Governing health data across changing contexts: A focus group study of citizen's views in England, Iceland, and Sweden

BACKGROUND

The governance structures associated with health data are evolving in response to advances in digital technologies that enable new ways of capturing, using, and sharing different types of data. Increasingly, health data moves between different contexts such as from healthcare to research, or to commerce and marketing. Crossing these contextual boundaries has the potential to violate societal expectations about the appropriate use of health data and diminish public trust. Understanding citizens' views on the acceptability of and preferences for data use in different contexts is essential for developing information governance policies in these new contexts.

METHODS

Focus group design presenting data sharing scenarios in England, Iceland, and Sweden.

RESULTS

Seventy-one participants were recruited. Participants supported the need for data to help understand the observable world, improve medical research, the quality of public services, and to benefit society. However, participants consistently identified the lack of information, transparency and control as barriers to trusting organisations to use data in a way that they considered appropriate. There was considerable support for fair and transparent data sharing practices where all parties benefitted.

CONCLUSION

Data governance policy should involve all stakeholders' perspectives on an ongoing basis, to inform and implement changes to health data sharing practices that accord with stakeholder views. The Findings showed that (1) data should be used for ethical purposes even when there was commercial interest; (2) data subjects and/or public institutions that provide and share data should also receive benefits from the sharing of data; (3) third parties use of data requires greater transparency and accountability than currently exists, (4) there should be greater information provided to empower data subjects.

Using Digital Tools to Advance Alzheimer's Drug Trials During a Pandemic: The EU/US CTAD Task Force

The 2020 COVID-19 pandemic has disrupted Alzheimer’s disease (AD) clinical studies worldwide. Digital technologies may help minimize disruptions by enabling remote assessment of subtle cognitive and functional changes over the course of the disease. The EU/US Clinical Trials in Alzheimer’s Disease (CTAD) Task Force met virtually in November 2020 to explore the opportunities and challenges associated with the use of digital technologies in AD clinical research. While recognizing the potential of digital tools to accelerate clinical trials, improve the engagement of diverse populations, capture clinically meaningful data, and lower costs, questions remain regarding the stability, validity, generalizability, and reproducibility of digital data. Substantial concerns also exist regarding regulatory acceptance and privacy. Nonetheless, the Task Force supported further exploration of digital technologies through collaboration and data sharing, noting the need for standardization of digital readouts. They also concluded that while it may be premature to employ remote assessments for trials of novel experimental medications, remote studies of non-invasive, multi-domain approaches may be feasible at this time.

Intrinsic Capacitiy Monitoring by Digital Biomarkers in Integrated Care for Older People (ICOPE)

The WHO action plan on aging expects to change current clinical practices by promoting a more personalized model of medicine. To widely promote this initiative and achieve this goal, healthcare professionals need innovative monitoring tools. Use of conventional biomarkers (clinical, biological or imaging) provides a health status assessment at a given time once a capacity has declined. As a complement, continuous monitoring thanks to digital biomarkers makes it possible to remotely collect and analyze real life, ecologically valid, and continuous health related data. A seamless assessment of the patient's health status potentially enables early diagnosis of IC decline (e.g. sub-clinical or transient events not detectable by episodic evaluations) and investigation of its probable causes. This narrative review aims to develop the concept of digital biomarkers and its implementation in IC monitoring.

Glycaemic stability of a cyclist with Type 1 diabetes: 4011 km in 20 days on a ketogenic diet

BACKGROUND

Maintaining glycaemic control during exercise presents a significant challenge for people living with Type 1 diabetes. Significant glycaemic variability has been observed in athletes with Type 1 diabetes in competitive contexts. While very-low-carbohydrate ketogenic diets have been shown to minimize glycaemic excursions, no published data have examined if this translates to exercise.

CASE REPORT

We report the case of a 37-year-old man with Type 1 diabetes who successfully undertook a 4011 km cycle across Australia over 20 consecutive days whilst consuming a very-low-carbohydrate ketogenic diet. Continuous glucose monitoring data capture was 98.4% for the ride duration and showed remarkable glycaemic stability, with a standard deviation of 2.1 mmol/l (average interstitial glucose 6.1 mmol/l) and 80.4% of time spent within a range of 3.9-10 mmol/l. Interstitial glucose was <3 mmol/l for 2.1% of this time, with only a single episode of symptomatic hypoglycaemia prompting brief interruption of exercise for carbohydrate administration.

CONCLUSION

This case demonstrates the viability of a very-low-carbohydrate ketogenic diet in an individual with Type 1 diabetes undertaking exercise. While the effect of a very-low-carbohydrate ketogenic diet is yet to be examined more broadly in athletes with Type 1 diabetes, the glycaemic stability observed suggests that fat adaptation may attenuate glycaemic swings and reduce reliance on carbohydrate consumption during exercise for maintaining euglycaemia.

Abstract P6-18-27: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Odom D, Mitra D, Hollis K, Richardson D, Kaye JA, McRoy L. Withdrawn [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 P6-18-27.

Controls on nitrogen transformation rates on restored floodplains along the Cosumnes River, California

Levee construction results in the systematic replumbing of river systems and reduces the frequency of floodplain inundation, which impacts nutrient delivery and transformations in floodplains. Floodplain restoration via levee removal affects downstream water quality by restoring soil microbial metabolic pathways such as denitrification, anaerobic ammonium oxidation (anammox), and dissimilatory nitrate reduction to ammonium (DNRA). Although these metabolisms are important for the nitrogen cycle, few studies have quantified the contribution of all three pathways to nitrate retention or loss in restored floodplains. The objectives of this study were to quantify the relevance of denitrification, anammox and DNRA to nitrogen retention, characterize the hydrologic conditions most favorable to each pathway, and estimate the potential for floodplain restoration to improve nitrogen cycling in the Cosumnes River watershed. To address these goals, we simulated flood conditions in soil mesocosms collected from two floodplains where levees were breached in 1997 and 2014 along the Lower Cosumnes River in the San Joaquin Basin of California. River water enriched with K¹⁵NO₃ tracer was pumped into each mesocosm at a constant rate for a period of 3 months. Samples were collected from the surface water and soil pore water for measurements of NO₃^-, NO₂^-, and NH₄⁺ concentrations, and δ¹⁵N of dissolved gases (N₂ and N₂O). To the best of our knowledge, this study reports the highest relative contribution to N₂ production due to anammox for freshwater systems (41 to 84%) to date. High anammox rates were associated with heterogeneous grain size distribution across depth and high nitrification rates. We quantify the capacity of restored floodplain soils with distinct textural and chemical characteristics to retain or release nitrogen during large and small floods in a particular water year.

Real-world outcomes in patients with ALK-positive non-small cell lung cancer treated with crizotinib

Background

Crizotinib has shown greater efficacy in clinical trials than chemotherapy in patients with anaplastic lymphoma kinase-positive (alk+) non-small cell lung cancer (nsclc), but little information is available on its use and outcomes in real-world settings. We therefore assessed treatment patterns and outcomes in alk+ nsclc patients treated with crizotinib in regular clinical practice.

Methods

A retrospective medical record review was conducted in North America for adults with alk+ nsclc treated with crizotinib as first- or later-line therapy for metastatic disease between 1 August 2011 and 31 March 2013 (for the United States) or 1 May 2012 and 31 March 2013 (for Canada). Crizotinib-related trial enrollees were excluded. Descriptive analyses were conducted to assess treatment patterns and objective response rate (orr). Progression-free survival (pfs) and overall survival (os) were descriptively analyzed using Kaplan-Meier methods.

Results

Data were extracted for 212 patients in the United States (n = 147) and Canada (n = 65). Mean (standard deviation [sd]) age was 58.9 (9.5) years, and 69% were male. Seventy-nine patients (37%) were deceased at record abstraction. Sixty-five percent (n = 137) initiated crizotinib as first-line therapy. Mean (sd) duration of crizotinib treatment was 8.7 (4.9) months. Objective response rate was 66% (69% for first-line recipients, 60% for second-/later-line). Median (95% ci) pfs and os from crizotinib initiation were 9.5 (8.7, 10.1) and 23.4 (19.5, -) months, respectively. One- and two-year survival probabilities were 82% and 49%, respectively.

Conclusions

Outcomes for crizotinib recipients in this study align with previous trials, with orr appearing more favourable in first-line recipients. Our findings indicate that crizotinib outcomes in clinical studies may translate to regular clinical practice.

Abstract P3-10-14: Clinical and economic burden of HER2-positive breast cancer recurrence in the US: A literature review

Background: Despite available treatment for early-stage breast cancer (BC), 15%-25% of patients with early-stage human epidermal growth factor receptor 2–positive (HER2+) BC eventually experience recurrence after initial treatment. The prognosis for women with HER2+ disease recurrence is poor. Most recurrences involve incurable metastatic disease. In the US, the total cost to society attributable to metastatic BC of any subtype was $12.2 billion accrued over 5 years, or $2.4 billion per year ($98,571 per patient-year). Treatment-related cost, 57% of total costs, was the largest contribution, with over $1.0 billion per year. The purpose of this study was to assess the clinical and economic burden of recurrence in patients with early-stage HER2+ BC.

Methods: We conducted two systematic literature reviews (SLRs) and one targeted literature review (TLR) in PubMed, Embase, and Cochrane databases. The SLRs (no publication date limit; clinical SLR conducted on November 8, 2016; economic SLR conducted on October 25, 2016) searched for randomized clinical trials of neratinib and other treatments and economic data (models, utility, resource use, and cost), and the TLR (publications published from January 2006 to September 2016) searched for burden-of-illness studies in early-stage HER2+ BC.

Results: A total of 4,708 abstracts (2,649 clinical SLR; 969 economic SLR; 1,090 TLR) were identified from all searches, and full-text review was conducted for 796 articles (507 clinical SLR; 151 economic SLR; 138 TLR). Of these, 159 (72 clinical SLR; 33 economic SLR; 54 TLR) followed protocol-specified criteria for inclusion. Based on clinical trials in the neoadjuvant and/or adjuvant setting, disease-free survival rates at 4 years ranged from 78% to 90%. HER2-targeting adjuvant regimens such as lapatinib added to trastuzumab and extending trastuzumab to 2 years have been unsuccessful in reducing the risk of recurrence. Women who had a recurrence, regardless of HER2 status, reported significantly poorer functioning on various quality of life (QoL) domains compared with women who remained disease free. All patients with early-stage BC, regardless of HER2 status, diagnosed with their first recurrence experienced cancer-related distress and no improvement in QoL (physical health and functioning) after 1 year. In the US, the total expected per-patient costs for all BC, regardless of HER2 status, over 10 years was $53,454 with metastatic recurrence, $61,601 with locoregional recurrence, and $61,188 with contralateral recurrence as compared with $42,005 (background costs) with no recurrence (2004 US $). The overall cost of recurrence in women with HER2+ BC in the US was estimated to be $240 million to $1.7 billion over the lifetimes of each 1-year cohort of 7,298 patients (2008 US $).

Conclusions: These results identified few studies on patients with early-stage HER2+ BC and suggest that future studies are warranted. Recurrence in women with HER2+ BC is associated with decreased QoL and high costs. After adjuvant therapy, there is still risk of recurrence, thus the clinical and economic burden remains. There is an unmet medical need in early-stage HER2+ BC, and new therapies are needed to reduce the risk of recurrence.

Citation Format: Masaquel C, Hurley D, Barnett B, Krieger T, Pearson I, Copley-Merriman C, Kaye JA, Moy B. Clinical and economic burden of HER2-positive breast cancer recurrence in the US: A literature review [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 P3-10-14.

Abstract OT3-03-01: MADELINE: A prospective observational study of mobile app-based patient reported outcomes in advanced breast cancer

BACKGROUND: There have been few studies evaluating the day-to-day effects of advanced breast cancer (ABC) and its treatment on patients in a real-world setting.Palbociclib is a novel CDK4/6 inhibitor approved in the US for hormone-receptor positive, human epidermal growth factor receptor negative (HR+, HER2-) ABC/metastatic breast cancer (MBC) in combination with letrozole as initial endocrine based therapy in postmenopausal women or with fulvestrant in women with disease progression following endocrine therapy. With the introduction of this first-in-class drug it is important to understand the experiences of patients initiating ABC therapies including palbociclib in real-world settings and to document the management of these therapies. A smartphone-based mobile application has been developed to collect patient-reported outcome (PRO) data to assess the impact of ABC and associated treatment on symptoms, functioning and quality of life (QOL) as reported by patients. The application is further designed to provide patients initiating palbociclib with a virtual community to connect to others enrolled in the study for peer support. Additionally, clinical data on therapy management (e.g. dose modifications, interruptions, discontinuations, adverse event management and monitoring) will be obtained from patients' medical records to explore the association between patient reported functioning and neutropenia.

Study Design: A prospective, observational, non-interventional study. PROs collected via a mobile application and clinical data via case report forms completed by investigator.

Eligibility Criteria: Women with HR+/HER2– ABC receiving palbociclib in combination with letrozole or fulvestrant as per US label (Group 1) orapproved therapies for ABC other than palbociclib (Group 2). No comparison is intended between the 2 groups.

Specific Aims: The primary goals are to describe changes in patients' general health status as measured by monthly administration of the 12-Item Short Form Health Survey, describe changes in patients' psychological distress as measured by monthly administration of the Center for Epidemiological Studies Depression Scale, and describe the extent to which ABC and its treatment are associated with changes in patients' lives in terms of symptoms, functioning and QOL as measured by daily and weekly administration of targeted patient-reported questions. Additionally, for patients who are employed at baseline, time lost from work in relation to breast cancer and its treatment will be quantified.Data from patients' medical records will be used to document changes in therapy as well as the incidence, severity, and duration of neutropenia. The association between patient reported functioning and neutropenia will also be assessed. Finally, real-world monitoring patterns will be assessed.

Statistical Methods: Descriptive statistics will be used to summarize all endpoints. Meta-data regarding use of virtual community resources will be explored for relationships to PRO data.

Present Accrual and Target Accrual: Approximately 450 patients from up to 30 US sites will be enrolled. Study duration will be approximately 12 months assuming 6 months of recruitment. It is expected the study will start enrollment Q3 2016.

Sponsor: Pfizer.

Citation Format: McRoy LL, Mitra D, Hollis K, Kaye JA, Zelnak A, Cheyl J. MADELINE: A prospective observational study of mobile app-based patient reported outcomes in advanced breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT3-03-01.

Abstract P5-08-18: Treatment patterns and resource utilization among patients with HR+/HER2– metastatic breast cancer in a privately insured US population

Background

Hormone receptor positive (HR+)/HER2– tumors are the most common subtype among patients with metastatic breast cancer (MBC). Several newer therapeutic options have become available over the last decade, but little is known about the real-world treatment patterns and health care resource use (HCRU) in privately insured women with HR+/HER2– MBC.

Methods

An analysis of Truven MarketScan databases containing medical and drug utilization and productivity data from nearly 350 US payers was conducted. Patients aged 18-64 years with an ICD-9 diagnosis code of breast cancer along with ≥2 claims for secondary malignancy between 2007 and 2013 were selected. HR+/HER2– patients were identified based on receipt of endocrine therapy (ET) and absence of HER2-targeted therapies. Use of cancer-directed treatments following MBC diagnosis was analyzed. Treatment characteristics were examined by line of therapy (LOT). Average monthly all-cause and MBC-related HCRU were descriptively assessed.

Results

A total of 5,563 women with HR+/HER2– MBC (mean [SD] age, 54 [7.8] yrs) met the selection criteria. Overall, 97% of the total sample received ≥1 cancer-directed treatment. The most common treatment was ET (85%), followed by chemotherapy (CT) (70%), radiation (62%), and surgery (11%). Treatment patterns for CT alone and ET alone, including the top regimens by LOT, are presented in Table 1. Among those receiving a second LOT, nearly 44% switched to CT in the second line after having received ET alone in the first line. During the study follow-up, 56% of patients had ≥1 all-cause inpatient admission, 49% had ≥1 all-cause emergency department visit, and 9% had a hospice admission.

Table 1. Treatment patterns by LOT in patients with HR+/HER2- MBCLine 1 Line 2 Line 3 Line 4 n=5,179 (93%)* n=2,900 (52%)* n=1,608 (29%)* n=882 (16%)*  n (%) n (%) n (%) n (%)ET Alone3265 (63)ET Alone1468 (51)ET Alone534 (33)ET Alone217 (25)Anastrozole895 (27)Fulvestrant354 (24)Fulvestrant138 (26)Fulvestrant65 (30)Letrozole782 (24)Tamoxifen258 (18)Exemestane89 (17)Exemestane44 (20)Tamoxifen577 (18)Exemestane239 (16)Letrozole82 (15)Tamoxifen25 (12)Fulvestrant428 (13)Anastrozole239 (16)Tamoxifen82 (15)Letrozole20 (9)Exemestane299 (9)Letrozole197 (13)Anastrozole65 (12)Anastrozole14 (6)CT Alone1533 (30)CT Alone1057 (36)CT Alone818 (51)CT Alone505 (57)Paclitaxel413 (27)Capecitabine331 (31)Capecitabine265 (32)Capecitabine140 (28)Capecitabine286 (19)Paclitaxel224 (21)Paclitaxel156 (19)Paclitaxel93 (18)Cyclophosphamide-Doxorubicin → Taxane93 (6)Gemcitabine63 (6)Gemcitabine70 (9)Vinorelbine55 (11)Cyclophosphamide-Docetaxel82 (5)Docetaxel46 (4)Vinorelbine54 (7)Gemcitabine52 (10)Carboplatin-Paclitaxel77 (5)Vinorelbine46 (4)Doxorubicin45 (6)Doxorubicin34 (7)*Out of total 5,563 patients. Only top CT and ET regimens are listed.

Conclusions

A substantial decrease in the use of ET, with simultaneous increase in the use of CT, was observed as patients progressed to subsequent LOTs. Nearly half of those receiving ET alone in the first LOT switched to CT in the second LOT, suggesting a need for more effective non-CT treatments to bridge unmet therapeutic needs in this patient population.

Citation Format: Goyal RK, Carter GC, Nagar SN, Smyth EN, Price GL, Huang Y-J, Bromund JL, Li L, Schilder JM, Davis KL, Kaye JA. Treatment patterns and resource utilization among patients with HR+/HER2– metastatic breast cancer in a privately insured US population [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-08-18.

Abstract P5-08-19: Treatment patterns and resource utilization among elderly Medicare patients with HR+/HER2– metastatic breast cancer

Background

Therapeutic advances in metastatic breast cancer (MBC) over the last decade have led to several novel agents for the treatment of patients with hormone receptor positive (HR+)/HER2– MBC. However, current literature has little data on real-world treatment patterns and health care resource use, particularly among elderly women with HR+/HER2– MBC in the United States Medicare population.

Methods

A retrospective analysis of patients aged ≥66 years diagnosed with MBC during 2007 to 2011 was conducted using the SEER-Medicare database. Patients' HR and HER2 status was obtained from the SEER registry data. For patients with no HER2 data available, HER2− disease was determined based on the absence of HER2-targeted therapies within 12 months of diagnosis. Health care utilization and treatment patterns after MBC diagnosis were examined. Use of cancer-directed therapies, including chemotherapy (CT) and endocrine therapy (ET), were descriptively analyzed by line of therapy (LOT).

Results

A total of 3,622 women with HR+/HER2– MBC (mean [SD] age, 77 [7.3] years) were included. Over 90% of women received ≥1 cancer-directed treatment after MBC diagnosis, with ET being the most common (77%), followed by CT (50%), radiation (48%), and surgery (19%). Treatment with ET alone trended downward across LOTs, from 74% in the first LOT to 36% in the fourth LOT, with a corresponding increase in treatment with CT alone from 21% to 46% (Table 1). Among those receiving a second LOT, nearly 26% switched to CT in the second line after having received ET alone in the first line.

Table 1. Pharmaceutical treatment patterns by line of therapy among patients diagnosed with HR+/HER2– MBC (n = 3622)First-Line Second-Line Third-Line Fourth-Line N = 2,981 (82%)* N = 1,449 (40%)* N = 750 (21%)* N = 356 (10%)*  n (%) n (%) n (%) n (%)ET Alone2215 (74)ET Alone973 (67)ET Alone381 (51)ET Alone127 (36)Anastrozole893 (40)Fulvestrant282 (29)Fulvestrant99 (26)Fulvestrant38 (30)Letrozole602 (27)Exemestane190 (20)Exemestane76 (20)Tamoxifen27 (21)Tamoxifen253 (11)Anastrozole162 (17)Tamoxifen71 (19)Exemestane25 (20)Fulvestrant243 (11)Tamoxifen152 (16)Anastrozole46 (12)Anastrozole13 (10)Exemestane156 (7)Letrozole107 (11)Letrozole38 (10)Exemestane-FulvestrantN/ACT Alone639 (21)CT Alone336 (23)CT Alone264 (35)CT Alone165 (46)Paclitaxel136 (21)Paclitaxel76 (23)Paclitaxel78 (30)Paclitaxel39 (24)Cyclophosphamide-Docetaxel72 (11)Gemcitabine57 (17)Gemcitabine46 (17)Gemcitabine32 (19)Cyclophosphamide-Doxorubicin → Taxane69 (11)Docetaxel28 (8)Vinorelbine31 (12)Vinorelbine21 (13)Carboplatin-Paclitaxel43 (7)Vinorelbine27 (8)Docetaxel22 (8)Doxorubicin17 (10)Docetaxel39 (6)Doxorubicin21 (6)Doxorubicin21 (8)DocetaxelN/AN/A = not available (in accordance with the SEER-Medicare data use agreement, data for categories with cell size less than 11 are suppressed). *Out of total 3,622 patients. Note: Percentages do not add up to 100% as only the top CT and ET regimens are listed.

Conclusions

ET was the most common first-line treatment for elderly women with HR+/HER2– MBC in this study period. However, as patients progressed from first to fourth LOT, the proportion of patients treated with ET decreased substantially.

Citation Format: Goyal RK, Carter GC, Nagar SN, Smyth EN, Price GL, Huang Y-J, Bromund JL, Li L, Schilder JM, Davis KL, Kaye JA. Treatment patterns and resource utilization among elderly Medicare patients with HR+/HER2– metastatic breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-08-19.

The RUDY study platform - a novel approach to patient driven research in rare musculoskeletal diseases

BACKGROUND

Research into rare diseases is becoming more common, with recognition of the significant diagnostic and therapeutic care gaps. Registries are considered a key research methodology to address rare diseases. This report describes the structure of the Rare UK Diseases Study (RUDY) platform that aims to improve research processes and address many of the challenges of carrying out rare musculoskeletal disease research. RUDY is an internet-based platform with online registration, initial verbal consent, online capture of patient reported outcome measures and events within a dynamic consent framework. The database structure, security and governance framework are described.

RESULTS

There have been 380 participants recruited into RUDY with completed questionnaire rates in excess of 50 %. There has been one withdrawal and two participants have amended their consent options.

CONCLUSIONS

The strengths of RUDY include low burden for the clinical team, low research administration costs with high participant recruitment and ease of data collection and access. This platform has the potential to be used as the model for other rare diseases globally.

A Duty To Warn Relatives in Clinical Genetics: Arguably 'Fair just and reasonable' in English Law?

The use of 'next-generation' genetic sequencing technology that allows the sequencing of large parts, or even the entirety, of a patient's genome is advancing rapidly in the UK and around the world. This is set to greatly increase the level of health information that will be of relevance to relatives and the latest medical guidance advises that there is a professional duty to consider warning a patient's relatives of a serious genetic risk in limited circumstances. However, the High Court in ABC v St George's Healthcare NHS Trust [2015] EWHC 1394 (QB), recently found that a legal duty on the part of doctors to warn a patient's daughter of a genetic risk of Huntington's Disease without the patient's consent, was not even 'reasonably arguable' and would not be 'fair, just and reasonable'. This article considers the courts' approach to a duty of care towards 'third parties' in this context and concludes that some form of a duty of care to genetic relatives in clinical genetics is at very least arguably 'fair, just and reasonable'.

Healthcare professional requirements for the care of adult diabetes patients managed with insulin pumps in Australia

BACKGROUND

Healthcare professional (HCP) time supporting insulin pump therapy (IPT) has not been documented, yet it is important in planning and allocating resources for effective care.

AIM

This study aims to determine HCP time spent in IPT patient care to inform resource planning for optimal IPT delivery.

METHODS

Twenty-four Australian adult IPT-experienced institutions (14 government funded, seven private, three both) collected data between April 2012 and January 2013 prospectively, including: patient demographics, HCP classification, purpose of HCP-patient interaction, interaction mode and HCP time with the patient. A subset of patients was tracked from pre-pump education until stable on IPT.

RESULTS

Data on 2577 HCP-adult patient interactions (62% face-to-face, 29% remote, 9% administrative) were collected over 12.2 ± 6.4 weeks for 895 patients; age 35.4 ± 14.2 years; 67% female; 99% type 1 diabetes, representing 25% of all IPT patients of the institutions. Time (hours) spent on IPT interactions per centre per week were: nurses 5.4 ± 2.8, dietitians 0.4 ± 0.2 and doctors 1.0 ± 0.5. IPT starts accounted for 48% of IPT interaction time. The percentage of available diabetes clinic time spent on outpatient IPT interactions was 20.4%, 4.6% and 2.7% for nurses, dietitians and doctors respectively. Fifteen patients tracked from pre-pump to stabilisation over 11.8 ± 4.5 weeks, required a median (range) of 9.2 (3.0-20.9), 2.4 (0.5-6.0) and 1.8 (0.5-5.4) hours per patient from nurses, dietitians and doctors respectively.

CONCLUSIONS

IPT patient care represents a substantial investment in HCP time, particularly for nurses. Funding models for IPT care need urgent review to ensure this now mainstream therapy integrates well into healthcare resources.

Characterizing the white matter hyperintensity penumbra with cerebral blood flow measures

Objective

White matter hyperintensities (WMHs) are common with age, grow over time, and are associated with cognitive and motor impairments. Mechanisms underlying WMH growth are unclear. We aimed to determine the presence and extent of decreased normal appearing white matter (NAWM) cerebral blood flow (CBF) surrounding WMHs to identify ‘WM at risk’, or the WMH CBF penumbra. We aimed to further validate cross-sectional finding by determining whether the baseline WMH penumbra CBF predicts the development of new WMHs at follow-up.

Methods

Sixty-one cognitively intact elderly subjects received 3 T MPRAGE, FLAIR, and pulsed arterial spin labeling (PASL). Twenty-four subjects returned for follow-up MRI. The inter-scan interval was 18 months. A NAWM layer mask, comprised of fifteen layers, 1 mm thick each surrounding WMHs, was generated for periventricular (PVWMH) and deep (DWMH) WMHs. Mean CBF for each layer was computed. New WMH and persistent NAWM voxels for each penumbra layer were defined from follow-up MRI.

Results

CBF in the area surrounding WMHs was significantly lower than the total brain NAWM, extending approximately 12 mm from both the established PVWMH and DWMH. Voxels with new WMH at follow-up had significantly lower baseline CBF than voxels that maintained NAWM, suggesting that baseline CBF can predict the development of new WMHs over time.

Conclusions

A CBF penumbra exists surrounding WMHs, which is associated with future WMH expansion. ASL MRI can be used to monitor interventions to increase white matter blood flow for the prevention of further WM damage and its cognitive and motor consequences.

•

We examined cerebral blood flow (CBF) surrounding white matter hyperintensity (WMH) lesions.

•

We examined whether low baseline CBF is associated with WMH expansion over time.

•

WMH CBF penumbra exists, extending ~12 mm from both periventricular and deep WMH lesions.

•

Baseline CBF can predict the development of new WMHs over time.

•

ASL MRI can be used to monitor interventions to increase white matter blood flow.

Insulin oedema and treatment-induced neuropathy occurring in a 20-year-old patient with Type 1 diabetes commenced on an insulin pump

BACKGROUND

Oedema may occur following initiation or intensification of insulin therapy in patients with Type 1 and Type 2 diabetes. Mild oedema is thought to be not uncommon, but under-reported, whilst generalized oedema with involvement of serous cavities has rarely been described. Multiple pathogenic mechanisms have been proposed, including insulin-induced sodium and water retention. Patients at greater risk for insulin oedema include those with poor glycaemic control. Dramatic improvement in glycaemic control is also associated with sensory and autonomic neuropathy.

CASE REPORT

We describe a case of generalized oedema occurring in a 20-year-old, low body weight patient with Type 1 diabetes with poor glycaemic control 3 days following commencement of an insulin pump; blood sugars had dramatically improved with this treatment. Alternative causes for oedema were excluded. Oedema slowly improved with insulin dose reduction with higher blood sugar targets plus frusemide treatment. Subsequent to oedema resolution, the patient unfortunately developed generalized neuropathic pain, thought to be another manifestation of rapid improvement in glycaemic control.

CONCLUSION

Caution should be taken when a patient with diabetes that is poorly controlled has an escalation in therapy that may dramatically improve their blood sugar levels; this includes the initiation of an insulin pump. Clinicians and patients should be aware of the potential risk of insulin oedema, treatment-induced neuropathy and worsening of diabetic retinopathy in the setting of rapid improvement in glycaemic control.

Serum vitamin D concentrations are associated with falling and cognitive function in older adults

OBJECTIVES

To elucidate the mechanism through which vitamin D is associated with decreased falls.

DESIGN

This was a convenience sample from a larger observational study examining correlations between vitamin D and 1) falls, 2) motor function, and 3) cognition (n=159).

SETTING

Falls data were collected via weekly on-line surveys completed in the participants' homes. Yearly evaluations of motor and cognitive function were conducted in an out-patient setting of a large tertiary medical center.

PARTICIPANTS

Participants from the Intelligent Systems for Assessment of Aging Changes Study (ISAAC), a community-based cohort study of independently living older adults over age 70, who had vitamin D concentration within 6 months of clinical evaluations were included in the analysis.

RESULTS

Participants mean age was 85 years and 74% were women. Fallers (n=37) had significantly lower vitamin D concentration (32.9ng/ml) compared to non-fallers (39.2ng/ml) (p<0.01). The relationship between vitamin D and falls remained significant after adjusting for age, health status (via CIRS), and supplement use (p=0.004). Vitamin D concentration were significantly associated with cognitive impairment (Clinical Dementia Rating = 0.5) (p=0.02) and MMSE (p<0.01) after adjusting for age, gender, and education. Vitamin D concentrations did not correlate with any motor measures.

CONCLUSION

Vitamin D concentrations correlated with cognition and falls, but not with motor measures. Further research is needed to demonstrate a causal relationship between vitamin D and cognitive function and determine if cognition plays a role in falls reduction.

In-home walking speeds and variability trajectories associated with mild cognitive impairment

OBJECTIVE

To determine whether unobtrusive long-term in-home assessment of walking speed and its variability can distinguish those with mild cognitive impairment (MCI) from those with intact cognition.

METHODS

Walking speed was assessed using passive infrared sensors fixed in series on the ceiling of the homes of elderly individuals participating in the Intelligent Systems for Assessing Aging Change (ISAAC) cohort study. Latent trajectory models were used to analyze weekly mean speed and walking speed variability (coefficient of variation [COV]).

RESULTS

ISAAC participants living alone included 54 participants with intact cognition, 31 participants with nonamnestic MCI (naMCI), and 8 participants with amnestic MCI at baseline, with a mean follow-up of 2.6 ± 1.0 years. Trajectory models identified 3 distinct trajectories (fast, moderate, and slow) of mean weekly walking speed. Participants with naMCI were more likely to be in the slow speed group than in the fast (p = 0.01) or moderate (p = 0.04) speed groups. For COV, 4 distinct trajectories were identified: group 1, the highest baseline and increasing COV followed by a sharply declining COV; groups 2 and 3, relatively stable COV; and group 4, the lowest baseline and decreasing COV. Participants with naMCI were more likely to be members of either highest or lowest baseline COV groups (groups 1 or 4), possibly representing the trajectory of walking speed variability for early- and late-stage MCI, respectively.

CONCLUSION

Walking speed and its daily variability may be an early marker of the development of MCI. These and other real-time measures of function may offer novel ways of detecting transition phases leading to dementia.

Consent and research governance in biobanks: evidence from focus groups with medical researchers

Much is known about patient attitudes to ethical and legal questions in the context of biobanking, particularly regarding privacy protection and consent. However, little is known about the attitudes of medical researchers who use biobanks for research to these issues. Four focus groups with medical researchers in the UK were conducted in 2010-2011. The study highlights a range of issues associated with the research oversight and consent process (including obtaining ethical approval to use biobank samples and particular concerns for international studies), the benefits and limitations of broad consent and the possibilities of revoking consent. Many of these issues originate in the relatively static consent processes that currently govern the biobanking process. However, it is now possible to develop reliable, dynamic processes using information technology that can resolve many of these ethical and legal concerns. The 'dynamic consent' approach therefore offers the opportunity to fundamentally transform the process of medical research in a manner that addresses the concerns of both patients and medical researchers.

Navigating the perfect [data] storm

Bioscience has recently undergone a series of knowledge-based and technological revolutions. A critical consequence has been increasing recognition of the need to invest in infrastructure. Good access to data (and samples) from multiple studies is axiomatic to the value of this infrastructure. Access must be streamlined, secure, and based upon transparent and ‘fair’ decision making. It must be clear who has created and who has used which data. Ethico-legal policies and guidelines, which reflect dominant local cultural and societal norms, must take account of the increasingly global nature of bioscience research. A robust data infrastructure must also be attentive to the translational aims and social impact of its knowledge generation. In order to maintain the trust of its constituency – the general public as well as professional, political, commercial stakeholders – it must develop mechanisms to take account of all of these perspectives. These considerations form the basis of an emerging data economy. Building on extant achievements and pursuing the ideas outlined here could revolutionise the way we use and manage large-scale data. They have critical implications for biomedical and public health research communities and will be of central relevance for healthcare managers and policy makers, governments and industry. However, if the major challenges are to be met we must continue to invest,both nationally and internationally, in developing the cooperative infrastructures that provide a complementary foil to competitive resourcing mechanisms that drive hypothesis-driven science.

Nutrient biomarker patterns, cognitive function, and MRI measures of brain aging

OBJECTIVE

To examine the cross-sectional relationship between nutrient status and psychometric and imaging indices of brain health in dementia-free elders.

METHODS

Thirty plasma biomarkers of diet were assayed in the Oregon Brain Aging Study cohort (n = 104). Principal component analysis constructed nutrient biomarker patterns (NBPs) and regression models assessed the relationship of these with cognitive and MRI outcomes.

RESULTS

Mean age was 87 ± 10 years and 62% of subjects were female. Two NBPs associated with more favorable cognitive and MRI measures: one high in plasma vitamins B (B1, B2, B6, folate, and B12), C, D, and E, and another high in plasma marine ω-3 fatty acids. A third pattern characterized by high trans fat was associated with less favorable cognitive function and less total cerebral brain volume. Depression attenuated the relationship between the marine ω-3 pattern and white matter hyperintensity volume.

CONCLUSION

Distinct nutrient biomarker patterns detected in plasma are interpretable and account for a significant degree of variance in both cognitive function and brain volume. Objective and multivariate approaches to the study of nutrition in brain health warrant further study. These findings should be confirmed in a separate population.