A step closer to parenthood with non-obstructive azoospermia: Unveiling the impact of microdissection testicular sperm extraction in Australia's largest single-centre study

BACKGROUND

Non-obstructive azoospermia (NOA) diagnosis poses challenges for couples seeking parenthood. Microdissection testicular sperm extraction (MD-TESE) excels in retrieving testicular sperm cells for NOA cases. However, limited live birth data in Australian NOA patients hinders accurate counselling.

AIMS

This study aimed to determine the likelihood of infertile couples with a male partner diagnosed with NOA conceiving biological children using MD-TESE / intracytoplasmic sperm injection (ICSI).

MATERIALS AND METHODS

A retrospective cohort study included 108 NOA men treated at a public fertility unit and a private fertility centre (May 2009-May 2022).

PRIMARY OUTCOME

live birth rate (LBR); secondary outcomes: sperm retrieval rate, pregnancy rate, and neonatal outcomes.

RESULTS

Among 108 patients undergoing MD-TESE, the positive sperm retrieval rate (PSRR) was 64.8% (70/108). Histology best predicted sperm retrieval success, with hypo-spermatogenesis yielding a 94.1% PSRR. Age, testicular volume, and hormonal parameters had no significant impact. Mean male age: 35.4 years; mean partner age: 32.7 years. Fertilisation rate: 50.7%. LBR per initiated cycle: 58.7% (37/63); per embryo transfer: 63.8% (37/58); per initially diagnosed NOA man: 34.3% (37/108). Cumulative LBR: 74.1% (43/58); twin rate: 10.8% (4/37). No neonatal deaths or defects were observed among 47 live offspring.

CONCLUSION

This study provides valuable data for counselling NOA couples on the probability of conceiving biological offspring. MD-TESE and ICSI yielded favourable PSRR (64.8%) and LBR (63.8%). However, couples should be aware that once NOA is confirmed, the chance of taking home a baby is 34%.

A rare case of mosaic Klinefelter syndrome in a 45-year-old man leading to successful live birth through ejaculated spermatozoa: a case report and literature review

Background: Men diagnosed with Klinefelter syndrome (KS) commonly exhibit non-obstructive azoospermia or rarely having sperm in their ejaculate, rendering them traditionally considered sterile prior to the introduction of intracytoplasmic sperm injection (ICSI). The presence of mosaic KS may mask the classical phenotype, resulting in underdiagnosis throughout their lifetime. Surgical sperm retrieval through Microdissection Testicular Sperm Extraction (Micro-TESE) combined with ICSI has become the gold standard approach, maximizing reproductive outcomes in these individuals. However, it is noteworthy that approximately 7% of men with KS may exhibit sperm in their ejaculate, providing an opportunity for them to achieve biological parenthood through ICSI. Case Presentation: In this report, we present an exceptional case of a 45-year-old man with Mosaic KS and severe oligozoospermia who successfully achieved pregnancy utilizing ICSI with freshly ejaculated sperm. Remarkably, this case represents the oldest recorded instance of a man with Klinefelter syndrome fathering his own biological child using sperm derived from fresh ejaculate. Conclusion: Although this case is exceedingly rare, it underscores the critical importance of exhausting all possibilities to facilitate biological parenthood in men with KS before considering alternative options such as sperm donation or adoption. By recognizing the potential for successful conception using ejaculated sperm in this population, we can provide individuals with mosaic KS the opportunity to fulfill their desire for biological offspring.

Overweight and obesity management in musculo-skeletal primary care: a survey of Australian health practitioners exploring ‘the elephant in the room&#x2019

BACKGROUND

Overweight and obesity has a bi-directional association with the growing burden of musculoskeletal (MSk) dysfunction and pain. It seems inevitable that MSk practitioners will see increasing numbers of patients who are overweight and or obese and require this to be addressed as part of their management. Little evidence exists to describe the engagement of patients and their MSk practitioner in weight management as an adjunct or direct component of their intervention or therapy.

METHODS

A self-administered electronic survey was constructed with 13 items to collect self-reported data from Australian practitioners who have a focus on MSk management. The target group was from a multidisciplinary MSk network of 350 members.

RESULTS

A total of 204 completed surveys were analysed from respondents working in one of seven MSk- related professions. It was found that 70% of patients/clients seen by respondents were overweight or obese and that <18% of these patients had weight management included as part of their treatment.

CONCLUSIONS

Sixty percent of the respondents in this survey indicated that they do not include weight management as part of their practice despite 70% of their patients/clients being overweight and or obese. With the exception of Medical Practitioners and Exercise Physiologists, in this survey, the other therapists including Chiropractors, Osteopaths, Physiotherapists and Occupational Therapists, indicated that they lacked confidence, knowledge and methods to engage a systematic approach to weight management with their patients/clients.

P-114 INVESTIGATING THE ROLE OF BOTOX IN THE EMERGENCY MANAGEMENT OF COMPLEX ABDOMINAL WALL HERNIAS

Aims

Botulinum toxin (Botox) has an established role in the elective management of complex abdominal wall hernia, but its role in the emergency setting has not been investigated. Clinical effects of Botox peak at 2–3 weeks after injection, but effects become apparent within 48 hours. We aimed to determine if these early effects can facilitate the acute reduction of irreducible hernia.

Materials and methods

Patients with irreducible abdominal wall hernias over a 30 month period were considered for Botox therapy. Suitable patients were given 300 units of Botox under ultrasound guidance into the anterolateral muscles bilaterally. Data were collected on outcomes.

Results

Twelve patients received Botox. All had incisional hernias and an ASA of 3 or more. Six were on antiplatelets and/or anticoagulation. All received Botox with standard conservative management. In ten patients, the hernia was reduced and symptoms resolved. One patient required surgery at 48 hours due to bowel ischaemia from inter-sac adhesions. A second patient experienced recurrent obstruction despite successful hernia reduction but was palliated due to advanced age and frailty.

Conclusions

This case series is the first study to investigate the role of Botox in the acute management of irreducible hernias. Our findings suggest that in selected patients, Botox can aid hernia reduction and avoid the morbidity of emergency repair. This is of particular value in high risk patients and those with complex defects who benefit from preoperative optimisation techniques. The accurate identification of strangulation is crucial however, as it excludes patients from this approach.

Re‐imaging health care delivery in the era of COVID‐19

The COVID‐19 pandemic has exposed the deficiencies of the current healthcare system of the disconnect between primary and tertiary care and increasing subspecialisation, the focus on acute episodic care rather than on prevention in a time where chronic disease prevails and an inefficient use of healthcare resources. Herein, we present the case for an alternative model of healthcare delivery – Shared Medical Appointments – which are efficient, effective, empowering and can be transitioned to the virtual environment successfully. We highlight the barriers to implementation and how these can be overcome.

This article is protected by copyright. All rights reserved.

Energetics of a Single Qubit Gate

Qubits are physical, a quantum gate thus not only acts on the information carried by the qubit but also on its energy. What is then the corresponding flow of energy between the qubit and the controller that implements the gate? Here we exploit a superconducting platform to answer this question in the case of a quantum gate realized by a resonant drive field. During the gate, the superconducting qubit becomes entangled with the microwave drive pulse so that there is a quantum superposition between energy flows. We measure the energy change in the drive field conditioned on the outcome of a projective qubit measurement. We demonstrate that the drive's energy change associated with the measurement backaction can exceed by far the energy that can be extracted by the qubit. This can be understood by considering the qubit as a weak measurement apparatus of the driving field.

An approach to defining and achieving restoration targets for a threatened plant community

Connecting scientific research and government policy is essential for achieving objectives in sustaining biodiversity in an economic context. Our approach to connecting theoretical ecology, applied ecology, and policy was devised using principles of restoration ecology and the requisite methodology to restore biodiverse ecosystems. Using a threatened ecological community (TEC) with >120 plant species, we posit our approach as a guide for interpreting and achieving regulatory compliance (i.e., government conditions) enacted to manage or offset environmental impacts of development. We inform the scientific approach necessary to delivering outcomes appropriate to policy intent and biodiverse restoration through theoretical and applied research into the ecological restoration of the highly endemic flora of banded ironstone formations of the Mid West of Western Australia. Our approach (1) defines scale-appropriate restoration targets that meet regulatory compliance (e.g., Government of Western Australia Ministerial Conditions); (2) determines the optimal method to return individual plant species to the restoration landscape; (3) develops a conceptual model for our system, based on existing restoration frameworks, to optimize and facilitate the pathway to the restoration of a vegetation community (e.g., TEC) using diverse research approaches; and (4) develops an assessment protocol to compare restoration achievements against the expected regulatory outcomes using our experimental restoration trials as a test example. Our approach systematically addressed the complex challenges in setting and achieving restoration targets for an entire vegetation community, a first for a semiarid environment. We interpret our approach as an industry application relevant to policy- or regulator-mediated mine restoration programs that seek to return biodiverse species assemblages at landscape scales.

P-003 Sperm retrieved by microdissection testicular sperm extraction (MD-TESE) is associated with altered sex ratio of offspring after intracytoplasmic sperm injection in men with non-obstructive azoospermia

Study question

Does the sperm retrieved surgically by MD-TESE of men with Non-Obstructive Azoospermia affect the live birth sex ratio?

Summary answer

Our data indicates that sperm retrieved in men with non-obstructive azoospermia alters the sex ratio in favor of female offspring.

What is known already

Non-Obstructive Azoospermia is the most severe form of male infertility and is the most common cause of Azoospermia. Among the different surgical techniques, MD-TESE gives the highest rate of sperm retrieval and when combined with intracytoplasmic sperm injection (ICSI), live births had been achieved with variable success, Sex ratio of offspring can vary substantially due to several variables, however no studies have investigated the resultant birth sex ratio in this setting.

Study design, size, duration

Retrospective Cohort study. Data were collected between May 2009 and December 2019. A total of 100 consecutive men with non-obstructive Azoospermia underwent MD-TESE for sperm retrieval. 46 couples underwent ICSI and live birth rate, cumulative live birth rate and sex ratio of offspring analysed.

Participants/materials, setting, methods

One-hundred men underwent MD-TESE out of which 46 proceeded with ICSI. Demographic data including male and female age, testicular volumes and serum hormone values are given as mean ± SD with a range (minimum and maximum). Fertility outcomes including sperm retrieval, fertilization rate, number of embryos transferred, and live birth rates and cumulative live birth rates were recorded. Chi-square test was performed to compare the proportions.

Main results and the role of chance

Sperm retrieval was successful in 58%(58/100). Testicular volume and hormonal parameters did not vary among patients with positive or negative sperm retrieval. Histology gave best correlation with sperm retrieval. Hypospermatogenesis yielded the highest sperm retrieval 93%(26/29), followed by Maturation arrest 78%(7/9), then Hyalinosis 46% (6/13) and lastly Sertoli cell only 38%(19/50). 46 couples underwent ICSI cycles where the mean age of patients and their wives were 36.4 ± 3.7y and 33.0 ± 4.3y. Fertilization rate and mean number of transferred embryos were 51.4 % and 1.7. Live birth rate and Cumulative Live Birth rate per Embryo transfer were 60.5% (26/43) and 74.4% (32/43) and per started ICSI cycle were 56.5% (26/46) and 69.6% (32/46), with a twin rate of 15.3%(4/26). Mean gestational length and mean body weight at birth were 39.0 ± 1.4w and 3228.5 ± 5.5 g. Number of live offspring were 36 (Female: Male = 26:10) giving rise to sex ratio of 2.6 to1 in favor of female offspring (P &lt; 0.05). There were no neonatal death, and one baby had phenylketonuria.

Limitations, reasons for caution

This is the first study to test the hypothesis of sex ratio variation related to the source of sperm; the strength of our study is that all procedures were performed by the same surgeon, so there are no operator-dependent differences. This finding needs to be confirmed in larger cohort studies.

Wider implications of the findings

It has been demonstrated that different stressors may alter the sex of the offspring. While in the present study the stressor is the parental hypogonadism associated with non-obstructive azoospermia, We hypothesise that testicular environment may direct spermatogenesis in favor of X carrying sperm around the time of sperm retrieval.

Trial registration number

N/A

Shared Medical Appointments in Weight Management: A Culturally Responsive Process for Aboriginal Women. Translational Trial Results

Introduction: This paper presents a secondary analysis of data from a study of 216 people participating in a trial of program shared medical appointments (PSMA) in weight management. The focus of this paper is the Aboriginal women who participated in this translational research project and who were not reported on specifically in the primary analysis and publication. This paper, therefore, examines the use of PSMA as a culturally safe and responsive procedure to facilitate weight management. Method: Twogroups, totalling 25 Aboriginal women, participated in a 6-session 12-week culturally responsive weight management PSMA. Repeated weight and satisfaction measures at 3, 6 and 12 months were collected. Results: 19 of 25 (76%) Aboriginal women completed the MYU. 16 (84%) lost some weight, and 5 (26%) lost clinically significant weight (> 5%), sustained for 1 year. The participants and providers rated the procedure > 4 on 5-point Likert scales for satisfaction. 95% reported that they preferred MYUs for weight management over 1:1 consultations with their general practitioner. Conclusion: The data indicates that programmed shared medical appointments appear to be a culturally safe and responsive procedure to support the Aboriginal women, in this study, to manage their weight.

Post-warming embryo morphology is associated with live birth: a cohort study of single vitrified-warmed blastocyst transfer cycles

Purpose

This study aims to examine whether blastocyst morphology post-warming correlates with live birth.

Methods

In this cohort study, morphological characteristics post-warming were reviewed in all single vitrified-warmed blastocyst transfer cycles performed between November 2016 and May 2017. Immediately before transfer, the degree of blastocoel re-expansion was graded as A, fully expanded; B, partially expanded ≥ 50%; C, partially expanded < 50%; and D, collapsed. The degree of post-warming cell survival was graded on a scale of 50 to 100% and was then classified into 4 groups: very low 50–70%, low 71–80%, moderate 81–90%, and high 91–100%.

Results

Overall, 612 cycles were reviewed, of which 196 included PGT-A tested embryos. The live birth rate (LBR) increased from 11.4% in the collapsed blastocysts group to 38.9% in the post-warming full re-expansion group (p < 0.001) and from 6.5% for blastocysts with a very low cell survival rate to 34.7% for blastocysts with high cell survival rate (p = 0.001). LBR was 6.7% for blastocysts with the worst post-warming morphological characteristics, namely, collapsed with very low cell survival rate. On multivariate analyses, partial blastocyst re-expansion ≥ 50%, full re-expansion, and high cell survival rate remained significantly associated with live birth, after controlling for female age, pre-vitrification morphological grading, and PGT-A. A sub-analysis of cycles using PGT-A tested embryos showed similar results.

Conclusion

Post-warming re-expansion and high cell survival rate are associated with higher LBR in euploid and untested blastocysts. However, embryos with poor post-warming morphology still demonstrate a considerable probability of live birth, and they should not be discarded.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10815-021-02390-z.

Suboptimal uptake, retention, and adherence of daily oral PrEP among people with OUD receiving HCV treatment

Background

Daily oral preexposure prophylaxis (PrEP) with tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) prevents human immunodeficiency (HIV) among people who inject drugs (PWID). Despite rising HIV incidence and injection drug use (IDU), PrEP use remains low and there is limited research about uptake, adherence, and retention among PWID.

Methods

The ANCHOR investigation evaluated a community-based care model collocating hepatitis C virus (HCV) treatment, medication for opioid use disorder (OUD), and PrEP in individuals in Washington, DC, and Baltimore, Maryland. PrEP counseling was conducted from HCV treatment day 0 until week 24. Subjects could start any time during this window, were followed for 48 weeks, and were assessed for adherence by self-report and dried blood spot TDF analysis.

Results

One hundred ninety-eight participants were enrolled, of whom 185 (93%) were HIV negative. Twenty-nine individuals (15.7% of HIV-negative cohort) initiated PrEP. One hundred sixteen participants (62.7%) met 2014 Centers for Disease Control and Prevention (CDC) PrEP criteria due to IDU (82 [44.3%]), sex (9 [4.9%]), or both practices (25 [13.5%]). Providers recommended PrEP to 94 individuals (50.8%), and recommendation was associated with PrEP uptake. Median treatment duration was 104 days (interquartile range, 28–276 days), with 8 participants retained through week 48. Adherence was variable over time by self-report and declined by TDF analysis. No HIV seroconversions occurred.

Conclusions

This cohort of people with HCV and OUD experienced low uptake of PrEP despite the majority meeting CDC criteria. High rates of disruption and discontinuation, compounded by variable adherence, made TDF/FTC a suboptimal prevention strategy. Emerging modalities like long-acting formulations may address these barriers, but PWID have been excluded from their development to date.

Implementing recovery-oriented practice in older people

Personal recovery is central to Australian mental health standards, but promoting recovery-oriented practice remains a wicked problem (ie complex, with definitions and appropriate interventions impacted upon by context and values), with limited evidence regarding effective implementation. This case study re-examines a statewide initiative to enhance recovery-oriented practice in older people's mental health services in New South Wales from the perspective of complex adaptive systems. The initiative consisted of three key strategies: (1) statewide collaborative leadership and practice resources; (2) locally determined and led improvement projects; and (3) evaluating, disseminating and sustaining initiative outcomes. Published outcomes of the initiative, related policy and benchmarking materials and author reflections are used to propose lessons for other services and policy makers. From a systems perspective, a relatively small investment from a state policy unit to enhance a facilitating environment resulted in the emergence of local leaders and voluntary participation of services within 80% of local health districts without funding incentives. Local leaders and activities informed statewide policies and models of care to sustain practice change. Limitations included variability in project scopes and the involvement of people with lived experience, as well as the level of refinement in change management approach. Self-audit and consumer-rated experience suggest resilience of practice and culture change. The outcomes are consistent with conceptualisations of mental health services being complex adaptive systems requiring distributive leadership. Established mechanisms encouraging statewide cooperation between clinicians, service managers and policy makers may have been significant facilitators of engagement in practice change.What is known about this topic?Recovery remains an important concept for older people with mental ill health, with implementation of recovery-oriented practice a wicked problem.What does this paper add?Central policy investment in a collaborative facilitatory environment can stimulate the emergence of local leadership and investment in actions to enhance recovery orientation. As predicted by complex adaptive systems theory, the impact of the leaders developed may be broader than the sum of individual project outcomes.What are the implications for practitioners?A start where you can message can engage and enable leaders in feasible and locally relevant changes consistent with a statewide strategy. This may be a feasible approach to improving recovery orientation in mental health care services for and beyond older people, with potential implications for addressing other wicked problems in health care.

Impact of an Australian/New Zealand organisational position statement on extended-release opioid prescribing among surgical inpatients: a dual centre before-and-after study

Extended-release opioids are often prescribed to manage postoperative pain despite being difficult to titrate to analgesic requirements and their association with long-term opioid use. An Australian/New Zealand organisational position statement released in March 2018 recommended avoiding extended-release opioid prescribing for acute pain. This study aimed to evaluate the impact of this organisational position statement on extended-release opioid prescribing among surgical inpatients. Secondary objectives included predictors and clinical outcomes of prescribing extended-release opioids among surgical inpatients. We conducted a retrospective, dual centre, 11-month before-and-after study and time-series analysis by utilising electronic medical records from two teaching hospitals in Sydney, Australia. The primary outcome was the proportion of patients prescribed an extended-release opioid. For surgical patients prescribed any opioid (n = 16,284), extended-release opioid prescribing decreased after the release of the position statement (38.4% before vs. 26.6% after, p < 0.001), primarily driven by a reduction in extended-release oxycodone (31.1% before vs. 14.1% after, p < 0.001). There was a 23% immediate decline in extended-release opioid prescribing after the position statement release (p < 0.001), followed by an additional 0.2% decline per month in the following months. Multivariable regression showed that the release of the position statement was associated with a decrease in extended-release opioid prescribing (OR 0.54, 95%CI 0.50-0.58). Extended-release opioid prescribing was also associated with increased incidence of opioid-related adverse events (OR 1.52, 95%CI 1.35-1.71); length of stay (RR 1.44, 95%CI 1.39-1.51); and 28-day re-admission (OR 1.26, 95%CI 1.12-1.41). Overall, a reduction in extended-release opioid prescribing was observed in surgical inpatients following position statement release.

Adverse Childhood Experiences as “Upstream” Determinants of Lifestyle-Related Chronic Disease: A Scoping Perspective

We have previously proposed a list of determinants (causes) of modern lifestyle-related chronic disorders, which provides a structure for the emerging discipline of lifestyle medicine. This consists of lifestyle factors with a common immune biomarker ( metaflammation) that interact in a systems fashion linked with chronic disease outcomes. We considered this to be a work in progress and later added 3 psychosocial determinants into the causal mix: meaninglessness, alienation, and loss of culture and identity (MAL). Here, we propose adverse childhood experiences (ACEs) as deeper, or even more distal, disease drivers that may act directly or indirectly through MAL to influence later chronic disease. The links with metaflammation and the need for recognition of these embedded scars in the management of lifestyle-related health problems is discussed.

Tumour profiling tests to guide adjuvant chemotherapy decisions in early breast cancer: a systematic review and economic analysis

BACKGROUND

Breast cancer and its treatment can have an impact on health-related quality of life and survival. Tumour profiling tests aim to identify whether or not women need chemotherapy owing to their risk of relapse.

OBJECTIVES

To conduct a systematic review of the effectiveness and cost-effectiveness of the tumour profiling tests oncotype DX^® (Genomic Health, Inc., Redwood City, CA, USA), MammaPrint^® (Agendia, Inc., Amsterdam, the Netherlands), Prosigna^® (NanoString Technologies, Inc., Seattle, WA, USA), EndoPredict^® (Myriad Genetics Ltd, London, UK) and immunohistochemistry 4 (IHC4). To develop a health economic model to assess the cost-effectiveness of these tests compared with clinical tools to guide the use of adjuvant chemotherapy in early-stage breast cancer from the perspective of the NHS and Personal Social Services.

DESIGN

A systematic review and health economic analysis were conducted.

REVIEW METHODS

The systematic review was partially an update of a 2013 review. Nine databases were searched in February 2017. The review included studies assessing clinical effectiveness in people with oestrogen receptor-positive, human epidermal growth factor receptor 2-negative, stage I or II cancer with zero to three positive lymph nodes. The economic analysis included a review of existing analyses and the development of a de novo model.

RESULTS

A total of 153 studies were identified. Only one completed randomised controlled trial (RCT) using a tumour profiling test in clinical practice was identified: Microarray In Node-negative Disease may Avoid ChemoTherapy (MINDACT) for MammaPrint. Other studies suggest that all the tests can provide information on the risk of relapse; however, results were more varied in lymph node-positive (LN+) patients than in lymph node-negative (LN0) patients. There is limited and varying evidence that oncotype DX and MammaPrint can predict benefit from chemotherapy. The net change in the percentage of patients with a chemotherapy recommendation or decision pre/post test ranged from an increase of 1% to a decrease of 23% among UK studies and a decrease of 0% to 64% across European studies. The health economic analysis suggests that the incremental cost-effectiveness ratios for the tests versus current practice are broadly favourable for the following scenarios: (1) oncotype DX, for the LN0 subgroup with a Nottingham Prognostic Index (NPI) of > 3.4 and the one to three positive lymph nodes (LN1-3) subgroup (if a predictive benefit is assumed); (2) IHC4 plus clinical factors (IHC4+C), for all patient subgroups; (3) Prosigna, for the LN0 subgroup with a NPI of > 3.4 and the LN1-3 subgroup; (4) EndoPredict Clinical, for the LN1-3 subgroup only; and (5) MammaPrint, for no subgroups.

LIMITATIONS

There was only one completed RCT using a tumour profiling test in clinical practice. Except for oncotype DX in the LN0 group with a NPI score of > 3.4 (clinical intermediate risk), evidence surrounding pre- and post-test chemotherapy probabilities is subject to considerable uncertainty. There is uncertainty regarding whether or not oncotype DX and MammaPrint are predictive of chemotherapy benefit. The MammaPrint analysis uses a different data source to the other four tests. The Translational substudy of the Arimidex, Tamoxifen, Alone or in Combination (TransATAC) study (used in the economic modelling) has a number of limitations.

CONCLUSIONS

The review suggests that all the tests can provide prognostic information on the risk of relapse; results were more varied in LN+ patients than in LN0 patients. There is limited and varying evidence that oncotype DX and MammaPrint are predictive of chemotherapy benefit. Health economic analyses indicate that some tests may have a favourable cost-effectiveness profile for certain patient subgroups; all estimates are subject to uncertainty. More evidence is needed on the prediction of chemotherapy benefit, long-term impacts and changes in UK pre-/post-chemotherapy decisions.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017059561.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Virtual group consultations offer continuity of care globally during Covid-19

Covid-19 has led to virtual care (mainly telephone consultations) becoming a default worldwide, despite well-documented shortcomings. Published evidence on virtual group consultations is limited, although interest and front-line experience have grown substantially since pandemic onset. Unpublished data are summarised showing feasibility of transitioning care to this model across different countries, care settings and conditions. An international webinar series has supported development and sharing of best practice and representative data on spread and utilisation of virtual groups. This model of care creates time and space for more questions and answers, so once engaged patients become staunch advocates. Group care supports personalised care and lifestyle medicine, which is growing very rapidly. In the current context, even healthcare providers under pressure can implement virtual group consultations. Most virtual group consultations have a facilitator, so this allows roles to be extended and support education of both students and new team members. These can confer greater access, continuity of care, peer support and timely information about Covid-19 and may result in better health outcomes. Given the rapid and widespread implementation of virtual care during this pandemic, data should be shared effectively and methodologically sound observational studies and clinical trials to test safety and effectiveness should be promoted now.

0487 Effects of Suvorexant on Sleep Architecture in Patients with Alzheimer’s Disease and Insomnia

Introduction

Suvorexant, an orexin receptor antagonist that enables sleep to occur via competitive antagonism of wake-promoting orexins, improved total sleep time (TST) in a sleep laboratory polysomnography (PSG) study of patients with AD and insomnia. Here we report on the effects of suvorexant on sleep architecture in the study.

Methods

This was a randomized, double-blind, 4-week trial (ClinicalTrials.gov NCT02750306). Participants who met diagnostic criteria for both probable AD dementia (of mild to moderate severity) and insomnia were randomized to suvorexant 10mg (could be increased to 20mg based on clinical response) or matching placebo. Overnight sleep laboratory PSG was performed on 3 nights: screening, baseline, and Night-29 (last night of dosing). Suvorexant differences from placebo in changes-from-baseline at Night-29 for sleep architecture were analyzed as exploratory endpoints.

Results

A total of 274 participants were included in the analysis (suvorexant N=135, placebo N=139). At Night-29, suvorexant improved TST by 28 minutes versus placebo (p=0.001). There were no significant differences between suvorexant and placebo in the % of TST spent in REM (1.3%, 95% CI: -0.5, 3.0), N1 (0.6%, 95% CI: -1.2, 2.5), N2 (-1.0%, 95% CI: -3.2, 1.2), or N3 (-0.6%, 95% CI: -1.8, 0.6). There was no significant difference between suvorexant and placebo in latency to REM (-5.4 minutes, 95% CI: -23.4, 12.7).

Conclusion

Suvorexant improves TST without altering the underlying sleep architecture in AD patients with insomnia.

Support

Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA

0488 Pilot Evaluation of an Actigraphy Watch Compared to Polysomnography in a Clinical Trial of Suvorexant for Treating Insomnia in Patients with Alzheimer’s Disease

Introduction

Suvorexant, an orexin receptor antagonist, improved total sleep time (TST) in a sleep laboratory polysomnography (PSG) study of patients with Alzheimer’s disease (AD) and insomnia. The study included a pilot evaluation of an actigraphy watch for continuously recording patient’s sleep and daytime activity. We report on the utility of the watch for assessing sleep in relation to gold-standard PSG.

Methods

This was a randomized, double-blind, 4-week trial (ClinicalTrials.gov NCT02750306). Participants who met diagnostic criteria for both probable AD dementia and insomnia were randomized to suvorexant 10-20mg or placebo. Overnight sleep laboratory PSG was performed on 3 nights: screening, baseline, and Night-29 (last dose). An actigraphy watch (Garmin vívosmart® HR) was worn continuously by the patient. Separate analyses were performed for PSG and watch. We compared treatment effects on change-from-baseline in PSG-TST at Night-29 and WATCH-TST at Week-4 (average TST per night over Week-4). We also analyzed Night-29 data only with watch data restricted to the PSG recording time.

Results

A total of 274 participants were included in the Night-29 PSG analysis (suvorexant=135, placebo=139) and 223 in the Week-4 watch analysis (suvorexant=113, placebo=110). Suvorexant improved Night-29 PSG-TST by 28 minutes versus placebo (p=0.001) and Week-4 WATCH-TST by 17 minutes versus placebo (p=0.144). In the subgroup who had usable data for both assessments at Night-29 (suvorexant=57, placebo=50), the watch overestimated TST compared to PSG (e.g. placebo baseline scores = 412 minutes for WATCH-TST and 265 minutes for PSG-TST) and underestimated change-from-baseline treatment effects: the suvorexant versus placebo difference was 35 minutes for PSG-TST (p=0.057) and 20 minutes for WATCH-TST (p=0.405).

Conclusion

The watch was less sensitive than PSG for evaluating treatment effects on TST. However, results obtained with the watch were directionally similar to PSG in indicating a benefit of suvorexant versus placebo for improving TST in AD patients with insomnia.

Support

Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA

Prevalence of respiratory conditions among people who use illicit opioids: a systematic review

BACKGROUND AND AIMS

There are growing concerns over the respiratory health of people who use illicit opioids due to high rates of opioid inhalation and tobacco smoking in this group. This study aimed to summarize the evidence relating illicit opioid use with poor respiratory health.

METHODS

A systematic review of the literature on the association between illicit opioid use and respiratory health was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance (PROSPERO ID = CRD42017059953). Electronic searches of MEDLINE, Embase, PsycINFO, CINAHL and the Cochrane Library databases were undertaken (English language, published January 1980-November 2018). All study designs excluding case studies were considered. Studies were undertaken in community and hospital settings in the United States (n = 23), United Kingdom (n = 7), Australia (n = 7), the Netherlands (n = 2), Canada (n = 2), Ireland (n = 1), Spain (n = 1) and Iran (n = 1). Measurements of respiratory disease, including asthma and chronic obstructive pulmonary disease (COPD) and related symptoms were extracted. Data on respiratory-related deaths and hospital admissions were also extracted. Meta-analysis of prevalence data was undertaken using a random effects meta-analysis model with parameters estimated using Markov chain Monte Carlo simulation.

RESULTS

Meta-analyses estimated prevalence of asthma in people who inject illicit opioids as 8.5% [95% predictive interval (PrI) = 0.2%, 74.0%] and as 20.2% (95% PrI = 4.2%, 59.2%) in people who inhale illicit opioids. Prevalence of COPD in people who inject illicit opioids was estimated as 2.7% (95% PrI = 0.0%, 50.4%) and as 17.9% (95% PrI = 0.6%, 89.5%) in people who inhale illicit opioids. There was evidence of moderate to extreme heterogeneity across studies.

CONCLUSIONS

There is evidence of increased burden of respiratory diseases in people who use illicit opioids. Due to the heterogeneity of study design and samples, it is difficult to gain accurate estimates of the prevalence of respiratory disease in this population.

Lifestyle Medicine in Australia: A Potted History-So Far

Lifestyle medicine commenced in Australia in response to the rise in chronic diseases following the epidemiological transition that began in the 1980s. Today, it is flourishing with an annual conference, a variety of multidisciplinary members, and a developed pedagogy for the "art-science."

How Uncertain is the Survival Extrapolation? A Study of the Impact of Different Parametric Survival Models on Extrapolated Uncertainty About Hazard Functions, Lifetime Mean Survival and Cost Effectiveness

BACKGROUND AND OBJECTIVE

The extrapolation of estimated hazard functions can be an important part of cost-effectiveness analyses. Given limited follow-up time in the sample data, it may be expected that the uncertainty in estimates of hazards increases the further into the future they are extrapolated. The objective of this study was to illustrate how the choice of parametric survival model impacts on estimates of uncertainty about extrapolated hazard functions and lifetime mean survival.

METHODS

We examined seven commonly used parametric survival models and described analytical expressions and approximation methods (delta and multivariate normal) for estimating uncertainty. We illustrate the multivariate normal method using case studies based on four representative hypothetical datasets reflecting hazard functions commonly encountered in clinical practice (constant, increasing, decreasing, or unimodal), along with a hypothetical cost-effectiveness analysis.

RESULTS

Depending on the survival model chosen, the uncertainty in extrapolated hazard functions could be constant, increasing or decreasing over time for the case studies. Estimates of uncertainty in mean survival showed a large variation (up to sevenfold) for each case study. The magnitude of uncertainty in estimates of cost effectiveness, as measured using the incremental cost per quality-adjusted life-year gained, varied threefold across plausible models. Differences in estimates of uncertainty were observed even when models provided near-identical point estimates.

CONCLUSIONS

Survival model choice can have a significant impact on estimates of uncertainty of extrapolated hazard functions, mean survival and cost effectiveness, even when point estimates were similar. We provide good practice recommendations for analysts and decision makers, emphasizing the importance of considering the plausibility of estimates of uncertainty in the extrapolated period as a complementary part of the model selection process.

Shared Medical Appointments and Mindfulness for Type 2 Diabetes-A Mixed-Methods Feasibility Study

INTRODUCTION

Type 2 diabetes (T2DM) is a major health concern with significant personal and healthcare system costs. There is growing interest in using shared medical appointments (SMAs) for management of T2DM. We hypothesize that adding mindfulness to SMAs may be beneficial. This study aimed to assess the feasibility and acceptability of SMAs with mindfulness for T2DM within primary care in Australia.

MATERIALS AND METHODS

We conducted a single-blind randomized controlled feasibility study of SMAs within primary care for people with T2DM living in Western Sydney, Australia. People with T2DM, age 21 years and over, with HbA1c > 6.5% or fasting glucose >7.00 mmol/L within the past 3 months were eligible to enroll. The intervention group attended six 2-h programmed SMAs (pSMAs) which were held fortnightly. pSMAs included a structured education program and mindfulness component. The control group received usual care from their healthcare providers. We collected quantitative and qualitative data on acceptability as well as glycemic control (glycated hemoglobin and continuous glucose monitoring), lipids, anthropometric measures, blood pressure, self-reported psychological outcomes, quality of life, diet, and physical activity using an ActiGraph accelerometer.

RESULTS

Over a 2-month period, we enrolled 18 participants (10 females, 8 males) with a mean age of 58 years (standard deviation 9.8). We had 94.4% retention. All participants in the intervention group completed at least four pSMAs. Participants reported that attending pSMAs had been a positive experience that allowed them to accept their diagnosis and empowered them to make changes, which led to beneficial effects including weight loss and better glycemic control. Four pSMA participants found the mindfulness component helpful while two did not. All of the seven participants who contributed to qualitative evaluation reported improved psychosocial wellbeing and found the group setting beneficial. There was a significant difference in total cholesterol levels at 12 weeks between groups (3.86 mmol/L in intervention group vs. 4.15 mmol/L in the control group; p = 0.025) as well as pain intensity levels as measured by the PROMIS-29 (2.11 vs. 2.38; p = 0.034).

CONCLUSION

pSMAs are feasible and acceptable to people with T2DM and may result in clinical improvement. A follow-up fully-powered randomized controlled trial is warranted.

CLINICAL TRIAL REGISTRATION

Australia and New Zealand Clinical Trial Registry, identifier ACTRN12619000892112.

Determination of Immunoglobulin G in Bovine Colostrum and Milk Powders, and in Dietary Supplements of Bovine Origin by Protein G Affinity Liquid Chromatography: Collaborative Study

An AOAC collaborative study was conducted to evaluate an affinity LC procedure for measuring immunoglobulin G (IgG) in selected dairy powders. The powders were extracted with 0.15 M sodium chloride solution and the pH was adjusted to 4.6 to precipitate caseins, which would otherwise lead to an overestimation of IgG. The analyte was then bound to a commercially available Protein G affinity cartridge and selectively eluted with a glycine buffer at pH 2.5. Detection was at 280 nm and quantification was made against a calibration curve prepared from bovine serum IgG. The samples analyzed included the likely matrixes for which this assay will find commercial use, namely, high- and low-protein-content colostrum powders, tablets containing colostrum powder, and some IgG-containing dairy powders; milk protein isolate, whey protein concentrate, and skim milk powder. Eleven laboratories provided data for the study and assayed blind duplicates of six materials. The repeatability RSD values ranged from 2.1 to 4.2 and the reproducibility RSD values ranged from 6.4 to 18.5. The Protein G method with casein removal has adequate reproducibility for measuring IgG in colostrum-derived powders that are traded on the basis of IgG content as a colostral marker.

A Review of Survival Analysis Methods Used in NICE Technology Appraisals of Cancer Treatments: Consistency, Limitations, and Areas for Improvement

Objectives. In June 2011, the National Institute for Health and Care Excellence (NICE) Decision Support Unit published a Technical Support Document (TSD) providing recommendations on survival analysis for NICE technology appraisals (TAs). Survival analysis outputs are influential inputs into economic models estimating the cost-effectiveness of new cancer treatments. Hence, it is important that systematic and justifiable model selection approaches are used. This study investigates the extent to which the TSD recommendations have been followed since its publication. Methods. We reviewed NICE cancer TAs completed between July 2011 and July 2017. Information on survival analyses undertaken and associated critiques for overall survival (OS) and progression-free survival were extracted from the company submissions, Evidence Review Group (ERG) reports, and final appraisal determination documents. Results. Information was extracted from 58 TAs. Only 4 (7%) followed all TSD recommendations for OS outcomes. The vast majority (91%) compared a range of common parametric models and assessed their fit to the data (86%). Only a minority of TAs included an assessment of the shape of the hazard function (38%) or proportional hazards assumption (40%). Validation of the extrapolated portion of the survival function using external data was attempted in a minority of TAs (40%). Extrapolated survival functions were frequently criticized by ERGs (71%). Conclusions. Survival analysis within NICE TAs remains suboptimal, despite publication of the TSD. Model selection is not undertaken in a systematic way, resulting in inconsistencies between TAs. More attention needs to be given to assessing hazard functions and validation of extrapolated survival functions. Novel methods not described in the TSD have been used, particularly in the context of immuno-oncology, suggesting that an updated TSD may be of value.

Psychosocial Determinants of Chronic Disease: Implications for Lifestyle Medicine

We have previously identified a number of "determinants" of chronic disease, using the acronym NASTIE ODOURS. These have been given the collective term "anthropogens," in this journal and other publications, to help direct the management of modern chronic ailments to a monocausal focus, akin to that afforded infectious diseases by the "germ theory." We suggested the acronym NASTIE ODOURS as a starting point for a taxonomy of lifestyle medicine determinants. In the current article, we add 3, less quantifiable, but currently increasingly more important psychosocial experiences to these: Lack of Meaning, Alienation, and Loss of culture, changing the previous acronym to NASTIE MAL ODOURS. As with other determinants, all have accumulating evidence of an underlying low-grade, systemic, inflammatory physiological base ("metaflammation"), but with the need for further research to solidify these findings.

Assessing prognosis and prediction of treatment response in early rheumatoid arthritis: systematic reviews

BACKGROUND

Rheumatoid arthritis (RA) is a chronic, debilitating disease associated with reduced quality of life and substantial costs. It is unclear which tests and assessment tools allow the best assessment of prognosis in people with early RA and whether or not variables predict the response of patients to different drug treatments.

OBJECTIVE

To systematically review evidence on the use of selected tests and assessment tools in patients with early RA (1) in the evaluation of a prognosis (review 1) and (2) as predictive markers of treatment response (review 2).

DATA SOURCES

Electronic databases (e.g. MEDLINE, EMBASE, The Cochrane Library, Web of Science Conference Proceedings; searched to September 2016), registers, key websites, hand-searching of reference lists of included studies and key systematic reviews and contact with experts.

STUDY SELECTION

Review 1 - primary studies on the development, external validation and impact of clinical prediction models for selected outcomes in adult early RA patients. Review 2 - primary studies on the interaction between selected baseline covariates and treatment (conventional and biological disease-modifying antirheumatic drugs) on salient outcomes in adult early RA patients.

RESULTS

Review 1 - 22 model development studies and one combined model development/external validation study reporting 39 clinical prediction models were included. Five external validation studies evaluating eight clinical prediction models for radiographic joint damage were also included. c-statistics from internal validation ranged from 0.63 to 0.87 for radiographic progression (different definitions, six studies) and 0.78 to 0.82 for the Health Assessment Questionnaire (HAQ). Predictive performance in external validations varied considerably. Three models [(1) Active controlled Study of Patients receiving Infliximab for the treatment of Rheumatoid arthritis of Early onset (ASPIRE) C-reactive protein (ASPIRE CRP), (2) ASPIRE erythrocyte sedimentation rate (ASPIRE ESR) and (3) Behandelings Strategie (BeSt)] were externally validated using the same outcome definition in more than one population. Results of the random-effects meta-analysis suggested substantial uncertainty in the expected predictive performance of models in a new sample of patients. Review 2 - 12 studies were identified. Covariates examined included anti-citrullinated protein/peptide anti-body (ACPA) status, smoking status, erosions, rheumatoid factor status, C-reactive protein level, erythrocyte sedimentation rate, swollen joint count (SJC), body mass index and vascularity of synovium on power Doppler ultrasound (PDUS). Outcomes examined included erosions/radiographic progression, disease activity, physical function and Disease Activity Score-28 remission. There was statistical evidence to suggest that ACPA status, SJC and PDUS status at baseline may be treatment effect modifiers, but not necessarily that they are prognostic of response for all treatments. Most of the results were subject to considerable uncertainty and were not statistically significant.

LIMITATIONS

The meta-analysis in review 1 was limited by the availability of only a small number of external validation studies. Studies rarely investigated the interaction between predictors and treatment.

SUGGESTED RESEARCH PRIORITIES

Collaborative research (including the use of individual participant data) is needed to further develop and externally validate the clinical prediction models. The clinical prediction models should be validated with respect to individual treatments. Future assessments of treatment by covariate interactions should follow good statistical practice.

CONCLUSIONS

Review 1 - uncertainty remains over the optimal prediction model(s) for use in clinical practice. Review 2 - in general, there was insufficient evidence that the effect of treatment depended on baseline characteristics.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016042402.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Dexamethasone implant for non-infectious uveitis: is it cost-effective?

BACKGROUND

Uveitis is inflammation inside the eye. The objective of this study is to assess the cost-effectiveness of a dexamethasone implant plus current practice (immunosuppressants and systemic corticosteroids) compared with current practice alone, in patients with non-infectious intermediate, posterior or pan-uveitis and to identify areas for future research.

METHODS

A Markov model was built to estimate the costs and benefits of dexamethasone. Systematic reviews were performed to identify available relevant evidence. Quality of life data from the key randomised-controlled trial (HURON) was used to estimate the interventions' effectiveness compared with the trial's comparator arm (placebo plus limited current practice (LCP)). The analysis took a National Health Service and Personal Social Services perspective. Costs were calculated based on standard UK sources.

RESULTS

The incremental cost-effectiveness ratio (ICER) of one dexamethasone implant compared with LCP is estimated as £19 509 per quality-adjusted life year (QALY) gained. The factors with the largest impact on the results were rate of blindness and relative proportion of blindness cases avoided by dexamethasone. Using plausible alternative assumptions, dexamethasone could be cost saving or it may be associated with an ICER of £56 329 per QALY gained compared with LCP.

CONCLUSIONS

Dexamethasone is estimated to be cost-effective using generally accepted UK thresholds. However, there is substantial uncertainty around these results due to scarcity of evidence. Future research on the following would help provide more reliable estimates: effectiveness of dexamethasone versus current practice (instead of LCP), with subgroup analyses for unilateral and bilateral uveitis, incidence of long-term blindness and effectiveness of dexamethasone in avoiding blindness.

Integrated Effects of Genetic Resistance and Prothioconazole + Tebuconazole Application Timing on Fusarium Head Blight in Wheat

Integrated Fusarium head blight (FHB) management programs consisting of different combinations of cultivar resistance class and an application of the fungicide prothioconazole + tebuconazole at or after 50% early anthesis were evaluated for efficacy against FHB incidence (INC; percentage of diseased spikes), index (IND; percentage of diseased spikelets per spike), Fusarium damaged kernel (FDK), deoxynivalenol (DON) toxin contamination, grain yield, and test weight (TW) in inoculated field trials conducted in 11 U.S. states in 2014 and 2015. Mean log response ratios and corresponding percent control values for INC, IND, FDK, and DON, and mean differences in yield and TW relative to a nontreated, inoculated susceptible check (S_CK), were estimated through network meta-analyses as measures of efficacy. Results from the analyses were then used to estimate the economic benefit of each management program for a range of grain prices and fungicide applications costs. Management programs consisting of a moderately resistant (MR) cultivar treated with the fungicide were the most efficacious, reducing INC by 60 to 69%, IND by 71 to 76%, FDK by 66 to 72%, and DON by 60 to 64% relative to S_CK, compared with 56 to 62% for INC, 68 to 72% for IND, 66 to 68% for FDK, and 58 to 61% for DON for programs with a moderately susceptible (MS) cultivar. The least efficacious programs were those with a fungicide application to a susceptible (S) cultivar, with less than a 45% reduction of INC, IND, FDK, or DON. All programs were more efficacious under conditions favorable for FHB compared with less favorable conditions, with applications made at 50% early anthesis being of comparable efficacy to those made 2 to 7 days later. Programs with an MS cultivar resulted in the highest mean yield increases relative to S_CK (541 to 753 kg/ha), followed by programs with an S cultivar (386 to 498 kg/ha) and programs with an MR cultivar (250 to 337 kg/ha). Integrated management programs with an MS or MR cultivar treated with the fungicide at or after 50% early anthesis were the most likely to result in a 50 or 75% control of IND, FDK, or DON in a future trial. At a fixed fungicide application cost, these programs were $4 to $319/MT more economically beneficial than corresponding fungicide-only programs, depending on the cultivar and grain price. These findings demonstrate the benefits of combining genetic resistance with a prothioconazole + tebuconazole treatment to manage FHB, even if that treatment is applied a few days after 50% early anthesis.

Perceptions of anger and aggression in rural adolescent Australian males

Problematic anger is often the outward manifestation and expression of deeper mental health issues in young men with strong links to depression, aggression, and suicide. Few studies have explored adolescent anger and aggression from the perspective of adolescent males and even fewer studies focus specifically on a rural context. This research aimed to understand the role of anger and aggression from the perspective of Australian rural adolescent males. Mental health nurses can build upon this knowledge to promote more adaptive ways of coping with anger therefore identifying specific interventions for the prevention of violence and promotion of mental health in this cohort. One hundred and eighty-seven rural adolescent males participated in focus groups that were conducted during their participation in the Rock and Water Program (RWP). Participants identified a number of factors they felt contributed to the aggression they both witnessed and experienced with eight themes emerging in response to the research questions. Four themes related to personological factors, that is racism, homophobia, family influences, and media influence. A further four themes related to situational factors, that is alcohol, territorialism, school context, and peer pressure. The study identified that racist and homophobic attitudes and beliefs were evident and clearly contributed to aggressive scripts as did family and media messages that normalized aggressive behaviour by way of endorsing stereotypical images of an aggressive masculinity. Situational factors such as alcohol use, territorialism, school context, and peer pressure were directly linked by participants to aggressive incidents embedded within their notions of masculinity.

PROCESS AND SYSTEMS: A systems approach to embedding group consultations in the NHS

Group consultations are an important care option that is -starting to gain traction in the USA and Australia. This review summarises the likely benefits accruing from a systems -approach to implementing group consultations widely in the NHS and other socialised healthcare systems. Existing evidence is mapped to five distinct systems approaches: (1) development; (2) different age groups; (3) patient-centred pathway of care; (4) NHS system changes; and (5) education. Implications are discussed for patients and staff, who both benefit from group consultations once embedded; ranging from improved access and efficiency to more enjoyable multidisciplinary team working, improved resource management, and maintained/better outcomes. Moreover, even patients who don't attend group consultations can benefit from system effects of long-term implementation. Changing behaviour and health systems is challenging, but change requires systematic experimentation and documentation of evidence. We conclude that group consultations have unique potential for delivering system-wide benefits across the NHS.

Ibrutinib for Treating Waldenström's Macroglobulinaemia: An Evidence Review Group Perspective of a NICE Single Technology Appraisal

As part of its Single Technology Appraisal (STA) process, the UK National Institute for Health and Care Excellence (NICE) invited the manufacturer of ibrutinib (Janssen) to submit evidence on the clinical and cost effectiveness of ibrutinib for treating Waldenström's macroglobulinaemia (WM). The School of Health and Related Research Technology Assessment Group at the University of Sheffield was commissioned to act as the independent Evidence Review Group (ERG). The ERG produced a critical review of the evidence for the clinical and cost effectiveness of ibrutinib based on the company's submission to NICE. The clinical evidence was derived from one phase II, single-arm, open-label study of ibrutinib in adult patients with WM who had received at least one prior therapy (Study 1118E) and an indirect comparison using a matched cohort from a retrospective European chart review of patients receiving various treatments for WM. The indirect comparison suggested a hazard ratio for progression-free survival (PFS) of 0.25 (95% confidence interval 0.11-0.57). The ERG had concerns regarding the high risk of bias in Study 1118E, the limited generalisability of the study, and the absence of randomised controlled trial evidence. The company's Markov model assessed the cost effectiveness of ibrutinib versus rituximab/chemotherapy for patients with relapsed/refractory (R/R) WM from the perspective of the National Health Service (NHS) and Personal Social Services (PSS) over a lifetime horizon. Based on the company's original Patient Access Scheme (PAS), the company's probabilistic model generated an incremental cost-effectiveness ratio (ICER) for ibrutinib versus rituximab/chemotherapy of £58,905 per quality-adjusted life-year (QALY) gained. Following a critique of the model, the ERG's preferred analysis, which corrected cost errors and used the observed mortality rate from Study 1118E, generated a probabilistic ICER of £61,219 per QALY gained. Based on this amended model, additional exploratory analyses produced ICERs for ibrutinib that were > £60,000 per QALY gained. Subsequently, the company offered to provide ibrutinib at a price that resulted in ibrutinib being cost effective within the Cancer Drugs Fund (CDF). The Committee recommended ibrutinib for use in the CDF as an option for treating WM in adults who have had at least one prior therapy, only if the conditions in the managed access agreement for ibrutinib are followed.

External Validation of Equations that Use Demographic and Anthropometric Measurements to Predict Percent Body Fat

OBJECTIVE

Numerous equation to predict percent body fat using demographics and anthropometrics have been published but external validation of these equations is limited. The objective of this study was to validate published equations that use anthropometrics for prediction of percent body fat using external data.

METHODS

Data were from the Visceral Fat, Metabolic Rate, and Coronary Heart Disease Risk I (VIM I) Study and the Fels Longitudinal Study (Fels). VIM I was conducted in a subset of subjects from the CARDIA study and included black and white adults 28-40 years (n = 392). Fels consisted of white participants 8-88 years (n = 1,044). Percent body fat assessed by dual X-ray absorptiometry (DXA) in these two studies was compared to results calculated using 13 equations from Stevens et al. and nine other published equations.

RESULTS

In general, the Stevens equations performed better than equations from other studies. For example, equation "I" in women in VIM I, Fels adults, and Fels youth, R2 estimates were 0.765, 0.757 and 0.789, respectively. In men the estimates were 0.702 in VIM I, 0.822 in Fels adults and 0.905 in Fels youth. None of the results from the nine published equations showed R2 this high in corresponding groups.

CONCLUSIONS

Our results indicate that several of the Stevens equations have external validity superior to that of nine other published equations among varying age groups, genders and races.

Absorption and Safety With Sustained Use of RELiZORB Evaluation (ASSURE) Study in Patients With Cystic Fibrosis Receiving Enteral Feeding

OBJECTIVES

Pancreatic insufficiency (PI) and malabsorption of fats lead to reduced caloric intake, inability to maintain weight, and increased gastrointestinal symptoms. Thus, enteral nutrition (EN) is used in patients with cystic fibrosis (CF) and poor nutritional status. The current study evaluated safety, tolerability, and improvement of fatty acid (FA) status in red blood cell (RBC) membranes, a marker of long-term FA absorption, with an in-line digestive cartridge (RELiZORB) that hydrolyzes fat in enteral formula.

METHODS

Patients with CF receiving EN participated in a multicenter, 90-day open-label study during which RELiZORB was used with overnight EN. The primary endpoint was change over time in RBC uptake of docosahexaenoic acid (DHA)+ eicosapentaenoic acid (EPA). Gastrointestinal symptoms were collected to evaluate safety and tolerability. Several clinical and anthropometric parameters were also assessed throughout the study.

RESULTS

A total of 36 subjects completed the study with a mean age of 13.8 years, body mass index of 17.7 and 6.2 years mean use of overnight EN. Fat absorption significantly improved as shown by increased RBC levels of DHA+EPA, improved ω-6/ω-3 ratio, and increased plasma levels of DHA+EPA. RELiZORB use was not associated with any unanticipated adverse events.

CONCLUSIONS

RELiZORB use was found to be safe, well tolerated, and resulted in increased levels of FAs in RBCs and plasma. This is the first prospective study to show EN can improve FA abnormalities in CF. Because improvement in omega-3 levels has been shown to help pulmonary and inflammatory status as well as anthropometric parameters in CF, RELiZORB may have important long-term therapeutic benefits in patients with CF.

Platelet-rich plasma for androgenetic alopecia: A review of the literature and proposed treatment protocol

Androgenetic alopecia (AGA) is a common hair loss disorder caused by genetic and hormonal factors that are characterized by androgen-related progressive thinning of scalp hair in a defined pattern. By the age of 60 years, 45% of men and 35% of women develop AGA. Currently, U.S. Food and Drug Administration-approved treatments for AGA include oral finasteride and topical minoxidil. Due to the limited number of effective therapies for AGA, platelet-rich plasma (PRP) has become an effective alternative treatment. PRP is an autologous concentration of platelets in plasma with numerous growth factors that contribute to hair regeneration. The growth factors contained within the alpha granules of platelets act on stem cells in the bulge area of the hair follicles and stimulate the development of new follicles along with neovascularization. PRP has become a promising treatment modality for AGA. Although there have been several studies previously reported, a standard practice for PRP preparation and administration as well as a method to evaluate results have not been established. This literature review was conducted to evaluate the effectiveness of PRP for AGA and discuss the various treatment protocols that have been proposed.