Patient-Reported Outcomes in Pleural Effusions: A Systematic Review

Pleural effusions cause breathlessness, decreased activity levels, and impaired quality of life. Clinical trials of drainage of pleural effusion use patient-reported outcome measures (PROMs) to assess these variables. This systematic review aimed to identify which PROMs have been used in clinical trials in pleural effusions, what variables were assessed, whether they were responsive to pleural interventions, and whether they have been validated in patients with pleural effusions, including a defined minimal clinically important difference (MCID). A systematic review was performed to identify relevant clinical trials from Medline, EMBASE, Emcare, and CINAHL and data were extracted. From 329 abstracts, 29 clinical trials of pleural effusion drainage that used PROMs as an outcome measure were identified. A total of 16 different PROMs were used. The most used PROMs were unidimensional measurements of breathlessness, particularly the visual analogue scale for dyspnoea (VASD), all of which nearly showed improvements in breathlessness following pleural fluid drainage. Other variables commonly assessed included activity levels and health-related quality of life. Multidimensional PROMs showed inconsistent responsiveness to pleural fluid drainage. Only the VASD was validated in this patient group with a defined MCID. A range of PROMs are used in clinical trials of pleural fluid drainage. No single PROM measures all the outcomes of interest. Unidimensional measurements of breathlessness are responsive to pleural fluid drainage. Only the VASD is validated with an MCID. There is a need for properly validated, response PROMs which measure the key outcomes of interest in this patient group.

A Randomised Clinical Feasibility Trial of a Breast Immobilisation Device: The SuPPORT 4 All Bra

AIMS

Despite the breast being a mobile organ, there is currently no standard suitable immobilisation device to optimise radiotherapy for women with larger breasts treated after a wide local excision. The SuPPORT 4 All (S4A) bra was co-designed with patients and radiotherapy professionals. The purpose of this study was to test the feasibility of using the S4A bra in the existing breast cancer radiotherapy pathway.

MATERIALS AND METHODS

A randomised feasibility trial was conducted in a single institution; the primary feasibility endpoint was the recruitment of 50 participants. Efficacy endpoints were also tested, including assessment of skin reactions, dose to organs at risk and patient comfort. Fifty women were randomised to receive either standard radiotherapy with no immobilisation (control) or radiotherapy with the S4A bra (intervention). A separate planning study was undertaken on the cases randomised to receive the S4A bra. Participants in the intervention arm (S4A bra) underwent two planning computed tomography scans, one with the bra on and one without the bra; allowing direct comparison of organs at risk data for S4A bra versus no bra.

RESULTS

All women who started radiotherapy wearing the S4A bra completed treatment with the bra; patient comfort did not change across the 3 weeks of treatment. Positional accuracy using the bra was comparable with existing published accuracy for methods without immobilisation. The mean ipsilateral lung doses showed some improvement when positioning with the S4A bra was compared with the no bra set-up (3.72 Gy versus 4.85 Gy for right-sided cases, 3.23 Gy versus 3.62 Gy for left-sided cases).

CONCLUSIONS

The S4A bra is feasible to use in the radiotherapy pathway with good patient adherence. The S4A bra has potential to reduce dose to organs at risk (specifically ipsilateral lung dose) while maintaining good breast tissue coverage, and improved patient dignity, warranting further investigation on a larger scale.

Staging by Thoracoscopy in potentially radically treatable Lung Cancer associated with Minimal Pleural Effusion (STRATIFY): protocol of a prospective, multicentre, observational study

INTRODUCTION

Recurrence rate following radical therapy for lung cancer remains high, potentially reflecting occult metastatic disease, and better staging tools are required. Minimal pleural effusion (mini-PE) is associated with particularly high recurrence risk and is defined as an ipsilateral pleural collection (<1/3 hemithorax on chest radiograph), which is either too small to safely aspirate fluid for cytology using a needle, or from which fluid cytology is negative. Thoracoscopy (local anaesthetic thoracoscopy (LAT) or video-assisted thoracoscopic surgery (VATS)) is the gold-standard diagnostic test for pleural malignancy in patients with larger symptomatic effusions. Staging by Thoracoscopy in potentially radically treatable Lung Cancer associated with Minimal Pleural Effusion (STRATIFY) will prospectively evaluate thoracoscopic staging in lung cancer associated-mini-PE for the first time.

METHODS AND ANALYSIS

STRATIFY is a prospective multicentre observational study. Recruitment opened in January 2020. The primary objective is to determine the prevalence of detectable occult pleural metastases (OPM). Secondary objectives include assessment of technical feasibility and safety, and the impact of thoracoscopy results on treatment plans, overall survival and recurrence free survival. Inclusion criteria are (1) suspected/confirmed stages I-III lung cancer, (2) mini-PE, (3) Performance Status 0-2 (4), radical treatment feasible if OPM excluded, (5) ≥16 years old and (6) informed consent. Exclusion criteria are any metastatic disease or contraindication to the chosen thoracoscopy method (LAT/VATS). All patients have LAT or VATS within 7 (±5) days of registration, with results returned to lung cancer teams for treatment planning. Following an interim analysis, the sample size was reduced from 96 to 50, based on a lower-than-expected OPM rate. An MRI substudy was removed in November 2022 due to pandemic-related site setup/recruitment delays. These also necessitated a no-cost recruitment extension until October 2023.

ETHICS AND DISSEMINATION

Protocol approved by the West of Scotland Research Ethics Committee (Ref: 19/WS/0093). Results will be published in peer-reviewed journals and presented at international meetings.

TRIAL REGISTRATION NUMBER

ISRCTN13584097.

The patient experience of radiotherapy for breast cancer: A qualitative investigation as part of the SuPPORT 4 All study

Introduction

Breast cancer is a global health problem with 2.09 million cases of breast cancer diagnosed worldwide in 2018. With an increase in breast cancer survival attention has now focussed on the impact treatment side effects can have on the quality of life for women during survivorship. The aim of the SuPPORT 4 All project is to develop a support bra for use during radiotherapy, that can reduce normal tissue toxicity (for women with larger breasts) and provide accuracy, dignity and modesty for all women. The first stage of the project involved a co-design process to understand the current patient experience where no support bra or modesty device is used.

Method

A participatory co-design methodology was adopted. Workshops were held with patient representatives (n = 9) to seek understanding of experience during radiotherapy; a total of three workshops over 4 h. The workshops were audio recorded and framework analysis was adopted to identify key patient experiences.

Results

Twelve categories and twenty-six sub categories were identified specific to patient experience. Patient concerns focussed on information provision, Healthcare Practitioner (HCP) knowledge of breast lymphoedema, lack of choice, experiences of being naked, and feelings of disempowerment.

Conclusions

A number of areas were identified that had negative effects on overall patient experience.

Implications for practice

Practitioners should consider patient dignity when configuring services to support patient needs regarding undressing, outside or inside the linear accelerator room. Additionally, practitioners should have an understanding of the impact permanent tattoos may have on some patients’ wellbeing and the impact that breast lymphoedema has on patient quality of life. Practitioners should also consider methods to encourage patient empowerment during radiotherapy; supporting patient self-monitoring of side-effects may be one way to facilitate this.

Ambulatory management of primary spontaneous pneumothorax: an open-label, randomised controlled trial

BACKGROUND

Primary spontaneous pneumothorax occurs in otherwise healthy young patients. Optimal management is not defined and often results in prolonged hospitalisation. Data on efficacy of ambulatory options are poor. We aimed to describe the duration of hospitalisation and safety of ambulatory management compared with standard care.

METHODS

In this open-label, randomised controlled trial, adults (aged 16-55 years) with symptomatic primary spontaneous pneumothorax were recruited from 24 UK hospitals during a period of 3 years. Patients were randomly assigned (1:1) to treatment with either an ambulatory device or standard guideline-based management (aspiration, standard chest tube insertion, or both). The primary outcome was total length of hospital stay including re-admission up to 30 days after randomisation. Patients with available data were included in the primary analysis and all assigned patients were included in the safety analysis. The trial was prospectively registered with the International Standard Randomised Clinical Trials Number, ISRCTN79151659.

FINDINGS

Of 776 patients screened between July, 2015, and March, 2019, 236 (30%) were randomly assigned to ambulatory care (n=117) and standard care (n=119). At day 30, the median hospitalisation was significantly shorter in the 114 patients with available data who received ambulatory treatment (0 days [IQR 0-3]) than in the 113 with available data who received standard care (4 days [IQR 0-8]; p<0·0001; median difference 2 days [95% CI 1-3]). 110 (47%) of 236 patients had adverse events, including 64 (55%) of 117 patients in the ambulatory care arm and 46 (39%) of 119 in the standard care arm. All 14 serious adverse events occurred in patients who received ambulatory care, eight (57%) of which were related to the intervention, including an enlarging pneumothorax, asymptomatic pulmonary oedema, and the device malfunctioning, leaking, or dislodging.

INTERPRETATION

Ambulatory management of primary spontaneous pneumothorax significantly reduced the duration of hospitalisation including re-admissions in the first 30 days, but at the expense of increased adverse events. This data suggests that primary spontaneous pneumothorax can be managed for outpatients, using ambulatory devices in those who require intervention.

FUNDING

UK National Institute for Health Research.

Adherence to a Mediterranean Diet Is Not Associated with Risk of Sarcopenic Symptomology: A Cross-Sectional Analysis of Overweight and Obese Older Adults in Australia

Adherence to a Mediterranean Diet (MedDiet) is inversely associated with sarcopenia. The aim of this study was to examine the association between adherence to a MedDiet and sarcopenic symptomology in obese older adults. For confirmation of sarcopenia, low appendicular skeletal muscle (ASM: males, ≤7.25kg/m2; females, ≤5.5kg/m2) accompanied low handgrip strength (males, ≤30kg; females, ≤20kg) or low physical performance (Short Physical Performance Battery [SPPB]: ≤8; or gait speed: ≤0.8m/sec). Adherence to a MedDiet was determined using the Mediterranean Diet Adherence Screener (MEDAS). Sixty-five older adults were included. Adherence to a MedDiet was not associated with a decreased risk of sarcopenic symptomology (SPPB: OR = 0.20; 95% CI: 0.01-3.1; P = 0.234; Muscle strength: OR = 1.81; 95% CI: 0.32-10.15; P = 0.499; Gait speed: OR = 0.58; 95% CI: 0.13-2.50; P = 0.468). Future research should investigate whether a Mediterranean-style intervention can prevent or improve sarcopenic symptomology, including in non-Mediterranean populations.

A simulation study assessing the accuracy and reliability of orchidometer estimation of testicular volume

CONTEXT

Measuring testicular volume (TV) by orchidometer is the standard method of male pubertal staging. A paucity of evidence exists as to its inter- and intra-observer reliability and the impact of clinicians' gender, training and experience on accuracy.

OBJECTIVE

Prosthetic testicular models were engineered to investigate accuracy and reliability of TV estimation.

DESIGN

Simulation study.

SETTING

Conducted over three-day 2015 British Society for Paediatric Endocrinology and Diabetes (BSPED) meeting.

PARTICIPANTS

Two hundred fifteen meeting delegates (161F, 54M): 50% consultants, 30% trainees, 9% clinical nurse specialists, 11% other professionals.

INTERVENTION

Three child-sized mannequins displayed latex scrotum containing prosthetic testicles of 3, 4, 5, 10 and 20 mL. Demographic data, paediatric endocrinology experience, TV examination training, examination technique and TV estimations were collected. Delegates were asked to repeat their measurements later during the meeting. Scrotum order was changed daily.

MAIN OUTCOME MEASURES

Accuracy by variance from the simulated TV. Inter- and intra-observer variability.

RESULTS

One thousand two hundred eighty four individual estimations were obtained. Eighty-five participants repeated measurements. Delegates measured TV accurately on 33.4% (±2.6) of occasions: overestimations 37% (±2.3), underestimations 28% (±1.8) (Fleiss' Kappa score 0.04). The accuracy of assessing a 4 mL testis was 36%-39%. Observers underestimated the volume when paired with a 3 mL testis and overestimated when paired with a 5 mL testis demonstrating a tendency impose biological symmetry. Intra-observer reliability was lacking; individuals giving different estimations for the same size testicle on 61% (±4.2) of occasions, 20% (±3.5) of estimations were more than 1 size outside the previous measurement. On only 39% (±4.2) of occasions did individuals agree with their previous estimation (irrespective of whether or not it was initially accurate). Training did not impact on results but experience did improve accuracy.

CONCLUSIONS

Overall TV estimation accuracy was poor. Considerable variation exists between and within subjects. Seniority slightly improved measurement estimation.

Abstract P6-12-05: Metastatic breast cancer collateral damage project (MBCCD): Development and preliminary results of the survey of health, impact, needs, and experiences (SHINE)

Rationale: People living with metastatic breast cancer face unique challenges, which have not been well characterized. The aim of the MBCCD was to characterize the MBC patient experience in order to identify and address potential areas of need in this underserved population.

Method: We crowdsourced input and gathered free-text data from 353 people living with MBC to document the breadth of challenges affecting quality of life. From the responses, we developed a new measure (SHINE) with 79 patient-driven items regarding the experience of MBC, including verbatim statements from crowdsourcing data. Validated quality of life scales, clinical information, and demographic data were also collected. Participants were recruited from Dr. Susan Love Research Foundation's Army of Women® and other advocacy organizations; 515 completed the questionnaire. Confirmatory and exploratory factor analyses were conducted to assess model fit for SHINE and to identify subscales. Next, differences in MBC-specific concerns and experiences as a function of age, marital status, financial status, education, children, metastatic site location(s), and current medical treatment were examined with ANOVAs and t-tests.

Results: Factor analyses indicated good model fit (CFI=.96, RMSEA=.05, SRMR=.04) for a 36-item scale of MBC-specific concerns and experiences with nine subscales: 1) Employment/achievement, 2) Finances, 3) Insurance, 4) Mortality/uncertainty, 5) Activity disruption, 6) Concern for others, 7) Social isolation/withdrawal, 8) Self-concept disruption, 9) Benefit finding. A within-subjects ANOVA revealed that participants were most bothered by mortality/uncertainty concerns, followed by activity disruption, financial, employment/achievement, and insurance concerns, respectively (F(4,508)=111.38, p&lt;0.01). Additionally, participants endorsed strongest agreement with benefit finding, followed by concern for others, self-concept disruption, and social isolation/withdrawal (F(4,508)=101.53, p&lt;.01). Participants younger than 50 years and those with lower financial status reported higher concerns on all subscales (ps&lt;0.01), except for benefit finding (ps&gt;0.18). Participants with a child under 18 living at home, those on combination therapies, and those with metastases to multiple sites or bone only reported higher concerns on several subscales (ps&lt;0.05). Being married was significantly associated with higher concern for others and lower concern about finances (ps&lt;0.02). Education was not significantly related to any subscale.

Conclusions: Several important concerns and experiences related to MBC are not captured adequately in existing measures. This study developed a new measure (SHINE), which reliably assessed these disease-specific concerns and experiences in 515 adults living with MBC. Concerns regarding mortality and uncertainty were most prominent. Specific demographic and medical characteristics modified responses on eight subscales, but not on the benefit finding subscale. Findings can aid the development of supportive care efforts that address areas of need (e.g., concerns about mortality and uncertainty) in this understudied medical population.

Citation Format: Stanton A, Williamson T, Clague DeHart J, Jorge A, Eshraghi L, Cooper Ortner H, Love S. Metastatic breast cancer collateral damage project (MBCCD): Development and preliminary results of the survey of health, impact, needs, and experiences (SHINE) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-12-05.

Abstract P6-12-07: Metastatic breast cancer collateral damage project: Associations of disease-specific concerns and experiences with psychological health, illness management, and health behaviors

Rationale: Research has identified risk and protective factors that predict health and well-being in adults with breast cancer, but this work has been focused largely on women with early-stage disease. Metastatic breast cancer (MBC) patients report worse psychological health and poorer quality of life compared to those with early-stage breast cancer. We investigated whether a newly developed measure of MBC-specific concerns and experiences, the Survey of Health, Impact, Needs, and Experiences (SHINE), is associated with psychological health, illness management, and health behaviors in a sample of MBC patients.

Method: SHINE includes 36 items capturing the experience of MBC, including verbatim statements from previously collected crowdsourcing data. Participants (N=515) were recruited from Dr. Susan Love Research Foundation's Army of Women® and other advocacy organizations. Participants also completed measures of psychological health (i.e., depression, anxiety), illness management (i.e., self-efficacy for managing medications/treatments and symptoms), and health behaviors (i.e., sleep, degree of moderate physical activity). The nine SHINE subscales, along with age, marital status, financial status, children, metastatic site location(s), and current medical treatment(s), were entered as simultaneous predictors in a multivariate regression. Psychological health, illness management, and health behaviors were entered as dependent variables in separate models.

Results: With demographic and medical variables controlled, MBC-specific concerns were associated significantly with depressive symptoms (ΔR2=.38), anxiety (ΔR2=.37), efficacy for medication/treatment management (ΔR2=.08), efficacy for symptom management (ΔR2=.32), sleep disruption (ΔR2 =.10), and physical activity (ΔR2=.17), with all ps&lt;.01. Specifically, higher depressive symptoms and anxiety were associated greater mortality/uncertainty concerns (ps&lt;.01), greater social isolation/withdrawal (ps&lt;.01), and higher self-concept disruption (ps&lt;.02). Anxiety was uniquely associated with greater financial concerns (p&lt;.02), whereas depression was uniquely associated with fewer positive experiences (p&lt;.05). Higher self-efficacy for managing symptoms was related to more positive experiences, higher mortality concerns, and more self-concept and activity disruption (ps&lt;.01), whereas higher efficacy for managing medications/treatments was associated with lower social isolation/withdrawal (p&lt;.03). More sleep disruption was associated with higher concern for others (p&lt;.05), and less physical activity was associated with more activity disruption (p&lt;.01).

Conclusions: After controlling for demographic and medical characteristics, MBC-specific concerns were related significantly to psychological health, self-efficacy for illness management, and health behaviors. Mortality/uncertainty concerns, social isolation/withdrawal, and self-concept disruption were especially important correlates of depressive symptoms, anxiety, and MBC-related self-efficacy. Higher concern for others was related to more sleep disruption. Approaches that address these MBC-specific concerns and promote positive experiences may be beneficial for patients.

Citation Format: Williamson T, Stanton A, Clague DeHart J, Jorge A, Eshraghi L, Cooper Ortner H, Love S. Metastatic breast cancer collateral damage project: Associations of disease-specific concerns and experiences with psychological health, illness management, and health behaviors [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-12-07.

A review of atmospheric and land surface processes with emphasis on flood generation in the Southern Himalayan rivers

Floods in the southern rim of the Indian Himalayas are a major cause of loss of life, property, crops, infrastructure, etc. They have long term socio-economic impacts on the habitat living along/across the Himalayas. In the recent decade extreme precipitation events have led to numerous flash floods in and around the Himalayan region. Sporadic case-based studies have tried to explain the mechanisms causing the floods. However, in some of the cases, the causative mechanisms have been elusive. Various types of flood events have been debated at different spatial and temporal scales. The present study provides an overview of mechanisms that lead to floods in and around the southern rim of the Indian Himalayas. Atmospheric processes, landuse interaction, and glacier-related outbreaks are considered in the overview.

Assessment of the Sheffield Support Snood, an innovative cervical orthosis designed for people affected by neck muscle weakness

BACKGROUND

This study aimed at quantifying the biomechanical features of the Sheffield Support Snood, a cervical orthosis specifically designed for patients with neck muscle weakness. The orthosis is designed to be adaptable to a patient's level of functional limitation using adjustable removable supports, which contribute support and restrict movement only in desired anatomical planes.

METHODS

The snood was evaluated along with two commercially available orthoses, the Vista and Headmaster, in a series of flexion, extension, axial-rotation and lateral flexion movements. Characterization was performed with twelve healthy participants with and without the orthoses. Two inertial-magneto sensors, placed on the forehead and sternum, were used to quantify the neck's range of motion.

FINDINGS

In its less supportive configuration, the snood was effective in limiting movements to the desired planes, preserving free movement in other planes. The Headmaster was only effective in limiting flexion. The range of motion achieved with the snood in its rigid configuration was equivalent (P>0.05, effect size<0.4) to that achieved with the Vista, both in trials performed reaching the maximum amplitude (range of motion reduction: 25%-34% vs 24%-47%) and at maximum speed (range of motion reduction: 24%-29% vs 25%-43%).

INTERPRETATION

The Sheffield Support Snood is effectively adaptable to different tasks and, in its most supportive configuration, offers a support comparable to the Vista, but providing a less bulky structure. The chosen method is suitable for the assessment of range of motions while wearing neck orthoses and is easily translatable in a clinical context.

The Reed-Stanton press rig for the generation of reproducible fingermarks: Towards a standardised methodology for fingermark research

In the search for better or new methods/techniques to visualise fingermarks or to analyse them exploiting their chemical content, fingermarks inter-variability may hinder the assessment of the method effectiveness. Variability is due to changes in the chemical composition of the fingermarks between different donors and within the same donor, as well as to differential contact time, pressure and angle. When validating a method or comparing it with existing ones, it is not always possible to account for this type of variability. One way to compensate for these issues is to employ, in the early stages of the method development, a device generating reproducible fingermarks. Here the authors present their take on such device, as well as quantitatively describing its performance and benefits against the manual production of marks. Finally a short application is illustrated for the use of this device, at the method developmental stages, in an emerging area of fingerprinting research concerning the retrieval of chemical intelligence from fingermarks.