Medication persistence and its impact on type 2 diabetes

OBJECTIVES

Medication persistence in type 2 diabetes (T2D) is a critical factor for preventing adverse clinical events. We assessed persistence among newly treated patients with T2D and documented the impact of persistence on clinical outcomes and costs.

STUDY DESIGN

Retrospective study of Optum Clinformatics Data Mart commercial and Medicare Advantage enrollees from 2007 to 2020.

METHODS

We identified adult patients who initiated antidiabetic treatments. Patients were required to have at least 1 treatment-free year prior to their first T2D prescription. Persistence was measured as the duration of continuous therapy until a 60-day gap in drug availability appeared in any antidiabetic therapy. Factors associated with duration were documented, focusing on the initial class(es) of T2D drugs. The impact of treatment duration on the risk of hospitalization and on total health care costs was also examined.

RESULTS

A total of 673,265 patients were included, with a median follow-up of 7 years. Only 22% of patients maintained continuous treatment, of whom 10% added a second medication. A 1-month increase in duration was associated with reduced risk of hospitalization due to stroke by 0.54% (95% CI, 0.46%-0.60%), acute myocardial infarction by 0.51% (95% CI, 0.44%-0.57%), and all-cause hospitalization by 0.36% (95% CI, 0.34%-0.37%). A 1-month increase in duration was associated with a year-to-year decrease in medical costs of $51 (95% CI, -$54 to -$48) and an increase in year-to-year drug costs of $14 (95% CI, $13-$14).

CONCLUSIONS

Our findings show low persistence among patients with T2D and emphasize the importance of medication persistence, which is associated with cost savings and lower risk of hospitalizations.

Cost-effectiveness of second-line lisocabtagene maraleucel in relapsed or refractory diffuse large B-cell lymphoma

ABSTRACT

Lisocabtagene maraleucel (liso-cel), a chimeric antigen receptor (CAR) T-cell therapy, received the US Food and Drug Administration approval in 2022 for second-line treatment of diffuse large B-cell lymphoma (DLBCL) for patients with refractory disease or early relapse after first-line chemoimmunotherapy. This decision was based on the TRANSFORM study demonstrating improvements in event-free survival with liso-cel compared with standard care. Given the high costs of CAR T-cell therapies, particularly as they transition to second-line treatment, a cost-effectiveness analysis is essential to determine their economic viability. The study used a partitioned survival model with standard parametric functions to evaluate the cost-effectiveness of liso-cel aganist platinum-based chemotherapy followed by high-dose chemotherapy and autologous hematopoietic stem cell transplantation over a lifetime horizon The analysis relied on data from the TRANSFORM and TRANSCEND trials, established literature, and public data sets to calculate the incremental cost-effectiveness ratio (ICER). For a representative cohort of US adults aged 60 years, ICER of liso-cel was $99 669 per quality-adjusted life-year (QALY) from a health care sector perspective and $68 212 per QALY from a societal perspective, confirming its cost-effectiveness at the $100 000 per QALY threshold. Nonetheless, under certain scenarios, liso-cel surpasses this benchmark but remains within the US acceptable range of $150 000 per QALY. A key finding underlines the importance of incorporating productivity losses into such analyses to capture the broader societal values of novel therapies. Although these therapies offer substantial clinical benefits, their high acquisition costs and limited long-term data critically challenge their economic sustainability.

Cost-effectiveness of Axicabtagene Ciloleucel and Tisagenlecleucel as Second-line or Later Therapy in Relapsed or Refractory Diffuse Large B-Cell Lymphoma

IMPORTANCE

Chimeric antigen receptor (CAR) T cell therapies are approved as a third-line or later therapy for several hematological malignant neoplasms. Recently, randomized clinical trials have investigated their efficacy as a second-line treatment in high-risk relapsed or refractory diffuse large B-cell lymphoma (DLBCL) compared with salvage chemotherapy followed by hematopoietic stem cell transplantation (HSCT).

OBJECTIVE

To evaluate the cost-effectiveness of axicabtagene ciloleucel and tisagenlecleucel vs standard care (SC) as second-line or later therapy for relapsed or refractory DLBCL, from both US health care sector and societal perspectives at a cost-effectiveness threshold of $150 000 per quality-adjusted life-year (QALY).

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation assessed cost-effectiveness using a partitioned survival model with 2021 US dollars and QALYs over a lifetime horizon. Model inputs were derived from 2 randomized clinical trials (ZUMA-7 and BELINDA) and published literature. In the trials, patients who did not respond to SC received CAR T cells (treatment switching or crossover), either outside the protocol (ZUMA-7) or as part of the protocol (BELINDA). A separate scenario analysis compared second-line axicabtagene ciloleucel with SC alone without treatment crossover to CAR T cell therapy. Data analysis was performed from December 18, 2021, to September 13, 2022.

EXPOSURES

CAR T cell therapy (axicabtagene ciloleucel and tisagenlecleucel) compared with salvage chemotherapy followed by HSCT.

MAIN OUTCOMES AND MEASURES

Costs and QALYs were used to derive incremental cost-effectiveness ratios (ICERs) for the health care sector and societal perspectives. Cost and QALYs were discounted at 3.0% annually. Univariate and multivariate probabilistic sensitivity analysis using 10 000 Monte Carlo simulations were applied to test model uncertainty on the ICER.

RESULTS

Second-line axicabtagene ciloleucel was associated with an ICER of $99 101 per QALY from the health care sector perspective and an ICER of $97 977 per QALY from the societal perspective, while second-line tisagenlecleucel was dominated by SC (incremental costs of $37 803 from the health care sector and $39 480 from the societal perspective with decremental QALY of -0.02). Third-line or later tisagenlecleucel was associated with an ICER of $126 593 per QALY from the health care sector perspective and an ICER of $128 012 per QALY from the societal perspective. Based on the scenario analysis of no treatment switching, second-line axicabtagene ciloleucel yielded an ICER of $216 790 per QALY from the health care sector perspective and an ICER of $218 907 per QALY from the societal perspective, compared with SC. When accounting for patients achieving prolonged progression-free survival who would not incur progression-related costs, in this scenario ICER changed to $125 962 per QALY from the health care sector perspective and $122 931 per QALY from the societal perspective. These results were most sensitive to increased list prices of CAR T cell therapy and QALY losses associated with axicabtagene ciloleucel and tisagenlecleucel.

CONCLUSIONS AND RELEVANCE

These findings suggest that second-line axicabtagene ciloleucel and third-line or later tisagenlecleucel were cost-effective in treating patients with relapsed or refractory DLBCL at the cost-effectiveness threshold of $150 000 per QALY. However, uncertainty remains regarding the best candidates who would experience value gains from receiving CAR T cell therapy.

Nanoconfinement effects of chemically reduced graphene oxide nanoribbons on poly(vinyl chloride)

Polymeric nanocomposites with graphene-based nanocarbons (GNCs) have been extensively studied with emphasis on the percolation of nanofillers toward electrical, rheological, and mechanical reinforcement. In this study, we report an unusual indirect reinforcing phenomenon of highly defective GNCs dispersed in the poly(vinyl chloride) (PVC) matrix via densification of the polymer packing originating from nanoscale confinement. Herein, chemically reduced graphene oxide nanoribbons (C-rGONRs) are employed as a nanofiller. The inclusion of defective and oxygen-functionalized C-rGONRs resulted in a dramatic densification of the PVC host with extremely low C-rGONR loading, largely exceeding the theoretical calculation from a rule of mixture. Along with the densification, the glass transition temperature of PVC also increased by 28.6 °C at 0.1 wt% filler loading. Remarkably, the oxygen barrier property and mechanical toughness under tension for the PVC/C-rGONR nanocomposite were the maximum when the greatest densification occurred. The structure-property relationship of the nanocomposites has been discussed with an emphasis on the nanoscale confinement phenomenon.

Faucial Pillar Perforation by Glidescope Intubation with Incorrectly Placed Stylet

Glidescope GVL® is frequently used in intubation of difficult airway. We report a case of right side of faucial pillar perforation during intubation with Glidescope®. A rigid stylet can facilitate placing of endotracheal tube quickly but it may also penetrate the soft tissue to cause injuries.

Estimation of pork quality traits using exsanguination blood and postmortem muscle metabolites

The current study was designed to estimate the pork quality traits using metabolites from exsanguination blood and postmortem muscle simultaneously under the Korean standard pre- and post-slaughter conditions. A total of 111 Yorkshire (pure breed and castrated male) pigs were evaluated under the Korean standard conditions. Measurements were taken of the levels of blood glucose and lactate at exsanguination, and muscle glycogen and lactate content at 45 min and 24 h postmortem. Certain pork quality traits were also evaluated. Correlation analysis and multiple regression analysis including stepwise regression were performed. Exsanguination blood glucose and lactate levels were positively correlated with each other, negatively related to postmortem muscle glycogen content and positively associated with postmortem muscle lactate content. A rapid and extended postmortem glycolysis was associated with high levels of blood glucose and lactate, with high muscle lactate content, and with low muscle glycogen content during postmortem. In addition, these were also correlated with paler meat color and reduced water holding capacity. The results of multiple regression analyses also showed that metabolites in exsanguination blood and postmortem muscle explained variations in pork quality traits. Especially, levels of blood glucose and lactate and content of muscle glycogen at early postmortem were significantly associated with an elevated early glycolytic rate. Furthermore, muscle lactate content at 24 h postmortem alone accounted for a considerable portion of the variation in pork quality traits. Based on these results, the current study confirmed that the main factor influencing pork quality traits is the ultimate lactate content in muscle via postmortem glycolysis, and that levels of blood glucose and lactate at exsanguination and contents of muscle glycogen and lactate at postmortem can explain a large portion of the variation in pork quality even under the standard slaughter conditions.

Improved Survival with Anti-VEGF Therapy in the Treatment of Unresectable Appendiceal Epithelial Neoplasms

BACKGROUND

Currently, cytoreductive surgery and hyperthermic intraperitoneal chemotherapy are accepted treatments for surgically resectable appendiceal epithelial neoplasms. However, for nonsurgical candidates, systemic treatment may be considered. The purpose of this analysis was to determine the benefit of biologic therapy (anti-vascular endothelial growth factor and anti-epidermal growth factor receptor) in addition to systemic chemotherapy in this select patient population.

METHODS

The MD Anderson Cancer Center tumor registry was retrospectively reviewed for systemic treatment-naive appendiceal epithelial neoplasm patients registered between January 2000 to July 2007 for prior cytoreductive surgery and hyperthermic intraperitoneal chemotherapy status, histologic grade, signet ring pathology, systemic chemotherapy, biologic therapy, tumor markers (carcinoembryonic antigen, carbohydrate antigen [CA] 125, and/or CA19-9), progression-free survival (PFS), overall survival (OS), and disease control rate. Kaplan-Meier method, log-rank, and Cox proportional hazard regression models were used for statistical analysis.

RESULTS

A total of 353 patients were identified; 130 patients met the inclusion criteria. Fifty-nine patients received biologic therapy. The use of the anti-vascular endothelial growth factor (VEGF) agent bevacizumab improved both OS (42 months vs. 76 months, hazard ratio 0.49 [95 % confidence interval 0.25-0.94] P = 0.03) and PFS (4 months vs. 9 months, hazard ratio 0.69 [95 % confidence interval 0.47-0.995], P = 0.047) for all histologic subtypes. Moderately differentiated tumors had an improved PFS relative to well-differentiated tumors, 9 months versus 3 months (P = 0.05).

CONCLUSIONS

Bevacizumab in combination with chemotherapy appears to play a role in surgically unresectable appendiceal epithelial neoplasm patients, with an improvement in PFS and OS. Anti-VEGF agents should be strongly considered in the management of patients with higher-grade appendiceal epithelial neoplasms who are suboptimal candidates for surgical resection.

Association of blood glucose, blood lactate, serum cortisol levels, muscle metabolites, muscle fiber type composition, and pork quality traits

The objective of this study was to investigate the relationship of blood glucose levels with blood lactate, serum cortisol levels, postmortem muscle glycogen and lactate content, muscle fiber type composition, and pork quality traits. Compared to pigs with lower blood glucose levels, pigs with higher blood glucose levels showed higher blood lactate and serum cortisol levels at exsanguination, and they had lower residual glycogen and higher lactate content in the muscle at 45min postmortem. In addition, pigs with higher blood glucose levels had higher type IIB and lower type I area composition and finally exhibited lower muscle pH, paler color, and excessive loss of fluid on surface. These results imply that measuring blood glucose levels at exsanguination can be useful to indicate early glycolytic rates during postmortem and thus may be of value in the identification of pork with undesirable quality traits.

Effects of muscle cortisol concentration on muscle fiber characteristics, pork quality, and sensory quality of cooked pork

The effect of muscle cortisol concentration on muscle fiber characteristics and technological and sensory quality of pork was investigated. With the exception of the percentage of type IIA fibers, muscle fiber characteristics were not associated to cortisol levels. However, muscle cortisol concentration was positively associated with muscle pH(24h) (r = 0.23, P<0.05) and negatively associated with drip loss (r = -0.49, P<0.001), lightness (r = -0.24, P<0.05), shear force (r = -0.25, P<0.05), and texture profile analysis-hardness (r = -0.35, P<0.01). Additionally, the water-holding capacity of meat samples was affected by cortisol levels, with lower cortisol concentrations associated with less tender samples. These results indicate that the concentration of cortisol in the muscle is related with meat quality as well as the sensory quality of cooked pork.

The influence of pork quality traits and muscle fiber characteristics on the eating quality of pork from various breeds

The purpose of this study was to compare parameters associated with pork quality, muscle fiber, and eating quality among various breeds, and to examine if differences in eating quality were associated to pork quality and muscle fiber characteristics. For carcass and pork quality, although there were significant differences among breeds, the values of parameters in all pigs were assigned a normal quality class, a likely outcome of the similarity in the area percentage of type I and IIB fibers. For eating quality, pork loins from Berkshire pigs were more tender and full of pork flavor than Landrace and Yorkshire pigs. Except juiciness and mouth coating, over 20% of the variability in the eating quality parameters can be explained by pork quality traits and muscle fiber characteristics using multiple regression analysis. Furthermore, differences in muscle pH(24h), cooking loss, shear force, and NPPC marbling score could explain a large proportion of variation in eating quality parameters associated with the texture of pork.

Practical use of surimi-like material made from porcine longissimus dorsi muscle for the production of low-fat pork patties

This study evaluates the effect of replacing fat with surimi-like material (SLM) made from the porcine longissimus dorsi muscle on the physicochemical and sensory characteristics of pork patties. Pork patties were produced with different levels of fat and SLM using a commercial method. Pork patties produced with 20% SLM had the lowest fat content (1.76%, P<0.001), and had a higher cooking yield (87.41 vs. 78.57%, P<0.05) and less shrinkage (4.01 vs. 9.02%, P<0.001) than patties produced with 20% back-fat (control). Moreover, patties produced with SLM exhibited more acceptable organoleptic characteristics, including tenderness (P<0.01) and overall acceptability (P<0.001), than full-fat control patties. These results indicated that SLM cannot only be used as a fat replacer, but that it also improves the physicochemical and sensory characteristics of low-fat pork patties.

Correlations of trained panel sensory values of cooked pork with fatty acid composition, muscle fiber type, and pork quality characteristics in Berkshire pigs

The objective was to examine the relationship of trained panel sensory scores of cooked pork with fatty acid composition, muscle fiber type, and meat quality characteristics from Berkshire pigs. No or few associations were found between the panel sensory scores of cooked meat, especially tenderness attributes, and fatty acid composition; however, intramuscular fat content positively correlated with off-flavor score (r=0.31). On the other hand, the morphological characteristics of muscle fibers were correlated with panel sensory values. Muscles with smaller cross-sectional area and higher density of fibers were more closely associated with softer, more tender panel scores and a lower number of chews than muscles with larger fiber area and lower density of fibers. The water holding capacity test of filter-paper fluid uptake was moderately correlated with panel scores of softness (r=0.33), initial tenderness (r=0.38), chewiness (r=0.40), juiciness (r=-0.27), flavor intensity (r=-0.23), and off-flavor (r=0.30). Panel sensory values of Berkshire pig meat was moderately related to postmortem meat quality, especially water holding capacity. A more thorough understanding of the relationships between fatty acid composition and muscle fiber type with palatability is needed.

Sensory evaluations of porcine longissimus dorsi muscle: Relationships with postmortem meat quality traits and muscle fiber characteristics

The objective of this study was to investigate sensory evaluations and their relationships with meat quality measurements and histochemical characteristics in both fresh and cooked pork. Based on the results, postmortem meat quality traits were closely related to almost all the evaluated sensory attributes. With regard to histochemical characteristics, muscle fiber area was related to both fresh- (r=0.18, P<0.05) and cooked-meat color (r=-0.24, P<0.01) as well as abnormal flavor intensity (r=0.25, P<0.01), and muscle fiber composition was associated with fresh pork color and taste acceptability after cooking. There were no significant relationships (P>0.05) between type IIa muscle fiber content and the evaluated sensory attributes; however, good meat sensory quality was partially explained by the percentage of type I fiber.

The relation of blood glucose level to muscle fiber characteristics and pork quality traits

The purpose of this study was to examine the relationships between blood glucose level, muscle fiber characteristics, and pork quality. Muscle samples were classified into three groups based on blood glucose level measured at slaughter. Pigs with higher area percentages of fiber type IIB showed higher blood glucose levels compared to pigs with lower area percentages of fiber type IIB. The high blood glucose level group presented lower pH values at 45min and 24h postmortem, and also had higher L(∗) values and reduced water holding capacity. In addition, blood glucose level had a negative relationship with pH(45min) and the solubility of sarcoplasmic and myofibrillar proteins, whereas it had a positive relationship with drip loss and filter-paper fluid uptake. In conclusion, blood glucose level was related to muscle fiber area composition and could partially indicate ultimate pork quality.

The relation between glycogen, lactate content and muscle fiber type composition, and their influence on postmortem glycolytic rate and pork quality

This study examined the relation between glycogen, lactate content and muscle fiber type composition, and evaluated their influence on postmortem glycolytic rate and meat quality. Muscle samples were classified based on their glycogen and lactate content at 45min postmortem. Muscles with low glycogen and high lactate levels showed low muscle pH(45min) and high R-values. However, muscles with low glycogen and lactate levels showed normal rates of postmortem glycolysis and normal meat quality. On the other hand, muscles with high glycogen and lactate content showed rapid postmortem glycolysis, paler surface color, higher drip loss, and higher extents of protein denaturation than muscles with high glycogen and low lactate content. These results may be partially explained by muscle fiber type composition. Muscles with low glycogen and lactate content at early postmortem are composed of significantly higher fiber type I and lower fiber type IIB as compared to muscles with high glycogen and lactate content.

Quantification of proteinuria in children using the urinary protein-osmolality ratio

A prospective study was conducted to determine the correlation of early morning urinary protein/osmolality ratio (mg/l/mosmol/kg) with 24-h urinary protein excretion (mg/m2/day). Study patients consisted of 53 children (aged 1 month to 15 years). Early morning urine samples and 24-h urine samples were collected and analyzed. In group 1 (children without proteinuria), early morning urinary protein/creatinine ratio (Uprot/Ucr, mg/mg) was 0.061 +/- 0.011 and the protein/osmolality ratio (Uprot/Uosm, mg/l/mosmol/kg) was 0.073 +/- 0.014. Twenty-four hour urinary protein excretion in group 1 had no significant correlation with Uprot/Ucr or Uprot/Uosm. In group II (children with proteinuria), Uprot/Ucr was 5.78 +/- 1.10 and Uprot/Uosm was 4.42 +/- 1.34. Twenty-four hour urinary protein excretion in group 2 was 1483.6 +/- 303.7 mg/m2/day and its correlation with both Uprot/Uosm and Uprot/Ucr was highly significant (r = 0.87, P < 0.001 and r = 0.88, P < 0.001, respectively). The accepted nephrotic level of proteinuria of 40 mg/m2/h coincides with a Uprot/Uosm ratio of 1.9. In conclusion, early morning urinary Uprot/Uosm is a simple and potentially useful test for 24-h urinary protein excretion, and possibly could be used safely for the assessment of the degree of proteinuria in children.

Macroamylasemia in a patient with acute appendicitis: a case report

Macroamylasemia is a condition of persistent, elevated serum amylase activity with no apparent clinical symptoms of a pancreatic disorder. In Korea, however, no such case has been reported to date. We report a case of a 17-year-old female diagnosed with macroamylasemia and acute appendicitis. One day earlier, she developed epigastric and right lower quadrant abdominal pain. She was characterized by high level of serum amylase, but normal lipase. Amylase isoenzyme analysis demonstrated increased fraction of salivary type and follow-up amylase level was persistently increased. Immunofixation disclosed the macroamylase binding with an immunoglobulin, consisting of IgA and kappa chain. The patient was treated by appendectomy, and the abdominal pain subsided.

Heterogeneity of human papillomavirus DNA in a patient with Bowenoid papulosis that progressed to squamous cell carcinoma

Bowenoid papulosis (BP) of the genitalia, characterized by the histological findings of a squamous cell carcinoma, follows a largely benign clinical course. The detection of oncogenic human papilloma viruses (HPV) from BP points to an aetiological role of these viral infections. A 47-year-old man with multiple genital skin lesions was seen over a 10-year period with the diagnosis of BP. Recently, he attended again with a recurrent genital tumour that was diagnosed as squamous cell carcinoma. His genital lesions progressed and became polymorphic in appearance, from a wart-like tumour to a reddish invasive plaque. To screen for the presence of different HPV sequences from different skin lesions and to correlate each HPV type with distinct clinical manifestations, polymerase chain reaction and single-strand conformational polymorphism (PCR-SSCP) were performed. PCR-SSCP revealed the presence of several types of HPV from different genital lesions. Sequencing results disclosed that he had a mixed infection of HPV6b, HPV16, HPV18 and HPV33, respectively. Interestingly, the clinical findings were fairly well correlated with the oncogenic potential of HPV found from each lesion.

Hepatitis C virus genotypes in Korea and their relationship to clinical outcome in type C chronic liver diseases

OBJECTIVES

The relationship between HCV genotype and the development of more serious liver disease has not been clearly established. This study was to investigate the distribution pattern of HCV genotypes in Korea and their relationship to the viremic level and to progression of chronic liver disease.

METHODS

Study population was 217 patients with type C chronic liver disease. They were divided into 4 groups; 83 patients with near-normal ALT (group 1), 64 patients with elevated ALT (group 2), 20 patients with decompensated liver cirrhosis (group 3) and 50 patients with hepatocellular carcinoma (group 4). HCV genotypes were determined by reverse transcription polymerase chain reaction (RT-PCR) using mixed primer sets, and then the fidelity of genotyping was confirmed by cloning and sequencing. HCV RNA concentration was measured by quantitative competitive RT-PCR for 23 patients in group 2.

RESULTS

The genotypes could be determined in 166 (76%) out of 217 patients. Type 1b and type 2a were predominantly occurring over the other types in somewhat similar frequency (45% and 51%, respectively). The genotype distribution of type 1b and 2a among four different groups showed 42% and 54% in group 1, 49% and 45% in group 2, 53% and 47% in group 3 and 41% and 57% in group 4; thus there was no significant difference in genotype distribution among 4 different disease groups. However, the viremia levels in patients with genotype 1b infection were significantly higher than those with genotype 2a.

CONCLUSION

Genotype 2a infection is as prevalent as genotype 1b in Korea, and genotype 2a infection may pose no less risk for progression of disease despite lower replication level than genotype lb infection.