Galectins in epithelial-mesenchymal transition: roles and mechanisms contributing to tissue repair, fibrosis and cancer metastasis

Galectins are soluble glycan-binding proteins that interact with a wide range of glycoproteins and glycolipids and modulate a broad spectrum of physiological and pathological processes. The expression and subcellular localization of different galectins vary among tissues and cell types and change during processes of tissue repair, fibrosis and cancer where epithelial cells loss differentiation while acquiring migratory mesenchymal phenotypes. The epithelial-mesenchymal transition (EMT) that occurs in the context of these processes can include modifications of glycosylation patterns of glycolipids and glycoproteins affecting their interactions with galectins. Moreover, overexpression of certain galectins has been involved in the development and different outcomes of EMT. This review focuses on the roles and mechanisms of Galectin-1 (Gal-1), Gal-3, Gal-4, Gal-7 and Gal-8, which have been involved in physiologic and pathogenic EMT contexts.

Neurocognitive correlates of the varied domains of outcomes at 20 year follow-up of first-episode psychosis

Little is known about long-term outcomes of the first episode of psychosis (FEP) other than in the symptomatic domain. We hypothesised that cognitive impairment is associated with poorer multi-domain outcomes at a long-term follow-up of FEP patients. We followed-up 172 FEP patients for a mean of 20.3 years. Ten outcome dimensions were assessed (symptomatic, functional and personal recovery, social disadvantage, physical health, suicide attempts, number of episodes, current drug use, chlorpromazine equivalent doses (CPZ), and schizophrenia/schizoaffective disorder final diagnosis). Cognition was assessed at follow-up. Processing speed and verbal memory deficits showed significant associations with poor outcomes on symptomatic, social functioning, social disadvantage, higher number of episodes, and higher CPZ. Significant associations were found between visual memory impairments were significantly associated with low symptomatic and functional recovery, between attentional deficits and a final diagnosis of schizophrenia/schizoaffective disorder, and between social cognition deficits and poor personal recovery.Lower cognitive global scores were significantly associated with all outcome dimensions except for drug abuse and physical status. Using multiple outcome dimensions allowed for the inclusion of the patients' perspective and other commonly neglected outcome measures. Taken together, cognitive impairment in FEP patients is strongly related to poor performance on several outcome dimensions beyond symptomatic remission.

AB0882 Guselkumab: description of cardiovascular risk and efficacy in psoriasis and psoriatic arthritis in real clinical practice

Background

Guselkumab is the first human monoclonal antibody that binds selectively to the p19 subunit of IL23. It’s approved for the treatment of moderate to severe psoriasis and psoriatic arthritis.

Objectives

We present a case series of patients with psoriasis and / or psoriatic arthritis who had a good response to Guselkumab and theirs cardiovascular risk factors.

Methods

An observational and retrospective study of patients with psoriasis and / or psoriatic arthritis under treatment with Guselkumab in the Dermatology and Rheumatology consultation at our hospital. A total of 11 patients were included. Baseline characteristics, comorbidities, and cardiovascular risk were collected. The SCORE (European High Risk Chart) and cardiovascular risk categories (European Society of Cardiology, European Atherosclerosis Society 2019) were used. Disease severity and treatment response were assessed by PASI, DLQI, DAPSA and ASDAS at baseline and after 12, 24 and 36 weeks.

Results

Our cases had a mean age of 52.45 years, 63.6% of them were women. A total of 45.5% had polyarticular psoriatic arthritis. 90.9% were obese, 45.45% were type 2 obesity, with a mean BMI of 34.88. Dyslipidemia and hypertension were observed in 54.5% and 72.7% of the patients, respectively. They all had varying degrees of Non-alcoholic fatty liver disease (NAFLD). A total of 45.5% had SCORE >1% and 90.9% were in moderate category of cardiovascular risk. At baseline their disease parameters were: PASI=11.09 (± 7.01), DLQI=15.09 (± 7.33), DAPSA=19.11 (± 9.95) and ASDAS=2.12 (± 0.43). After 12 weeks of treatment, the mean reduction of PASI and DLQI was 7.09 and 6.45, which continued improving at week 36. None of them were naive. There were no adverse effects, with a treatment survival of 76.73 weeks (± 42.93).

Conclusion

Guselkumab showed excellent results in our clinical practice in the control of psoriasis and / or psoriatic arthritis in non-naive patients with cardiovascular risk factors, with a good safety profile.

References

[1]Hawkes JE, Yan BY, Chan TC, Krueger JG. Discovery of the IL-23/IL-17 Signaling Pathway and the Treatment of Psoriasis. J Immunol. 2018;201(6):1605-1613. doi:10.4049/jimmunol.1800013

[2]Nawas Z, Hatch M, Ramos E, et al. A Review of Guselkumab, an IL-23 Inhibitor, for Moderate-to-Severe Plaque Psoriasis. Skin Therapy Lett. 2017;22(2):8-10

[3]Mease PJ, McInnes IB, Tam LS, et al. Comparative effectiveness of guselkumab in psoriatic arthritis: results from systematic literature review and network meta-analysis. Rheumatology (Oxford). 2021;60(5):2109-2121. doi:10.1093/rheumatology/keab119.

[4]Sans S, Fitzgerald AP, Royo D, Conroy R, Graham I. Calibración de la tabla SCORE de riesgo cardiovascular para España [Calibrating the SCORE cardiovascular risk chart for use in Spain]. Rev Esp Cardiol. 2007;60(5):476-485.

[5]Mach F, Baigent C, Catapano AL, et al. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk [published correction appears in Eur Heart J. 2020 Nov 21;41(44):4255]. Eur Heart J. 2020;41(1):111-188. doi:10.1093/eurheartj/ehz455

Disclosure of Interests

None declared

POS0292 INCREASE OF PRO-INFLAMMATORY CYTOKINES IS ASSOCIATED WITH ANTI-IDIOTYPE EVENTS IN RHEUMATOID ARTHRITIS PATIENTS TREATED WITH INFLIXIMAB OR ADALIMUMAB

Background

A significant percentage of rheumatoid arthritis (RA) patients undergoing Infliximab (IFX) or Adalimumab (ADA) treatment develop antidrug antibodies with potential negative effects over their clinical activity; however, it is unknown if these anti-idiotype events could be associated with changes in cytokines levels

Objectives

To evaluate the association between blood cytokine levels, anti-idiotype events and clinical activity in RA patients treated with IFX or ADA.

Methods

All patients complied with ACR/EULAR 2021 criteria for RA and received anti-TNFa agents. Blood samples were collected during the drug trough and kept at -75ºC until analysis. Clinical activity was based on DAS28-ESR. Specific anti-drug antibodies to IFX and ADA were evaluated by sandwich ELISA. Cytokine blood levels were quantified using a multiplex system or sandwich ELISA.

Results

57 patients with RA were recruited, 17 treated with IFX and 40 with ADA. According to the presence of anti-drug antibodies and sub-optimal levels of the biologic drug, patients were classified as immunogenic (29.8%; n=17) and non-immunogenic (70.2%; n=40), the first showed significantly higher ESR (p<0.001) and DAS28 (p<0.005). A significant association was seen between antidrug antibodies and increases of IFNg (2.1 OR, CI95%:1.2-3.8, p<0.01); MCP-1 (3.9 OR, CI95%:1.1-14.5, p<0.05); MIF (2.8 OR, CI95%:1.3-5.7, p<0.01) and TNFa 3.0 OR, CI95%:1.3-6.6, p<0.01 (see Table 1). Although anti-idiotype events were more frequent in IFX treated patients (41%), a significant difference was not seen when comparing with ADA treated patients (25%).

Table 1.

Association analysis between anti-Idiotype events with cytokine levels.

Anti-Idiotype events vsCrude results OR (IC, 95%)pModel 1* OR (IC, 95%)pModel 2** OR (IC, 95%)pIL-1β2.04 (1.26-3.30)0.0042.18 (1.27-3.74)0.0052.72 (1.41-5.24)0.003IL-61.29 (1.02-1.64)0.031.30 (1.00-1.69)0.041.33 (1.03-1.72)0.02IL-81.20 (0.80-1.79)0.371.24 (0.81-1.88)0.321.22 (0.79-1.90)0.35IL-101.18 (0.91-1.51)0.201.16 (0.89-1.53)0.261.22 (0.92-1.62)0.15IL-12p401.73 (1.09-2.76)0.021.67 (1.00-2.80)0.041.90 (1.12-3.22)0.01IL-17A1.39 (0.95-2.02)0.081.31 (0.90-1.91)0.151.51 (1.01-2.25)0.04INFϒ2.38 (1.37-4.12)0.0022.36 (1.32-4.23)0.0042.97 (1.57-5.61)0.001Leptina6.15 (0.77-48.72)0.094.79 (0.63-1.07)0.127.30 (0.78-68.37)0.08MIF3.94 (1.07-14.48)0.045.86 (1.28-26.65)0.023.45 (0.87-13.68)0.07MCP-12.98 (1.34-6.62)0.0073.28 (1.38-7.78)0.0073.74 (1.47-9.49)0.005TNFα2.79 (1.38-5.63)0.0042.55 (1.27-5.14)0.0082.72 (1.30-5.71)0.008Anti-Idiotype events vsCrude results*** OR (IC, 95%)pModel 1* OR (IC, 95%)pModel 2** OR (IC, 95%)pIL-1β1.07 (1.02-1.12)0.0041.08 (1.02-1.13)0.0051.10 (1.03-1.17)0.003IL-61.02 (1.00-1.05)0.031.02 (1.00-1.05)0.041.02 (1.00-1.05)0.02IL-81.02 (0.98-1.06)0.371.02 (0.98-1.06)0.321.01 (0.97-1.06)0.35IL-101.02 (0.99-1.04)0.201.01 (0.99-1.04)0.261.01 (0.99-1.04)0.15IL-12p401.05 (1.01-1.10)0.021.05 (1.00-1.10)0.041.06 (1.01-1.11)0.01IL-17A1.03 (0.99-1.07)0.081.03 (0.99-1.06)0.151.03 (1.00-1.08)0.04INFϒ1.09 (1.03-1.14)0.0021.08 (1.02-1.14)0.0041.10 (1.04-1.17)0.001Leptina1.19 (0.98-1.45)0.091.16 (0.95-1.40)0.121.20 (0.97-1.49)0.08MIF1.14 (1.01-1.29)0.041.18 (1.02-1.36)0.021.12 (0.98-1.28)0.07MCP-11.11 (1.03-1.20)0.0071.12 (1.03-1.21)0.0071.13 (1.03-1.23)0.005TNFα1.10 (1.03-1.18)0.0041.09 (1.02-1.16)0.0081.10 (1.02-1.18)0.008

*Model 1: Adjusted by age + Body mass index; **Model 2: Adjusted by Time since onset of disease + Time with biologic + complementary treatment with MTX; ***Adjusted to 10% increase of cytokine.

Conclusion

Patients with antidrug antibodies to IFX or ADA had higher ESR and DAS28 and a showed a significant association with higher levels of IFNg, MCP-1, MIF and TNFa.

References

[1]Parikh CR, Ponnampalam JK, Seligmann G, et al. Therapeutic Advances in Musculoskeletal Disease. 2021. doi:10.1177/1759720X211002685

Disclosure of Interests

Daniel Xavier Xibille Friedmann Speakers bureau: Lilly, Abbvie, Paid instructor for: Lilly, Abbvie, Consultant of: Lilly, Abbvie, Sandra Miriam Carrillo Vazquez Speakers bureau: Abbvie, Roche, Paid instructor for: Abbvie, Roche, Consultant of: Abbvie, Roche, Judith González Christen: None declared, David Vega Morales Speakers bureau: Abbvie, Roche, Paid instructor for: Abbvie, Roche, Consultant of: Abbvie, Roche, Mario Garza Elizondo Speakers bureau: Abbvie, Roche, Paid instructor for: Abbvie, Roche, Consultant of: Abbvie, Roche, Ramiro Hernández: None declared, José Eduardo Ortíz Panozo: None declared, José Luis Montiel Hernández: None declared

[Thymectomy in thymomatous and non-thymomatous myasthenia gravis: analysis of a cohort of 46 patients]

INTRODUCTION

Factors predicting remission after thymectomy for myasthenia gravis are not well known.

AIM

To analyze the clinical evolution of the patients after this intervention and discuss about predictors of response.

PATIENTS AND METHODS

We retrospectively reviewed all clinical data of thymectomies in myasthenia gravis patients performed at our hospital between 2006 from 2016. Using the MGFA-PIS classification, «complete stable remission», «pharmacologic remission», «minimal manifestations» and «improved» were defined as «good clinical outcome», and «unchanged», «worse», «exacerbation» or «died», as «poor clinical outcome».

RESULTS

In 46 consecutive thymectomies for myasthenia gravis, women comprised 71.7%. Median age was 37 years and 10.9% had concomitant autoimmune disorders associated. Thymoma (23.96%) was more frequent in older patients (53 ± 20 vs 33 ± 24 years) and men (54.5% vs 18.8%). A year after thymectomy, 28.2% of patients were in poor clinical outcome group and 54.3% had good clinical outcome. On univariate analysis, thymomatous myasthenia was associated with poor clinical outcome a year after surgical intervention. After ten years of follow-up, 9.8% reached complete stable remission, a total of 32 patients (78%) had a favourable outcome and thymoma was not correlated.

CONCLUSION

Thymectomy is considered an effective treatment for myasthenia gravis but the benefit is not immediate. The presence of thymoma may determine a worse initial clinical response following thymectomy in patients with myasthenia gravis.

Thrust stand based on a single point load cell for impulse measurements from plasma thrusters

We introduce a simple thrust stand for the direct measurement of the millinewton impulses or thrusts delivered by small thrusters intended for in-space electric propulsion. The thruster under test, with a weight below 1.5 kg, is disposed on a horizontal platform and its impulse is measured as an overweight by using a strain gauge cell physically protected from the ambient plasma and vacuum conditions. This system provides ten thrust readings per second with noise peak to peak amplitudes of 0.10-0.18 mN. The calibration procedures to verify its dynamic response to time dependent thrusts in the range of 0-15 mN using control weights as well as its minimum thrust sensitivity δT_s = 0.3 mN are discussed. Additionally, its simple conception permits a plain data reduction and analysis of steady state and low frequency thrust transients. This thrust stand was employed under low pressure and plasma ambient conditions to measure the steady impulses delivered by the Alternative Low Power Hybrid Ion Engine (ALPHIE) of 0.4-4.0 mN with absolute errors ΔT = ±0.3 mN. Finally, the experimental results show that a control electric voltage governs the ALPHIE thruster throttle.

Lithraea caustic (Litre) Extract Promotes an Antitumor Response Against B16 Melanoma

Melanoma immunotherapy, specifically the autotransplant of dendritic cells charged with tumors antigens, has shown promising results in clinical trials. The positive clinical effects of this therapy have been associated to increased Th17 response and delayed-type hypersensitivity (DTH) against to tumor antigens. Some synthetic compounds, such as diphenylcyclopropenone (DPCP), are capable of triggering a DTH response in cutaneous malignancies and also to induce clinically relevant effects against melanoma. In this work, we evaluated Litre extract (LExT), a standardized extract of a Chilean stinging plant, Lithraea caustic (Litre). As Litre plant is known to induce DTH, we used a murine B16 melanoma model to compare the topical and intratumor efficacy of LExT with synthetic DTH inducers (DPCP and 2,4-dinitrochlorobenzene [DNCB]). LExt contained mainly long chain catechols and sesquiterpenes. The intratumor injection of LExT induced a significant delay in tumor growth, similarly topical treatment of an established tumor with 0.1% LExT ointment induced a growth delay and even tumor regression in 15% of treated animals. No significant changes were observed on the T-cell populations associated to LExT treatment, and neither DNCB nor DPCP were capable to induce none of the LExT-induced antitumoral effects. Interestingly, our results indicate that LExT induces an antitumor response against melanoma in a mouse model and could bring a new –and affordable- treatment for melanoma in humans.

Optimal duration of first-line chemotherapy for advanced gastric cancer: data from the AGAMENON registry

BACKGROUND

The optimal duration of first-line chemotherapy for patients with advanced gastric cancer is unknown. Diverse clinical trials have proposed different strategies including limited treatment, maintenance of some drugs, or treatment until progression.

METHOD

The sample comprises patients from the AGAMENON multicenter registry without progression after second evaluation of response. The objective was to explore the optimal duration of first-line chemotherapy. A frailty multi-state model was conducted.

RESULTS

415 patients were divided into three strata: discontinuation of platinum and maintenance with fluoropyrimidine until progression (30%, n = 123), complete treatment withdrawal prior to progression (52%, n = 216), and full treatment until progression (18%, n = 76). The hazard of tumor progression decreased by 19% per month with the full treatment regimen. However, we found no evidence that fluoropyrimidine maintenance (hazard ratio [HR] 1.07, confidence interval [CI] 95%, 0.69-1.65) worsened progression-free survival (PFS) with respect to treatment until progression. Predictive factors for PFS were ECOG performance status, ≥ 3 metastatic sites, prior tumor response, and bone metastases. Toxicity grade 3/4 was more common in those who continued the full treatment until progression vs fluoropyrimidine maintenance (16% vs 6%).

CONCLUSION

The longer duration of the full initial regimen exerted a protective effect on the patients of this registry. Platinum discontinuation followed by fluoropyrimidine maintenance yields comparable efficacy to treatment up to PD, with a lower rate of serious adverse events.

miR-328 mediates a metabolic shift in colon cancer cells by targeting SLC2A1/GLUT1

Purpose

Increasing evidence shows that altered metabolism is a critical hallmark in colon cancer. There is a strong need to explore the molecular mechanisms underlying cancer metabolism. Whether the aberrant expression of microRNAs contributes to cancer metabolism is not fully understood. miR-328 is a putative potential target of SLC2A1, but the regulating mechanism between them remains unknown. We have examined whether miR-328 directly regulates SLC2A1/GLUT1 expression in colon cancer cells.

Methods

We performed in silico bioinformatic analyses to identify miR-328-mediated molecular pathways and targets. We also performed luciferase assays and western blot analyses in LOVO and SW480 colon cancer cell lines. In addition, we assessed miR-328 expression in 47 paired tumor and normal tissue specimens from resected colon cancer patients.

Results

Luciferase reporter assays showed that miR-328 directly targeted SLC2A1 3′-untranslated region (UTR), with a significant decrease in luciferase activity in both LOVO and SW480 cell lines. These results were validated by western blot. miR-328 expression was significantly downregulated in tumor tissue compared with paired normal tissue.

Conclusions

Our results show that miR-328 targets SLC2A1/GLUT1. We suggest that miR-328 may be involved in the orchestration of the Warburg effect in colon cancer cells. Furthermore, miR‐328 expression is reduced in colon cancer patients and thus inversely correlates with the classically reported upregulated SLC2A1/GLUT1 expression in tumors.

Anthracycline-based triplets do not improve the efficacy of platinum-fluoropyrimidine doublets in first-line treatment of advanced gastric cancer: real-world data from the AGAMEMON National Cancer Registry

BACKGROUND

Although anthracycline-based triplets are one of the most widely used schedules to treat advanced gastric cancer (AGC), the benefit of including epirubicin in these therapeutic combinations remains unknown. This study aims to evaluate both the efficacy and tolerance of triplets with epirubicin vs. doublets with platinum-fluoropyrimidine in a national AGC registry.

METHODS

Patients with AGC treated with polychemotherapy without trastuzumab at 28 hospitals in Spain between 2008 and 2016 were included. The effect of anthracycline-based triplets against doublets was evaluated by propensity score matching (PSM) and Cox proportional hazards (PH) regression.

RESULT

A total of 1002 patients were included (doublets, n = 653; anthracycline-based triplets, n = 349). The multivariable Cox PH regression failed to detect significantly increased OS in favor of triplets with anthracyclines: HR 0.90 (95% CI, 0.78-1.05), p = 0.20035. After PSM, the sample contained 325 pairs with similar baseline characteristics. This method was also unable to reveal an increase in OS: 10.5 (95% CI, 9.7-12.3) vs. 9.9 (95% CI, 9.2-11.4) months, HR 0.91 (CI 95%, 0.76-1.083), and (log-rank test, p = 0.226). Response rates (42.1 vs. 33.1%, p = 0.12) and PFS (HR 0.95, CI 95%, 0.80-1.13, log-rank test, p = 0.873) were not significantly higher with epirubicin-based regimens. The triplets were associated with greater grade 3-4 hematological toxicity, and increased hospitalization due to toxicity by 68%. The addition of epirubicin is viable, but 23.7% discontinued treatment because of adverse effects or patient decision.

CONCLUSION

Anthracyclines added to platinum-fluoropyrimidine doublets did not improve the response rate or survival outcomes in patients with AGC but entailed greater toxicity.

Magnetically responsive biopolymeric multilayer films for local hyperthermia

We present a proof of concept on the use of thermomagnetic polymer films (TMFs) as heating devices for magnetic hyperthermia in vitro. The TMFs were prepared through spray assisted layer-by-layer assembly of polysaccharides and magnetic iron oxide nanoparticles, yielding an alternate magnetic-polymer multilayer structure. By applying a remote alternating magnetic field (AMF) (f = 180 kHz; H = 35 kA m^-1) we increased the temperature of the TMFs in a thickness-dependent way, up to 12 °C within the first 5 minutes. To test our films as heating substrates for magnetic hyperthermia, a series of in vitro experiments were designed using human neuroblastoma SH-SY5Y cells, known by their tolerance to thermal stress. The application of two AMF cycles (30 minutes each) showed that the exogenous magnetic hyperthermia resulted in an 85% reduction of cell viability. This capacity of the TMFs of hyperthermia-mediated cell killing using a remote AMF opens new options for the treatment of small and superficial tumor lesions by means of remotely-triggered magnetic hyperthermia.

Nomogram-based prediction of survival in patients with advanced oesophagogastric adenocarcinoma receiving first-line chemotherapy: a multicenter prospective study in the era of trastuzumab

Background:

To develop and validate a nomogram and web-based calculator to predict overall survival (OS) in Caucasian-advanced oesophagogastric adenocarcinoma (AOA) patients undergoing first-line combination chemotherapy.

Methods:

Nine hundred twenty-four AOA patients treated at 28 Spanish teaching hospitals from January 2008 to September 2014 were used as derivation cohort. The result of an adjusted-Cox proportional hazards regression was represented as a nomogram and web-based calculator. The model was validated in 502 prospectively recruited patients treated between October 2014 and December 2016. Harrell's c-index was used to evaluate discrimination.

Results:

The nomogram includes seven predictors associated with OS: HER2-positive tumours treated with trastuzumab, Eastern Cooperative Oncology Group performance status, number of metastatic sites, bone metastases, ascites, histological grade, and neutrophil-to-lymphocyte ratio. Median OS was 5.8 (95% confidence interval (CI), 4.5–6.6), 9.4 (95% CI, 8.5–10.6), and 14 months (95% CI, 11.8–16) for high-, intermediate-, and low-risk groups, respectively (P<0.001), in the derivation set and 4.6 (95% CI, 3.3–8.1), 12.7 (95% CI, 11.3–14.3), and 18.3 months (95% CI, 14.6–24.2) for high-, intermediate-, and low-risk groups, respectively (P<0.001), in the validation set. The nomogram is well-calibrated and reveals acceptable discriminatory capacity, with optimism-corrected c-indices of 0.618 (95% CI, 0.591–0.631) and 0.673 (95% CI, 0.636–0.709) in derivation and validation groups, respectively. The AGAMENON nomogram outperformed the Royal Marsden Hospital (c-index=0.583; P=0.00046) and Japan Clinical Oncology Group prognostic indices (c-index=0.611; P=0.03351).

Conclusions:

We developed and validated a straightforward model to predict survival in Caucasian AOA patients initiating first-line polychemotherapy. This model can contribute to inform clinical decision-making and optimise clinical trial design.

Testicular torsion and its effects on the spermatogenic cycle in the contralateral testis of the rat

The aim of the present study was to evaluate the effects of unilateral testicular torsion on the contralateral testis with respect to the stages of the cycle of the seminiferous epithelium (CSE). Fifty-five male Wistar rats, 60 days old, were used. The animals were divided into 11 groups. Groups 1-5 were subjected to unilateral testicular torsion from 3 to 48 h, followed by detorsion. Groups 6-10 had unilateral orchiectomies after unilateral testicular torsion for 3 to 48 h. Animals constituting group 11 served as the control sham-operated group. All animals were killed after 2 months. The percentage of affected tubules (tubules showing pathological changes) in the contralateral testis was estimated based on the CSE stages. In the torsion/detorsion group, the percentage of affected tubules was significantly greater (58.6%) than in torsion/orchiectomy group (48.0%). Stages VI-XI of the spermatogenic cycle were the most affected when compared with the rest of the stages in each experimental group ( P <0.05). These results show that stages VI-XI of the spermatogenic cycle, the stages associated with low antioxidant capacities, are the most sensitive to the effects of testicular torsion on the contralateral testis.

Bence Jones proteinuria in smoldering multiple myeloma as a predictor marker of progression to symptomatic multiple myeloma

The diagnosis of smoldering multiple myeloma (SMM) includes patients with a heterogeneous risk of progression to active multiple myeloma (MM): some patients will never progress, whereas others will have a high risk of progression within the first 2 years. Therefore, it is important to improve risk assessment at diagnosis. We conducted a retrospective study in a large cohort of SMM patients, in order to investigate the role of Bence Jones (BJ) proteinuria at diagnosis in the progression to active MM. We found that SMM patients presenting with BJ proteinuria had a significantly shorter median time to progression (TTP) to MM compared with patients without BJ proteinuria (22 vs 88 months, respectively; hazard ratio=2.3, 95% confidence interval=1.4-3.9, P=0.002). We also identified risk subgroups based on the amount of BJ proteinuria: ⩾500 mg/24 h, <500 mg/24 h and without it, with a significantly different median TTP (13, 37 and 88 months, P<0.001). Thus, BJ proteinuria at diagnosis is an independent variable of progression to MM that identifies a subgroup of high-risk SMM patients (51% risk of progression at 2 years) and ⩾500 mg of BJ proteinuria may allow, if validated in another series, to reclassify these patients to MM requiring therapy before the end-organ damage development.

Double-membrane thermoresponsive hydrogels from gelatin and chondroitin sulphate with enhanced mechanical properties

Novel methodology to obtain thermoresponsive mechanically strong hydrogels of gelatin and chondroitin sulphate organized in layers.

Analogs of sex pheromone of processionary moth,Thaumetopoea pityocampa: Synthesis and biological activity

The synthesis and biological activity of some analogs of (Z)-13-hexadecen-11-ynyl acetate1, the major component of the sex pheromone of the processionary mothThaumetopoea pityocampa is described. The analogs have been formally derived by structural modification of the enyne and acetate functions of the parent compound1. In field tests, trifluoroacetate ester16 and the analog,11, with fluorine substitution at the olefin site, decreased the pheromone action, whereas epoxy derivative,10, from epoxidation of the olefin moiety in1, and propionate ester15 gave synergistic activity. The formate14 had a variable effect according to the composition of the lure. Formal reduction of the enyne to give the acetylene2 was found to retain activity. Alcohols12 and13, resulting from hydrolysis of the enyne1 and acetylene2, respectively, inhibited the action of their parent compounds.

Surveillance for ocular hypertension: an evidence synthesis and economic evaluation

OBJECTIVES

To determine effective and efficient monitoring criteria for ocular hypertension [raised intraocular pressure (IOP)] through (i) identification and validation of glaucoma risk prediction models; and (ii) development of models to determine optimal surveillance pathways.

DESIGN

A discrete event simulation economic modelling evaluation. Data from systematic reviews of risk prediction models and agreement between tonometers, secondary analyses of existing datasets (to validate identified risk models and determine optimal monitoring criteria) and public preferences were used to structure and populate the economic model.

SETTING

Primary and secondary care.

PARTICIPANTS

Adults with ocular hypertension (IOP > 21 mmHg) and the public (surveillance preferences).

INTERVENTIONS

We compared five pathways: two based on National Institute for Health and Clinical Excellence (NICE) guidelines with monitoring interval and treatment depending on initial risk stratification, 'NICE intensive' (4-monthly to annual monitoring) and 'NICE conservative' (6-monthly to biennial monitoring); two pathways, differing in location (hospital and community), with monitoring biennially and treatment initiated for a ≥ 6% 5-year glaucoma risk; and a 'treat all' pathway involving treatment with a prostaglandin analogue if IOP > 21 mmHg and IOP measured annually in the community.

MAIN OUTCOME MEASURES

Glaucoma cases detected; tonometer agreement; public preferences; costs; willingness to pay and quality-adjusted life-years (QALYs).

RESULTS

The best available glaucoma risk prediction model estimated the 5-year risk based on age and ocular predictors (IOP, central corneal thickness, optic nerve damage and index of visual field status). Taking the average of two IOP readings, by tonometry, true change was detected at two years. Sizeable measurement variability was noted between tonometers. There was a general public preference for monitoring; good communication and understanding of the process predicted service value. 'Treat all' was the least costly and 'NICE intensive' the most costly pathway. Biennial monitoring reduced the number of cases of glaucoma conversion compared with a 'treat all' pathway and provided more QALYs, but the incremental cost-effectiveness ratio (ICER) was considerably more than £30,000. The 'NICE intensive' pathway also avoided glaucoma conversion, but NICE-based pathways were either dominated (more costly and less effective) by biennial hospital monitoring or had a ICERs > £30,000. Results were not sensitive to the risk threshold for initiating surveillance but were sensitive to the risk threshold for initiating treatment, NHS costs and treatment adherence.

LIMITATIONS

Optimal monitoring intervals were based on IOP data. There were insufficient data to determine the optimal frequency of measurement of the visual field or optic nerve head for identification of glaucoma. The economic modelling took a 20-year time horizon which may be insufficient to capture long-term benefits. Sensitivity analyses may not fully capture the uncertainty surrounding parameter estimates.

CONCLUSIONS

For confirmed ocular hypertension, findings suggest that there is no clear benefit from intensive monitoring. Consideration of the patient experience is important. A cohort study is recommended to provide data to refine the glaucoma risk prediction model, determine the optimum type and frequency of serial glaucoma tests and estimate costs and patient preferences for monitoring and treatment.

FUNDING

The National Institute for Health Research Health Technology Assessment Programme.

Quality control procedures at Euskalmet data center

Abstract. The Basque Country Mesonet measures more than 130 000 observations daily from its 85 Automatic Weather Stations (AWS). It becomes clear that automated software is an indispensable tool for quality assurance (QA) of this mesoscale surface observing network. This work describes a set of experimental semi-automatic quality control (QC) routines that is applied at Euskalmet data center. It has paid special attention to level validation design and associated flags, as well as to the system outputs, which are used by meteorologist and maintenance staff.

The clinical effectiveness and cost-effectiveness of different surveillance mammography regimens after the treatment for primary breast cancer: systematic reviews registry database analyses and economic evaluation

BACKGROUND

Following primary breast cancer treatment, the early detection of ipsilateral breast tumour recurrence (IBTR) or ipsilateral secondary cancer in the treated breast and detection of new primary cancers in the contralateral breast is beneficial for survival. Surveillance mammography is used to detect these cancers, but the optimal frequency of surveillance and the length of follow-up are unclear.

OBJECTIVES

To identify feasible management strategies for surveillance and follow-up of women after treatment for primary breast cancer in a UK setting, and to determine the effectiveness and cost-effectiveness of differing regimens.

METHODS

A survey of UK breast surgeons and radiologists to identify current surveillance mammography regimens and inform feasible alternatives; two discrete systematic reviews of evidence published from 1990 to mid 2009 to determine (i) the clinical effectiveness and cost-effectiveness of differing surveillance mammography regimens for patient health outcomes and (ii) the test performance of surveillance mammography in the detection of IBTR and metachronous contralateral breast cancer (MCBC); statistical analysis of individual patient data (West Midlands Cancer Intelligence Unit Breast Cancer Registry and Edinburgh data sets); and economic modelling using the systematic reviews results, existing data sets, and focused searches for specific data analysis to determine the effectiveness and cost-utility of differing surveillance regimens.

RESULTS

The majority of survey respondents initiate surveillance mammography 12 months after breast-conserving surgery (BCS) (87%) or mastectomy (79%). Annual surveillance mammography was most commonly reported for women after BCS or after mastectomy (72% and 53%, respectively). Most (74%) discharge women from surveillance mammography, most frequently 10 years after surgery. The majority (82%) discharge from clinical follow-up, most frequently at 5 years. Combining initiation, frequency and duration of surveillance mammography resulted in 54 differing surveillance regimens for women after BCS and 56 for women following mastectomy. The eight studies included in the clinical effectiveness systematic review suggest surveillance mammography offers a survival benefit compared with a surveillance regimen that does not include surveillance mammography. Nine studies were included in the test performance systematic review. For routine IBTR detection, surveillance mammography sensitivity ranged from 64% to 67% and specificity ranged from 85% to 97%. For magnetic resonance imaging (MRI), sensitivity ranged from 86% to 100% and specificity was 93%. For non-routine IBTR detection, sensitivity and specificity for surveillance mammography ranged from 50% to 83% and from 57% to 75%, respectively, and for MRI from 93% to 100% and from 88% to 96%, respectively. For routine MCBC detection, one study reported sensitivity of 67% and specificity of 50% for both surveillance mammography and MRI, although this was a highly select population. Data set analysis showed that IBTR has an adverse effect on survival. Furthermore, women experiencing a second tumour measuring >20 mm in diameter were at a significantly greater risk of death than those with no recurrence or those whose tumour was <10 mm in diameter. In the base-case analysis, the strategy with the highest net benefit, and most likely to be considered cost-effective, was surveillance mammography alone, provided every 12 months at a societal willingness to pay for a quality-adjusted life-year of either £20,000 or £30,000. The incremental cost-effectiveness ratio for surveillance mammography alone every 12 months compared with no surveillance was £4727.

LIMITATIONS

Few studies met the review inclusion criteria and none of the studies was a randomised controlled trial. The limited and variable nature of the data available precluded any quantitative analysis. There was no useable evidence contained in the Breast Cancer Registry database to assess the effectiveness of surveillance mammography directly. The results of the economic model should be considered exploratory and interpreted with caution given the paucity of data available to inform the economic model.

CONCLUSIONS

Surveillance is likely to improve survival and patients should gain maximum benefit through optimal use of resources, with those women with a greater likelihood of developing IBTR or MCBC being offered more comprehensive and more frequent surveillance. Further evidence is required to make a robust and informed judgement on the effectiveness of surveillance mammography and follow-up. The utility of national data sets could be improved and there is a need for high-quality, direct head-to-head studies comparing the diagnostic accuracy of tests used in the surveillance population.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

[Case report: laparoscopic cholecystectomy and common bile duct exploration in a 60 year-old patient with situs inversus]

This is a case report of a 60 year-old male patient with acute cholecystitis and jaundice, unaware of having situs inversus. Patient underwent successfully laparoscopic cholecystectomy with bile duct exploration in spite of the unusual clinical situation. A literature review using Pubmed database, since 1989, in Spanish and English literature was performed. We found only two reports of cholecystectomy and common bile duct exploration in patients with situs inversus. This is the first case reported in our country.

[Circumferences to evaluate changes in body mass and amount of total fat of women in second and third trimester of pregnancy]

OBJECTIVE

To evaluate the maternal nutritional state through simple anthropometric indicators as middle-arm circumference (MAC), half thigh (HTC) and calf (CC), to value changes in the body mass and quantity of total fat, in women on second and third pregnancy trimester.

METHODOLOGY

A sample of 76 pregnant aged between 18 and 40 years, from suburban communities of the municipalities Baruta and The Hatillo, Venezuela were evaluated. Weigh, height, MAC, HTC and CC, besides triceps, biceps, subscapular, half thigh and calf skinfolds were measured that allowed the construction of indicators of mass and quantity of total body fat.

RESULTS

The HTC and CC showed differences (p < 0.05) between second and third pregnancy trimester. Average values of MAC presented no statistical significance among the evaluated trimesters, neither the arm fat area, but the thigh fat area and calf what could explain the differences observed in the circumferences of these members among the evaluated trimesters.

CONCLUSIONS

Circumferences of inferior members (half thigh and calf), probably be the variables that can be used for evaluate the anthropometric nutritional maternal status, allow to predict the possible changes in the fat component, and therefore in the body composition of pregnant.

Romiplostim for the treatment of chronic immune or idiopathic thrombocytopenic purpura: a single technology appraisal

This paper presents a summary of the evidence review group (ERG) report into the clinical and cost-effectiveness of romiplostim for the treatment of adults with chronic immune or idiopathic thrombocytopenic purpura (ITP) based upon a review of the manufacturer's submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The submission's evidence came from two relatively high-quality randomised controlled trials (RCTs). The ERG found no evidence that any important data were missed or that data extraction was inaccurate. In both RCTs more patients in the romiplostim than in the placebo group achieved a durable platelet response [non-splenectomised patients: romiplostim 25/41 (61%), placebo 1/21 (5%), odds ratio (OR) 24.45, 95% confidence interval (CI) 3.34 to 179.18; splenectomised patients: romiplostim 16/42 (38%), placebo 0/21 (0%), OR 8.5 (95% CI 1.15 to 372)] and an overall platelet response [non-splenectomised patients: romiplostim 36/41 (88%), placebo 3/21 (14%), OR 34.74, 95% CI 7.77 to 155.38; splenectomised patients: romiplostim 33/42 (79%), placebo 0/21 (0%), OR 16.6 (95% CI 2.37 to 706]. The difference in mean period with a platelet response was 13.9 weeks (95% CI 10.5 to 17.4) in favour of romiplostim in the RCT of non-splectomised patients and 12.1 weeks (95% CI 8.7 to 15.6) in favour of romiplostim in the RCT of splectomised patients. The manufacturer's economic model evaluated the cost-effectiveness of romiplostim compared with standard care. The ERG had concerns about the way the decision problem was addressed in the economic model and about the non-adjustment of findings for confounding factors. In non-splenectomised patients, using romiplostim as a first option treatment, the base-case incremental cost-effectiveness ratio (ICER) was 14,840 pounds per quality-adjusted life-year (QALY). In splenectomised patients the ICER was 14,655 pounds per QALY. Additional sensitivity analyses performed by the ERG identified two issues of importance: whether individuals entered the model on watch and rescue or on active therapy in the comparator arm (ICER 21,674 pounds per QALY for non-splenectomised patients, 29,771 pounds per QALY for splenectomised patients); whether it was assumed that any unused medicine would be wasted. Combining all of the separate sensitivity analyses, and assuming that watch and rescue was not the first-line treatment, increased the ICERs further (non-splenectomised 37,290 pounds per QALY; splenectomised 131,017 pounds per QALY). In conclusion, the manufacturer's submission and additional work conducted by the ERG suggest that romiplostim has short-term efficacy for the treatment of ITP, but there is no robust evidence on long-term effectiveness or cost-effectiveness of romiplostim compared with relevant comparators.

A randomised controlled trial of the use of aciclovir and/or prednisolone for the early treatment of Bell's palsy: the BELLS study

OBJECTIVE

To determine whether oral prednisolone or aciclovir, used separately or in combination, early in the course of Bell's palsy, improves the chances of recovery at 3 and 9 months.

DESIGN

A 2 x 2 factorial randomised double-blind trial. Patients were randomly assigned to treatment by an automated telephone service using a permuted block randomisation technique with block sizes of four or eight, and no stratification.

SETTING

Mainland Scotland, with referrals mainly from general practice to 17 hospital trial sites.

PARTICIPANTS

Adults (aged 16 years or older) with unilateral facial nerve weakness of no identifiable cause presenting to primary care, the emergency department or NHS24 within 72 hours of symptom onset.

INTERVENTIONS

Patients were randomised to receive active preparations or placebo for 10 days: (1) prednisolone (50 mg per day, 2 x 25-mg capsules) and aciclovir (2000 mg per day, 5 x 400-mg capsules); (2) prednisolone and placebo (lactose, indistinguishable); (3) aciclovir and placebo; and (4) placebo and placebo.

OUTCOME MEASURES

The primary outcome was recovery of facial function assessed by the House-Brackmann scale. Secondary outcomes included health status, pain, self-perceived appearance and cost-effectiveness.

RESULTS

Final outcomes were available for 496 patients, balanced for gender; mean age 44 years; initial facial paralysis moderate to severe. One half of patients initiated treatment within 24 hours of onset of symptoms, one-third within 24-48 hours and the remainder within 48-72 hours. Of the completed patients, 357 had recovered by 3 months and 80 at 9 months, leaving 59 with a residual deficit. There were significant differences in complete recovery at 3 months between the prednisolone comparison groups (83.0% for prednisolone, 63.6% for no prednisolone, a difference of + 19.4%; 95% confidence interval (CI): + 11.7% to + 27.1%, p < 0.001). The number needed to treat (NNT) in order to achieve one additional complete recovery was 6 (95% CI: 4 to 9). There was no significant difference between the aciclovir comparison groups (71.2% for aciclovir and 75.7% for no aciclovir). Nine-month assessments of patients recovered were 94.4% for prednisolone compared with 81.6% for no prednisolone, a difference of + 12.8% (95% CI: + 7.2% to + 18.4%, p < 0.001); the NNT was 8 (95% CI: 6 to 14). Proportions recovered at 9 months were 85.4% for aciclovir and 90.8% for no aciclovir, a difference of -5.3%. There was no significant prednisolone-aciclovir interaction at 3 months or at 9 months. Outcome differences by individual treatment (the four-arm model) showed significant differences. At 3 months the recovery rate was 86.3% in the prednisolone treatment group, 79.7% in the aciclovir-prednisolone group, 64.7% in the placebo group and 62.5% in the aciclovir group. At 9 months the recovery rates were respectively 96.1%, 92.7%, 85.3% and 78.1%. The increase in recovery rate conferred by the addition of prednisolone (both for prednisolone over placebo and for aciclovir-prednisolone over aciclovir) is highly statistically significant (p < 0.001). There were no significant differences in secondary measures apart from Health Utilities Index Mark 3 (HUI3) at 9 months in those treated with prednisolone.

CONCLUSIONS

This study provided robust evidence to support the early use of oral prednisolone in Bell's palsy as an effective treatment which may be considered cost-effective. Treatment with aciclovir, either alone or with steroids, had no effect on outcome.

Switching to sirolimus in renal transplant recipients with hepatitis C virus: a safe option

INTRODUCTION

The presence of hepatitis C virus (HCV) in renal transplant recipients is an independent risk factor for death and graft failure. Chronic allograft nephropathy (CAN) favored by the use of calcineurin inhibitors (CNI) is one of the main causes of graft loss, whereas sirolimus (SRL) has proven to maintain better graft function with lower rates of CAN.

OBJECTIVES AND METHODS

We developed a protocol to evaluate the safety of SRL in transplant recipients with respect to HCV. We studied 5 patients (3 men) of mean age 52 +/- 9.2 years with HCV who had not received antiviral treatment. The viral genotypes were 1b in 4 cases and 2a/2c in 1 case. Basic immunosuppression was mycophenolate mofetil (MMF) and corticosteroids in all patients, cyclosporine (CsA) in 4 cases, and tacrolimus (Tac) in 1 case. Before the switch, a renal biopsy was performed and viral replication and cryoglobulins determined.

RESULTS

Biopsy provided a diagnosis of CAN in 1 case, CNI toxicity-associated CAN in 2 cases, CNI toxicity in 1 case, and no renal damage in the remaining case. We observed a nonsignificant decrease in the number (log) of viral copies with a stabilization of renal function but with a slight to moderate increase in proteinuria.

CONCLUSIONS

The switch seemed to be safe with no increase in viral copies. Graft renal function remained stable with increased proteinuria that must be supervised, even though it did not reach statistical significance.

The PRaCTICaL study of nurse led, intensive care follow-up programmes for improving long term outcomes from critical illness: a pragmatic randomised controlled trial

OBJECTIVES

To test the hypothesis that nurse led follow-up programmes are effective and cost effective in improving quality of life after discharge from intensive care.

DESIGN

A pragmatic, non-blinded, multicentre, randomised controlled trial.

SETTING

Three UK hospitals (two teaching hospitals and one district general hospital).

PARTICIPANTS

286 patients aged >or=18 years were recruited after discharge from intensive care between September 2006 and October 2007.

INTERVENTION

Nurse led intensive care follow-up programmes versus standard care. Main outcome measure(s) Health related quality of life (measured with the SF-36 questionnaire) at 12 months after randomisation. A cost effectiveness analysis was also performed.

RESULTS

286 patients were recruited and 192 completed one year follow-up. At 12 months, there was no evidence of a difference in the SF-36 physical component score (mean 42.0 (SD 10.6) v 40.8 (SD 11.9), effect size 1.1 (95% CI -1.9 to 4.2), P=0.46) or the SF-36 mental component score (effect size 0.4 (-3.0 to 3.7), P=0.83). There were no statistically significant differences in secondary outcomes or subgroup analyses. Follow-up programmes were significantly more costly than standard care and are unlikely to be considered cost effective.

CONCLUSIONS

A nurse led intensive care follow-up programme showed no evidence of being effective or cost effective in improving patients' quality of life in the year after discharge from intensive care. Further work should focus on the roles of early physical rehabilitation, delirium, cognitive dysfunction, and relatives in recovery from critical illness. Intensive care units should review their follow-up programmes in light of these results.

TRIAL REGISTRATION

ISRCTN 24294750.

High prevalence of diabetes and impaired fasting glucose in urban Latin America: the CARMELA Study

AIMS

Cardiovascular risk is increased with glucose metabolism abnormalities. Prevalence data can support public health initiatives required to address this risk. The Cardiovascular Risk Factor Multiple Evaluation in Latin America (CARMELA) study was designed to estimate the prevalence of Type 2 diabetes, impaired fasting glucose and related risk factors in seven urban Latin American populations.

METHODS

CARMELA was a cross-sectional, population-based study of 11 550 adults 25-64 years of age. With a multi-stage sample design of a probabilistic nature, approximately 1600 subjects were randomly selected in each city.

RESULTS

Overall, the prevalence of diabetes was 7.0% (95% confidence intervals 6.5-7.6%). The prevalence of individuals with diabetes or impaired fasting glucose increased with increasing age. In the oldest age category, 55-64 years of age, prevalence of diabetes ranged from 9 to 22% and prevalence of impaired fasting glucose ranged from 3 to 6%. Only 16.3% of people with prior diagnosis of diabetes and who were receiving pharmacologic treatment, were in good glycaemic control (fasting glucose < 6.1 mmol/l). The prevalence of diabetes in individuals with abdominal obesity was approximately twofold higher. Participants with hypertension, elevated serum triglycerides and increased common carotid artery intima-media thickness were also more likely to have diabetes.

CONCLUSIONS

The prevalence of diabetes and impaired fasting glucose is high in seven major Latin American cities; intervention is needed to avoid substantial medical and socio-economic consequences. CARMELA supports the associations of abdominal obesity, hypertension, elevated serum triglycerides and carotid intima-media thickness with diabetes.

Romiplostim for the treatment of chronic immune or idiopathic thrombocytopenic purpura: a single technology appraisal

This paper presents a summary of the evidence review group (ERG) report into the clinical and cost-effectiveness of romiplostim for the treatment of adults with chronic immune or idiopathic thrombocytopenic purpura (ITP) based upon a review of the manufacturer’s submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The submission’s evidence came from two relatively high-quality randomised controlled trials (RCTs). The ERG found no evidence that any important data were missed or that data extraction was inaccurate. In both RCTs more patients in the romiplostim than in the placebo group achieved a durable platelet response [non-splenectomised patients: romiplostim 25/41 (61%), placebo 1/21 (5%), odds ratio (OR) 24.45, 95% confidence interval (CI) 3.34 to 179.18; splenectomised patients: romiplostim 16/42 (38%), placebo 0/21 (0%), OR 8.5 (95% CI 1.15 to 372)] and an overall platelet response [non-splenectomised patients: romiplostim 36/41 (88%), placebo 3/21 (14%), OR 34.74, 95% CI 7.77 to 155.38; splenectomised patients: romiplostim 33/42 (79%), placebo 0/21 (0%), OR 16.6 (95% CI 2.37 to 706]. The difference in mean period with a platelet response was 13.9 weeks (95% CI 10.5 to 17.4) in favour of romiplostim in the RCT of non-splectomised patients and 12.1 weeks (95% CI 8.7 to 15.6) in favour of romiplostim in the RCT of splectomised patients. The manufacturer’s economic model evaluated the cost-effectiveness of romiplostim compared with standard care. The ERG had concerns about the way the decision problem was addressed in the economic model and about the non-adjustment of findings for confounding factors. In non-splenectomised patients, using romiplostim as a first option treatment, the base-case incremental cost-effectiveness ratio (ICER) was £14,840 per quality-adjusted life-year (QALY). In splenectomised patients the ICER was £14,655 per QALY. Additional sensitivity analyses performed by the ERG identified two issues of importance: whether individuals entered the model on watch and rescue or on active therapy in the comparator arm (ICER £21,674 per QALY for non-splenectomised patients, £29,771 per QALY for splenectomised patients); whether it was assumed that any unused medicine would be wasted. Combining all of the separate sensitivity analyses, and assuming that watch and rescue was not the first-line treatment, increased the ICERs further (non-splenectomised £37,290 per QALY; splenectomised £131,017 per QALY). In conclusion, the manufacturer’s submission and additional work conducted by the ERG suggest that romiplostim has short-term efficacy for the treatment of ITP, but there is no robust evidence on long-term effectiveness or cost-effectiveness of romiplostim compared with relevant comparators.