Economic impact of managing invasive mold disease with isavuconazole compared with liposomal amphotericin B followed by posaconazole in Spain

BACKGROUND

Invasive fungal infections (IFI) are associated with significant morbidity and mortality. The objective of this work was to compare the costs per adult patient, associated with intravenous isavuconazole (ISAV) followed by oral ISAV versus the regimen of liposomal amphotericin B followed by posaconazole (L-AMB→POSA) in the treatment of IFI. The comparison was conducted from the perspective of the Spanish National Health System (SNS).

METHODS

As indirect comparisons have demonstrated similar efficacy between the comparators, a cost-minimization approach was taken. Drug acquisition, administration, hospitalization, laboratory tests and adverse events costs were evaluated from SNS perspective. Deterministic and probabilistic sensitivity analyzes were performed.

RESULTS

Total costs per-patient were €24,715.54 with ISAV versus €29,753.53 with L-AMB→POSA, resulting in cost-savings per patient treated with ISAV of €5,037.99 (-16.9%). Treatment costs of IFI remained lower for ISAV than for L-AMB→POSA across all sensitivity analyses (-7,968.89€ to -326.59€), being treatment duration the most influential parameter.

CONCLUSION

According to the present model, the treatment of IFIs with ISAV would generate savings for the SNS compared to L-AMB→POSA. These savings are attributed to the shorter duration of IV treatment, reduced use of healthcare resources and lower costs associated with managing adverse effects when ISAV was employed.

Detection of novel drug-adverse drug reaction signals in rheumatoid arthritis and ankylosing spondylitis: analysis of Korean real-world biologics registry data

This study aimed to detect signals of adverse drug reactions (ADRs) associated with biological disease-modifying antirheumatic drugs (DMARDs) and targeted therapies in rheumatoid arthritis (RA) and ankylosing spondylitis (AS) patients. Utilizing the KOrean College of Rheumatology BIOlogics & Targeted Therapy Registry (KOBIO) data, we calculated relative risks, excluded previously reported drug-ADR pairs, and externally validated remaining pairs using US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) and single centre's electronic health records (EHR) data. Analyzing data from 2279 RA and 1940 AS patients, we identified 35 significant drug-ADR pairs in RA and 26 in AS, previously unreported in drug labels. Among the novel drug-ADR pairs from KOBIO, 15 were also significant in the FAERS data. Additionally, 2 significant drug-laboratory abnormality pairs were found in RA using CDM MetaLAB analysis. Our findings contribute to the identification of 14 novel drug-ADR signals, expanding our understanding of potential adverse effects related to biological DMARDs and targeted therapies in RA and AS. These results emphasize the importance of ongoing pharmacovigilance for patient safety and optimal therapeutic interventions.

Recommendations on the use of azole antifungals in hematology-oncology patients

The administration of antifungals for therapeutic and, especially, prophylactic purposes is virtually a constant in patients requiring hematology-oncology treatment. Any attempt to prevent or treat Aspergillus or Mucor infections requires the administration of some drugs in the azole group, which include voriconazole, posaconazole and isavuconazole, noted for their activity against these pathogens. One very relevant aspect is the potential risk of interaction when associated with one of the antineoplastic drugs used to treat hematologic tumors, with serious complications. In this regard, acalabrutinib, bortezomib, bosutinib, carfilzomib, cyclophosphamide, cyclosporine A, dasatinib, duvelisib, gilteritinib, glasdegib, ibrutinib, imatinib, nilotinib, ponatinib, prednisone, ruxolitinib, tacrolimus, all-transretinoic acid, arsenic trioxide, venetoclax, or any of the vinca alkaloids, are very clear examples of risk, in some cases because their clearance is reduced and in others because of increased risk of QTc prolongation, which is particularly evident when the drug of choice is voriconazole or posaconazole.

EZH2 mutations at diagnosis in follicular lymphoma: a promising biomarker to guide frontline treatment

EZH2 is mutated in nearly 25% of follicular lymphoma (FL) cases. Little is known about how EZH2 affects patients’ response to therapy. In this context, the aim of this study was to retrospectively analyze the frequency of mutations in EZH2 at diagnosis in tissue and ctDNA in patients with FL and to assess the patients’ outcomes after receiving immunochemotherapy, depending on the EZH2 mutation status. Among the 154 patients included in the study, 27% had mutated EZH2 (46% with high-grade and 26% with low-grade FL). Of the mutated tissue samples, the mutation in ctDNA was identified in 44% of cases. EZH2 mutation in ctDNA was not identified in any patient unmutated in the tissue.

Unmutated patients who received R-CHOP had significantly more relapses than patients who received R-Bendamustine (16/49 vs. 2/23, p = 0.040). Furthermore, our results show that patients with mutated EZH2 treated with R-CHOP vs. those treated with R-Bendamustine present a lower incidence of relapse (10% vs. 42% p = 0.09 at 4 years), a higher PFS (92% vs. 40% p = 0.039 at 4 years), and higher OS (100% vs. 78% p = 0.039 at 4 years). Based on these data, RCHOP could be a more suitable regimen for mutated patients, and R-bendamustine for unmutated patients. These findings could mean the first-time identification of a useful biomarker to guide upfront therapy in FL.

Phase II study of ceralasertib (AZD6738) in combination with durvalumab in patients with advanced/metastatic melanoma who have failed prior anti-PD-1 therapy

BACKGROUND

Modulating the DNA damage response and repair (DDR) pathways is a promising strategy for boosting cancer immunotherapy. Ceralasertib (AZD6738) is an oral inhibitor of the serine/threonine protein kinase ataxia telangiectasia and Rad3-related protein, which is crucial for DDR.

PATIENTS AND METHODS

This phase II trial evaluated ceralasertib plus durvalumab for the treatment of patients with metastatic melanoma who had failed anti-programmed cell death protein 1 therapy.

RESULTS

Among the 30 patients, we observed an overall response rate of 31.0% and a disease control rate of 63.3%. Responses were evident across patients with acral, mucosal, and cutaneous melanoma. The median duration of response was 8.8 months (range, 3.8-11.7 months). The median progression-free survival was 7.1 months (95% confidence interval, 3.6-10.6 months), and the median overall survival was 14.2 months (95% confidence interval, 9.3-19.1 months). Common adverse events were largely hematologic and manageable with dose interruptions and reductions. Exploratory biomarker analysis suggested that tumors with an immune-enriched microenvironment or alterations in the DDR pathway were more likely to respond to the study treatment.

CONCLUSION

We conclude that ceralasertib in combination with durvalumab has promising antitumor activity among patients with metastatic melanoma who have failed anti-programmed cell death protein 1 therapy, and constitute a population with unmet needs.

Molecular profiling of Asian patients with advanced melanoma receiving check-point inhibitor treatment

Objective

Melanoma is major medical challenge and being able to monitor treatment response is critical. This study aimed to use molecular profiling of Asian patients with advanced melanoma who were receiving treatment with check-point inhibitors (CPIs) to identify novel biomarkers of tumor response.

Methods

Next-generation sequencing (NGS) was performed using tumor specimens collected from 178 Asian patients with metastatic melanoma receiving CPIs. The NGS data and clinical-pathological factors were analyzed for potential genetic biomarkers of tumor response to CPI treatment.

Results

The most common melanoma subtype was acral melanoma (40%), followed by cutaneous melanoma (32%), mucosal melanoma (26%), and others (2%). For calculation of treatment efficacy, 164 of the patients could be evaluated. The overall response rate was 45.7%, of which 41 cases exhibited complete responses (25.0%) and 34 showed partial responses (20.7%). There were no significant differences in tumor responses based on melanoma subtype (P = 0.295). Genetically, NRAS mutations, TP53 mutations, and NF2 deletions were significantly associated with resistance to CPIs (P < 0.05). In contrast, MYC and RPS6KB1 amplifications were associated with responsiveness to CPIs (P < 0.05). Median progression-free survival (PFS) for patients treated with CPIs was 5.9 months (95% CI, 3.8-8.05 months). Univariate analysis identified TP53 and BRAF mutations, NF2 deletions, and BIRC2 amplifications as poor prognostic factors for PFS (P < 0.05).

Conclusions

This study determined the integrated genomic profiles of Asian patients with metastatic melanoma receiving CPIs and identified candidate biomarkers that reflected treatment outcomes.

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The molecular characterization of Asian melanoma patients receiving check-point inhibitors (CPIs) using NGS has not been reported.

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NRAS and TP53 mutations and NF2 deletions were significantly associated with resistance to CPIs.

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MYC and RPS6KB1 amplifications were associated with responsiveness to CPIs.

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TP53 and BRAF mutations, NF2 deletions, and BIRC2 amplifications were poor prognostic factors for progression-free survival.

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This is the largest integrated genomic study to date that identifying novel biomarkers of CPIs in Asian melanoma patients.

0268 Development of an Integrated Model of Sleep Deprivation in Adolescence

Introduction

Sleep deprivation is a consistently and widely concerning problem among adolescents. Although a few models have been proposed to explain the relationships and pathways through which factors influence sleep in adolescents, there are lack of theoretical models that apply both biological and behavioral factors that contribute to sleep deprivation across the trajectory of adolescent development. The current study proposes an integrated model that draws upon constructs from several influential theories with an aim to re-conceptualize factors associated with sleep deprivation as a chronic and cyclic problem that emerges from biological and behavioral changes in youth.

Methods

The Two Process Model of Sleep Regulation, Spielman’s 3p model, the theory of planned behavior, dual systems model, and sleep health framework are used to develop an integrated model of factors that lead to sleep deprivation in adolescents.

Results

The resulting integrated model highlights the importance of adolescent’s inherent nature of delayed sleep phase at pubertal onset (two process model); increased reward-seeking that precedes the structural maturation of their cognitive control and emotions (dual systems model); and their attitudes/perceptions towards sleep (theory of planned behavior), which is often geared toward not prioritizing sleep. Sleep health framework adequately frames the pattern of sleep-wakefulness in adolescents using a multidimensional approach of sleep. Moreover, the new model presents contextual factors (Spielman’s 3p model) and the way that these constructs interact in order to maintain a vicious cycle of insufficient sleep which leads to chronic sleep deprivation.

Conclusion

The current model portrays a wide-ranging view of mechanisms underlying sleep deprivation among adolescence by integrating both biological and behavioral aspects. The model is proposed to encourage researchers to explore these conceptual elements of biological and neurobiological changes, and behavioral problems in order to operationalize relevant measures to relate the concepts to sleep deprivation and subsequent health outcomes in adolescents.

Support

None

1051 Level Of Agreement Between Objective And Subjective Sleep Measures In Lung Cancer Survivors With Insomnia

Introduction

Lung cancer survivors (LCS) have the second-highest incidence of impaired sleep among cancer population. Clinical studies use self-reported and objective measures to assess insomnia in LCS. However, negative beliefs of sleep patterns may impair sleep perception, impact psychological state, and influence insomnia treatment and survivorship outcomes. This study aims to assess the level of agreement between subjective and objective sleep measures in LCS.

Methods

Forty-four non-small cell lung cancer survivors, stage I-III, at least 6 weeks after treatment completion, with Insomnia Severity Index &gt;7, were recruited from two sites from 2014-2016. Individuals with sleep apnea, menopause, rotating shift work, uncontrolled substance abuse, or unstable medical/psychiatric illnesses were excluded from the study. Agreement between total sleep time (TST), sleep latency (SL) and sleep efficiency (SE) from Sleep Diary and wrist-actigraphy (i.e. CamNtech) were assessed with Intraclass Correlation (ICC) and Bland-Altman plots. Analysis of ICC, mean difference, standard deviation (SD) and 95% confidence interval (CI) were conducted using SPSS 24.

Results

LCS were male (63.6%), 60-69 years old (52.3%), married or living with a partner (50%). Self-reported measurements underestimated TST (-68.2 minutes, ICC 0.45, CI 95%, SD 108.1) and SL (-25.9 minutes, ICC 95%, ICC -0.54, DS 17.5). Objective and self-reported measurements largely overlapped for SE, with a small actigraphy-based overestimation (9.2, ICC 0.2, CI95%, SD 7.3). Bland-Altman plots revealed that the agreement increased with lower SE values.

Conclusion

LCS tended to underestimate TST and SL. An apparent agreement between objective and self-reported measures for SE may indicate sleep state misperception. Differences in various sleep parameters and potential covariates should be investigated for contribution to the unexplained considerable individual variability in behavioral treatment response among cancer survivors in larger sample sizes.

Support

1R01NR018215-01 (GED); T32GM099607(CW).

Rydberg-Mediated Entanglement in a Two-Dimensional Neutral Atom Qubit Array

We demonstrate high fidelity two-qubit Rydberg blockade and entanglement on a pair of sites in a large two-dimensional qubit array. The qubit array is defined by a grid of blue detuned lines of light with 121 sites for trapping atomic qubits. Improved experimental methods have increased the observed Bell state fidelity to F_{Bell}=0.86(2). Accounting for errors in state preparation and measurement we infer a fidelity of F_{Bell}^{-SPAM}=0.88. Accounting for errors in single qubit operations we infer that a Bell state created with the Rydberg mediated C_{Z} gate has a fidelity of F_{Bell}^{C_{Z}}=0.89. Comparison with a detailed error model based on quantum process matrices indicates that finite atom temperature and laser noise are the dominant error sources contributing to the observed gate infidelity.

Diagnostic Accuracy and Scope of Intraoperative Transoral Ultrasound and Transoral Ultrasound-Guided Fine-Needle Aspiration of Retropharyngeal Masses

The use of transoral sonography-guided fine-needle aspiration for intraoperative localization of retropharyngeal masses has been described by Fornage et al. The purpose of this study was to assess the accuracy of this technique. We reviewed the images and medical records of 26 patients with a retropharyngeal lesion suspicious for a metastatic lymph node of Rouviere identified on CT and/or PET/CT. There were 14 patients with a history of thyroid cancer, 7 with mucosal squamous cell carcinoma, 1 with renal cell carcinoma, 1 with parotid acinic cell cancer, 1 with metastatic colon adenocarcinoma, and 2 with no history of cancer. Intraoperative transoral sonography was performed using a commercially available endovaginal transducer. A transoral sonography-guided fine-needle aspiration was performed with a 25-cm-long 20-ga Chiba needle through a needle guide attached to the transducer shaft. Cytopathologic results were categorized as malignant, benign, or nondiagnostic. Transoral sonography and transoral sonography-guided fine-needle aspiration were performed in all patients. A diagnostic specimen was obtained in 25 of 26 (96%) patients with a 100% overall accuracy. Twelve patients underwent subsequent transoral resection of the retropharyngeal mass. In each patient, surgical pathology confirmed the fine-needle aspiration biopsy result. In 4 patients, transoral sonography-guided injection of methylene blue was used to facilitate intraoperative localization of the metastatic retropharyngeal mass. Transoral sonography and transoral sonography-guided fine-needle aspiration of suspicious masses in the retropharyngeal space are highly accurate procedures for identification and cytologic evaluation of benign and metastatic lymph nodes of Rouviere and for presurgical localization.

Randomized clinical trial of duct-to-mucosa pancreaticogastrostomy versus handsewn closure after distal pancreatectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) remains a major cause of morbidity after distal pancreatectomy. The aim of this study was to investigate whether duct-to-mucosa pancreaticogastrostomy of the pancreatic stump decreased clinical POPF formation compared with handsewn closure after distal pancreatectomy.

METHODS

This multicentre RCT was performed between April 2012 and June 2014. Patients undergoing distal pancreatectomy were assigned randomly to either duct-to-mucosa pancreaticogastrostomy or handsewn closure. The primary endpoint was the incidence of clinical POPF. Secondary endpoints were rates of other complications and length of hospital stay.

RESULTS

Some 80 patients were randomized, and 73 patients were evaluated in an intention-to-treat analysis: 36 in the pancreaticogastrostomy group and 37 in the handsewn closure group. The duration of operation was significantly longer in the pancreaticogastrostomy group than in the handsewn closure group (mean 268 versus 197 min respectively; P < 0·001). The incidence of clinical POPF did not differ between groups (7 of 36 versus 7 of 37; odds ratio (OR) 1·03, 95 per cent c.i. 0·32 to 3·10; P = 1·000). The rate of intra-abdominal fluid collection was significantly lower in the pancreaticogastrostomy group (6 of 36 versus 21 of 37; OR 0·15, 0·05 to 0·45; P < 0·001). There were no statistically significant differences in the rates of other complications or length of hospital stay.

CONCLUSION

Duct-to-mucosa pancreaticogastrostomy did not reduce the incidence of clinical POPF compared with handsewn closure of the pancreatic stump after distal pancreatectomy. Registration number UMIN000007426 (http://www.umin.ac.jp).

Paradoxical delay of senescence upon depletion of BRCA2 in telomerase-deficient worms

BRCA2 is a multifunctional tumor suppressor involved in homologous recombination (HR), mitotic checkpoint regulation, and telomere homeostasis. Absence of Brca2 in mice results in progressive shortening of telomeres and senescence, yet cells are prone to neoplastic transformation with elongated telomeres, suggesting that BRCA2 has positive and negative effects on telomere length regulation along the path to tumorigenesis. Using Caenorhabditis elegans as a model, we show here that depletion of BRC‐2, an ortholog of BRCA2, paradoxically delays senescence in telomerase‐deficient mutant worms. Telomerase‐deficient worms (trt‐1) exhibit early replication senescence due to short telomeres. It should be noted that worms mutated in brc‐2 are not viable as well due to massive genotoxic insults. However, when BRC‐2 is depleted by RNA interference in trt‐1 mutant worms, the number of generations is unexpectedly increased with telomere length maintained, compared to telomerase mutants. Interestingly, depletion of other HR genes such as rad‐51 and rad‐54 exhibited similar effects. In worms doubly deficient of telomerase and brc‐2, rad‐51, or rad‐54, extra telomeric C‐circles were generated, suggesting that abrogation of HR induces an alteration in telomere environment favorable to illegitimate telomere maintenance when telomerase is absent. Collectively, absence of BRC‐2 in telomerase‐deficient background first leads to telomere shortening, followed by an induction of an as‐yet‐unknown telomere maintenance pathway, resulting in delay of senescence. The results have implications in the understanding of dysfunctional BRCA2‐associated tumorigenesis.