Burden of cardiovascular disease on coronavirus disease 2019 hospitalizations in the USA

BACKGROUND

Patients with cardiovascular disease (CVD) and risk factors have increased rates of adverse events and mortality after hospitalization for coronavirus disease 2019 (COVID-19). In this study, we attempted to identify and assess the effects of CVD on COVID-19 hospitalizations in the USA using a large national database.

METHODS

The current study was a retrospective analysis of data from the US National (Nationwide) Inpatient Sample from 2020. All adult patients 18 years of age and older who were admitted with the primary diagnosis of COVID-19 were included. The primary outcome was in-hospital mortality, while secondary outcomes included prolonged hospital length of stay, mechanical ventilation, and disposition other than home. Prolonged hospital length of stay was defined as a length of stay greater than the 75th percentile for the full sample. The diagnoses were identified using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes.

RESULTS

A total of 1 050 040 patients were included in the study, of which 454 650 (43.3%) had prior CVD. Patients with CVD had higher mortality during COVID-19 hospitalization (19.3 vs. 5.0%, P < 0.001). Similarly, these patients had a higher rate of prolonged hospital length of stay (34.5 vs. 21.0%, P < 0.001), required mechanical ventilation (15.4 vs. 5.6%, P < 0.001), and were more likely to be discharged to a disposition other than home (62.5 vs. 32.3%, P < 0.001). Mean hospitalization cost was also higher in patients with CVD during hospitalization ($24 023 vs. $15 320, P < 0.001). Conditional logistic regression analysis showed that the odds of in-hospital mortality [odds ratio (OR), 3.23; 95% confidence interval (CI), 2.91-3.45] were significantly higher for COVID-19 hospitalizations with CVD, compared with those without CVD. Similarly, prolonged hospital length (OR, 1.82; 95% CI, 1.43-2.23), mechanical ventilation (OR, 3.31; 95% CI, 3.06-3.67), and disposition other than home (OR, 2.01; 95% CI, 1.87-2.21) were also significantly higher for COVID-19 hospitalizations with coronary artery disease.

CONCLUSION

Our study showed that the presence of CVD has a significant negative impact on the prognosis of patients hospitalized for COVID-19. There was an associated increase in mortality, length of stay, ventilator use, and adverse discharge dispositions among COVID-19 patients with CVD. Adjustment in treatment for CVD should be considered when providing care to patients hospitalized for COVID-19 to mitigate some of the adverse hospital outcomes.

Development of a Value Assessment Framework for Pediatric Health Technologies Using Multicriteria Decision Analysis: Expanding the Value Lens for Funding Decision Making

OBJECTIVES

A health technology assessment (HTA) does not systematically account for the circumstances and needs of children and youth. To supplement HTA processes, we aimed to develop a child-tailored value assessment framework using a multicriteria decision analysis approach.

METHODS

We constructed a multicriteria-decision-analysis-based model in multiple phases to create the Comprehensive Assessment of Technologies for Child Health (CATCH) framework. Using a modified Delphi process with stakeholders having broad disciplinary and geographic variation (N = 23), we refined previously generated criteria and developed rank-based weights. We established a criterion-pertinent scoring rubric for assessing incremental benefits of new drugs. Three clinicians independently assessed comprehension by pilotscoring 9 drugs. We then validated CATCH for 2 childhood cancer therapies through structured deliberation with an expert panel (N = 10), obtaining individual scores, consensus scores, and verbal feedback. Analyses included descriptive statistics, thematic analysis, exploratory disagreement indices, and sensitivity analysis.

RESULTS

The modified Delphi process yielded 10 criteria, based on absolute importance/relevance and agreed importance (median disagreement indices = 0.34): Effectiveness, Child-specific Health-related Quality of Life, Disease Severity, Unmet Need, Therapeutic Safety, Equity, Family Impacts, Life-course Development, Rarity, and Fair Share of Life. Pilot scoring resulted in adjusted criteria definitions and more precise score-scaling guidelines. Validation panelists endorsed the framework's key modifiers of value. Modes of their individual prescores aligned closely with deliberative consensus scores.

CONCLUSIONS

We iteratively developed a value assessment framework that captures dimensions of child-specific health and nonhealth gains. CATCH could improve the richness and relevance of HTA decision making for children in Canada and comparable health systems.

Commercialising everyday distress: neurasthenia and traditional Chinese medicine in colonial Hong Kong, 1950s to 1980s

The persistent use of neurasthenia in Asia, an out-dated diagnostic category in modern psychiatry, has confounded many psychiatrists from the 1960s. This paper attempts to understand the prevalence of neurasthenia among the lay public in post-World War II Hong Kong. It examines the social history of psychiatry and focuses on the roles of traditional Chinese medicine in shaping public perceptions and responses towards neurasthenia. This research reveals that, when psychiatrists discarded the term as an ineffective label in the 1950s, practitioners and pharmaceutical companies of Chinese medicine seized on the chance to reinvent themselves as experts in neurasthenia. By commericialising everyday distress, they provided affordable, accessible and culturally familiar healing options to the Chinese public. A case study of neurasthenia, therefore, is not simply about changing disease categories but an important example to illustrate the tensions between traditional medicine and Western psychiatry in Asia.

Patient, Family, Caregiver, and Community Engagement in Research: A Sensibility Evaluation of a Novel Infographic and Planning Guide

Background

Engaging patients, families, caregivers, and the community (PFCCs) throughout the research cycle ensures that research is meaningful for the target population. Although tools have been developed to promote PFCC engagement, many are lengthy, complex, and lack recommended behaviours. This study evaluated the sensibility of an infographic and accompanying planning guide for facilitating engagement of PFCCs in research.

Methods

Thirteen rehabilitation researchers reviewed the PFCC engagement tool and planning guide, participated in a semi-structured interview, and completed a 10-item sensibility questionnaire. Interviews were transcribed, imported into NVivo, and analyzed using direct content analysis. Median scores and proportions of responses for each of the 10 items in the questionnaire were calculated.

Results

Median scores for all questionnaire items were ≥ 4 on a 7-point Likert Scale. Participants reported the tool was easy to navigate, contained relevant items to promote PFCC engagement, and followed a logical sequence. Suggested modifications of the tool related to formatting, design, and changing the title.

Conclusions

The tool was deemed sensible for overt format, purpose and framework, face and content validity, and ease of usage and provides guidance to engage PFCCs across the research cycle. Further studies are recommended to assess the effectiveness of the tool to engage PFCCs in research.

The impact of marginalization on diffuse large B-cell lymphoma overall survival: a retrospective cohort study

The aim of this study was to describe the impact of marginalization on DLBCL overall survival (OS) within the Canadian setting. We conducted a population-based retrospective cohort study of adult patients with newly diagnosed DLBCL in Ontario between 1 January 2005 and 31 December 2017 receiving a rituximab-containing chemotherapy regimen with curative intent followed until 1 March 2020. Our primary exposure of interest was the Ontario Marginalization Index (ON-Marg). The primary outcome was 2-year OS, accounting for patient age, sex, cancer characteristics, comorbidity burden, and rural dwelling status. While two-year overall survival was inferior for individuals in the most deprived marginalization quintile (70.4% Q5 vs. 76.0% Q1), after adjustment for relevant covariates neither the composite ON-Marg nor any of its dimensions had a significant effect. Within the Canadian context, among patients who receive chemotherapy, marginalization may not have a significant association with overall survival when accounting for key patient covariates, lending support for preserved outcomes.

Prevalence and effects of acute myocardial infarction on hospital outcomes among COVID-19 patients

BACKGROUND

Acute myocardial infarction (AMI) is one of the most lethal complications of COVID-19 hospitalization. In this study, we looked for the occurrence of AMI and its effects on hospital outcomes among COVID-19 patients.

METHODS

Data from the 2020 California State Inpatient Database was used retrospectively. All COVID-19 hospitalizations with age ≥ 18 years were included in the analyses. Adverse hospital outcomes included in-hospital mortality, prolonged length of stay (LOS), vasopressor use, mechanical ventilation, and ICU admission. Prolonged LOS was defined as any hospital LOS ≥ 75th percentile. Multivariate logistic regression analyses were used to understand the strength of associations after adjusting for cofactors.

RESULTS

Our analysis had 94 114 COVID-19 hospitalizations, and 1548 (1.6%) had AMI. Mortality (43.2% vs. 10.8%, P  < 0.001), prolonged LOS (39.9% vs. 28.2%, P  < 0.001), vasopressor use (7.8% vs. 2.1%, P  < 0.001), mechanical ventilation (35.0% vs. 9.7%, P  < 0.001), and ICU admission (33.0% vs. 9.4%, P  < 0.001) were significantly higher among COVID-19 hospitalizations with AMI. The odds of adverse outcomes such as mortality (aOR 3.90, 95% CI: 3.48-4.36), prolonged LOS (aOR 1.23, 95% CI: 1.10-1.37), vasopressor use (aOR 3.71, 95% CI: 3.30-4.17), mechanical ventilation (aOR 2.71, 95% CI: 2.21-3.32), and ICU admission (aOR 3.51, 95% CI: 3.12-3.96) were significantly more among COVID-19 hospitalizations with AMI.

CONCLUSION

Despite the very low prevalence of AMI among COVID-19 hospitalizations, the study showed a substantially greater risk of adverse hospital outcomes and mortality. COVID-19 patients with AMI should be aggressively treated to improve hospital outcomes.

Single Institute Experience Treating Uterine Carcinosarcoma: Outcome Analysis

PURPOSE/OBJECTIVE(S)

Uterine carcinosarcoma (UCS) is rare with a poor prognosis. We report over 10 years' experience, reporting prognostic and predictive factors for overall survival (OS) and disease-free survival (DFS).

MATERIALS/METHODS

Patient, tumor, treatment and relapse characteristics of 168 women with stages I-IVB UCS treated at our institute between 2010 and 2020 were analyzed. OS and DFS at 2 and 5 years were the primary outcomes, estimated with Kaplan-Meier. The benefit of adjuvant chemotherapy and radiotherapy in the curative cohort was estimated using the log rank test.

RESULTS

Median follow up was 23 months (range 1-137 months). 34% had FIGO stage IA disease, 10% IB, 8% II. 16% IIIA-IIIC1, and 10% IIIC2 and 22% IVB. The overall 2-year OS was 52% and 5-year OS 30%. 2-year OS by FIGO stage were: IA 66%; IB 63%; II 54%; IIIA-IIIC1 54%; IIIC2 45%; IVB 26%. Within the curative cohort who were surgically staged, 2-year DFS was 47% and 5-year was 30%. 2-year DFS were 61% in IA disease, 53% IB, 12% II, 51% IIIA-IIIC1, and 45% IIIC2 and 4% IVB. A greater risk of death was conferred by lack of adjuvant treatment (lack of chemo > lack of radiotherapy). The most common chemotherapy regimen used was Carboplatin Paclitaxel and pelvic radiotherapy 45Gy 25F over 5 weeks. The combination of surgery and chemotherapy +/- radiotherapy significantly improved OS compared to surgery +/- radiotherapy (HR 0.5 with CI 0.3 - 0.9) p<0.05. Radiotherapy improved OS compared to surgery only (HR 0.4 with CI 0.2 - 1.1) p<0.05. Relapse rate in all patients following curative treatment is 72% within year 1 and 86% within year 2 from diagnosis. In 52 patients with stage 1A disease treated with surgery +/- radiotherapy only, 42.4% relapsed, median time to relapse was 8 months from diagnosis. Relapse occurred despite 69.2 % stage 1A patients receiving adjuvant pelvic EBRT and in these patients relapse within the pelvis occurred in 50%.

CONCLUSION

This study constitutes the largest retrospective analyses of long-term mortality outcomes in UCS and confirms poor outcomes despite curative surgery and adjuvant therapy. Most patients relapse within the first year following curative treatment. The use of adjuvant chemotherapy improves OS in all stages. In stage 1A disease 42 % patients relapse locally and distantly. This is an area of controversy and this data would strongly suggest that the addition of adjuvant paclitaxel-carboplatin or cisplatin-doxorubicin chemotherapy to EBRT should be considered in all patients including earliest stage disease.

Real-World Experience of Intensity Modulated Radiation Therapy and Concurrent Chemotherapy for Anal Cancer with Long-Term Follow up and Clinical Outcomes

PURPOSE/OBJECTIVE(S)

The standard treatment for epidermoid anal cancer (AC) is concurrent chemoradiation (CRT). Here we present real world evidence of the safety and outcomes of AC patients managed by IMRT and concurrent chemotherapy at a single academic cancer center.

MATERIALS/METHODS

We retrospectively reviewed the outcomes of 180 AC patients treated with definitive CRT between 2011 and 2018. Patients were managed according to a prospectively designed protocol of IMRT with radiation dose escalated according to tumor stage: 50.4, 55.8 and 63 Gy for T1, T2 and T3/T4 disease respectively, and 36 Gy for elective nodal RT. Involved nodes were given the same dose based on T category. Concurrent chemotherapy consisted of two cycles of mitomycin C (MMC, 12 mg/m2) and 5-fluorouracil (5FU, 1000 mg/m2/day x 4 days) given on week 1 and 5. There was no planned treatment break. Univariate and multivariate analysis for outcomes were performed using Cox proportional hazard method and likelihood ratio statistics. Overall survival (OS) disease free (DFS), colostomy-free survival (CFS) and local failure rates (LFR) were described by Kaplan-Meier methods.

RESULTS

There were 128 female and 52 male patients with a median age of 64 (IQR 55-74). The median size of the primary was 4.0 cm (0.6-11.0 cm). There were 18 T1, 91 T2, 38 T3 and 33 T4 lesions; 50.6% (91/180) of the patients had N0 disease. Thirteen (7.2%) did not receive concurrent chemotherapy, and 16 (8.9%) failed to complete treatment as planned. Forty-three (23.9%) patients had a treatment gap >5 (6-33) days. Eighteen of 147 (12%) with T1-3 disease failed locally, LF was observed in 13/33 (39%) T4 lesions (P = 0.0002). The 5-year OS, DFS, CFS and LFR were 85.1%, 75.6%, 87.6% and 15.5% respectively. On multivariate analysis, increasing age and N+ disease were significant for worse OS, and increasing size of the primary tumor was the only significant factor for worse DFS, CFS and LFR. Grade ≥3 acute toxicities were observed in 42.8% of patients, with grade ≥3 neutropenia and febrile neutropenia observed in 18.9% and 13.9% of patients respectively. Six patients (3.3%) died of acute toxicities. Thirteen (7%) patients experienced grade ≥3 late toxicities.

CONCLUSION

Size of the primary appears to be the most important determinant of outcome following standard CRT using IMRT for AC. Despite IMRT, almost 1 in 4 patients required a treatment break, and over 40% experienced grade ≥3 acute toxicities including neutropenia and febrile neutropenia. Future studies with RT dose escalation or de-escalation, stratifying patients based on tumor size, HPV status and molecular markers are necessary to improve outcomes and decrease treatment related toxicity.

Healthcare expenditure trends among adult stroke patients in the United States, 2011-2020

BACKGROUND

In the US, between 2018 and 2019, approximately $57 billion were expended on stroke and related conditions. The aim of this study was to understand trends in direct healthcare expenditures among stroke patients using novel cost estimation methods and a nationally representative database.

METHODS

This study was a retrospective analysis of 193,003 adults, ≥18 years of age, using the Medical Expenditure Panel Survey during 2009-2016. Manning and Mullahy's two-part model were used to calculate adjusted mean and incremental medical expenditures after adjusting for covariates.

RESULTS

The mean (Standard Deviation) direct annual healthcare expenditure among stroke patients was $16,979.0 ($16,222.0- $17,736.0) and was nearly 3 times greater than non-stroke participants which were $5,039.7 ($4,951.0-$5,128.5) and were mainly spent on inpatient services, prescription medications, and office-based visits. Stroke patients had an additional healthcare expenditure of $4096.0 (3543.9, 4648.1) per person per year, compared to participants without stroke after adjusting for covariates (P<0.001). The total mean annual direct healthcare expenditure for stroke survivors increased from $16,142.0 (15,017.0-17,267.0) in 2007-2008 to $16,979.0 (16,222.0-17,736.0) in 2015-2016.

CONCLUSION

Our study showed that stroke survivors had significantly greater healthcare expenses, compared to non-stroke individuals, mainly due to higher expenditures on inpatient services, prescription drugs, and office visits. These findings are concerning because the prevalence of stroke is projected to increase due to aging population and increased survival rates.

Brain Maturation Patterns on Normalized FLAIR MR Imaging in Children and Adolescents

BACKGROUND AND PURPOSE

Signal analysis of FLAIR sequences is gaining momentum for studying neurodevelopment and brain maturation, but FLAIR intensity varies across scanners and needs to be normalized. This study aimed to establish normative values for standardized FLAIR intensity in the pediatric brain.

MATERIALS AND METHODS

A new automated algorithm for signal normalization was used to standardize FLAIR intensity across scanners and subjects. Mean intensity was extracted from GM, WM, deep GM, and cortical GM regions. Regression curves were fitted across the pediatric age range, and ANOVA was used to investigate intensity differences across age groups. Correlations between intensity and regional volume were also examined.

RESULTS

We analyzed 429 pediatric FLAIR sequences in children 2-19 years of age with a median age of 11.2 years, including 199 males and 230 females. WM intensity had a parabolic relationship with age, with significant differences between various age groups (P < .05). GM and cortical GM intensity increased over the pediatric age range, with significant differences between early childhood and adolescence (P < .05). There were no significant relationships between volume and intensity in early childhood, while there were significant positive and negative correlations (P < .05) in WM and GM, respectively, for increasing age groups. Only the oldest age group showed significant differences between males and females (P < .05).

CONCLUSIONS

This work presents a FLAIR intensity standardization algorithm to normalize intensity across large data sets, which allows FLAIR intensity to be used to compare regions and individuals as a surrogate measure of the developing pediatric brain.

What, Where, and How to Collect Real-World Data and Generate Real-World Evidence to Support Drug Reimbursement Decision-Making in Asia: A reflection Into the Past and A Way Forward

BACKGROUND

Globally, there is increasing interest in the use of real-world data (RWD) and real-world evidence (RWE) to inform health technology assessment (HTA) and reimbursement decision-making. Using current practices and case studies shared by eleven health systems in Asia, a non-binding guidance that seeks to align practices for generating and using RWD/RWE for decision-making in Asia was developed by the REAL World Data In ASia for HEalth Technology Assessment in Reimbursement (REALISE) Working Group, addressing a current gap and needs among HTA users and generators.

METHODS

The guidance document was developed over two face-to-face workshops, in addition to an online survey, a face-to-face interview and pragmatic search of literature. The specific focus was on what, where and how to collect RWD/ RWE.

RESULTS

All 11 REALISE member jurisdictions participated in the online survey and the first in-person workshop, 10 participated in the second in-person workshop, and 8 participated in the in-depth face-to-face interviews. The guidance document was iteratively reviewed by all working group members and the International Advisory Panel. There was substantial variation in: (a) sources and types of RWD being used in HTA, and (b) the relative importance and prioritization of RWE being used for policy-making. A list of national-level databases and other sources of RWD available in each country was compiled. A list of useful guidance on data collection, quality assurance and study design were also compiled.

CONCLUSION

The REALISE guidance document serves to align the collection of better quality RWD and generation of reliable RWE to ultimately inform HTA in Asia.

Prevalence and trends of perioperative major adverse cardiovascular and cerebrovascular events during cancer surgeries

Major adverse cardiovascular and cerebrovascular events (MACCE) is an important cause of morbidity and mortality during perioperative period. In this study, we looked for national trends in perioperative MACCE and its components as well as cancer types associated with high rates of perioperative MACCE during major cancer surgeries. This study was a retrospective analysis of the National Inpatient Sample, 2005-2014. Hospitalizations for surgeries of prostate, bladder, esophagus, pancreas, lung, liver, colorectal, and breast among patients 40 years and greater were included in the analysis. MACCE was defined as a composite measure that included in-hospital all-cause mortality, acute myocardial infarction (AMI), and ischemic stroke. A total of 2,854,810 hospitalizations for major surgeries were included in this study. Of these, 67,316 (2.4%) had perioperative MACCE. Trends of perioperative MACCE showed that it decreased significantly for AMI, death and any MACCE, while stroke did not significantly change during the study period. Logistic regression analysis for perioperative MACCE by cancer types showed that surgeries for esophagus, pancreas, lung, liver, and colorectal cancers had significantly greater odds for perioperative MACCE. The surgeries identified to have greater risks for MACCE in this study could be risk stratified for better informed decision-making and management.

A cross-sectional retrospective study comparing handwritten operation notes with electronic operation notes

INTRODUCTION

Electronically completed medical notes have been shown to be superior in legibility and completeness to handwritten ones. Despite this, surgeons continue to use handwritten operation notes. This paper aims to compare the quality of handwritten versus electronic operation notes.

METHODS

This is a retrospective cross-sectional single-centre study done at Darent Valley Hospital, a district general hospital at Dartford, UK. We looked at 405 operation notes of patients who had general surgery procedures between 1 January 2020 to 31 January 2021 checking for legibility and completeness of operation note criteria as given by the Royal College of Surgeons of England's Good Surgical Practice. Data were collated using an app that populates comparison criteria in an Excel sheet and were analysed using SPSS (Statistical Package for the Social Sciences). The results are presented in bar graphs and frequency table.

RESULTS

In 17 out of the 18 criteria in RCS England's Good Surgical Practice, electronic notes were better completed than handwritten ones (p<0.001). Signature as a criterion had comparable level of completeness in both handwritten and electronic notes, 95% versus 91% respectively. There was 8.3% illegibility in the handwritten note and none in the electronic ones.

CONCLUSIONS

Electronic notes are far better completed than handwritten notes in 17 out of the 18 criteria of a good operation note by RCS England. The difference between both forms of notes is far too much; we propose a complete shift in practice from handwritten to electronic format.

Recommendations for the management of advanced and metastatic renal cell carcinoma: joint consensus statements from the Hong Kong Urological Association and the Hong Kong Society of Uro-Oncology

INTRODUCTION

Kidney cancer, primarily renal cell carcinoma (RCC), ranks among the top 10 most common malignancies in the male population of Hong Kong. In 2019, members of two medical societies in Hong Kong formed an expert panel to establish a set of consensus statements for the management of metastatic RCC. On 22 June 2021, the same panel met to review recent evidence and reassess their positions regarding the management of advanced and metastatic RCC, with the aim of providing recommendations for physicians in Hong Kong.

PARTICIPANTS

The panel included 12 experts (6 clinical oncologists and 6 urologists) who had extensive experience managing patients with RCC in Hong Kong.

EVIDENCE

The panel reviewed randomised controlled trials, observational studies, systematic reviews/meta-analyses, and international clinical guidelines to address key clinical questions that were identified before the meeting.

CONSENSUS PROCESS

In total, 15 key clinical questions were identified before the meeting, covering the surgical and systemic treatment of advanced or metastatic clear cell, sarcomatoid, and non-clear cell RCCs. At the meeting, the panellists voted on these questions, then discussed relevant evidence and practical considerations.

CONCLUSIONS

The treatment landscape for advanced and metastatic RCC continues to evolve. More immune checkpoint inhibitor (ICI)-based combination regimens will be indicated for the treatment of metastatic clear cell RCC. There is increasing evidence concerning the benefit of adjuvant ICI treatment for resected advanced RCC. This article summarises recent evidence and expert insights regarding a series of key clinical questions about the management of advanced and metastatic RCC.

A perspective on life-cycle health technology assessment and real-world evidence for precision oncology in Canada

Health technology assessment (HTA) can be used to make healthcare systems more equitable and efficient. Advances in precision oncology are challenging conventional thinking about HTA. Precision oncology advances are rapid, involve small patient groups, and are frequently evaluated without a randomized comparison group. In light of these challenges, mechanisms to manage precision oncology uncertainties are critical. We propose a life-cycle HTA framework and outline supporting criteria to manage uncertainties based on real world data collected from learning healthcare systems. If appropriately designed, we argue that life-cycle HTA is the driver of real world evidence generation and furthers our understanding of comparative effectiveness and value. We conclude that life-cycle HTA deliberation processes must be embedded into healthcare systems for an agile response to the constantly changing landscape of precision oncology innovation. We encourage further research outlining the core requirements, infrastructure, and checklists needed to achieve the goal of learning healthcare supporting life-cycle HTA.

Changes in healthcare costs and survival in the era of immunotherapy and targeted systemic therapy for melanoma

ObjectivesMelanoma treatment has evolved over the past decade with the adoption of adjuvant and palliative immunotherapies and targeted therapies and changes in use of sentinel node biopsy. The impact on real-world healthcare costs and outcomes is uncertain. Here we examine changes in healthcare costs and survival using administrative data. ApproachUsing data from the universal healthcare system in Ontario, Canada, we examine a propensity-matched, retrospective cohort of patients aged 20+ years with Stage I-IV invasive cutaneous melanoma from 2018-2019 compared with those from 2007-2012. The primary outcomes were public payer’s mean healthcare per-person costs, and overall survival (OS). Costs were estimated with an established case-mix and claim-based costing algorithm for Ontario, in which person-level costs are allocated for the various healthcare utilizations over time. Standardized mean differences were used to compare costs, and the log-rank test and Cox regression were used to compare survival among stage-stratified, propensity-score matched cohorts. ResultsWe identified 1,138 patients with melanoma from 2018-2019 and 7,654 from 2007-2012. After stage stratification and propensity-matching (N=1,101 per cohort), sentinel lymph node biopsy (62.3% vs. 43.4%) and systemic therapy use (27.3% vs. 12.5%) were more frequent in 2018-2019 compared to 2007-2012. 2018-2019 patients had greater mean healthcare (including systemic therapy) costs compared to 2007-2012 with Stage II ($27,835 vs. $21,179), III ($90,508 vs. $46,242) and IV disease ($118,398 vs. $46,500). There was a seven-to-twelve-fold increase in mean systemic therapy costs for treated patients with Stage III ($68,207 vs. $9,832) and IV disease ($80,905 vs. $6,883). OS was greater in 2018-2019 versus 2007-2012 (2-year OS: 87.8% [95% Confidence Interval {CI}: 85.8-89.6%] vs. 83.7% [95% CI: 81.3-85.7%]; Hazard Ratio {HR}: 0.72 [95% CI: 0.59-0.89]; p<0.05). ConclusionThese real-world data highlight trade-offs with adoption of new effective systemic therapies for melanoma, with a greater economic burden to the healthcare system but an associated improvement in survival. Such evolving paradigm changes may prompt dynamic evaluations of healthcare resources and policies to ensure cancer care is sustainable.

Clinical features of glioma patients who develop pneumocystis pneumonia with temozolomide chemoradiotherapy

INTRODUCTION

The treatment of glioma with temozolomide chemoradiotherapy predisposes patients to pneumocystis pneumonia (PCP). Because PCP is a rare outcome, very little is known about specific clinical risk factors for its development in patients with glioma.

METHODS

We performed a population-based retrospective cohort study of glioma patients undergoing temozolomide chemoradiotherapy 2005 to 2019 in Ontario, Canada. We compared clinical features of patients who did not versus did develop PCP within one year of chemoradiotherapy. We examined the overall survival of patients by PCP status.

RESULTS

There were 5130 patients with glioma treated with temozolomide chemoradiotherapy. Ultimately, 38 patients (0.74%) were diagnosed with PCP within 1 year of chemoradiotherapy. Most (71%) infections occurred between 0-90 days and 29% occurred between 91-365 days. Median survival was 12.3 months in patients who did not develop PCP and 8.6 months in those who did develop PCP (P < 0.001). Trough 90-day lymphocyte counts were lower in the PCP group. When the lymphocytes fell below 0.19 × 10⁹/L (or 0.25 × 10⁹/L among patients without PCP prophylaxis), the risk of PCP was > 3.5%.

CONCLUSIONS

Pneumocystis pneumonia is rare in glioma patients who receive temozolomide chemoradiotherapy. Infection is associated with shorter survival and the development of lymphopenia. Reserving PCP prophylaxis for patients whose lymphocyte counts drop below 0.25 × 10⁹/L may be a reasonable strategy.

Search for Subsolar-Mass Binaries in the First Half of Advanced LIGO's and Advanced Virgo's Third Observing Run

We report on a search for compact binary coalescences where at least one binary component has a mass between 0.2  M_{⊙} and 1.0  M_{⊙} in Advanced LIGO and Advanced Virgo data collected between 1 April 2019 1500 UTC and 1 October 2019 1500 UTC. We extend our previous analyses in two main ways: we include data from the Virgo detector and we allow for more unequal mass systems, with mass ratio q≥0.1. We do not report any gravitational-wave candidates. The most significant trigger has a false alarm rate of 0.14  yr^{-1}. This implies an upper limit on the merger rate of subsolar binaries in the range [220-24200]  Gpc^{-3} yr^{-1}, depending on the chirp mass of the binary. We use this upper limit to derive astrophysical constraints on two phenomenological models that could produce subsolar-mass compact objects. One is an isotropic distribution of equal-mass primordial black holes. Using this model, we find that the fraction of dark matter in primordial black holes in the mass range 0.2  M_{⊙}<m_{PBH}<1.0  M_{⊙} is f_{PBH}≡Ω_{PBH}/Ω_{DM}≲6%. This improves existing constraints on primordial black hole abundance by a factor of ∼3. The other is a dissipative dark matter model, in which fermionic dark matter can collapse and form black holes. The upper limit on the fraction of dark matter black holes depends on the minimum mass of the black holes that can be formed: the most constraining result is obtained at M_{min}=1  M_{⊙}, where f_{DBH}≡Ω_{DBH}/Ω_{DM}≲0.003%. These are the first constraints placed on dissipative dark models by subsolar-mass analyses.

Timing of tracheostomy in patients with severe traumatic brain injuries: The need for tailored practice management guidelines

INTRODUCTION

Traumatic brain injury (TBI) is one of the leading causes of fatal trauma, and patients often require prolonged ventilation and tracheostomy. There are currently no standardized guidelines regarding the optimal timing of tracheostomy placement for mechanically ventilated patients with severe TBI. This review aims to investigate the impact of tracheostomy timing on the clinical outcomes in patients with severe TBI.

METHODS

A literature search was conducted according to PRISMA 2020 guidelines. PubMed, Google Scholar, EMBASE, MedLine, Web of Science, Cochrane, and CINAHL were searched for studies evaluating the impact of early versus late tracheostomy on TBI patient outcomes. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) and Newcastle-Ottawa Scale (NOS) were used for quality of evidence and risk of bias assessment, respectively.

RESULTS

A total of nine studies met eligibility criteria. All nine studies investigated tracheostomy timing in severe TBI patients and demonstrated that early tracheostomy is associated with decreased ICU length-of-stay (LOS) and increased ventilator free-days compared to late tracheostomy.

CONCLUSION

Current evidence suggests that patients with severe TBI following traumatic injury may benefit from an early tracheostomy due to improved clinical outcomes, including decreased MV duration and ICU-LOS, compared to late tracheostomy. Further multi-institutional studies are needed to develop evidence-based guidelines.

Polysaccharide Peptide Extract From Coriolus versicolor Increased Tmax of Tamoxifen and Maintained Biochemical Serum Parameters, With No Change in the Metabolism of Tamoxifen in the Rat

Background: Polysaccharide peptide (PSP) extract of Coriolus versicolor (L.) Quél. (1886) (Trametes; Polyporaceae) is increasingly used in cancer to support the immune system. However, its interaction with tamoxifen is unknown.

Aim of the study: To investigate the effect of a PSP extract on the pharmacokinetics, biochemical parameters, and depletion of tamoxifen.

Methods: The pharmacokinetic and biochemical parameters of tamoxifen (20 mg/mL oral single dose and repeated dosing for 12 days) was investigated in female Sprague Dawley rats with or without PSP (340 mg/kg orally for 7 days) (n = 5 per group). Tamoxifen (5 µM) depletion rate with PSP (10–100 μg/mL) was measured in female rat hepatic microsomes in vitro.

Results: Compared to tamoxifen alone, the time to reach maximum concentration (T_max) significantly increased by 228% (4.15 ± 1.15 versus 13.6 ± 2.71 h) in the single tamoxifen dose with PSP and 93% (6 ± 2.17 versus 11.6 ± 0.4 h) in the repeated tamoxifen dosing with PSP (p < 0.05). No significant changes in the area-under-curve and maximum concentration were observed in the single dose and repeated tamoxifen dosing plus PSP compared to tamoxifen alone. Pharmacodynamically, the repeated tamoxifen dosing with PSP maintained 19 out of 23 hepatic, renal and cardiac biochemical serum parameters in rats compared to untreated rats (p > 0.05). PSP extract did not significantly alter in vitro intrinsic clearance of tamoxifen compared to tamoxifen control.

Conclusion: With the increased use of PSP as an adjunct therapy, this study highlights the importance of clinician’s knowledge of its interaction with tamoxifen to avoid compromising clinical actions and enhancing clinical therapy.

396 Rotator Cuff Assessment Following Traumatic Anterior Shoulder Dislocation

Aim

Glenohumeral joint dislocation is the most common traumatic joint dislocation with a high recurrence rate correlating with age at first dislocation. There is an associated increased incidence in concurrent rotator cuff tears with increasing age affecting 40% aged 40–60. Patient care was assessed against BESS/BOA standard: These patients should have rotator cuff assessment and those aged 40–60 should undergo routine MRI/Ultrasound imaging.

Method

All patients admitted to the emergency departments of the 3 Lanarkshire hospitals undergoing first time traumatic anterior dislocation of the shoulder in February 2021 were included. This was the third cycle of this audit. Previous interventions were presentation at a CPD meeting after cycle one and an NHS Lanarkshire regional meeting after cycle two.

Results

Cycle one (2018)-14 patients. 3/14 underwent rotator cuff assessment. 5/14 aged 40–60. 1/5 underwent rotator cuff imaging.

Cycle two (2020)-11 patients. 0/9 underwent rotator cuff assessment (Two excluded as managed operatively). 4/11 aged 40–60. 0/4 underwent rotator cuff imaging.

Cycle three (2021)-13 patients. 3/11 underwent rotator cuff assessment (Two excluded as managed operatively). 3/13 aged 40–60. 0/3 underwent rotator cuff imaging.

Conclusions

Although a slight improvement has been made over the 3 cycles with rotator cuff assessment the BOA standard is not being met. There has been no improvement in the additional imaging required in traumatic anterior shoulder dislocations in those aged 40–60 over the 3 cycles. These patients may develop pain, reduced function, and rotator cuff arthropathy. There is now an aim to introduce a pathway for these patients across the health board.

Indications and Recommendations for Tracheostomy in Trauma Population With COVID-19 Infection: A Review of the Literature

This review explores the current body of evidence pertaining to tracheostomy placement in COVID-19 seropositive patients and summarizes the research by tracheostomy indications, timing, and procedure. Literature review was performed in accordance with the 2020 PRISMA guidelines and includes 12 papers discussing protocols for adult patients seropositive for COVID-19. The studies demonstrated high mortality rates after tracheostomy, especially in geriatric patients, and suggested a multifactorial determination of whether to perform a tracheostomy. There was inconclusive data regarding wait time between testing seropositive, tracheostomy, and weaning off of ventilation. COVID-19 generally reaches highest infectivity between days 9 and 10; furthermore, high early mortality rates seen in COVID-19 may confound mortality implicated by tracheostomy placement. Due to the aerosol-generating nature of tracheostomy placement, management and maintenance, techniques, equipment, and personnel should be carefully considered and altered for COVID-19 patients. With surgical tracheostomy, literature suggested decreased usage of electrocautery; with percutaneous tracheostomy, single-use bronchoscope should be used. The nonemergent exchange of tracheostomy should be done only after the patient tested negative for COVID-19. Placement of tracheostomy should only be considered in COVID-19 patients who are no longer transmissible, with rigorous attention to safety precautions. Understanding procedures for airway maintenance in a respiratory disease like COVID-19 is imperative, especially due to current shortages in ventilators and PPE. However, because of a lack of available data and its likelihood of change as more data emerges, we lack complete guidelines for tracheostomy placement in COVID-19 seropositive patients, and those existing will likely evolve with the disease.

795 Adequacy of Surgical Excision Margins in Lentigo Maligna: An Audit

Aim

The optimal excision margin for Lentigo Maligna (LM) lesions has been a frequent topic of debate. An audit was carried out to compare the excision margins used for LM excisions with current NICE guidelines, and to assess the adequacy of these excision margins.

Method

A retrospective study was carried out to analyse all excisions of LM lesions in 2018. 33 patients were identified from the plastic surgery departmental database. Patient demographics, the site and distribution of LM lesions, and any history of previous skin cancer were analysed. Patient electronic records, operative notes, and histopathological reports were examined to determine the number of excisions done for each LM lesion along with the peripheral and deep surgical excision margins, and the histological clearance achieved. Complete histological clearance was determined by the Multidisciplinary team for each lesion.

Results

60 cases were identified. 60% of cases were located on the head and neck. The average peripheral surgical excision margin at first excision was 2.3mm. 55% of patients had a 2nd excision. The average peripheral surgical excision margin at 2nd excision was 5.4mm. 70.6% of cases achieved complete histological clearance at 2nd excision. 72.7% of lesions excised at 2nd excision with a 5mm or less surgical excision margin achieved complete histological clearance.

Conclusions

Taking &gt;5mm surgical excision margins did not increase the rate of complete histological clearance for Lentigo Maligna lesions.

The diverse and complex modes of action of anti-NMDA receptor autoantibodies

NMDA receptors are ligand-gated ion channels that are found throughout the brain and are required for both brain development and many higher order functions. A variety of human patients with diverse clinical phenotypes have been identified that carry autoantibodies directed against NMDA receptor subunits. Here we focus on two general classes of autoantibodies, anti-GluN1 antibodies associated with anti-NMDA receptor encephalitis and anti-GluN2 antibodies associated with systemic lupus erythematosus (SLE). These two general classes of anti-NMDA receptor autoantibodies display a wide range of pathophysiological mechanisms from altering synaptic composition to gating of NMDARs. While we have made progress in understanding how these autoantibodies work at the molecular and cellular level, many unanswered questions remain including their long-term actions on brain function, the significance of clonal variations, and their effects on different NMDA receptor-expressing cell types in local circuits. This information will be needed to define fully the transition from anti-NMDA receptor autoantibodies to a clinical phenotype.

Oxyresveratrol Modulates Genes Associated with Apoptosis, Cell Cycle Control and DNA Repair in MCF-7 Cells

Oxyresveratrol (OXY) is a small molecule phytochemical which has been reported to have important biological function. The aim of this study was to elucidate the gene expression and biological pathways altered in MCF-7, breast cancer cells following exposure to OXY. The cytotoxicity to different cancer cell lines was screened using MTT assay and then whole gene expression was elucidated using microarray. The pathways selected were also validated by quantitative PCR analysis, fluorometric and western blot assay. A total of 686 genes were found to have altered mRNA expression levels of two-fold or more in the 50 μM OXY-treated group, while 2,338 genes were differentially expressed in the 100 µM-treated group. The relevant visualized global expression patterns of genes and pathways were generated. Apoptosis was activated through mitochondria-lost membrane potential, caspase-3 expression and chromatin condensation without DNA damage. G0/G1 and S phases of the cell cycle control were inhibited dose-dependently by the compound. Rad51 gene (DNA repair pathway) was significantly down-regulated (p < 0.0001). These results indicate that OXY moderates key genes and pathways in MCF-7 cells and that it could be developed as a chemotherapy or chemo-sensitizing agent.

The Mechanisms of Yu Ping Feng San in Tracking the Cisplatin-Resistance by Regulating ATP-Binding Cassette Transporter and Glutathione S-Transferase in Lung Cancer Cells

Cisplatin is one of the first line anti-cancer drugs prescribed for treatment of solid tumors; however, the chemotherapeutic drug resistance is still a major obstacle of cisplatin in treating cancers. Yu Ping Feng San (YPFS), a well-known ancient Chinese herbal combination formula consisting of Astragali Radix, Atractylodis Macrocephalae Rhizoma and Saposhnikoviae Radix, is prescribed as a herbal decoction to treat immune disorders in clinic. To understand the fast-onset action of YPFS as an anti-cancer drug to fight against the drug resistance of cisplatin, we provided detailed analyses of intracellular cisplatin accumulation, cell viability, and expressions and activities of ATP-binding cassette transporters and glutathione S-transferases (GSTs) in YPFS-treated lung cancer cell lines. In cultured A549 or its cisplatin-resistance A549/DDP cells, application of YPFS increased accumulation of intracellular cisplatin, resulting in lower cell viability. In parallel, the activities and expressions of ATP-binding cassette transporters and GSTs were down-regulated in the presence of YPFS. The expression of p65 subunit of NF-κB complex was reduced by treating the cultures with YPFS, leading to a high ratio of Bax/Bcl-2, i.e. increasing the rate of cell death. Prim-O-glucosylcimifugin, one of the abundant ingredients in YPFS, modulated the activity of GSTs, and then elevated cisplatin accumulation, resulting in increased cell apoptosis. The present result supports the notion of YPFS in reversing drug resistance of cisplatin in lung cancer cells by elevating of intracellular cisplatin, and the underlying mechanism may be down regulating the activities and expressions of ATP-binding cassette transporters and GSTs.

Cardiopulmonary and metabolic physiology during hemodialysis and inter/intradialytic exercise

Hemodialysis is associated with numerous symptoms and side effects that, in part, may be due to subclinical hypoxia. However, acute cardiopulmonary and metabolic physiology during hemodialysis is not well defined. Intradialytic and interdialytic exercise appear to be beneficial and may alleviate these side effects. To better understand these potential benefits, the acute physiological response to exercise should be evaluated. The aim of this study was to compare and characterize the acute physiological response during hemodialysis, intradialytic exercise, and interdialytic exercise. Cardiopulmonary physiology was evaluated during three conditions: 1) hemodialysis without exercise (HD), 2) intradialytic exercise (IDEx), and 3) interdialytic exercise (Ex). Exercise consisted of 30-min constant load cycle ergometry at 90% V̇O₂AT (anaerobic threshold). Central hemodynamics (via noninvasive bioreactance) and ventilatory gas exchange were recorded during each experimental condition. Twenty participants (59 ± 12 yr, 16/20 male) completed the protocol. Cardiac output (Δ = -0.7 L/min), O₂ uptake (Δ = -1.4 mL/kg/min), and arterial-venous O₂ difference (Δ = -2.0 mL/O₂/100 mL) decreased significantly during HD. Respiratory exchange ratio exceeded 1.0 throughout HD and IDEx. Minute ventilation was lower (P = 0.001) during IDEx (16.5 ± 1.1 L/min) compared with Ex (19.8 ± 1.0 L/min). Arterial-venous O₂ difference was partially restored further to IDEx (4.6 ± 1.9 mL/O₂/100 mL) compared with HD (3.5 ± 1.2 mL/O₂/100 mL). Hemodialysis altered cardiopulmonary and metabolic physiology, suggestive of hypoxia. This dysregulated physiology contributed to a greater physiological demand during intradialytic exercise compared with interdialytic exercise. Despite this, intradialytic exercise partly normalized cardiopulmonary physiology during treatment, which may translate to a reduction in the symptoms and side effects of hemodialysis.NEW & NOTEWORTHY This study is the first, to our knowledge, to directly compare cardiopulmonary and metabolic physiology during hemodialysis, intradialytic exercise, and interdialytic exercise. Hemodialysis was associated with increased respiratory exchange ratio, blunted minute ventilation, and impaired O₂ uptake and extraction. We also identified a reduced ventilatory response during intradialytic exercise compared with interdialytic exercise. Impaired arterial-venous O₂ difference during hemodialysis was partly restored by intradialytic exercise. Despite dysregulated cardiopulmonary and metabolic physiology during hemodialysis, intradialytic exercise was well tolerated.

3 Estimating the Burden of Dementia in Latin America and the Caribbean: A Systematic Review and Meta-Analysis

Background and Objectives

Rapid increase in life expectancy has resulted in an increase in the global burden of dementia that is expected to become a leading cause of morbidity in the future. Low- and middle-income countries are expected to bear an increasing majority of the burden, but lack data for accurate burden estimates that are key for informing policy and planning. Bayesian methods have recently gained recognition over traditional frequentist approaches for modelling disease burden for their superiority in dealing with severely limited data. This study provides updated estimates of dementia prevalence in Latin America and the Caribbean (LAC) for the years 2015, 2020 and 2030. Given the paucity of data, estimates were developed using a Bayesian methodology and confirmed by the traditional frequentist approach, with the aim of providing methodological insights for future disease burden estimates.

Methods

A comprehensive systematic literature search was conducted to identify all relevant primary studies published between the years 2010–2018. The quality of the included studies was critically assessed. A random-effects model (REM) and a Bayesian normal-normal hierarchical model (NNHM) were used to obtain the pooled prevalence estimate of dementia for people aged 60 and above. The latter model was also developed to estimate age-specific dementia prevalence. Using UN population estimates, total and age-specific projections of the burden of dementia were calculated.

Results

The prevalence of dementia in LAC was found to be 14% (10–21%) in those above age 60 based on REM, and 8% (5–11.5%) based on NNHM. The prevalence increased from 2% (1–4%) in people aged 60–69 to 29% (20–37%) in people above the age of 80. The number of people living with dementia in LAC in 2015 was estimated at 5.68 million, with future projections of 6.86 million in 2020 and 9.94 million in 2030.

Conclusions

The findings of this review found that burden of dementia in LAC is substantial and continues to rapidly grow. The projected rise in dementia cases in the future should prompt urgent governmental response to address this growing public health issue. We were also able to demonstrate that given the overall paucity of data, a Bayesian approach was superior for estimating disease prevalence and burden.

End-of-life outcomes with or without early palliative care: a propensity score matched, population-based cancer cohort study

OBJECTIVES

To investigate whether cancer decedents who received palliative care early (ie, >6 months before death) and not-early had different risk of using hospital care and supportive home care in the last month of life.

DESIGN/SETTING

We identified a population-based cohort of cancer decedents between 2004 and 2014 in Ontario, Canada using linked administrative data. Analysis occurred between August 2017 to March 2019.

PARTICIPANTS

We propensity-score matched decedents on receiving early or not-early palliative care using billing claims. We created two groups of matched pairs: one that had Resident Assessment Instrument (RAI) home care assessments in the exposure period (Yes-RAI group) and one that did not (No-RAI group) to control for confounders uniquely available in the assessment, such as health instability and pain. The outcomes were the absolute risk difference between matched pairs in receiving hospital care, supportive home care or hospital death.

RESULTS

In the No-RAI group, we identified 36 238 pairs who received early and not-early palliative care. Those in the early palliative care group versus not-early group had a lower absolute risk difference of dying in hospital (-10.0%) and receiving hospital care (-10.4%) and a higher absolute risk difference of receiving supportive home care (23.3%). In the Yes-RAI group, we identified 3586 pairs, where results were similar in magnitude and direction.

CONCLUSIONS

Cancer decedents who received palliative care earlier than 6 months before death compared with those who did not had a lower absolute risk difference of receiving hospital care and dying in hospital, and an increased absolute risk difference of receiving supportive home care in the last month of life.

High-Cost Patients and Preventable Spending: A Population-Based Study

BACKGROUND

Although high-cost (HC) patients make up a small proportion of patients, they account for most health system costs. However, little is known about HC patients with cancer or whether some of their care could potentially be prevented. This analysis sought to characterize HC patients with cancer and quantify the costs of preventable acute care (emergency department visits and inpatient hospitalizations).

METHODS

This analysis examined a population-based sample of all HC patients in Ontario in 2013. HC patients were defined as those above the 90th percentile of the cost distribution; all other patients were defined as non-high-cost (NHC). Patients with cancer were identified through the Ontario Cancer Registry. Sociodemographic and clinical characteristics were examined and the costs of preventable acute care for both groups by category of visit/condition were estimated using validated algorithms.

RESULTS

Compared with NHC patients with cancer (n=369,422), HC patients with cancer (n=187,770) were older (mean age 70 vs 65 years), more likely to live in low-income neighborhoods (19% vs 16%), sicker, and more likely to live in long-term care homes (8% vs 0%). Although most patients from both cohorts tended to be diagnosed with breast, prostate, or colorectal cancer, those with multiple myeloma or pancreatic or liver cancers were overrepresented among the HC group. Moreover, HC patients were more likely to have advanced cancer at diagnosis and be in the initial or terminal phase of treatment compared with NHC patients. Among HC patients with cancer, 9% of spending stemmed from potentially preventable/avoidable acute care, whereas for NHC patients, this spending was approximately 30%.

CONCLUSIONS

HC patients with cancer are a unique subpopulation. Given the type of care they receive, there seems to be limited scope to prevent acute care spending among this patient group. To reduce costs, other strategies, such as making hospital care more efficient and generating less costly encounters involving chemotherapy, should be explored.

Pulmonary pressure-to-longitudinal strain ratio by echocardiography: a rapid surrogate to magnetic resonance for right ventricular failure assessment

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): United Christian Hospital Ruttonjee and Tang Siu Kin Hospitals

Background

Better risk stratification in pulmonary hypertension (PH) by echocardiography (echo) to detect ventricular vascular uncoupling may act as gate-keeper for downstream management, such as MRI and expensive therapies. Studies showed modest correlation found between RV peak global longitudinal strain (RVGLS), which is afterload dependent, and right ventricular ejection fraction (RVEF)

Purpose

To test the accuracy and optimal cut-off of echo derived mean PA pressure-to-RVGLS ratio against MRI detected severe RV dysfunction (defined as RVEF&lt; 35%), RV dilatation (defined as RVEDVi &gt;87ml), and correlate native T1-values (nT1)

Method

Strain analyses by echo and volumetric assessment by 1.5 tesla MRI were performed in all patients. Contoured MRI short axis images provided RVEF. In a subgroup of pulmonary arterial hypertension (PAH), right heart catheterization and MRI non-contrast native T1 mapping were performed (Figure 1). Using previous study data, to identify a difference of 1.8 pressure-to-strain ratio between mild and severe PH with a variance  of 2.2 , power of 80% and a significance level of 0.05, a total of 11 participants per group were needed

Result

Thirty-one PH patients (13 female, age 60 ± 14y, 13 had PAH) were recruited prospectively. Strong correlation was demonstrated between the mean PA pressure-to-RVGLS ratio to MRI derived RVEF (r = 0.80, p &lt; 0.01), and to catheterization derived pulmonary vascular resistance and indexed cardiac output (r = -0.80, p= 0.001; r= -0.75, p = 0.003 respectively). The cut-off value of -2.5 had best accuracy in ROC analyses (Table 1)

In PAH patients, this ratio correlated with global nT1 at basal short-axis level (r= -0.91, p = 0.004), but not at the mid short-axis level. Their basal posterior interventricular insertion regions had significantly higher nT1 than those of age-matched normal controls at the same region on the same scanner (1256 ± 217 ms vs. 932 ± 25 ms, p = 0.04)

Conclusion

In terms of detection of severe right ventricular dysfunction by echocardiography, mean PA pressure-to-RVGLS ratio performed better than RVGLS alone, and a ratio cutoff of -2.5 predicts MRI determined ventricular vascular uncoupling in pulmonary hypertension

Table 1 Echo detect MRI AUC standard error 95% CI sens (%) spec (%) p Mean PA pressure -to-RVGLS ratio RVEF &lt; 35% 0.86 0.073 0.71-1.00 72 83 0.007 RVEDVi &gt; 87ml 0.81 0.081 0.65-0.97 83 70 0.004 RVGLS RVEF &lt; 35% 0.76 0.100 0.57-0.96 60 83 0.048 RVEDVi &gt; 87ml 0.73 0.090 0.55-0.91 67 70 0.032 PA pulmonary artery; RVGLS: RV global longitudinal strain; RVEDVi: indexed RV end-diastolic volume Abstract Figure 1

A matching-adjusted indirect comparison of combination nivolumab plus ipilimumab with BRAF plus MEK inhibitors for the treatment of BRAF-mutant advanced melanoma☆

Background

Approved first-line treatments for patients with BRAF V600–mutant advanced melanoma include nivolumab (a programmed cell death protein 1 inhibitor) plus ipilimumab (a cytotoxic T lymphocyte antigen-4 inhibitor; NIVO+IPI) and the BRAF/MEK inhibitors dabrafenib plus trametinib (DAB+TRAM), encorafenib plus binimetinib (ENCO+BINI), and vemurafenib plus cobimetinib (VEM+COBI). Results from prospective randomized clinical trials (RCTs) comparing these treatments have not yet been reported. This analysis evaluated the relative efficacy and safety of NIVO+IPI versus DAB+TRAM, ENCO+BINI, and VEM+COBI in patients with BRAF-mutant advanced melanoma using a matching-adjusted indirect comparison (MAIC).

Patients and methods

A systematic literature review identified RCTs for DAB+TRAM, ENCO+BINI, and VEM+COBI in patients with BRAF-mutant advanced melanoma. Individual patient-level data for NIVO+IPI were derived from the phase III CheckMate 067 trial (BRAF-mutant cohort) and restricted to match the inclusion/exclusion criteria of the comparator trials. Treatment effects for overall survival (OS) and progression-free survival (PFS) were estimated using Cox proportional hazards and time-varying hazard ratio (HR) models. Safety outcomes (grade 3 or 4 treatment-related adverse events) with NIVO+IPI and the comparators were compared.

Results

In the Cox proportional hazards analysis, NIVO+IPI showed improved OS compared with DAB+TRAM (HR = 0.53; 95% confidence interval [CI], 0.39-0.73), ENCO+BINI (HR = 0.60; CI, 0.42-0.85), and VEM+COBI (HR = 0.50; CI, 0.36-0.70) for the overall study period. In the time-varying analysis, NIVO+IPI was associated with significant improvements in OS and PFS compared with the BRAF/MEK inhibitors 12 months after treatment initiation. There were no significant differences between NIVO+IPI and BRAF/MEK inhibitor treatment from 0 to 12 months. Safety outcomes favored DAB+TRAM over NIVO+IPI, whereas NIVO+IPI was comparable to VEM+COBI.

Conclusion

Results of this MAIC demonstrated durable OS and PFS benefits for patients with BRAF-mutant advanced melanoma treated with NIVO+IPI compared with BRAF/MEK inhibitors, with the greatest benefits noted after 12 months.

•

First-line treatments for BRAF V600-mutant melanoma include NIVO+IPI and BRAF/MEK inhibitors.

•

Results from prospective RCTs comparing NIVO+IPI and BRAF/MEK inhibitors have not yet been reported.

•

This MAIC evaluated NIVO+IPI versus BRAF/MEK inhibitors for BRAF-mutant advanced melanoma.

•

OS and PFS benefits were noted with NIVO+IPI versus BRAF/MEK inhibitors beginning at 12 months.

•

These findings may provide information relevant to the selection of treatments for BRAF-mutant advanced melanoma.