Characterization of Objective Skin Color Changes during and after Breast and Chest Wall Radiotherapy and Correlation with Radiation-Induced Skin Toxicity in Breast Cancer Patients, Including Patients with Skin of Color

PURPOSE/OBJECTIVE(S)

Radiation dermatitis (RD) is common among women undergoing breast and chest wall radiotherapy (RT); however, existing scales to assess the severity of RD are subjective and do not account for variability in skin of color (SOC). For instance, the Common Terminology Criteria for Adverse Events (CTCAE) criteria do not include hyperpigmentation in the grading scale. There is data indicating worse RD in African American and Hispanic patients; however, the rate and severity in SOC remains unknown given the lack of data using objective measures of RD. Spectrophotometry is one method to quantify the appearance of color by measuring spectral characteristics without the bias associated with subjective clinical scoring. We present a phase I prospective non-therapeutic clinical trial to objectively define SOC at baseline and evaluate spectrophotometric skin changes during and after breast or chest wall RT in parallel with physician-graded RD using CTCAE criteria. We hypothesize that there will be greater discrepancy between physician graded RD and objective measures of RD in patients with SOC in whom hyperpigmentation will be undercaptured by physician-grading. This is the first study intending to correlate SOC with objective changes after RT as a reliable indicator of RD. We offer a novel system for evaluating RD that is applicable to SOC.

MATERIALS/METHODS

A total of 60 patients with localized breast cancer (stage 0-III) undergoing conventional whole breast or chest wall RT (50Gy/ 25 fx), hypofractionated whole breast RT (40.5Gy/15 fx) or ultrahypofractionated partial breast RT (6Gy x5), with or without regional nodal RT were enrolled. 3 skin color readouts using the Commission International de l'Eclairage 3D color system (l*, a*, b*) were measured within the radiation field using a spectrophotometer at baseline, once weekly during RT, 10 days post RT, 4 weeks and 12 months post RT. The spectrophotometer is a non-invasive, hand-held device that is used in the clinic room with no additional equipment or setup requirements. Data is automatically exported to a spreadsheet organized by timepoint and patient. The l* axis is a gray scale (0 = black, 100 = white) correlating with skin pigmentation and the a* axis describes red and green values correlating with erythema. The primary objective is to evaluate the changes from baseline in skin color readouts in the quadrant of tumor location during and after RT based on fractionation. The secondary objective is to evaluate changes within and across groups defined by baseline skin color. Exploratory objectives include evaluating the association of baseline color readouts and changes after RT with acute and late grade > 2 clinician-rated skin and subcutaneous tissue effects according to the CTCAE, v5.0, physician graded cosmesis and clinical interventions to treat RD, such as use of topical steroids and oral analgesics. As of January 2023, we have enrolled 100% of the planned patients.

RESULTS

To be determined.

CONCLUSION

To be determined. Clinical Study Identifier: S22-00192.

Anti-Asian racism related stigma, racial discrimination, and protective factors against stigma: a repeated cross-sectional survey among university students during the COVID-19 pandemic

Background

Since the onset of the COVID-19 pandemic in March 2020, reports of anti-Asian American or Pacific Islander (AAPI) hate have increased in the United States. Institutions of higher education provide a unique opportunity to examine COVID-19 related stigma and protective factors in AAPI young adults enrolled in college.

Objective

The goal of this research was to examine COVID-19 related stigma among a diverse college student population. We posited that AAPI students experience more racial discrimination, internalized stigma, and/or anticipated racial discrimination than other students. We also sought to identify protective behavioral factors against stigma.

Methods

This study includes data from a repeated cross-sectional survey that was administered among college students at a large public university in the United States in April (n = 1,359) and November 2020 (n = 1,196). All university enrolled students with an active email account were eligible to participate in the online survey, which included questions about COVID-19 stigma (anticipated, enacted, internalized), stigma resistance, sources of COVID-19 information, lifestyle behaviors, and sociodemographic information. Binary logistic regression models were utilized to assess differences in stigma between race and ethnic groups and to identify factors associated with stigma.

Results

AAPI students were more likely to experience all three types of stigma compared to other race and ethnic groups. AAPI students in both waves were at least 2 times more likely to experience enacted stigma and 7.3 times more likely to experience anticipated stigma in the earlier wave compared to non-Hispanic White students. Students who had experienced enacted stigma were more likely to experience anticipated stigma, and those who experienced enacted and anticipated stigma were more likely to experience internalized stigma. Higher education level, living with neighbors/roommates, maintaining a healthy lifestyle, and thinking positively about oneself may act as protective factors against different types of stigma.

Conclusion

AAPI students have a greater risk of experiencing COVID-19 stigma compared to those from other race and ethnic groups. Universities should combat anti-AAPI sentiments and COVID-19 stigma and promote public health efforts to build resistance against the negative effects of stigma.

Use of Community-Engaged Research Approaches in Clinical Interventions for Neurologic Disorders in the United States: A Scoping Review and Future Directions for Improving Health Equity Research

BACKGROUND AND OBJECTIVES

Evidence suggests a significant prevalence of race and ethnic disparities in the United States among people with neurologic conditions including stroke, Alzheimer disease and related dementia (ADRD), Parkinson disease (PD), epilepsy, spinal cord injury (SCI), and traumatic brain injury (TBI). Recent neurologic research has begun the paradigm shift from observational health disparities research to intervention research in an effort to narrow the disparities gap. There is an evidence base that suggests that community engagement is a necessary component of health equity. While the increase in disparities focused neurologic interventions is encouraging, it remains unclear whether and how community-engaged practices are integrated into intervention design and implementation. The purpose of this scoping review was to identify and synthesize intervention studies that have actively engaged with the community in the design and implementation of interventions to reduce disparities in neurologic conditions and to describe the common community engagement processes used.

METHODS

Two databases, PubMed and CINAHL, were searched to identify eligible empirical studies within the United States whose focus was on neurologic interventions addressing disparities and using community engagement practices.

RESULTS

We identified 392 disparity-focused interventions in stroke, ADRD, PD, epilepsy, SCI, and TBI, of which 53 studies incorporated community engagement practices: 32 stroke studies, 15 ADRD, 2 epilepsy studies, 2 PD studies, 1 SCI study, and 1 TBI study. Most of the interventions were designed as randomized controlled trials and were programmatic in nature. The interventions used a variety of community engagement practices: community partners (42%), culturally tailored materials and mobile health (40%), community health workers (32%), faith-based organizations and local businesses (28%), focus groups/health need assessments (25%), community advisory boards (19%), personnel recruited from the community/champions (19%), and caregiver/social support (15%).

DISCUSSION

Our scoping review reports that the proportion of neurologic intervention studies incorporating community engagement practices is limited and that the practices used within those studies are varied. The major practices used included collaboration with community partners and utilization of culturally tailored materials. We also found inconsistent reporting and dissemination of results from studies that implemented community engagement measures in their interventions. Future directions include involving the community in research early and continuously, building curricula that address challenges to community engagement, prioritizing the inclusion of community engagement reporting in peer-reviewed journals, and prioritizing and incentivizing research of subpopulations that experience disparities in neurologic conditions.

Abstract WP183: Social Activities Are Positively Associated With Medication Adherence In Stroke Survivors

Introduction: Social support may influence illness incidence or recovery through effects on health-related behaviors, and one aspect is emotional support, which includes the offering of empathy, friendship, care, and trust along with information. While we have previously reported on the positive relationship of family and friend networks in risk reduction, our objective was to examine whether participation in formalized group activities was related to medication adherence post-stroke.

Methods: Using Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) data, information regarding religious and nonreligious social activities was collected at baseline. The outcome variable was measured by the self-reported 8-item Morisky Medication Adherence Scale (MMAS-8; score 0-8). Medium/high adherence (MMAS-8≥6) at 6- and 12-months post-discharge was modeled against social activities separately using logistic regression adjusting for age, gender, race/ethnicity, education, family and friend networks, NIH stroke scale at admission, and the intervention.

Results: Of the 541 participants who completed the baseline questionnaire, 286 and 344 had valid MMAS-8 scores for post 6-months and 12-months follow-up data collection. Medication adherence was poor among the participants. Only 44% for 6-months and 46% for 12-months had medium or high medication adherence. Participants going to nonreligious social events (n = 67, 21%) had higher odds of having medium/high medication adherence (OR = 3.08, 95% CI: 1.15-8.25) at 12-months.

Discussion: Nonreligious social activities, including meetings of social clubs or other non-religious groups not relevant to work, were shown to be positively related to 12-months post-discharge medication adherence among stroke patients. Social activities may play an important role in emotional support and may be an opportunity for targeted secondary stroke prevention.

Abstract WP186: Fewer Self-reported Memory Problems Are Associated With Better Blood Pressure Control Post-stroke

Introduction: Memory problems, a common cognitive issue, can have a negative influence on one’s ability to function and contributes to increased risk of secondary stroke.

Objective: To examine the association between self-reported memory problems at 6 months and blood pressure control at 12 months post-stroke.

Methods: This study utilized follow-up data from the Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) stroke risk factor reduction trial (n=226). Sample size was restricted to those who answered memory questions and had a 12-month blood pressure (BP) reading. Exclusion criteria for DESERVE included any significant memory disorder prior to the baseline stroke. Seven memory domain questions (Table 1) from the Stroke Impact Scale were used separately to assess the association with systolic BP, with control defined as ≤120mmHg, at 12 months in logistic regression models adjusted for race, gender, education, age, and intervention status. Models were additionally adjusted for 6-month BP control as a mediator.

Results: Participants were almost equally white (28%), Black (33%), or Hispanic (34%) and 52% were female with a mean age of 65 (SD=13). About 25% had BP control at 6 or 12 months. Memory measures were not significantly associated with BP control prior to adjusting for BP control at 6 months. After adjusting for 6-month BP control, participants with less difficulty remembering things that people just told them (OR=1.69, 95% CI: 1.09, 2.63) or remembering to do things (OR=1.76, 95% CI:1.09, 2.86) had better odds of having their BP controlled at 12 months. Memory items 2 and 4-7 did not show an association with better BP control.

Discussion: Stroke survivors who were better at remembering what people told them and remembering to do things were more likely to achieve blood pressure control 1-year post-stroke. Evaluating early memory post-stroke may be an important target for secondary prevention strategies and should be further researched.

Abstract WP81: The Association Between Health-related Locus Of Control And Post-stroke Disability, Quality Of Life, And Depression

Introduction: Beliefs regarding ones’ control over their health can lie internally, influenced by their own actions, or externally, controlled by others or due to chance.

Objective: To examine the association between health-related locus of control (HRLC) type and post-stroke disability, quality of life, and depression.

Methods: This study utilized data from the Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) trial (n=552). Participants were categorized into three groups based on their highest Multidimensional Health Locus of Control (MHLC) score. The Stroke Impact Scale (SIS) was used to assess post-stroke disability and quality of life. Linear regression was used to identify differences in each SIS domain score between the three groups while adjusting for the intervention. Depression was defined as a Center for Epidemiological Studies Depression (CESD) score ≥16. Logistic regression was used to examine differences in depression between the three groups while adjusting for the intervention.

Results: Of the 529 participants who completed the MHLC questionnaire at baseline, 179 (33.3%) were categorized into the internal group , 163 (30.8%) into the powerful others group, and 190 (35.9%) into the chance group. Of the 297 participants who completed the CESD questionnaires at 12 months, 163 (54.8%) scored ≥ 16. Participant’s mean scores for each SIS domain are reported in Table 1. For the SIS communication domain, the chance group’s mean score was 3.03 points lower than the powerful others group’s score (SE=1.39, p=.029). There were no statistically significant differences in scores for the other seven SIS domains or for depression between groups (Table 1).

Discussion: External HRLC based on chance may be a predictor of communication difficulties in patients post-stroke. However, mean communication scores are skewed. Control beliefs are important in post-stroke recovery. More research is needed to validate these findings.

Abstract P723: Adaptation of Stroke Prevention Interventions for Low- and Middle-Income Countries: A Scoping Review

Introduction: Stroke is a leading cause of mortality globally, with 85% of stroke death occurring in low- and middle-income countries (LMICs). Translation of evidence-based stroke prevention interventions from their original setting to the novel context in which they will be implemented is often unreported; especially in LMICs where it has been severely understudied. Thus, our objective was to investigate how adaptation has been examined within research on stroke prevention interventions in LMICs through a scoping review of the available literature in order to highlight benefits and best-practices, identify gaps, and develop a greater understanding of these efforts that will ultimately support attempts to address the global burden of stroke.

Methods: This review was conducted in accordance with PRISMA-ScR guidelines. Five databases were searched (PubMed, PsycINFO, CINAHL, EMBASE, and Web of Science), for eligible studies using a search strategy developed in consultation with a research librarian. Two reviewers independently assessed the retrieved articles for selection based on the inclusion criteria (peer-reviewed empirical papers or protocols, reported on adaptation of stroke prevention interventions, and occurred in at least one LMIC) through a two phase process consisting of (1) title and abstract screening and (2) full-text screening. Discrepancies were resolved through discussion until consensus was reached. Data were charted and a narrative synthesis, guided by the FRAME framework, was used to analyze and interpret the findings.

Results: Of 380 articles retrieved, a total of six articles reporting adaptation of primary (n=4) or secondary (n=2) stroke prevention interventions in LMICs were identified. Types of interventions included use of community health workers (n = 2), use of mHealth tools (n=2), and interventions aimed at risk factor modification (n = 2). Adaptations were proactively planned, with multiple adaptation goals reported.

Conclusions: This is the first review of its kind to focus on adaptation of evidence-based stroke prevention interventions in LMICs. Through our systematic investigation, we highlight the need for additional research to assess the processes and outcomes of stroke prevention interventions.

Abstract P681: Implementation of Stroke Prevention Interventions in Low- and Middle-Income Countries: A Scoping Review

Background: Stroke is the second leading cause of death globally and an increasing concern in low- and middle-income countries (LMIC) where, due to limited capacity to treat stroke, preventative efforts are critically important. Although some research on evidence-based interventions for stroke prevention in LMIC exists, there remains a significant gap in understanding of their implementation across various contexts in LMIC.

Objectives: In this scoping review, our objective was to identify and synthesize the implementation outcomes (using Proctor et al.’s taxonomy, 2011) for stroke prevention interventions, as well as to describe the diverse interventions employed.

Methods: Eligible studies were empirical, focused on implementation of stroke prevention programs or policies, and occurred in at least one LMIC. Five databases were searched, including PubMed, PsycINFO, CINAHL, EMBASE, and Web of Science. Two reviewers independently assessed studies for selection and charted data; discrepancies were resolved through discussion with a third reviewer until consensus was reached. Narrative synthesis was used to analyze and interpret the findings.

Results: Studies were predominantly focused in Asia, targeting primary or secondary prevention, and facility-based. Interventions were conducted at the level of individual (n=11), system (n=12), or both (n=4). Various implementation outcomes were reported, most commonly cost (n=10), acceptability (n=7), fidelity (n=7), and feasibility (n=6), but also adoption (n=4), penetration (n=3), appropriateness (n=1), and sustainability (n=1).

Conclusions: Findings highlight the breadth of evidence-based interventions for stroke prevention available to implement in LMIC settings, including culturally acceptable education interventions, cost-effective medications, and community-based interventions implemented by community health workers. Implementation outcomes remain under-reported, and more rigorous research is needed to better plan and evaluate the implementation of these interventions to prevent stroke.

Effects of an Exoskeleton-Assisted Gait Motor Imagery Training in Functional Brain Connectivity

Lower-limb exoskeletons have been used in gait rehabilitation to facilitate the restoration of motor skills. These robotics systems could be complemented by Brain-Computer Interfaces (BCIs) to assist or rehabilitate people with walking disabilities. In this preliminary study, electroencephalography-based brain functional connectivity is analyzed during exoskeleton-assisted gait motor imagery (MI) training. Partial Directed Coherence (PDC) analysis was employed to assess the exchange of information flow between EEG signals during gait MI in four healthy subjects, two using an exoskeleton and two without using it. Besides, in order to explore the functional connectivity, an outflow index based on the number of significant directed connectivities revealed by the PDC analysis is proposed. We found that the outflow index increases in the central zone (C2, C3, C4) while decreases in the central-parietal (CP1, CP2) and fronto-central (FC1) zones when the training was assisted by an exoskeleton. The results obtained can be useful to obtain informative features for BCI applications as well as in motor rehabilitation.

First operation in SPIDER and the path to complete MITICA

The requirements of ITER neutral beam injectors (1 MeV, 40 A negative deuterium ion current for 1 h) have never been simultaneously attained; therefore, a dedicated Neutral Beam Test Facility (NBTF) was set up at Consorzio RFX (Padova, Italy). The NBTF includes two experiments: SPIDER (Source for the Production of Ions of Deuterium Extracted from Rf plasma), the full-scale prototype of the source of ITER injectors, with a 100 keV accelerator, to investigate and optimize the properties of the ion source; and MITICA, the full-scale prototype of the entire injector, devoted to the issues related to the accelerator, including voltage holding at low gas pressure. The present paper gives an account of the status of the procurements, of the timeline, and of the voltage holding tests and experiments for MITICA. As for SPIDER, the first year of operation is described, regarding the solution of some issues connected with the radiofrequency power, the source operation, and the characterization of the first negative ion beam.