Critical Examination of Modeling Approaches Used in Economic Evaluations of First-Line Treatments for Locally Advanced or Metastatic Non-Small Cell Lung Cancer Harboring Epidermal Growth Factor Receptor Mutations: A Systematic Literature Review

BACKGROUND

Non-small cell lung cancer (NSCLC) is the most common type of lung cancer, with up to 32% of patients with NSCLC harboring an epidermal growth factor receptor (EGFR) mutation. NSCLC harboring an EGFR mutation has a dedicated treatment pathway, with EGFR tyrosine kinase inhibitors and platinum-based chemotherapy often being the therapy of choice.

OBJECTIVE

The aim of this study was to systemically review and summarize economic models of first-line treatments used for locally advanced or metastatic NSCLC harboring EGFR mutations, as well as to identify areas for improvement for future models.

METHODS

Literature searches were conducted via Ovid in PubMed, MEDLINE, MEDLINE In-Process, Embase, Evidence-Based Medicine Reviews: Health Technology Assessment, Evidence-Based Medicine Reviews: National Health Service Economic Evaluation Database, and EconLit. An initial search was conducted on 19 December 2022 and updated on 11 April 2023. Studies were selected according to predefined criteria using the Population, Intervention, Comparator, Outcome and Study design (PICOS) framework.

RESULTS

Sixty-seven articles were included in the review, representing 59 unique studies. The majority of included models were cost-utility analyses (n = 52), with the remaining studies being cost-effectiveness analyses (n = 4) and a cost-minimization analysis (n = 1). Two studies incorporated both a cost-utility and cost-minimization analysis. Although the model structure across studies was consistently reported, justification for this choice was often lacking.

CONCLUSIONS

Although the reporting of economic models in NSCLC harboring EGFR mutations is generally good, many of these studies lacked sufficient reporting of justification for structural choices, performing extensive sensitivity analyses and validation in economic evaluations. In resolving such gaps, the validity of future models can be increased to guide healthcare decision making in rare indications.

Automated Category and Trend Analysis of Scientific Articles on Ophthalmology Using Large Language Models: Development and Usability Study

BACKGROUND

In this paper, we present an automated method for article classification, leveraging the power of large language models (LLMs).

OBJECTIVE

The aim of this study is to evaluate the applicability of various LLMs based on textual content of scientific ophthalmology papers.

METHODS

We developed a model based on natural language processing techniques, including advanced LLMs, to process and analyze the textual content of scientific papers. Specifically, we used zero-shot learning LLMs and compared Bidirectional and Auto-Regressive Transformers (BART) and its variants with Bidirectional Encoder Representations from Transformers (BERT) and its variants, such as distilBERT, SciBERT, PubmedBERT, and BioBERT. To evaluate the LLMs, we compiled a data set (retinal diseases [RenD] ) of 1000 ocular disease-related articles, which were expertly annotated by a panel of 6 specialists into 19 distinct categories. In addition to the classification of articles, we also performed analysis on different classified groups to find the patterns and trends in the field.

RESULTS

The classification results demonstrate the effectiveness of LLMs in categorizing a large number of ophthalmology papers without human intervention. The model achieved a mean accuracy of 0.86 and a mean F1-score of 0.85 based on the RenD data set.

CONCLUSIONS

The proposed framework achieves notable improvements in both accuracy and efficiency. Its application in the domain of ophthalmology showcases its potential for knowledge organization and retrieval. We performed a trend analysis that enables researchers and clinicians to easily categorize and retrieve relevant papers, saving time and effort in literature review and information gathering as well as identification of emerging scientific trends within different disciplines. Moreover, the extendibility of the model to other scientific fields broadens its impact in facilitating research and trend analysis across diverse disciplines.

Justifying the source of external comparators in single-arm oncology health technology submissions: a review of NICE and PBAC assessments

Background: The drive to expedite patient access for diseases with high unmet treatment needs has come with an increasing use of single-arm trials (SATs), especially in oncology. However, the lack of control arms in such trials creates challenges to assess and demonstrate comparative efficacy. External control (EC) arms can be used to bridge this gap, with various types of sources available to obtain relevant data. Objective: To examine the source of ECs in single-arm oncology health technology assessment (HTA) submissions to the National Institute for Health and Care Excellence (NICE) and the Pharmaceutical Benefits Advisory Committee (PBAC) and how this selection was justified by manufacturers and assessed by the respective HTA body. Methods: Single-arm oncology HTA submission reports published by NICE (England) and PBAC (Australia) from January 2011 to August 2021 were reviewed, with data qualitatively synthesized to identify themes. Results: Forty-eight oncology submissions using EC arms between 2011 and 2021 were identified, with most submissions encompassing blood and bone marrow cancers (52%). In HTA submissions to NICE and PBAC, the EC arm was typically constructed from a combination of data sources, with the company's justification in data source selection infrequently provided (PBAC [2 out of 19]; NICE [6 out of 29]), although this lack of justification was not heavily criticized by either HTA body. Conclusion: Although HTA bodies such as NICE and PBAC encourage that EC source justification should be provided in submissions, this review found that this is not typically implemented in practice. Guidance is needed to establish best practices as to how EC selection should be documented in HTA submissions.

Navigating the unknown: how to best 'reflect' standard of care in indications without a dedicated treatment pathway in health technology assessment submissions

There is an urgent need for expedited approval and access for new health technologies targeting rare and very rare diseases, some of which are associated with high unmet treatment needs. Once a new technology achieves regulatory approval, the technology needs to be assessed by health technology assessment (HTA) bodies to inform coverage and reimbursement decisions. This assessment quantitatively examines the clinical effectiveness, safety and/or economic impact of the new technology relative to standard of care (SoC) in a specific market. However, in rare and very rare diseases, the patient populations are small and there is often no established treatment pathway available to define 'SoC'. In these situations, several challenges arise to assess the added benefit of a new technology - both clinically and economically - due to lack of established SoC to guide an appropriate comparator selection. These challenges include: How should 'SoC' be defined and characterized in HTA submissions for new technologies aiming to establish new treatment standards? What is usual care without an established clinical pathway? How should the evidence for the comparator 'SoC' (i.e., usual care) arm be collected in situations with low patient representation and, sometimes, limited disease-specific clinical knowledge in certain geographies? This commentary outlines the evidence generation challenges in designing clinical comparative effectiveness for a new technology when there is a lack of established SoC. The commentary also proposes considerations to facilitate the reliable integration of real-world evidence into HTA and decision-making based on the collective experience of the authors.

Efficacy of Mobocertinib and Amivantamab in Patients With Advanced Non-Small Cell Lung Cancer With EGFR Exon 20 Insertions Previously Treated With Platinum-Based Chemotherapy: An Indirect Treatment Comparison

INTRODUCTION

Exon 20 insertions (ex20ins) mutations of the EGFR gene account for 1% to 2% of all non-small-cell lung cancers (NSCLCs). Targeted therapies have been developed to treat this cancer type but have not been studied in head-to-head trials. Our objective was to use a matching-adjusted indirect comparison (MAIC) to assess the efficacy of mobocertinib and amivantamab in patients with NSCLC EGFR ex20ins mutations who were previously treated with platinum-based chemotherapy.

MATERIALS AND METHODS

An unanchored MAIC was conducted to estimate the treatment effects of mobocertinib and amivantamab using individual-level data from the mobocertinib phase I/II single-arm trial (NCT02716116) and published data from the amivantamab single-arm CHRYSALIS trial (NCT02609776). Confirmed overall response rate (cORR), progression-free survival (PFS), overall survival (OS), and duration of response (DoR) were assessed.

RESULTS

Both trials were comparable in terms of study population, study design, and outcome definitions and included 114 patients who received mobocertinib and 114 patients who received amivantamab. After MAIC weighting, all reported baseline characteristics were balanced between mobocertinib and amivantamab. The weighted odds ratio (OR) [95% confidence interval (CI)] comparing mobocertinib to amivantamab was 0.56 (0.30-1.04) for independent review committee (IRC)-assessed cORR and 0.98 (0.53-1.82) for investigator (INV)-assessed cORR. The weighted hazard ratio (HR) comparing mobocertinib to amivantamab was 0.74 (0.51-1.07) for IRC-assessed PFS, 0.92 (0.57-1.48) for OS, and 0.59 (0.30-1.18) for INV-assessed DoR.

CONCLUSION

MAIC analysis showed that mobocertinib and amivantamab had similar efficacy in patients with NSCLC harboring EGFR ex20ins mutations whose disease progressed during or after platinum-based chemotherapy. These findings may benefit patients by supporting future treatment options.

Role of Sleep Apnea and Long-Term CPAP Treatment in the Prognosis of Patients With Melanoma: A Prospective Multicenter Study of 443 Patients

BACKGROUND

OSA has been associated with increased incidence and aggressiveness of melanoma. However, the long-term impact of OSA and CPAP treatment on the prognosis of melanoma remains unexplored.

RESEARCH QUESTION

Are OSA and CPAP treatment associated independently with a poor prognosis for cutaneous melanoma?

STUDY DESIGN AND METHODS

Four hundred forty-three patients with a diagnosis of cutaneous melanoma (2012-2015) underwent a sleep study within 6 months of diagnosis. The main 5-year outcome of the study was a composite of melanoma recurrence, metastasis, or mortality. Patients were divided into four groups: baseline apnea-hypopnea index (AHI) of fewer than 10 events/h (no OSA; control group), OSA treated with CPAP and good adherence, untreated or poor CPAP adherence in moderate (AHI, 10-29 events/h), and severe OSA (AHI, ≥ 30 events/h). Survival analysis was used to determine the independent role of OSA and CPAP treatment on melanoma composite outcome.

RESULTS

Three hundred ninety-one patients (88.2%) were available for analysis at 5-year follow-up (mean age, 65.1 ± 15.2 years; 49% male; Breslow index, 1.7 ± 2.5 mm). One hundred thirty-nine patients had AHI of fewer than 10 events/h (control group); 78 patients with OSA were adherent to CPAP; and 124 and 50 patients had moderate and severe OSA, respectively, without CPAP treatment. Median follow-up was 60 months (interquartile range, 51-74 months). During follow-up, 32 relapses, 53 metastases, and 52 deaths occurred (116 patients showed at least one of the main composite outcomes). After adjusting for age, sex, sentinel lymph nodes affected at diagnosis, BMI, diabetes, nighttime with an oxygen saturation below 90%, Breslow index, Epworth sleepiness scale scores, and melanoma treatment, moderate (hazard ratio [HR], 2.45; 95% CI, 1.09-5.49) and severe OSA (HR, 2.96; 95% CI, 1.36-6.42) were associated with poorer prognosis of melanoma compared with the control group. However, good adherence to CPAP avoided this excess risk (HR, 1.66; 95% CI, 0.71-3.90).

INTERPRETATION

Moderate to severe untreated OSA is an independent risk factor for poor prognosis of melanoma. Treatment with CPAP is associated with improved melanoma outcomes compared with untreated moderate to severe OSA.

Characterizing ruminal acidosis risk: A multiherd, multicountry study

A multicenter observational study was conducted on early lactation Holstein cows (n = 261) from 32 herds from 3 regions (Australia, AU; California, CA; and Canada, CAN) to characterize their risk of acidosis into 3 groups (high, medium, or low) using a discriminant analysis model previously developed. Diets ranged from pasture supplemented with concentrates to total mixed ration (nonfiber carbohydrates = 17 to 47 and neutral detergent fiber = 27 to 58% of dry matter). Rumen fluid samples were collected <3 h after feeding and analyzed for pH, and ammonia, d- and l-lactate, and volatile fatty acid (VFA) concentrations. Eigenvectors were produced using cluster and discriminant analysis from a combination of rumen pH, and ammonia, d-lactate, and individual VFA concentrations and were used to calculate the probability of the risk of ruminal acidosis based on proximity to the centroid of 3 clusters. Bacterial 16S ribosomal DNA sequence data were analyzed to characterize bacteria. Individual cow milk volume, fat, protein, and somatic cell count values were obtained from the closest herd test to the rumen sampling date (median = 1 d before rumen sampling). Mixed model analyses were performed on the markers of rumen fermentation, production characteristics, and the probability of acidosis. A total of 26.1% of the cows were classified as high risk for acidosis, 26.8% as medium risk, and 47.1% as low risk. Acidosis risk differed among regions with AU (37.2%) and CA (39.2%) having similar prevalence of high-risk cows and CAN only 5.2%. The high-risk group had rumen phyla, fermentation, and production characteristics consistent with a model of acidosis that reflected a rapid rate of carbohydrate fermentation. Namely, acetate to propionate ratio (1.98 ± 0.11), concentrations of valerate (2.93 ± 0.14 mM), milk fat to protein ratio (1.11 ± 0.047), and a positive association with abundance of phylum Firmicutes. The medium-risk group contains cows that may be inappetant or that had not eaten recently or were in recovery from acidosis. The low-risk group may represent cattle that are well fed with a stable rumen and a slower rumen fermentation of carbohydrates. The high risk for acidosis group had lower diversity of bacteria than the other groups, whereas CAN had a greater diversity than AU and CA. Rumen fermentation profile, abundance of ruminal bacterial phyla, and production characteristics of early lactation dairy cattle from 3 regions were successfully categorized in 3 different acidosis risk states, with characteristics differing between acidosis risk groups. The prevalence of acidosis risk also differed between regions.

Accelerated Vascular Aging in Chronic Kidney Disease: The Potential for Novel Therapies

The pathophysiology of vascular disease is linked to accelerated biological aging and a combination of genetic, lifestyle, biological, and environmental risk factors. Within the scenario of uncontrolled artery wall aging processes, CKD (chronic kidney disease) stands out as a valid model for detailed structural, functional, and molecular studies of this process. The cardiorenal syndrome relates to the detrimental bidirectional interplay between the kidney and the cardiovascular system. In addition to established risk factors, this group of patients is subjected to a plethora of other emerging vascular risk factors, such as inflammation, oxidative stress, mitochondrial dysfunction, vitamin K deficiency, cellular senescence, somatic mutations, epigenetic modifications, and increased apoptosis. A better understanding of the molecular mechanisms through which the uremic milieu triggers and maintains early vascular aging processes, has provided important new clues on inflammatory pathways and emerging risk factors alike, and to the altered behavior of cells in the arterial wall. Advances in the understanding of the biology of uremic early vascular aging opens avenues to novel pharmacological and nutritional therapeutic interventions. Such strategies hold promise to improve future prevention and treatment of early vascular aging not only in CKD but also in the elderly general population.

Indirect comparison of mobocertinib and real-world therapies for pre-treated non-small cell lung cancer with EGFR exon 20 insertion mutations

OBJECTIVES

Mobocertinib, a novel oral epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor, is available for the treatment of non-small cell lung cancer (NSCLC) with EGFR exon 20 insertion (ex20ins) mutations after platinum chemotherapy. We performed an indirect comparison of clinical trial data and real-world data (RWD) to determine the relative efficacy of mobocertinib vs. other treatments for these patients.

MATERIALS AND METHODS

Data on the efficacy of mobocertinib from a phase I/II trial (NCT02716116) were compared to RWD from a retrospective study in 12 German centers using inverse probability of treatment weighting to adjust for age, sex, Eastern Cooperative Oncology Group score, smoking status, presence of brain metastasis, time from advanced diagnosis, and histology. Tumor response assessment was based on RECIST v1.1.

RESULTS

The analysis included 114 patients in the mobocertinib group and 43 in the RWD group. The confirmed overall response rate (cORR) according to investigator assessment was 0% for standard treatments and 35.1% (95% confidence interval [CI], 26.4-44.6) for mobocertinib (p < 0.0001). Compared to standard regimens in the weighted population, mobocertinib prolonged overall survival (OS, median [95% CI] = 9.8 [4.3-13.7] vs. 20.2 [14.9-25.3] months; hazard ratio [HR] = 0.42 [0.25-0.69], p = 0.0035), progression-free survival (PFS, median [95% CI] = 2.6 [1.5-5.7] vs. 7.3 [5.6-8.8] months; HR = 0.28 [0.18-0.44], p < 0.0001), and time to treatment discontinuation (median [95% CI] = 2.1 [1.2-3.1] vs. 7.4 [6.4-8.5] months; HR = 0.34 [0.18-0.65], p = 0.0004).

CONCLUSION

Mobocertinib was associated with an improved cORR and prolonged PFS and OS compared to standard treatments for patients with EGFR ex20ins-positive NSCLC previously treated with platinum-based chemotherapy.

The budget impact of introducing mobocertinib for the postplatinum treatment of advanced non-small cell lung cancer harboring epidermal growth factor receptor exon 20 insertion mutations

BACKGROUND: Lung cancer is a leading cause of cancer morbidity and death in the United States. Non-small cell lung cancer (NSCLC) accounts for 85% of lung cancer cases, and oncogenic mutations in the gene encoding the epidermal growth factor receptor (EGFR) are among its most common genetic causes. Although NSCLC tumors harboring more common oncogenic EGFR mutations can be effectively treated with EGFR tyrosine kinase inhibitors (TKIs), those harboring EGFR exon 20 insertion mutations respond poorly to treatment with therapies approved for advanced NSCLC, including TKIs. Mobocertinib, a first-in-class potent, oral, irreversible TKI, is effective in this population. OBJECTIVE: To estimate the budget impact, for a US health plan with 10 million members, of introducing mobocertinib for the treatment of patients with locally advanced or metastatic NSCLC harboring EGFR exon 20 insertion mutations who have been previously treated with platinum-based chemotherapy. METHODS: A budget impact model was developed to compare 2 scenarios: a reference scenario in which 50% of patients received amivantamab and 50% received physician's choice/usual care therapy and an alternative scenario in which mobocertinib replaced the physician's choice/usual care option. The model had a 5-year time horizon in the base case. The model included epidemiologic inputs to estimate the size of the treatment-eligible population; clinical inputs to estimate treatment duration and efficacy, as well as adverse event frequency; and cost inputs for treatment acquisition and administration, management of adverse events, monitoring, and terminal care. The duration and cost of subsequent therapies were also considered. Budget impact was reported as a total cost, as per-member per-year costs, and as per-member per-month (PMPM) costs. To assess the robustness of model estimates and identify cost drivers, one-way sensitivity analyses and a range of scenario analyses were conducted. RESULTS: The model estimated an eligible treatment population of 55 patients (11 per year) over a 5-year time horizon. In the base case, the estimated budget impact of introducing mobocertinib was $5,615,808, or $0.01 PMPM. Model findings were robust to one-way sensitivity analyses and a range of sensitivity analyses; none of these analyses led to a PMPM budget impact of more than $0.06. Cost drivers included the percentage of eligible patients, the median duration of physician's choice/usual care therapy, patient weight, and the percentage of patients who undergo molecular testing. CONCLUSIONS: The estimated budget impact of mobocertinib is low, primarily because NSCLC harboring EGFR exon 20 insertion mutations is rare. DISCLOSURES: Dr Hernandez is an employee of Takeda Pharmaceuticals America, Inc. Dr Young was an employee of Takeda Pharmaceuticals America, Inc., at the time this study was conducted. This study and the editorial assistance were funded by Takeda Pharmaceuticals America, Inc.

Simulation in thoracic surgery-A mini review of a vital educational tool to maximize peri-operative care and minimize complications

Thoracic surgery is an increasingly expanding field, and the addition of national screening programs has resulted in increasing operative numbers and complexity. Thoracic surgery overall has an approximately 2% mortality and 20% morbidity with common specific complications including persistent air leak, pneumothorax, and fistulas. The nature of the surgery results in complications being unique to thoracic surgery and often very junior members of the surgical team feel underprepared to deal with these complications after very little exposure during their medical school and general surgical rotations. Throughout medicine, simulation is being increasingly used as a method to teach the management of complicated, rare, or significant risk occurrences and has shown significant benefits in learner confidence and outcomes. In this mini review we explain the learning theory and benefits of simulation learning. We also discuss the current state of simulation in thoracic surgery and its potential future in aiding complication management and patient safety.

Matching-adjusted indirect comparison (MAIC) of mobocertinib versus amivantamab in patients with non–small cell lung cancer (NSCLC) with EGFR exon 20 insertions (ex20ins)

9115

Background: Mobocertinib (mobo) and amivantamab (ami) are FDA-approved treatments for patients (pts) with locally advanced or metastatic NSCLC with EGFR ex20ins whose disease progressed on or after platinum-based chemotherapy. An unanchored MAIC was used to compare confirmed overall response rate (cORR), duration of response (DoR), progression-free survival (PFS) and overall survival (OS) between mobo and ami. Methods: Clinical outcomes were compared in platinum-pretreated pts with EGFR ex20ins+ NSCLC treated with mobo 160 mg QD in a phase I/II single-arm study (NCT02716116, cut-off 1 Nov 2020, n=114) or with ami 1,050 mg (1,400 mg, ≥80 kg) in a phase I single-arm study (NCT02609776, cut-off 8 June 2020, n=81). Differences in baseline characteristics reported in both studies, including age, race, sex, smoking status, Eastern Cooperative Oncology Group, histology, sites of metastasis (brain, bone and liver), time from advanced diagnosis, number of prior lines of therapy, prior immuno-oncology therapy, prior EGFR tyrosine kinase inhibitor treatment and prior EGFR ex20ins targeted therapy, were adjusted with MAIC. Results: After MAIC weighting all reported baseline characteristics were balanced between mobo and ami. OS and cORR per investigator assessment (INV) were similar between mobo and ami (Table). cORR per independent review committee (IRC) was numerically higher for ami (odds ratio [OR]=0.64, p value=0.230). For PFS per IRC, the adjusted hazard ratio (HR) was numerically favorable for mobo (HR=0.82, p value=0.417). Among the responders, DoR was longer for mobo (DoR per INV: HR=0.44, p value=0.049; DoR per IRC: HR=0.56, p value=0.149). Conclusions: Mobo and ami appear to have overall similar efficacy. As each has a different mechanism of action and route of administration, they provide multiple options in the treatment of EGFR ex20ins+ NSCLC. Clinical trial information: NCT02716116. [Table: see text]

Global Health Security Preparedness and Response: An Analysis of the Relationship between Joint External Evaluation Scores and COVID-19 Response Performance

OBJECTIVES

The COVID-19 pandemic has highlighted the importance and complexity of a country's ability to effectively respond. The Joint External Evaluation (JEE) assessment was launched in 2016 to assess a country's ability to prevent, detect and respond to public health emergencies. We examined whether JEE indicators could be used to predict a country's COVID-19 response performance to tailor a country's support more effectively.

DESIGN

From April to August 2020, we conducted interviews with Centers for Disease Control and Prevention country offices that requested COVID-19 support and previously completed the JEE (version 1.0). We used an assessment tool, the 'Emergency Response Capacity Tool' (ERCT), to assess COVID-19 response performance. We analysed 28 ERCT indicators aligned with eight JEE indicators to assess concordance and discordance using strict agreement and weighted kappa statistics. Generalised estimating equation (GEE) models were used to generate predicted probabilities for ERCT scores using JEE scores as the independent model variable.

RESULTS

Twenty-three countries met inclusion criteria. Of the 163 indicators analysed, 42.3% of JEE and ERCT scores were in agreement (p value=0.02). The JEE indicator with the highest agreement (62%) was 'Emergency Operations Center (EOC) operating procedures and plans', while the lowest (16%) was 'capacity to activate emergency operations'. Findings were consistent with weighted kappa statistics. In the GEE model, EOC operating procedures and plans had the highest predicted probability (0.86), while indicators concerning response strategy and coordination had the lowest (≤0.5).

CONCLUSIONS

Overall, there was low agreement between JEE scores and COVID-19 response performance, with JEE scores often trending higher. JEE indicators concerning coordination and operations were least predictive of COVID-19 response performance, underscoring the importance of not inferring country response readiness from JEE scores alone. More in-depth country-specific investigations are likely needed to accurately estimate response capacity and tailor countries' global health security activities.

Effect of continuous positive airway pressure in very elderly with moderate-to-severe obstructive sleep apnea pooled results from two multicenter randomized controlled trials

STUDY OBJECTIVE

There is very limited information about the effect of continuous positive airway pressure (CPAP) in the very elderly. Here we aimed to analysed the effect of CPAP on a clinical cohort of patients with obstructive sleep apnea (OSA) ≥80 years old.

METHODS

Post-hoc pooled analysis of two open-label, multicenter clinical trials aimed to determine the effect of CPAP in a consecutive clinical cohort of elderly (≥70 years old) with moderate-to-severe OSA (apnea-hipopnea index ≥15 events/hour) randomized to receive CPAP or no CPAP for three months. Those consecutive patients ≥80 years old were included in the study. The primary endpoint was the change in Epworth Sleepiness scale (ESS). Secondary outcomes included sleep-related symptoms, quality of life, neurocognitive and mood status as well as office blood pressure measurements.

RESULTS

From the initial 369 randomized individuals with ≥70 years, 97 (26.3%) with ≥80 years old were included (47 in the CPAP group and 50 in the no-CPAP group). The mean (SD) age was 81.5 (2.4) years. Average use of CPAP was 4.3 (2.6) hours/night (53% with good adherence) Patients in the CPAP group significantly improved snoring and witnessed apneas as well as AHI (from 41.9 to 4.9 events/hour). However no clinical improvements were seen in ESS (-1.2 points, 95%CI, 0.2 to -2.6), any domain of QSQ, any neurocognitive test, OSA-related symptoms, depression/anxiety or blood pressure levels.

CONCLUSIONS

The present study does not support the use of CPAP in very elderly patients with moderate-to-severe OSA.

Predictors of Health Utility in Relapsing-Remitting and Secondary-Progressive Multiple Sclerosis: Implications for Future Economic Models of Disease-Modifying Therapies

BACKGROUND

Decision-analytic models used in economic evaluations of disease-modifying therapies for relapsing-remitting multiple sclerosis (RRMS) have characterized disease progression and accrue quality-adjusted life-years from utility values based on the Expanded Disability Status Scale (EDSS), the occurrence of relapses, and progression to secondary-progressive multiple sclerosis (SPMS). The EDSS, used to characterize disability progression, has several limitations. If the EDSS is the only disability measure used in economic evaluations, the long-term clinical and economic implications of disease-modifying therapies may not be properly assessed.

OBJECTIVE

The objective of this study was to explore if supplementary disability measures including the Timed 25-Foot Walk (T25FW), 9-Hole Peg Test (9HPT), and Paced Auditory Serial Addition Test (PASAT) significantly contribute additional information on health utility in RRMS and SPMS otherwise not captured by the EDSS and relapses and, therefore, should be considered in future economic evaluations of disease-modifying therapies.

METHODS

Short-Form Six-Dimension utility scores were derived from the RAND 36-Item Health Survey 1.0 individual-level data available in the Multiple Sclerosis Outcome Assessment Consortium (MSOAC) Placebo Database. Repeated-measures mixed-effects models were conducted to estimate the effects of EDSS, T25FW, 9HPT (dominant and non-dominant hand), PASAT, and relapses on changes in utility over time, controlling for demographics.

RESULTS

A higher level of EDSS, longer time to complete the T25FW test, and a recent relapse were significant predictors of lower utility in people with RRMS and SPMS. 9HPT and PASAT were not significant predictors.

CONCLUSIONS

This study suggests that in addition to EDSS and recent relapses, T25FW significantly predicts utility in RRMS and SPMS. These findings support the use of T25FW to supplement the EDSS and the occurrence of relapses to characterize the course of disease progression and to more accurately accrue quality-adjusted life-years in future economic evaluations of disease-modifying therapies for the treatment of RRMS.

Identification and Characterization of a Minimal Functional Splicing Regulatory Protein, PTBP1

Polypyrimidine tract binding protein 1 (PTBP1) is a well-studied RNA binding protein that serves as an important model for understanding molecular mechanisms underlying alternative splicing regulation. PTBP1 has four RNA binding domains (RBDs) connected via linker regions. Additionally, PTBP1 has an N-terminal unstructured region that contains nuclear import and export sequences. Each RBD can bind to pyrimidine rich elements with high affinity to mediate splicing activity. Studies support a variety of models for how PTBP1 can mediate splicing regulation on target exons. Obtaining a detailed atomic view hinges on determining a crystal structure of PTBP1 bound to a target RNA transcript. Here, we created a minimal functional PTBP1 with deletions in both linker 1 and linker 2 regions and assayed for activity on certain regulated exons, including the c-Src N1 exon. We show that for a subset of PTBP1-regulated exons the linker regions are not necessary for splicing repression activity. Gel mobility shift assays reveal the linker deletion mutant binds with 12-fold higher affinity to a target RNA sequence compared to wild-type PTBP1. A minimal PTBP1 that also contains an N-terminal region deletion binds to a target RNA with an affinity higher than that of wild-type PTBP1. Moreover, this minimal protein oligomerizes readily to form a distinct higher-order complex previously shown to be required for mediating splicing repression. This minimal functional PTBP1 protein can serve as a candidate for future structure studies to understand the mechanism of splicing repression for certain regulated exons.

Economic Implications of Preventing Major Cardiovascular and Limb Events with Rivaroxaban plus Aspirin in Patients with Coronary or Peripheral Artery Disease in the United States

BACKGROUND

Patients with chronic coronary artery disease (CAD) and/or peripheral artery disease (PAD) have increased risks for cardiovascular (CV)-related morbidity and mortality. In the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) clinical trial of such patients, rivaroxaban plus aspirin demonstrated a significant reduction in major adverse CV events (MACE), a composite of stroke, myocardial infarction, and CV death, and major adverse limb events (MALE), a composite of chronic and acute limb ischemia, and major amputation resulting from vascular events, versus aspirin alone.

OBJECTIVE

To estimate the 1-year economic implications of preventing MACE and MALE with the use of rivaroxaban plus aspirin versus aspirin alone among patients with chronic CAD and/or PAD in a US commercial health plan.

METHOD

A cost-consequence model was developed to evaluate the economic impact of rivaroxaban plus aspirin in a hypothetical 1-million-member health plan. The model inputs were taken from the COMPASS study (ie, the efficacy and safety of rivaroxaban plus aspirin vs aspirin), Optum Integrated Database (ie, the prevalence of chronic CAD and/or PAD, incidence rates, and healthcare costs of MACE, MALE, and major bleeding), and the RED BOOK (ie, wholesale drug acquisition costs). The cost inputs were in 2019 US dollars. One-way sensitivity analyses and subgroup analyses were conducted.

RESULTS

A 1-year treatment with rivaroxaban plus aspirin resulted in reductions of MACE and MALE, which balance the increased risk for bleeding versus aspirin alone and indicate a net health benefit for this drug regimen. These reductions were achieved at an incremental per-member per-month (PMPM) cost of $0.16, mainly because of rivaroxaban's acquisition cost. In patients with ≥2 MACE or MALE risk factors, the incremental PMPM cost was $0.09, given the increased offset in rivaroxaban's acquisition cost by reduced rates of MACE or MALE.

CONCLUSIONS

In an era of emerging thrombocardiology, treatment with rivaroxaban plus aspirin offers an effective thrombotic risk management strategy for healthcare stakeholders in the management of chronic CAD and/or PAD. The contribution of rivaroxaban would be greater in patients with ≥2 risk factors for MACE or MALE.

AB0538 PREGNANCY OUTCOMES IN PATIENTS WITH TAKAYASU’S ARTERITIS: CASE SERIES

Background:

Takayasu’s arteritis (TA) is most prevalent in women of childbearing age. Although its activity and risk of relapse are low during pregnancy, up to 40% of patients may have unfavorable obstetric outcomes and therefore it is important to know their clinical behavior.

Objectives:

To describe the clinical features and obstetric outcomes of pregnant women with TA treated in a tertiary center.

Methods:

Retrospective evaluation of medical records of 6 pregnancies in 6 women with TAs treated in a tertiary center in Medellin, Colombia between 2011-2018.

Results:

Six women who were 17.5 (RI 9.25) years old at diagnosis and 24 (RI 8.25) years old at delivery, their disease duration were 5.5 (RI 10.5) years. Three patients had extensive aortic involvement classified as Numano type V, two as type IIB and one as type I. At delivery, three patients were active and required immunosuppressants, five had high blood pressure, one developed preeclampsia in the second trimester, one had severe mitral and tricuspid insufficiency with decreased ejection fraction of the left ventricle; two had aneurysms (left subclavian artery and ascending aorta). There were two fetal deaths, one due to intrauterine growth restriction and placental insufficiency and another of unknown etiology; both patients with disease activity, extensive aortic condition and arterial hypertension; no pregnancy resulted in abortion or preterm birth. Five deliveries were by caesarean section by maternal indication; there was no aortic dissection, aneurismal rupture or cerebral hemorrhage (table).

Table

Patient’s characteristics

PatientAge at diagnosisAge at deliveryClinical featuresHata-Numano classificationMaternal outcomeFetal outcome1617HT, absence of left brachial and radial pulses, L carotid and subclavian murmurs, LVEF 47%VHT, C-sectionTerm delivery, SGA22226HT, abscence of L brachial and radial pulses, L carotid and subclavian murmurs, dyspnea, anginaV(plus pulmonary)HT, vaginal birthPlacental insufficiency, IUGR, fetal death31438HT, abscence of L brachial and radial pulses, L carotid and subclavian murmurs, intermittent claudication, dyspnea, aortic regurgitationIIBHT, C-sectionTerm delivery, SGA41824HT, malaise,, abscence of L brachial and radial pulses, intermittent claudication, arthralgiaIIBPreeclampsia, C-sectionTerm delivery, SGA51722Fever, malaise, intermittent claudication, arthralgiaIC-sectionTerm delivery, SGA62124HT, abscense of bilateral femoral, popliteal, tibial and pedial pulses, headache, dizziness, amaurosisVHT, C-sectionFetal death

HT: hypertension; L: left; LVEF: left ventricular ejection fraction; C-section: cesarean section; SGA: small for gestational age; IUGR: intrauterine growth restriction

Conclusion:

Pregnant women with active disease and extensive aortic condition presented unfavorable obstetric results, suggesting that an inadequate control of vasculitis may lead to greater maternal-fetal complications.

References:

[1]Assad APL, da Silva TF, Bonfa E, Pereira RMR. Maternal and Neonatal Outcomes in 89 Patients with Takayasu Arteritis (TA): Comparison Before and After the TA Diagnosis. J Rheumatol. 2015 Oct;42(10):1861–4.

[2]Hidaka N, Yamanaka Y, Fujita Y, Fukushima K, Wake N. Clinical manifestations of pregnancy in patients with Takayasu arteritis: experience from a single tertiary center. Arch Gynecol Obstet. 2012 Feb;285(2):377–85.

Disclosure of Interests:

None declared

FRI0222 MAGNETIC RESONANCE IMAGING OF MUSCLE INVOLVEMENT IN POLYARTERITIS NODOSA

Background:

muscle involvement is frequently reported in polyarteritis nodosa (PAN), mostly as myalgia, muscle swelling, and gait difficulty due to intramuscular arteries involvement, peripheral neuropathy, or myositis with slightly or no elevation of muscle enzymes. Magnetic resonance imaging (MRI) findings of compromised muscles have been reported in isolated cases, mainly as a limited form of PAN, however, muscular involvement patterns in MRI of patients with PAN have been recently described

Objectives:

to describe MRI of legs findings in patients with PAN in a tertiary center from Medellin-Colombia.

Methods:

it was performed a retrospective cross-sectional descriptive study of 15 adult patients who were clinically assessed as having PAN and who had undergone MRI of legs between January 2011 and December 2019. Characteristics already informed in previous studies, affected structures (muscle, subcutaneous tissue, and bone) and pattern of hyperintensities were described as diffuse pattern (signal alterations affecting the entire area of the involved muscle), patched pattern (areas of hyperintensities alternating areas of normal muscle signal intensity), and fluffy nodular pattern or cotton-wool appearance (round hyperintense lesions with fluffy margins centered on blood vessels).

Results:

clinical characteristics:myalgia, especially calf pain, was the most frequent muscular complaint; other clinical manifestations were: constitutional symptoms (80%), arthralgias or arthritis (50%), mono/polyneuropathy (33%), subcutaneous nodules (33%), livedo reticularis (20%), lower limbs ulcers (13%), abdominal symptoms (13%), and purpura (7%).MRI findings:bilateral muscular edema was found in all patients (100%), fatty infiltration (20%), edema of the subcutaneous cellular tissue (20%), and muscular atrophy (13%) were also described. A diffuse pattern occurred in 46% (n=7) of patients (figure panel A), a patched pattern (figure panel B) in 46% (n=7), and a fluffy nodular pattern or cotton-wool appearance (figure panel C) in 6% (n=1). The most frequently affected muscular group was gastrocnemius and soleus (67%), followed by anterior tibialis (27%), plantar, long peroneus, first finger flexors, and long flexors only affected in 7%. Bone involvement was found in 53%, being the tibia the most affected, followed by the fibula and the calcaneus. MRI led to guide the site of muscle biopsy to prove histological medium-size vasculitis in half of the patients.

Conclusion:

in patients with PAN suspicion who have muscular complaints, especially calf pain, MRI arises as an important diagnostic tool, and also as a guide to muscular biopsy to prove vasculitis. The patterns associated with PAN are diffuse, patched or fluffy nodular hyperintensities in gastrocnemius and soleus with or without bone compromise.

References:

[1]Kang, Y. et al. Muscle involvement in polyarteritis nodosa: Report of eight cases with characteristic contrast enhancement pattern on MRI. Am. J. Roentgenol. 206, 378–384 (2016).

[2]Hofman DM, Lems WF, Witkamp TD, Putte VD, Bijlsma JW. Demonstration of calf abnormalities by magnetic resonance imaging in polyarteritis nodosa. Clin Rheumatol 1992; 11:402–404.

Figure

Disclosure of Interests:

None declared

AB0487 TAKAYASU’S ARTERITIS: RECOGNIZING AN OLD ENEMY

Background:

Takayasu’s arteritis (AT) is a systemic vasculitis that affects large vessels, mainly the aorta, its branches and the pulmonary arteries. There are few data on their behavior in our region.

Objectives:

to describe the clinical and angiographic characteristics and outcomes of a group of patients with AT.

Methods:

a cross-sectional, retrospective study based on a secondary source taken from two high complexity hospitals in Medellin - Colombia between August 2011 and December 2018.

Results:

medical records of 41 patients were evaluated, 87.5% met the 1990 ACR criteria of AT. The majority were women (95.1%), with a median age at the time of diagnosis of 22 years (IR 52), 11 patients (26.8%) were over 40 years old at debut. The median delay in diagnosis was 12 months (IR: 167). Systemic symptoms included general malaise (29.3%), weight loss (29.3%) and fever (19.5%); the main vascular manifestations were hypertension and blood pressure difference (61%), headache (39%), upper limb claudication (31.7%), dyspnea (29.3%), angina (26.8%) and carotidinia (22%). Most frequent findings on physical examination were pulse absence or decrease (78%) and subclavian murmur (53.7%). ESR and CRP were found high in 85.3% and 22%, respectively. Angiographic studies revealed stenosis or occlusion in multiple arterial territories, being the stenosis of the left subclavian artery the most frequent lesion (68.3%), followed by the involvement of the abdominal aorta (58.5%) and thoracic (51%). The distribution according to Hata-Numano classification was: type V (58.5%), type I (17.1%) and type IIa (7.3%), indicating complex vascular lesions and associated serious complications. Abnormalities of the renal arteries, pulmonary arteries involvement, and aortic insufficiency were present in 39%, 14.6%, and 7.3% respectively. Seventy-five percent of patients had active disease, glucocorticoids were the main treatment in 90.2% of the cases, used isolated (2.4%) or in combination with other immunosuppressants (87.8%), including methotrexate (75.6%), azathioprine (26.8%) and cyclophosphamide (14.6%); vascular interventions were performed in 11 patients (26.8%). Most relevant vascular complications were renovascular hypertension (26.8%), stroke (19.5%), chronic kidney disease (19.5%) and chronic heart failure (17.1%). From the clinical point of view, our findings were similar to those shown in series from Brazil, Japan, and Turkey. Contrary to what was reported in other series, carotidinia was a finding that occurred in almost a quarter of our patients (23%) and maybe one of the initial symptoms of the disease. The findings of the vascular physical examination are similar to those reported by the IRAVAS group, where the asymmetry of the pulses was most frequent, followed by the presence of murmurs and the difference in blood pressure, claudication being less frequent in the upper and lower limbs.

Conclusion:

patients in this series are characterized by having an extensive disease partly due to a late diagnosis, with a high percentage of complications associated with vascular stenotic compromise, which generates morbidity and impact on the quality of life.

References:

[1]Sato EI, et al. Takayasu arteritis. Treatment and prognosis in a university center in Brazil, Int J Cardiol. 2000; 75 Suppl 1: S163-6.

[2]Arnaud L, et al. Takayasu arteritis in France: a single-center retrospective study of 82 cases comparing white, North African, and black patients. Medicine (Baltimore). 2010; 89(1): 1-17.

Disclosure of Interests: :

None declared

FRI0468 SYSTEMIC AND CUTANEOUS POLYARTERITIS NODOSA IN COLOMBIAN PEDIATRIC PATIENTS: CUTANEOUS POLYARTERITIS IS NOT SO BENIGN

Background:

Polyarteritis nodosa (PAN) is the third most frequent vasculitis in pediatrics, Cutaneous PAN (CPAN) being more common that Systemic PAN (SPAN). CPAN is frequently described as a benign disease. In children, PAN onset is frequent between 9 and 11 years of age, with no sex differences, and its clinical features may be nonspecific.

Objectives:

To characterize pediatric patients who were diagnosed with CPAN and SPAN and to compare their clinical features, treatments, and outcome.

Methods:

A descriptive study was conducted in two centers from Medellin- Colombia, using retrospective data from January 2010 to December 2019. Patients under 18 years of age classified as PAN according to EULAR/PRINTO/PRES(1) criteria were included. CPAN patients were defined according to EULAR/PRES definition (2). Data from medical records were registered, and were expressed in median and ranges and mean and standard deviation (SD) according to their distribution. A univariate analysis was carried out by comparing signs, symptoms, and treatment between CPAN and SPAN, and ap-value < 0,05was considered as significant.

Results:

Twenty patients were included. The median age at diagnosis was ten years. 60% were boys. The median follow-up period was 27 months. CPAN was diagnosed in 11 (55%) and SPAN in 9 patients (45%). The most frequent symptoms were cutaneous manifestations (95%), fever (60%) and Calf Pain (55%). Mucosal ulcers were described in four patients; 3 of them were defined as CPAN. Lingual necrosis was present in two CPAN, and peripheral nervous system involvement was found in one SPAN and two CPAN patients in skin affected with lesions; even though, no significant statistical differences between CPAN and SPAN were found in constitutional, cutaneous, muscle-skeletal symptoms, and acute phase reactants. Arteriographic anomalies as hepatic and renal microaneurysms, carotidal aneurysms without aortic involvement, and renal infarction were found in one patient each. Skin Biopsy was performed in 18 patients, being compatible with PAN in 16. All PAN patients (CPAN and SPAN) required treatment with glucocorticoids. None of the patients died during the follow-up period.

Conclusion:

In this Colombian pediatric cohort of PAN patients, the disease was more common in boys than girls, and CPAN was more frequent than SPAN, as already been described. As is evident in this cohort, although CPAN has been considered a benign disease, these patients may be severely ill, requiring glucocorticoid treatment. Pediatric CPAN patients should be strictly followed with particular attention to identify systemic involvement, considering that constitutional, cutaneous, and muscle-skeletal features may be very similar between CPAN and SPAN.

References:

[1]Ozen S, Pistorio A, Iusan S, et al. EULAR/PRINTO/PRES criteria for Henoch-Schönlein purpura, childhood polyarteritis nodosa, childhood Wegener granulomatosis and childhood Takayasu arteritis: Ankara 2008. Part II: Final classification criteria. Ann Rheum Dis. 2010 May;69(5):798–806.

[2]Ozen S, Ruperto N, Dillon M, et al. EULAR/PReS endorsed consensus criteria for the classification of childhood vasculitides. Ann Rheum Dis. 2006;65(7):936–41.

Disclosure of Interests:

None declared

Antipsychotics and women: Yes, prolactin is important

Introduction

The hormonal imbalance produced by antipsychotics can be detected by symptoms, such as: infertility, acne, hirsutism, sexual dysfunction and galactorrhea. We consider especially important the study of women's diseases, which may develop due to hyperprolactinemia, specifically: breast cancer, endometrial cancer and osteoporosis.

Objective

To undertake a systematic review about the relationship between hyperprolactinemia as a result of the treatment with antipsychoticsand endometrial and breast cancer.

Method

An exhaustive search was performed on PUBMED and COCHRANE (from 2006 to 2015).

Fifteen papers were selected including comparative studies, clinical trials and clinical reviews.

Results

With respect to endometrial carcinoma, there is no direct relationship with the use of antipsychotics. However, most papers have suggested that the blood prolactin elevation is a risk factor in the development of endometrial engrossment, which could lead to endometrial hyperplasia, polyps and endometrial cancer. Related to the use of antipsychotics as a treatment for schizophrenic women and breast carcinoma, a significant association was found and this association is strengthened through the interaction of other factors like the fact that women with schizophrenia are less worried about going to the clinical screening reviews in their health centre, smoking, and lower physical activity than healthy women.

Conclusions

Aripiprazolis associated with a low prevalence of hyperprolactinemia. Menopausal women, the obese, and women who smoke receiving antipsychotics that produce hyperprolactinemia have the greatest risk of developing endometrial pathology. Schizophrenic women with hyperprolactinemia due to antipsychotics and loss of motivation to go to screening activities have a greater risk of breast cancer. Sexual dysfunction could be a non-adherence treatment factor.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Cost-Effectiveness Analysis of Vedolizumab Compared with Other Biologics in Anti-TNF-Naïve Patients with Moderate-to-Severe Ulcerative Colitis in Japan

BACKGROUND

Vedolizumab (VDZ) was approved by the Japanese Ministry of Health, Labor and Welfare in 2018 for the treatment of patients with moderate-to-severe active ulcerative colitis (UC). The comparative cost-effectiveness of VDZ compared with other biologics is unknown in Japan. This information could be useful for decision makers at the time of repricing biologics for the treatment of patients with moderate-to-severe UC.

OBJECTIVE

The aim was to assess the cost-effectiveness of VDZ versus other branded biologics for the treatment of patients with moderate-to-severe UC who were anti-tumor necrosis factor (TNF)-naïve, from the Japanese public healthcare payer perspective.

METHODS

A hybrid decision tree/Markov model was developed to predict the number of patients who achieved response and remission at the end of the induction phase and sustained it during the maintenance phase, translating this into quality-adjusted life-years (QALYs) and costs. Treatment-related adverse events, discontinuation and surgery, and their impact on QALYs and costs were also modeled. A systematic literature review and network meta-analysis were conducted to estimate the comparative efficacy of each treatment versus placebo. Rates of adverse events, surgery, surgery complications, and utilities were from the literature. Costs (2018 Japanese yen) were obtained from the Japanese National Health Insurance drug price list and medical fee table and local claims databases. Clinical and economic outcomes were projected over a lifetime and discounted at 2% annually.

RESULTS

Over a lifetime, VDZ yielded greater QALYs and cost savings compared with golimumab and was cost-effective compared with adalimumab and infliximab (incremental cost-effectiveness ratios ¥4,821,940 and ¥4,687,692, respectively). Deterministic and probabilistic analyses supported the robustness of the findings in the base-case analysis, indicating that VDZ was either dominant or cost-effective in most scenarios and replications. The main limitations of this analysis include excluding tofacitinib and infliximab biosimilar as comparators, health-state utility estimates were obtained from population studies in the United Kingdom, and the impact of subsequent (i.e., second-line) biologic treatment was not evaluated.

CONCLUSION

Our analysis suggests that VDZ is dominant or cost-effective compared with other branded biologics for the treatment of anti-TNF-naïve patients with moderate-to-severe UC in Japan.

Polymorphism analyses and protein modelling inform on functional specialization of Piwi clade genes in the arboviral vector Aedes albopictus

Current knowledge of the piRNA pathway is based mainly on studies on Drosophila melanogaster where three proteins of the Piwi subclade of the Argonaute family interact with PIWI-interacting RNAs to silence transposable elements in gonadal tissues. In mosquito species that transmit epidemic arboviruses such as dengue and chikungunya viruses, Piwi clade genes underwent expansion, are also expressed in the soma and cross-talk with proteins of recognized antiviral function cannot be excluded for some Piwi proteins. These observations underscore the importance of expanding our knowledge of the piRNA pathway beyond the model organism D. melanogaster. Here we focus on the emerging arboviral vector Aedes albopictus and we couple traditional approaches of expression and adaptive evolution analyses with most current computational predictions of protein structure to study evolutionary divergence among Piwi clade proteins. Superposition of protein homology models indicate possible high structure similarity among all Piwi proteins, with high levels of amino acid conservation in the inner regions devoted to RNA binding. On the contrary, solvent-exposed surfaces showed low conservation, with several sites under positive selection. Analysis of the expression profiles of Piwi transcripts during mosquito development and following infection with dengue serotype 1 or chikungunya viruses showed a concerted elicitation of all Piwi transcripts during viral dissemination of dengue viruses while maintenance of infection relied on expression of primarily Piwi5. Opposite, establishment of persistent infection by chikungunya virus is accompanied by increased expression of all Piwi genes, particularly Piwi4 and, again, Piwi5. Overall these results are consistent with functional specialization and a general antiviral role for Piwi5. Experimental evidences of sites under positive selection in Piwi1/3, Piwi4 and Piwi6, that have complex expression profiles, provide useful knowledge to design tailored functional experiments.

A-50 A Comprehensive Neuropsychological Case Study of a Child with Perinatal Hyperbilirubinemia

Objective

Neonatal jaundice (hyperbilirubinemia) remains present in 60% of births in the United States1. Current literature links hyperbilirubinemia with neurodevelopmental problems, particularly with attention deficit hyperactivity disorder (ADHD), general learning difficulties, and non-progressive developmental delays. Moderate elevations in bilirubin are also suggested to increase the risk for cognitive, perceptual, motor, and auditory disorders. Imaging studies have shown selective patterns of injury to specific brain regions associated with deficits in executive function, including impulse control and working memory as well as different subtypes of attention problems grounded in reward circuitry system dysfunction in children with bilirubin encephalopathy.

Method

Neuropsychological functioning of a 12-year old Hispanic female with a history of high levels of perinatal bilirubin, and subsequent developmental and cognitive difficulties in speech, learning, attention and memory as well as problems with socialization and anxiety is presented with the purpose of adding to existing literature. Comprehensive neuropsychiatric interview and neuropsychological testing was completed.

Results

Results revealed several areas of neurocognitive weaknesses with deficits in areas of intellectual functioning, learning (reading and mathematics), expressive language, visual memory, attention, and auditory processing. Emotional and behavioral measures evidenced significant deficits in social-emotional functioning, particularly with interpersonal skills, sense of adequacy, and self-reliance, which resulted in increased anxiety contributing to cognitive and academic deficits.

Conclusions

Neuropsychological profile was consistent with cognitive, academic, behavioral and emotional manifestations theoretically associated with neuropathological findings in hyperbilirubinemia. Furthermore, similar to existing literature, cognitive deficits were observed in the absence of a clear cause of neonatal jaundice following a full-term, uncomplicated pregnancy.

SUN-155 Clinical Experience of SGLT2 Inhibitors in a Hispanic Population: Should We Consider Its Use as Add-On Treatment?

Introduction: 1 in 11 adults have DM globally,¹ and Hispanics have higher complication rates.² A study determined that ~$16,750/year are spent by patients in medical related costs, of which ~$9,600 are related to diabetes.³ Half of Type 2 Diabetes Mellitus (T2DM) patients aren't achieving HbA1C targets,⁴ uncovering the need for treatment intensification. The primary purpose of this study was to assess the mean reduction in HbA1C between T2DM patients treated with SGLT2 inhibitors (SGLT2I) as adjunct therapy versus patients using other treatments not including SGLT2I. METHOD: T2DM patients with HbA1C > 7 (n=130) were selected for this retrospective cohort study; 69 SGLT2I users and 61 SGLT2I non-users. Medical records were reviewed and demographics, treatment received, HbA1C and side effects were evaluated during a 6-month follow-up period. RESULTS: The average baseline HbA1C for patients using vs not using SGLT2I as add-on was similar with a mean difference of 0.225 [CI -0.41-0.86], p<0.486. The mean difference in HbA1C at 6 months follow-up between both groups was -1.06 [95%CI: -1.70, -0.42], p<0.001. Adjusting for confounders resulted in a regression coefficient of -1.07 [95%CI: -1.85, -0.29], p<0.008, the null hypothesis was rejected and it was concluded that the use of SGLT2I is responsible for the increased HbA1C in the treatment group. CONCLUSION: Puerto Rico is under an economic crisis that affects patients treatment warranted by the availability of some medications due to affordability as supported by Roglic et al.⁵ The present study depicts a higher A1C reduction in patients using SGLT2 inhibitors as adjunctive treatment. But should we consider it as add-on treatment of T2DM? We may say that if patients are able to bear the expense of SGLT2I and/or are close to target it may be used as adjunctive treatment since the mean difference in A1C between both groups was -1.07 at 6 months. Limitations were the short follow up duration and a small population using SGLT2I due to high medication costs. REFERENCES: 1. Zheng Y, et al. (2017) Global Aetiology and Epidemiology of T2DM and its Complications. Nat Rev Endocrinol, 14(2), 88-98. 2. Hazel L, et al. (2015) Racial/Ethnic and Gender Differences in Severity of Diabetes-Related Complications, Health Care Resource Use, and Costs in a Medicare Population. Popul Health Manag, 18(2), 115-22. 3. Campos C. (2007) Addressing Cultural Barriers to the Successful Use of Insulin in Hispanics With T2 Diabetes. South Med J, 100(8), 812- 20. 4. Ali M, et al. (2013) Achievement of Goals in U.S. Diabetes Care, 1999-2010. N Engl J Med, 368(17), 1613-24. 5. Roglic G, et al. (2018) Medicines for Treatment Intensification in T2 Diabetes and Type of Insulin in T1 and T2 Diabetes in Low-Resourse Settings: Synopsis of the WHO on Second and Third Line Medicines and Type of Insulin for the Control of Blood Glucose Levels in Nonpregnant Adults With DM. Ann Intern Med, 169(6), 394-97.

Building Simulation Exercise Capacity in Latin America to Manage Public Health Emergencies

Simulation exercises, whether discussion- or operations-based, are an essential component of public health emergency preparedness and response-so much so that the ability to conduct exercises is included as a key indicator for measurement of emergency response operations in the Joint External Evaluation and as a requirement of the International Health Regulations. Exercises allow ministry of health partners to actually practice and demonstrate their learned capacities and show progress toward those global health security goals. In recent years, the general technique in the global health security arena has been for external partners to design, facilitate, and evaluate public health emergency exercises for ministry of health partners. However, in 2017, the Centers for Disease Control and Prevention (CDC) Global Response Preparedness Team (GRPT) piloted regional training for ministry of health representatives from 4 countries in Latin America to build their internal capacity to design, facilitate, and evaluate simulation exercises using the US Homeland Security Exercise Evaluation Program (HSEEP). Using this program as the source material, the team modified the content for application to an international audience, facilitated it as a 4-day workshop, and designed an evaluation protocol to measure participants' satisfaction with the course as well as their ability to apply concepts learned in their day-to-day jobs. Representatives of 3 of the 4 ministries of health that attended the workshop designed exercises to implement in their home countries, with 2 having completed the facilitation and evaluation of their exercises at the time of this publication.

Voluntary control of breathing affects center of pressure complexity during static standing in healthy older adults

Background Physiological/biomechanical systems display high degrees of complexity in their corresponding physiological and/or biomechanical outputs, indicative of normal healthy physiological functioning, though little attention has been paid to potential mechanisms which may affect complexity. Center of pressure (CoP) dynamics also display high degrees of complexity and may be affected via altered respiratory-motor interactions such as during voluntary control of breathing. Purpose The purpose of this study was to investigate the differences in the complexity of CoP dynamics during autonomous vs. voluntary control of breathing and between different voluntarily controlled breathing conditions. Methods Center of pressure recordings were taken from 18 older adults during static standing under three different breathing conditions: 1) neutral breathing, 2) abdominal breathing, and 3) thoracic breathing, the first constituting the autonomous breathing condition and the latter two constituting voluntarily controlled breathing conditions. CoP dynamics were quantified using sample entropy, standard deviation, 95% sway area, and average radial velocity. Repeated measure MANOVAs were used to assess the effect of breathing on CoP dynamics, with top-down application of ANOVAs and pairwise comparison as needed. Results Voluntary control of breathing during both conditions resulted in significantly higher CoP variability and lower sample entropy than during autonomous control of breathing in the mediolateral direction, indicating less complex dynamics and loss of system control. No significant differences between voluntary breathing conditions were observed. Conclusion Voluntary control of breathing significantly affected on CoP dynamics during static standing. The complexity of the postural control system may be affected via alterations in respiratory-motor interactions.

Seed Cryostorage Enhances Subsequent Plant Productivity in the Forage Species Teramnus Labialis (L.F.) Spreng

BACKGROUND

Teramnus labialis is an herbaceous legume that serves as a source of carbohydrates and proteins for animals and humans, and is valued for its nitrogen contribution to soil. The benefits of this species are, however, limited by low seed availability, small seed size and low in situ seed germination levels, due to physical dormancy. Cryostorage has been shown to be beneficial for both seed storage and breaking physical dormancy in seeds of various species. However, its potential effects on subsequent seedling emergence, plant growth and seed production need to be studied before large-scale implementation for T. labialis.

OBJECTIVE

To record agricultural traits of T. labialis after seed exposure to liquid nitrogen.

MATERIALS AND METHODS

Seeds were maintained at 5 degree C (control) or stored in LN before sowing. Seedling emergence percentage and traits related to plant growth and seed production were evaluated for 6 months.

RESULTS

Except for seed weight, all traits differed significantly between seedlings generated from cryostored and control seeds. Except for pod number, seedling emergence and plant growth traits were enhanced by cryostorage to a greater extent than seed production traits. Cryostorage resulted in cracks and breaks in the seed coat which were absent in control seeds (scanning electron microscopy), and in breaking physical dormancy may have facilitated more rapid seedling emergence than for control seeds.

CONCLUSION

Seed cryostorage enhances subsequent plant productivity in terms of growth and to a lesser extent seed production in Teramnus labialis, validating its use for commercial growth of this species.

Sleep-Disordered Breathing Is Independently Associated With Increased Aggressiveness of Cutaneous Melanoma: A Multicenter Observational Study in 443 Patients

BACKGROUND

Sleep-disordered breathing (SDB) has been associated with a greater incidence and mortality of cancer, although such findings are inconsistent. However, no large studies are currently available to investigate this association in patients with a specific type of cancer. This study seeks to assess potential relationships between SDB severity and aggressiveness markers of cutaneous melanoma.

METHODS

Four hundred and forty-three patients with a diagnosis of melanoma underwent a sleep study within 6 months of diagnosis. General demographics were collected, along with melanoma characteristics and polygraphic parameters consisting of the apnea-hypopnea index (AHI) and indices of both continuous and intermittent night-time oxyhemoglobin desaturation (DI4%). An exploration of independent relationships between SDB and various objective melanoma aggressiveness markers (Breslow index, presence of ulceration, presence of regression, mitotic index, stage of severity, damage to the sentinel lymph, and spreading of the melanoma) was performed.

RESULTS

Patients in the upper tertiles of AHI or DI4% were 1.94 (95% CI, 1.14-3.32; P = .022) and 1.93 (95% CI, 1.14-3.26; P = .013) times more likely, respectively, to present with aggressive melanoma (Breslow index > 1 mm) than those in the lowest tertiles of these sleep attributes after adjustment for age, sex, tumor location, and BMI. This association was particularly prominent among patients < 56 years of age with Breslow index > 2 mm. The presence of the additional markers of aggressiveness was also associated with higher AHI and DI4% values.

CONCLUSIONS

The severity of SDB was independently associated with greater aggressiveness of cutaneous melanoma, particularly among younger patients.

Modeling Approaches in Cost-Effectiveness Analysis of Disease-Modifying Therapies for Relapsing-Remitting Multiple Sclerosis: An Updated Systematic Review and Recommendations for Future Economic Evaluations

BACKGROUND

Numerous cost-effectiveness analyses (CEAs) of disease-modifying therapies (DMTs) for relapsing-remitting multiple sclerosis (RRMS) have been published in the last three decades. Literature reviews of the modeling methods and results from these CEAs have also been published. The last literature review that focused on modeling methods, without country or time horizon in the inclusion criteria, included studies published up to 2012. Since then, new DMTs have become available, and new models and data sources have been used to assess their cost effectiveness.

OBJECTIVE

The aim of this systematic review was to provide a detailed and comprehensive description of the relevant aspects of economic models used in CEAs of DMTs for RRMS, to understand how these models have progressed from recommendations provided in past reviews, what new approaches have been developed, what issues remain, and how they could be addressed.

METHODS

EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), the National Health System (NHS) Economic Evaluations Database, the Health Technology Assessment (HTA) Database, and EconLit were searched for cost-effectiveness studies of DMTs for RRMS that used decision-analytic models, published in English between 1 January 2012 and 24 December 2017. The inclusion criteria were as follows: being a full economic evaluation, a decision-analytic model was used, the target population concerned adult patients with RRMS, and being available in full-text format. Studies were not excluded based on the methodological quality. The background information of the included studies, as well as specific information on the components of the economic models related to the areas of recommendation from previous reviews were extracted.

RESULTS

Twenty-three studies from ten countries were included. The model structure of these studies has converged over time, characterizing the course of disease progression in terms of changes in disability and the occurrence of relapses over time. Variations were found in model approach; data sources for the natural course of the disease and comparative efficacy between DMTs; number of lines of treatment modeled; long-term efficacy waning and treatment discontinuation assumptions; type of withdrawal; and criteria for selecting adverse events. Main areas for improvement include using long-term time horizons and societal perspective; reporting relevant health outcomes; conducting scenario analyses using different sources of natural history and utility values; and reporting how the model was validated.

CONCLUSION

The structure of economic models used in CEAs of DMTs for RRMS has converged over time. However, variation remains in terms of model approach, inputs, and assumptions. Though some recommendations from previous reviews have been incorporated in later models, areas for improvement remain.

Intravitreal Aflibercept Versus Ranibizumab for Wet Age-Related Macular Degeneration: A Cost-Effectiveness Analysis

BACKGROUND

Age-related macular degeneration (AMD) is the leading cause of vision loss in the United States. The most severe vision loss occurs in patients with neovascular AMD, known as wet AMD (wAMD). The most commonly used antivascular endothelial growth factor (VEGF) therapies approved by the FDA to treat patients with wAMD are ranibizumab, 0.5 mg administered by intravitreal injection once a month (approximately every 28 days), and intravitreal aflibercept injection (IAI), 2 mg every 4 weeks (monthly) for the first 12 weeks (3 months), followed by IAI 2 mg once every 8 weeks (2 months). Given the similar efficacy and safety profiles between IAI and ranibizumab, their associated costs and comparative cost-effectiveness are key factors in determining which one represents a more rational investment of scarce health care resources to help address the increasing cost of prescription drugs in the United States, a source of concern for patients, prescribers, payers, and policymakers.

OBJECTIVE

To assess the cost-effectiveness of intravitreal aflibercept injection 2 mg every 8 weeks after 3 initial monthly doses (IAI 2q8) versus ranibizumab 0.5 mg monthly (Rq4) and pro re nata (PRN) in the treatment of patients with wAMD from a U.S. payer perspective.

METHODS

A Markov cohort model was developed to estimate the lifetime quality-adjusted life-years (QALYs) and costs of treating patients with wAMD with IAI 2q8, Rq4, and ranibizumab PRN. The model considered changes in best-corrected visual acuity in the affected and fellow eyes over time, and the effect of blindness on mortality. Efficacy for IAI 2q8 and Rq4 was from VIEW 1 and VIEW 2 studies and from the Comparison of AMD Treatments Trials for ranibizumab PRN. Utilities and costs (in 2016 U.S. dollars) were from published literature. Health outcomes and costs were discounted at an annual rate of 3%.

RESULTS

Over a lifetime, IAI 2q8 provided equal health benefits with Rq4 (5.44 QALYs) at a lower total cost ($33,745 vs. $48,031) as a result of fewer injections. IAI 2q8 yielded slightly greater QALYs versus ranibizumab PRN (5.44 vs. 5.40) at a slightly higher cost ($33,745 vs. $33,652), with an incremental cost per QALY gained of $2,583. Results were sensitive to variations in drug acquisition costs and number of injections of both drugs and the baseline age of the cohort.

CONCLUSIONS

IAI 2q8 can be cost saving and cost-effective compared with Rq4 and ranibizumab PRN for the treatment of wAMD in the United States.

DISCLOSURES

This study was funded by Regeneron Pharmaceuticals, the manufacturer of aflibercept. Hernandez, Lanitis, Cele, and Toro-Diaz are employed by Evidera, which received funding from Regeneron Pharmaceuticals to conduct this study. Gibson and Kuznik are employed by and own stock in Regeneron Pharmaceuticals.