Impact of telephone follow-up on hepatocellular carcinoma patients receiving oral chemotherapy from an ambulatory-care setting

INTRODUCTION

In recent years, most molecular target drugs have been administered orally, as prescribed at ambulatory services in hospitals and at patients' homes. Telephone follow-up is increasingly being used in clinical practice for patients needing additional support post-discharge and for the prevention of hospital readmissions. The purpose of this study was to clarify the clinical benefits of telephone follow-up while administering oral anticancer drugs.

METHODS

This was a single-center, observational, retrospective study. We evaluated hepatocellular carcinoma patients who received sorafenib or lenvatinib between March 2010 and February 2018. The primary endpoint was the incidence of adverse events.

RESULTS

From the total of 130 patients, 83 patients received telephone follow-up and 47 did not. The incidence of hand-foot skin reactions significantly reduced in patients with telephone follow-up (odds ratio (OR) 3.69, 95% confidence interval (CI) 1.16-11.8, p = 0.020). The median durations (ranges) of adherence to oral chemotherapy were 259 days (15-1730) for the telephone follow-up group and 121 days (14-1105) for the no-telephone follow-up group (p < 0.001). Moreover, the disease control rate was significantly higher in the telephone follow-up group (OR 2.52, 95% CI 1.15-5.53, p = 0.020).

CONCLUSIONS

Remote interventions, such as telephone follow-up, are useful means of managing adverse events in patients receiving oral anticancer drugs and can lead to improved treatment results.

Community pharmacists’ measurement of health-related quality of life for breast cancer with positive hormone receptors: A prospective observational study

Objectives:

Many patients with hormone-receptor positive breast cancer undergo prolonged treatment. However, the long-term patient quality of life assessment has not been examined. Using community pharmacists’ assistance is one method for assessing long-term quality of life. Thus, this study aimed to understand the ongoing health-related quality of life and quality-adjusted life year among breast cancer patients so that community pharmacists may contribute to their pharmacotherapy.

Methods:

We conducted a prospective observational study with 22 breast cancer patients who had health-related quality of life at the initial measurement and 6 months later.

Results:

Regarding the health-related quality of life, quality-adjusted life year concerning all patients was 0.890 (95% confidence interval: 0.846–0.935). Quality-adjusted life year concerning those younger than 65 years was 0.907 (95% confidence interval: 0.841–0.973), and that for individuals older than 65 years was 0.874 (95% confidence interval: 0.804–0.943). The adjuvant chemotherapy group had a lower health-related quality of life at the initial measurement (0.887; 95% confidence interval: 0.833–0.941) but showed a higher quality of life 6 months later (0.951; 95% confidence interval: 0894–1.010). Quality-adjusted life year for individuals regarding adjuvant chemotherapy was 0.919 (95% confidence interval: 0.874–0.964). In contrast, the life-prolonged group had a higher health-related quality of life at the initial measurement, which was lower 6 months later.

Conclusions:

As a result of measuring quality of life using the EuroQol 5-dimensions-5-levels, this study revealed a decline in health-related quality of life in patients undergoing hormonal therapy for breast cancer. The study is expected to assist community pharmacists in managing outpatients.

Natural history of severe aortic stenosis in elderly heart failure patients who declined transcatheter aortic valve implantation

Background

Transcatheter aortic valve implantation (TAVI) is an established minimally invasive treatment for elderly patients with severe aortic stenosis (AS). Although it is a relatively minimally invasive procedure, many elderly patients cannot undergo TAVI due to advanced age, advanced dementia, significantly impaired ADL, or because the patient or family does not wish to undergo TAVI. In general, severe AS patients died 5 years after an angina attack, 3 years after syncope symptoms, and 2 years after heart failure symptoms. However, few studies have investigated the prognosis of elderly patients with severe AS who declined TAVI.

Purpose

This study aimed to comprehend the natural history of elderly severe AS patients who declined aortic valve intervention and identify risk factors for death in the TAVI era.

Methods

We retrospectively reviewed 2,786 echocardiographic data from our hospital between 2017 and 2021. We identified 504 patients with AS in the echocardiography database. The severe AS was defined by the following echocardiography parameters: peak aortic flow velocity ≥4.0 m/s, aortic valve mean gradient ≥40 mmHg, aortic valve area (AVA)&lt;1.0 cm2, or AVA index&lt;0.6 cm2/m2. Patients with mild and moderate AS and patients who underwent surgical or transcatheter aortic valve intervention were excluded. Eventually, 82 patients fulfilled the study criteria and were analyzed in this study. Clinical events were investigated, and Cox proportional hazards analysis was performed to elucidate risk factors for mortality.

Results

The mean age was 89±6 years, and 63 (77%) were women. AHA/ACC classification was Stage A/B/C/D: 0%/52.4%/39.0%/8.5%. As event occurrence, we detected 34 (41.5%) all-cause deaths, 41 (50.0%) major adverse cardiovascular events, 32 (39.0%) development of heart failure, 13 (15.9%) chest pain attacks, and 3 (3.7%) syncope. The time from diagnosis of severe AS to all-cause death was 227±273 days, and the 1-, 2-, and 3-year survival rates were 61.5%, 46.2%, and 36.9%, respectively. Of the heart failure-onset population, 16 (50.0%) were found to have severe AS on initial heart failure admission. The incidence of heart failure at 1, 2, and 3 years after diagnosis of severe AS was 60.1%, 56.7%, and 45.4%, respectively. The time from heart failure to death was 107±147 days. Cox proportional hazards analysis adjusted with age, sex, comorbidities revealed that dementia (HR 4.5, P=0.014) and Katz index &lt;5 (HR7.8, P=0.009) were independent risk factors for mortality.

Conclusions

Compared to the comprehension of the natural history of AS patients, the prognosis in severe AS patients who declined TAVI was extremely poor. Although the elderly patients did not have a high rate of angina attacks or syncope symptoms, probably due to their reduced ADL, the results suggest that dementia prevention and maintenance of exercise tolerance are essential since dementia and reduced ADL (Katz&lt;5) are independent risk factors for mortality.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Clinical Research Promotion Foundation Reiwa 2 Michinari Hieda

Community pharmacists' measurement of health-related quality of life in outpatients taking high-risk drugs

Patients experiencing severe side effects when taking high-risk drugs may have a significantly reduced health-related quality of life (QOL); therefore, it is important to identify changes in the health-related QOL in these patients. This study aimed to determine the health-related QOL in community pharmacy outpatients taking high-risk drugs. This prospective observational study was conducted in 29 community pharmacies with 71 pharmacists in 12 regions and cities in Japan from October to December 2020 and 760 patients were enrolled. Using descriptive questionnaires of EuroQOL-5-dimensions-5-levels (EQ-5D-5L), community pharmacists obtained health-related QOL data from outpatients taking high-risk drugs. The mean health-related QOL of all outpatients was 0.869. The health-related QOL decreased with increasing age. The outpatient health-related QOL was 0.700, 0.763, 0.785, and 0.817 when taking antiepileptic, antidepressant, digitalis, and antiarrhythmic drugs, respectively, which was lower than the average health-related QOL of all outpatients. Mobility and pain/ discomfort accounted for a large proportion of the decline in the health-related QOL with increasing age. There were no significant differences in personal care with increasing age; however, the number of outpatients with mobility, normal activity, and pain challenges decreased with age. In contrast, outpatients aged <65 years with anxiety/depression showed a lower than overall average health-related QOL. To the best of our knowledge, this is the first study in Japan to report an investigation by community pharmacists regarding health-related QOL assessment in outpatients taking high-risk drugs.

Impact of coronavirus of 2019 on the delivery of pharmacy services to patients with cancer: An international survey of oncology pharmacy practitioners

INTRODUCTION

The coronavirus of 2019 pandemic has necessitated vast and rapid changes in the way oncology pharmacy services are delivered around the world.

METHODS/AIMS

An international survey of oncology pharmacists and technicians was conducted via the International Society of Oncology Pharmacy Practitioners and collaborating global pharmacy organisations to determine the impact that the coronavirus of 2019 has had on pharmacy service delivery, pharmacy practitioners and oncology practice.

RESULTS

The survey received 862 responses from 40 different countries from September to October 2020. The majority of respondents were pharmacists (n = 841, 97.6%), with 24% involved in the direct care of patients with the coronavirus of 2019. Of the survey participants, 55% increased their time working remotely, with remote activities including dispensing, patient assessment/follow-up and attending multi-disciplinary rounds. Respondents reported a 72% increase in the use of technology to perform remote patient interaction activities and that participation in educational meetings and quality improvement projects was reduced by 68% and 44%, respectively. Workforce impacts included altered working hours (50%), cancelled leave (48%) and forced leave/furloughing (30%). During the pandemic, respondents reported reduced access to intensive care (19%) and anti-cancer (15%) medications. In addition, 39% of respondents reported reduced access to personal protective equipment, including N95 masks for chemotherapy compounding. Almost half of respondents (49%) reported that cancer treatments were delayed or intervals were altered for patients being treated with curative intent. A third of practitioners (30%) believed that patient outcomes would be adversely impacted by changes to pharmacy services. Sixty-five percent of respondents reported impacts on their mental health, with 12% utilising support services.

CONCLUSION

The coronavirus of 2019 pandemic has altered the way oncology pharmacy services are delivered. These results demonstrate the adaptability of the oncology pharmacy profession and highlight the importance of formal evaluation of the varied practice models to determine the evidence-based practices that enhance pharmacy services and, thus, should be reinstated as soon as practical and reasonable.

Cost-effectiveness of primary prophylaxis of febrile neutropenia with pegfilgrastim in docetaxel, cisplatin and 5-fluorouracil therapy for esophageal cancer

Objective: The efficacy of docetaxel, cisplatin, and 5-fluorouracil (DCF) therapy in treating esophageal cancer has been reported. However, febrile neutropenia (FN) is a potentially serious adverse event of DCF therapy with an incidence of 10 to 40%. Pegfilgrastim, a granulocyte colony-stimulating factor (G-CSF), has been shown to have a primary prophylactic role in FN. However, it has been suggested that excessive use of expensive G-CSF should be avoided. Therefore, we performed a cost-utility analysis of primary prophylaxis with pegfilgrastim. Design: Cost-effectiveness analysis using decision tree modelling. Methods: We used a decision tree analysis model based on the report of primary prophylaxis with pegfilgrastim. Based on a previous study, the FN incidence rate was set at 40.0% (95% confidence interval (CI): 11.9-68.1) for the pegfilgrastim group and 43.5% (95%CI: 21.6-65.4) for the no pegfilgrastim group. The FN treatment cost was US$726.63, and the duration of FN was 3.65±1.20 days. The utility value of patients who received DCF therapy was 0.643, and the change in utility value at FN onset was -0.15. Expected cost, quality-adjusted life year (QALY), and incremental cost-effectiveness ratio (ICER) were calculated, and cost-utility analysis was performed. Results: The ICER of pegfilgrastim was 184,976.75 USD/QALY. As a result of sensitivity analysis, the utility of FN had the greatest impact on the cost-effectiveness analysis, followed by the drug cost of pegfilgrastim. Conclusion: Primary prophylaxis of FN with pegfilgrastim might not be cost-effectiveness. In determining whether to administer pegfilgrastim it is necessary to consider patient factors, not just the incidence of FN.

POS0527 ACUTE KIDNEY INJURY (AKI) IN PATIENTS WITH RHEUMATOID ARTHRITIS (RA)

Background:

Methotrexate has been an anchor drug for patients with rheumatoid arthritis (RA). However, it is strictly prohibited to prescribe MTX to patients with severely decreased renal function because it can induce a fatal adverse event such as pancytopenia in these patients. On the other hand, since the average age of RA patients is gradually increasing, and many of them already have mildly to moderately impaired renal function, their renal function can easily decrease to below the critical level of the estimated glomerular filtration rate. Therefore, new development of acute kidney injury (AKI) during MTX administration might induce a fatal adverse event, making the identification of patients susceptible to AKI very important.

Objectives:

To clarify the frequency of AKI and the factors involved in it in RA patients.

Methods:

Two hundred and fifty-two RA patients (211 females, 41 males, mean age 62.3 ± 12.5 years, disease duration 11.0 ± 9.5 years) diagnosed more than 3 years earlier and followed for more than 5 years, and also, others diagnosed ≥3 years earlier but followed for ≤5 years were enrolled. We measured BUN, Cr, RF and aCCP in patient serum, urinary proteins, urinary blood, and urinary casts and evaluated CDAI, SDAI, disease activity score (DAS) 28-CRP and DAS28-ESR. Steinbrocker functional classification and radiological grading were evaluated. History of diabetes mellitus, hypertension and hyperlipidemia was determined from the medical records. Medications for RA, including non-steroid anti-inflammatory drugs (NSAIDs), prednisolone, csDMARD (MTX, Tacrolimus, etc.), bDMARDs and tsDMARDs were evaluated. Estimated glomerular filtration rate (eGFR) was calculated by the new Japanese coefficient-modified Modification of Diet in Renal disease (MDRD) study equation. The criteria of AKI were that serum Cr increased by 0.3 mg /dl or increased by 1.5-fold between consecutive visits according to the KIDIGO criteria 1) and the report of Leither et al2).

Results:

Twenty (7.9%) patients developed AKI, 22 times. The causes of AKI were 10 infections, 6 dehydrations, 2 enteritis, 1 urticaria, 2 hypercalcemia due to VitD administration, and 1 ureteral stone. We divided our patients into group A (with AKI) and group B (without AKI). Group A was older (69.9±10.1 vs 61.7±12.6 years), had greater physician VAS (29.5±27.7 vs 15.7±18.3 mm), higher serum creatinine (0.79±0.19 vs 0.60±0.16 mg/dl), higher BUN (18.4±5.7 vs 15.1±4.4 mg/dl), lower eGFR(65.5±23.3 vs 86.4±22.4 ml/min), more frequent prednisolone administration (75.0% vs 41.9%), more frequent hyperlipidemia (50.0% vs 19.2%) and more frequent hypertension (60.0% vs 30.6%) than Group B by univariate analysis significantly (p<0.01). We then performed multifactorial analysis using logistic regression analysis. Greater physician VAS (OR 1.02, 1.00-1.04), lower eGFR (OR 1.04, 1.01-1.08) and prednisolone administration (OR 3.29, 1.02-10.63) were found as independent relevant factors for group A.

Conclusion:

Our study indicated that AKI developed in RA patients and suggested that renal function decline and prednisolone administration may be implicated. RA patients with impaired renal function and prednisolone administration need to be treated with special attention to the onset of AKI.

References:

[1]Kidney Disease: Improving Global Outcomes (KDIGO) Practice Guideline for Acute Kidney Injury. Kidney Int Suppl 2: 1-138, 2012

[2]Leither MD, Murphy DP, Bicknese L et al. The impact of outpatient acute kidney injury on mortality and chronic kidney disease: a retrospective cohort study. Nephrol Dial Transplant. 34:493-501, 2019

Disclosure of Interests:

None declared

Contamination of lenalidomide on blister packages after administration and its exposure countermeasures

BACKGROUND

Reliable exposure control measures are needed to avoid occupational exposures from hazardous drugs. However, there is little information on blister packages concerning exposure. We investigated the contamination and exposure control methods of lenalidomide.

MATERIALS AND METHODS

Nine facilities involved with the RevMate program (the Japanese REMS program) participated in this study. Blister packages (10 capsules/ sheet, no cuts) were collected from each institution after the administration of 5-mg Revlimid capsules. Additionally, the safety performance of different gloves was tested.

RESULTS

A total of 18 samples were analyzed and the results revealed that all samples were contaminated with lenalidomide. Our questionnaire revealed that all pharmacists handled the blister packages with their bare hands when they were checking the remaining capsules of lenalidomide. We analyzed gloves made from four different materials (nitrile, polyvinyl chloride, latex, and polyethylene) and found no permeability in any glove type.

CONCLUSION

We conclude that the spent blister package is a potential source of exposure to lenalidomide. All medical staff and caregivers should wear gloves when they handle lenalidomide.

Estimating the effect of optimizing anticancer drug vials on medical costs in Japan based on the data from a cancer hospital

Background

The substantial increase in the use of expensive anticancer drugs has been accompanied by an increase in the amount of disposing residual liquid from drug preparations. Many Western countries, including the United States, have implemented drug vial optimization (DVO) to prevent the waste of anticancer drugs and have reported the reductions in the total drug costs. This study was designed to estimate the expected reduction in spending on anticancer drugs by Japanese cancer hospitals when DVO was implemented instead of individual preparations and to test the effectiveness of this approach.

Methods

We investigated the doses of drugs used and quantity specifications for individually prepared vials for patients who received anticancer drug treatment in December 2017 at the Outpatient Treatment Center of the National Cancer Center Hospital East. Based on these findings, we calculated the total quantity of each drug used on a given day, and the minimum cost for preparation of the number of specified combinations corresponding to the total cost (DVO preparation). Based on the differences in these two costs, we estimated the economic impact of implementing DVO.

Results

While the cost for anticancer drugs for the 1-month study period was US$3,305,595 (US$1 = \110) for individual preparations, the estimated cost for DVO preparations was US$3,092,955, equivalent to a reduction of US$212,640.

Conclusions

Based on these study results, implementation of DVO-based preparation of injectable anticancer drugs in Japan in 2017 would have resulted in saving approximately US$460 million. This calculation revealed the need for the Japanese government to modify the methods employed to calculate drug costs in the insurance system and develop policies for the proper and optimal use of medical resources.

International Society of Oncology Pharmacy Practitioners global position on the use of biosimilars in cancer treatment and supportive care

With the development of innovative cancer treatments over recent decades, the cost of cancer care has risen exponentially, limiting patient access to patented originator biotherapeutics in many countries. The introduction of biosimilars to the market has created new opportunities as well the need for changes in practice within healthcare institutions. A ‘biosimilar’ is a biotherapeutic product which is highly similar in terms of quality, safety and efficacy to an already licensed originator product. Although biosimilars lack clinically meaningful differences in therapeutic activity as compared to the originator product, these complex biological molecules are not considered identical chemical copies, unlike generics, and minor differences in molecular structure and inactive compounds may exist. A thorough understanding of these differences and their clinical implications is necessary for optimising medicines-use practices involving biosimilars. This position statement, developed by the International Society of Oncology Pharmacy Practitioners Biosimilars Taskforce, aims to provide the global oncology pharmacy community with guidance to support decisions around biosimilar use. The 11 statements cover the regulation and evaluation of biosimilars, practical issues around local implementation, the education of healthcare staff and patients, and the requirement for ongoing pharmacovigilance and outcome monitoring.

Clinical impact of renal impairment on the safety and efficacy of S-1 plus oxaliplatin in patients with advanced gastric cancer: a single institutional study

BACKGROUNDS

S-1 plus oxaliplatin appears effective in chemo-naïve patients with advanced gastric cancer. However, comprehensive safety and efficacy data for S-1 plus oxaliplatin is limited for patients with impaired renal function.

METHODS

We retrospectively extracted data from advanced gastric cancer patients with normal renal function (normal group, CLcr ≥ 60 ml/min), who were treated with standard doses of S-1 (80 mg/m2) plus oxaliplatin (100 mg/m2), and patients with impaired renal function (impaired group, CLcr < 60 ml/min) who were treated with standard or reduced doses of S-1 (60 mg/m2 or 40 mg/m2) plus standard doses of oxaliplatin. Treatment efficacy and safety between the groups were compared.

RESULTS

Data from 100 normal patients and 42 patients with impaired renal function were extracted. Baseline characteristics differed significantly between the two groups, including age (median, 64 vs 72 years, P < 0.0001) and body surface area (median, 1.68 vs 1.51 m2, P < 0.0001). In the impaired group, 66.6% (28/42) started with a reduced dose. Within the impaired group, more patients had a reduced initial S-1 dose when CLcr <50 ml/min (77.3%). The median progression-free and overall survival between the normal and impaired groups was 6.1 vs 5.7 months (P = 0.698) and 16.1 vs 18.5 months (P = 0.638), respectively.

CONCLUSIONS

S-1 plus oxaliplatin in advanced gastric cancer patients with impaired renal function appears safe and has demonstrated efficacy given appropriate dose modification.

Wire-loop lesion is associated with serological immune abnormality, but not renal prognosis, in lupus nephritis

BACKGROUND

Wire-loop lesion (WL) is one of the active lesions of lupus nephritis (LN). However, few reports have focused on the clinicopathological relationships of WL to serological immune abnormality and renal prognosis.

METHODS

We enrolled 126 Japanese LN patients subjected to renal biopsy in 11 hospitals from 2000 to 2018. In patients with class III or IV of the International Society of Nephrology/Renal Pathology Society classification, we retrospectively compared clinicopathological findings between those with WL (WL+ group) and without WL (WL- group) to detect factors associated with WL. Chronic kidney disease (CKD) was defined as an estimated glomerular filtration rate of <60 mL/min/1.73m² for more than three months. We also compared these findings between those with CKD (CKD+ group) and without CKD (CKD- group) at the last visit to investigate factors associated with renal prognosis.

RESULTS

Of 126 patients, 100 (79.4%) were classified as class III or IV. WL was found in 36 (36.0%) of them. Although the renal function did not differ, the WL+ group had a higher titre of serum anti-dsDNA antibodies and lower serum complement 3 levels than the WL- group. Linear regression analysis revealed a significant association only between anti-dsDNA antibodies and WL (β = 0.27, 95% confidence interval (CI) 0.001-0.100, p = 0.01). Of these patients, 69 were tracked for 59.6 ± 55.1 months. Kaplan-Meier analysis showed no difference in renal prognosis between these groups. Next, the CKD+ group included 15 (22.1%) patients. They were older and had higher frequencies of hypertension and hyperuricaemia, serum creatinine (Cr) level, glomerulosclerosis, interstitial inflammation, interstitial fibrosis and tubular atrophy than the CKD- group at the time of renal biopsy. The frequency of WL was not significantly different. Cox regression analysis revealed significant associations of CKD with hypertension, hyperuricaemia, serum Cr level at the time of renal biopsy clinically and with tubular atrophy histologically.

CONCLUSIONS

WL was associated with serum anti-dsDNA antibodies but not with renal prognosis, suggesting that WL reflects immune abnormality but is not an independent factor predictive of renal prognosis in LN.

P824The clinical impact of polyunsaturated fatty acid on clinical outcomes in acute coronary syndrome with dyslipidemia: HIJ-PROPER sub-analysis

Background

Polyunsaturated fatty acids, especially omega-3 and -6 series, are key essential nutrients that play an important role in humans to maintain cell membranes and function. A recent randomized trial reported that adding eicosapentaenoic acid (EPA) to statins was beneficial to cardiovascular disease patients who had a residual risk factor. Further, several studies have reported that the low baseline value for EPA to arachidonic acid (AA) ratio is related to worse clinical outcome and plaque vulnerability in coronary artery disease patients. However, effects of baseline EPA/AA ratio on clinical outcomes in ACS patients have not been thoroughly evaluated.

Objectives

This study aimed to examine the impact of baseline eicosapentaenoic acid to arachidonic acid (EPA/AA) ratio on clinical outcomes of acute coronary syndrome (ACS) patients and how lipid-lowering therapy affects serum EPA/AA levels in these patients.

Methods

This is a sub-analysis of HIJ-PROPER assessing the effect of aggressive low-density lipoprotein cholesterol (LDL-C)-lowering treatment with pitavastatin+ezetimibe in 1,734 ACS patients with dyslipidemia. Patients were divided into two groups based on EPA/AA level on admission (cut-off: 0.34 μg/mL; median of baseline EPA/AA level) and clinical outcomes were examined.

Results

Percent reduction of LDL-C from baseline to follow-up and mean LDL-C level during follow-up were similar regardless of baseline EPA/AA ratio. In the low EPA/AA group, the Kaplan–Meier estimate for the primary endpoint at 3 years was 27.2% in the pitavastatin+ezetimibe group, compared with 36.6% in the pitavastatin-monotherapy group [hazard ratio (HR), 0.69; 95% confidence interval (CI), 0.52–0.93; P=0.015). However, in the high EPA/AA group, there was no significant reduction in the primary endpoint by pitavastatin+ezetimibe therapy (HR, 0.92; 95% CI, 0.70–1.20; P=0.52).

Conclusions

Aggressive lipid-lowering therapy with ezetimibe had a positive effect on clinical outcomes in the low EPA/AA group of ACS patients with dyslipidemia, but not in the high EPA/AA group. This effect was independent of LDL-C reduction and suggests that EPA/AA measurement on admission in ACS patients contributes to a “personalized” lipid-lowering approach.

P3541Change in left ventricular ejection fraction and outcome in heart failure patients with mid-range ejection fraction: from the HIJ-HF prospective study

Introduction

Heart failure (HF) is categorized on the basis of the eft ventricular ejection fraction (LVEF). The European Society of Cardiology has proposed mid-range EF (HFmrEF) as a new category of HF that includes patients with an LVEF of 40–49%. However, the clinical characteristics, change in LVEF following treatment, and outcome of patients with HFmrEF remain clear.

Methods

We conducted a prospective observational study of Japanese hospitalized HF patients between 2015 and 2018 at a single-center (HIJ-HF III). HFmrEF was defined as 40–49% of LVEF on echocardiography at admission. We followed these patients and performed echocardiography to assess LVEF per year after hospital discharge. Clinical outcome was death from any cause.

Methods and results

We studied 138 patients with HFmrEF (median age 71 years, 69% male). They had 32% of ischemic heart disease, 9% of New York Heart Association functional class III or IV at discharge. During median follow-up of 20 [13–28] months, we assessed change in LVEF for 110 patients with HFmrEF. One year after hospital discharge, 49 patients (44%) improved LVEF (≥50%) and 21 patients (19%) reduced LVEF (<40%). HFmrEF patients who reduced LVEF (<40%) were significantly higher mortality rate than those who improved LVEF (≥50%) (14% vs. 2%, p<0.05) (Figure).

Conclusions

This study demonstrated that 44% of HFmrEF patients improved LVEF following treatment but 19% patients reduced LVEF. Reduced LVEF was associated with poor prognosis.

P830Differences in the usefulness of aggressive lipid-lowering therapy among single-vessel and multi-vessel coronary artery disease patients: HIJ-PROPER sub-study

Background

Acute coronary syndrome (ACS) patients with multi-vessel disease (MVD) are at high risk of recurrent cardiovascular events. Previous study, examining stable atherosclerotic cardiac disease, reported that aggressive lipid-lowering therapy was more beneficial in MVD patients than in single-vessel disease (SVD) patients. However, no report has investigated the effects of aggressive lipid-lowering treatment according to the number of diseased coronary arteries in ACS patients.

Purpose

The purpose of the present study was to elucidate the efficacy of aggressive lipid-lowering therapy in ACS patients with MVD and SVD in modern early invasive strategy era.

Methods

The study population was derived from the HIJ-PROPER study, in which, ACS patients with dyslipidemia were randomized to pitavastatin + ezetimibe therapy (targeting LDL-C less than 70mg/dl) or pitavastatin-monotherapy (targeting LDL-C less than 90mg/dl). In the present study, the treatment efficacy was compared between patients with MVD and SVD. The primary end point was a composite of major advanced cardiovascular events (MACEs), including all-cause death, non-fatal myocardial infarction, non-fatal stroke, and ischemia driven revascularization.

Results

We identified 1702 eligible patients (mean age, 65.6 years; male, 75.6%); 869 patients (51.1%) had MVD and 833 (48.9%) patients had SVD. The rate of acute revascularization was 96.2%. The incidence of MACEs was significantly higher in MVD group compared to SVD group (43.7% vs 25.9%, hazard ratio 1.95, 95% confidence interval 1.65–2.31, p<0.001). In MVD group, there was no significant difference in MACEs between pitavastatin + ezetimibe therapy and pitavastatin-monotherapy group. (43.5% vs. 43.9%, 1.0, 0.82–1.23; p=0.95). However, in SVD group, pitavastatin + ezetimibe therapy showed significantly fewer MACEs than pitavastatin-monotherapy (34.6% vs. 47.4%, 0.72, 0.55–0.94, p=0.02). (Figure)

Conclusion

This study showed that ACS patients with SVD enjoyed significantly greater benefits from pitavastatin + ezetimibe therapy compared with pitavastatin monotherapy, whereas the patients with MVD did not. High rate of revascularization in acute phase of ACS might affect the efficacy of aggressive lipid-lowering therapy and our results in the present study suggest different treatment approach would be necessary in ACS patients with MVD in modern early invasive strategy era.

Surface contamination of the outer and blister packages of oral anticancer drugs: A multicenter study

INTRODUCTION

All guidelines necessitate wearing personal protective equipment during dispensing of oral anticancer drugs. This study aims to measure the degree of contamination on the press-through-package strips of oral anticancer drugs in Japan.

METHOD

Surface contamination of the external packaging of anticancer drugs was examined by performing wipe tests at four hospitals and two community pharmacies. The following commercially available drugs were examined: Xeloda®, TS-1®, and methotrexate tablets and SA-1® and Rheumatrex® capsules.

RESULTS

The wipe tests' results revealed that the contamination levels of Xeloda® and TS-1® tablets and SA-1® capsules were within their detection limits. In some facilities, the contamination levels on the press-through-package strips of Rheumatrex® capsules were 3.27 × 10^-1, which is close to its detection limit. However, across all facilities, the contamination level of methotrexate tablets was above its detection limit.

CONCLUSION

The results of this study suggested that adherence to oral anticancer drugs may not occur during manufacture or transportation. However, it may be due to the presence of pollutants in the facilities. Prevention of pollution in facilities might eliminate the need to wear personal protective equipment during dispensing of oral anticancer drugs.

Short-term risk of hepatocellular carcinoma after hepatitis C virus eradication following direct-acting anti-viral treatment

BACKGROUND

With the development of direct-acting anti-virals (DAAs), almost all patients with chronic hepatitis C virus (HCV) infection can achieve sustained viral response (SVR).

AIM

To evaluate the short-term risk of HCC among patients with SVR by DAAs, including those with cirrhosis or previous HCC.

METHODS

This large-scale, multicentre cohort study included 1,675 consecutive patients who achieved SVR by treatment with interferon-free sofosbuvir-based regimens, divided into groups with (n = 152) or without previous HCC (n = 1,523). The Kaplan-Meier method and Cox proportional hazard analysis were used to calculate the cumulative HCC incidence and related factors of HCC.

RESULTS

During the follow-up period (median: 17 months), 46 (2.7%) patients developed HCC. The 1-year cumulative rates of de novo HCC were 0.4% and 4.9% for the noncirrhosis and cirrhosis groups respectively (log-rank test: P < 0.001). For cirrhotic patients, serum α-fetoprotein level at the end of treatment (EOT-AFP) was the strongest predictor of de novo HCC. The 1-year cumulative de novo HCC rates were 1.4% and 13.1% in the EOT-AFP < 9.0 ng/mL and ≥ 9.0 ng/mL groups (cut-off value) respectively (log-rank test: P < 0.001). The 1-year cumulative rates of HCC recurrence were 6.5% and 23.1% for the noncirrhosis and cirrhosis groups respectively (log-rank test: P = 0.023). For cirrhotic patients, previous HCC characteristics were significantly associated with HCC recurrence. In contrast, sex, age and metabolic features did not influence de novo HCC or recurrence.

CONCLUSIONS

For cirrhotic patients after elimination of HCV, serum EOT-AFP level and previous HCC characteristics would be useful markers for predicting de novo HCC or recurrence.

[Safe Handling of Cancer Chemotherapy Drugs in Pharmacy(Preparations, Transport and Safe Deposit)]

Recently, 1 out of 2 people are diagnosed as cancer, the number of patients who are given chemotherapy increases year by year. As a result, amount of anticancer drugs used also increases. Anticancer drug preparation work is one of pharmacist work. In many hospital, pharmacists prepare anticancer drugs at pharmacy. However, it is enough to take steps to exposure measures at all facilities. According to the United States Pharmacopeial(USP)and the handling standards of hazardous and drugs, there are 3 levels, the first level(safety cabinet), the second level(anticancer agent preparation room in pharmacy) and supplemental engineering control(CSTD). It is described that exposure control should be carried out with exposure control. Strict standards are stated for each. In Japan, efforts to cope with exposure gradually are spreading gradually after exposure GL is published. Proper preparation environment/equipment, personal protective equipment, procedures and supplementary equipment are required for adequate exposure control measures. Also, it is important for exposure control to focus not only on anticancer drug preparation work but also on transportation and storage. This time, we describe exposure preparation, transportation to storage from dispensing.

Retrospective analysis of premedication, glucocorticosteroids, and H1-antihistamines for preventing infusion reactions associated with cetuximab treatment of patients with head and neck cancer

Objectives

We evaluated infusion-related reactions associated with cetuximab combination chemotherapy comprising an H1-receptor antagonist plus dexamethasone as anti-allergy premedications for patients with head and neck cancer.

Methods

We retrospectively evaluated 248 patients who received a cetuximab combination regimen between December 2012 and August 2015. All patients received 5 mg intravenous dichlorpheniramine (H1-receptor antagonist), and dexamethasone (DEX) was adjusted from 6.6 mg to 13.2 mg according to the emetogenic risk.

Results

We identified 248 subjects, including 13 (5.2%) with infusion-related reactions (grade 1 in five [2.0%], grade 2 in seven [2.8%], and grade 4 in one [0.4%]). The incidence of these reactions in cetuximab combination regimens, each employing an H1-receptor antagonist, using a higher dose of dexamethasone (13.2 mg) was not significantly lower compared with those using 6.6 mg DEX (2.4% vs 8.3%, respectively; p = 0.43). Twelve patients experienced infusion-related reactions associated with the first cetuximab administration, and one reaction occurred after the third administration.

Conclusions

The incidence of infusion-related reactions was lower compared with those of previous studies. Dexamethasone combined with an H1-receptor antagonist was useful for preventing allergic responses. The incidence of infusion-related reactions was not lower with 13.2 mg dexamethasone, and 6.6 mg DEX prevented infusion-related reactions.

Salient Features and Outline of the Joint Japanese Guidelines for Safe Handling of Cancer Chemotherapy Drugs

The purpose of this paper is to introduce the outline and describe the salient features of the “Joint Guidelines for Safe Handling of Cancer Chemotherapy Drugs” (hereinafter, “Guideline”), which were published in July 2015. The purpose of this Guideline is to provide guidance to protect against occupational exposure to hazardous drugs (HDs) to all medical personnel involved in cancer chemotherapy, including physicians, pharmacists, and nurses and home health-care providers. The Guideline was developed according to the Medical Information Network Distribution Service guidance for developing clinical practice guidelines, with reference to five authoritative guidelines used worldwide. PubMed, Cumulative Index to Nursing and Allied Health Literature, Ichushi-Web, and Cochrane Central Register of Controlled Trials were used for a systematic search of the literature. Eight clinical questions (CQs) were eventually established, and the strength of recommendation for each CQ is presented based on 867 references. The salient features of the Guideline are that it was jointly developed by three societies (Japanese Society of Cancer Nursing, Japanese Society of Medical Oncology, and Japanese Society of Pharmaceutical Oncology), contains descriptions including the definition of HDs and the concept of hierarchy of controls, and addresses exposure control measures during handling of chemotherapy drugs. Our future task is to collect additional evidence for the recommended exposure control measures and to assess whether publication of the Guideline has led to adherence of measures to prevent occupational exposure.

Chemotherapy regimen checks performed by pharmacists contribute to safe administration of chemotherapy

Background

Computerized provider order entry (CPOE) has been developed and implemented within cancer center hospitals nationwide in Japan. To ensure that high-quality services are routinely provided by oncology pharmacists, this study was designed to evaluate the interventions through reviewing the orders that are generated by CPOE.

Methods

The objective of this retrospective chart review was to evaluate how pharmacists contributed to safe cancer treatment using paper-based pharmacy records. Data were collected from a total of 35,062 chemotherapy regimens for 18,515 outpatients between January and December 2013.

Results

Of these 35,062 chemotherapy regimens, the rate of pharmacists’ interventions was 1.1% ( n = 408). Among them, 53.1% (217/408) of the chemotherapy prescriptions were modified due to pharmacist interventions. The reasons for interventions included “changes in the chemotherapy regimen were unclear” in 49.5%, “physicians’ prescription errors” (22.0%), “pharmacist suggestions to improve chemotherapy” (15.1%), and “finding differences between physicians’ chemotherapy records and their chemotherapy prescriptions” (13.2%). The top three reasons for the 217 prescription modifications due to pharmacist interventions were “finding prescription errors” (34.5%), “reasons for change in the chemotherapy regimen were unclear” (32.7%), and “finding differences between physicians’ chemotherapy records and their chemotherapy prescriptions” (28.5%).

Conclusion

The computer could not evaluate chemotherapy protocols or adjust doses of anticancer medicines according to patients’ conditions. Therefore, oncology pharmacists should continue to ensure safe and appropriate administration of cancer chemotherapy.

Risk Factors for the Discontinuation of Home Medical Care among Low-functioning Older Patients

OBJECTIVES

Older patients receiving home medical care often have declining functional status and multiple disease conditions. It is important to identify the risk factors for care transition events in this population in order to avoid preventable transitions. In the present study, therefore, we investigated the factors associated with discontinuation of home medical care as a potentially preventable care transition event in older patients.

METHODS

Baseline data for participants in the Observational study of Nagoya Elderly with HOme MEdical (ONEHOME) study and data on the mortality, institutionalization, or hospitalisation of the study participants during a 2-year follow-up period were used. Discontinuation of home care was defined as admission to a hospital for any reason, institutionalization, or death. Univariate and multivariate Cox hazard models were used to assess the association of each of the factors with the discontinuation of home care during the observational period. The covariates included in the multivariate analysis were those significantly associated with the discontinuation of home care at the level of P<0.05 in the univariate analysis.

RESULTS

The univariate Cox hazard model revealed that a low hemoglobin level (< 11g/dL), low serum albumin level (< 3g/dL), higher Charlson Comorbidity Index score, and low Mini Nutritional Assessment Short Form score (< 7) were significantly associated with the discontinuation of home care. A multivariate Cox hazard model including these four factors demonstrated that all four were independently associated with home-care discontinuation.

CONCLUSIONS

The present results demonstrated that anemia, hypoalbuminemia, malnourishment, and the presence of serious comorbidities were associated with the discontinuation of home medical care among low-functioning older patients.

[Evaluation of Drug Interaction between S-1 and Warfarin]

Prolonged prothrombin time is observed in patients taking warfarin (WF) with a fluoropyrimidine, such as S-1. When WF is combined with S-1, the prothrombin time-international normalized ratio (PT-INR) and dose adjustment of WF should be closely monitored. To date, no clinical data have been reported in terms of the relation between temporal variation of PT-INR and its therapeutic range. In this study, we retrospectively collected patients' clinical data including PT-INR. We identified 21 patients receiving WF therapy before the start of S-1 treatment. Patient characteristics were male/female: 18/3, median age: 69 (range 48-81) years old, cancer of gastric/lung/pancreatic/other: 8/5/4/4, and history of deep vein thrombosis (DVT)/atrial fibrillation (AF)/cerebral infarction (CI)/other: 11/6/2/2. The PT-INR of 16 patients exceeded normal upper limits after taking S-1 with WF. The median time to exceed the PT-INR upper therapeutic range is 25 (range 3-77) days. Patients receiving WF anticoagulant therapy concomitant with S-1 should have their PT-INR closely monitored and WF doses adjusted accordingly.

Effectiveness of triple therapy with simeprevir for chronic hepatitis C genotype 1b patients with prior telaprevir failure

Favourable efficacy and safety profiles for simeprevir in combination with pegylated interferon alpha (PEG-IFNα) and ribavirin (triple therapy) have been shown in clinical trials. This study was carried out to evaluate the effectiveness of simeprevir-based triple therapy for patients with prior telaprevir treatment failure. This multicentre, observational cohort consisted of 345 consecutive Japanese patients infected with HCV genotype 1b, including 20 who had experienced telaprevir-based triple therapy. Amino acid substitutions in the NS3/4A region were identified by direct sequencing at the time of relapse or breakthrough in treatment with telaprevir and at the initiation of treatment with simeprevir. Patients were stratified according to prior response to PEG-IFNα and ribavirin. Of the 20 patients with telaprevir treatment failure, 10 (50.0%) achieved sustained virological response at week 12 after the end of treatment (SVR12). For patients treatment naïve [3/4 (75.0%)] or with prior relapse [1/1 (100%)] or partial response [5/6 (83.3%)] to PEG-IFNα and ribavirin, almost all achieved SVR12, mainly because of the improvement of treatment adherence, especially to direct-acting antiviral agent and ribavirin. However, of the nine patients with prior null response to PEG-IFNα and ribavirin, only one (11.1%) achieved SVR12, despite all having received an adequate treatment dosage, and five (55.6%) achieved rapid virological response. The treatment outcome of simeprevir-based triple therapy for HCV genotype 1b patients with prior telaprevir failure depended on the prior response to PEG-IFNα and ribavirin. For patients with prior null response to PEG-IFNα and ribavirin, retreatment with simeprevir-based triple therapy is not a useful option.

Anisotropic multi-step etching for large-area fabrication of surface microstructures on stainless steel to control thermal radiation

Controlling the thermal radiation spectra of materials is one of the promising ways to advance energy system efficiency. It is well known that the thermal radiation spectrum can be controlled through the introduction of periodic surface microstructures. Herein, a method for the large-area fabrication of periodic microstructures based on multi-step wet etching is described. The method consists of three main steps, i.e., resist mask fabrication via photolithography, electrochemical wet etching, and side wall protection. Using this method, high-aspect micro-holes (0.82 aspect ratio) arrayed with hexagonal symmetry were fabricated on a stainless steel substrate. The conventional wet etching process method typically provides an aspect ratio of 0.3. The optical absorption peak attributed to the fabricated micro-hole array appeared at 0.8 μm, and the peak absorbance exceeded 0.8 for the micro-holes with a 0.82 aspect ratio. While argon plasma etching in a vacuum chamber was used in the present study for the formation of the protective layer, atmospheric plasma etching should be possible and will expand the applicability of this new method for the large-area fabrication of high-aspect materials.