Large-scale analysis of structural brain asymmetries during neurodevelopment: Associations with age and sex in 4265 children and adolescents

Only a small number of studies have assessed structural differences between the two hemispheres during childhood and adolescence. However, the existing findings lack consistency or are restricted to a particular brain region, a specific brain feature, or a relatively narrow age range. Here, we investigated associations between brain asymmetry and age as well as sex in one of the largest pediatric samples to date (n = 4265), aged 1-18 years, scanned at 69 sites participating in the ENIGMA (Enhancing NeuroImaging Genetics through Meta-Analysis) consortium. Our study revealed that significant brain asymmetries already exist in childhood, but their magnitude and direction depend on the brain region examined and the morphometric measurement used (cortical volume or thickness, regional surface area, or subcortical volume). With respect to effects of age, some asymmetries became weaker over time while others became stronger; sometimes they even reversed direction. With respect to sex differences, the total number of regions exhibiting significant asymmetries was larger in females than in males, while the total number of measurements indicating significant asymmetries was larger in males (as we obtained more than one measurement per cortical region). The magnitude of the significant asymmetries was also greater in males. However, effect sizes for both age effects and sex differences were small. Taken together, these findings suggest that cerebral asymmetries are an inherent organizational pattern of the brain that manifests early in life. Overall, brain asymmetry appears to be relatively stable throughout childhood and adolescence, with some differential effects in males and females.

Factors Associated With Cardiac Radiation Dose Reduction After Hypofractionated Radiation Therapy for Localized, Left-Sided Breast Cancer in a Large Statewide Quality Consortium

PURPOSE

Limiting cardiac radiation dose is important for minimizing long-term cardiac toxicity in patients with left-sided early-stage breast cancer.

METHODS AND MATERIALS

Prospectively collected dosimetric data were analyzed for patients undergoing moderately hypofractionated radiation therapy to the left breast within the Michigan Radiation Oncology Quality Consortium from 2016 to 2022. The mean heart dose (MHD) goal was progressively tightened from ≤2 Gy in 2016 to MHD ≤ 1.2 Gy in 2018. In 2021, a planning target volume (PTV) coverage goal was added, and the goal MHD was reduced to ≤1 Gy. Multivariate logistic regression models were developed to assess for covariates associated with meeting the MHD goals in 2016 to 2020 and the combined MHD/PTV coverage goal in 2021 to 2022.

RESULTS

In total, 4165 patients were analyzed with a median age of 64 years. Overall average cardiac metric compliance was 91.7%. Utilization of motion management increased from 41.8% in 2016 to 2020 to 46.5% in 2021 to 2022. Similarly, use of prone positioning increased from 12.2% to 22.2% in these periods. On multivariate analysis in the 2016 to 2020 cohort, treatment with motion management (odds ratio [OR], 5.20; 95% CI, 3.59-7.54; P < .0001) or prone positioning (OR, 3.21; 95% CI, 1.85-5.57; P < .0001) was associated with meeting the MHD goal, while receipt of boost (OR, 0.25; 95% CI, 0.17-0.39; P < .0001) and omission of hormone therapy (OR, 0.65; 95% CI, 0.49-0.88; P = .0047) were associated with not meeting the MHD goal. From 2021 to 2022, treatment with motion management (OR, 1.89; 95% CI, 1.12-3.21; P = .018) or prone positioning (OR, 3.71; 95% CI, 1.73-7.95; P = .0008) was associated with meeting the combined MHD/PTV goal, while larger breast volume (≥1440 cc; OR, 0.34; 95% CI, 0.13-0.91; P = .031) was associated with not meeting the combined goal.

CONCLUSIONS

In our statewide consortium, high rates of compliance with aggressive targets for limiting cardiac dose were achievable without sacrificing target coverage.

Pectoralis Muscle Dosimetry and Posttreatment Rehabilitation Utilization for Patients With Early-Stage Breast Cancer

PURPOSE

Up to 50% of women treated for localized breast cancer will experience some degree of arm or shoulder morbidity. Although radiation is thought to contribute to this morbidity, the mechanism remains unclear. Prior studies have shown biologic and radiographic changes in the pectoralis muscles after radiation. This study thus aimed to investigate the relationship between radiation to the pectoralis muscles and referrals for rehabilitation services posttreatment for arm and shoulder morbidity.

METHODS AND MATERIALS

A retrospective 1:1 matched case-control study was conducted for patients with breast cancer who were and were not referred for breast or shoulder rehabilitation services between 2014 and 2019 at a single academic institution. Patients were included if they had a lumpectomy and adjuvant radiation. Patients who underwent an axillary lymph node dissection were excluded. Cohorts were matched based on age, axillary surgery, and use of radiation boost. Muscle doses were converted to equivalent dose in 2 Gy fractions assuming an α:β ratio of 2.5 and were compared between the 2 groups.

RESULTS

In our cohort of 50 patients of a median age 60 years (interquartile range, 53-68 years), 36 patients (72%) underwent a sentinel lymph node biopsy in addition to a lumpectomy. Although pectoralis muscle doses were generally higher in those receiving rehabilitation services, this was not statistically significant. Pectoralis major V20-40 Gy reached borderline significance, as did pectoralis major mean dose (17.69 vs 20.89 Gy; P = .06).

CONCLUSIONS

In this limited cohort of patients, we could not definitively conclude a relationship between pectoralis muscle doses and use of rehabilitation services. Given the borderline significant findings, this should be further investigated in a larger cohort.

Shoulder Muscle Dosimetry and Post-Treatment Rehabilitation Utilization for Early-Stage Breast Cancer Patients

PURPOSE/OBJECTIVE(S)

Rehabilitation services for recovery of impaired physical function following breast cancer treatments are largely underutilized. We previously found that breast cancer survivors treated with radiation who received higher radiation doses to the pectoralis major are more likely to self-report shoulder pain and disability. This study aims to address whether radiation dose delivered to the pectoralis major (Pmaj) and pectoralis minor (Pmin) are correlated with referrals for rehabilitation services post-treatment.

MATERIALS/METHODS

A retrospective 1:1 matched case-control study was conducted for breast cancer patients who were and were not referred for breast or shoulder rehabilitation services between 2014-2019 at a single academic institution. Patients were included if they had a lumpectomy and adjuvant radiation without regional nodal irradiation. Cohorts were matched based on age, axillary surgery (none vs. sentinel lymph node biopsy (SLNB)), and use of radiation boost. We used non-parametric Mann-Whitney U tests to determine whether Pmaj or Pmin doses (mean, V50Gy, V45Gy, V40Gy, V35Gy, V30Gy, V20Gy) were different between the two groups. Muscle doses were converted to EQD2 assuming an α/β ratio of 2.5.

RESULTS

In our study of 30 patients of a median age 57 years (IQR 12.75), 20 (66.67%) patients underwent SLNB in addition to lumpectomy. Median tumor size was 1.1cm (range 0.16 - 7.30cm). Stage was 0 for 11 patients (36.67%), I for 14 patients (46.67%), and II for 5 patients (16.67%). 3D conformal radiation was delivered to the whole breast with a moderately hypofractionated (n = 17) or conventionally fractionated regimen (n = 13). The most common rehabilitation diagnoses were lymphedema (n = 8), scar management (n = 7) and shoulder pain (n = 5). Mean dose to both the Pmaj (20.8Gy vs. 18.6Gy; p = 0.02) and Pmin (30.6Gy vs. 24.6Gy; p = 0.01) were significantly higher in patients who received post-treatment rehabilitation compared to those without. The V40Gy, V35Gy, V30Gy and V20Gy (all p<0.02) for the Pmin and V35Gy, V30Gy and V20Gy for the Pmaj (all p<0.04) were also significantly higher in those who underwent rehabilitation.

CONCLUSION

In this cohort of patients with early-stage breast cancer, increased mean doses to the pectoralis muscles were correlated with increased use of rehabilitation services after radiation. Physicians might consider using these dosimetric data to complement clinical symptoms in the decision-making process for referrals for rehabilitation services. This may help facilitate earlier referral to rehabilitation interventions, which is important since early intervention is correlated with improved shoulder morbidity.

Impact of Breast Volume on Achieving a Conservative Heart and Target Coverage Metric for Patients Receiving Whole Breast Radiotherapy in a Statewide Consortium

PURPOSE/OBJECTIVE(S)

Radiation to large breast volumes (BV) has been associated with increased dose inhomogeneities, breast fibrosis, and induration. Radiation exposure to the heart during breast radiotherapy has been associated with late cardiovascular morbidity and mortality. This study, therefore, investigates the impact of BV on achieving optimal lumpectomy cavity target coverage (V95% [%] >95) while maintaining mean heart dose constraints (MHD, mean [Gy] <1) across a range of BV from patients enrolled in a statewide consortium.

MATERIALS/METHODS

A retrospective analysis was conducted for 2,506 patients receiving left-sided whole breast moderately-hypofractionated (2.5-2.8 Gy/fx) radiotherapy without nodal fields between 2018-2022. The BV was calculated for each patient from contours in the treatment planning system, and the volume distribution partitioned into quartiles. Dosimetric parameters were calculated from dose-volume histograms. The percentage of patients in which the metrics were achieved was calculated for each BV quartile for different treatment positions: all positions, supine, supine with breathing motion management, and prone.

RESULTS

The BV ranges within the quartiles (∼620 patients/quartile) were ≤720.0 cc, 720.1 to ≤1065.0 cc, 1065.1 to ≤1500.0 cc, and >1500.0 cc for quartiles Q1-Q4, respectively. Of the 2,506 patients, 76% were treated supine (of which 41.6% were treated using breathing motion management techniques), 23.5% were treated prone, and 0.5% were treated decubitus. Discrete percentages of patients able to meet the metrics are provided in the table. An increase in BV from Q1 to Q4 correlated with lower percentages of patients meeting the MHD metric, however no correlation was observed between BV and target coverage. Treating supine with breathing motion management resulted in a higher percentage of patients meeting the MHD metric (odds ratio (OR) = 1.96 relative to supine without motion management, p<0.0001), while the prone setup proved to be the superior technique across all quartiles (OR = 3.95 relative to supine, p<0.0001).

CONCLUSION

Increasing BVs resulted in lower percentages of patients receiving MHD≤1 Gy. Thus, cardiac sparing may be more difficult to achieve in patients with larger BV. Utilization of alternate treatment positions, such as supine with breathing motion management and prone, greatly improved the percentage of patients able to meet the MHD metric without sacrificing target coverage in all quartiles. Prone positioning was the technique least susceptible to BV effects in meeting the MHD≤1 Gy goal.

Factors Associated with Cardiac Radiation Dose Reduction Following Hypofractionated Radiation Therapy for Localized, Left-Sided Breast Cancer in a Large Statewide Quality Consortium

PURPOSE/OBJECTIVE(S)

Limiting radiation dose to the heart is important for minimizing the risk of long-term cardiac toxicity in patients with left-sided early-stage breast cancer.

MATERIALS/METHODS

Prospectively collected dosimetric data were analyzed for patients undergoing hypofractionated radiation therapy to the left breast for localized node-negative breast cancer within the Michigan Radiation Oncology Quality Consortium (MROQC) from 2016-2022. Goals for limiting cardiac dose were adjusted over time. From 2016-2020, the cardiac quality metric focused on total mean heart dose (MHD) from the composite whole breast and boost plans, tightening from a goal of MHD ≤2 Gy to MHD ≤1.2 Gy by 2020. In 2021-2022, the cardiac metric transitioned to a combined goal of MHD ≤1.0 Gy from the whole breast plan and ≥95% lumpectomy cavity planning target volume (PTV) receiving 95% of the prescription dose. Separate multivariate logistic regression models were developed to assess for covariates associated with meeting the MHD goal in 2016-2020 and combined MHD/PTV coverage goal in 2021-2022.

RESULTS

In total, 4,165 patients were analyzed with a median age of 64 years. Most patients (86%) had either Tis or T1 disease, and 66% received hormone therapy. Baseline demographic and disease characteristics did not change substantially between treatment periods. Use of breath-hold or motion gating increased from 42% in 2016-2020 to 46% in 2021-2022. Similarly, use of prone positioning increased from 12% to 20%. From 2016-2020, 90.9% of plans achieved the MHD goal, compared to 93.6% of plans achieving the composite MHD/PTV goal from 2021-2022. On multivariate analysis in the 2016-2020 cohort, treatment with motion management (OR 5.20, 95% CI [3.59-7.54], p<0.0001) or prone positioning (OR 3.21, 95% CI [1.85-5.57], p < 0.0001) were associated with meeting the MHD goal, while receipt of boost (OR 0.25, 95% CI [0.17-0.39], p<0.0001) and omission of hormone therapy (OR 0.65, 95% CI [0.49-0.88], p = 0.0047), were associated with not meeting the MHD goal. During the era including composite heart dose and PTV coverage goals (2021-2022), treatment with motion management (OR 1.89, 95% CI [1.12-3.21], p = 0.018) or prone positioning (OR 3.71, 95% CI [1.73-7.95], p = 0.0008) were associated with meeting the combined goal, while larger breast volume (≥1440 cc, OR 0.34, 95% CI [0.13 - 0.91], p = 0.031) and treatment at an academic center (OR 0.36, 95% CI [0.22-0.67], p = 0.0009) were associated with not meeting the combined goal.

CONCLUSION

In our statewide consortium, rates of compliance with aggressive targets for limiting cardiac dose remain high, despite tightening of these goals to include lower mean heart doses and inclusion of a concurrent PTV coverage goal. Treatment using motion management or prone positioning is associated with achieving the cardiac dose goals.

Patient Factors and Preferences in Choosing Sleep Surgery for Obstructive Sleep Apnea: A Qualitative Study

OBJECTIVE

There are several obstructive sleep apnea (OSA) treatment options available to patients, including surgery and less invasive therapies. Little is known about the factors that influence patient preferences for treatment. We aimed to understand factors influencing patient experience and decision making for undergoing sleep surgery.

STUDY DESIGN

Retrospective qualitative study.

SETTING

Tertiary sleep surgery clinic.

METHODS

We conducted semistructured interviews with adults who previously underwent any nasal and/or pharyngeal sleep surgery. We asked open-ended questions about their decision-making process within a preconceived thematic framework of chief OSA symptoms, expectations for recovery, and sources of information. The interviews were audio recorded and transcribed, and content was analyzed for defined, emergent, and prevalent themes.

RESULTS

Ten patients were interviewed from December 11, 2020 through January 29, 2021. Six patients underwent nasal surgery, 1 underwent pharyngeal surgery, and 3 underwent staged nasal and pharyngeal procedures. All patients were beyond the acute recovery phase. Reasons for pursuing surgical consultation varied from sleep apnea burden to external factors, such as recommendations from significant others. Duration of sleep surgery consideration varied from months to years. Major concerns about sleep surgery involved anesthesia and postoperative pain. External factors influencing patients' decisions to pursue sleep surgery included family and friend support. Postoperative outcomes of surgery included patient satisfaction with decision for surgery, given OSA improvements.

CONCLUSION

Understanding patient factors that influence decision making for sleep surgery may guide clinicians in patient-centered counseling that engages patients in decision making, aligning with clinical symptoms and patient preferences.

Knowledge-Based Quality Assurance and Model Maintenance in Lung Cancer Radiation Therapy in a Statewide Quality Consortium of Academic and Community Practice Centers

PURPOSE

Locally advanced lung cancer (LALC) treatment planning is often complex due to challenging tradeoffs related to large targets near organs at risk, making the judgment of plan quality difficult. The purpose of this work was to update and maintain a multi-institutional knowledge-based planning (KBP) model developed by a statewide consortium of academic and community practices for use as a plan quality assurance (QA) tool.

METHODS AND MATERIALS

Sixty LALC volumetric-modulated arc therapy plans from 2021 were collected from 24 institutions. Plan quality was scored, with high-quality clinical (HQC) plans selected to update a KBP model originally developed in 2017. The model was validated via automated KBP planning, with 20 cases excluded from the model. Differences in dose-volume histogram metrics in the clinical plans, 2017 KBP model plans, and 2022 KBP model plans were compared. Twenty recent clinical cases not meeting consortium quality metrics were replanned with the 2022 model to investigate potential plan quality improvements.

RESULTS

Forty-seven plans were included in the final KBP model. Compared with the clinical plans, the 2022 model validation plans improved 60%, 65%, and 65% of the lung V20Gy, mean heart dose, and spinal canal D0.03cc metrics, respectively. The 2022 model showed improvements from the 2017 model in hot spot management at the cost of greater lung doses. Of the 20 recent cases not meeting quality metrics, 40% of the KBP model-replanned cases resulted in acceptable plans, suggesting potential clinical plan improvements.

CONCLUSIONS

A multi-institutional KBP model was updated using plans from a statewide consortium. Multidisciplinary plan review resulted in HQC model training plans and model validation resulted in acceptable quality plans. The model proved to be effective at identifying potential plan quality improvements. Work is ongoing to develop web-based training plan review tools and vendor-agnostic platforms to provide the model as a QA tool statewide.

Barriers and communication behaviors impacting referral to sleep surgery: qualitative patient perspectives

STUDY OBJECTIVES

Physician-patient interactions influence the immediate encounter and leave lasting impressions for future health care encounters. We aimed to understand patient experiences and decision-making for considering sleep surgery, in terms of barriers and communication behaviors that facilitate or hinder referral for consideration of sleep surgery management of obstructive sleep apnea (OSA) when continuous positive airway pressure (CPAP) therapy has failed.

METHODS

We employed qualitative methods, using semistructured interviews of adults with OSA who presented for sleep surgery consultation after unsatisfactory therapy with CPAP. Open-ended questions traced symptoms and progression of sleep apnea burden, trials of noninvasive OSA therapies, outcomes, and patient expectations and concerns. The interviews were audio-recorded, transcribed, and analyzed using content analysis to identify themes.

RESULTS

Ten adult patients with OSA were enrolled March through April 2021 and reached predominant thematic saturation. Barriers to sleep surgery consultation included: (1) delays in OSA diagnosis due to limited OSA awareness among patients or primary providers and patients' perceived inconvenience of sleep testing, (2) patients faulted for slow progress, (3) patient-reported lack of urgency by providers in troubleshooting noninvasive management options, (4) scheduling delays and waitlists, and (5) cost. Patients were receptive to noninvasive treatment options, but inadequate improvement led to frustration after multiple encounters. Patients appreciated empathetic providers who shared information through transparent and understandable explanations and who presented multiple treatment options.

CONCLUSIONS

Experiences of patients with OSA highlight the need for shared decision-making through improved communication of unresolved concerns and alternative management options, including timely referral for sleep surgery consultation when indicated.

CITATION

Ikeda AK, McShay C, Marsh R, et al. Barriers and communication behaviors impacting referral to sleep surgery: qualitative patient perspectives. J Clin Sleep Med. 2023;19(1):111-117.

Diversified Farming Systems: Impacts and Adaptive Responses to the COVID-19 Pandemic in the United States, Norway and China

The COVID-19 pandemic fully exposed the vulnerability of the global agri-food system to shocks and stresses, highlighting the need for transformation and action to make it more resilient and inclusive. This paper offers a unique insight into the global nature of the COVID-19 pandemic by examining impacts and responses in the agri-food sector within three very distinct contexts, namely the United States, Norway, and China. Focusing on small, diversified farms, the study builds on prior research with the same farmers and support organizations from an on-going collaboration. Firstly, we conducted a short review of policy adaptations to understand how governments, the private sector, non-profit organizations, and communities “stepped up” to provide emergency relief, specialized training, and recovery support for farmers, support that was instrumental in preventing more devastating impacts in all three countries. Secondly, drawing from in-depth interviews with farmers (23) and government and non-governmental support organizations (19), we mapped the vulnerability and resiliency of selected farmers to shocks that severely disrupted traditional supply chains during the COVID-19 pandemic. Data were collected on both the negative and positive impacts of the pandemic to farmer inputs, including labor, operations, and markets, how these changed from the initial lockdowns in early 2020 and through 2021, and on farmer adaptive responses to these impacts. In some contexts, innovation and adaptive responses counteracted negative impacts. We saw diversifying markets, catering to consumer safety concerns, switching to direct and e-markets, hiring in more labor or relying on family labor, and switching to high demand crops and products as the most prominent adaptive responses. Farmers who lacked access to information and government programs, in large part because of language, technology and institutional barriers, missed out on pandemic related opportunities and suffered the most. As we enter the post-pandemic new normal it is important to take stock of lessons learned, and to continue to support those initiatives and innovations that were pivotal not only for weathering the storm, but for building a more inclusive and resilient agri-food system in the long-run.

POS0339 POINTS TO CONSIDER AT THE EARLIEST STAGES OF THE DIAGNOSIS AND MANAGEMENT OF HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS/MACROPHAGE ACTIVATION SYNDROME (HLH/MAS)

Background

Hemophagocytic Lymphohistiocytosis (HLH) and Macrophage Activation Syndrome (MAS) are life-threatening systemic hyperinflammatory syndromes that occur in many contexts and are often called by many names. They nevertheless can progress rapidly, and early identification and management are critical for preventing organ failure and mortality.

Objectives

The purpose of this effort was to develop a series of ‘points to consider’ to assist clinicians at the earliest stages of evaluation and diagnosis, management, and monitoring of patients with HLH/MAS in order to improve patient outcomes.

Methods

A working group of adult and pediatric rheumatologists (14), hematologist/oncologists (4), immunologists (2), infectious disease specialists (2), intensivists (3), allied health care professionals (1), and patients/parents (2) formulated relevant research questions for a systematic literature review (SLR). We then used the SLR results, Delphi questionnaires, and consensus methodology to devise and refine overarching and specific ‘points to consider’ statements.

Results

The group arrived at six overarching statements and 24 specific points-to-consider relevant to early decision-making in diagnostics, initial management, and monitoring of HLH/MAS. Major themes included the a) need for prompt recognition, evaluation, and management of underlying triggers and conditions, b) multi-disciplinary/expert input, and c) early, tailored intervention with the goals of halting disease progression and preventing life- and organ-threatening immunopathology

Conclusion

These 2022 EULAR/ACR Points to Consider provide guidance on the initial evaluation, management, and monitoring of patients during the initial consideration of HLH/MAS.

Disclosure of Interests

Bita Shakoory: None declared, Ashley Geerlinks: None declared, Marta Wilejto: None declared, Kate Kernan: None declared, Erkan Demirkaya: None declared, Angelo Ravelli: None declared, Rashmi Sinha: None declared, Raphaela goldbach-mansky Grant/research support from: SOBI, Novartis, Regneneron, IFM, Lilly, Pfizer, Fabrizio De Benedetti Consultant of: abbvie, sobi, novimmune, novartis, roche, sanofi, Grant/research support from: sobi novimmune novartis roche sanofi, Rebecca Marsh: None declared, Scott Canna Consultant of: Simcha Therapeutics, Grant/research support from: Immvention therapeutics, AB2Bio Ltd, Novartis

0794 Understanding Barriers and Communication Behaviors Impacting Referral to Sleep Surgery: Qualitative Patient Perspectives

Introduction

Shared decision-making is a process when patients, families, and clinicians work together to make optimal, personalized medical choices in the face of more than one reasonable treatment option. These interactions can influence the joint decision and may have lasting impressions for future healthcare encounters. Considering the American Academy of Sleep Medicine’s recent clinical practice guideline on the referral of adults with obstructive sleep apnea (OSA) for surgical consultation, we aimed to understand patient experiences, in terms of barriers and communication behaviors in the referral process to sleep surgery consultation.

Methods

We performed a qualitative study consisting of in-depth semi-structured virtual interviews with adult patients (aged ≥18 years) with OSA (apnea-hypopnea index ≥5 events per hour of sleep, scored by AASM-accredited standards) and who were recommended for sleep surgery at a tertiary Sleep Surgery Clinic. Open ended questions focused on patient experiences during healthcare encounters from diagnosis, trials with noninvasive management options and ultimate referral to sleep surgery. The interviews were audio-recorded, transcribed, and analyzed using content analysis to identify themes.

Results

Ten adult patients with OSA who were evaluated in sleep surgery clinic were approached and enrolled from March through April 2021. Barriers to sleep surgery clinic included delays in OSA diagnosis due to limited OSA awareness and perceived inconvenience of sleep study, providers faulting patient for persistent sleep symptoms, patient-reported lack of urgency by providers in troubleshooting noninvasive management options, scheduling delays and waitlists, and cost. Patients were open to trialing noninvasive treatment options, though opportunities for reevaluation and shared decision-making may address unmet needs, as inadequate improvements led to frustration after multiple encounters. Patients appreciated providers who were empathetic and provided information sharing, in terms of transparent and understandable explanations.

Conclusion

This study focused on experiences of patients with OSA and barriers faced to reach sleep surgery consultation. Improved communication structure to discuss unresolved concerns and remaining management options, as well as vetted resources, would set the foundation for effective shared decision-making and timely referral for sleep surgery consultation.

Support (If Any)

Academy of Otolaryngology Head and Neck Surgery Resident Research Centralized Otolaryngology Research Efforts (CORE). NIH T32 DC000018.

Comparative Effectiveness Analysis of 3D-Conformal Radiation Therapy Versus Intensity Modulated Radiation Therapy (IMRT) in a Prospective Multicenter Cohort of Patients With Breast Cancer

PURPOSE

Simple intensity modulation of radiation therapy reduces acute toxicity compared with 2-dimensional techniques in adjuvant breast cancer treatment, but it remains unknown whether more complex or inverse-planned intensity modulated radiation therapy (IMRT) offers an advantage over forward-planned, 3-dimensional conformal radiation therapy (3DCRT).

METHODS AND MATERIALS

Using prospective data regarding patients receiving adjuvant whole breast radiation therapy without nodal irradiation at 23 institutions from 2011 to 2018, we compared the incidence of acute toxicity (moderate-severe pain or moist desquamation) in patients receiving 3DCRT versus IMRT (either inverse planned or, if forward-planned, using ≥5 segments per gantry angle). We evaluated associations between technique and toxicity using multivariable models with inverse-probability-of-treatment weighting, adjusting for treatment facility as a random effect.

RESULTS

Of 1185 patients treated with 3DCRT and conventional fractionation, 650 (54.9%) experienced acute toxicity; of 774 treated with highly segmented forward-planned IMRT, 458 (59.2%) did; and of 580 treated with inverse-planned IMRT, 245 (42.2%) did. Of 1296 patients treated with hypofractionation and 3DCRT, 432 (33.3%) experienced acute toxicity; of 709 treated with highly segmented forward-planned IMRT, 227 (32.0%) did; and of 623 treated with inverse-planned IMRT, 164 (26.3%) did. On multivariable analysis with inverse-probability-of-treatment weighting, the odds ratio for acute toxicity after inverse-planned IMRT versus 3DCRT was 0.64 (95% confidence interval, 0.45-0.91) with conventional fractionation and 0.41 (95% confidence interval, 0.26-0.65) with hypofractionation.

CONCLUSIONS

This large, prospective, multicenter comparative effectiveness study found a significant benefit from inverse-planned IMRT compared with 3DCRT in reducing acute toxicity of breast radiation therapy. Future research should identify the dosimetric differences that mediate this association and evaluate cost-effectiveness.

Cardiac Magnetic Resonance Imaging and Blood Biomarkers for Evaluation of Radiation-Induced Cardiotoxicity in Patients With Breast Cancer: Results of a Phase 2 Clinical Trial

PURPOSE

Radiation therapy (RT) can increase the risk of cardiac events in patients with breast cancer (BC), but biomarkers predicting risk for developing RT-induced cardiac disease are currently lacking. We report results from a prospective clinical trial evaluating early magnetic resonance imaging (MRI) and serum biomarker changes as predictors of cardiac injury and risk of subsequent cardiac events after RT for left-sided disease.

METHODS

Women with node-negative and node-positive (N-/+) left-sided BC were enrolled on 2 institutional review board (IRB)-approved protocols at 2 institutions. MRI was conducted pretreatment (within 1 week of starting radiation), at the end of treatment (last day of treatment ±1 week), and 3 months after the last day of treatment (±2 weeks) to quantify left and right ventricular volumes and function, myocardial fibrosis, and edema. Perfusion changes during regadenoson stress perfusion were also assessed on a subset of patients (n = 28). Serum was collected at the same time points. Whole heart and cardiac substructures were contoured using CT and MRI. Models were constructed using baseline cardiac and clinical risk factors. Associations between MRI-measured changes and dose were evaluated.

RESULTS

Among 51 women enrolled, mean heart dose ranged from 0.80 to 4.7 Gy and mean left ventricular (LV) dose from 1.1 to 8.2 Gy, with mean heart dose 2.0 Gy. T1 time, a marker of fibrosis, and right ventricular (RV) ejection fraction (EF) significantly changed with treatment; these were not dose dependent. T2 (marker of edema) and LV EF did not significantly change. No risk factors were associated with baseline global perfusion. Prior receipt of doxorubicin was marginally associated with decreased myocardial perfusion after RT (P = .059), and mean MHD was not associated with perfusion changes. A significant correlation between baseline IL-6 and mean heart dose (MHD) at the end of RT (ρ 0.44, P = .007) and a strong trend between troponin I and MHD at 3 months post-treatment (ρ 0.33, P = .07) were observed. No other significant correlations were identified.

CONCLUSIONS

In this prospective study of women with left-sided breast cancer treated with contemporary treatment planning, cardiac radiation doses were very low relative to historical doses reported by Darby et al. Although we observed significant changes in T1 and RV EF shortly after RT, these changes were not correlated with whole heart or substructure doses. Serum biomarker analysis of cardiac injury demonstrates an interesting trend between markers and MHD that warrants further investigation.

452 Patient Factors and Preferences in Decision for Sleep Surgery: A Qualitative Analysis

Introduction

Patients with obstructive sleep apnea (OSA) are offered many treatment options spanning the spectrum of lifestyle modification, device therapy, and surgery. Sleep surgery, while often effective, results in moderate morbidity and has variable effectiveness on OSA improvement. Little is known about what patients consider when choosing treatment. We aim to identify factors that influenced the decision for sleep surgery among adults with OSA.

Methods

We conducted semi-structured virtual interviews with patients (≥18 years) with OSA (apnea-hypopnea index ≥5 events per hour of sleep) who underwent sleep surgery at a tertiary academic center, querying patients about factors in their decision for OSA treatment. Interviews were audio-recorded, transcribed, and analyzed for thematic content. We anticipate enrolling 10–18 total participants based on previously reported sample size in specialty groups for thematic saturation in specialty groups (ie, when no new concepts or factors emerge from interviews). Here we report pilot qualitative analysis results.

Results

Of nine eligible patients, eight enrolled (mean +/- standard deviation age 45.8 +/- 13.4 years, 2 female/6 males). Four patients underwent nasal surgery only, two patients underwent staged procedures, one underwent pharyngeal surgery only, and the last underwent nasal surgery with tori removal. Patients reported decision making duration of days to years for scheduling surgery. Reasons for pursuing sleep surgery included fatigue, quality of life, work performance, and safety. Overarching thematic domains related to decision for surgery were (1) major concerns, (2) external factors influencing decision, and (3) retrospective satisfaction/regret with decision. Major concerns involved factors beyond surgeon’s control, such as anesthesia and postoperative pain management, not surgery itself. Family and friends were reported to be highly influential in the process, both in favor and against surgery. Social media features and celebrity patients with OSA heightened awareness of sleep surgery and set preconceived expectations. Patients were mostly satisfied with outcomes, despite unanticipated acute recovery challenges.

Conclusion

This pilot qualitative analysis identifies factors influencing patients’ OSA treatment decisions. Understanding patients’ major concerns and sources of information may help to guide physician counseling, set realistic expectations, offer peri-operative support, and better engage parents in shared decision-making for sleep surgery.

Support (if any)

None.

Engaging a wider public health workforce: bringing public health into architecture education

Background

Current public health challenges necessitate the closer working of public health with built environment professionals. Despite growing evidence of benefits, there remains little progress in practice. Architects can play a key role in ensuring urban and building design is health promoting, however there is no requirement to teach health by architectural accreditation bodies across Europe.

Objectives

In the United Kingdom in 2010, the Public Health Practitioner in Residence programme (PHPiR) was established to address this situation. Public health professionals are embedded within the Faculty of Environment and Technology at the University of the West of England, and contribute to research, pedagogic programme development, teaching and mentoring. The aim was to embed public health concepts and issues into architecture training, to empower the profession as part of the wider workforce, to improve health and wellbeing when designing buildings and places. The PHPiR was evaluated using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. Data was collected (questionnaires, focus group, semi-structured interviews, programme documentation) on a Masters of Architecture cohort (N = 34) at intervals from 2011-2019 to see if the PHPiR has long lasting effects as students enter practice.

Results

Public health concepts including; inequalities, life course approach, and social capital, became embedded into the architecture curriculum. Projects produced had increased reference to wider health promoting issues and participants thinking shifted from the building itself to who would use the building, suggesting the intervention achieved its aims.

Conclusions

The PHPiR offers a novel approach for built environment professions to better understand public health issues and the relevance to their chosen fields. This model could be applied to other courses and replicated in educational institutions and public health training programmes across Europe.

Key messages

The PHPiR influenced the architecture curriculum, improved architects understanding and public health issues and concepts, and empowered them to create more health promoting environments. Embedding public health professionals into training for other disciplines may be an effective, sustainable method for increasing the wider public health workforce.

Seasonal intensification and trends of rogue wave events on the US western seaboard

Studies of changes in wave climate typically consider trends in sea state statistics, such as the significant wave height. However, the temporal variability of individual rogue waves, which pose a hazard to users of the sea and coastal environment has not been investigated. We use time series of continuous surface elevation over 124–270 months (spanning 1994–2016), from 15 wave buoys along the US western seaboard, to investigate regional trends in significant wave height and individual rogue waves. We find high spatial variability in trends in significant wave height and rogue waves across the region. Rogue wave occurrence displays a mostly decreasing trend, but the relative height – or severity – of the waves is increasing. We also identify seasonal intensification in rogue waves with increased rogue wave occurrence, of higher severity, in the winter than in the summer. Therefore, the common practice of stating a single occurrence likelihood for an ocean basin is not valid. In addition, the buoy data show that the magnitude and significance of trends in significant wave height increases towards higher percentiles, supporting previous findings.

Post-disaster agricultural transitions in Nepal

In Spring 2015, a series of earthquakes and aftershocks struck Nepal. The earthquakes caused significant changes in labor and land availability, cash income needs, and land quality. We examine how these post-earthquake impacts converged with ongoing agricultural shifts. Earthquake-related socio-economic and landscape changes specifically motivate the adoption of cardamom, Amomum subulatum, a high-value ecologically beneficial, and low labor commercial crop. We investigate reasons for the increased interest in cardamom post-earthquake, and challenges associated with it. We find that adopting cardamom serves as an important post-disaster adaptation. However, more broadly, unevenly distributed interventions coupled with the high capital costs of agricultural transition exacerbate social differentiation in communities after the disaster. Adoption is often limited to economically better off smallholder farmers. This paper extends previous research on disasters and smallholder farming by highlighting the specific potential of disasters to accelerate agricultural transitions and resulting inequality from the changes.