Caregiver-reported impact of access to switch-adapted toys on play for children with complex medical conditions

BACKGROUND

Play is essential for children's development of motor, social-emotional and cognitive skills. Traditional play activities are often difficult for children with complex medical conditions to access, which threatens their ability to maximize their developmental potential. Switch-adapted toys are a common strategy for expanding the play repertoire of children with disabilities by lowering the barrier to play with electronic toys. The aim of this study is to investigate the relationship between providing switch-adapted toys to children with disabilities and the children's total and self-initiated play time and access to a variety of cognition-appropriate toys, age-appropriate toys and independently accessible toys as reported by their caregivers.

METHODS

Caregivers and their children with complex medical conditions were provided switch-adapted toys at a giveaway event. At the giveaway event and 6 months later, caregivers completed a survey that included questions about each child's current participation in play and their type of play, child's access to toys and questions specific to switches and switch-adapted toys. Data were analysed using Wilcoxon signed-rank tests with a Benjamini-Hochberg procedure to control for multiple comparisons.

RESULTS

Nineteen caregivers completed both the pre- and post-surveys. The increases in the variety of toys and the number of independently accessibly and cognitively appropriate toys were statistically significant. The change in number of age-appropriate toys and the amount of total and active play time were not statistically significant.

CONCLUSIONS

Providing switch-adapted toys may be an effective way to increase the number of independently accessible and cognitively appropriate toys for children with complex medical conditions. However, increasing the number of such toys may not be sufficient to increase active and total play time. Further research is needed to identify variables impacting play time and distal outcomes associated with switch-adapted toy access.

Single Dose vs. Fractionated High-Dose Rate Brachytherapy in Localized Prostate Cancer: Long Term Results

PURPOSE/OBJECTIVE(S)

To evaluate long-term freedom from biochemical relapse (FFbR) and overall survival (OS) after single-dose high-dose-rate brachytherapy (HDR-BT) compared with 2 or 3 fraction schedules.

MATERIALS/METHODS

HDR-BT, delivering 1 × 19 Gy or 1 × 20 Gy (A = 49), 2 × 13 Gy (B = 138) or 3 × 10.5 Gy (C = 106), was given to patients with intermediate or high-risk prostate cancer as their sole treatment. Patients were staged with pelvic MRI and isotope bone scan. Transperineal transrectal ultrasound guided implantation was followed by MRI based CTV definition based on GEC ESTRO guidelines. Biochemical relapse was assessed using the Phœnix definition (PSA nadir plus 2 µg/L). Patients were evaluated prospectively from 6 months after implant and bi-annually thereafter. Estimates of freedom from biochemical relapse, and overall survival (OS) were calculated using the Kaplan-Meier (K-M) method and the log-rank test to test for significance. Univariate and multivariate hazard ratios (HR) were obtained using Cox's proportional hazard model. For multivariate modelling a stepwise reduction method was used.

RESULTS

Median follow-up was 123, 116 and 120 months (p = 0.4), (A, B, C, respectively). Neo-adjuvant and adjuvant androgen deprivation treatment was given to 80% of all patients, median duration was 9 months for A and 6 months for B and C. K-M estimates of FFbR, at 8 and 10 years, were 67% and 64% (Group A), 78% and 72% (Group B), and 80% and 76% (Group C). Differences in FFbR between dose groups was not significant (p = 0.2). Similarly, no significant difference was seen in OS. Eight and 10-year estimates were 81% and 75% (A), 85% and 74% (B), and 90% and 83% (C); p = 0.5. Hazard Ratios for risk of biochemical recurrence were significant for ADT administration (yes/no) and overall risk category, in multivariate analyses. Only the latter was significant in univariate analysis for risk of death, Gleason risk (low, intermediate, high), MRI tumor stage risk and overall risk category were significant in univariate analyses. Only tumor stage and Gleason risk were significant in multivariate analyses.

CONCLUSION

Concerns around the efficacy of 19-20 Gy single dose HDR BT as monotherapy, based on early data, may have been unfounded. Long-term outcome data up to 10 years show no significant difference in PSA control and overall survival compared to 2 and 3 fractions of HDR-BT.

Gamma Secretase Inhibition Sensitizes Pancreatic Adenocarcinoma Tumors to RT In Vivo

PURPOSE/OBJECTIVE(S)

Pancreatic adenocarcinoma (PDAC) is an extremely aggressive cancer that lacks curative treatment options. Almost half of patients present with unresectable disease limiting treatment to non-curative options. Patients treated with neoadjuvant radiation therapy (RT) exhibit increases in fibrosis and epithelial-to-mesenchymal transition (EMT). ADAM10, an extracellular sheddase, can stimulate stromal fibrosis, EMT, and radioresistance. ADAM10 also mediates EMT through Notch signaling by cleaving its extracellular domain. Further cleavage by gamma secretase produces the Notch intracellular domain (NICD), which translocates to the nucleus and activates downstream transcriptional targets. Here, we explore whether inhibition of Notch cleavage by gamma secretase radiosensitizes PDAC tumors.

MATERIALS/METHODS

Bilateral flank subcutaneous PDAC isografts were produced in 40 mice using PK5L1940 KPC cells. Intraperitoneal injections of the gamma secretase inhibitor, DAPT (5 mg/kg), were delivered daily for 7 days, starting 3 days prior to RT. A single dose of 20 Gy was administered to each flank tumor, and volumes were measured twice weekly. Colony formation assays of KPC cells were performed after RT, in the presence or absence of DAPT. Since stromal fibrosis can mediate radio-resistance in the tumor microenvironment (TME), the effect of tumor cells on Notch pathway activation in mouse fibroblasts (3T3 cells) was investigated using a luciferase reporter assay. Thus, 3T3 cells transfected with a Notch pathway luciferase reporter were incubated with PDAC cells for 48 h, followed by measurement of luciferase activity.

RESULTS

In vivo, the combination of DAPT and RT significantly delayed tumor growth, and some tumors were completely eradicated. Mean tumor size for the combination at 21 days was 21 mm3 (range = 0-53, p = 0.005), while tumor size was 577 mm3 (range = 217-955, p = 0.69) for DAPT alone, 435 mm3 for RT alone (range = 51-932, p = 0.79), and 367 mm3 for untreated vehicle (range = 97-1144). Surprisingly, DAPT did not reduce clonogenic survival in vitro. Both ADAM10 knockout and DAPT decreased NICD cleavage and transcription of the downstream target Hes1 in vivo and in vitro. Co-culture with PDAC cells increased Notch luciferase reporter activity in fibroblasts. This effect was not mimicked by PDAC-conditioned media, suggesting a requirement for intercellular contact.

CONCLUSION

Notch pathway inhibition sensitizes PDAC tumors to RT in vivo, but not in vitro, suggesting involvement of the TME. Indeed, co-culture with PDAC cells stimulates notch signaling in fibroblasts, suggesting non-cell autonomous mechanisms mediating fibrosis in the TME driving radioresistance. Future studies will determine if ADAM10 inhibition targeting PDAC cells and/or gamma secretase inhibition targeting the TME enhances radiation sensitivity in vivo by blocking fibroblast Notch signaling.

Tonsillitis and Tonsilloliths: Diagnosis and Management

Tonsillitis, or inflammation of the tonsils, makes up approximately 0.4% of outpatient visits in the United States. Tonsillitis is caused by a viral infection in 70% to 95% of cases. However, bacterial infections caused by group A beta-hemolytic streptococcus (Streptococcus pyogenes) account for tonsillitis in 5% to 15% of adults and 15% to 30% of patients five to 15 years of age. It is important to differentiate group A beta-hemolytic streptococcus from other bacterial or viral causes of pharyngitis and tonsillitis because of the risk of progression to more systemic complications such as abscess, acute glomerulonephritis, rheumatic fever, and scarlet fever after infection with group A beta-hemolytic streptococcus. A variety of diagnostic tools are available, including symptom-based validated scoring systems (e.g., Centor score), and oropharyngeal and serum laboratory testing. Treatment is focused on supportive care, and if group A beta-hemolytic streptococcus is identified, penicillin should be used as the first-line antibiotic. In cases of recurrent tonsillitis, watchful waiting is strongly recommended if there have been less than seven episodes in the past year, less than five episodes per year for the past two years, or less than three episodes per year for the past three years. Tonsilloliths, or tonsil stones, are managed expectantly, and small tonsilloliths are common clinical findings. Rarely, surgical intervention is required if they become too large to pass on their own.

Exercise induced coronary inflammation in masters athletes

Background

Chronic endurance exercise has been linked to increased prevalence of coronary artery disease (CAD) in male master athletes. Data are limited regarding the presence of exercise-induced coronary inflammation and its association with atherosclerosis in master endurance athletes. Human coronary inflammation can be detected non-invasively by imaging pericoronary adipose tissue (PCAT). We tested the hypothesis that chronic endurance exercise leads to increased prevalence of atherosclerosis via coronary inflammation.

Methods

Computed tomography coronary angiogram CTCA scans from 2 cohorts of master athletes and age-matched controls, without known risk factors for CAD, were analysed post-hoc and the PCAT attenuation index was calculated around the proximal right coronary artery (FAIRCA). The athletes and the healthy controls also underwent an electrocardiogram, an echocardiogram, a cardiopulmonary exercise test (CPET), a 24-hour Holter tape and a Cardiac Magnetic Resonance (CMR) scan.

Results

Scans from 243 masters endurance athletes (62% females) and 58 age and Framingham CAD risk score matched healthy controls were analysed. FAIRCA was significantly higher (less negative) in male masters athletes vs female masters athletes [−61.3 Hounsfield Units (HU) vs −62.8 HU, p=0.01], in male athletes vs male controls (−61.3 HU vs −68.6 HU, p<0.001) and in female athletes vs female controls (−62,8 HU vs −67.5 HU, p=0.005). In female masters athletes, peak oxygen consumption during CPET (peak VO2) statistically significantly predicted the FAIRCA, F(1,146) = 22.62, p<0.0001. There was no correlation between the FAIRCA and presence of atherosclerosis in male masters athletes.

Conclusions

Masters athletes show increased markers of coronary inflammation. This effect appears to be greater in male masters athletes and is associated with a higher peak VO2 in female masters athletes. However, we did not identify a link between coronary inflammation and coronary atherosclerosis in this cohort.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Cardiac Risk in the Young, UK

P01-14 National policy response to the Sustainable Development Goals: a physical activity case study of Wales

Issue

Population level changes in physical activity (PA) may benefit from policy intervention. In response to the UN Sustainable Development Goals, Wales introduced legislation (the Well-being of Future Generations (Wales) Act 2015) to holistically improve health and well-being, including the translation of national policy into practice. This audit provides a case study approach that could be replicated by researchers in other countries to appraise the role of PA actions in national and sub-national policies.

Description

An audit of policies published by national and sub-national public bodies between 2015 and 2020 was conducted. The list of identified policies was reviewed by an external panel to act as a ?critical friend? to verify its inclusiveness. Content of the policies were extracted and synthesised to determine: (i) how many policies included a PA action; (ii) what the drivers of those policies were; (iii) the content of the PA actions; and (iv) how the PA actions aligned with the Well-being of Future Generations (Wales) Act 2015.

Results

A final list of 73 policies was obtained. Only 16 national-level documents had a PA action, which had been published by 4/13 public bodies (who are bound by the Act). Of the 19 sub-national well-being policies, 15 included PA actions. Most policies were considered reactive and varied in terms of the clarity and specificity of the actions, the assignment roles/responsibilities, and the setting of targets; all overarching principles which can be used to strengthen national and sub-national policy in the future. The most common theme of action across the national-level documents was the broad action of PA promotion, which was identified in nine of the 16 documents. The actions within the national-level documents were reflected in the sub-national well-being plans.

Lessons

This research used a novel approach to assess alignment of policies related to PA and the Sustainable Development Goals (SDGs) in Wales. It provides an overview of the current status of policy related to PA in Wales, which can be used in manifestos and frameworks to shape the subsequent actions of public bodies.

Main messages

This case study provides a valuable example of how to utilise PA to address broader health and wellbeing agendas, and specifically the SDGs. It also demonstrates an approach to achieving stronger connections between national and sub-national policy to support the translation of policies into practice.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Safety, immunogenicity, and reactogenicity of BNT162b2 and mRNA-1273 COVID-19 vaccines given as fourth-dose boosters following two doses of ChAdOx1 nCoV-19 or BNT162b2 and a third dose of BNT162b2 (COV-BOOST): a multicentre, blinded, phase 2, randomised trial

BACKGROUND

Some high-income countries have deployed fourth doses of COVID-19 vaccines, but the clinical need, effectiveness, timing, and dose of a fourth dose remain uncertain. We aimed to investigate the safety, reactogenicity, and immunogenicity of fourth-dose boosters against COVID-19.

METHODS

The COV-BOOST trial is a multicentre, blinded, phase 2, randomised controlled trial of seven COVID-19 vaccines given as third-dose boosters at 18 sites in the UK. This sub-study enrolled participants who had received BNT162b2 (Pfizer-BioNTech) as their third dose in COV-BOOST and randomly assigned them (1:1) to receive a fourth dose of either BNT162b2 (30 μg in 0·30 mL; full dose) or mRNA-1273 (Moderna; 50 μg in 0·25 mL; half dose) via intramuscular injection into the upper arm. The computer-generated randomisation list was created by the study statisticians with random block sizes of two or four. Participants and all study staff not delivering the vaccines were masked to treatment allocation. The coprimary outcomes were safety and reactogenicity, and immunogenicity (anti-spike protein IgG titres by ELISA and cellular immune response by ELISpot). We compared immunogenicity at 28 days after the third dose versus 14 days after the fourth dose and at day 0 versus day 14 relative to the fourth dose. Safety and reactogenicity were assessed in the per-protocol population, which comprised all participants who received a fourth-dose booster regardless of their SARS-CoV-2 serostatus. Immunogenicity was primarily analysed in a modified intention-to-treat population comprising seronegative participants who had received a fourth-dose booster and had available endpoint data. This trial is registered with ISRCTN, 73765130, and is ongoing.

FINDINGS

Between Jan 11 and Jan 25, 2022, 166 participants were screened, randomly assigned, and received either full-dose BNT162b2 (n=83) or half-dose mRNA-1273 (n=83) as a fourth dose. The median age of these participants was 70·1 years (IQR 51·6-77·5) and 86 (52%) of 166 participants were female and 80 (48%) were male. The median interval between the third and fourth doses was 208·5 days (IQR 203·3-214·8). Pain was the most common local solicited adverse event and fatigue was the most common systemic solicited adverse event after BNT162b2 or mRNA-1273 booster doses. None of three serious adverse events reported after a fourth dose with BNT162b2 were related to the study vaccine. In the BNT162b2 group, geometric mean anti-spike protein IgG concentration at day 28 after the third dose was 23 325 ELISA laboratory units (ELU)/mL (95% CI 20 030-27 162), which increased to 37 460 ELU/mL (31 996-43 857) at day 14 after the fourth dose, representing a significant fold change (geometric mean 1·59, 95% CI 1·41-1·78). There was a significant increase in geometric mean anti-spike protein IgG concentration from 28 days after the third dose (25 317 ELU/mL, 95% CI 20 996-30 528) to 14 days after a fourth dose of mRNA-1273 (54 936 ELU/mL, 46 826-64 452), with a geometric mean fold change of 2·19 (1·90-2·52). The fold changes in anti-spike protein IgG titres from before (day 0) to after (day 14) the fourth dose were 12·19 (95% CI 10·37-14·32) and 15·90 (12·92-19·58) in the BNT162b2 and mRNA-1273 groups, respectively. T-cell responses were also boosted after the fourth dose (eg, the fold changes for the wild-type variant from before to after the fourth dose were 7·32 [95% CI 3·24-16·54] in the BNT162b2 group and 6·22 [3·90-9·92] in the mRNA-1273 group).

INTERPRETATION

Fourth-dose COVID-19 mRNA booster vaccines are well tolerated and boost cellular and humoral immunity. Peak responses after the fourth dose were similar to, and possibly better than, peak responses after the third dose.

FUNDING

UK Vaccine Task Force and National Institute for Health Research.

Systematic Review of Real-World Treatment Patterns of Oral Antipsychotics and Associated Economic Burden in Patients with Schizophrenia in the United States

Background

Schizophrenia is a chronic mental disorder associated with substantial morbidity and mortality affecting 0.25–1.6% of adults in the USA. Antipsychotic treatment is the standard of care for schizophrenia, but real-world treatment patterns and associated costs have not been systematically reviewed.

Objective

We conducted a systematic review to summarize treatment patterns and associated costs related to oral antipsychotic treatment of patients with schizophrenia in the USA.

Data Sources

We searched Medline (via PubMed) and Embase to identify relevant observational studies published from January 1, 2008, to June 1, 2018; costs were converted to 2018 US dollars.

Study Eligibility

Observational, real-world studies reporting on patterns of treatment and/or associated costs for adult patients with schizophrenia treated with oral antipsychotics in the USA were included.

Results

Eighty-one studies were identified. Frequently prescribed oral second-generation antipsychotics were olanzapine (up to 50.9%), risperidone (up to 40.0%), and quetiapine (up to 30.7%). Suboptimal adherence was common across studies. Antipsychotic switching occurred in about half of patients, while antipsychotic combination therapy occurred in nearly 30%; all were associated with increased medication-related costs. Mean annual direct medical costs differed by treatment, with reported costs of $17,115 to $26,138 for patients treated with olanzapine, $18,395 for risperidone, and $17,656 to $28,101 for quetiapine.

Limitations

This systematic review is limited by the variations in definitions of schizophrenia-related clinical terms used between studies and by the inclusion of studies focused on only the US health care system.

Conclusions

In the treatment of schizophrenia, suboptimal adherence, antipsychotic switching, and antipsychotic augmentation were all associated with high costs of care in comparison to patients who were adherent and did not require antipsychotic switching or augmentation. These findings illustrate the need for the development of new treatments that address efficacy and adherence challenges of currently available therapies.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-022-02232-z.

Schizophrenia is a debilitating mental disorder that affects up to 1.6% of adults in the USA. Antipsychotic medications reduce symptoms of the disease, but many patients with schizophrenia are not fully adherent or choose to discontinue treatment entirely, increasing their risk of hospitalization. In others, efforts to achieve better symptom control or to avoid intolerable side effects may result in switching antipsychotic medications or adding additional medications, leading to higher medical treatment costs. The magnitude of these cost increases is unclear. This study sought to assess medical costs associated with antipsychotic treatment adherence, switching, and adding additional antipsychotics. We reviewed 81 studies published from January 2008 through June 2018 examining treatment adherence in patients with schizophrenia. We calculated rates of adherence, switching, and adding antipsychotics, as well as associated medical costs. Overall adherence to antipsychotic treatment was less than 50%, with up to 50% of patients switching medications and up to 29% adding an additional antipsychotic medication to their current treatment. Patients who were not treatment adherent incurred annual medical costs of $10,316 compared with $5723 in patients who were adherent. The costs of immediate or delayed switching of antipsychotic medications ranged from $21,922 to $28,232, while costs of adding an additional antipsychotic ranged from $24,045 to $29,344. These data suggest that suboptimal medication adherence, along with high rates of patient discontinuation and medication switching, lead to higher treatment costs in the management of patients with schizophrenia.

Diffuse lymphadenopathy and fever without a rash: an atypical presentation of secondary syphilis

A woman in her 30s presented to the emergency department with 4 days of fever, headache and back pain. The patient was admitted for pain control, inability to tolerate oral intake and intravenous antibiotics for presumed diagnosis of pyelonephritis. Following admission, CT of the abdomen/pelvis showed multiple prominent pelvic and inguinal lymph nodes, and the patient was noted to have anterior and posterior cervical and submandibular lymphadenopathy on examination. The differential diagnosis was broadened to infectious, haematological, malignant and autoimmune aetiologies of diffuse lymphadenopathy. Workup included serum studies, imaging, lumbar puncture and lymph node biopsy. Rapid plasma reagin (RPR) returned positive with titre 1:16 and confirmatory reactive Treponema pallidum particle agglutination. With an otherwise unrevealing workup, the diagnosis of secondary syphilis was confirmed. This case highlights the differential and diagnostic approach for diffuse lymphadenopathy and an unusual presentation of secondary syphilis. Additionally, it indicates that secondary syphilis can be present even with a relatively low RPR titre.

294 Implementation of Colorectal Robotic Assisted Surgical Programme During a Global Pandemic: Collaboration Between Territorial and National Waiting Times Centre

Introduction

Golden Jubilee National Hospital (GJNH) established a thoracic Robotic Assisted Surgical (RAS) programme in 2018. In March 2021, GJNH invested in a new elective colorectal service and in response to the Scottish Government robotic investment established a collaboration with a territorial health board to host their robot and start a RAS colorectal programme. We provide an overview of barriers and facilitators leading to establishing this new collaboration.

Method

An observational review of RAS training timeline. Demographics, surgical operations, and hospital length of stay were documented. Surgeons, perioperative team, management, and industry (Intuitive) were interviewed to provide insights into implementation and training.

Results

Boards approved RAS business case in April 2021, robot on-site with GJNH governance approval in May. First cohort of colorectal surgeons completed proctored training July 2021. To date, 17 RAS resections performed (mean age 64, 9 males: 8 female). Mean length of stay 4.65 days. No anastomotic leaks and no mortality reported. Interviews revealed key facilitators: advantage of having an established RAS perioperative team and building on pre-existing industry links; developing and strengthening collaborative working between different health boards and surgeons. Barriers included: education of all team members to ensure patient safety for new specialty; multisite collaborative working.

Conclusions

This work provides a template model for future RAS collaborations between different sites and health boards. Collaborative working in a green-hospital setting may improve equity of access for patients whilst future-proofing surgery against further waves of the pandemic.

Next Level Health: a holistic health and wellbeing program to empower New Zealand women

Improving equity in women's health requires gender-specific and empowering approaches. However, health programs often disempower women by adopting a 'one-size-fits-all' approach that emphasizes diet, exercise and weight loss over other important aspects like sleep and mental wellbeing. This article reports on the design of Next Level Health (NLH), a program that aims to empower women through developing a wide range of health behaviors to support their holistic wellbeing. NLH is grounded by ethics, theory and evidence to support women to make achievable, sustainable changes that are relevant to their everyday lives. Women utilized the NLH framework to develop an integrative health routine across six domains: physical activity, sleep, nutrition, eating behavior, self-care and stress management. The framework guided them to set small, incremental goals that were adaptive to their needs and built from their existing circumstances. Participants reflected on their progress with a facilitator during monthly meetings, accessed a social media support page and received monthly text messages. Health programs remain an essential approach to improving women's health alongside community- and policy-level strategies. The development of NLH exemplifies how evidence may partner with modern health promotion values to inform relevant and ethical program design for women.

DREAMM-2: Indirect Comparisons of Belantamab Mafodotin vs. Selinexor + Dexamethasone and Standard of Care Treatments in Relapsed/Refractory Multiple Myeloma

Introduction

Single-agent belantamab mafodotin (belamaf; BLENREP) demonstrated deep and durable responses in patients with relapsed/refractory multiple myeloma and ≥ 3 prior lines of therapy, including an immunomodulatory agent, proteasome inhibitor, and anti-CD38 antibody (DREAMM-2; NCT03525678).

Methods

At the time of this study, STORM Part 2, NCT02336815 (selinexor plus low-dose dexamethasone; sel + dex) was systematically identified as the only feasible comparator to the DREAMM-2 cohort. Matching-adjusted indirect comparisons (MAIC) evaluated efficacy and safety of belamaf (2.5 mg/kg; n = 97) versus sel + dex (80 mg + 20 mg, respectively; n = 123). Populations were weighted for clinically validated effect modifiers and prognostic factors. Outcomes included overall survival (OS), progression-free survival (PFS), duration of response (DoR), overall response rate (ORR), time to response (TTR), and safety. The relative efficacy of belamaf versus standard of care (SoC) on OS was estimated by a Bucher indirect treatment comparison using the MAIC-adjusted hazard ratios (HR) for OS of belamaf (DREAMM-2) versus sel + dex (STORM Part 2) and a HR adjusted for refractoriness to carfilzomib and high-risk cytogenetics of sel + dex (STORM) versus SoC (MAMMOTH).

Results

Belamaf demonstrated improved OS (HR 0.53; 95% confidence interval 0.34, 0.83; p = 0.005) and DoR (0.41; 0.21, 0.83; p = 0.013) versus sel + dex. There were no statistically significant differences in ORR, TTR, and PFS. Belamaf had a favorable safety profile for most evaluable hematologic (any-grade, Grade 3–4) and non-hematologic (any-grade) adverse events versus sel + dex. Significantly improved OS was observed with belamaf versus SoC (0.29; 0.16, 0.54; p < 0.001).

Conclusion

Single-agent belamaf represents a new treatment option for triple-class refractory patients with RRMM.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-01884-7.

1484Selection bias in COVID-19 research: Prospective analyses of two UK cohort studies

Background

Non-random sampling could bias estimates of association in observational studies but the extent to which this occurs in studies of SARS-CoV-2 infection/COVID-19 severity is not well established.

Methods

Using ALSPAC and UK Biobank we investigated pre-pandemic predictors of selection (i.e. having data on SARS-CoV-2 infection and COVID-19 severity from self-report and/or health record linkage). We conducted empirical analyses and simulations to explore the potential presence, direction and magnitude of bias due to selection when estimating the association of BMI with SARS-CoV-2 infection and COVID-19 severity.

Results

A broad range of characteristics related to selection in both cohorts, sometimes in opposite directions. We found bias in all simulated scenarios, mostly of small magnitude. Both the direction and magnitude of bias was influenced by the presence of an effect of BMI on SARS-CoV-2 infection and COVID-19 severity and the control group definition used (e.g. assuming no effect of BMI on SARS-CoV-2 infection our main simulation showed bias equivalent to an estimated odds ratio of 0.99 when using non-infected controls but 1.16 when using controls combining non-infected and non-assessed).

Conclusions

Despite small amounts of bias in most scenarios, a control group definition including those non-assessed (e.g. non-tested) can induce more bias. In large samples such as UK Biobank the statistical power means incorrect conclusions could be made.

Key messages

Observational studies estimating associations of factors with SARS-CoV-2 or COVID-19 may be biased due to non-random selection into the analytic sample.

Accelerated theta burst stimulation for the treatment of depression: A randomised controlled trial

INTRODUCTION

Theta burst pattern repetitive transcranial magnetic stimulation (TBS) is increasingly applied to treat depression. TBS's brevity is well-suited to application in accelerated schedules. Sizeable trials of accelerated TBS are lacking; and optimal TBS parameters such as stimulation intensity are not established.

METHODS

We conducted a three arm, single blind, randomised, controlled, multi-site trial comparing accelerated bilateral TBS applied at 80 % or 120 % of the resting motor threshold and left unilateral 10 Hz rTMS. 300 patients with treatment-resistant depression (TRD) were recruited. TBS arms applied 20 bilateral prefrontal TBS sessions over 10 days, while the rTMS arm applied 20 daily sessions of 10 Hz rTMS to the left prefrontal cortex over 4 weeks. Primary outcome was depression treatment response at week 4.

RESULTS

The overall treatment response rate was 43.7 % and the remission rate was 28.2 %. There were no significant differences for response (p = 0.180) or remission (p = 0.316) across the three groups. Response rates between accelerated bilateral TBS applied at sub- and supra-threshold intensities were not significantly different (p = 0.319). Linear mixed model analysis showed a significant effect of time (p < 0.01), but not rTMS type (p = 0.680).

CONCLUSION

This is the largest accelerated bilateral TBS study to date and provides evidence that it is effective and safe in treating TRD. The accelerated application of TBS was not associated with more rapid antidepressant effects. Bilateral sequential TBS did not have superior antidepressant effect to unilateral 10 Hz rTMS. There was no significant difference in antidepressant efficacy between sub- and supra-threshold accelerated bilateral TBS.

Network meta-analysis of eribulin versus other chemotherapies used as second- or later-line treatment in locally advanced or metastatic breast cancer

BACKGROUND

Eribulin mesylate (ERI; Halaven®) is a microtubule inhibitor approved in the United States for metastatic breast cancer patients with at least two prior chemotherapy regimens for metastatic breast cancer, and in the European Union in locally advanced breast cancer or metastatic breast cancer patients who progressed after at least one chemotherapy for advanced disease. This network meta-analysis compared the efficacy and safety of ERI versus other chemotherapies in this setting.

METHODS

Systematic searches conducted in MEDLINE, Embase, and the Cochrane Central Register of Clinical Trials identified randomized controlled trials of locally advanced breast cancer/metastatic breast cancer chemotherapies in second- or later-line settings. Efficacy assessment included pre-specified subgroup analysis of breast cancer subtypes. Included studies were assessed for quality using the Centre for Reviews and Dissemination tool. Bayesian network meta-analysis estimated primary outcomes of overall survival and progression-free survival using fixed-effect models. Comparators included: capecitabine (CAP), gemcitabine (GEM), ixabepilone (IXA), utidelone (UTI), treatment by physician's choice (TPC), and vinorelbine (VIN).

RESULTS

The network meta-analysis included seven trials. Results showed that second- or later-line patients treated with ERI had statistically longer overall survival versus TPC (hazard ratio [HR]: 0.81; credible interval [CrI]: 0.66-0.99) or GEM+VIN (0.62; 0.42-0.90) and statistically longer progression-free survival versus TPC (0.76; 0.64-0.90), but statistically shorter progression-free survival versus CAP+IXA (1.40; 1.17-1.67) and CAP+UTI (1.61; 1.23-2.12). In triple negative breast cancer, ERI had statistically longer overall survival versus CAP (0.70; 0.54-0.90); no statistical differences in progression-free survival were observed in triple negative breast cancer.

CONCLUSIONS

This network meta-analysis suggests that ERI may provide an overall survival benefit in the overall locally advanced breast cancer/metastatic breast cancer populations and triple negative breast cancer subgroup compared to standard treatments. These findings support the use of ERI in second- or later-line treatment of patients with locally advanced breast cancer/metastatic breast cancer.

Epidemiological and clinical burden associated with plexiform neurofibromas in pediatric neurofibromatosis type-1 (NF-1): a systematic literature review

PURPOSE

Patients with neurofibromatosis type-1 (NF-1) and associated plexiform neurofibromas (PNs) often have a high burden of illness owing to debilitating symptoms of these tumors and limited management options. To investigate this complex disease, a systematic literature review (SLR) was conducted on the epidemiology of pediatric NF-1 and associated PNs, the burden of illness, and outcomes of surgical resection of these tumors.

METHODS

Searches of MEDLINE and Embase (from database inception to October 2019) and conference proceedings (2017-2019) were performed to identify relevant studies. The review methodology was informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Twenty studies were identified. Evidence confirmed NF-1 is rare but that occurrence may differ geographically. Only limited data on the birth incidence of NF-1 were identified. Prevalence estimates for pediatric NF-1 varied from one per 960 individuals (aged 17 years) to one per 5681 children (aged < 16 years) across five large registry/surveillance studies (each involving > 19,000 individuals). The prevalence of associated PNs was 0-29.6%. PNs carried increased mortality risk in pediatric NF-1 in both studies that explored this potential association. Patients with PNs reported high use of analgesics. The complication rate post-surgery for PNs was around 17-19%. The recurrence rate (18-68%) was dependent on the extent of excision achieved during surgery.

CONCLUSIONS

Data suggest NF-1 is a rare disease with increased morbidity and mortality in children with associated PNs. Surgical outcomes for PNs are often poor. These findings suggest significant unmet needs in patients with NF-1-associated PNs.

Systematic literature review of the real-world burden and use of chemotherapies for treatment of advanced or recurrent endometrial carcinoma

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Background: Women diagnosed with advanced or recurrent endometrial cancer (EC) have a poor prognosis, with a 5-year survival of only 15% to 17%. While a multi-modality approach is often used for newly diagnosed EC including platinum-based chemotherapy, there are no definitively approved standard treatment options for advanced or recurrent EC following prior systemic therapy (FPST). The real-world evidence surrounding the effectiveness of chemotherapies in this setting is not well characterized. We conducted a systematic literature review to attempt to fill this evidence gap. Methods: Systematic searches were run in Embase, MEDLINE, and the Cochrane Library to identify English-language publications from January 2000 to July 2020. Additional hand searches of 5 key conferences held from 2018 to 2020 were also conducted. The review included observational studies reporting the clinical effectiveness, safety, or treatment patterns of pharmacological treatments in adult women with advanced or recurrent EC. Results: Seventy-seven observational studies met the inclusion criteria, of these 63 studies reported on the effectiveness of chemotherapies. While 57 studies described adjuvant chemotherapy use, 6 described use of chemotherapies FPST, including 1 study in the second line or later. Only one of these 6 studies reported a sample size greater than 100 patients. Chemotherapy FPST included paclitaxel/carboplatin (3 studies), doxorubicin (2 studies), etoposide (1 study), or any platinum-based chemotherapy (1 study). Shorter median overall survival (OS) was observed in patients with treatment-free intervals (TFI) < 6 months from prior systemic therapy (5.5-11.3 months; 2 studies) compared to those with TFI > 6 months (13.0-27.0 months; 3 studies). Similarly, shorter median progression-free survival (PFS) was seen in patients with TFI < 6 months from prior systemic therapy (2.0-3.2 months; 2 studies) vs. those with TFI > 6 months (6.0-10.0 months; 3 studies). Conclusions: Women with advanced or recurrent EC have poor OS and PFS with current chemotherapy regimens, especially for those with TFI < 6 months. The time at recurrence from prior systemic therapy seems to correlate with the outcomes of subsequent treatment. Novel efficacious treatment strategies are required to improve patients’ outcomes in the FPST setting. While extensive real-world evidence exists for patients with EC receiving adjuvant chemotherapy, real world data is limited for use of chemotherapy in advanced or recurrent setting, warranting further research in larger samples of patients.

Left ventricular remodelling in masters athletes

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): I have received a research fellowship grant from the UK based charity Cardiac Risk in the Young

Objectives

We investigated the effect of long-term exercise and sex on left ventricular (LV) geometry in a large group of female and male masters athletes.

Background

Studies assessing LV geometry in masters athletes are scarce.

Methods

Different types of LV geometry were identified according to echocardiography-derived relative wall thickness (RWT) and left ventricular mass (LVM) values as per international guidelines. 4 groups were formed: normal (normal LVM/normal RWT), concentric hypertrophy (increased LVM/increased RWT), eccentric hypertrophy (increased LVM/normal RWT), and concentric remodeling (normal LVM/increased RWT).

Results

A total of 277 healthy, elite, caucasian endurance masters athletes (65% female; mean age54.8 ± 7.7 years) were assessed. The athletes were exercising for a mean 32 ± 11.7 years and have completed a median 70 competitions including a median 13 marathon-type competitions. Females exhibited lower absolute LVM (127.7 ± 30.31g vs 196.57 ± 45.0g, p &lt; 0.001), indexed LVM (76.8 ± 18.0 g/m2 vs. 103.6 ± 22.7 g/m2; p &lt; 0.001), RWT (0.36 ± 0.07 vs. 0.42 ± 0.08; p &lt; 0.001) and absolute LV end-diastolic dimension (LVEDD) (46.3 ± 4.1 mm vs 50.1 ± 5.11 mm, p &lt; 0.001) but greater indexed LVEDD (27.7 ± 2.7mm/m2 vs 26.5 ± 2.7 mm/m2, p &lt; 0.001) compared with male athletes. Most female athletes showed normal LV geometry (72% vs 38% in male athletes, P &lt; 0.001) and significantly less concentric remodeling (12% vs 35%, p &lt; 0.001) and concentric hypertrophy (5% vs 13%, p = 0.01) (table & figure).

Conclusions

A sex-specific response to chronic exercise is observed. Male masters athletes exhibit significantly more frequently abnormal LV geometry with concentric LV remodeling and/or concentric hypertrophy.

Cohort characteristics Male masters athletes N = 97 Female masters athletes N = 180 P value Age (years) 55.0 ± 9.0 54.7 ± 6.9 0.68 Years of exercise 32.0 ± 12.8 33.3 ± 11.1 0.14 LV Mass (g) 127.7 ± 30.31 196.57 ± 45.0 &lt;0.001 LV Mass Indexed (g/m2) 76.8 ± 18.0 103.6 ± 22.7 &lt;0.001 LVEDD (mm) 46.3 ± 4.1 50.1 ± 5.11 &lt;0.001 LVEDD Indexed (mm/m2) 27.7 ± 2.7 26.5 ± 2.7 &lt;0.001 Normal Remodeling 36 (37) 130 (72) &lt;0.001 Eccentric Hypertrophy 14 (14) 18 (10) 0.27 Concentric Remodeling 34 (35) 23 (13) &lt;0.001 Concentric Hypertrophy 13 (13) 9 (5) 0.01 LV Left Ventricular, LVEDD: Left Ventricular End Diastolic Dimension Abstract Figure. Patterns of left ventricular remodeling

Correction to: Crisaborole Ointment, 2%, for Treatment of Patients with Mild-to-Moderate Atopic Dermatitis: Systematic Literature Review and Network Meta-Analysis

The authors would like to replace 2 small sections of the published manuscript that refer to a qualitative review of safety data for included studies (together with an associated safety table), to provide some further clarifications on these safety data and to include some quantitative updates for rates.

DREAMM-2: Assessing efficacy via indirect comparison of single-agent belantamab mafodotin versus selinexor plus dexamethasone combination in anti-CD38 exposed relapsed/refractory multiple myeloma (RRMM)

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Background: Single-agent belantamab mafodotin (GSK2857916) is a first-in-class immunoconjugate targeting B-cell maturation antigen that demonstrated deep and durable responses in heavily pretreated patients with RRMM in the pivotal DREAMM-2 study (NCT03525678; Lancet Oncol 2020). Methods: DREAMM-2 included patients with late-line RRMM treated with ≥3 prior lines of therapy, refractory to an immunomodulatory agent and a proteasome inhibitor, with prior exposure to an anti-CD38 antibody. Evidence from Phase II/III trials in a similar patient population was systematically identified following PRISMA guidelines. Based on the specificity of the DREAMM-2 population, selinexor plus low-dose dexamethasone (sel+dex) was identified as the only feasible comparator (STORM Part 2, NCT02336815). Matching-adjusted indirect comparisons (MAIC) were used to investigate the efficacy of single-agent belantamab mafodotin vs. sel+dex. Populations were matched for all clinically validated effect modifiers and prognostic factors with available data. MAIC were performed for overall response rate (ORR), time to response (TTR), duration of response (DoR), progression-free survival (PFS), and overall survival (OS), as per NICE guidelines. Results: Single-agent belantamab mafodotin was more efficacious than sel+dex in terms of OS and DoR (Table). Results for ORR, TTR, and PFS showed no statistical difference between the two regimens. Conclusions: MAIC of single-agent belantamab mafodotin vs. sel+dex in this patient population with RRMM showed significantly improved efficacy on OS and DoR for belantamab mafodotin. Further validation is required owing to limited data availability. Additional safety analyses will further inform comparisons of the two. Clinical trial information: NCT03525678; NCT02336815. Funding: GlaxoSmithKline (207145). Drug linker technology licensed from Seattle Genetics; monoclonal antibody produced using POTELLIGENT Technology licensed from BioWa. [Table: see text]

Peer support groups after acquired brain injury: a systematic review

BACKGROUND

Peer support groups can be a way to obtain support, problem solve, and widen social networks. However, there has been no systematic literature review examining the evidence for the use of peer support groups after an acquired brain injury (ABI).

OBJECTIVE

This review sought to systematically evaluate the evidence for (1) the psychosocial effectiveness, and (2) the experience of peer support groups in adults who had experienced ABI's.

METHODS

The systematic literature search was conducted across the following four databases: PsycINFO, PsycARTICLES, MEDLINE, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) in October 2019. The mixed methods appraisal tool was used to examine the quality of the research.

RESULTS

13 papers were included in this review. Limited evidence was found for the psychosocial effectiveness of peer support groups in ABI, although the experience of partaking in a peer support group was largely found to be positive. The benefits and helping factors of taking part in a peer support group can be summarized as: being connected, interacting with others, and providing and receiving support.

CONCLUSIONS

The findings of this review suggest that peer support groups could be a promising intervention to support individuals and promote adjustment following an ABI.

Brivaracetam efficacy and tolerability in clinical practice: A UK-based retrospective multicenter service evaluation

PURPOSE

This multicenter service evaluation explores the efficacy and tolerability of brivaracetam (BRV) in an unselected, consecutive population in 'real-life' clinical settings.

METHOD

We retrospectively collected data from patient records at 11 UK hospitals and epilepsy centers. Consecutive patients prescribed BRV with at least 3 months of follow-up (FU) were included. Apart from reporting effectiveness and tolerability of BRV across the whole cohort, we compared treatment outcomes depending on previous levetiracetam use (LEV+ versus LEV-), comorbid learning disability (LD+ versus LD-), and epilepsy syndrome (focal versus generalized epilepsy).

RESULTS

Two hundred and ninety patients (46% male, median age: 38 years, range: 15 to 77) with ≥3 months of FU were included. The median duration of BRV exposure was 12 months (range: 1 day to 72 months). Overall BRV retention was 71.1%. While 56.1% of patients improved in terms of seizure frequency category (daily, weekly, monthly, yearly seizures), 23.1% did not improve on this measure and 20.8% deteriorated. In terms of seizure frequency, 21% of patients experienced a ≥50% reduction, with 7.0% of all patients becoming seizure-free. Treatment-emergent adverse events (AEs) were reported by 107 (36.9%) patients, but there were no serious AEs. The commonest AEs were sedation/fatigue (18.3%), mood changes (9.0%), and irritability/aggression (4.8%). There were no significant differences in drug retention, seizure frequency outcomes, or AEs between the LEV+ and LEV- subgroups, or between patients with generalized or focal epilepsies. Although 15.5% of patients in the LD+ group achieved a ≥50% reduction, this rate was lower than in the LD- group.

CONCLUSIONS

This 'real-life' evaluation suggests that reductions in seizure frequency can be achieved with BRV in patients with highly refractory epilepsy. Brivaracetam may be a useful treatment option in patients who have previously failed to respond to or tolerate LEV, those with LD, or (off-label) those with generalized epilepsies.