Tacrolimus-Induced Neurotoxicity After Transplant: A Literature Review

Tacrolimus, a calcineurin inhibitor, is an immunosuppressant used globally to prevent rejection after organ transplantation. Although it significantly improves outcomes for solid organ transplant patients, it is associated with various side effects such as nephrotoxicity and neurotoxicity. Tacrolimus-induced neurotoxicity is frequently encountered in clinical practice and can present with a variety of symptoms that may occur even at therapeutic levels. Although tacrolimus-induced neurotoxicity is well documented, there is limited literature available on pharmacologic management. Twenty-eight case reports of tacrolimus-induced neurotoxicity were identified and analyzed in addition to other literature including reviews, retrospective studies, and animal model studies. The severity of cases of tacrolimus-induced neurotoxicity reported ranged from mild symptoms that could be managed with symptomatic treatment to conditions such as posterior reversible encephalopathy syndrome and chronic inflammatory demyelinating polyradiculoneuropathy that may require more immediate intervention. This information was utilized in addition to clinical experience to compile potential management options for prevention and treatment of neurotoxic adverse events. This review is limited by the utilization of primarily retrospective studies and case reports. The available literature on the subject is largely narrative and there are no guidelines on treatment of tacrolimus-induced neurotoxicity at the time of this research. This comprehensive review may guide further studies to investigate the pathophysiology of tacrolimus-induced neurotoxicity and to define patient-specific strategies for mitigation or minimization of neurotoxicity. This is especially important given that management of tacrolimus-induced neurotoxicity can include changes to immunosuppression that can result in an increased risk of rejection.

Primary outcomes from Partner2Lose: A randomized controlled trial to evaluate partner involvement on long-term weight loss

Background

Partner support is associated with better weight loss outcomes in observational studies, but randomized trials show mixed results for including partners. Unclear is whether teaching communication skills to couples will improve weight loss in index participants.

Purpose

To compare the efficacy of a partner-assisted intervention versus participant-only weight management program on long-term weight loss.

Methods

This community-based study took place in Madison, WI. Index participants were eligible if they met obesity guideline criteria to receive weight loss counseling, were aged 74 years or younger, lived with a partner, and had no medical contraindications to weight loss; partners were aged 74 years or younger and not underweight. Couples were randomized 1:1 to a partner-assisted or participant-only intervention. Index participants in both arms received an evidence-based weight management program. In the partner-assisted arm, partners attended half of the intervention sessions, and couples were trained in communication skills. The primary outcome was index participant weight at 24 months, assessed by masked personnel; secondary outcomes were 24-month self-reported caloric intake and average daily steps assessed by an activity tracker. General linear mixed models were used to compare group differences in these outcomes following intent-to-treat principles.

Results

Among couples assigned to partner-assisted (n=115) or participant-only intervention (n=116), most index participants identified as female (67%) and non-Hispanic White (87%). Average baseline age was 47.27 years (SD 11.51 years) and weight was 106.55 kg (SD 19.41 kg). The estimated mean 24-month weight loss was similar in the partner-assisted (2.66 kg) and participant-only arms (2.89 kg) (estimated mean difference, 0.23 kg [95% CI, -1.58, 2.04 kg]). There were no differences in 24-month average daily caloric intake (50 cal [95% CI: -233, 132 cal]) or steps (806 steps [95% CI: -1675, 64 steps]). The percentage of participants reporting an adverse event with at least possible attribution to the intervention did not differ by arm (partner-assisted: 9%, participant-only, 3%, p=0.11).

Conclusions

Partner-assisted and individual weight management interventions led to similar outcomes in index participants.

Trial registration

Clinicaltrials.gov NCT03801174.

A non-invasive 25-Gene PLNM-Score urine test for detection of prostate cancer pelvic lymph node metastasis

BACKGROUND

Prostate cancer patients with pelvic lymph node metastasis (PLNM) have poor prognosis. Based on EAU guidelines, patients with >5% risk of PLNM by nomograms often receive pelvic lymph node dissection (PLND) during prostatectomy. However, nomograms have limited accuracy, so large numbers of false positive patients receive unnecessary surgery with potentially serious side effects. It is important to accurately identify PLNM, yet current tests, including imaging tools are inaccurate. Therefore, we intended to develop a gene expression-based algorithm for detecting PLNM.

METHODS

An advanced random forest machine learning algorithm screening was conducted to develop a classifier for identifying PLNM using urine samples collected from a multi-center retrospective cohort (n = 413) as training set and validated in an independent multi-center prospective cohort (n = 243). Univariate and multivariate discriminant analyses were performed to measure the ability of the algorithm classifier to detect PLNM and compare it with the Memorial Sloan Kettering Cancer Center (MSKCC) nomogram score.

RESULTS

An algorithm named 25 G PLNM-Score was developed and found to accurately distinguish PLNM and non-PLNM with AUC of 0.93 (95% CI: 0.85-1.01) and 0.93 (95% CI: 0.87-0.99) in the retrospective and prospective urine cohorts respectively. Kaplan-Meier plots showed large and significant difference in biochemical recurrence-free survival and distant metastasis-free survival in the patients stratified by the 25 G PLNM-Score (log rank P < 0.001 and P < 0.0001, respectively). It spared 96% and 80% of unnecessary PLND with only 0.51% and 1% of PLNM missing in the retrospective and prospective cohorts respectively. In contrast, the MSKCC score only spared 15% of PLND with 0% of PLNM missing.

CONCLUSIONS

The novel 25 G PLNM-Score is the first highly accurate and non-invasive machine learning algorithm-based urine test to identify PLNM before PLND, with potential clinical benefits of avoiding unnecessary PLND and improving treatment decision-making.

Prevalence of Hospital-Onset Bacteremia Pre- and Post-Implementation of a Needleless Blood Sampling Device From Existing Peripheral Catheters

Repeated access of peripheral intravenous (IV) devices theoretically increases the risk of bacterial exposure. PIVO™ (VelanoVascular) is a needleless, single-use device that enables blood sampling from an existing peripheral IV. The goal of this retrospective observational exploratory study was to evaluate the influence of PIVO use on rates of hospital-onset bacteremia and fungemia (HOB) by comparing HOB rates in the year before and after PIVO introduction in hospitals implementing PIVO and over similar time periods in "control" hospitals with no PIVO. Two hospitals implementing PIVO (Hospital 1, a large community hospital; Hospital 2, a tertiary oncology center), and 71 control hospitals were included. During the 1-year period before and after PIVO introduction, HOB rates decreased in hospitals 1 and 2 by 31.9% and 41.8%, respectively. Control hospitals that did not use PIVO had a 12.4% decrease in HOB rates. Multivariable logistic regression analyses found that PIVO was associated with a lower risk (Hospital 1 odds ratio [OR]: 0.63; 95% CI, 0.42-0.94) or no change (Hospital 2 OR: 1.05; 95% CI, 0.72-1.52) in HOB rates. Control hospitals also showed no change in HOB rates between the 2 time periods. These data do not support concerns about increased risk of bacteremia with PIVO.

Development of an integrated rheumatoid arthritis simulation that reinforces specialty pharmacy and managed care concepts

BACKGROUND AND PURPOSE

As pharmacy services expand, it is critical for schools/colleges of pharmacy to prepare learners to provide patient care in a variety of settings and to subsequently assess skills that are necessary for clinical practice. The objectives of this study were to (1) develop and implement a simulation that required students to integrate knowledge from multiple courses and disciplines, (2) assess students' performance and perceptions of the activity, and (3) measure student confidence related to managed care, specialty pharmacy, and clinical and foundational concepts prior to and after the simulation.

EDUCATIONAL ACTIVITY AND SETTING

Faculty developed an integrated simulation that required students to provide information for prior authorization of a new medication, counsel a patient on rheumatoid arthritis and the medication, and address patient questions about insurance formularies, cost, and prior authorization processes. Students completed pre- and post-surveys to determine changes in knowledge and perceptions of the simulation. Exam questions that corresponded to simulation concepts were also analyzed.

FINDINGS

Analysis of pre-post surveys indicated that students' self-perceived knowledge and confidence significantly improved in all areas (P < .001 and P < .05, respectively). Student perceptions of the simulation were positive, with comments referencing the activity's realism. Correct answers on knowledge-based questions related to simulation concepts were selected by at least 90% of students on course examinations.

SUMMARY

This integrated simulation was effective at increasing self-perceived student knowledge and confidence on concepts from all disciplines, and it can easily be replicated and adapted at other pharmacy institutions.

Monitoring for a new I3 resistance gene-breaking race of F. oxysporum f. sp. lycopersici (Fusarium wilt) in California processing tomatoes following recent widespread adoption of resistant (F3) cultivars: Challenges with race 3 and 4 differentiation methods

Fusarium wilt, caused by Fusarium oxysporum f. sp. lycopersici (Fol), causes losses in tomato production worldwide, with major impacts on Californian tomato processing. Single-gene resistance is the primary management tool, but its efficacy has been compromised following the emergence of two successive resistance-breaking races, which, in California, emerged within 12 years of resistance deployment. Fol race 3-resistant (F3) processing tomato cultivars (containing the I3 resistance gene) were deployed in the state starting in approximately 2009. The emergence of a new resistance-breaking race (which would be called race 4) is imminent, and early detection will be critical to delay the spread while new resistance is sought. The detection of Fol race 4 is challenged by the lack of validated, rapid, and accurate diagnostic tools. In evaluating in planta phenotyping methods, this study found that rapid seedling phenotyping is not reliable and generates false positives for nonpathogens. Longer (10 weeks) mature plant assays are the most reliable, but may not be sufficiently timely. As an additional challenge, based on field and greenhouse studies, Fol race 3 can cause symptoms in resistant F3 cultivars at frequencies greater (30%) than expected for off-types (<2%). We developed a three-F3 cultivar in planta assay to overcome the challenges this posed to differentiating Fol race 3 and Fol race 4. Using the assay, we determined that all putative resistance-breaking cases were Fol race 3; Fol race 4 was not detected in these early survey efforts. These results highlight the need for developing rapid Fol race 4 detection tools and a better understanding of the factors underlying inconsistent I3 gene expression in Fol race 3.

High continuous positive airway pressures versus non-invasive positive pressure ventilation in preterm neonates: protocol for a multicentre pilot randomised controlled trial

INTRODUCTION

Low pressure nasal continuous positive airway pressure (nCPAP) has long been the mainstay of non-invasive respiratory support for preterm neonates, at a constant distending pressure of 5-8 cmH2O. When traditional nCPAP pressures are insufficient, other modes including nasal intermittent positive pressure ventilation (NIPPV) are used. In recent years, high nCPAP pressures (≥9 cmH2O) have also emerged as an alternative. However, the comparative benefits and risks of these modalities remain unknown.

METHODS AND ANALYSIS

In this multicentre pilot randomised controlled trial, infants <29 weeks' gestational age (GA) who either: (A) fail treatment with traditional nCPAP or (B) being extubated from invasive mechanical ventilation with mean airway pressure ≥10 cmH2O, will be randomised to receive either high nCPAP (positive end-expiratory pressure 9-15 cmH2O) or NIPPV (target mean Paw 9-15 cmH2O). Primary outcome is feasibility of the conduct of a larger, definitive trial as assessed by rates of recruitment and protocol violations. The main secondary outcome is failure of assigned treatment within 7 days postrandomisation. Multiple other clinical outcomes including bronchopulmonary dysplasia will be ascertained. All randomised participants will be analysed using intention to treat. Baseline and demographic variables as well as outcomes will be summarised and compared using univariate analyses, and a p<0.05 will be considered significant.

ETHICS AND DISSEMINATION

The trial has been approved by the respective research ethics boards at each institution (McMaster Children's Hospital: Hamilton integrated REB approval #2113; Royal Alexandra Hospital: Health Research Ethics Board approval ID Pro00090244; Westmead Hospital: Human Research Ethics Committee approval ID 2022/ETH01343). Written, informed consent will be obtained from all parents/guardians prior to study enrolment. The findings of this pilot study will be disseminated via presentations at national and international conferences and via publication in a peer-reviewed journal. Social media platforms including Twitter will also be used to generate awareness.

TRIAL REGISTRATION NUMBER

NCT03512158.

Toward Optimal High Continuous Positive Airway Pressure as Postextubation Support in Preterm Neonates: A Retrospective Cohort Study

OBJECTIVE

 This study aimed to evaluate whether the initial pressure level on high continuous positive airway pressure (CPAP; ≥9 cm H2O), in relation to preextubation mean airway pressure (Paw), influences short-term clinical outcomes in preterm neonates.

STUDY DESIGN

 In this retrospective cohort study, preterm neonates <29 weeks' gestational age (GA) extubated from mean Paw ≥9 cm H2O and to high CPAP (≥9 cm H2O) were classified into "higher level CPAP" (2-3 cm H2O higher than preextubation Paw) and "equivalent CPAP" (-1 to +1 cm H2O in relation to preextubation Paw). Only the first eligible extubation per infant was analyzed. The primary outcome was failure within ≤7 days of extubation, defined as any one or more of (1) need for reintubation, (2) escalation to an alternate noninvasive respiratory support mode, or (3) use of CPAP >preextubation Paw + 3 cm H2O. Secondary outcomes included individual components of the primary outcome, along with other clinical and safety outcomes.

RESULTS

 Over a 10-year period (Jan 2011-Dec 2020), 175 infants were extubated from mean Paw >9 cm H2O to high CPAP pressures. Twenty-seven patients (median GA = 24.7, [interquartile range (IQR)]: (24.0-26.4) weeks and chronological age = 31, IQR: [21-40] days) were classified into the "higher level CPAP" group while 148 infants (median GA = 25.4, IQR: [24.6-26.6] weeks and chronological age = 26, IQR: [10-39] days) comprised the "equivalent CPAP" group. There was no difference in the primary outcome (44 vs. 51%; p = 0.51), including postadjustment for confounders (adjusted OR [aOR] = 0.47 [95% confidence interval (CI): 0.17-1.29; p = 0.14]). However, reintubation risk within 7 days was lower with higher level CPAP (7 vs. 37%; p < 0.01), including postadjustment (aOR = 0.07; 95% CI: 0.02-0.35; p < 0.01).

CONCLUSION

 In this cohort, use of initial distending CPAP pressures 2 to 3 cm H2O higher than preextubation Paw did not alter the primary outcome of failure but did lower the risk of reintubation. The latter is an interesting hypothesis-generating finding that requires further confirmation.

KEY POINTS

· Use of high CPAP pressures (≥9 cm H2O) is gradually increasing in the care of preterm neonates.. · This study compares higher level versus equivalent CPAP in relation to preextubation Paw.. · The findings demonstrate no difference in failure as defined with use of higher level CPAP pressures..

LGG-63 MEK inhibitor-associated retinopathy (MEKAR) in a pediatric patient with an optic pathway glioma

Pediatric low-grade glioma (LGG) and plexiform neurofibroma (PN) universally have up-regulation of the RAS-mitogen-activated protein kinase (MAPK) pathway. Recent phase I and II clinical trials evaluating MEK inhibitors for the treatment pediatric LGG and PN report efficacy and tolerable side effects, including no reported ophthalmologic toxicity. Contrary to the pediatric experience, adult trials using MEK inhibitors describe several ophthalmologic side effects, including MEK inhibitor-associated retinopathy (MEKAR), also termed central serous-like retinopathy. MEKAR is defined as accumulation of subretinal fluid. It occurs in up to 90% of adults on MEK inhibitors, usually causing minimal to no symptoms, and typically resolving without MEK inhibitor dose adjustment. We report a case of MEKAR in a 15 year old boy with an optic pathway pilocytic astrocytoma with duplication of BRAF (7q34). Baseline ophthalmic exam showed 20/20 vision in his right eye with loss of the temporal hemifield and no light perception vision in the left eye. Nine months into treatment with Selumetinib his ophthalmologic exam and optical coherence tomography (OCT) showed asymptomatic bilateral subretinal fluid. Selumetinib was held for 2 weeks resulting in resolution of the subretinal fluid. Selumetib was resumed at the prior dose and MEKAR recurred 2 weeks later but then permanently resolved 4 weeks later despite remaining on Selumetib. Review of the literature discovered a single publication of 2 pediatric patients with optic pathway glioma who developed MEKAR around 6-7 months after initiating Selumetinib, which resolved after stopping Selumetinib. One patient was symptomatic and despite resolution of symptoms, Selumetinib was not resumed. The other patient was asymptomatic and resumed Selumetib, but redeveloped MEKAR 8 months after restarting Selumetinib. Based on adult experience and the limited pediatric experience outlined above, we recommend pediatric patients with asymptomatic and mild-moderate symptomatic MEKAR undergo close monitoring without Selumetinib dose interruption or modification unless symptoms progress.

Nursing Home Residents' Positive Behavioral Responses to Individualized Music Predict Improvements in Sundowning Symptoms After Music Listening

Objective: The goal of this exploratory study was to predict which long-term care residents with dementia would experience improvements in their sundowning symptoms after listening to personalized music playlists. Methods: We studied 101 residents with moderate to severe dementia from 15 long-term care facilities across 8 months. We observed residents' behavioral responses to individualized music while they listened and recorded sundowning symptoms both before and after each listening session. Results: As hypothesized, residents who exhibited a greater number of positive reactive behaviors while listening to music also evidenced more improvements in their confusion, disengagement, unresponsiveness, and restlessness after their music-listening session. Discussion: Our results reveal that observing behavioral responses during music listening is an effective way to determine when nursing home residents are benefiting from personalized music playlists. These findings inform music programs in long-term care settings by identifying residents whose sundowning symptoms are most amenable to music intervention.

Gene-Mutation-Based Algorithm for Prediction of Treatment Response in Colorectal Cancer Patients

Purpose: Despite the high mortality of metastatic colorectal cancer (mCRC), no new biomarker tools are available for predicting treatment response. We developed gene-mutation-based algorithms as a biomarker classifier to predict treatment response with better precision than the current predictive factors. Methods: Random forest machine learning (ML) was applied to identify the candidate algorithms using the MSK Cohort (n = 471) as a training set and validated in the TCGA Cohort (n = 221). Logistic regression, progression-free survival (PFS), and univariate/multivariate Cox proportional hazard analyses were performed and the performance of the candidate algorithms was compared with the established risk parameters. Results: A novel 7-Gene Algorithm based on mutation profiles of seven KRAS-associated genes was identified. The algorithm was able to distinguish non-progressed (responder) vs. progressed (non-responder) patients with AUC of 0.97 and had predictive power for PFS with a hazard ratio (HR) of 16.9 (p < 0.001) in the MSK cohort. The predictive power of this algorithm for PFS was more pronounced in mCRC (HR = 16.9, p < 0.001, n = 388). Similarly, in the TCGA validation cohort, the algorithm had AUC of 0.98 and a significant predictive power for PFS (p < 0.001). Conclusion: The novel 7-Gene Algorithm can be further developed as a biomarker model for prediction of treatment response in mCRC patients to improve personalized therapies.

Establishment and Evaluation of Scalable COVID-19 Vaccine Clinics at a Large University

Background

Previous large-scale vaccination clinics have been successful before the coronavirus disease 2019 (COVID-19) pandemic; however, owing to the strict storage requirements and pharmaceutical preparation needed for the COVID-19 vaccines, careful thought and planning were necessary to successfully deploy these clinics immediately after vaccine availability. The focus of this manuscript is to describe the development and implementation of COVID-19 vaccination clinics in a large public university, using professionals from within and outside of its health sciences schools.

Objectives

The primary objective of this project was to (1) implement COVID-19 vaccination clinics for university faculty, staff, students, and community members. Additional objectives of the clinics were to (2) actively incorporate pharmacy, nursing, and medical students into the clinic workflow; (3) promote interprofessional collaboration among faculty and students; and (4) assess patient satisfaction.

Practice description

The School of Pharmacy faculty, in conjunction with the Office of Strategic Initiatives, planned and coordinated COVID-19 vaccination clinics from December 2020 to July 2021. Students and faculty from schools of pharmacy, nursing, and medicine were used. COVID-19 vaccinations were offered to university faculty, staff, and students and community members based on the Centers for Disease Control and Prevention priority groups. The clinic processes were designed such that they could be scaled from 100 to 2,000 participants per day.

Practice innovation

The School of Pharmacy led approach was adjustable depending on the number of patients, continuously monitored and adaptable. The importance of pharmacists as part of the interprofessional health care team was exemplified by faculty and students involved.

Evaluation methods

All patients receiving COVID-19 vaccinations at the clinics were e-mailed anonymous surveys for assessment of the quality of the vaccination encounter after completion of their primary vaccine series.

Results

More than 15,000 COVID-19 vaccinations were provided through the clinics from December 2020 to July 2021. Professional staffing totaled 3352 hours for the 48 clinics. Thirty-eight percent of the vaccinated patients responded to the clinic satisfaction survey with predominately excellent ratings.

Conclusion

COVID-19 vaccination clinics can be successfully planned and implemented in a scalable fashion in a large university setting using an interprofessional team approach.

Technology-enabled multidisciplinary team in-reach for oral corticosteroid stewardship and optimizing care of suspected airways disease exacerbations

Overuse of corticosteroids is an important problem not only in asthma but also the management of other airways diseases including bronchiectasis and COPD and results in associated risks of serious side effects and irreversible harm. We report a pilot using an in-reach solution to review patients, optimise their care and facilitate early discharge. We discharged >20% of our patients immediately, which is potentially a significant reduction in hospital bed use and, most importantly, through this approach we were able to establish early diagnosis and reduce inappropriate oral corticosteroid use.

A competency roadmap for advanced practice nursing education using PRIME-NP

BACKGROUND

Clinical competency validation is essential for nurse practitioner (NP) education and public accountability. While there has been robust discussion around what constitutes clinical competency and assessment, clear and consistent definitions and measurements remain elusive.

PURPOSE

This article describes the PRIME-NP clinical competency model that is scalable, reproducible and accurately documents NP student competency across clinical courses.

METHODS

To develop the model, work in 5 discrete domains was necessary: (a) model development, (b) assessment tool to be used in Objective Structured Clinical Exams (OSCE), (c) rubrics to accompany the OSCE exam, (d) faculty education, and (e) evaluating the model use.

FINDINGS

Faculty and student outcomes reveal that the model and assessment tool acceptability and effectiveness of the model, especially for early identification for at risk students.

CONCLUSION

The PRIME-NP offered faculty the opportunity to identify at-risk students, identify a more nuanced remediation plan, and assess student competency in simulated environments.

Accuracy of identifcation of traumatic brain injuries in routine hospital data

Background

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Much work on the epidemiology of TBI uses routinely collected health care data. There is no separate code for TBI in ICD-10, a common coding system for acute care. One reason for reported variations in TBI prevalence between countries is differences in the identification of TBI from routine data. This study assessed the performance of an Australian classification system (Pozzatto et al 2019), using a standardised approach to ICD-10 codes to identify cases of likely TBI in routine hospital discharge data.

Methods

The original study was done on hospital data from New South Wales. We replicated their approach using Irish hospital data, held by Health Intelligence, from 2013 to 2020. Cases not classified as TBI by this system, but with codes, such as loss-of-consciousness, skull fracture or intra-cranial injury were manually reviewed.

Results

All 98,419 discharges with any code in S00 to S99 were reviewed. 27,851 (28.3%) had a skull fracture or intracranial injury. 12,106 (12.3%) had loss-of-consciousness and/or post-traumatic amnesia. 11,976 (98.9%) of these (12.2% of the total) had either a skull fracture or an intra-cranial injury reported. 26,085 (26.5%) of the original 98,419 cases were classified as TBI using the NSW classification. Manual review of 1.3% (1,356) cases added a maximum of 0.32% (321) further possible cases of TBI, suggesting a sensitivity of the classification of 98.8% (95% CI 98.6% - 98.9%).

Discussion

The main limitation is that it is not possible to identify false positive cases - those coded as TBI, but where no TBI was present. This approach to identifying TBI works well, and is feasible for wider implementation. It provides comparability between different studies.

Pozzato I et al. (2019), Epidemiology of hospitalised traumatic brain injury in the state of New South Wales, Australia: a population-based study. Australian and New Zealand Journal of Public Health. 2019

Key messages

There are problems comparing data on TBI between different countries because no single code for TBI exists in ICD-10, and this is a real challenge for epidemiologists and health services researchers. The use of an agreed system, developed in Australia, for recoding injury data to identify TBI has promise, and shows excellent sensitivity in two countries.

Non-invasive Urine Test for Molecular Classification of Clinical Significance in Newly Diagnosed Prostate Cancer Patients

Objective: To avoid over-treatment of low-risk prostate cancer patients, it is important to identify clinically significant and insignificant cancer for treatment decision-making. However, no accurate test is currently available.

Methods: To address this unmet medical need, we developed a novel gene classifier to distinguish clinically significant and insignificant cancer, which were classified based on the National Comprehensive Cancer Network risk stratification guidelines. A non-invasive urine test was developed using quantitative mRNA expression data of 24 genes in the classifier with an algorithm to stratify the clinical significance of the cancer. Two independent, multicenter, retrospective and prospective studies were conducted to assess the diagnostic performance of the 24-Gene Classifier and the current clinicopathological measures by univariate and multivariate logistic regression and discriminant analysis. In addition, assessments were performed in various Gleason grades/ISUP Grade Groups.

Results: The results showed high diagnostic accuracy of the 24-Gene Classifier with an AUC of 0.917 (95% CI 0.892–0.942) in the retrospective cohort (n = 520), AUC of 0.959 (95% CI 0.935–0.983) in the prospective cohort (n = 207), and AUC of 0.930 (95% 0.912-CI 0.947) in the combination cohort (n = 727). Univariate and multivariate analysis showed that the 24-Gene Classifier was more accurate than cancer stage, Gleason score, and PSA, especially in the low/intermediate-grade/ISUP Grade Group 1–3 cancer subgroups.

Conclusions: The 24-Gene Classifier urine test is an accurate and non-invasive liquid biopsy method for identifying clinically significant prostate cancer in newly diagnosed cancer patients. It has the potential to improve prostate cancer treatment decisions and active surveillance.

P04.11 10-Year Institutional Retrospective Case Series of WHO Grade II Gliomas and Correlation of Seizures, Lobar Location, Histopathological Subtype and IDH-1 Mutation (2010–2020)

BACKGROUND

A 10-year retrospective case series was undertaken of all patients who had a tissue diagnosis of a World Health Organisation (WHO) Grade II glioma, i.e. low grade glioma (LGGM), at the Institute of Neurological Sciences (INS) between January 2010 and January 2020 (NB: pre-2016 World Health Organisation classification). The objective was to assess the correlation of World Health Organisation (WHO) Grade II gliomas to seizure symptomology, intracerebral tumour location, histopathological glioma sub-type and molecular markers including isocitrate dehydrogenase-1 (IDH-1) mutation.

MATERIAL AND METHODS

We extracted data regarding clinical, radiological, histological, molecular discriminators and functional outcomes in patients. The pre-operative symptomology was restricted to seizures, headache and focal neurological deficits.

RESULTS

84 patients underwent resection and had a mean age of 42rs (range: 21-77yrs]). Seizures (NB: pre-2017 International League against Epilepsy classification [ILAE]) occurred in 71% and of these 52% were generalised, 37% partial and 11% mixed. 31% had ongoing seizures postoperatively. Headache occurred in 38% (of these 50% had headache and seizures). Focal neurological deficits (FNDs) occurred in 21% (of these 61% had FNDs and seizures). Seizure, as an isolated pre-operative symptom occurred in 48% patients compared to isolated headache in 10% and isolated FNDs in 4%. Anatomically, 58% of lesions were frontal. The seizure spatial frequency was 60% frontal. Histologically, 60% were diffuse astrocytomas and 40% oligodendrogliomas. Furthermore, 71% of oligodendrogliomas and 49% of diffuse astrocytomas had a frontal location. IDH-1 mutation occurred in 80% patients (75% of these had seizures) and of these 66% were frontal.

CONCLUSIONS

Our analysis confirms a correlation between incidence of seizures, frontal lobar location, histopathological subtype and IDH-1 mutations (p = &lt;0.05

The Effects of Individualized Music Listening on Affective, Behavioral, Cognitive, and Sundowning Symptoms of Dementia in Long-Term Care Residents

OBJECTIVES

This study aimed to replicate music's positive effects on dementia-related symptoms, determine whether a 6-month intervention would lead to greater positive outcomes than typical 3- to 4-month interventions, and examine changes in sundowning symptoms after music listening.

METHODS

282 nursing home residents with dementia listened to personalized music playlists 1-3 times weekly for 30 minutes across 6 months. Standardized assessments of affect, behavior, and cognition and direct observations of sundowning symptoms comprised the outcomes.

RESULTS

Results documented significant improvements in residents' general neuropsychiatric symptoms, agitation, and depression across the first 3 months, but no additional improvements across the subsequent 3 months. Seven sundowning symptoms significantly improved following music listening, with some (e.g., disengagement) being more amenable to music than others (e.g., aggression).

DISCUSSION

Results support short-term individualized music listening as an effective non-pharmacological approach for improving dementia-related symptoms in nursing home residents and suggest new applications of music-related interventions.

Effects of Influenza Vaccine on Mortality and Cardiovascular Outcomes in Patients With Cardiovascular Disease: A Systematic Review and Meta-Analysis

Background

Influenza infection causes considerable morbidity and mortality in patients with cardiovascular disease. We assessed the effects of the influenza vaccine on mortality and cardiovascular outcomes in patients with cardiovascular disease.

Methods and Results

We searched PubMed, Embase, and the Cochrane Library through January 2020 for randomized controlled trials and observational studies assessing the effects of influenza vaccine on mortality and cardiovascular outcomes in patients with cardiovascular disease. Estimates were reported as random effects risk ratios (RRs) with 95% CIs. Analyses were stratified by study design into randomized controlled trials and observational studies. A total of 16 studies (n=237 058), including 4 randomized controlled trials (n=1667) and 12 observational studies (n=235 391), were identified. Participants' mean age was 69.2±7.01 years, 36.6% were women, 65.1% had hypertension, 31.1% had diabetes mellitus, and 23.4% were smokers. At a median follow‐up duration of 19.5 months, influenza vaccine was associated with a lower risk of all‐cause mortality (RR, 0.75; 95% CI, 0.60–0.93 [P=0.01]), cardiovascular mortality (RR, 0.82; 95% CI, 0.80–0.84 [P<0.001]), and major adverse cardiovascular events (RR, 0.87; 95% CI, 0.80–0.94 [P<0.001]) compared with control. The use of the influenza vaccine was not associated with a statistically significant reduction of myocardial infarction (RR, 0.73; 95% CI, 0.49–1.09 [P=0.12]) compared with control.

Conclusions

Data from both randomized controlled trials and observational studies support the use of the influenza vaccine in adults with cardiovascular disease to reduce mortality and cardiovascular events, as currently supported by clinical guidelines. Clinicians and health systems should continue to promote the influenza vaccine as part of comprehensive secondary prevention.

A matching-adjusted indirect comparison of combination nivolumab plus ipilimumab with BRAF plus MEK inhibitors for the treatment of BRAF-mutant advanced melanoma☆

Background

Approved first-line treatments for patients with BRAF V600–mutant advanced melanoma include nivolumab (a programmed cell death protein 1 inhibitor) plus ipilimumab (a cytotoxic T lymphocyte antigen-4 inhibitor; NIVO+IPI) and the BRAF/MEK inhibitors dabrafenib plus trametinib (DAB+TRAM), encorafenib plus binimetinib (ENCO+BINI), and vemurafenib plus cobimetinib (VEM+COBI). Results from prospective randomized clinical trials (RCTs) comparing these treatments have not yet been reported. This analysis evaluated the relative efficacy and safety of NIVO+IPI versus DAB+TRAM, ENCO+BINI, and VEM+COBI in patients with BRAF-mutant advanced melanoma using a matching-adjusted indirect comparison (MAIC).

Patients and methods

A systematic literature review identified RCTs for DAB+TRAM, ENCO+BINI, and VEM+COBI in patients with BRAF-mutant advanced melanoma. Individual patient-level data for NIVO+IPI were derived from the phase III CheckMate 067 trial (BRAF-mutant cohort) and restricted to match the inclusion/exclusion criteria of the comparator trials. Treatment effects for overall survival (OS) and progression-free survival (PFS) were estimated using Cox proportional hazards and time-varying hazard ratio (HR) models. Safety outcomes (grade 3 or 4 treatment-related adverse events) with NIVO+IPI and the comparators were compared.

Results

In the Cox proportional hazards analysis, NIVO+IPI showed improved OS compared with DAB+TRAM (HR = 0.53; 95% confidence interval [CI], 0.39-0.73), ENCO+BINI (HR = 0.60; CI, 0.42-0.85), and VEM+COBI (HR = 0.50; CI, 0.36-0.70) for the overall study period. In the time-varying analysis, NIVO+IPI was associated with significant improvements in OS and PFS compared with the BRAF/MEK inhibitors 12 months after treatment initiation. There were no significant differences between NIVO+IPI and BRAF/MEK inhibitor treatment from 0 to 12 months. Safety outcomes favored DAB+TRAM over NIVO+IPI, whereas NIVO+IPI was comparable to VEM+COBI.

Conclusion

Results of this MAIC demonstrated durable OS and PFS benefits for patients with BRAF-mutant advanced melanoma treated with NIVO+IPI compared with BRAF/MEK inhibitors, with the greatest benefits noted after 12 months.

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First-line treatments for BRAF V600-mutant melanoma include NIVO+IPI and BRAF/MEK inhibitors.

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Results from prospective RCTs comparing NIVO+IPI and BRAF/MEK inhibitors have not yet been reported.

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This MAIC evaluated NIVO+IPI versus BRAF/MEK inhibitors for BRAF-mutant advanced melanoma.

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OS and PFS benefits were noted with NIVO+IPI versus BRAF/MEK inhibitors beginning at 12 months.

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These findings may provide information relevant to the selection of treatments for BRAF-mutant advanced melanoma.

Interaction of RIPK1 and A20 modulates MAPK signaling in murine acetaminophen toxicity

Acetaminophen (APAP)-induced liver necrosis is a form of regulated cell death (RCD) in which APAP activates the mitogen-activated protein kinases (MAPKs) and specifically the c-Jun-N-terminal kinase (JNK) pathway, leading to necrotic cell death. Previously, we have shown that receptor interacting protein kinase-1 (RIPK1) knockdown is also protective against APAP RCD upstream of JNK. However, whether the kinase or platform function of RIPK1 is involved in APAP RCD is not known. To answer this question, we used genetic mouse models of targeted hepatocyte RIPK1 knockout (RIPK1^HepCKO) or kinase dead knock-in (RIPK1^D138N) and adult hepatocyte specific knockout of the cytoprotective protein A20 (A20^HepCKO), known to interact with RIPK1, to study its potential involvement in MAPK signaling. We observed no difference in injury between WT and RIPK^1D138N mice post APAP. However, RIPK1^HepCKO was protective. We found that RIPK1^HepCKO mice had attenuated pJNK activation, while A20 was simultaneously upregulated. Conversely, A20^HepCKO markedly worsened liver injury from APAP. Mechanistically, we observed a significant upregulation of apoptosis signal-regulating kinase 1 (ASK1) and increased JNK activation in A20^HepCKO mice compared with littermate controls. We also demonstrated that A20 coimmunoprecipitated (co-IP) with both RIPK1 and ASK1, and that in the presence of RIPK1, there was less A20-ASK1 association than in its absence. We conclude that the kinase-independent platform function of RIPK1 is involved in APAP toxicity. Adult RIPK1^HepCKO mice are protected against APAP by upregulating A20 and attenuating JNK signaling through ASK1, conversely, A20^HepCKO worsens injury from APAP.

Establishing a Urine-Based Biomarker Assay for Prostate Cancer Risk Stratification

One of the major features of prostate cancer (PCa) is its heterogeneity, which often leads to uncertainty in cancer diagnostics and unnecessary biopsies as well as overtreatment of the disease. Novel non-invasive tests using multiple biomarkers that can identify clinically high-risk cancer patients for immediate treatment and monitor patients with low-risk cancer for active surveillance are urgently needed to improve treatment decision and cancer management. In this study, we identified 14 promising biomarkers associated with PCa and tested the performance of these biomarkers on tissue specimens and pre-biopsy urinary sediments. These biomarkers showed differential gene expression in higher- and lower-risk PCa. The 14-Gene Panel urine test (PMP22, GOLM1, LMTK2, EZH2, GSTP1, PCA3, VEGFA, CST3, PTEN, PIP5K1A, CDK1, TMPRSS2, ANXA3, and CCND1) was assessed in two independent prospective and retrospective urine study cohorts and showed high diagnostic accuracy to identify higher-risk PCa patients with the need for treatment and lower-risk patients for surveillance. The AUC was 0.897 (95% CI 0.939–0.855) in the prospective cohort (n = 202), and AUC was 0.899 (95% CI 0.964–0.834) in the retrospective cohort (n = 97). In contrast, serum PSA and Gleason score had much lower accuracy in the same 202 patient cohorts [AUC was 0.821 (95% CI 0.879–0.763) for PSA and 0.860 (95% CI 0.910–0.810) for Gleason score]. In addition, the 14-Gene Panel was more accurate at risk stratification in a subgroup of patients with Gleason scores 6 and 7 in the prospective cohort (n = 132) with AUC of 0.923 (95% CI 0.968–0.878) than PSA [AUC of 0.773 (95% CI 0.852–0.794)] and Gleason score [AUC of 0.776 (95% CI 0.854–0.698)]. Furthermore, the 14-Gene Panel was found to be able to accurately distinguish PCa from benign prostate with AUC of 0.854 (95% CI 0.892–0.816) in a prospective urine study cohort (n = 393), while PSA had lower accuracy with AUC of 0.652 (95% CI 0.706–0.598). Taken together, the 14-Gene Panel urine test represents a promising non-invasive tool for detection of higher-risk PCa to aid treatment decision and lower-risk PCa for active surveillance.

Optimizing surgery of metaphyseal-diaphyseal fractures of the fifth metatarsal: a cadaveric study on implications of intramedullary screw position, screw parameters and surrounding anatomic structures

AIMS

Many advocate screw fixation of fractures to the metaphyseal-diaphyseal junction of the fifth metatarsal base, better known as Jones fractures (JF), to facilitate quicker ambulation and return to sport. Maximizing screw parameters based on fifth metatarsal (MT5) anatomy, alongside understanding the anatomic structures compromised by screw insertion, may optimize surgical outcomes. This study aims to (1) correlate the proximity of JF to the peroneus brevis (PB) and plantar fascia (PF) footprints and (2) quantify optimal screw parameters given MT5 anatomy.

MATERIALS AND METHODS

3D CT-scan reconstructions were made of 21 cadaveric MT5s, followed by meticulous mapping of the PB and PF onto the reconstructions. Based on bone length, shape, narrowest intramedullary canal (IMC) diameter, and surrounding anatomy, two traditional debated screw positions were modeled for each reconstruction: (1) an anatomically positioned screw (AP), predicated on maximizing screw length by following the IMC for as long as possible, and (2) a clinically achievable screw (CA), predicated on maximizing screw length without violating the fifth tarso-metatarsal joint or adjacent cuboid bone. Fixation parameters were calculated for all models.

RESULTS

The PB and PF extended into the JF site in 29% and 43%, respectively. AP's did not affect PB and PF footprint but required screw entry through the cuboid and fifth tarso-metatarsal joint in all specimens. CA screw entry sites, avoiding the cuboid and fifth tarso-metatarsal joint, partially compromised the PB and PF insertions in 33% and 62% with a median surface loss of 1.6%%(range 0.2-3.2%) and 0.81%%(range 0.05-1.6%), respectively. Mean AP screw length was 64±3.6mm and thread length 49±4.2mm. Mean CA screw length was 48±5.8mm and thread length 28±6.9mm.

CONCLUSION

This study underscores the challenges associated with surrounding MT5 anatomy as they relate to optimal JF treatment. Both the extent of JF as well as a clinically achievable positioned screw violate the PB and PF footprints - although the degree to which even partial disruption of these footprints has on outcome remains unclear. To minimize damage to surrounding structures, including the PB and PF footprint, while allowing a screw length approximately two thirds of the metatarsal length, the CA screw position is recommended. This position balances the desire to maximize pull out strength while avoiding cortical penetration or inadvertent fracture site distraction.

Development and validation of a 25-Gene Panel urine test for prostate cancer diagnosis and potential treatment follow-up

BACKGROUND

Heterogeneity of prostate cancer (PCa) contributes to inaccurate cancer screening and diagnosis, unnecessary biopsies, and overtreatment. We intended to develop non-invasive urine tests for accurate PCa diagnosis to avoid unnecessary biopsies.

METHODS

Using a machine learning program, we identified a 25-Gene Panel classifier for distinguishing PCa and benign prostate. A non-invasive test using pre-biopsy urine samples collected without digital rectal examination (DRE) was used to measure gene expression of the panel using cDNA preamplification followed by real-time qRT-PCR. The 25-Gene Panel urine test was validated in independent multi-center retrospective and prospective studies. The diagnostic performance of the test was assessed against the pathological diagnosis from biopsy by discriminant analysis. Uni- and multivariate logistic regression analysis was performed to assess its diagnostic improvement over PSA and risk factors. In addition, the 25-Gene Panel urine test was used to identify clinically significant PCa. Furthermore, the 25-Gene Panel urine test was assessed in a subset of patients to examine if cancer was detected after prostatectomy.

RESULTS

The 25-Gene Panel urine test accurately detected cancer and benign prostate with AUC of 0.946 (95% CI 0.963-0.929) in the retrospective cohort (n = 614), AUC of 0.901 (0.929-0.873) in the prospective cohort (n = 396), and AUC of 0.936 (0.956-0.916) in the large combination cohort (n = 1010). It greatly improved diagnostic accuracy over PSA and risk factors (p < 0.0001). When it was combined with PSA, the AUC increased to 0.961 (0.980-0.942). Importantly, the 25-Gene Panel urine test was able to accurately identify clinically significant and insignificant PCa with AUC of 0.928 (95% CI 0.947-0.909) in the combination cohort (n = 727). In addition, it was able to show the absence of cancer after prostatectomy with high accuracy.

CONCLUSIONS

The 25-Gene Panel urine test is the first highly accurate and non-invasive liquid biopsy method without DRE for PCa diagnosis. In clinical practice, it may be used for identifying patients in need of biopsy for cancer diagnosis and patients with clinically significant cancer for immediate treatment, and potentially assisting cancer treatment follow-up.

Event history and topological data analysis

Persistent homology is used to track the appearance and disappearance of features as we move through a nested sequence of topological spaces. Equating the nested sequence to a filtration and the appearance and disappearance of features to events, we show that simple event history methods can be used for the analysis of topological data. We propose a version of the well-known Nelson–Aalen cumulative hazard estimator for the comparison of topological features of random fields and for testing parametric assumptions. We suggest a Cox proportional hazards approach for the analysis of embedded metric trees. The Nelson–Aalen method is illustrated on globally distributed climate data and on neutral hydrogen distribution in the Milky Way. The Cox method is used to compare vascular patterns in fundus images of the eyes of healthy and diabetic retinopathy patients.

Identifying patterns and predictors of lifestyle modification in electronic health record documentation using statistical and machine learning methods

Just under half of the 85.7 million US adults with hypertension have uncontrolled blood pressure using a hypertension threshold of systolic pressure ≥ 140 or diastolic pressure ≥ 90. Uncontrolled hypertension increases risks of death, stroke, heart failure, and myocardial infarction. Guidelines on hypertension management include lifestyle modification such as diet and exercise. In order to improve hypertension control, it is important to identify predictors of lifestyle modification assessment or advice to tailor future interventions using these effective, low-risk interventions. Electronic health record data from 14,360 adult hypertension patients at an academic medical center were analyzed using statistical and machine learning methods to identify predictors and timing of lifestyle modification. Multiple variables were statistically significant in analysis of lifestyle modification documentation at multiple time points. Random Forest was the best machine learning method to classify lifestyle modification documentation at any time with Area Under the Receiver Operator Curve (AUROC) 0.831. Logistic regression was the best machine learning method for classifying lifestyle modification documentation at ≤3 months with an AUROC of 0.685. Analyzing narrative and coded data from electronic health records can improve understanding of timing of lifestyle modification and patient, clinic and provider characteristics that are correlated with or predictive of documentation of lifestyle modification for hypertension. This information can inform improvement efforts in hypertension care processes, treatment implementation, and ultimately hypertension control.

The Moderating Effects of Dynamic Capability on Radical Innovation and Incremental Innovation Teams in the Global Pharmaceutical Biotechnology Industry

The purpose of this paper is to conduct a quantitative, integrative and systematic literature review of the moderating effects of dynamic capability associated with radical innovation and incremental innovation teams in the global pharmaceutical biotechnology industry. This paper utilizes a conceptual framework of dynamic capability and socio-technical theory to underpin the study. The study includes 250 articles which were originally surveyed, and then a final selection of 66 articles was based on a structured coding system. The study outcome reveals that knowledge sharing strengthens existing professional knowledge and enhances internal work coordination and consistency in employees’ behavior, and effectively integrates diverse team knowledge and experience. Open innovation has a positive effect on radical innovation and enables knowledge acquisition to form a symbiotic relationship with knowledge sharing. Learning orientation has a stronger effect on incremental innovation than on radical innovation. The limitations of the study are related to a systematic literature review for this research does not establish causality. The mediating effects of dynamic capability on teams are not explored for this research. The implications for management are as follows, teams must be given the autonomy to make decisions from a technical perspective. Tacit knowledge, open innovation, knowledge acquisition and learning orientation are areas in which priority must be given during and after acquisitions in the pharmaceutical biotechnology industry.

The effects of monoclonal anti-CD47 on RBCs, compatibility testing, and transfusion requirements in refractory acute myeloid leukemia

BACKGROUND

CD47 is a novel therapeutic target in the treatment of solid-organ and hematologic malignancies. CD47 is also expressed on RBCs. Here, we report our experience of the RBC effects and the impact on blood bank testing and transfusion management in a Phase 1 trial of the humanized anti-CD47 monoclonal antibody Hu5F9-G4 in relapsed or primary refractory acute myeloid leukemia (AML) (NCT02678338).

STUDY DESIGN AND METHODS

Nineteen patients with relapsed or primary refractory AML treated across five UK centers were included for analysis. Patients received escalating doses of Hu5F9-G4. Serial laboratory data were collected to evaluate impact on hemoglobin (Hb), markers of hemolysis (bilirubin, lactate dehydrogenase, reticulocyte count), transfusion requirements, and blood compatibility testing.

RESULTS

A decline in Hb was observed with drug administration (median Hb change, -1.0 g/dL; range, 0.4-1.6) with associated increase in transfusion requirements. Patients responded to transfusion with a median Hb increment per unit of 1.0 g/dL. RBC agglutination was seen in all cases without associated change in Hb, lactate dehydrogenase, bilirubin, or reticulocyte count. Nine of 19 (47%) patients developed a newly positive antibody screen with a pan-agglutinin identified in plasma. Invalid ABO blood grouping occurred in 4 of 12 (33%) non-group O patients due to anomalous reactivity in the reverse ABO-type results.

CONCLUSIONS

Treatment with Hu5F9-G4 in patients with AML resulted in an Hb decline and increased transfusion requirements. Problems with ABO blood typing and compatibility testing were widely observed and should be expected by centers treating recipients of Hu5F9-G4.

Four Years of CHEER: Cost and QALY Savings of a Free Nurse-run Walk-in Clinic Serving an Uninsured, Predominantly Spanish-speaking Immigrant Population in Providence

Non-emergent visits to emergency departments by uninsured patients impose unnecessary costs on both patients and safety-net institutions. We evaluated the health and economic impacts of providing free, walk-in care to low-income, uninsured adults-most of them Hispanic-at a free clinic between January 2013 and December 2016. Providing access to health care services for uninsured patients at Clínica Esperanza/Hope Clinic reduced emergency department expenditures in Rhode Island by approximately $448,876 (range: $410,377-$487,375) annually and may have also reduced future healthcare costs for this population by more than $48 million ($12,034,469 annually) over the four-year evaluation period. For every $1 in funding for walk-in clinic operation, delivering free care provided a return on investment of $71.18 (range: $70.95-71.40) in healthcare value. Providing access to non-emergent walk-in care at the more than 12,000 free healthcare clinics nationwide may save billions in ED costs while improving the health of uninsured individuals.

A Comparison of Summer and Winter Emergency Hospitalisations in Ireland

There is increasing demand on the Irish health service, particularly in winter months. This study described and compared acute hospitals admissions across summer and winter periods from 2015 to 2018. The analysis used Hospital In-Patient Enquiry data accessed through the National Quality Assurance Information System – NQAIS Clinical. There were 84 additional emergency hospitalisations in winter per week compared with summer (1.2% increase). Across diagnostic categories, emergency hospitalisations reduced in winter, except respiratory conditions which increased by 379 per week representing a 40.5% increase. The profile of emergency respiratory admissions were similar in summer and winter in terms of age, length of stay, day of week and medical card status. Length of stay was approximately one day longer for weekend admissions in both seasons. This research highlights the importance of taking a whole-population approach to winter resilience planning, focussing on prevention and optimal management of respiratory conditions.

Protective Effects of Facilitated Removal of Blood Alcohol and Acetaldehyde Against Liver Injury in Animal Models Fed Alcohol and Anti-HIV Drugs

BACKGROUND

We previously developed enzyme nanoparticles (ENP) of alcohol metabolism. This study was to evaluate protective effects of facilitated removal of blood alcohol and/or acetaldehyde on anti-HIV drugs and alcohol-induced liver injuries.

METHODS

ENP were prepared for degrading alcohol completely (ENP1) or partially into acetaldehyde (ENP2), which were applied to mice of acute binge or chronic-binge alcohol feeding in the presence of antivirals (ritonavir and lopinavir). Liver pathologies were examined to assess the protective effects of ENP.

RESULTS

In the acute model, ENP1 and ENP2 reduced the blood alcohol concentration (BAC) by 41 and 32%, respectively, within 4 hr, whereas in control without ENP, BAC was reduced only by 15%. Blood acetaldehyde concentration (BADC) was increased by 39% in alcohol-fed mice treated with ENP2 comparing to control. No significant effects of the anti-HIV drugs on BAC or BADC were observed. Plasma alanine aminotransferase (ALT) and expression of liver TNF-α were both significantly increased in the alcohol-fed mice, which were normalized by ENP1. In the presence of the antivirals, ALT was partially reduced by ENP1 or ENP2. In the chronic model, inflammation, fatty liver, and ALT were increased, which were deteriorated by the antivirals. ENP1 partially reduced BAC, BADC, ALT, and expression of inflammation markers of TNF-α, F4/80, and IL-6 and lipogenic factors of ACC, LXRα, and SREBP1. ENP2 reduced BAC without significant effects on ALT, inflammation, or lipogenesis. Antivirals and alcohol synergistically increased expression of organelle stress markers of CHOP, sXBP-1, ATF6, and GCP60. ENP1 reduced BAC, CHOP, and sXbp-1. However, no effects of ENP1 were found on ATF6 or GCP60.

CONCLUSIONS

Removal of blood alcohol and acetaldehyde by the ENP protects the liver against alcoholic injuries, and the protection is less effective in chronic alcohol and antiviral feeding due to additional drug-induced organelle stresses.

Improving Access to Diagnostic Assessments for Autism Spectrum Disorder Using an Arena Model

OBJECTIVE

To improve access to diagnostic evaluations for children younger than 3 years with concerns for possible autism spectrum disorder.

METHODS

A multidisciplinary "arena model" for children younger than 3 years was developed, tested, and implemented over an approximately 2-year period. Arena assessment teams comprised a developmental behavioral pediatrician (DBP), psychologist, and speech language pathologist (SLP). Quality improvement methods were used during the design phase, conducting Plan-Do-Study-Act (PDSA) cycles and collecting feedback from key stakeholders, and during implementation, plotting data on run charts to measure outcomes of the time to initial visit and time to diagnosis.

RESULTS

Over the 9-month implementation period, 6 arena assessment teams were formed to provide 60 evaluation slots per month for children younger than 3 years. The time to first visit was reduced from a median of 122 days to 19 days, and the time to final diagnosis was reduced from 139 days to 14 days, maintaining these outcomes at <35 and <18 days, respectively, over a 2-year period. Total visits required decreased from 4 to 5 visits to just 2 visits, and the average assessment cost was reduced by $992 per patient. Feedback from both providers and families participating in this model was overwhelmingly positive.

CONCLUSION

Access for young children referred for developmental assessments can be improved through an understanding of supply and demand and the development of creative and flexible care delivery models.

Can We Accurately Predict Cost Effectiveness Without Access to Overall Survival Data? The Case Study of Nivolumab in Combination with Ipilimumab for the Treatment of Patients with Advanced Melanoma in England

BACKGROUND

Nivolumab with ipilimumab (the Regimen) is the first immuno-oncology combination treatment to demonstrate long-term clinical benefit for advanced melanoma patients. We evaluated the cost effectiveness of the Regimen in this population, with and without the availability of overall survival (OS) data.

METHODS

A partitioned survival model and a Markov state-transition model were developed to estimate the lifetime costs and benefits of the Regimen versus ipilimumab. These models were built with and without the availability of OS data, as only progression-free survival data were available from the head-to-head, phase III trial against ipilimumab at the time of the National Institute for Health and Care Excellence (NICE) submission. Patient utilities and resource use data were sourced from trial data or the literature.

RESULTS

Incremental cost-effectiveness ratios (ICERs) and absolute costs were similar between the models with and without OS data, but the model with OS data generated more than 1 additional quality-adjusted life-year (QALY) across both treatment arms. In both models, based on list prices, the Regimen was the most cost-effective treatment.

CONCLUSIONS

The analyses show that the Regimen is a cost-effective treatment for advanced melanoma patients in England, and methods to overcome the lack of OS can give reasonable estimates of QALYs gained and ICERs.

Correction to: Can We Accurately Predict Cost Effectiveness Without Access to Overall Survival Data? The Case Study of Nivolumab in Combination with Ipilimumab for the Treatment of Patients with Advanced Melanoma in England

The second Key Point for Decision Makers, which reads.

Natural language processing of lifestyle modification documentation

Lifestyle modification, including diet, exercise, and tobacco cessation, is the first-line treatment of many disorders including hypertension, obesity, and diabetes. Lifestyle modification data are not easily retrieved or used in research due to their textual nature. This study addresses this knowledge gap using natural language processing to automatically identify lifestyle modification documentation from electronic health records. Electronic health record notes from hypertension patients were analyzed using an open-source natural language processing tool to retrieve assessment and advice regarding lifestyle modification. These data were classified as lifestyle modification assessment or advice and mapped to a coded standard ontology. Combined lifestyle modification (advice and assessment) recall was 99.27 percent, precision 94.44 percent, and correct classification 88.15 percent. Through extraction and transformation of narrative lifestyle modification data to coded data, this critical information can be used in research, metric development, and quality improvement efforts regarding care delivery for multiple medical conditions that benefit from lifestyle modification.