Movements and spatial distribution of an endangered fish (Sciaena umbra) within a marine protected area

The brown meagre (Sciaena umbra) is an endangered species, which requires specific protection measures to ensure its conservation. These measures need to be informed by high-quality scientific knowledge on their space use patterns. Here, we used acoustic telemetry to assess its seasonal movement patterns and habitat use within a marine protected area (MPA). Our results suggested that S. umbra is a highly sedentary species (home range < 1.0 km2) and, therefore, the MPA is extensive enough to protect the local population. Their population was discretely distributed in two main areas within the MPA, which was likely a result of habitat segregation and density-dependent movements. The temporal variability of their movements further uncovered when and where spawning occurs (mainly, but probably not only, in the fully protected area in June) and indicated that spillover of this species is limited but still possible. Overall, we highlight the importance of MPAs in the recovery of S. umbra, we advocate the need to perpetuate the current national fishing bans and extend it to other countries in the Mediterranean region, and we emphasize that considering the fine-scale movements of S. umbra in future management actions is key to achieving a successful recovery of their populations.

Contraceptive Adoption and Changes in Empowerment in Kenya, Nigeria, and Senegal

Women's empowerment and contraceptive use are critical to achieving gender equality. The positive association between more empowered women and higher rates of contraceptive use has been well-established by cross-sectional research. However, there remains a gap in understanding the longitudinal relationship between contraceptive adoption and changes to women's empowerment. This study represents a novel approach to understanding the relationship between contraceptive adoption and women's empowerment longitudinally, at the individual level. To the authors' knowledge, this is the first attempt to measure the relationship between contraceptive adoption and women's empowerment using more than one wave of panel data. We leverage the longitudinal design of the Urban Reproductive Health Initiative data to code empowerment items by change over time (e.g., more empowered, no change, less empowered). We use sparse principal component analysis to establish empowerment change domains and calculate individual scores standardized by country-level averages. We estimate mixed effects models on these change domains, to investigate the link between contraceptive adoption and empowerment. We find common themes in empowerment across contexts-but contraceptive adoption has both positive and negative effects on those domains, and this varies across context. We discuss the need for cohort studies to examine this relationship.

Towards Clinical Translation of Microbeam Radiation Therapy (MRT) with a Compact Source

PURPOSE/OBJECTIVE(S)

MRT is an innovative concept of spatially fractionated radiation therapy that has demonstrated substantially improved normal tissue tolerance while achieving local tumor control in a wealth of preclinical studies. In MRT a collimator shapes a few micrometers wide planar x-ray beams with a spacing of a few 100 µm. MRT has the potential to improve cancer treatment substantially. However, until now, only a few large 3rd generation synchrotrons provide beam parameters that would allow patient treatments and therefore, MRT has not yet become clinically available. For a clinical translation, compact x-ray sources are required, that produce high dose rate orthovoltage x-rays from a micrometer sized emitter.

MATERIALS/METHODS

We developed and built a first prototype of a line focus x-ray tube (LFxT) dedicated to preclinical MRT research. By exploiting the heat capacity limit, the LFxT can deliver dose rates above 100 Gy/s from a just 50 µm-wide focal spot without destroying the rapidly (>200 Hz) rotating x-ray target. A bespoke collimator splits the homogeneous x-ray field into 50 µm wide high-dose peaks separated by 350 µm wide low-dose troughs (valleys). While the prototype in our lab is restricted to a power of 90 kW and 10 Gy/s at 300 kVp, we have started the development of the first clinically usable LFxT-2 at 1.5 MW power and >100 Gy/s at 600 kVp beam quality. We investigated the clinical applicability of the LFxT-2 by performing retrospective treatment planning studies. In particular, we were examining, whether 600 kVp photons would suffice to meet clinical dose constraints in MRT treatments treatment scenarios for first clinical use of MRT. We coupled the open source platform 3D Slicer with an in-house developed dose calculation algorithm for MRT treatment planning. For comparability of spatially fractionated MRT doses with conventional broad beam treatments, the MRT dose was converted to equivalent uniform dose (EUD) and equivalent doses in 2-Gy-fractions (EQD2). The 3D Slicer RT toolkit enabled the dosimetric analysis based on dose volume histograms (DVHs).

RESULTS

We installed a preclinical prototype of the LFxT that is currently put into operation and commissioned. Simulations show the feasibility of the next generation LFxT-2 with more than 100 Gy/s peak dose rate. Planned MRT dose distributions with the LFxT-2 meet established radiotherapy dose constraints in many of the investigated clinical cases. However, treatment planning procedures are not yet optimal and require improvement.

CONCLUSION

In a next step, we will build the LFxT-2 and aim for first clinical MRT trials at this source. In order to further improve calculated MRT dose distributions, we will implement inverse treatment planning techniques.

Validity Assessment of an Automated Brain Morphometry Tool for Patients with De Novo Memory Symptoms

BACKGROUND AND PURPOSE

Automated volumetric analysis of structural MR imaging allows quantitative assessment of brain atrophy in neurodegenerative disorders. We compared the brain segmentation performance of the AI-Rad Companion brain MR imaging software against an in-house FreeSurfer 7.1.1/Individual Longitudinal Participant pipeline.

MATERIALS AND METHODS

T1-weighted images of 45 participants with de novo memory symptoms were selected from the OASIS-4 database and analyzed through the AI-Rad Companion brain MR imaging tool and the FreeSurfer 7.1.1/Individual Longitudinal Participant pipeline. Correlation, agreement, and consistency between the 2 tools were compared among the absolute, normalized, and standardized volumes. Final reports generated by each tool were used to compare the rates of detection of abnormality and the compatibility of radiologic impressions made using each tool, compared with the clinical diagnoses.

RESULTS

We observed strong correlation, moderate consistency, and poor agreement between absolute volumes of the main cortical lobes and subcortical structures measured by the AI-Rad Companion brain MR imaging tool compared with FreeSurfer. The strength of the correlations increased after normalizing the measurements to the total intracranial volume. Standardized measurements differed significantly between the 2 tools, likely owing to differences in the normative data sets used to calibrate each tool. When considering the FreeSurfer 7.1.1/Individual Longitudinal Participant pipeline as a reference standard, the AI-Rad Companion brain MR imaging tool had a specificity of 90.6%-100% and a sensitivity of 64.3%-100% in detecting volumetric abnormalities. There was no difference between the rate of compatibility of radiologic and clinical impressions when using the 2 tools.

CONCLUSIONS

The AI-Rad Companion brain MR imaging tool reliably detects atrophy in cortical and subcortical regions implicated in the differential diagnosis of dementia.

Under-correction of preoperative varus alignment does not lead to a difference in in-vivo bone loading in 3D-SPECT/CT compared to neutral alignment

BACKGROUND

The aim was to investigate the correlation of bone tracer uptake (BTU) in SPECT/CT and changes in coronal knee alignment after total knee arthroplasty (TKA). We questioned if undercorrection of preoperative varus alignment leads to a difference in BTU compared to neutral alignment.

METHODS

Consecutive 66 patients who received SPECT/CT before and after TKA were retrospectively included. Adjusted mechanical alignment was the alignment target. The alignment of the knee was measured on 3D-CT by selecting standardized landmarks. Maximum (mean ± SD) and relative BTU (ratio to the reference) were recorded using a previously validated localization scheme (p < 0.05).

RESULTS

In the native group, 20 knees were aligned (30.3%) in valgus (HKA > 181.5°), 12 (18.2%) in neutral (178.5°-181.5°) and 34 (51.5%) in varus (HKA < 178°). Overall TKA changed the alignment towards neutral. 48.5% remained in the same groups, whereas 50% of native valgus and 33% of varus knees changed to neutral after TKA. In native varus alignment mean BTU was significantly higher in some medial tibial and femoral regions (fem1ia (p = 0.010), fem1ip (p = 0.002), tib1a.mid (p = 0.005), tib1a.tray (p = 0.000), tib1p.tray (p = 0.000)); in native valgus alignment mean BTU was higher in the corresponding lateral tibial and femoral regions (fem2ip (p = 0.001), tib2a.tray (p = 0.011), tib2p.tray (p = 0.002)). After TKA, a significant decrease in femoral and tibial BTU (femoral preoperative BTU 1.64 +/-0.69; femoral postoperative BTU 0.95 +/-0.42; p = 0.000// tibial preoperative BTU 1.65 +/- 0.93; tibial postoperative BTU 1.16 +/- 0.48; p = 0.000) and an increase in patellar BTU was observed (p = 0.025). Native varus alignment correlated with a higher medial BTU decrease medially. Undercorrection of preoperative varus alignment showed no higher BTU after TKA.

CONCLUSION

Preoperative varus alignment correlated with a higher decrease in BTU in specific femoral and tibial medial regions. Preoperative valgus alignment correlated with a higher decrease in the corresponding lateral regions. Undercorrection of preoperative varus alignment did not lead to higher bone loading reflected by BTU after TKA.

The Extent of Task Specificity for Visual and Tactile Sequences in the Auditory Cortex of the Deaf and Hard of Hearing

It has been proposed that the auditory cortex in the deaf humans might undergo task-specific reorganization. However, evidence remains scarce as previous experiments used only two very specific tasks (temporal processing and face perception) in visual modality. Here, congenitally deaf/hard of hearing and hearing women and men were enrolled in an fMRI experiment as we sought to fill this evidence gap in two ways. First, we compared activation evoked by a temporal processing task performed in two different modalities, visual and tactile. Second, we contrasted this task with a perceptually similar task that focuses on the spatial dimension. Additional control conditions consisted of passive stimulus observation. In line with the task specificity hypothesis, the auditory cortex in the deaf was activated by temporal processing in both visual and tactile modalities. This effect was selective for temporal processing relative to spatial discrimination. However, spatial processing also led to significant auditory cortex recruitment which, unlike temporal processing, occurred even during passive stimulus observation. We conclude that auditory cortex recruitment in the deaf and hard of hearing might involve interplay between task-selective and pluripotential mechanisms of cross-modal reorganization. Our results open several avenues for the investigation of the full complexity of the cross-modal plasticity phenomenon.SIGNIFICANCE STATEMENT Previous studies suggested that the auditory cortex in the deaf may change input modality (sound to vision) while keeping its function (e.g., rhythm processing). We investigated this hypothesis by asking deaf or hard of hearing and hearing adults to discriminate between temporally and spatially complex sequences in visual and tactile modalities. The results show that such function-specific brain reorganization, as has previously been demonstrated in the visual modality, also occurs for tactile processing. On the other hand, they also show that for some stimuli (spatial) the auditory cortex activates automatically, which is suggestive of a take-over by a different kind of cognitive function. The observed differences in processing of sequences might thus result from an interplay of task-specific and pluripotent plasticity.

Exploring the Cost Effectiveness of Shared Decision Making for Choosing between Disease-Modifying Drugs for Relapsing-Remitting Multiple Sclerosis in the Netherlands: A State Transition Model

Background

Up to 31% of patients with relapsing-remitting multiple sclerosis (RRMS) discontinue treatment with disease-modifying drug (DMD) within the first year, and of the patients who do continue, about 40% are nonadherent. Shared decision making may decrease nonadherence and discontinuation rates, but evidence in the context of RRMS is limited. Shared decision making may, however, come at additional costs. This study aimed to explore the potential cost-effectiveness of shared decision making for RRMS in comparison with usual care, from a (limited) societal perspective over a lifetime.

Methods

An exploratory economic evaluation was conducted by adapting a previously developed state transition model that evaluates the cost-effectiveness of a range of DMDs for RRMS in comparison with the best supportive care. Three potential effects of shared decision making were explored: 1) a change in the initial DMD chosen, 2) a decrease in the patient’s discontinuation in using the DMD, and 3) an increase in adherence to the DMD. One-way and probabilistic sensitivity analyses of a scenario that combined the 3 effects were conducted.

Results

Each effect separately and the 3 effects combined resulted in higher quality-adjusted life years (QALYs) and costs due to the increased utilization of DMD. A decrease in discontinuation of DMDs influenced the incremental cost-effectiveness ratio (ICER) most. The combined scenario resulted in an ICER of €17,875 per QALY gained. The ICER was sensitive to changes in several parameters.

Conclusion

This study suggests that shared decision making for DMDs could potentially be cost-effective, especially if shared decision making would help to decrease treatment discontinuation. Our results, however, may depend on the assumed effects on treatment choice, persistence, and adherence, which are actually largely unknown.

[Role of university hospitals in Bavaria during the COVID-19 pandemic]

Hintergrund

Anfang 2020 wurde deutschlandweit das Gesundheitswesen bedingt durch die coronavirus disease 2019 (COVID-19)-Pandemie auf einen Notbetrieb umgestellt. In Bayern wurde durch das zuständige Innen- und Gesundheitsministerium zu Beginn der ersten Welle eine Allgemeinverfügung erlassen, in der unter anderem die Organisation der Krankenhausbelegung, Neukonzeption der Informationstechnologie(IT)-Steuerung und Meldepflichten angeordnet wurden. Ziel dieser Auswertung war es, die Bedeutung der universitären Medizin für die stationäre Behandlung von COVID-19-Patienten in Bayern zu untersuchen.

Methoden

Es erfolgte eine retrospektive Auswertung aller stationär behandelten COVID-19-Patienten, die über das Modul IVENA Sonderlage (IVENA eHealth, [IVENA, interdisziplinärer Versorgungsnachweis, mainis IT-Service GmbH, Offenbach am Main, Deutschland]) gemeldet wurden. Hierbei wurden die gemeldeten Behandlungstage aller bayerischen Kliniken, die an der Versorgung von COVID-19-Patienten teilgenommen haben, ausgewertet.

Ergebnisse

Im Rahmen der ersten Welle der COVID-19-Pandemie wurden 90,9 % der Behandlungstage von kommunalen und öffentlichen sowie privaten Krankenhäusern in Bayern bereitgestellt. Neben der medizinischen Versorgung von COVID-19-Patienten mit komplexen Verläufen (20 % der Intensivstations[ICU]- und Intermediate-care-Stations [IMC]-Behandlungstage) leistete die Universitätsmedizin in Bayern mit ihren Kliniken einen relevanten wissenschaftlichen Beitrag und war wesentlich an der Beratung von Ärzten, Krankenhäusern und Politik zur Pandemie beteiligt.

DLSR: a solution to the parallax artefact in X-ray diffraction computed tomography data

A new tomographic reconstruction algorithm is presented, termed direct least-squares reconstruction (DLSR), which solves the well known parallax problem in X-ray-scattering-based experiments. The parallax artefact arises from relatively large samples where X-rays, scattered from a scattering angle 2θ, arrive at multiple detector elements. This phenomenon leads to loss of physico-chemical information associated with diffraction peak shape and position (i.e. altering the calculated crystallite size and lattice parameter values, respectively) and is currently the major barrier to investigating samples and devices at the centimetre level (scale-up problem). The accuracy of the DLSR algorithm has been tested against simulated and experimental X-ray diffraction computed tomography data using the TOPAS software.

Tracheal obstruction due to tumour: use of veno-venous extracorporeal membrane oxygenation during rigid bronchoscopy

Tracheal tumour is rare but can lead to upper airway obstruction and acute respiratory distress. Its management includes surgical resection, radiotherapy or interventional bronchoscopy. Ventilation or difficulties with tracheal intubation can occur during the peri-operative course resulting in serious adverse consequences. We report the case of an 83-year-old man with an obstructive tracheal chondrosarcoma resected by rigid bronchoscopy undergoing veno-venous extracorporeal membrane oxygenation. Such support should be considered when the patient's airway patency cannot be ensured by conventional methods.

Projection of Costs of Polio Eradication Compared to Permanent Control

Despite increased efforts and spending toward polio eradication, it has yet to be eliminated worldwide. We aimed to project economic costs of polio eradication compared to permanent control. We used historical Financial Resource Requirements from the Global Polio Eradication Initiative, as well as vaccination and population data from publicly available sources, to project costs for routine immunization, immunization campaigns, surveillance and laboratory resources, technical assistance, social mobilization, treatment, and overhead. We found that cumulative spending for a control strategy would exceed that for an eradication strategy in 2032 (range, 2027-2051). Eradication of polio would likely be cost-saving compared to permanent control.

Feed-forward neural networks using cerebral MR spectroscopy and DTI might predict neurodevelopmental outcome in preterm neonates

Objectives

We aimed to evaluate the ability of feed-forward neural networks (fNNs) to predict the neurodevelopmental outcome (NDO) of very preterm neonates (VPIs) at 12 months corrected age by using biomarkers of cerebral MR proton spectroscopy (¹H-MRS) and diffusion tensor imaging (DTI) at term-equivalent age (TEA).

Methods

In this prospective study, 300 VPIs born before 32 gestational weeks received an MRI scan at TEA between September 2013 and December 2017. Due to missing or poor-quality spectroscopy data and missing neurodevelopmental tests, 173 VPIs were excluded. Data sets consisting of 103 and 115 VPIs were considered for prediction of motor and cognitive developmental delay, respectively. Five metabolite ratios and two DTI characteristics in six different areas of the brain were evaluated. A feature selection algorithm was developed for receiving a subset of characteristics prevalent for the VPIs with a developmental delay. Finally, the predictors were constructed employing multiple fNNs and fourfold cross-validation.

Results

By employing the constructed fNN predictors, we were able to predict cognitive delays of VPIs with 85.7% sensitivity, 100% specificity, 100% positive predictive value (PPV) and 99.1% negative predictive value (NPV). For the prediction of motor delay, we achieved a sensitivity of 76.9%, a specificity of 98.9%, a PPV of 90.9% and an NPV of 96.7%.

Conclusion

FNNs might be able to predict motor and cognitive development of VPIs at 12 months corrected age when employing biomarkers of cerebral ¹H-MRS and DTI quantified at TEA.

Key Points

• A feed-forward neuronal network is a promising tool for outcome prediction in premature infants.

• Cerebral proton magnetic resonance spectroscopy and diffusion tensor imaging can be used for the construction of early prognostic biomarkers.

• Premature infants that would most benefit from early intervention services can be spotted at the time of optimal neuroplasticity.

Electronic supplementary material

The online version of this article (10.1007/s00330-020-07053-8) contains supplementary material, which is available to authorized users.

Correlation Between Sarcopenia and Growth Rate of the Future Liver Remnant After Portal Vein Embolization in Patients with Colorectal Liver Metastases

PURPOSE

To investigate whether sarcopenia and myosteatosis correlate with the degree of hypertrophy (DH) and kinetic growth rate (KiGR) of the future liver remnant (FLR) in patients with colorectal liver metastases undergoing portal vein embolization (PVE) in preparation for right hepatectomy.

MATERIALS AND METHODS

Forty-two patients were included. Total liver volume and FLR volume were measured before and 2-4 weeks after PVE. KiGR of the FLR was calculated. Sarcopenia was assessed using the total psoas muscle volume (PMV), the psoas muscle cross-sectional area (PMCS) and the total skeletal muscle index (L3SMI) at the level of 3rd lumbar vertebra. Degree of myosteatosis was assessed by mean muscle attenuation at L3 (L3MA). Correlations between muscle indices and DH and KiGR were assessed using simple linear regression analyses.

RESULTS

Mean DH was 8.9 ± 5.7%, and mean KiGR was 3.6 ± 2.3. Mean PMV was 55.56 ± 14.19 cm3/m3, mean PMCS was 8.76 ± 2.3 cm2/m2, mean L3SMI was 45.6 ± 9.89 cm2/m2, and mean L3MA was 27.9 ± 18.6 HU. There was a strong positive correlation between PMV and DH (R = 0.503, p = 0.001) and PMV and KiGR (R = 0.545, p < 0.001). Furthermore, there was a moderate correlation between PMCS and KiGR (R = 0.389, p = 0.014). L3SMI and L3MA were neither associated with DH (p = 0.390 and p = 0.768, respectively) nor with KiGR (p = 0.188 and p = 0.929, respectively).

CONCLUSION

We identified a positive correlation between PMV and PMCS, as markers for sarcopenia, and the KiGR of the FLR after PVE. PMV and PMCS might therefore aid to identify patients who are poor candidates for FLR augmentation using PVE alone.

SAT0325 STELLATE BLOCKADE COMBINED TO ILOPROST AS SUPPORTIVE TREATMENT OPTION IMPROVES PAIN AND ISCHAEMIC SYMPTOMS IN PATIENTS WITH SYSTEMIC SCLEROSIS

Background:

Peripheral ischaemia is a common symptom in systemic sclerosis (SSc) patients with risk of development of digital ulcers (DU). For its treatment, intravenous iloprost is the most effective option. Accompanying pain symptoms worsen the ischaemic symptoms, so a combination with anaesthetic procedures may improve ischaemic status and the subjective sensation of raynaud and pain. The aim of this study was to observe the impact of a combined treatment of iloprost with stellate blockade (ILOST) in improvement of ischaemic symptoms compared to iloprost treatment only (ILO).

Objectives:

To evaluate efficacy of the ILOST treatment on changes in vascularisation and sensation of patients with SSc and indication for vasodilatative treatment with Iloprost.

Methods:

Twenty SSc-patients with indication for ILO-treatment (prophylactic or due to digital ulcerations (DU)) will be included in a prospective observational study. Patients will be offered to combine ILO with stellate blockade (ILOST). Beside documentation of disease activity characteristics (mRSS, number of DU, capillary microscopy at baseline, after ILO-treatment and at week 12), patients are assessed using fluorescence-optical imaging (FOI) as innovative method for illustration of changes in microvascularisation and patient reported outcomes (DASH, VAS) at week 12.

Results:

This interims analysis includes the result of the first 11 patients treated. Mean baseline characteristics (age and gender) are well balanced. Iloprost treatment was initiated due to prophylactic treatment to avoid DU in all patients. 100% of the patients in the ILOST-group were diagnosed as limited SSc compared to 60% in the ILO-group (diffuse type with 40%). All patients showed abnormalities in capillary microscopy (ILOST group: 83,3% late pattern 16.7% active pattern; ILO group: 80% late pattern, 20% early pattern). MRSS was low in both groups with 1.8, the disease duration in mean 15.3 years in the ILOST-group compared to 13.2 in the ILO-group, respectively. In both groups, no new DU occurred in the 12-week follow-up. Improvement in VAS pain was reported in 83% of the patients in the ILOST group compared to 60% in the ILO group. DASH improved with a mean of 5.5 points in the ILOST group compared to 3 points in the ILO group. FOI was compared individual at both arms in the ILOST group only. The arm with stellatum blockade showed a pronounced increase of FOI signals of 5% in mean whereas the opposite site showed a decrease of the signal shortly after ILO treatment indicating a pronounced increase of vascularisation in the ILOST treated body site.

Conclusion:

A new treatment approach to improve acute ischaemic symptoms was tested by combining stellate blockade to iloprost treatment. No new DU occurred up to 12 weeks after treatment in all patients of both groups indicating the relevance of iloprost as effective vascular dilatative therapy in SSc. The additional intervention was well tolerated and asked to repeat. Subjective sensation on pain of the hands as well as DASH was improved in the combined group. FOI showed a relevant increase in vascularisation in the blockade arm compared to the opposite site in which signals decreased indicating a stronger effect of the combined treatment for improvement of vascularisation.

Disclosure of Interests:

Franziska Höcketstaller Grant/research support from: Rheumazentrum Rhein-Main, Ulf Henkemeier: None declared, Michael Zimmermann: None declared, Harald Burkhardt Grant/research support from: Pfizer, Roche, Abbvie, Consultant of: Sanofi, Pfizer, Roche, Abbvie, Boehringer Ingelheim, UCB, Eli Lilly, Chugai, Bristol Myer Scripps, Janssen, and Novartis, Speakers bureau: Sanofi, Pfizer, Roche, Abbvie, Boehringer Ingelheim, UCB, Eli Lilly, Chugai, Bristol Myer Scripps, Janssen, and Novartis, Frank Behrens Grant/research support from: Pfizer, Janssen, Chugai, Celgene, Lilly and Roche, Consultant of: Pfizer, AbbVie, Sanofi, Lilly, Novartis, Genzyme, Boehringer, Janssen, MSD, Celgene, Roche and Chugai, Ulrich Drott: None declared, Michaela Köhm Grant/research support from: Pfizer, Janssen, BMS, LEO, Consultant of: BMS, Pfizer, Speakers bureau: Pfizer, BMS, Janssen, Novartis

Fatty Acid and Carnitine Metabolism Are Dysregulated in Systemic Sclerosis Patients

Systemic sclerosis (SSc) is a rare chronic disease of unknown pathogenesis characterized by fibrosis of the skin and internal organs, vascular alteration, and dysregulation of the immune system. In order to better understand the immune system and its perturbations leading to diseases, the study of the mechanisms regulating cellular metabolism has gained a widespread interest. Here, we have assessed the metabolic status of plasma and dendritic cells (DCs) in patients with SSc. We identified a dysregulated metabolomic signature in carnitine in circulation (plasma) and intracellularly in DCs of SSc patients. In addition, we confirmed carnitine alteration in the circulation of SSc patients in three independent plasma measurements from two different cohorts and identified dysregulation of fatty acids. We hypothesized that fatty acid and carnitine alterations contribute to potentiation of inflammation in SSc. Incubation of healthy and SSc dendritic cells with etoposide, a carnitine transporter inhibitor, inhibited the production of pro-inflammatory cytokines such as IL-6 through inhibition of fatty acid oxidation. These findings shed light on the altered metabolic status of the immune system in SSc patients and opens up for potential novel avenues to reduce inflammation.

Cost-utility analysis of surveillance strategies for soft tissue sarcoma recurrence

11565

Background: Soft tissue sarcomas (STS) are uncommon malignancies with significant biological and clinical variation. After primary curative therapy, patients enter a program of surveillance for recurrence with periodic chest x-rays (CXR) or computed tomography (CT). We compared costs and health outcomes of CXR and CT at a range of frequencies and durations of follow-up. Methods: We used a Markov model to simulate a cohort of 10,000 STS patients through their surveillance experience for lung metastasis after completion of definitive treatment for stage II or III primary disease. Health states in the model were no evidence of disease, recurrence, and death. We assessed the method of chest imaging, duration of follow-up, and interval (every 3 months or 6 months) of surveillance in the first 3 years. Cost effectiveness was assessed for each screening modality and screening frequency. Recurrence probabilities, utilities, treatment costs, and other parameters were from previously published data. Outcomes were costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICER). Results: The initial evaluation comparing screening every 3 months for 3 years, every 6 months for years 4 and 5, and annually from years 6 to 10 resulted in 632,264 QALYs and $1,038,351,481 costs for CT, compared to 631,834 QALYs and $746,019,937 for CXR, resulting in an ICER of $679,322/QALY. In comparing screening intervals, less frequent screening intervals of every 6 months compared to every 3 months for the first three years using CT resulted in an ICER of $690,527/QALY and for CXR, the ICER was $271,423/QALY. In comparing screening duration between 6 years and 10 years of follow-up, strategies with longer follow-up resulted in slightly higher QALYs in each of the comparison scenarios, at a much higher cost. Conclusions: In our evaluation, more frequent screening the first 3 years and longer duration of surveillance resulted in higher QALYs in both screening modalities. However, in the comparisons the ICERs exceed common willingness to pay thresholds of $150,000/QALY gained; CXR is the more cost-effective imaging modality. Limitation of this model includes the simplification of disease progression and heterogeneity in STS.

Japanese encephalitis vaccination in the Philippines: A cost-effectiveness analysis comparing alternative delivery strategies

INTRODUCTION

Japanese encephalitis (JE) is a mosquito-borne viral infection of the brain that can cause permanent brain damage and death. In the Philippines, efforts are underway to deliver a live attenuated JE vaccine (CD-JEV) to children under five years of age (YOA), who are disproportionately infected. Multiple vaccination strategies are being considered.

METHODS

We conducted a cost-effectiveness analysis comparing three vaccination strategies to the current state of no vaccination from the societal and government perspectives: (1) national routine vaccination only, (2) sub-national campaign followed by national routine, and (3) national campaign followed by national routine. We developed a Markov model to estimate impact of vaccination or no vaccination over the child's lifetime horizon, assuming an annual incidence of 10.6 cases per 100,000. Costs of illness ($859/case), vaccine ($0.50/dose), routine vaccination ($0.95/dose), and campaign vaccination ($0.98/dose) were based on hospital financial records, expert opinion and literature. The societal perspective included transportation and opportunity costs of caregiver time, in addition to costs incurred by the health system.

RESULTS

JE vaccination via national campaign followed by national routine delivery was the most cost-effective strategy modeled with a cost per disability adjusted life year (DALY) averted of $233 and $29 from the government and societal perspectives, respectively. Results were similar for other delivery strategies with cost/DALY ranging from $233 to $265 from the government perspective and $29-$57 from the societal perspective. JE vaccination was projected to prevent 27,856-37,277 cases, 5571-7455 deaths, and 173,233-230,704 DALYs among children under five over 20 consecutive birth cohorts. Total incremental costs of vaccination versus no vaccination over 20 birth cohorts were $6.6-$9.8 million from the societal perspective ($230 K-$440 K annually) and $45.9-$53.9 million ($2.2 M-$2.7 M annually) from the governmental perspective.

CONCLUSION

Vaccination with CD-JEV in the Philippines is projected to be cost-effective, reducing long-term costs associated with JE illness and improving health outcomes compared to no vaccination.

High Pressure Liquid Chromatographic Determination of Glycyrrhizic Acid or Glycyrrhizic Acid Salts in Various Licorice Products: Collaborative Study

A collaborative study determining glycyrrhizic acid or glycyrrhizic acid salts content of various licorice products has been conducted using high pressure liquid chromatography (HPLC). Five samples containing various concentrations of glycyrrhizic acid were analyzed in blind replicates by 8 collaborators. The results indicate excellent repeatability and reproducibility with coefficients of variation less than 7.5%. In addition, this method allows the determination of glycyrrhizic acid in less than 15 min compared with 3 days for the conventional gravimetric and colorimetric methods. The method has been adopted official first action.

Novel insights into dendritic cells in the pathogenesis of systemic sclerosis

Systemic sclerosis (SSc) is a severe autoimmune fibrotic disease characterized by fibrosis, vasculopathy, and immune dysregulation. Dendritic cells (DCs) are the most potent antigen-presenting cells, specialized in pathogen sensing, with high capacity to shape the immune responses. The most recent technological advances have allowed the discovery of new DC subsets with potential implications in inflammatory conditions. Alterations of DC distribution in circulation and affected tissue as well as impaired DC function have been described in SSc patients, pointing towards a crucial role of these cells in SSc pathogenesis. In particular, recent studies have shown the importance of plasmacytoid DCs either by their high capacity to produce type I interferon or other inflammatory mediators implicated in SSc pathology, such as chemokine C-X-C motif ligand 4 (CXCL4). In-vivo models of SSc have been vital to clarify the implications of DCs in this disease, especially DCs depletion and specific gene knock-down studies. This review provides these new insights into the contribution of the different DCs subsets in the pathogenesis of SSc, as well as to the novel developments on DCs in in-vivo models of SSc and the potential use of DCs and their mediators as therapeutic targets.

Influence of CAD/CAM Fabrication and Sintering Procedures on the Fracture Load of Full-Contour Monolithic Zirconia Crowns as a Function of Material Thickness

OBJECTIVE

The purpose of this in vitro study was to analyze the effect of computer-aided design/computer-aided manufacturing (CAD/CAM) fabrication and sintering procedures on the fracture load of monolithic zirconia crowns with different material thicknesses adhesively seated to methacrylate dies fabricated with stereolithography technology.

METHOD

Monolithic zirconia crowns were fabricated from inCoris TZI C material with a chairside CAD/CAM system (CEREC MCXL) comprising three material thicknesses (0.5/1.0/1.5 mm, n=8 each). Two CAD/CAM fabrication procedures (milling, MI; grinding, GR), two chairside sintering procedures (superspeed, SS; speedfire sintering, SF), and one labside sintering procedure (classic, CL) were evaluated. In total, 144 crowns were fabricated. Restorations were adhesively seated to methacrylate dies fabricated with SLA technology. Thermomechanical cycling (TCML) was performed before fracture testing. Loading forces until fracture were registered and statistically analyzed with one-way analysis of variance (ANOVA), post hoc Scheffé test, and three-way ANOVA (α=0.05).

RESULTS

Test groups showed statistically significant differences (p<0.05). The highest mean value was found for 1.5-mm crowns of group GR_SF with 3678.6 ± 363.9 N. The lowest mean value was found for group 0.5-mm crowns of group MI_SF with 382.4 ± 30.7 N. There was a significant three-way interaction effect between thickness, sintering, and processing [F(4,126)=9.542; p<0.001; three-way ANOVA, significance level α=0.05].

CONCLUSIONS

CAD/CAM fabrication and sintering procedures influence the maximum loading force of monolithic zirconia crowns with different material thicknesses. A material thickness of 0.5 mm should be considered as a critical thickness for monolithic zirconia crown restorations.

T^{3} Stern-Gerlach Matter-Wave Interferometer

We present a unique matter-wave interferometer whose phase scales with the cube of the time the atom spends in the interferometer. Our scheme is based on a full-loop Stern-Gerlach interferometer incorporating four magnetic field gradient pulses to create a state-dependent force. In contrast to typical atom interferometers that make use of laser light for the splitting and recombination of the wave packets, this realization uses no light and can therefore serve as a high-precision surface probe at very close distances.

Short-Term Oral Sorafenib for Therapy of Intratumoral Shunts of Hepatocellular Carcinoma to Enable Intraarterial Treatment

INTRODUCTION

Significant intratumoral shunts between tumor-supplying arteries and portal or liver veins are a contraindication for transarterial therapy of HCC because interventional treatment of these shunts is frequently insufficient. Sorafenib has anti-angiogenic effects and is indicated for palliative treatment of patients with HCC. Here, we report our experience with the use of sorafenib for the closure of intratumoral shunts in patients scheduled for transarterial therapy of HCC.

MATERIALS AND METHODS

Three patients with HCC, aged 65, 82 and 79 years, exhibited a significant intratumoral shunting from tumor artery to portal (n = 1) or liver veins (n = 2). In all cases, intratumoral shunting had already been suspected based on pre-interventional CT angiography, and DSA confirmed the shunt. Oral sorafenib (800 mg/day) was administered for at least four weeks, only and specifically to occlude the shunt. Hereafter, patients were re-evaluated by CT and DSA.

RESULTS

All patients tolerated the full prescribed dose for at least 4 weeks. In one case, therapy was prolonged with an adapted dose (400 mg/day) due to sorafenib-related hand-foot syndrome. After sorafenib treatment, CT and DSA confirmed a complete closure of intratumoral shunts for all patients. No tumor progression was observed. All three patients hereafter underwent successful transarterial treatment by TACE (n = 2) or TARE (n = 1) without complications. Progression-free survival according to mRECIST was 501, 397 and 599 days, respectively.

CONCLUSION

Even short-term oral sorafenib seems to effectively close intratumoral shunts in patients with HCC and thus might enable transarterial treatment of these patients.

Household Costs of Diarrhea by Etiology in 7 Countries, The Global Enterics Mulitcenter Study (GEMS)

Background

Although there are many overlapping features, pediatric diarrheal diseases can vary in severity, duration, clinical manifestations, and sequelae according to the causal pathogen, which in turn can impact the economic burden on patients and their families. We aimed to evaluate the household costs of diarrheal disease by pathogen in 7 countries.

Methods

We analyzed data from the Global Enteric Multicenter Study (GEMS), a prospective, age-stratified, matched case–control study of moderate to severe diarrheal disease among children aged 0–59 months in 7 low-income countries; 4 in Africa (Kenya, Mali, Mozambique, The Gambia) and 3 in Asia (Bangladesh, India, Pakistan). Demographic, epidemiological, economic, and clinical data were collected, and a stool sample was obtained for microbiological analysis at enrollment. We used a multivariate generalized linear model to assess the effect of rotavirus, Cryptosporidium, heat-stable toxin (ST)–producing enterotoxigenic Escherichia coli (ETEC [ST only or LT plus ST]), Shigella, Campylobacter jejuni, norovirus GII, Vibrio cholerae O1, age, gender, in/outpatient, and country on total costs to the patient/family.

Results

Household out-of-pocket costs were higher in Mali than any other country. Within countries, household cost differences between pathogens were minimal and not statistically significantly different.

Conclusions

We found no significant differences in household costs by pathogen. Despite data limitations, understanding pathogen-specific household costs (or lack thereof) is useful, as decision-makers could consider broader illness cost information and its relevance to a particular pathogen’s economic burden and contribution to poverty when deciding which pathogens to target for interventions.

Abstract P1-08-32: Treatment delivery waiting times for stage I-III breast cancer patients in Switzerland : A pooled analysis of 7 cancer registries over the 2003-2008 period

Background: To examine time intervals between needle/core biopsy, breast cancer diagnosis, surgery and radiotherapy (RT) as quality metrics in the management of stage I-III breast cancer in a representative Swiss population sample.

Methods: Based on seven regional cancer registries covering 45% of the Swiss population, we identified 2628 women which underwent surgery for stage I-III breast cancer without receiving (neo)-adjuvant chemotherapy between January 1, 2003 and December 31, 2005.

Four different time intervals were defined: a) time between needle/core biopsy and diagnosis of breast cancer, b) time between diagnosis of breast cancer and surgery, c) time between needle/core biopsy and surgery, d) time between surgery and adjuvant RT.

These four time intervals were analyzed according to age, nationality, health insurance status, public vs. private hospitals and geography. We also investigated whether case discussion at tumor board delayed patient management.

A one-way analysis of variance (ANOVA) and multiple comparison tests were used to assess differences between groups. All tests were performed using STATA v.15.

Results: 2628 women were identified, median age was 67 years (IQR: 58-77). Breast-conserving surgery was performed in 1899 cases (72.3%), mastectomy in 539 cases (20.5%), unspecified surgery /missing data in 190 cases (7.2%). Adjuvant RT was delivered in 1546/2628 patients (58.8 %).

Time interval between biopsy and surgery was age-dependent, ranging from 22 days (95% CI: 19.6 - 25.2) for women &lt; 60 years to 39 days (95% CI: 27.0-50.3) for women 80+ years old (p&lt;0.001). After biopsy, women waited on average 19 days until surgery in private clinics (95% CI: 16.4-21.6) and 30 days in public hospitals (95% CI: 26.6-33.3) (p&lt;0.001). Women with private insurance were operated 24 days after biopsy (95% CI: 17.0-31.1), compared with 30 days (95% CI: 27.1-33.2) (p&lt;0.01)for women with basic state insurance. After biopsy, time interval for foreign nationals was significantly longer than for Swiss citizen (30 vs 24 days, p&lt;0.01). Tumor board presentation postponed surgery by 10 days (31 vs 22 days, p&lt;0.01).

Time between surgery and RT did not correlate with age (p=0.83); the interval was 33% longer in tertiary teaching hospitals than in private clinics (61 vs. 46 days, p&lt;0.001), and 8 days longer for patients with private insurance than for those without (61 vs 53 days, p&lt;0.01). There was a trend for foreign nationals to receive adjuvant RT later than Swiss citizen (58 vs 55 days, p=0.09). RT started later in larger metropolitan areas compared to more rural regions (59 vs 53 days, p&lt;0.01). Presenting patients at a tumor board after surgery had no impact on RT start (p=0.12).

Conclusions: Major differences in treatment waiting times were observed between patients with stage I-III breast cancer. Elderly and foreign patients were at risk for delayed surgery after biopsy. Data from patients with longer timelines need to be analyzed to identify further reasons for delays.

Citation Format: Zwahlen DR, Herrmann C, Mousavi M, Bordoni A, Bouchardy C, Konzelmann I, Staehlin K, Rohrmann S, Oehler C, Zimmermann M. Treatment delivery waiting times for stage I-III breast cancer patients in Switzerland : A pooled analysis of 7 cancer registries over the 2003-2008 period [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-08-32.

Cost Utility of Voretigene Neparvovec for Biallelic RPE65-Mediated Inherited Retinal Disease

OBJECTIVE

The gene therapy voretigene neparvovec (VN) is the first Food and Drug Administration-approved treatment for vision loss owing to the ultra-rare RPE65-mediated inherited retinal disorders. We modeled the cost-utility of VN compared with standard of care (SoC).

STUDY DESIGN

A 2-state Markov model, alive and dead, with a lifetime horizon.

METHODS

Visual acuity (VA) and visual field (VF) were tracked to model quality-adjusted life-years (QALYs). VN led to an improvement in VA and VF that we assumed was maintained for 10 years followed by a 10-year waning period. The cost of VN was $850 000, and other direct medical costs for depression and trauma were included for a US healthcare system perspective. A modified societal perspective also included direct nonmedical costs and indirect costs.

RESULTS

VN provided an additional 1.3 QALYs over the remaining lifetime of an individual. The average total lifetime direct medical cost for individuals treated with VN was $1 039 000 compared with $213 400 for SoC, leading to an incremental cost-effectiveness ratio (ICER) of $643 800/QALY from the US healthcare system perspective. Direct nonmedical costs totalled $1 070 900 for VN and $1 203 300 for SoC, and indirect costs totalled $405 400 for VN and $482 900 for SoC, leading to an ICER of $480 100/QALY from the modified societal perspective.

CONCLUSIONS

At the current price, VN was unlikely to reach traditional cost-effectiveness standards compared with SoC. VN has important implications for both development and pricing of future gene therapies; therefore clinical and economic analyses must be carefully considered.

Disease-Modifying Therapies for Relapsing-Remitting and Primary Progressive Multiple Sclerosis: A Cost-Utility Analysis

BACKGROUND

Several disease-modifying therapies (DMTs) treat relapsing-remitting multiple sclerosis (RRMS) and primary progressive multiple sclerosis (PPMS). Few comprehensive cost-effectiveness analyses exist in this area, particularly from a payer perspective, despite rapidly increasing prices of DMTs.

OBJECTIVE

We aimed to systematically compare cost effectiveness of all relevant DMTs for first-line treatment of RRMS, second-line treatment of RRMS, and first-line treatment of PPMS.

METHODS

We used a Markov model with health states based on Expanded Disability Status Score categories. Upon discontinuing first-line treatment, RRMS patients continued to second-line therapy then to supportive care, and PPMS patients moved directly to supportive care. Data was sourced from clinical trials and commercially and publicly available sources. The target population was treatment-naïve adults with RRMS or PPMS. We used a lifetime horizon from a US payer perspective, and compared DMTs for RRMS (first-line: dimethyl fumarate, glatiramer acetate, interferon β-1a, interferon β-1b, peginterferon β-1a, teriflunomide, natalizumab, fingolimod, and ocrelizumab; second-line: alemtuzumab, natalizumab, fingolimod, and ocrelizumab), ocrelizumab for PPMS, and supportive care. Outcome measures included total costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs).

RESULTS

For RRMS first-line therapy, ocrelizumab dominated the other DMTs with an ICER of US$166,338/QALY compared with supportive care. For RRMS second-line therapy, alemtuzumab dominated the other three DMTs, providing more QALYs for lower costs. For PPMS, ocrelizumab had an ICER of US$648,799/QALY compared with supportive care. Wide variability in results was observed in the probabilistic sensitivity analysis. Results were sensitive to the relative risk of progression and cost of DMTs.

CONCLUSIONS

Ocrelizumab would likely be cost effective as a first-line treatment for RRMS with a discounted price but was not cost effective for PPMS. Alemtuzumab dominated other options for second-line treatment of RRMS. Other DMTs were generally similar in terms of costs and health outcomes, providing health benefits compared to supportive care but with significant added costs. If drug prices were lowered, more DMTs could be cost effective.

Accuracy of Buccal Scan Procedures for the Registration of Habitual Intercuspation

Clinical Relevance:

Accurate reproduction of the jaw relationship is important in many fields of dentistry. Maximum intercuspation can be registered with digital buccal scan procedures implemented in the workflow of many intraoral scanning systems.

Objective:

The aim of this study was to investigate the accuracy of buccal scan procedures with intraoral scanning devices for the registration of habitual intercuspation in vivo. The hypothesis was that there is no statistically significant difference for buccal scan procedures compared to registration methods with poured model casts.

Methods and Materials:

Ten individuals (full dentition, no dental rehabilitations) were subjects for five different habitual intercuspation registration methods: (CI) poured model casts, manual hand registration, buccal scan with inEOS X5; (BC) intraoral scan, buccal scan with CEREC Bluecam; (OC4.2) intraoral scan, buccal scan with CEREC Omnicam software version 4.2; (OC4.5β) intraoral scan, buccal scan with CEREC Omnicam version 4.5β; and (TR) intraoral scan, buccal scan with Trios 3. Buccal scan was repeated three times. Analysis of rotation (Rot) and translation (Trans) parameters was performed with difference analysis software (OraCheck). Statistical analysis was performed with one-way analysis of variance and the post hoc Scheffé test (p&lt;0.05).

Results:

Statistical analysis showed no significant (p&gt;0.05) differences in terms of translation between groups CI_Trans (98.74±112.01 μm), BC_Trans (84.12±64.95 μm), OC4.2_Trans (60.70±35.08 μm), OC4.5β_Trans (68.36±36.67 μm), and TR_Trans (66.60±64.39 μm). For rotation, there were no significant differences (p&gt;0.05) for groups CI_Rot (0.23±0.25°), BC_Rot (0.73±0.52°), OC4.2_Rot (0.45±0.31°), OC4.5β_Rot (0.50±0.36°), and TR_Rot (0.47±0.65°).

Conclusions:

Intraoral scanning devices allow the reproduction of the static relationship of the maxillary and mandibular teeth with the same accuracy as registration methods with poured model casts.

Patient's perception: shorter and more severe prodromal phase in GBA-associated PD

BACKGROUND

Prevalence and time of occurrence of prodromal symptoms of Parkinson's disease (PD) in relation to the onset of classical motor manifestation varies between patients. Possible modifying factors might be different genetic architectures predisposing to varying burden of manifestations.

OBJECTIVES

To characterize the prodromal phase in PD patients with heterozygous mutations in the GBA gene compared to PD patients without GBA mutation.

METHODS

In a retrospective design, 151 participants [47 PD patients carrying a GBA mutation (PD_GBA ), 52 idiopathic PD patients (PD_idiopathic ), 52 healthy elderly (CON)] underwent a validated structured interview designed to assess prevalence and time of occurrence of prodromal symptoms.

RESULTS

PD_GBA showed a higher prevalence of prodromal symptoms and almost simultaneous occurrence of non-motor and early motor symptoms shortly before PD diagnosis whereas PD_idiopathic reported a longer prodromal phase starting with non-motor symptoms.

CONCLUSION

The short and severe prodromal phase in PD_GBA might call for shorter assessment intervals in yet premanifest GBA mutation carriers.

Influence of Different CAM Strategies on the Fit of Partial Crown Restorations: A Digital Three-dimensional Evaluation

Objective:

CAM fabrication is an important step within the CAD/CAM process. The internal fit of restorations is influenced by the accuracy of the subtractive CAM procedure. Little is known about how CAM strategies might influence the fit of CAD/CAM fabricated restorations. The aim of this study was to three-dimensionally evaluate the fit of CAD/CAM fabricated zirconia-reinforced lithium silicate ceramic partial crowns fabricated with three different CAM strategies. The null hypothesis was that different CAM strategies did not influence the fitting accuracy of CAD/CAM fabricated zirconia-reinforced lithium silicate ceramic partial crowns.

Methods and Materials:

Preparation for a partial crown was performed on a maxillary right first molar on a typodont. A chairside CAD/CAM system with the intraoral scanning device CEREC Omnicam (Dentsply Sirona, York, PA, USA) and the 3+1 axis milling unit CEREC MCXL was used. There were three groups with different CAM strategies: step bur 12 (12), step bur 12S (12S), and two step-mode (12TWO). The zirconia-reinforced lithium silicate ceramic Celtra Duo (Dentsply Sirona) was used as the CAD/CAM material. A new 3D method for evaluating the fit was applied, consisting of the quadrant scan with the intraoral scanning device CEREC Omnicam. The scan of the PVS material adherent to the preparation and the preparation scan were matched, and the difference analysis was performed with special software OraCheck (Cyfex AG, Zurich, Switzerland). Three areas were selected for analysis: margin (MA), axial (AX), and occlusal (OC). Statistical analysis was performed using 80% percentile, one-way ANOVA, and the post hoc Scheffé test with α=0.05.

Results:

Statistically significant differences were found both within and between the test groups. The aspect axial fit results varied from 90.5 ± 20.1 μm for the two-step milling mode (12TWO_AX) to 122.8 ± 12.2 μm for the milling with step bur 12S (12S_AX). The worst result in all groups was found for the aspect occlusal fit with the highest value for group 12S of 222.8 ± 35.6 μm. Group two-step milling mode (12TWO) performed statistically significantly better from groups 12 and 12S for the occlusal fit (p&lt;0.05). Deviation patterns were visually analyzed with a color-coded scheme for each restoration.

Conclusions:

CAM strategy influenced the internal adaptation of zirconia-reinforced lithium silicate partial crowns fabricated with a chairside CAD/CAM system. Sensible selection of specific areas of internal adaptation and fit is an important factor for evaluating the CAM accuracy of CAD/CAM systems.

Economic Evaluation of Dupilumab for Moderate-to-Severe Atopic Dermatitis: A Cost-Utility Analysis

BACKGROUND

Moderate-to-severe atopic dermatitis can be difficult and costly to treat. The long-term health and economic outcomes of a new therapy, dupilumab, have yet to be evaluated. We aimed to identify the cost-effectiveness of dupilumab compared to usual care in moderate-to-severe atopic dermatitis.

METHODS

We compared dupilumab to usual care with emollients for adults with moderate-to-severe atopic dermatitis inadequately controlled with topical therapy, or for whom topical therapies were medically inadvisable. Subpopulations of moderate and severe patients were examined separately. We used a lifetime Markov model from a US payer perspective with health states categorized by the percent decrease in Eczema Area and Severity Index (EASI) score after a patient began an intervention: at least a 50% decrease (EASI 50), 75% decrease (EASI 75), 90% decrease (EASI 90), or no response.

RESULTS

The expected lifetime cost for patients treated with dupilumab was $509,600, including $267,800 in dupilumab drug costs and $241,800 in other healthcare costs. Average lifetime cost for usual care was $271,500. Dupilumab provided an additional 1.91 quality-adjusted life years (QALYs) over the remaining lifetime of a patient, leading to an incremental cost-effectiveness ratio (ICER) of $124,500. The ICER was lower for patients with severe atopic dermatitis ($95,800) than those with moderate atopic dermatitis ($160,000). Key drivers of the model were utility values for quality-of-life for non-responders, and the price of dupilumab.

CONCLUSIONS

This study was limited by data for health outcomes and costs over long time periods, particularly stratified by severity. We estimated that dupilumab improved health outcomes compared to usual care but with additional costs, with an ICER below commonly cited thresholds for cost-effectiveness. Dupilumab was projected to be more cost-effective in patients with severe atopic dermatitis, but even in patients with moderate atopic dermatitis, the ICER remained below the upper range of commonly cited thresholds. J Drugs Dermatol. 2018;17(7):750-756.

Heart rate variability testing: could it change spending for rheumatoid arthritis patients in the United States? An exploratory economic analysis

BACKGROUND

Autonomic nervous system (ANS) testing with heart rate variability (HRV) has been shown in early research to predict 52-week outcomes in rheumatoid arthritis (RA). HRV testing could be combined with putative ANS biologic pathways to improve treatment response for RA patients. This study explored potential costs and health outcomes of introducing HRV testing into RA treatment, without and with ANS optimization.

METHODS

A decision tree exploratory economic model compared HRV testing to standard care in moderate-to-severe biologic-eligible patients over a 10-year time horizon. HRV data was derived from an observational study of RA patients (n = 33). Patients were stratified into treatment groups based on HRV test scores indicating "low probability of response" and "moderate to high probability of response". This study explored adding ANS optimization based on HRV score followed by clinically-appropriate treatment. Costs and quality-adjusted life-years (QALYs) for the US population were estimated.

RESULTS

HRV testing in biologic-eligible patients decreased non-effective biologic use, reducing US healthcare costs by $34.6 billion over 10 years with QALYs unchanged. When combined with ANS optimization in biologic-eligible patients, HRV testing could increase costs by $3.6 billion over 10 years but save over 350,000 QALYs. Among all RA patients, HRV testing with ANS optimization could save over $8 billion and over 100,000 QALYs over 10 years, depending on the positive predictive value (PPV) of the HRV test.

CONCLUSIONS

The potential economic impact of introducing HRV testing and ANS optimization into RA treatment appears substantial and cost-effective based on the exploratory analysis. Additional rigorous studies are warranted in larger patient samples to better inform decision-making.

Membrana de látex natural de Hevea brasiliensis auxilia no processo de reparação tecidual em bovinos

RESUMO Feridas cutâneas em bovinos são um constante desafio clínico cirúrgico por desencadearem perdas econômicas bastante significativas. O látex proveniente da seiva da seringueira (Hevea brasiliensis) apresenta potencial terapêutico para incrementar o processo de reparação tecidual. Portanto, pretendeu-se com esse estudo avaliar o tipo de reação tecidual e os possíveis mecanismos de angiogênese desencadeados pelo implante de uma membrana de látex natural em bovinos. Para tal, foram utilizados seis bovinos da raça Nelore, submetidos ao implante subcutâneo experimental de três fragmentos de membranas de látex natural. Foram coletadas amostras de tecido e da membrana aos 15, 30 e 45 dias após a implantação, para avaliações histológicas, ultraestruturais por microscopia eletrônica de varredura e imunoistoquímicas com anticorpos antimarcador de macrófagos (MAC), CYR 61 e VEGF. O implante de látex proporcionou aumento da angiogênese e reparação tecidual em bovinos, não mediada pela expressão do VEGF e CYR 61.

Assessment tool for establishing local pharmaceutical manufacturing in low- and middle-income countries

OBJECTIVE

In many low- and middle-income countries (LMICs), limited availability, substandard quality and high prices of pharmaceutical products lead to lack of access to essential medicines and poor health outcomes. Manufacturing pharmaceuticals in LMICs may improve access for patients while increasing the market size for manufacturers.

METHODS

We present a tool for assessment of local manufacturing feasibility of pharmaceuticals, intended for use among key stakeholders during the business development process. The tool consists of five domains: product selection and capacity, market sizing, market entry, funding and quality assurance.

KEY FINDINGS

The tool is intended to identify barriers and facilitators for local manufacturing and provide a roadmap for decision-making across multiple stakeholders. A case study in Namibia identified key barriers and facilitators to successful manufacturing in that county.

CONCLUSIONS

Careful consideration of feasibility and potential for success may lead to improved health for the populations of LMIC as well as significant market potential for pharmaceutical manufacturers.

Generation of 3-dimensional multi-patches on silica particles via printing with wrinkled stamps

A simple route towards patchy particles with anisotropic patches with respect to a different functionality and directionality is presented. This method is based on microcontact printing of positively charged polyethylenimine (PEI) on silica particles using wrinkled stamps. Due to the wrinkled surface, the number of patches on the particles as well as the distance between two patches can be controlled.

Substrate and electron donor limitation induce phenotypic heterogeneity in different metabolic activities in a green sulphur bacterium

Populations of genetically identical cells can display marked variation in phenotypic traits; such variation is termed phenotypic heterogeneity. Here, we investigate the effect of substrate and electron donor limitation on phenotypic heterogeneity in N₂ and CO₂ fixation in the green sulphur bacterium Chlorobium phaeobacteroides. We grew populations in chemostats and batch cultures and used stable isotope labelling combined with nanometer-scale secondary ion mass spectrometry (NanoSIMS) to quantify phenotypic heterogeneity. Experiments in H₂ S (i.e. electron donor) limited chemostats show that varying levels of NH4+ limitation induce heterogeneity in N₂ fixation. Comparison of phenotypic heterogeneity between chemostats and batch (unlimited for H₂ S) populations indicates that electron donor limitation drives heterogeneity in N₂ and CO₂ fixation. Our results demonstrate that phenotypic heterogeneity in a certain metabolic activity can be driven by different modes of limitation and that heterogeneity can emerge in different metabolic processes upon the same mode of limitation. In conclusion, our data suggest that limitation is a general driver of phenotypic heterogeneity in microbial populations.

MN1 overexpression is driven by loss of DNMT3B methylation activity in inv(16) pediatric AML

In acute myeloid leukemia (AML), specific genomic aberrations induce aberrant methylation, thus directly influencing the transcriptional programing of leukemic cells. Therefore, therapies targeting epigenetic processes are advocated as a promising therapeutic tool for AML treatment. However, to develop new therapies, a comprehensive understanding of the mechanism(s) driving the epigenetic changes as a result of acquired genetic abnormalities is necessary. This understanding is still lacking. In this study, we performed genome-wide CpG-island methylation profiling on pediatric AML samples. Six differentially methylated genomic regions within two genes, discriminating inv(16)(p13;q22) from non-inv(16) pediatric AML samples, were identified. All six regions had a hypomethylated phenotype in inv(16) AML samples, and this was most prominent at the regions encompassing the meningioma (disrupted in balanced translocation) 1 (MN1) oncogene. MN1 expression primarily correlated with the methylation level of the 3' end of the MN1 exon-1 locus. Decitabine treatment of different cell lines showed that induced loss of methylation at the MN1 locus can result in an increase of MN1 expression, indicating that MN1 expression is coregulated by DNA methylation. To investigate this methylation-associated mechanism, we determined the expression of DNA methyltransferases in inv(16) AML. We found that DNMT3B expression was significantly lower in inv(16) samples. Furthermore, DNMT3B expression correlated negatively with MN1 expression in pediatric AML samples. Importantly, depletion of DNMT3B impaired remethylation efficiency of the MN1 exon-1 locus in AML cells after decitabine exposure. These findings identify DNMT3B as an important coregulator of MN1 methylation. Taken together, this study shows that the methylation level of the MN1 exon-1 locus regulates MN1 expression levels in inv(16) pediatric AML. This methylation level is dependent on DNMT3B, thus suggesting a role for DNMT3B in leukemogenesis in inv(16) AML, through MN1 methylation regulation.