Incorporating the patient perspective in the study of rare bone disease: insights from the osteogenesis imperfecta community

There is limited research which examines health concerns of individuals with osteogenesis imperfecta (OI). Discussion groups with leaders of the adult OI community identified a broad range of medical priorities beyond fractures and brittle bones. Our work underscores the need to include patient-reported outcomes in rare bone disease research.

INTRODUCTION

Osteogenesis imperfecta (OI) is a rare genetic disorder affecting collagen protein leading to brittle bones and a number of other medical complications. To date, there is limited research which examines the life-long process of aging with this rare disease, much less the perspective of individuals with OI.

METHODS

In order to explore and prioritize health concerns that adults with OI feel have been inadequately addressed in health care and research, investigators held discussions with leaders from the global adult OI community. The meetings were held in August 2017 at the 13th International Conference on OI in Oslo, Norway as part of the preconference seminar "Patient Participation in OI Research". Investigators were part of the Brittle Bone Disease Consortium (BBDC), a multicenter research program devoted to the study of OI, and their focus was on patient-reported outcomes (PRO).

RESULTS

Participants noted that while fractures and brittle bones are the most common feature of OI, a number of body systems are under-studied in this disorder. They particularly emphasized breathing, hearing, and the effects of aging as primary concerns that researchers and physicians may not fully understand or address. Other areas included pain, gastrointestinal problems, mental health, nutrition, menopause/pregnancy, and basilar invagination. Participants also emphasized that they must be informed of study results. They underscored that outcome measures incorporated into future drug trials must look beyond fractures and consider the whole patient.

CONCLUSIONS

This work will help guide the incorporation of PROs into the next phase of the BBDC Natural History Study of OI and underscores the importance of including PROs in the study of rare diseases.

Reprint of: Food reformulation and the (neo)-liberal state: new strategies for strengthening voluntary salt reduction programs in the UK and USA

Globally, excess salt intake is a significant cause of preventable heart disease and stroke, given the established links between high salt intake, high blood pressure, and cardiovascular disease. This paper describes and evaluates the voluntary approaches to salt reduction that operate in the United Kingdom and the United States, and proposes a new strategy for improving their performance. Drawing on developments in the theory and practice of public health governance, as well as theoretical ideas from the field of regulatory studies, this paper proposes a responsive regulatory model for managing food reformulation initiatives, including salt reduction programs. This model provides a transparent framework for guiding industry behavior, making full use of industry's willingness to participate in efforts to create healthier products, but using 'legislative scaffolding' to escalate from self-regulation towards co-regulation if industry fails to play its part in achieving national goals and targets.

Food reformulation and the (neo)-liberal state: new strategies for strengthening voluntary salt reduction programs in the UK and USA

Globally, excess salt intake is a significant cause of preventable heart disease and stroke, given the established links between high salt intake, high blood pressure, and cardiovascular disease. This paper describes and evaluates the voluntary approaches to salt reduction that operate in the United Kingdom and the United States, and proposes a new strategy for improving their performance. Drawing on developments in the theory and practice of public health governance, as well as theoretical ideas theoretical ideas from the field of regulatory studies, this paper proposes a responsive regulatory model for managing food reformulation initiatives, including salt reduction programs. This model provides a transparent framework for guiding industry behavior, making full use of industry's willingness to participate in efforts to create healthier products, but using 'legislative scaffolding' to escalate from self-regulation towards co-regulation if industry fails to play its part in achieving national goals and targets.

A comparison of patient-reported outcomes (PROs) in National Cancer Institute-sponsored cancer treatment trials conducted during two time periods: 1999–2003 and 2003–2008

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Background: Over the past decade, the U.S. National Cancer Institute (NCI) support for incorporating Patient-Reported Outcomes (PROs) into disease treatment clinical trials has grown considerably, both in the number of trials, as well as the types of research questions being addressed and the measures used to answer the questions. This presentation will compare the breadth of NCI supported Phase III treatment trials in breast, colo-rectal, lung, and prostate cancers that include PRO secondary endpoints activated during two time periods: 1999–2003 and 2003–2008. Both time periods will be compared to identify the number and type of PRO measures; in addition the targeted PRO domain will be examined by cancer site. Methods: For this study, PRO was broadly defined to include any self-report questionnaire that gathered data on the potential impact that disease treatment might have on patient functioning, quality of life, or symptoms. Using the terms, 'protocol title, lead disease, phase III, quality of life, and instrument name,’ a search was conducted of the NCI database containing breast, colo-rectal, lung, and prostate Phase III treatment trials activated during the two time periods. If a scale was used more than once or if different versions of the scale were used, i.e., FACT-G and FACT-BR, it was only counted once. Results: Between 1999 and 2003, 42 phase III trials in the four major cancers were activated, with 15 trials having one or more PROs as secondary endpoints. Between 2003 and 2008, 50 phase III trials in the four major cancers were activated, with 28 trials having one or more PROs as secondary endpoints. Although the data reveal a 20% increase in the number of phase III trials in the 4 diseases between the two time periods, the number of trials with PRO endpoints has doubled. Conclusions: This significant increase in the use of PROs in phase III trials gives investigators additional data to fully analyze the impact of new treatments. These PRO data will provide researchers, clinicians, and future patients with a more in-depth understanding of the potential for new cancer therapies and technologies to extend both the quantity and quality of life.

No significant financial relationships to disclose.

Is patient self-reporting more accurate than clinician reporting of symptoms for predicting survival in patients with cancer? Meta-analysis of 30 closed EORTC randomized controlled trials

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Background: This study investigated whether patient self-reporting of symptoms improved prediction of survival as compared to clinician reporting or whether it provided an additive value when taken together with clinician assessment of the same symptoms. Methods: Patients with advanced cancer from 30 European Organisation for Research and Treatment of Cancer (EORTC) Randomized Controlled Trials were included in this retrospective pooled analysis. Clinician [Common Toxicity Criteria (CTC)] and patient (EORTC QLQ-C30) symptom assessment were reported at entry into the study. Data were obtained for six symptoms: pain, fatigue, vomiting, nausea, diarrhea and constipation. The prognostic accuracy for survival was assessed by modeling the contrast in reporting using the Harrell's discrimination c-index (c). Results: Data were available from patient and clinician assessment for pain [number of trials (t) =8, number of patients (n) =1214], fatigue [t=5, n=1237], vomiting [t=5, n=824], nausea [t=6, n=1393], diarrhea [t=6, n=815] and constipation [t=4, n=751]. Fatigue (c=0.59 vs 0.55, p<.01) and constipation (c=0.57 vs 0.52, p=0.03) as reported by patients (vs clinicians) were significantly higher in predicting survival. Patient reported pain (c=0.59 vs 0.58, p=0.17), nausea (c=0.54 vs 0.52, p=0.51), vomiting (c=0.55 vs 0.52, p=0.21) and diarrhea (c=0.51 vs 0.52, p=0.49) did not predict survival any more accurately than clinician assessment. Patient and clinician assessment combined (vs clinicians alone) improved the prognostic accuracy for fatigue (c=0.61 vs 0.55, p=0.01), pain (c=0.60 vs 0.58, p<0.01), nausea (c=0.54 vs 0.52, p=0.04), vomiting (c=0.56 vs 0.52, p=0.04) and constipation (c=0.5 vs 0.52, p=0.01), but not for diarrhea (c=0.52 vs 0.52, p=0.44). Conclusions: Our results suggest that patients’ ratings of their own fatigue and constipation have more prognostic value than clinicians’ ratings of these symptoms. Further, the prognostic value of clinicians's ratings can be improved by combining them with patients’ assessments for the symptoms pain, fatigue, constipation, nausea and vomiting.

No significant financial relationships to disclose.

Relationships among health-related quality of life indicators in cancer patients: A pooled study of baseline EORTC QLQ-C30 data from 6,739 patients

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Background: Cancer patients frequently experience multiple and co-occuring problems due to their illness and therapies. Clusters are defined as groups of two or more Health-Related Quality of Life (HRQoL) indicators that occur concurrently and may or may not have a common related cause. The objective of this meta-analysis was to identify how HRQoL indicators cluster among cancer patients. Methods: Retrospective pooling of 29 European Organisation for Research and Treatment of Cancer (EORTC) randomized clinical trials, among 10 cancer sites, yielded baseline EORTC QLQ-C30 HRQoL data for a total of 6739 patients. A cluster analysis was performed to identify clusters among the 15 HRQoL scales, via Ward's method. Cronbach's alpha coefficient (α) was used to measure internal consistency. Dendrograms of the HRQoL indicators were plotted for the overall data and for each cancer site. Results: Three main clusters emerged from the pooled dataset: a physical function-related cluster, consisting of physical and role functioning, fatigue and pain (α = 0.83); a psychological function-related cluster, consisting of emotional and cognitive functioning and insomnia (α = 0.64); and a gastrointestinal cluster, consisting of nausea and vomiting and appetite loss (α = 0.68). The same clusters were found in patients with metastatic and non-metastatic disease. The gastrointestinal cluster was reproduced in all 10 cancer sites. We found that pain was not correlated with the other variables of the physical function cluster for patients with brain, colorectal or pancreatic cancer. For the psychological component cluster, cognitive functioning was not correlated with the other variables of the cluster for breast or pancreatic cancer patients, while insomnia was found not to be correlated with the other variables of the cluster for prostate cancer patients. Conclusions: This study shows that relationships among HRQoL indicators exist and that three major constructs can be found: a physical, a psychological and a gastrointestinal component. Understanding these relationships may aid diagnostic criteria, and assessment, management, and prioritization of symptom care.

No significant financial relationships to disclose.

Ventilator circuit and secretion management strategies: a Franco-Canadian survey

OBJECTIVE

To determine the use of ventilator circuit and secretion management strategies in France and Canada.

DESIGN

Binational cross-sectional survey.

POPULATION

Intensive care unit (ICU) directors in French and Canadian university hospitals.

MEASUREMENTS

We compared responses between countries regarding the use of seven circuit and secretion strategies, the rationales against their use, decisional responsibility for these strategies, whether ventilator-associated pneumonia (VAP) practice was audited, and whether VAP prevention guidelines addressing these strategies were used.

RESULTS

The response rate was 72/84 (85.7%) for French and 31/32 (96.9%) for Canadian ICUs. Endotracheal intubation was predominantly oral in both countries. Changing the ventilator circuits only for every new patient was more frequent in France than in Canada (p < .0001). Heated humidifiers were used more in Canada than France (p = .0003). Closed endotracheal suctioning was used more frequently in Canada (p < .0001). In both countries, subglottic secretion drainage and kinetic beds were rarely used. Semirecumbent positioning was reported more often by French than Canadian ICUs (p = .003). Reasons for nonuse of these strategies included adverse effects (heat and moisture exchangers), cost (kinetic beds), lack of convincing benefit (subglottic secretion drainage), and nurse inconvenience (semirecumbency). Decisional responsibility for each strategy differed among institutions. VAP prevention practice was periodically reviewed in 53% of French and 68% of Canadian ICUs (p = .20). VAP prevention guidelines were used in 64% and 30% of these ICUs, respectively (p = .002).

CONCLUSIONS

Our study does not support the notion that published recommendations substantially impact reported use of several ventilator circuit and secretion management strategies. Based on the use of more frequent ventilator circuit changes, closed suctioning systems, heated humidifiers, and respiratory therapists, ventilator circuit and secretion management practice appears more costly in Canada than in France.

The tolerometer: a fast, automated method for the measurement of righting reflex latency in chronic drug studies

We describe a fast, automated system for the measurement of righting reflex latencies in drug studies. This system, which we call a 'tolerometer', is especially useful for studies of drug tolerance which require a simple measurement of motor behaviour on a daily basis, for long periods of time. The tolerometer consists of a semi-cylindrical platform positioned on a 2 kg load cell, connected to a strain gauge amplifier (Radio Spares Ltd). The output from the amplifier is connected to a MacLab data acquisition system (Analog Digital Instruments), controlled by a Macintosh Classic computer. The MacLab Chart program is used to display, on the Macintosh screen, the load changes which occur during a righting reflex; sampling frequencies up to 40 kHz can be used, but we find 20-100 Hz adequate. Using measurement cursors provided by the Chart program, the latency from the point at which an animal is placed on the tolerometer platform in the supine position, until the completion of a righting reflex, can be measured accurately and easily.

Simple device for quantifying drug effects on the righting reflex

A simple, inexpensive device is described that allows quantification of the effects of drugs on the righting reflex. This device consists of a modified set of kitchen scales connected to a digital timer. Two moveable Hall effect switches are positioned around the pointer, which registers the weight of the animal on the scales; when the animal is placed on the scales in the supine position, the initiation of a righting reflex causes the pointer to cross one of the switches, stopping the digital timer and providing a measure of righting reflex latency (RRL). We describe an efficient protocol for using this device that provides quantification of drug effects on the RRL, which can then be subjected to analysis using parametric statistics such as analysis of variance.