend survival in minorities. Patient-specific initiatives for the CompLEEment-1 study (CLEE011A2404; NCT02941926), a single-arm, international Phase 3b study of ribociclib (600 mg/d, 3 weeks on/1 week off) plus letrozole (2.5 mg/d) in adults with hormone receptor–positive, human epidermal growth factor–negative advanced breast cancer, were developed in the United States to increase the enrollment of diverse populations and better understand the disease and patient response to treatment.

Methods: The enrollment initiatives included formation of a board of leading physicians and academics to advise on awareness initiatives and the cultural competency of tools used in clinical trials, a site selection process that brought the trial to the patient's clinic, a simplified expense reimbursement program to reduce patient economic burden, and partnerships with the Bridge Group and the National Black Church Initiative to bring clinical trial awareness and education to the African American church community. A tumor collection companion study (NCT03050398) was created to identify mechanisms of resistance among racial and ethnic groups. These initiatives aimed to increase the percentage of minorities from previous trials (eg, 5.7% in the MONALEESA-2 trial) and identify potential biological differences associated with race or ethnicity that might affect treatment response.

Results: Enrollment in the CompLEEment-1 study is ongoing. Among the first 57 US patients enrolled, 8 (14.0%) were minorities (not identified as Caucasian or Asian), 32 (56.1%) were <65 years old, 7 (12.3%) were premenopausal women, and 2 (3.5%) were men. Thirty-one patients were enrolled in the simplified expense reimbursement program. Of the open study sites, 35 (52.2%) were located >30 miles outside of metropolitan areas. Of the open study sites with enrolled patients, 16 enrolled 1, 8 enrolled 2, and 5 enrolled ≥3 patients.

Conclusions: Following discussions with physicians and assessments of patient feedback to identify reasons for underrepresentation of minority patient populations in clinical trials, patient-centered initiatives were developed for the CompLEEment-1 study in the United States to simultaneously reduce barriers to trial participation, reduce economic burden of enrolled patients, and identify biomarkers of therapeutic sensitivity and resistance. These initiatives resulted in an initial increase in the percentage of minorities enrolled to better reflect real-world populations.

Citation Format: Small T, Marsano-Feeley J, Fernandez A, Grasso T, Feldman K, Petrone S, Bugazia N, Wong C, Meyer J, Schutta K, Purkayastha D, Saintil K, Spatz Caplan E, Waltman-Johnson K. Patient-centered initiatives for improving trial participation of diverse patient populations in the open-label phase 3b compLEEment-1 study of ribociclib plus letrozole in the treatment of HR+/HER2- advanced breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-10-07.

MDR1 expression predicts outcome of Ph+ chronic phase CML patients on second-line nilotinib therapy after imatinib failure

In the face of competing tyrosine kinase inhibitors (TKIs), identification of chronic myeloid leukemia (CML) patients expecting favorable response to second-line treatment is warranted. At the time of imatinib resistance, the investigation of multidrug-resistance protein 1 (MDR1) and BCR-ABL yielded the following results: (i) Patients with high MDR1 transcript levels showed superior response at 48 months as compared with low-level MDR1 patients: major molecular response (MMR) in 41% vs 16% (P=0.014), complete cytogenetic response (CCyR) in 58% vs 39% (P=0.044), and progression-free survival (PFS) in 67% vs 46% (P=0.032). (ii) Patients with BCR-ABL(IS) <28% achieved higher MMR rates (48% vs 21%, P=0.009). (iii) PFS at 48 months was associated with in vitro resistance of BCR-ABL kinase domain mutations: 63% (no mutation) vs 61% (sensitive, intermediately sensitive or unknown IC50 (median inhibitory concentration)) vs 23% (resistant, P=0.01). (iv) Single-nucleotide polymorphisms (SNPs) at positions 1236 and 2677 were associated with higher MDR1 expression in comparison to wild type. (v) Nilotinib was able to impede proliferation of MDR1-overexpressing imatinib-resistant cells. High MDR1 gene expression might identify patients whose mode of imatinib resistance is essentially determined by increased efflux activity of MDR1 and therefore can be overcome by second-line nilotinib treatment.

Logistic risk model for mortality following elective abdominal aortic aneurysm repair

Background

The aim was to develop a multivariable risk prediction model for 30-day mortality following elective abdominal aortic aneurysm (AAA) repair.

Methods

Data collected prospectively on 2765 consecutive patients undergoing elective open and endovascular AAA repair from September 1999 to October 2009 in the North West of England were split randomly into development (1936 patients) and validation (829) data sets. Logistic regression analysis was undertaken to identify risk factors for 30-day mortality.

Results

Ninety-eight deaths (5·1 per cent) were recorded in the development data set. Variables associated with 30-day mortality included: increasing age (P = 0·005), female sex (P = 0·002), diabetes (P = 0·029), raised serum creatinine level (P = 0·006), respiratory disease (P = 0·031), antiplatelet medication (P &lt; 0·001) and open surgery (P = 0·002). The area under the receiver operating characteristic (ROC) curve for predicted probability of 30-day mortality in the development and validation data sets was 0·73 and 0·70 respectively. Observed versus expected 30-day mortality was 3·2 versus 2·0 per cent (P = 0·272) in low-risk, 6·1 versus 5·1 per cent (P = 0·671) in medium-risk and 11·1 versus 10·7 per cent (P = 0·879) in high-risk patients.

Conclusion

This multivariable model for predicting 30-day mortality following elective AAA repair can be used clinically to calculate patient-specific risk and is useful for case-mix adjustment. The model predicted well across all risk groups in the validation data set.

Safety and tolerability of vildagliptin vs. thiazolidinedione as add-on to metformin in type 2 diabetic patients with and without mild renal impairment: a retrospective analysis of the GALIANT study

OBJECTIVE

This retrospective analysis assessed safety and tolerability of vildagliptin (Vilda) as an add-on to metformin in type 2 diabetes mellitus (T2DM) patients with normal renal function (GFR >80mL/min/1.73m(2)) and mild renal impairment (GFR: >50 to ≤80mL/min/1.73m(2)).

METHODS

Adverse events (AE) from this 12-week, randomized, open-label study comparing Vilda 100mg and thiazolidinediones (TZD) as an add-on therapy in patients with T2DM inadequately controlled (HbA(1c): 7-10%) on a stable dose of metformin (≥1000mg/day) were analyzed.

RESULTS

Of 2627 randomized patients, 1278 in the Vilda and 635 in the TZD groups had normal renal function; 463 in the Vilda and 230 in the TZD groups had mild renal impairment. Higher incidence of headache and rash was noted in both Vilda groups, whereas those with mild renal impairment receiving TZD experienced a higher incidence of peripheral edema and URI. Fewer patients in the Vilda group discontinued the study due to AEs compared to TZD group. Serious AEs were greater in TZD groups (normal: 2.4%; mild renal impairment: 3.0%) compared to Vilda groups (normal: 1.6%; mild renal impairment: 2.4%).

CONCLUSION

The safety profile of Vilda or TZD as an add-on to metformin was similar in patients with mild renal impairment and normal renal function.

Comparison of vildagliptin and thiazolidinedione as add-on therapy in patients inadequately controlled with metformin: results of the GALIANT trial--a primary care, type 2 diabetes study

AIM

To assess the efficacy and tolerability of vildagliptin compared with thiazolidinediones (TZDs) as an add on to metformin treatment in a primary care patient population with type 2 diabetes.

METHODS

This was a randomized, 12-week, open-label study comparing vildagliptin (100 mg, n = 1653) and TZD (agent and dose at the investigators' discretion, n = 825) add-on therapy in patients inadequately controlled [haemoglobin A(1C) (HbA(1c)): 7-10%] on a stable dose of metformin (> or =1000 mg/day). The primary objective was to test non-inferiority of vildagliptin to TZDs for the difference in change in HbA(1c) from baseline [established if the upper limit of the two-sided 95% confidence intervals (CI) did not exceed 0.4%].

RESULTS

Mean (+/- s.e.) change in HbA(1c) from baseline to study endpoint was -0.68 +/- 0.02% in the vildagliptin group and -0.57 +/- 0.03% in the TZD group. The difference between groups was -0.11% (95% CI: -0.17% and -0.04%), establishing the non-inferiority of vildagliptin (p = 0.001) after 3 months of treatment. Vildagliptin was non-inferior to TZDs for subgroups of race, age and body mass index. Body weight increased in the TZD group (0.33 +/- 0.11 kg) and decreased in the vildagliptin group (mean: -0.58 +/- 0.09 kg; p < 0.001 for difference). Adverse events occurred in similar proportions of patients in both groups (vildagliptin: 39.5% and TZD: 36.3%) Hypoglycaemia and abnormal changes in liver enzymes were uncommon.

CONCLUSIONS

This short-term study suggests that vildagliptin is as effective as TZDs after 3-month treatment as an add-on to metformin in a primary care population that included diverse patient subgroups.

The design of an observational study of hypertension management, adherence and pressure control in Blood Pressure Success Zone Program participants

AIMS

The Blood Pressure Success Zone (BPSZ) Program, a nationwide initiative, provides education in addition to a complimentary trial of one of three antihypertensive medications. The BPSZ Longitudinal Observational Study of Success (BPSZ-BLISS) aims to evaluate blood pressure (BP) control, adherence, persistence and patient satisfaction in a representative subset of BPSZ Program participants. The BPSZ-BLISS study design is described here.

METHODS

A total of 20,000 physicians were invited to participate in the study. Using a call centre supported Interactive Voice Response System (IVRS), physicians report BP and other data at enrolment and every usual care visit up to 12 +/- 2 months; subjects self-report BPs, persistence, adherence and treatment satisfaction at 3, 6 and 12 months post-BPSZ Program enrolment. In addition to BPSZ Program enrolment medications, physicians prescribe antihypertensive medications and schedule visits as per usual care. The General Electric Healthcare database will be used as an external reference.

RESULTS

After 18 months, over 700 IRB approved physicians consented and enrolled 10,067 eligible subjects (48% male; mean age 56 years; 27% newly diagnosed); 97% of physicians and 78% of subjects successfully entered IVRS enrolment data. Automated IVRS validations have maintained data quality (< 5% error on key variables). Enrolment was closed 30 April 2007; study completion is scheduled for June 2008.

CONCLUSIONS

The evaluation of large-scale health education programmes requires innovative methodologies and data management and quality control processes. The BPSZ-BLISS design can provide insights into the conceptualisation and planning of similar studies.

Nateglinide, alone or in combination with metformin, is effective and well tolerated in treatment-naïve elderly patients with type 2 diabetes

AIM

The aim of this work was to assess the efficacy and tolerability of nateglinide alone or in combination with metformin in elderly patients with type 2 diabetes (T2DM).

METHODS

Study 1 was a 12-week, multicentre, randomized, double blind and placebo-controlled study of nateglinide monotherapy (120 mg, before meals) in 66 drug-naïve patients with T2DM aged >or=65 years. Study 2 was a 104-week, multicentre, randomized, double blind and active-controlled study of nateglinide (120 mg, before meals) or glyburide (up to 5 mg bid) in combination with metformin (up to 1000 mg bid) in 69 treatment-naïve patients with T2DM aged >or=65 years. HbA(1c), fasting and postprandial glucose levels, and safety assessments were made.

RESULTS

In Study 1, nateglinide significantly reduced HbA(1c) from baseline (7.6 +/- 0.1% to 6.9 +/- 0.1%; Delta = -0.7 +/- 0.1%, p < 0.001) and compared with placebo (between-group difference = -0.5%, p = 0.004 vs. nateglinide). No hypoglycaemia was reported. In Study 2, combination therapy with nateglinide/metformin significantly reduced HbA(1c) from baseline (7.8 +/- 0.2% to 6.6 +/- 0.1%; Delta = -1.2 +/- 0.2%, p < 0.001), as did glyburide/metformin (7.7 +/- 0.1% to 6.5 +/- 0.1%; Delta = -1.2 +/- 0.1%, p < 0.001). There was no difference between treatments (p = 0.310). One nateglinide/metformin-treated patient experienced a mild hypoglycaemic episode compared with eight episodes in eight patients on glyburide/metformin; one severe episode led to discontinuation. Target HbA(1c) (<7.0%) was achieved by 60% of patients receiving nateglinide (Study 1) and 70% of nateglinide/metformin-treated patients (Study 2).

CONCLUSION

Initial drug treatment with nateglinide, alone or in combination with metformin, is well tolerated and produces clinically meaningful improvements in glycaemic control in elderly patients with T2DM.

Hypoglycemic potential of nateglinide versus glyburide in patients with type 2 diabetes mellitus

Antidiabetic agents that augment insulin secretion can cause hypoglycemia. With the current trend toward early and aggressive treatment of patients with type 2 diabetes, the hypoglycemic potential of insulinotropic agents is of concern. This study aimed to compare the propensity of the "glinide," nateglinide, and the sulfonylurea (SU), glyburide, to elicit hypoglycemia in type 2 diabetic patients with moderately elevated fasting plasma glucose (FPG). Hyperglycemic clamps (target plasma glucose = 11.1 mmol/L) were initiated, and 30 minutes later patients received a single oral dose of nateglinide (120 mg, n = 15) or glyburide (10 mg, n = 12) in a double-blind fashion. At the end of the 2-hour clamp when the glucose infusion was terminated, plasma glucose and insulin levels were measured for 4 additional hours. The minimum plasma glucose level achieved after terminating the glucose infusion (glucose nadir) was used as an index of hypoglycemic potential. The mean (+/-SEM) glucose nadir was significantly lower in patients given glyburide (3.3 +/- 0.2 mmol/L) versus nateglinide (4.4 +/- 0.3 mmol/L, P = .025). Confirmed hypoglycemia (plasma glucose < or = 2.8 mmol/L) occurred in 2 of 12 patients given glyburide and in none of those given nateglinide. Plasma insulin levels were significantly higher from 100 to 240 minutes after clamp termination in patients given glyburide versus nateglinide. Nateglinide has less hypoglycemic potential than glyburide, suggesting that nateglinide may be a more appropriate insulinotropic agent for patients with moderate fasting hyperglycemia, such as elderly patients and those with comorbid cardiac ischemia.

Disturbances in cellular features and elemental homeostasis in the integument of a freshwater fish Channa punctatus (Bloch) in relation to hydrogen ion concentration of polluted water

Scanning electron microscopy revealed that the cellular and morphological defects in the integument of Channa punctatus, associated with heavy metal and other environmental pollution was related to a significant extent to the hydrogen ion concentration of the water. At low pH, the epidermis showed severe lesions, and the scale lost its attachment with the skin, due to lepidontal alterations of the circuli. Atomic absorption spectroscopic analysis of the tissue indicated disturbances in the homeostasis of several elements, which probably played a major role in causing the cellular and morphological defects. Experimental monitoring of the pH of the polluted water to near-neutral, reduced significantly the extent of cellular and morphological defects and disturbances in elemental homeostasis.