Oral docetaxel plus encequidar - A pharmacokinetic model and evaluation against IV docetaxel

The development of optimized dosing regimens plays a crucial role in oncology drug development. This study focused on the population pharmacokinetic modelling and simulation of docetaxel, comparing the pharmacokinetic exposure of oral docetaxel plus encequidar (oDox + E) with the standard of care intravenous (IV) docetaxel regimen. The aim was to evaluate the feasibility of oDox + E as a potential alternative to IV docetaxel. The article demonstrates an approach which aligns with the FDA's Project Optimus which aims to improve oncology drug development through model informed drug development (MIDD). The key question answered by this study was whether a feasible regimen of oDox + E existed. The purpose of this question was to provide an early GO / NO-GO decision point to guide drug development and improve development efficiency.

METHODS

 A stepwise approach was employed to develop a population pharmacokinetic model for total and unbound docetaxel plasma concentrations after IV docetaxel and oDox + E administration. Simulations were performed from the final model to assess the probability of target attainment (PTA) for different oDox + E dose regimens (including multiple dose regimens) in relation to IV docetaxel using AUC over effective concentration (AUCOEC) metric across a range of effective concentrations (EC). A Go / No-Go framework was defined-the first part of the framework assessed whether a feasible oDox + E regimen existed (i.e., a PTA ≥ 80%), and the second part defined the conditions to proceed with a Go decision.

RESULTS

 The overall population pharmacokinetic model consisted of a 3-compartment model with linear elimination, constant bioavailability, constant binding mechanics, and a combined error model. Simulations revealed that single dose oDox + E regimens did not achieve a PTA greater than 80%. However, two- and three-dose regimens at 600 mg achieved PTAs exceeding 80% for certain EC levels.

CONCLUSION

 The study demonstrates the benefits of MIDD using oDox + E as a motivating example. A population pharmacokinetic model was developed for the total and unbound concentration in plasma of docetaxel after administration of IV docetaxel and oDox + E. The model was used to simulate oDox + E dose regimens which were compared to the current standard of care IV docetaxel regimen. A GO / NO-GO framework was applied to determine whether oDox + E should progress to the next phase of drug development and whether any conditions should apply. A two or three-dose regimen of oDox + E at 600 mg was able to achieve non-inferior pharmacokinetic exposure to current standard of care IV docetaxel in simulations. A Conditional GO decision was made based on this result and further quantification of the "effective concentration" would improve the ability to optimise the dose regimen.

The inter-laboratory equivalence for lower limb kinematics and kinetics during unplanned sidestepping

Much inter-intra-tester kinematic and kinetic repeatability research exists, with a paucity investigating inter-laboratory equivalence. The objective of this research was to evaluate the inter-laboratory equivalence between time varying unplanned kinematics and moments of unplanned sidestepping (UnSS). Eight elite female athletes completed an established UnSS procedure motion capture laboratories in the UK and Australia. Three dimensional time varying unplanned sidestepping joint kinematics and moments were compared. Discrete variables were change of direction angles and velocity. Waveform data were compared using mean differences, 1D 95%CI and RMSE. Discrete variables were compared using 0D 95% CI. The mean differences and 95%CI for UnSS kinematics broadly supported equivalence between laboratories (RMSE≤5.1°). Excluding hip flexion/extension moments (RMSE = 1.04 Nm/kg), equivalence was also supported for time varying joint moments between laboratories (RMSE≤0.40 Nm/kg). Dependent variables typically used to characterise UnSS were also equivalent. When consistent experimental and modelling procedures are employed, consistent time varying UnSS lower limb joint kinematic and moment estimates between laboratories can be obtained. We therefore interpret these results as a support of equivalence, yet highlight the challenges of establishing between-laboratory experiments or data sharing, as well as establishing appropriate ranges of acceptable uncertainty. These findings are important for data sharing and multi-centre trials.

Optimal sample selection applied to information rich, dense data

Dense data can be classified into superdense information-poor data (type 1 dense data) and dense information-rich data (type 2 dense data). Arbitrary, random, or optimal thinning may be applied to type 1 dense data to minimise computational burden and statistical issues (such as autocorrelation). In contrast, a prospective or retrospective optimal design can be applied to type 2 dense data to maximise information gain from limited resources (capital and/or time). Here we describe a retrospective optimal selection strategy for quantification of unbound drug concentration from a discrete set of plasma samples where the total drug concentration has been measured.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Outcomes of Brain Metastases with Suspicious Imaging Undergoing Resection to Evaluate for Radionecrosis vs. Tumor Progression

PURPOSE/OBJECTIVE(S)

In patients treated with stereotactic radiosurgery (SRS) for brain metastases, radiographic changes on surveillance imaging may result from treatment effect/radionecrosis (RN) or tumor progression. Distinguishing between these processes is critical to appropriate management. We report long-term outcomes for a cohort of patients who demonstrated radiographic progression on serial imaging after initial radiation and ultimately underwent resection to inform further management.

MATERIALS/METHODS

A retrospective chart review identified 76 patients with an associated 82 brain lesions between 2009 and 2022 that were initially treated with SRS, then demonstrated suspicious imaging changes developing through at least two scan time points that led to pathologic confirmation of either tumor or RN. We report clinical outcomes and details of further treatments.

RESULTS

Of the 82 lesions, 55 (67.1%) were found to be pathologically-confirmed viable tumor and were treated with repeat radiation and 27 (32.9%) were found to be strictly RN and conservatively managed. Over half of the lesions (14/27) ultimately found to be radionecrotic required use of steroids pre-operatively due to neurologic symptoms. Among the 27 that were found to be RN, the most common histology was melanoma (33.3%, n = 9). The most common dose fractionation regimen was 20 Gy in 1 fx (n = 11, 40.7%; range: 16-20 Gy x 1Fx), and the median BED (10) was 50.4 Gy (IQR 41.6 - 50 Gy). None of these lesions required further intervention with median post-surgery follow up of 24.4 months (range 1-104 months). There were 55 instances (in 51 patients) of pathologically-confirmed recurrent/progressive tumor who were consequently treated with repeat radiation with either Cs-131 brachytherapy (12 (21.8%)) or SRS (43 (78.2%)). The most common histology was NSCLC (37.2%, n = 19). The most common fractionation for repeat irradiation with SRS was 8 Gy x 3 fx (n = 15, 27.3%), followed by 5 Gy x 5 fx (n = 10, 18.2%), and 4 Gy x 5 fx (n = 8, 14.6%). Four individuals each had two lesions that were re-irradiated for local recurrence. Among patients treated with re-irradiation, the median follow-up to local failure was 15.2 months (95% CI 7.3-26.6 months). Radionecrosis was confirmed on pathology in 4/55 (7.2%) of lesions. The median follow-up from date of SRS2 to local failure was 14.1 months (95% CI 7.6-24.3 months). The 2-yr local control rate was 74.8% (95% CI 61.7-90.7%).

CONCLUSION

We recommend cautious monitoring of possible progression after radiosurgery, with consideration of resection for continuous progression, as a significant proportion of radiographic progression are ultimately pure RN. Management determined by pathology (observation for RN; additional radiation for confirmed tumor) leads to excellent control.

Treatment of Recurrent Orbital Rhabdomyosarcoma with Exenteration and HDR Brachytherapy in a Custom Mold

PURPOSE/OBJECTIVE(S)

Rhabdomyosarcoma (RMS) is the most frequent cancer affecting the orbit in children. The orbit is classified as a favorable site for RMS as treatment with chemotherapy and radiation is effective. Local failure for patients with RMS of the orbit has ranged from 2-16% on IRS and COG protocols. In the event of local recurrence, survival is poor, and management is difficult. We report four patients with local recurrence of orbital RMS managed with orbital exenteration followed by high dose rate (HDR) brachytherapy.

MATERIALS/METHODS

Four patients were treated from 2016-2022. HDR brachytherapy with Ir-192 was delivered in a custom mold of the orbit made after the orbital exenteration procedure. Brachytherapy was given in 6-7 twice daily (BID) fractions starting 1 week after the orbital exenteration.

RESULTS

At the time of brachytherapy, patient ages were 3, 1, 7, and 7 years. Three patients had embryonal histology and underwent initial systemic therapy with ARST0331 regimen A. The fourth patient had alveolar, FOXO1 fusion positive RMS and was initially treated as per COG D9803 regimen A. All patients had received proton radiotherapy as part of initial treatment. Three received 50.40 Gy and one received 45 Gy. Patients developed biopsy-proven, recurrent disease an average of 56 weeks (range 38-77) after initial diagnosis. All patients received salvage chemotherapy before undergoing orbital exenteration at an average of 12 weeks after recurrence (range 5-16). Three patients received 30 Gy in 6 BID fractions, and one patient received 28 Gy in 7 fractions with HDR brachytherapy using an Ir-192 source. All four patients are alive without evidence of disease at an average of 27 months (range 6-70) from recurrence and 39 months (range 21-78) from initial diagnosis. All patients have acceptable orbit healing. Two patients have asymptomatic evidence of frontal lobe edema (and in one case possible necrosis) extending 1-2 cm above the orbit. This appears to be beyond the range of the brachytherapy dosimetry, but the combination of proton beam and brachytherapy are implicated. No other toxicities have occurred.

CONCLUSION

Orbital RMS has a favorable prognosis, but local failure after initial combined modality therapy can be fatal. Options for successful local salvage are limited. Orbital exenteration with HDR brachytherapy in a custom mold is an effective and safe procedure for local control in these difficult cases.

Low Dose Splenic Radiotherapy for Myeloproliferative Neoplasms prior to Allogeneic Hematopoietic Stem Cell Transplant

PURPOSE/OBJECTIVE(S)

Myeloproliferative neoplasms including primary and secondary myelofibrosis (MF) are a rare spectrum of chronic myeloproliferative disorders in which nearly 90% of patients experience splenomegaly. Importantly, splenic radiotherapy (SRT) may be used in combination with allogeneic stem cell transplant (alloSCT) to improve symptoms related to splenomegaly, though there currently is no consensus SRT dose/fractionation protocol reported in the literature for use in combination with alloSCT. We sought to report our institutional experience utilizing low dose SRT prior to alloSCT in the post-Jakafi era.

MATERIALS/METHODS

We performed a retrospective review of all patients diagnosed with MF at our institution from 2017-2022 who received reduced intensity alloHCT. Patients who underwent total lymphoid or body irradiation were excluded. Descriptive demographic and clinical characteristics of patients were summarized by means, medians, standard deviations, ranges and proportions as appropriate.

RESULTS

We identified 39 patients with MF who underwent reduced intensity conditioning (RIC) consisting of fludarabine/melphalan in preparation for alloHCT (median age 64.5, 12/16 males, median follow up 21 months). 16 patients with Jakafi-resistant splenomegaly completed low dose SRT prior to transplant (median spleen size: 24.5cm) with a median dose of 5Gy delivered in 5 fractions. 3D conformal therapy was used for all patients. All patients completed the planned total radiation course without treatment break or dose limiting acute toxicity. Thrombocytopenia was the most reported toxicity (CTCAE v5.0; 2 patients experienced grade 1, 1 patient experienced grade 2). No patients experienced grade 3 or higher acute cytopenias nor required transfusion during radiotherapy. All patients successfully received alloHCT a median of 7 days (range: 2-11) after the completion of SRT with a 94% (15/16) engraftment rate. Median neutrophil recovery (ANC > 500 × 3 days) time was 18 days (range: 13-31); median length of hospital stay was 23 days (range: 20-129). Overall survival was 75% in the SRT cohort (12/16, 2 with persistent disease, 2 due to other causes). Symptom burden data was available for 14/16 patients; 79% (11/14) of patients reported improvement in symptoms associated with splenomegaly or reduction in splenic size on physical examination.

CONCLUSION

In the largest reported experience of a low dose SRT only cohort to date, we observe low dose SRT is feasible, safe in combination with alloHCT with high engraftment rates, and may reduce symptoms related to splenomegaly thereby improving patient quality of life without compromising transplant related outcomes. A prospective study validating this protocol is currently underway.

hybpiper-nf and paragone-nf: Containerization and additional options for target capture assembly and paralog resolution

Premise

The HybPiper pipeline has become one of the most widely used tools for the assembly of target capture data for phylogenomic analysis. After the production of locus sequences and before phylogenetic analysis, the identification of paralogs is a critical step for ensuring the accurate inference of evolutionary relationships. Algorithmic approaches using gene tree topologies for the inference of ortholog groups are computationally efficient and broadly applicable to non-model organisms, especially in the absence of a known species tree.

Methods and Results

We containerized and expanded the functionality of both HybPiper and a pipeline for the inference of ortholog groups, providing novel options for the treatment of target capture sequence data, and allowing seamless use of the outputs of the former as inputs for the latter. The Singularity container presented here includes all dependencies, and the corresponding pipelines (hybpiper-nf and paragone-nf, respectively) are implemented via two Nextflow scripts for easier deployment and to vastly reduce the number of commands required for their use.

Conclusions

The hybpiper-nf and paragone-nf pipelines are easily installed and provide a user-friendly experience and robust results to the phylogenetic community. They are used by the Australian Angiosperm Tree of Life project. The pipelines are available at https://github.com/chrisjackson-pellicle/hybpiper-nf and https://github.com/chrisjackson-pellicle/paragone-nf.

Emergency presentation prior to lung cancer diagnosis: A national-level examination of disparities and survival outcomes

OBJECTIVES

A recent multinational investigation of emergency presentation within 30 days of cancer diagnosis, conducted within the International Cancer Benchmarking Programme (ICBP), observed that New Zealand had the highest rate of emergency presentation prior to lung cancer diagnosis compared to other similar countries. Here we use national-level health data to further investigate these trends, focussing on ethnic disparities in emergency presentation prior to lung cancer diagnosis. We have also compared survival outcomes between those who had an emergency presentation in the preceding 30 days to those who did not.

MATERIALS AND METHODS

Our study included all lung cancer registrations between 2007 and 2019 on the New Zealand Cancer Registry (N = 27,869), linked to national hospitalisation and primary healthcare data. We used descriptive (crude and age-standardised proportions) and logistic regression (crude and adjusted odds ratios) analyses to examine primary care access prior to cancer diagnosis, emergency hospitalisation up to and including 30 days prior to diagnosis, and one-year mortality post-diagnosis, both for the total population and between ethnicities. Regression models adjusted for age, sex, deprivation, rurality, comorbidity, tumour type and stage.

RESULTS

We found stark disparities by ethnic group, with 62% of Pacific peoples and 54% of Māori having an emergency presentation within 30 days prior to diagnosis, compared to 47% of Europeans. These disparities remained after adjusting for multiple covariates including comorbidity and deprivation (adj. OR: Māori 1.21, 95% CI 1.13-1.30; Pacific 1.50, 95% CI 1.31-1.71). Emergency presentation was associated with substantially poorer survival outcomes across ethnic groups (e.g. 1-year mortality for Māori: no emergency presentation 50%, emergency presentation 79%; adj. OR 2.40, 95% CI 2.10-2.74).

CONCLUSIONS

These observations reinforce the need for improvements in the early detection of lung cancer, particularly for Māori and Pacific populations, with a view to preventing diagnosis of these cancers in an emergency setting.

European-Australasian consensus on the management of advanced gastric and gastro-oesophageal junction cancer: current practice and new directions

Gastric carcinoma and gastro-oesophageal junction (GC/GEJ) carcinoma remain a significant global problem, with patients presenting with symptoms often found to have advanced or metastatic disease. Treatment options for these patients have broadened in recent years with new chemotherapy agents, agents targeting angiogenic pathways and the development of immune checkpoint inhibitors (ICIs). Most initial advances have occurred in the refractory setting, where it is important to balance treatment benefits versus toxicity and patient quality of life. In the first-line treatment of advanced/metastatic GC/GEJ, platinum- and fluoropyrimidine-based chemotherapy protocols remain the backbone of therapy (with or without HER2-targeted therapy), with the FOLFIRI regimen offering an alternative in patients deemed unsuitable for a platinum agent. Microsatellite instability-high or mismatch repair-deficient cancers have been shown to benefit most from ICIs. In unselected patients previously treated with doublet or triplet platinum- and fluoropyrimidine-based chemotherapy and second-line chemotherapy with irinotecan or taxanes have formed the backbone of therapy with or without the addition of the vascular endothelial growth factor receptor-2 inhibitor ramucirumab in addition to paclitaxel. Beyond this, efficacy has been demonstrated with oral trifluridine/tipiracil and with single-agent nivolumab, in selected refractory patients. In this review, we highlight the positive evidence from key trials that have led to our current practice algorithm, with particular focus on the refractory advanced disease setting, discussing the areas of active research and highlighting the factors, including biomarkers and the influence of ethnicity, that contribute to therapeutic decision-making.

An Impulsive Suicide Attempt in a Patient with No Psychiatric History and a Recent COVID-19 Diagnosis: A case report

Introduction

The coronavirus disease 19 (COVID-19) pandemic has prompted concerns regarding increased suicide rates and exacerbation of underlying mental illness symptoms. •There is evidence suggesting neurocognitive changes as well as immune response in COVID-19 infection may increase a patient’s propensity for suicidal ideation. • Patients who are diagnosed with COVID-19 may be affected by psychological factors of anxiety, stress related to having this novel virus as well as depression, post-traumatic stress disorder and sleep disorders throughout treatment and post-treatment of continued concerns. •The combination of psychiatric, neurological, and physical symptoms associated with COVID-19 may elevate suicide risk

Objectives

We present a case of a female with no prior psychiatric history who impulsively attempted suicide after a recent COVID-19 diagnosis and subsequent quarantine. Will explore possible link between increase of suicidal ideation and COVID-19 infection.

Methods

A case report.

Results

Link between increase of suicidal ideation and COVID-19 infection has not been clearly established but there have been reports, as in our case, of the possible vulnerability to mental illness and new onset suicidal ideation that COVID-19 survivors may experience. It may be useful to screen all patients for depressive symptoms after a COVID-19 infection. Early identification and treatment of depression in recovered COVID-19 patients will help to improve psychological impact on COVID-19 survivors and potentially reduce suicide rates.

Conclusions

As COVID-19 infection may trigger new onset mental illness, exacerbate symptoms of underlying mental illness, and may increase suicidal ideation, further research is needed to evaluate links between COVID-19 infection and depression with suicidal ideation

Disclosure

No significant relationships.

Reference Case Methods for Expert Elicitation in Health Care Decision Making

BACKGROUND

The evidence used to inform health care decision making (HCDM) is typically uncertain. In these situations, the experience of experts is essential to help decision makers reach a decision. Structured expert elicitation (referred to as elicitation) is a quantitative process to capture experts' beliefs. There is heterogeneity in the existing elicitation methodology used in HCDM, and it is not clear if existing guidelines are appropriate for use in this context. In this article, we seek to establish reference case methods for elicitation to inform HCDM.

METHODS

We collated the methods available for elicitation using reviews and critique. In addition, we conducted controlled experiments to test the accuracy of alternative methods. We determined the suitability of the methods choices for use in HCDM according to a predefined set of principles for elicitation in HCDM, which we have also generated. We determined reference case methods for elicitation in HCDM for health technology assessment (HTA).

RESULTS

In almost all methods choices available for elicitation, we found a lack of empirical evidence supporting recommendations. Despite this, it is possible to define reference case methods for HTA. The reference methods include a focus on gathering experts with substantive knowledge of the quantities being elicited as opposed to those trained in probability and statistics, eliciting quantities that the expert might observe directly, and individual elicitation of beliefs, rather than solely consensus methods. It is likely that there are additional considerations for decision makers in health care outside of HTA.

CONCLUSIONS

The reference case developed here allows the use of different methods, depending on the decision-making setting. Further applied examples of elicitation methods would be useful. Experimental evidence comparing methods should be generated.

Barriers to initiating and maintaining participation in parkrun

Interventions that increase population physical activity are required to promote health and wellbeing. parkrun delivers community-based, 5 km events worldwide yet 43% who register never participate in a parkrun event. This research had two objectives; i) explore the demographics of people who register for parkrun in United Kingdom, Australia, Ireland, and don’t initiate or maintain participation ii) understand the barriers to participating in parkrun amongst these people. Mandatory data at parkrun registration provided demographic characteristics of parkrun registrants. A bespoke online survey distributed across the three countries captured the reasons for not participating or only participating once. Of 680,255 parkrun registrants between 2017 and 19, 293,542 (43%) did not participate in any parkrun events and 147,148 (22%) only participated in one parkrun event. Females, 16–34 years and physically inactive were more likely to not participate or not return to parkrun. Inconvenient start time was the most frequently reported barrier to participating, with females more likely than males to report the psychological barrier of feeling too unfit to participate. Co-creating strategies with and for people living with a chronic disease, women, young adults, and physically inactive people, could increase physical activity participation within parkrun.

Quantifying Efficiency Gains of Innovative Designs of Two-Arm Vaccine Trials for COVID-19 Using an Epidemic Simulation Model

Clinical trials of a vaccine during an epidemic face particular challenges, such as the pressure to identify an effective vaccine quickly to control the epidemic, and the effect that time-space-varying infection incidence has on the power of a trial. We illustrate how the operating characteristics of different trial design elements maybe evaluated using a network epidemic and trial simulation model, based on COVID-19 and individually randomized two-arm trials with a binary outcome. We show that "ring" recruitment strategies, prioritizing participants at an imminent risk of infection, can result in substantial improvement in terms of power in the model we present. In addition, we introduce a novel method to make more efficient use of the data from the earliest cases of infection observed in the trial, whose infection may have been too early to be vaccine-preventable. Finally, we compare several methods of response-adaptive randomization (RAR), discussing their advantages and disadvantages in the context of our model and identifying particular adaptation strategies that preserve power and estimation properties, while slightly reducing the number of infections, given an effective vaccine.

Decreasing hospital burden of COVID-19 during the first wave in Regione Lombardia: an emergency measures context

BACKGROUND

The aim of this study is to quantify the hospital burden of COVID-19 during the first wave and how it changed over calendar time; to interpret the results in light of the emergency measures introduced to manage the strain on secondary healthcare.

METHODS

This is a cohort study of hospitalised confirmed cases of COVID-19 admitted from February-June 2020 and followed up till 17th July 2020, analysed using a mixture multi-state model. All hospital patients with confirmed COVID-19 disease in Regione Lombardia were involved, admitted from February-June 2020, with non-missing hospital of admission and non-missing admission date.

RESULTS

The cohort consists of 40,550 patients hospitalised during the first wave. These patients had a median age of 69 (interquartile range 56-80) and were more likely to be men (60%) than women (40%). The hospital-fatality risk, averaged over all pathways through hospital, was 27.5% (95% CI 27.1-28.0%); and steadily decreased from 34.6% (32.5-36.6%) in February to 7.6% (6.3-10.6%) in June. Among surviving patients, median length of stay in hospital was 11.8 (11.6-12.3) days, compared to 8.1 (7.8-8.5) days in non-survivors. Averaged over final outcomes, median length of stay in hospital decreased from 21.4 (20.5-22.8) days in February to 5.2 (4.7-5.8) days in June.

CONCLUSIONS

The hospital burden, in terms of both risks of poor outcomes and lengths of stay in hospital, has been demonstrated to have decreased over the months of the first wave, perhaps reflecting improved treatment and management of COVID-19 cases, as well as reduced burden as the first wave waned. The quantified burden allows for planning of hospital beds needed for current and future waves of SARS-CoV-2 i.

A Review of Web-Based Tools for Value-of-Information Analysis

Value-of-information analysis (VOI) is a decision-theoretic approach that is used to inform reimbursement decisions, optimise trial design and set research priorities. The application of VOI analysis for informing policy decisions in practice has been limited due, in part, to the perceived complexity associated with the calculation of VOI measures. Recent efforts have resulted in the development of efficient methods to estimate VOI measures and the development of user-friendly web-based tools to facilitate VOI calculations. We review the existing web-based tools including Sheffield Accelerated Value of Information (SAVI), the web interface to the BCEA (Bayesian Cost-Effectiveness Analysis) R package (BCEAweb), Rapid Assessment of Need for Evidence (RANE), and Value of Information for Cardiovascular Trials and Other Comparative Research (VICTOR). We describe what each tool is designed to do, the inputs they require, and the outputs they produce. Finally, we discuss how tools for VOI calculations might be improved in the future to facilitate the use of VOI analysis in practice.

Superspreaders drive the largest outbreaks of hospital onset COVID-19 infections

SARS-CoV-2 is notable both for its rapid spread, and for the heterogeneity of its patterns of transmission, with multiple published incidences of superspreading behaviour. Here, we applied a novel network reconstruction algorithm to infer patterns of viral transmission occurring between patients and health care workers (HCWs) in the largest clusters of COVID-19 infection identified during the first wave of the epidemic at Cambridge University Hospitals NHS Foundation Trust, UK. Based upon dates of individuals reporting symptoms, recorded individual locations, and viral genome sequence data, we show an uneven pattern of transmission between individuals, with patients being much more likely to be infected by other patients than by HCWs. Further, the data were consistent with a pattern of superspreading, whereby 21% of individuals caused 80% of transmission events. Our study provides a detailed retrospective analysis of nosocomial SARS-CoV-2 transmission, and sheds light on the need for intensive and pervasive infection control procedures.

Disparities in Cancer-Specific Survival Between Māori and Non-Māori New Zealanders, 2007-2016

PURPOSE

While cancer survival is improving across most developed nations, those improvements are not shared equally within their population. Using high-quality national data, we have reviewed the extent to which cancer survival inequities are persisting for indigenous Māori compared with non-Māori New Zealanders and the extent to which these disparities are driven by deprivation, comorbidity, and stage of disease.

METHODS

Incident cases of cancer (2007-2016) were extracted from the New Zealand Cancer Registry and linked to mortality and hospitalization data. Descriptive, Kaplan-Meier, and Cox regression methods were used to compare survival outcomes between Māori and non-Māori.

RESULTS

Māori continue to have poorer survival than non-Māori for 23 of the 24 most common causes of Māori cancer death, with the extent of this disparity ranging from 12% to 156%. The magnitude of these disparities varies according to deprivation, comorbidity, and stage. Of note, there was a tendency for survival disparities to be largest among those with no comorbidity.

CONCLUSION

Māori continue to experience substantial cancer survival inequities. These observations are in keeping with reports from previous decades, which suggest that these disparities persist despite heightened attention. Reduction of the cancer burden on Māori and achievement of equitable survival outcomes require us to prevent cancer for Māori where we can, diagnose Māori patients early when we cannot, and once diagnosed, deliver equitable care to Māori patients at each step along the treatment path.

Outgroup threat and the emergence of cohesive groups: A cross-cultural examination

Evolutionary models and empirical evidence suggest that outgroup threat is one of the strongest factors inducing group cohesion; however, little is known about the process of forming such cohesive groups. We investigated how outgroup threat galvanizes individuals to affiliate with others to form engaged units that are willing to act on behalf of their in-group. A total of 864 participants from six countries were randomly assigned to an outgroup threat, environmental threat, or no-threat condition. We measured the process of group formation through physical proximity and movement mirroring along with activity toward threat resolution, and found that outgroup threat induced activity and heightened mirroring in males. We also observed higher mirroring and proximity in participants who perceived the outgroup threat as a real danger, albeit the latter results were imprecisely estimated. Together, these findings help understand how sharing subtle behavioral cues influences collaborative aggregation of people under threat.

Informing the public health response to COVID-19: a systematic review of risk factors for disease, severity, and mortality

BACKGROUND

Severe Acute Respiratory Syndrome coronavirus-2 (SARS-CoV-2) has challenged public health agencies globally. In order to effectively target government responses, it is critical to identify the individuals most at risk of coronavirus disease-19 (COVID-19), developing severe clinical signs, and mortality. We undertook a systematic review of the literature to present the current status of scientific knowledge in these areas and describe the need for unified global approaches, moving forwards, as well as lessons learnt for future pandemics.

METHODS

Medline, Embase and Global Health were searched to the end of April 2020, as well as the Web of Science. Search terms were specific to the SARS-CoV-2 virus and COVID-19. Comparative studies of risk factors from any setting, population group and in any language were included. Titles, abstracts and full texts were screened by two reviewers and extracted in duplicate into a standardised form. Data were extracted on risk factors for COVID-19 disease, severe disease, or death and were narratively and descriptively synthesised.

RESULTS

One thousand two hundred and thirty-eight papers were identified post-deduplication. Thirty-three met our inclusion criteria, of which 26 were from China. Six assessed the risk of contracting the disease, 20 the risk of having severe disease and ten the risk of dying. Age, gender and co-morbidities were commonly assessed as risk factors. The weight of evidence showed increasing age to be associated with severe disease and mortality, and general comorbidities with mortality. Only seven studies presented multivariable analyses and power was generally limited. A wide range of definitions were used for disease severity.

CONCLUSIONS

The volume of literature generated in the short time since the appearance of SARS-CoV-2 has been considerable. Many studies have sought to document the risk factors for COVID-19 disease, disease severity and mortality; age was the only risk factor based on robust studies and with a consistent body of evidence. Mechanistic studies are required to understand why age is such an important risk factor. At the start of pandemics, large, standardised, studies that use multivariable analyses are urgently needed so that the populations most at risk can be rapidly protected.

REGISTRATION

This review was registered on PROSPERO as CRD42020177714 .

Printability, Durability, Contractility and Vascular Network Formation in 3D Bioprinted Cardiac Endothelial Cells Using Alginate-Gelatin Hydrogels

Background

3D bioprinting cardiac patches for epicardial transplantation are a promising approach for myocardial regeneration. Challenges remain such as quantifying printability, determining the ideal moment to transplant, and promoting vascularisation within bioprinted patches. We aimed to evaluate 3D bioprinted cardiac patches for printability, durability in culture, cell viability, and endothelial cell structural self-organisation into networks.

Methods

We evaluated 3D-bioprinted double-layer patches using alginate/gelatine (AlgGel) hydrogels and three extrusion bioprinters (REGEMAT3D, INVIVO, BIO X). Bioink contained either neonatal mouse cardiac cell spheroids or free (not-in-spheroid) human coronary artery endothelial cells with fibroblasts, mixed with AlgGel. To test the effects on durability, some patches were bioprinted as a single layer only, cultured under minimal movement conditions or had added fibroblast-derived extracellular matrix hydrogel (AlloECM). Controls included acellular AlgGel and gelatin methacryloyl (GELMA) patches.

Results

Printability was similar across bioprinters. For AlgGel compared to GELMA: resolutions were similar (200-700 μm line diameters), printing accuracy was 45 and 25%, respectively (AlgGel was 1.7x more accurate; p < 0.05), and shape fidelity was 92% (AlgGel) and 96% (GELMA); p = 0.36. For durability, AlgGel patch median survival in culture was 14 days (IQR:10-27) overall which was not significantly affected by bioprinting system or cellular content in patches. We identified three factors which reduced durability in culture: (1) bioprinting one layer depth patches (instead of two layers); (2) movement disturbance to patches in media; and (3) the addition of AlloECM to AlgGel. Cells were viable after bioprinting followed by 28 days in culture, and all BIO X-bioprinted mouse cardiac cell spheroid patches presented contractile activity starting between day 7 and 13 after bioprinting. At day 28, endothelial cells in hydrogel displayed organisation into endothelial network-like structures.

Conclusion

AlgGel-based 3D bioprinted heart patches permit cardiomyocyte contractility and endothelial cell structural self-organisation. After bioprinting, a period of 2 weeks maturation in culture prior to transplantation may be optimal, allowing for a degree of tissue maturation but before many patches start to lose integrity. We quantify AlgGel printability and present novel factors which reduce AlgGel patch durability (layer number, movement, and the addition of AlloECM) and factors which had minimal effect on durability (bioprinting system and cellular patch content).

The first case of HIV-2 in Scotland

HIV-1 infects an estimated 37 million people worldwide, while the rarer HIV-2 infects 1–2 million worldwide. HIV-2 is mainly restricted to West African countries. The majority of patients in Scotland are diagnosed with HIV-1, but in 2013 the West of Scotland Specialist Virology Centre (WoSSVC) diagnosed Scotland’s first HIV-2 positive case in a patient from Côte d’Ivoire. HIV-2 differs from HIV-1 in terms of structural viral proteins, viral transmissibility, prolonged period of latency, intrinsic resistance to certain antivirals and how to monitor the effectiveness of treatment. Over the course of 5 years the patient has required several changes in treatment due to both side effects and pill burden. This case highlights the complexity of HIV-2 patient management over time.

Toxic Epidermal Necrolysis and Steven-Johnson Syndrome: A Comprehensive Review

Significance: Toxic epidermal necrolysis (TEN) and Steven-Johnson syndrome (SJS) are potentially fatal acute mucocutaneous vesiculobullous disorders. Evidence to date suggests that outcomes for patients with both TEN and SJS are largely dependent on stopping the causative agent, followed by supportive care and appropriate wound management in a specialized burns unit. These are life-threatening conditions characterized by widespread full-thickness cutaneous and mucosal necrosis. This article outlines the approach to holistic management of such patients, in a specialized unit, highlighting various practical aspects of wound care to prevent complications such as infection, mucosal and adhesions, and ocular scaring. Recent Advances: There is improved understanding of pain and morbidity with regard to the type and frequency of dressing changes. More modern dressings, such as nanocrystalline, are currently favored as they may be kept in situ for longer periods. The most recent evidence on systemic agents, such as corticosteroids and cyclosporine, and novel treatments, are also discussed. Critical Issues: Following cessation of the culprit trigger, management in a specialized burns unit is the most important management step. It is now understood that a multidisciplinary team is essential in the care of these patients. Following admission of such patients, dermatology, ear, nose, and throat surgery, ophthalmology, urology, colorectal surgery, and gynecology should all be consulted to prevent disease sequelae. Future Directions: Looking forward, research is aimed at achieving prospective data on the efficacy of systemic immunomodulating agents and dressing types. Tertiary centers with burns units should develop policies for such patients to ensure that the relevant teams are consulted promptly to avoid mucocutaneous complications.

Computing the Expected Value of Sample Information Efficiently: Practical Guidance and Recommendations for Four Model-Based Methods

Value of information (VOI) analyses can help policy makers make informed decisions about whether to conduct and how to design future studies. Historically a computationally expensive method to compute the expected value of sample information (EVSI) restricted the use of VOI to simple decision models and study designs. Recently, 4 EVSI approximation methods have made such analyses more feasible and accessible. Members of the Collaborative Network for Value of Information (ConVOI) compared the inputs, the analyst's expertise and skills, and the software required for the 4 recently developed EVSI approximation methods. Our report provides practical guidance and recommendations to help inform the choice between the 4 efficient EVSI estimation methods. More specifically, this report provides: (1) a step-by-step guide to the methods' use, (2) the expertise and skills required to implement the methods, and (3) method recommendations based on the features of decision-analytic problems.

Stage at diagnosis for Māori cancer patients: disparities, similarities and data limitations

Māori are more likely than non-Māori to get cancer, and once they have cancer they are less likely to survive it. One frequently proposed explanation for this survival disparity is differences between these groups in terms of stage at diagnosis-whereby Māori may be less likely to be diagnosed at an earlier stage, when treatment is more feasible and outcomes are better for the patient. However, this simple explanation ignores the true complexity of the issue of stage at diagnosis as a driver of survival disparities, and makes critical assumptions about the quality of available staging data. In this manuscript we draw on New Zealand Cancer Registry and available clinical audit data to explore this issue in detail. We found that Māori are less likely than European/Other patients to have localised disease and more likely to have advanced disease for several commonly diagnosed cancers; however, we also found that this was not the case for several key cancers, including lung and liver cancer. There is evidence that Māori have more advanced disease at diagnosis for each of the cancers for which we currently have a national screening programme, reinforcing the importance of achieving equity in access to these programmes. Missing stage information on our national registry undermines our ability to both a) monitor progress towards achieving early diagnosis, and b) examine and monitor the role of stage at diagnosis as a driver of survival disparities for several important cancers for Māori, including lung, liver and stomach cancers.

Protein Content of Wheat by Near-Infrared Spectroscopy of Whole Grain: Collaborative Study

A collaborative study was performed to assess accuracy, repeatability, and reproducibility of a nearinfrared (near-IR) method for determining crude protein content (PC) of whole-grain wheat. Four types of commercially available near-IR instruments, representing various combinations of wavelength region, mode of energy capture, method of energy dispersion, and treatment of spectral data, were used. Eight, 9,10, and 11 collaborators were involved, the exact number depending on instrument type. All collaborators received 22 samples of whole-grain hard red winter (HRW) wheat. They were furnished reference PCs (i.e., protein concentrations, w/w) corrected to a 12% moisture basis for instrument standardization. AOAC Method 990.03— combustion analysis—was the reference procedure. Standardization consisted of performing one of the following treatments to the instrument manufacturer's (or federal agency's) PC equation: (1) bias correction, (2) slope and intercept correction, or (3) recalibration with inclusion of standardization sample spectra. Standardized equations were then applied to a test set of 12 unknown HRW wheat sample spectra, with 2 samples blindly duplicated. The PCs of test samples ranged from 9 to 16%. Near-IR predictions were compared with reference measurements. Averaged within instrument type, root mean square of differences were 0.22, 0.24, 0.25, and 0.26% PC, depending on instrument. Corrected for bias within the test set, standard errors became 0.22, 0.18, 0.21, and 0.24% PC, respectively. These values were approximately twice the estimated lower limit for error (representing sample inhomogeneity). Overall repeatability relative standard deviation (RSD,) values were 0.92, 0.36, 0.42, and 0.74%, respectively. Overall reproducibility relative standard deviation (RSDR) values were 1.15, 0.61,1.53, and 1.38%. Such values for within-laboratory and between-laboratory variations of the near- IR methods were equivalent to values reported for the combustion method (990.03) for wheat. An inhouse study that examined all 6 U.S. wheat classes with one of the 4 instrument types produced repeatability and reproducibility values similar to those of the collaborative study, suggesting that the near-IR technique may be applied to red, white, hard, soft, and durum wheats. The near-IR method for determination of PC of whole-grain wheat has been adopted First Action (997.06) by AOAC INTERNATIONAL.

Accelerating our response: Government of Canada five-year action plan on sexually transmitted and blood-borne infections

Sexually transmitted and blood-borne infections (STBBI)-which include HIV, hepatitis B and C, chlamydia, gonorrhea, syphilis and human papillomavirus-remain significant public health issues both nationally and globally. In 2018, a Pan-Canadian STBBI Framework for Action (the Framework) was released by federal, provincial and territorial governments to provide an overarching and comprehensive approach to addressing STBBI for all those involved. This includes all levels of government, First Nations, Inuit and Métis communities and leadership, frontline service providers, clinicians, public health practitioners, non-governmental organizations and researchers. The Framework includes strategic goals, guiding principles and pillars for action to address STBBI in Canada. In response, the Government of Canada released its own action plan in July 2019: Accelerating Our Response - Government of Canada Five-Year Action Plan on Sexually Transmitted and Blood-Borne Infections (the Action Plan). This document identifies seven priority areas for federal action on STBBI over the next five years: 1) moving toward truth and reconciliation with First Nations, Inuit and Métis Peoples; 2) stigma and discrimination; 3) community innovation-putting a priority on prevention; 4) reaching the undiagnosed-increasing access to STBBI testing; 5) providing prevention, treatment and care to populations that receive health services or coverage of health care benefits from the federal government; 6) leveraging existing knowledge and targeting future research; and 7) measuring impact-monitoring and reporting on trends and results. The Government of Canada is currently working with provincial and territorial governments, First Nations, Inuit and Métis partners, and other stakeholders to develop STBBI indicators and targets for the Canadian context that are appropriate, feasible and measurable against the shared strategic goals of the Framework and the Action Plan. In addition, the Government of Canada has also committed to reporting annually on its progress in implementing the priority areas laid out in the Action Plan.

Equity by 2030: achieving equity in survival for Māori cancer patients

Māori diagnosed with cancer are more likely to die-and to die sooner-than non-Māori with cancer. If we accept that these inequities are unfair and avoidable, then we need a well-resourced and focused approach to eliminating them for Māori. Closing this gap will require significant action and sustained resourcing; but first, it requires an aspirational objective to enable collective ownership and navigation. At the Cancer Care at a Crossroads conference held in Wellington in early 2019, the wider cancer sector accepted a tabled goal: to achieve equity in cancer survival for Māori by the year 2030. In this viewpoint, we provide rationale for this goal, provide some recommendations for how it might be achieved, and address its likely criticisms.

Predictive capacity of prodromal symptoms in first-episode psychosis of recent onset

BACKGROUND

Both the nature and number of a wide range of prodromal symptoms have been related to the severity and type of psychopathology in the psychotic phase. However, at present there is an incomplete picture focused mainly on the positive pre-psychotic dimension.

AIM

To characterize the prodromal phase retrospectively, examining the number and nature of prodromal symptoms as well as their relationship with psychopathology at the onset of first-episode psychosis.

METHODS

Retrospective study of 79 patients experiencing a first-episode psychosis of less than 1 year from the onset of full-blown psychosis. All patients were evaluated with a comprehensive battery of instruments including socio-demographic and clinical questionnaire, IRAOS interview, PANSS, stressful life events scale (PERI) and WAIS/WISC (vocabulary subtest). Bivariate associations and multiple regression analysis were performed.

RESULTS

Regression models revealed that several prodromal dimensions of IRAOS (delusions, affect, language, behaviour and non-hallucinatory disturbances of perception) predicted the onset of psychosis, with positive (22.4% of the variance) and disorganized (25.6% of the variance) dimensions being the most widely explained.

CONCLUSION

In addition to attenuated positive symptoms, other symptoms such as affective, behavioural and language disturbances should also be considered in the definitions criteria of at-high-risk people.

"What is the point of life?": An interpretative phenomenological analysis of suicide in young menwith first-episode psychosis

BACKGROUND

Lifetime risk of suicide in first-episode psychosis far exceeds the general population, with the risk of suicide persisting long after first presentation. There is strong evidence to suggest that women more frequently attempt suicide, while men are at a greater risk of completing suicide. First-hand experiential evidence is needed in order to better understand men's motives for, and struggles with, suicidality in early psychosis.

METHODS

Semi-structured interviews were conducted with 7 participants. The interviews explored each respondent's account of their suicide attempt within the broader context of their life, in relation to their past, present and future. In line with the exploratory, inductive nature of the study, an Interpretative Phenomenological Analysis was used to explore the meaning of suicide attempts in these accounts.

RESULTS

Three super-ordinate themes emerged: Self-as-vulnerable (intra- and inter-personal relationships), appraisal of cumulative life events as unbearable and meaning of recovery marked by shared sense of hope and imagery for the future.

CONCLUSIONS

Young men in the early stages of their treatment are seeking to find meaning for frightening, intrusive experiences with origins which often precede psychosis. These experiences permeate personal identity, relationships and recovery. Suicide was perceived as an escape from this conundrum, and was pursued angrily and impulsively. By contrast, the attainment of hope was marked by sharing one's burden and finding a sense of belonging. Specialized assertive outreach programmes may be beneficial in improving the social inclusion of young men who may be particularly marginalized.