Long-Term Effectiveness of Anti-IL4R Therapy Following Suboptimal Response to Anti-IL5/5R Therapy in Severe Eosinophilic Asthma

BACKGROUND

Dupilumab is an anti-IL4R monoclonal antibody (mAb) with proven efficacy in severe eosinophilic asthma (SEA). A suboptimal response to anti-IL5/5R mAbs is seen in some patients with ongoing evidence of T2 inflammation.

OBJECTIVE

To understand whether targeting IL-13 pathways with dupilumab in these patients may lead to better clinical outcomes.

METHODS

We performed a retrospective analysis of the extended clinical effectiveness of dupilumab up to 2 years of treatment in patients with SEA who had not responded adequately to anti-IL5/5R biologics. Ability to achieve clinical remission and change in the remission domains of exacerbation rate (AER), maintenance oral corticosteroid dose (mOCS), lung function (FEV1) and asthma control (ACQ6) were recorded.

RESULTS

Thirty-seven patients (mean age 41, 70% female) were included in the analysis. The mean (SD) AER fell by almost 90% from 3.16(1.28) at dupilumab initiation to 0.35(0.72) after 1 year. The median (IQR) mOCS dose (n=20) fell from 10(5-25) mg to 0 (0-5) mg at 1 year, with 14/20 (70%) able to stop prednisolone altogether. Clinical remission was achieved in 16/37 (43%). Patients who achieved remission had a higher pre-IL5/5R FeNO level (85ppb [39-198] vs 75ppb [42-96], p=0.03).

CONCLUSION

Significant improvements in clinical outcomes are possible following a switch to dupilumab in patients experiencing a suboptimal response to anti-IL5/5R therapies. A higher FeNO in poor responders to anti-IL5/5R who achieve remission with dupilumab is suggestive of an IL-13 driven sub-phenotype of T2-high asthma in which the eosinophil appears unlikely to play a key role in the disease pathogenesis.

Long-Term Effectiveness of Benralizumab in Eosinophilic Granulomatosis With Polyangiitis

BACKGROUND

Eosinophilic granulomatosis with polyangiitis (EGPA) is a multisystemic disease characterized by eosinophilic tissue inflammation. Benralizumab, an anti-IL-5 receptor (anti-IL-5R) monoclonal antibody, induces rapid depletion of eosinophils; its longer-term effect in EGPA is unknown.

OBJECTIVE

To assess the real-world effectiveness and clinical remission rates of anti-IL-5R therapy in EGPA.

METHODS

We performed a retrospective cohort analysis of patients with EGPA, who commenced treatment with benralizumab. Clinical remission, assessed at 1 year and 2 years after the initiation of benralizumab, was defined as an absence of active vasculitis (Birmingham Vasculitis Activity Score of 0) and an oral corticosteroid (OCS) dose of ≤4 mg/d of prednisolone. "Super-responders" were defined as patients in remission and free of any significant relapses (asthma or extrapulmonary) over the preceding 12 months. The corticosteroid-sparing capacity of benralizumab, patient-reported outcome measures, and characteristics associated with clinical remission and super-responder status were also analyzed.

RESULTS

A total of 70 patients completed at least 1 year of treatment with benralizumab, of whom 53 completed 2 years. Of 70 patients, 47 (67.1%) met the definition for clinical remission at 1 year, with a similar proportion in remission at 2 years. Excluding asthma-related relapses, 61 of 70 (87.1%) patients were relapse free at 1 year, and of the 53 who completed 2 years, 45 (84.9%) were relapse free. A total of 67.9% of patients no longer needed any OCS for disease control. No significant difference was seen between antineutrophilic cytoplasmic antibody (ANCA)-positive and ANCA-negative subgroups.

CONCLUSIONS

In this real-world setting of patients with EGPA, treatment with benralizumab was well tolerated and resulted in corticosteroid-free clinical remission for the majority of patients.

Harnessing the potential of data-driven strategies to optimise transfusion practice

No one doubts the significant variation in the practice of transfusion medicine. Common examples are the variability in transfusion thresholds and the use of tranexamic acid for surgery with likely high blood loss despite evidence-based standards. There is a long history of applying different strategies to address this variation, including education, clinical guidelines, audit and feedback, but the effectiveness and cost-effectiveness of these initiatives remains unclear. Advances in computerised decision support systems and the application of novel electronic capabilities offer alternative approaches to improving transfusion practice. In England, the National Institute for Health and Care Research funded a Blood and Transplant Research Unit (BTRU) programme focussing on 'A data-enabled programme of research to improve transfusion practices'. The overarching aim of the BTRU is to accelerate the development of data-driven methods to optimise the use of blood and transfusion alternatives, and to integrate them within routine practice to improve patient outcomes. One particular area of focus is implementation science to address variation in practice.

Advancing the social return on investment framework to capture the social value of public health interventions: semistructured interviews and a review of scoping reviews

OBJECTIVES

Investment in public health has far-reaching impacts, not only on physical health but also on communities, economies and the environment. There is increasing demand to account for the wider impact of public health and the social value that can be created, which can be captured through the use of the social return on investment (SROI) framework. This study aims to explore the application of SROI and identify areas of advancement for its use in public health.

STUDY DESIGN AND METHODS

Publically available SROI studies of public health interventions previously identified through published systematic scoping reviews were examined through a methodological lens. This was complemented by semistructured interviews with key public health academic experts with experience in the field of SROI. The results were thematically analysed and triangulated.

RESULTS

In total, 53 studies and nine interviews were included in the analysis. All interviewees agreed that SROI is a suitable framework to demonstrate the social value of public health interventions. Developmental aspects were also identified through the analysis. This included a more systematic use of SROI principles and methodological developments. Lastly, it was identified that further advancements were needed to promote awareness of SROI and how it can be used to generate investment.

CONCLUSION

By identifying key areas for advancement, the results from this study can be used to further refine the SROI framework for use within the speciality to promote investment in services and interventions that demonstrate maximum value to people, communities, economies and the environment.

Is YouTube™ a good source of information for patients to understand laparoscopic fundoplication?

INTRODUCTION

Gastro-oesophageal reflux disease affects 10-20% of the population, and laparoscopic fundoplication is one management option. As the most frequently accessed video-sharing website, YouTube has become a popular source of information for patients. This study conducted a cross-sectional analysis of the quality and demographics of patient education videos available on YouTube for laparoscopic fundoplication.

METHODS

Three searches were performed on YouTube using the phrases 'laparoscopic fundoplication', 'heartburn surgery' and 'reflux operation'. The Health on The Net (HON) code, DISCERN and Journal of the American Medical Association (JAMA) systems were used to score the first 75 results from each query. Information about each video was collected, including number of views, time since posting, number of comments and the author of the video. Relationships between these variables and video quality were investigated.

RESULTS

The median number of views was 3,793. The most common author category was videos produced by surgeons. Overall the quality was poor, mean HON score was 2.5/8, mean DISCERN score was 29.3/80 and mean JAMA score was 1.5/4. Surgeon-authored videos scored higher when scored using the HON and JAMA systems. Videos of longer duration scored higher using all three scoring systems. No other factors were found to be associated with video quality.

CONCLUSION

The quality of information in YouTube videos on laparoscopic fundoplication is unreliable. Doctors should be aware of this and caution their patients of YouTube's limitations. Further research is needed to develop validated scoring systems for evaluating the quality of patient education videos.

The health impact of the Triple Challenge of Brexit, COVID-19 and Climate Change in Wales

 

The COVID-19 pandemic has revealed the complex relationships between health, well-being, economy and society. The United Kingdom’s (UK) withdrawal from the European Union (Brexit) and climate change are having a cumulative, magnifying impact. UK nations have to tackle the multifaceted nature of Brexit, COVID-19 and climate change (‘Triple Challenge’ or TC) not only in isolation, but as a cumulative whole.This study provides a strategic overview of the interactions of the TC on determinants of health and equity in Wales and proposes opportunities to take forward. Using findings from existing Welsh Health Impact Assessments (HIAs) undertaken on the single challenges, rapid searches of the academic and grey literature were undertaken to identify evidence which focused on the TC and its impacts.From this, key determinants impacted and spotlight examples were identified and analysed. Evidence indicates the TC will have a wide range of compounding impacts across multiple determinants and inequalities. These will need to be viewed in synergy, not singularly. Determinants affected include i.e mental well-being, food insecurity, employment.Population groups potentially affected include rural communities, fishers/farmers, young people. Policy responses need to be constructed in an integrated way with cross sector involvement as actions intended to have positive impacts for one challenge could also have negative unintended impacts for others. This innovative work has highlighted the significant interconnectedness of the challenges. Developing an overarching policy approach could support lasting change.Having the TC as the underpinning focus point for new policies and strategies will help to maximise impact when addressing concerns in relation to post Brexit policy/actions, COVID recovery and climate change adaptation/mitigation.This work can be utilized by other nations as an example for challenges they may face in their context and nations in the UK/Europe affected by the TC.

Key messages

• Brexit, COVID-19 and climate change have cumulative health impacts which must be considered together.

• Health impact assessment can provide a core framework through which to explore inequalities and health impact of multiple policy and practical issues.

Health impact Assessment practice in Wales: factors conditioning its success

Historically, Public Health Institutes (PHIs) were formed to address emergency public health and environmental health related challenges for example, infectious disease outbreaks and sanitary conditions which will affect health. The COVID-19 pandemic has demonstrated the importance and value of PHIs and the specific knowledge and expertise sat within them in the 21st century in relation to critical health issues. However, PHIs have also the potential expertise to look at the wider determinants of health and how they might affect population health and inequalities. In doing so, they play a critical role to advocate for Health in All Policies (HiAP) and Health Impact Assessment (HIA) by engaging with decision makers from health and non-health sectors and providing evidence and health intelligence. Public Health Wales (PHW) has conducted very complex studies as the HIA of the impact of Brexit on the population of Wales, which was praised as very useful by the Welsh Government and local decision makers at a time when, otherwise, little robust evidence-based information was available. Other positive HIA experiences are the recently published HIA about impacts of climate change or COVID-19 pandemic. Those achievements were possible thanks to the establishment of a specific unit dedicated to HIA within PHW, and to the political support and resources. This has built awareness raising and trust in HIA as a tool to support decision making from all sectors in Wales, enabled also by much training and stakeholder participation.

International Horizon Scanning the impact of Covid-19 on increasing the health gap and vulnerability

 

The COVID-19 pandemic has caused unprecedented challenges for populations, health systems and governments worldwide, which have resulted in lasting economic, social and health impacts. The results of such have been felt disproportionately throughout society and existing vulnerabilities have been highlighted and heightened. A clear understanding of the extent of these vulnerabilities is needed in order to fully address the problem. The World Health Organization Collaborating Centre on Investment for Health and Well-being (WHOCC), Public Health Wales has developed a summary report focusing on the existing and emerging inequalities resulting from the pandemic, as identified through international evidence and learning from the International Horizon Scanning Reports. These reports, undertaken between May 2020 - August 2021, are based upon rapid evidence synthesis reviews of international literature. The summary report focuses on global learning and best practices in order to better understand and address the unequal impacts of the pandemic. The information has been categorised according to the five essential conditions required to enable a healthy life as presented within the WHO health equity conditions framework. The report provides evidence on groups most vulnerable to both direct and indirect impacts of the pandemic as well as promising practice to address the resulting inequity. Inequalities and related factors explored within the report include but are not limited to, level of deprivation and education. Taking a global perspective, this report summarises international evidence to support inclusive, sustainable, and equitable solutions, such as protecting economic well-being and taking an intergenerational lens in both response and recovery. To address and mitigate the impact of the pandemic upon vulnerable groups, collating and sharing international evidence and best practice has proven to support equitable long-term socio-economic and environmental recovery.

Key messages

• International learning provides vital insights to support recovery in Wales and beyond.

• Responses to the pandemic should address the needs of the vulnerable to reduce existing health gaps.

Health in All policies: what do we mean and where are we now?

This presentation sets what HiAP is and is not, and its evolution since it was conceived. It also addresses how HiAP can be mobilised in practice via the use of tools such as HIA and the key role that enabling structures and contexts - both politically strategic and locally operational- to ensure that health, wellbeing and equity is promoted in the European region. It discusses the enabling context of Wales, with the Future Generations (Wales) Act 2015, which provides political leverage for the implementation of HiAP in practical terms, enabling addressing health considerations intersectorially by non-health policies and projects. This Act along with supporting documents, guidance and legislation implicitly incorporates the principles of HiAP so the rest of non-health sector understand (and also have the statutory obligation) to address the health considerations of policies and plans. It does this by requiring all public bodies in Wales to strive to maximise 7 Well-being Goals - which include ‘A healthier Wales’, ‘A more equal Wales’ - and requires that they do so by working with other agencies in order to prevent negative impacts and promote participation, long-term thinking and integration to ensure that inequalities are minimised. These are key public health principles from which to have conversations. Wales also provides a good example with its advocacy and policy in respect to Economies of Wellbeing - a critical challenge for HIAP is that HiAP is, by its nature, political, and may challenge some policy proposals. Although the focus is on identifying ‘win:wins’ and co-benefits, sometimes there is a conflict between health and other outcomes. There may be a need to balance health gains against economic growth or other policy aims. The following debate intends to discuss the challenges and enablers to achieve that aim, and how public health can make its voice heard.

680 IMPROVING COMMUNICATION IN THE TIME OF COVID-19 - USING A DEDICATED COMMUNICATION SHEET

 

Title Improving ease and consistency of communication with Next of Kin (NoK) on an Acute Frailty Ward.

Background

A dedicated Communication Sheet was introduced on an Acute Frailty ward at the Royal Surrey County Hospital (by a Nurse-in-Charge and foundation doctors under the supervision of a Consultant Geriatrician) to improve communication between the Multidisciplinary team(MDT) and patients’ NoK/families.

Introduction

Communication with patients’ NoK is an essential part of providing holistic care & has become important given the COVID-19 visiting restrictions. Multidisciplinary Team (MDT) members were facing difficulties in knowing the following while updating NoK: 1. The correct contact details of the Next of Kin and other significant persons involved in care. 2. When the last NoK update was done and what was discussed. 3. If the patient has consented to NoK updates. This led to dissatisfaction and complaints from families regarding the frequency and consistency of updates. To make this easier for staff, a communication sheet was introduced.

Methods

A Plan-Do-Study-Act Method: was used. Following discussion at a ward governance meet, a survey was conducted to assess the difficulty faced by MDT members in NoK updates. A Communication Sheet designed by a Nurse-in-Charge and Foundation Doctors was trialled for 1 month. The sheet was updated following feedback. A repeat Survey was conducted to assess if NoK updates were easier after the intervention.

Results

After the Introduction: of the Communication Sheets, the number of staff facing ‘significant difficulty’ in the above-mentioned parameters reduced and those facing ‘no difficulty’ increased. Feedback from MDT members suggested that they found the intervention useful.

Conclusion

Dedicated communication sheets made updating families/NoK easier. This ensures consistent updates especially when visiting is restricted. This fosters a better patient-clinician relationship. Given its success, we plan to share this with other frailty wards to scale up this intervention.

Trade-offs between succulent and non-succulent epiphytes underlie variation in drought tolerance and avoidance

Epiphyte communities comprise important components of many forest ecosystems in terms of biomass and diversity, but little is known regarding trade-offs that underlie diversity and structure in these communities or the impact that microclimate has on epiphyte trait allocation. We measured 22 functional traits in vascular epiphyte communities across six sites that span a microclimatic gradient in a tropical montane cloud forest region in Costa Rica. We quantified traits that relate to carbon and nitrogen allocation, gas exchange, water storage, and drought tolerance. Functional diversity was high in all but the lowest elevation site where drought likely limits the success of certain species with particular trait combinations. For most traits, variation was explained by relationships with other traits, rather than differences in microclimate across sites. Although there were significant differences in microclimate, epiphyte abundance, and diversity, we found substantial overlap in multivariate trait space across five of the sites. We found significant correlations between functional traits, many of which related to water storage (leaf water content, leaf thickness, hydrenchymal thickness), drought tolerance (turgor loss point), and carbon allocation (specific leaf area, leaf dry matter content). This suite of trait correlations suggests that the epiphyte community has evolved functional strategies along with a drought avoidance versus drought tolerance continuum where leaf succulence emerged as a pivotal overall trait.

Climate Change in Wales and its health impact: Who is vulnerable and how?

In April 2019, Wales declared a climate emergency. Public Health Wales commissioned a Health Impact Assessment (HIA) to be carried out to assess the potential impact of Climate Change (CCh) on the population of Wales and inform key strategic decision makers to understand/plan for the potential differential health and inequalities impacts that may occur from CCh. A comprehensive mixed-method HIA was conducted over a 6 month period in 2019/2020. A review of peer-reviewed evidence on the potential impact of CCh/climate change events on health and population groups and a review of grey literature on direct impacts such as the environment, mental wellbeing and health care settings was conducted. 2 stakeholder workshops, qualitative interviews, a community health profile utilising sources such as the National Survey for Wales were also carried out. All findings were analysed, synthesized and collated into a report. Vulnerability is a critical aspect of population health and the HIA findings identified a range of positive and negative impacts on specific population groups which highlights their vulnerability to climate change. This includes children and young people; older people; coastal and rural communities and those on low incomes. These are often not explicitly highlighted in other environmentally focused assessments. The HIA also indicated significant potential impacts across the determinants of health including excess heat/cold; flooding; economy; access to services; mental well-being; and community resilience. The findings have informed decision-makers to prepare for CCh plans/policies using an evidence-informed approach and particularly to address who may be disproportionately negatively affected. The work has demonstrated the importance of HIA to assess significant, complex policies by mobilising a range of evidence through a transparent process, explicitly considering the impact on vulnerable groups, resulting in transferrable learning for others.

Maximising Social Value and Health Impact – what is the role of PHIs?

Issue

Public health Institutes (PHIs) need to build on traditional approaches to capture and measure their value and impact. As we transfer into the COVID-19 recovery phase, it is important to maximise the value of the health impact but also the social, economic and environmental impact of PHIs. Exploration is required to understand how the social value and impact of PHIs is, or can be, captured and measured. Existing research has illustrated the potential link between Health Impact Assessment (HIA) which assesses health and well-being through the lens of the determinants of health, and economic methods such as Social Return on Investment (SROI). This research aims to understand the current role which PHIs have, in order to strengthen advocacy for investment in public health and prevention in order to protect and improve population health.

Description of the problem

A scoping survey was designed and distributed digitally to national and regional PHIs via international networks. Semi-structured interviews were also used to add a qualitative value to the research to allow for triangulation of results. The survey data was analysed descriptively and interview data analysed thematically and coded.

Results

The results of the research present an understanding of the meaning of investment, social value and health impact within PHIs including how it is measured using SROI and HIA. It also highlights whether PHIs have considered how capturing social value and health impact can contribute to the recovery from COVID-19, and whether they believe that SROI and HIA have a role in achieving this.

Lessons

This innovative work aims to develop a picture of how PHIs are capturing and measuring the wider social, economic and environmental value of their programmes and services. Survey results will be used to help develop a framework for capturing the wider impact and value of public health at an international level, with an aim to achieving sustainable investment in future public health.

Key messages

Making the case for investing in public health by illustrating its social, economic and environmental value is vital.

Understanding how to capture and measure the wider value of public health is imperative to aid the recovery from COVID-19.

The Health and wellbeing impacts of Home and agile working in Wales: A HIA Approach

The SARS-COV-02 pandemic has globally resulted in a number of policies and interventions to address and reduce the transmission of the disease throughout the population. Mitigation measures have ranged from ‘Staying at Home' or ‘Lockdowns' to social distancing policies and requirements to work from home when you can. Whilst there are a number of papers which discuss the effects of home or remote working on employees and their families the large scale shift, accelerated pace and wider impacts of such a shift has not been well explored in the literature or has been focussed on specific topics, for example, productivity. HIA is promoted as a beneficial tool to identify the wider impacts of a policy, plan or intervention across a population and as such is well placed to examine and articulate who in a population may be affected and how, and the inequalities that may be created by an intervention such as home working. Using the lens of social determinants and equity focussed-HIA, this work examines the wider impact of home working in Wales during the COVID-19 pandemic. It provides a coherent overview of the major impacts on health and the particular populations affected. It articulates the process followed, the key evidence based findings, discusses the gaps in the evidence base that require further exploration and the impact and influence it has had to date. Finally, it shares the transferable learning, which will be of use to researchers, policy and decision makers, organisations and public health agencies.

Early cryoprecipitate transfusion versus standard care in severe postpartum haemorrhage: a pilot cluster-randomised trial

There is a lack of evidence evaluating cryoprecipitate transfusion in severe postpartum haemorrhage. We performed a pilot cluster‐randomised controlled trial to evaluate the feasibility of a trial on early cryoprecipitate delivery in severe postpartum haemorrhage. Pregnant women (>24 weeks gestation), actively bleeding within 24 h of delivery and who required at least one unit of red blood cells were eligible. Women declining transfusion in advance or with inherited clotting deficiencies were not eligible. Four UK hospitals were randomly allocated to deliver either the intervention (administration of two pools of cryoprecipitate within 90 min of first red blood cell unit requested plus standard care), or the control group treatment (standard care, where cryoprecipitate is administered later or not at all). The primary outcome was the proportion of women who received early cryoprecipitate (intervention) vs. standard care (control). Secondary outcomes included consent rates, acceptability of the intervention, safety outcomes and preliminary clinical outcome data to inform a definitive trial. Between March 2019 and January 2020, 199 participants were recruited; 19 refused consent, leaving 180 for analysis (110 in the intervention and 70 in the control group). Adherence to assigned treatment was 32% (95%CI 23–41%) in the intervention group vs. 81% (95%CI 70–90%) in the control group. The proportion of women receiving cryoprecipitate at any time‐point was higher in the intervention (60%) vs. control (31%) groups; the former had fewer red blood cell transfusions at 24 h (mean difference −0.6 units, 95%CI −1.2 to 0); overall surgical procedures (odds ratio 0.6, 95%CI 0.3–1.1); and intensive care admissions (odds ratio 0.4, 95%CI 0.1–1.1). There was no increase in serious adverse or thrombotic events in the intervention group. Staff interviews showed that lack of awareness and uncertainty about study responsibilities contributed to lower adherence in the intervention group. We conclude that a full‐scale trial may be feasible, provided that protocol revisions are put in place to establish clear lines of communication for ordering early cryoprecipitate in order to improve adherence. Preliminary clinical outcomes associated with cryoprecipitate administration are encouraging and merit further investigation.

First insight into plastics ingestion by fish in the Gulf of California, Mexico

Plastic particle occurrence in the digestive tracts of fishes from a tropical estuarine system in the Gulf of California was investigated. A total of 1095 fish were analysed, representing 15 species. In total 1384 particles of plastic debris were recovered from the gastrointestinal tracts of 552 specimens belonging to 13 species, and all consisted of threads, the majority of which were small microplastics (0.23 to 1.89), followed by large microplastics (2.07 to 4.49), and few mesoplastics (5.4 to 19.86). Plastic particles were identified using ATR-FTIR spectroscopy. The mean frequency of occurrence of plastics in the gastrointestinal tracts of fishes from this system was 50.5%, which is higher than frequencies reported in similar systems in other areas. The polymers identified by ATR-FTIR were polyamide (51.2%), polyethylene (36.6%), polypropylene (7.3%), and polyacrylic (4.9%). These results show the first evidence of plastic contamination for estuarine biota in the Gulf of California.

Real-World Effectiveness of Anti-IL-5/5R Therapy in Severe Atopic Eosinophilic Asthma with Fungal Sensitization

BACKGROUND

Severe asthma with fungal sensitization (SAFS) is a complex clinical phenotype associated with poorly controlled type 2 inflammation and significant morbidity from both the disease itself and a high steroid burden.

OBJECTIVE

To assess the effectiveness of biologic therapies targeting eosinophilic inflammation in SAFS.

METHODS

We assessed the effectiveness of treatment with mepolizumab or benralizumab in patients with SAFS, and compared outcomes with patients with severe atopic asthma without fungal sensitization and patients with severe nonatopic asthma. Baseline clinical characteristics and clinical outcomes at 48 weeks were evaluated. A subgroup analysis was performed of patients who met the criteria for allergic bronchopulmonary aspergillosis (ABPA) rather than SAFS.

RESULTS

A total of 193 patients treated with mepolizumab (n = 63) or benralizumab (n = 130) were included. Patients with SAFS had higher baseline IgE level compared with patients with severe atopic asthma without fungal sensitization and severe nonatopic asthma (733 ± 837 IU/mL vs 338 ± 494 and 142 ± 171, respectively; both P < .001). There were no other significant baseline differences in clinical characteristics between groups. At 48 weeks, there were significant improvements in 6-item asthma control questionnaire score and exacerbation frequency, and reduction in maintenance oral corticosteroid dose across all groups (all P < .05). No significant between-group differences in outcomes were observed at 48 weeks. Patients with ABPA (n = 9) had a significant reduction in exacerbation frequency (P = .013) with treatment.

CONCLUSIONS

Treatment with eosinophil-targeting biologics led to improvements in exacerbation frequency, oral corticosteroid requirements, and patient-reported outcomes in patients with SAFS, with a reduction in exacerbations in the subgroup of patients with ABPA. These data highlight the potential clinical utility of targeting eosinophilic inflammation in SAFS and ABPA.

Prothrombin complex concentrate vs. fresh frozen plasma in adult patients undergoing heart surgery - a pilot randomised controlled trial (PROPHESY trial)

There is equipoise regarding the use of prothrombin complex concentrate vs. fresh frozen plasma in bleeding patients undergoing cardiac surgery. We performed a pilot randomised controlled trial to determine the recruitment rate for a large trial, comparing the impact of prothrombin complex concentrate vs. fresh frozen plasma on haemostasis (1 h and 24 h post-intervention), and assessing safety. Adult patients who developed bleeding within 24 h of cardiac surgery that required coagulation factor replacement were randomly allocated to receive prothrombin complex concentrate (15 IU.kg^-1 based on factor IX) or fresh frozen plasma (15 ml.kg^-1 ). If bleeding continued after the first administration of prothrombin complex concentrate or fresh frozen plasma administration, standard care was administered. From February 2019 to October 2019, 180 patients were screened, of which 134 (74.4% (95%CI 67-81%)) consented, 59 bled excessively and 50 were randomly allocated; 25 in each arm, recruitment rate 35% (95%CI 27-44%). There were 23 trial protocol deviations, 137 adverse events (75 prothrombin complex concentrate vs. 62 fresh frozen plasma) and 18 serious adverse events (5 prothrombin complex concentrate vs. 13 fresh frozen plasma). There was no increase in thromboembolic events with prothrombin complex concentrate. No patient withdrew from the study, four were lost to follow-up and two died. At 1 h after administration of the intervention there was a significant increase in fibrinogen, Factor V, Factor XII, Factor XIII, α₂ -antiplasmin and antithrombin levels in the fresh frozen plasma arm, while Factor II and Factor X were significantly higher in the prothrombin complex concentrate group. At 24 h, there were no significant differences in clotting factor levels. We conclude that recruitment to a larger study is feasible. Haemostatic tests have provided useful insight into the haemostatic changes following prothrombin complex concentrate or fresh frozen plasma administration. A definitive trial is needed to ascertain the benefits and safety for each.

Steroid-sparing effects of benralizumab in patients with eosinophilic granulomatosis with polyangiitis

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare, anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis characterised by asthma, chronic rhinosinusitis and blood eosinophilia, which may be accompanied by neurological, cardiac, cutaneous and renal involvement [1]. Oral corticosteroids (OCS) are the most frequently used drugs to control eosinophilic inflammation and symptoms. Persistent symptoms or relapses are common, however, and many patients are at risk of developing long-term complications from systemic steroid therapy [2]. The ability of other immunosuppressant agents to achieve consistent disease control or to reduce maintenance OCS (mOCS) requirements appears to be limited [3].

Benralizumab reduces oral corticosteroid requirements in patients with EGPA and leads to improved patient-reported outcome measureshttps://bit.ly/2GI0vhf

Adding value to the use of Health Impact Assessment and social return on investment technologies

Health Impact Assessment (HIA) and Social Return on Investment (SROI) are beneficial public health methodologies that assess potential effects on health including social, economic and environmental factors and have synergies in their approaches. This paper explores how HIA and SROI can complement each other to capture and account for the impact and social value of an assessed intervention or policy.

A scoping review of academic and grey literature was undertaken to identify case studies published between January 1996 and April 2019 where HIA and SROI methods have been used to complement each other. Semi-structured interviews were carried out with nine international experts from a range of regulatory/legislative contexts to gain a better understanding of past experiences and expertise of both HIA and SROI. A thematic analysis was undertaken on the data collected. The review identified two published reports which outline when HIA and SROI have both been used to assess the same intervention. Interview results suggest that both methods have strengths as standalone processes i.e. HIAs are well-structured in their approach, assessing health in its broadest context and SROI can add value by monetizing social value as well as capturing social/environmental impact. Similarities of the two methods were identified i.e. a strong emphasis on stakeholder engagement and common shared principles. When questioned how the two methods could complement each other in practice, the results indicate the benefits of using HIA to explore initial impact, and as a platform on which to build SROI to monetarize social value.

HIA and SROI methodologies have cross-over. The research suggests potential benefits when used in tandem or combining the methods to assess impact and account for health and social value. Innovative work is now being carried out in Wales to understand the implications of this in practice and to understand how the results of the two methods could be used by decision-makers.

Key messages

HIA and SROI methods can be used in tandem to capture both the health impact and social value of policies and proposed interventions. HIA and SROI when used together can provide valuable information to inform decision makers around the health impact and social value of proposed policies and interventions.

Assessing the public health impact of climate change in Wales

In April 2019, Wales declared a climate emergency. Public Health Wales commissioned a Health Impact Assessment (HIA) to assess the potential impact of Climate Change on the population of Wales to be carried out to inform key strategic decision makers to understand/plan for the potential differential health impacts that may occur in Wales from climate change.

A comprehensive mixed-method HIA was conducted over a 6-month period in 2019/20. A review of peer-reviewed evidence on the potential impact of climate change/climate change events on health and population groups and a review of grey literature on direct impacts such as the environment, mental wellbeing and health care settings was conducted. The search was undertaken using MEDLINE, Embase, Proquest. 2 stakeholder workshops, qualitative interviews, a community health profile utilising recognised data sources (i.e. The National Survey for Wales) and a survey to identify the publics' views on climate change were also carried out. All findings were analysed, synthesized and collated into a report.

The HIA initial findings indicate significant potential impacts across the wider determinants of health and mental well-being i.e. Air quality, excess heat/cold; flooding; economic productivity; working conditions; access to services; infrastructure; and community resilience. A range of impacts were identified across population groups, settings, geographical areas including urban and rural contexts; outdoor workers; children and young people; older people; schools; hospitals/care homes and workplaces.

The impacts identified are both confirmed and potential. Undertaken in a short timeframe, the findings have been beneficial to inform decision-makers to prepare for Climate Change plans/policies using an evidence-informed approach. The work has demonstrated the value of a HIA approach for significant, complex policies by mobilising a range of evidence through a transparent process, resulting in transferrable learning for others.

Real-World Effectiveness of Benralizumab in Severe Eosinophilic Asthma

BACKGROUND

Benralizumab is an IL5-receptor monoclonal antibody licensed for the treatment of severe eosinophilic asthma (SEA). It has demonstrated efficacy in clinical trials in reducing asthma exacerbation rates and maintenance oral corticosteroids (mOCSs).

RESEARCH QUESTION

What is the real-world effectiveness of benralizumab and what baseline characteristics are associated with response to therapy?

STUDY DESIGN AND METHODS

We assessed outcomes in all SEA patients who began benralizumab treatment at our specialist center. At each dosing visit, exacerbation history, mOCS dose, spirometry, and Asthma Control Questionnaire (ACQ6) and Mini-Asthma Quality of Life Questionnaire (mAQLQ) scores were recorded. Response to treatment was defined as a reduction of ≥ 50% in annualized exacerbation rate (AER) or in mOCS dose after 48 weeks of treatment. Super response was defined as zero exacerbations and no mOCSs for asthma.

RESULTS

One hundred thirty patients were included in the analysis. At 48 weeks, a 72.8% reduction in AER was noted, from 4.92 ± 3.35 per year in the year preceding biologic treatment to 1.34 ± 1.71 per year (P < .001), including 57 patients (43.8%) who were exacerbation-free with benralizumab. In those receiving mOCSs (n = 74 [56.9%]), the median daily prednisolone dose fell from 10 mg (interquartile range, 5-20 mg) to 0 mg (interquartile range, 0-5 mg; P < .001), and 38 of 74 patients (51.4%) were able to discontinue mOCS therapy. Clinically and statistically significant improvements were found in ACQ6 scores, mAQLQ scores, and FEV₁. Overall, 51 patients (39%) met the super responder definition and 112 patients (86%) met the responder definition. The optimal regression model of super responders vs other responders included baseline characteristics associated with a strongly eosinophilic phenotype and less severe disease. Eighteen patients (13.8%) were nonresponders to benralizumab. Evidence of chronic airway infection was observed in 6 of 18 patients, and an increase in the blood eosinophil count consistent with the development of anti-drug antibodies was observed in 5 of 18 patients.

INTERPRETATION

In a large real-world SEA cohort, benralizumab led to significant improvements in all clinical outcome measures. A lack of response was seen in a minority of patients and should be a focus for future investigation.

Adherence to corticosteroids and clinical outcomes in mepolizumab therapy for severe asthma

INTRODUCTION

Inhaled corticosteroids (ICS) achieve disease control in the majority of asthmatic patients, although adherence to prescribed ICS is often poor. Patients with severe eosinophilic asthma may require treatment with oral corticosteroids (OCS) and/or biologic agents such as mepolizumab. It is unknown if ICS adherence changes on, or alters clinical response to, biologic therapy.

METHODS

We examined ICS adherence and clinical outcomes in OCS-dependent severe eosinophilic asthma patients who completed 1 year of mepolizumab therapy. The ICS medicines possession ratio (MPR) was calculated (the number of doses of ICS issued on prescription/expected number) for the year before and the year after biologic initiation. Good adherence was defined as MPR >0.75, intermediate 0.74-0.51 and poor <0.5. We examined outcomes after 12 months of biologic therapy, including OCS reduction and annualised exacerbation rate (AER), stratified by adherence to ICS on mepolizumab.

RESULTS

Out of 109 patients commencing mepolizumab, 91 who had completed 12 months of treatment were included in the final analysis. While receiving mepolizumab, 68% had good ICS adherence, with 16 (18%) having poor ICS adherence. ICS use within the cohort remained similar before (MPR 0.81±0.32) and during mepolizumab treatment (0.82±0.32; p=0.78). Patients with good adherence had greater reductions in OCS dose (median (interquartile range) OCS reduction 100 (74-100)% versus 60 (27-100)%; p=0.031) and exacerbations (AER change -2.1±3.1 versus 0.3±2.5; p=0.011) than those with poor adherence. Good ICS adherence predicted the likelihood of stopping maintenance OCS (adjusted OR 3.19, 95% CI 1.02-9.94; p=0.045).

CONCLUSION

ICS nonadherence is common in severe eosinophilic asthma patients receiving mepolizumab, and is associated with a lesser reduction in OCS requirements and AER.

Rescue of degenerating neurons and cells by stem cell released molecules: using a physiological renormalization strategy

Evidence suggests that adult stem cell types and progenitor cells act collectively in a given tissue to maintain and heal organs, such as muscle, through a release of a multitude of molecules packaged into exosomes from the different cell types. Using this principle for the development of bioinspired therapeutics that induces homeostatic renormalization, here we show that the collection of molecules released from four cell types, including mesenchymal stem cells, fibroblast, neural stem cells, and astrocytes, rescues degenerating neurons and cells. Specifically, oxidative stress induced in a human recombinant TDP‐43‐ or FUS‐tGFP U2OS cell line by exposure to sodium arsenite was shown to be significantly reduced by our collection of molecules using in vitro imaging of FUS and TDP‐43 stress granules. Furthermore, we also show that the collective secretome rescues cortical neurons from glutamate toxicity as evidenced by increased neurite outgrowth, reduced LDH release, and reduced caspase 3/7 activity. These data are the first in a series supporting the development of stem cell‐based exosome systems therapeutics that uses a physiological renormalization strategy to treat neurodegenerative diseases.

Real-World Effectiveness and the Characteristics of a "Super-Responder" to Mepolizumab in Severe Eosinophilic Asthma

BACKGROUND

Mepolizumab was the first licensed anti-IL5 monoclonal antibody for severe eosinophilic asthma (SEA). To date there are few data to confirm its efficacy in the real-world setting or assessment of baseline characteristics associated with response.

RESEARCH QUESTION

How do patients with severe eosinophilic asthma respond to mepolizumab in the real world setting and which characteristics are associated with a super-response to this therapy?

STUDY DESIGN AND METHODS

We conducted a retrospective review of all patients who received at least 16 weeks of treatment with mepolizumab (100 mg subcutaneously) for SEA at our regional asthma center in the United Kingdom. Clinical data were collected at each 4-week visit. At 16, 24, and 52 weeks, patients were classified as "responders" or "nonresponders." A response was defined as ≥50% reduction in exacerbations; for patients whose condition requires maintenance oral corticosteroids (mOCS), a response was defined as ≥50% reduction in prednisolone dose. Super responders were defined as exacerbation-free and off mOCS at one year.

RESULTS

Ninety-nine patients were included in the analysis. Asthma exacerbations decreased from a baseline of 4.04 ± 2.57 to 1.86 ± 2.17 per year at one year (54% reduction; P < .001). Sixty-eight patients were receiving mOCS at the time of commencing mepolizumab. By one year, the daily median dose fell from 10 mg (interquartile range, 10 to 15) to 0 mg (interquartile range, 0 to 10; P < .001). Fifty-seven percent of them were able to discontinue mOCS; 72.7% (95% CI, 63.0 to 80.7) of the patients were classified as responders, and 28.3% (95% CI, 20.2 to 38.0) of the patients were classified as super responders. Baseline characteristics associated with responder and super responder status included the presence of nasal polyposis (P = .012), lower baseline Asthma Control Questionnaire 6 (P = .006), a lower BMI (P = .014), and, in those patients receiving mOCS, a significantly lower prednisolone dose at baseline (P = .005). At 16 weeks, the one-year responder status was correctly identified in 80.8% patients; by 24 weeks, this status rose to 92.9%.

INTERPRETATION

In a real-world SEA cohort, treatment with mepolizumab reduced exacerbation frequency and mOCS requirements. Nasal polyposis, a lower BMI, and a lower maintenance prednisolone requirement at baseline were associated with better outcomes. Twelve-month response was identifiable in >90% of patients by week 24.

Oral corticosteroid-sparing effects of reslizumab in the treatment of eosinophilic granulomatosis with polyangiitis

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare but devastating vasculitis characterised by perivascular eosinophilic inflammation, severe asthma, peripheral eosinophilia and sinonasal disease, frequently complicated by cardiac, neurological or renal involvement [1, 2]. The mainstay of therapy for EGPA is use of systemic corticosteroids (OCS), with or without concomitant immunosuppression with methotrexate, azathioprine, cyclophosphamide or rituximab [3, 4]. The long-term use of these agents is associated with significant drug-related morbidity and the risk of relapse in EGPA patients remains significant despite treatment [1, 5]. Interleukin (IL)-5 is a critical cytokine regulating eosinophil development, migration and activation [2]. In EGPA, high doses of the IL-5 neutralising antibody mepolizumab lead to improved disease control and reduced requirement for OCS therapy, with an excellent safety profile [6, 7]. Reslizumab is another IL-5 neutralising antibody currently licensed for the treatment of severe eosinophilic asthma [8]; however, there are – to our knowledge – no published data exploring the utility of reslizumab in the management of EGPA. Here, we report clinical and patient-reported outcomes in a cohort of treatment-refractory, OCS-dependent EGPA patients with severe asthma commenced on reslizumab.

Blockade of interleukin-5 with reslizumab appears to have significant oral corticosteroid sparing effects in patients with eosinophilic granulomatosis with polyangiitis and severe eosinophilic asthmahttp://bit.ly/2D2yYSK

Skills and knowledge to facilitate competence for health and wellbeing in Environmental Impact Assessment

Findings

This paper describes a clear set of expected skills and knowledge outcomes that competent practitioners and multi-disciplinary teams need to exhibit; which policy makers and commissioners need to seek; and which reviewers should expect see applied, in order to ensure that high quality, fit for purpose EIAs are carried out which include the widest interpretation of health, wellbeing and inequalities. It discusses the work of the Wales HIA Support Unit to train and mentor practitioners and organisations and presents resources to enable this such as its Skills and Knowledge Development Framework, which provides a pathway to develop and support competence in practice, and the Quality Assurance Review Framework for HIA.

Conclusions

To enable competent broad holistic assessments to be carried out a clear set of criteria, tools, resources and training opportunities are needed in order to enable and facilitate a wide range of personnel to deliver a wide and inclusive health appraisal as part of EIA.

The Public Health Implications of Brexit: A Health Impact Assessment Approach

Key messages

HIA can inform and influence action in response to important strategic decisions. The Brexit HIA is a unique example which can inform international HIA practice.

The Public Health Implications of Brexit in Wales: A Health Impact Assessment (HIA) approach

Key messages

Brexit is a major policy change with major health impacts. HIA is an informative and influencing process to support planning and future policy making.

An Attempt to Quantitate "Value" In Medical Oncologic Therapy

Objective

We wanted to examine the incremental cost-effective ratio (ICER) for a variety of Food and Drug Administration (FDA) approved oncology drugs in the adjuvant or curative setting to determine the value provided.

Design

We examined the annualized incremental drug costs of a variety of FDA approved chemotherapeutic drugs used in an adjuvant or curative setting based on National Comprehensive Cancer Network (NCCN) category 1 practice guidelines for melanoma, Her2/neu over-expressive breast cancer, renal cell carcinoma, stage IIIA non-small cell lung cancer, myeloma, B cell lymphoma, and Hodgkin lymphoma. The studies we examined were randomized clinical trials on which the NCCN guidelines are based; we solely examined the incremental cost-effectiveness of the trial drug as we assumed that the costs of the health care provided were equivalent between the two treatment arms. We used a formula to determine the incremental cost-effectiveness ratio (ICER). The ICER compares a new intervention (C new) with its alternate (C alt) divided by the quality-adjusted life-years (QALY) that results from the new intervention (QALY new) versus the alternate (QALY alt) and is expressed as ICER = (C new-C alt)/(QALY new-QALY alt). The QALY’s were derived from what was reported in the study and based on the incremental disease-free survival.

Results

Drugs such as rituximab provide high value in the curative therapy for lymphoma. Drugs such as adjuvant dabrafenib and trametinib provide intermediate value in the treatment of melanoma, and similarly with maintenance lenalidomide in myeloma and adjuvant trastuzumab in breast cancer. Oncologic drugs that provide low value include adjuvant ipilimumab in melanoma, adjuvant sunitinib in renal cell carcinoma, adjuvant neratinib in breast cancer, adjuvant durvalumab in lung cancer, and brentuximab in the curative therapy for Hodgkin’s lymphoma.

Conclusion

The ICER needs to be evaluated for newly approved FDA oncology chemotherapeutic drugs before incorporating them into routine clinical practice.

Overcoming suvivorship care planning implementation challenges through decentralization

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Background: To meet Commission on Cancer accreditation requirements, cancer programs must implement processes to monitor the dissemination of survivorship care plans (SCP) for patients with Stages I-III cancers who were treated with curative intent and completed active therapy. Challenges of SCP delivery across disease sites include lack of designated/trained staff, time burden, knowledge of current evidence-based guidelines, and sustainability. We describe the challenges NorthShore University HealthSystem Kellogg Cancer Center (NKCC) and their Living in the Future (LIFE) Cancer Survivorship Program faced in meeting this standard and how evolving the SCP delivery process has resulted in a sustainable model. Methods: LIFE implemented a technology-based SCP tool using a centralized consultative model led by a nurse practitioner (NP) with specialized survivorship training. Physicians referred eligible patients to the survivorship clinic for an education visit where they received a SCP from the NP. Since the centralized model was dependent on one person for delivery, a more sustainable model was needed. NKCC transitioned to a decentralized process, moving SCP creation and delivery responsibility to all oncology care providers (OCPs). Although not all OCPs had specialized survivorship training, care quality was supported by automated SCP creation based on evidence-based care recommendations embedded in the technology. Results: To date, 143 evidence-based SCPs have been delivered since tool implementation in April 2017. During the centralized model (April 25– June 30) 67 SCPs were created by the lead LIFE NP; 76 were created during the decentralized process while the lead NP was on leave (July 3 – Oct 1). By using a technology-based SCP, OCPs incorporated SCP delivery into their workflow and no longer had to refer patients to a separate clinic. Conclusions: This project demonstrates the feasibility of a sustainable, decentralized process using a technology-based SCP as an option for augmenting centralized SCP delivery. A comparable number of patients received a SCP during both processes with an equivalent number of SCPs being delivered via the decentralized model by OCPs supported by evidence-based technology.

Abstract OT3-05-10: A single arm phase II study of palbociclib in combination with tamoxifen as first line therapy for metastatic hormone receptor positive breast cancer

Background: Hormone receptor positive breast cancer is the most commonly diagnosed subset of breast cancer (60-65%). Endocrine therapy is effective for this subset of breast cancer, in both the adjuvant and metastatic settings. Despite advances in endocrine therapy, many patients relapse during or after completing adjuvant therapy and metastatic breast cancer remains incurable. Palbociclib is a reversible, oral, small molecule inhibitor of cyclin dependent kinases 4 and 6 (CDK4/6). CDK4 and CDK6 together with cyclin D have important roles in regulation of the G1/S transition via regulation of the phosphorylation state of retinoblastomaprotein (Rb). Palbociclib showed significantly improved progression-free survival taken together with endocrine agents in treatment of metastatic breast cancer. Preclinical data showed that in combination with tamoxifen, palbociclib had synergistic growth inhibitory activity as well as efficacy in a model of acquired tamoxifen resistance. Combining palbociclib with tamoxifen in first line treatment of metastatic hormone receptor positive breast cancer may offers an appealing alternative to other endocrine combinations. Methods: This is a non-randomized, open-label, single-arm, multicenter, phase II study of palbociclib in combination with tamoxifen in patients with hormone receptor positive/HER2 negative advanced breast cancer. The primary objective is to determine the objective response rate (complete or partial response) based on RECIST 1.1 or MDA Criteria (for patients with bone only disease). Secondary objectives are: safety and tolerability, progression-free survival, clinical benefit rate, 2-year overall survival. Correlative objectives will explore alterations in circulating tumor DNA and changes in gene expression pattern at the time of progression. Eligibility criteria: women or men with diagnosis of hormone receptor positive/ HER2 negative locally advanced or metastatic breast cancer, not amenable to curative surgery; no prior systemic anti-cancer therapy for advanced hormone receptor positive breast cancer; adequate organ function; pre and post menopausal women are allowed. Drug administration: palbociclib dose will be 125 mg orally once daily on days 1-21 of each 28-day cycle; tamoxifen dose will be 20 mg orally once daily for every day of the 28-day cycle. As of June 2017, the study enrolled 10/71 patients and it is still open to enrollment. NCT 02668666; ocdanciu@uic.edu

Citation Format: Danciu OC, Hoskins K, Tamkus D, Truica C, Blaes A, Green L, Liu L, Toppmeyer D, Wisinski K. A single arm phase II study of palbociclib in combination with tamoxifen as first line therapy for metastatic hormone receptor positive breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT3-05-10.