Longitudinal efficacy and toxicity of SARS-CoV-2 vaccination in cancer patients treated with immunotherapy

Despite more than 2 years having elapsed since the onset of SARS-CoV-2 pandemic, a level of hesitation around increased SARS-CoV-2 vaccine toxicity in cancer patients receiving immunotherapy (IO) remains. This hesitation stems from the idea that IO agents could elicit an overwhelming immune stimulation post vaccination and therefore increase the risk of vaccine-related toxicity. The aim of our study was to explore serological responses to SARS-CoV-2 vaccination in patients treated with IO and describe the level of immune stimulation using parameters such as blood cytokines, autoantibody levels and immune related adverse events (irAEs) post vaccination. Fifty-one evaluable patients were enrolled in this longitudinal study. Absolute levels and neutralization potential of anti-SARS-CoV-2 antibodies were not significantly different in the IO group compared to non-IO. Chemotherapy adversely affected seroconversion when compared to IO and/or targeted treatment. Following vaccination, the prevalence of grade ≥2 irAEs in patients treated with IO was not higher than the usual reported IO toxicity. We report, for the first time, that anti-SARS-CoV-2 vaccination, elicited the generation of five autoantibodies. The significantly increased autoantibodies were IgM autoantibodies against beta-2 glycoprotein (p = 0.02), myeloperoxidase (p = 0.03), nucleosome (p = 0.041), SPLUNC2 (p < 0.001) and IgG autoantibody against Myosin Heavy Chain 6 (MYH6) (p < 0.001). Overall, comprehensive analysis of a small cohort showed that co-administration of SARS-CoV-2 vaccine and IO is not associated with increased irAEs. Nevertheless, the detection of autoantibodies post anti-SARS-CoV-2 vaccination warrants further investigation (NCT03702309).

Correlates of maternal, newborn and child health services uptake, including male partner involvement: Baseline survey results from Bangladesh

South Asia bears a substantial proportion of the global maternal mortality burden, with adolescents disproportionately affected. Bangladesh has one of the highest adolescent pregnancy rates in the world, with low utilisation of maternal newborn and child health (MNCH) services. This hampers the country's efforts to achieve optimal health outcomes as envisioned by the Sustainable Development Goals. Male partner involvement is a recognised approach to optimise access to services and decision-making. In South Asia data on male involvement in MNCH service uptake is limited. Plan International's Strengthening Health Outcomes for Women and Children was implemented across four districts in Bangladesh between 2016 and 2020 and aimed to address these issues. Study results (N = 1,724) found higher maternal education levels were associated with use of MNCH services. After controlling for maternal education, service uptake was associated with male partner support level and perceived joint decision-making. The positive association between male support level and MNCH scale was robust to stratification by maternal education level, and by age group (i.e. adolescent vs. adult mothers). These findings suggest that one path for achieving optimal MNCH outcomes might be through structural-level interventions centred on women, combined with components targeting male partners or male heads of households.

Systematic development and feasibility testing of a multibehavioural digital prehabilitation intervention for patients approaching major surgery (iPREPWELL): A study protocol

Improving outcomes for people undergoing major surgery, specifically reducing perioperative morbidity and mortality remains a global health challenge. Prehabilitation involves the active preparation of patients prior to surgery, including support to tackle risk behaviours that mediate and undermine physical and mental health and wellbeing. The majority of prehabilitation interventions are delivered in person, however many patients express a preference for remotely-delivered interventions that provide them with tailored support and the flexibility. Digital prehabilitation interventions offer scalability and have the potential to benefit perioperative healthcare systems, however there is a lack of robustly developed and evaluated digital programmes for use in routine clinical care. We aim to systematically develop and test the feasibility of an evidence and theory-informed multibehavioural digital prehabilitation intervention 'iPREPWELL' designed to prepare patients for major surgery. The intervention will be developed with reference to the Behaviour Change Wheel, COM-B model, and the Theoretical Domains Framework. Codesign methodology will be used to develop a patient intervention and accompanying training intervention for healthcare professionals. Training will be designed to enable healthcare professionals to promote, support and facilitate delivery of the intervention as part of routine clinical care. Patients preparing for major surgery and healthcare professionals involved with their clinical care from two UK National Health Service centres will be recruited to stage 1 (systematic development) and stage 2 (feasibility testing of the intervention). Participants recruited at stage 1 will be asked to complete a COM-B questionnaire and to take part in a qualitative interview study and co-design workshops. Participants recruited at stage 2 (up to twenty healthcare professionals and forty participants) will be asked to take part in a single group intervention study where the primary outcomes will include feasibility, acceptability, and fidelity of intervention delivery, receipt, and enactment. Healthcare professionals will be trained to promote and support use of the intervention by patients, and the training intervention will be evaluated qualitatively and quantitatively. The multifaceted and systematically developed intervention will be the first of its kind and will provide a foundation for further refinement prior to formal efficacy testing.

CT Radiomics and Whole Genome Sequencing in Patients with Pancreatic Ductal Adenocarcinoma: Predictive Radiogenomics Modeling

We investigate whether computed tomography (CT) derived radiomics may correlate with driver gene mutations in patients with pancreatic ductal adenocarcinoma (PDAC). In this retrospective study, 47 patients (mean age 64 ± 11 years; range: 42-86 years) with PDAC, who were treated surgically and who underwent preoperative CT imaging at our institution were included in the study. Image segmentation and feature extraction was performed semi-automatically with a commonly used open-source software platform. Genomic data from whole genome sequencing (WGS) were collected from our institution's web-based resource. Two statistical models were then built, in order to evaluate the predictive ability of CT-derived radiomics feature for driver gene mutations in PDAC. 30/47 of all tumor samples harbored 2 or more gene mutations. Overall, 81% of tumor samples demonstrated mutations in KRAS, 68% of samples had alterations in TP53, 26% in SMAD4 and 19% in CDKN2A. Extended statistical analysis revealed acceptable predictive ability for KRAS and TP53 (Youden Index 0.56 and 0.67, respectively) and mild to acceptable predictive signal for SMAD4 and CDKN2A (Youden Index 0.5, respectively). Our study establishes acceptable correlation of radiomics features and driver gene mutations in PDAC, indicating an acceptable prognostication of genomic profiles using CT-derived radiomics. A larger and more homogenous cohort may further enhance the predictive ability.

COVID-19 and Cancer Patients in the Second Year of the Pandemic: Investigating Treatment Impact, Information Sources, and COVID-19-Related Knowledge, Attitudes and Practices

BACKGROUND

The novel coronavirus that has triggered the present COVID-19 pandemic continues to spread globally, resulting in widespread morbidity and mortality. Patients with cancer remain one of the most vulnerable subsets of the population to the disease. This study examined the effects of the pandemic on cancer patients' treatment, psychology, knowledge, attitudes, and practices.

METHODS

A survey was emailed to 9861 patients at a cancer centre in Toronto, Canada. Descriptive results were summarized. Qualitative feedback was coded and summarized. Regression modelling was used to explore factors associated with patient psychological well-being, knowledge, attitudes, and practices.

RESULTS

A total of 1760 surveys were completed, with a response rate of 17.8%. Most participants did not experience any pandemic-related treatment delays, and vaccination rates were high. Participants who identified themselves as non-white (OR 3.30, CI: 1.30-5.30; p ≤ 0.001), and those who referred to journal articles for information (p = 0.002) reported higher psychological impact scores. There were no significant predictors of whether participants would use personal protective equipment when leaving their homes or whether they would go to crowded places.

DISCUSSION

This study provides another snapshot of cancer patients perceptions and needs during the COVID-19 pandemic.

18F-DCFPyL PET/CT in advanced high-grade epithelial ovarian cancer: A prospective pilot study

Objectives

Glutamate carboxypeptidase-II (GCP-II), a zinc metalloenzyme that resides in cell membrane, has been reported as overexpressed in the neovasculature of ovarian cancers. The study objective was to determine whether GCP-II targeted imaging with ¹⁸F-DCFPyL PET/CT can detect disease sites in women with advanced high-grade serous ovarian cancer (HGSOC).

Materials and methods

Twenty treatment-naïve women with advanced HGSOC were recruited (median age 60 years). Prior to commencing therapy (primary cytoreductive surgery [n=9] or neoadjuvant chemotherapy [n=11]), subjects underwent routine staging with contrast-enhanced abdominopelvic CT (=CT), followed by ¹⁸F-DCFPyL PET/CT (=PET). CT and PET were reported independently using a standardized reporting template assessing 25 sites. The performance of PET was compared to CT in all subjects and to surgery and surgical histopathology in 9 patients who underwent primary cytoreductive surgery.

Results

Of the 25 sites assessed in 20 patients, CT detected disease in 292/500 (58.4%) locations and PET detected disease in 171/500 (34.2%). Compared to CT the sensitivity (95% CI) of PET to detect disease in the upper abdomen, the gastrointestinal tract or the peritoneum was 0.29 (0.20,0.40), 0.21 (0.11,0.33) and 0.74 (0.64,0.82), respectively. In the surgical cohort, 220 sites in 9 patients were evaluated. The sensitivity and specificity of CT and PET were 0.85 versus 0.54 (p<0.001) and 0.73 versus 0.93 (p<0.001), respectively.

Conclusion

Although ¹⁸F-DCFPyL has higher specificity than CT in detecting advanced HGSOC tumor sites, it detects less disease sites than CT, especially in the upper abdomen and along the gastrointestinal tract, likely limiting its clinical utility.

Clinical trial registration

ClinicalTrials.gov, NCT03811899.

The impact of an integrated, interprofessional knowledge translation intervention on access to inpatient rehabilitation for persons with cognitive impairment

Introduction

Stroke rehabilitation teams’ skills and knowledge in treating persons with cognitive impairment (CI) contribute to their reduced access to inpatient rehabilitation. This study examined stroke inpatient rehabilitation referral acceptance rates for persons with CI before and after the implementation of a multi-faceted integrated knowledge translation (KT) intervention aimed at improving clinicians’ skills in a cognitive-strategy based approach, Cognitive Orientation to daily Occupational Performance (CO-OP), CO-OP KT.

Methods

CO-OP KT was implemented at five inpatient rehabilitation centres, using an interrupted time series design and data from an electronic referral and database system called E-Stroke. CO-OP KT included a 2-day workshop, 4 months of implementation support, health system support, and a sustainability plan. A mixed effects model was used to model monthly acceptance rates for 12 months prior to the intervention and 6 months post.

Results

The dataset was comprised of 2604 pre-intervention referrals and 1354 post. In the mixed effects model, those with CI had a lower pre-intervention acceptance rate than those without. Post-intervention the model showed the acceptance rate for those with CI increased by 8.6% (p = 0.02), whereas those with no CI showed a non-significant increase of less than 1%.

Conclusions

Proportionally more persons with CI gained access to inpatient stroke rehabilitation following an integrated KT intervention.

Modelling prevalent cardiovascular disease in an urban Indigenous population

OBJECTIVE

Studies have highlighted the inequities between the Indigenous and non-Indigenous populations with respect to the burden of cardiovascular disease and prevalence of predisposing risks resulting from historical and ongoing impacts of colonization. The objective of this study was to investigate factors associated with cardiovascular disease (CVD) within and specific to the Indigenous peoples living in Toronto, Ontario, and to evaluate the reliability and validity of the resulting model in a similar population.

METHODS

The Our Health Counts Toronto study measured the baseline health of Indigenous community members living in Toronto, Canada, using respondent-driven sampling. An iterative approach, valuing information from the literature, clinical insight and Indigenous lived experiences, as well as statistical measures was used to evaluate candidate predictors of CVD (self-reported experience of discrimination, ethnic identity, health conditions, income, education, age, gender and body size) prior to multivariable modelling. The resulting model was then validated using a distinct, geographically similar sample of Indigenous people living in Hamilton, Ontario, Canada.

RESULTS

The multivariable model of risk factors associated with prevalent CVD included age, diabetes, hypertension, body mass index and exposure to discrimination. The combined presence of diabetes and hypertension was associated with a greater risk of CVD relative to those with either condition and was the strongest predictor of CVD. Those who reported previous experiences of discrimination were also more likely to have CVD. Further study is needed to determine the effect of body size on risk of CVD in the urban Indigenous population. The final model had good discriminative ability and adequate calibration when applied to the Hamilton sample.

CONCLUSION

Our modelling identified hypertension, diabetes and exposure to discrimination as factors associated with cardiovascular disease. Discrimination is a modifiable exposure that must be addressed to improve cardiovascular health among Indigenous populations.

Uncovering SARS-COV-2 vaccine uptake and COVID-19 impacts among First Nations, Inuit and Métis Peoples living in Toronto and London, Ontario

Background:

First Nations, Inuit and Métis Peoples across geographies are at higher risk of SARS-CoV-2 infection and COVID-19 because of high rates of chronic disease, inadequate housing and barriers to accessing health services. Most Indigenous Peoples in Canada live in cities, where SARS-CoV-2 infection is concentrated. To address gaps in SARS-CoV-2 information for these urban populations, we partnered with Indigenous agencies and sought to generate rates of SARS-CoV-2 testing and vaccination, and incidence of infection for First Nations, Inuit and Métis living in 2 Ontario cities.

Methods:

We drew on existing cohorts of First Nations, Inuit and Métis adults in Toronto (n = 723) and London (n = 364), Ontario, who were recruited using respondent-driven sampling. We linked to ICES SARS-CoV-2 databases and prospectively monitored rates of SARS-CoV-2 testing, diagnosis and vaccination for First Nations, Inuit and Métis, and comparator city and Ontario populations.

Results:

We found that SARS-CoV-2 testing rates among First Nations, Inuit and Métis were higher in Toronto (54.7%, 95% confidence interval [CI] 48.1% to 61.3%) and similar in London (44.5%, 95% CI 36.0% to 53.1%) compared with local and provincial rates. We determined that cumulative incidence of SARS-CoV-2 infection was not significantly different among First Nations, Inuit and Métis in Toronto (7364/100 000, 95% CI 2882 to 11 847) or London (7707/100 000, 95% CI 2215 to 13 200) compared with city rates. We found that rates of vaccination among First Nations, Inuit and Métis in Toronto (58.2%, 95% CI 51.4% to 64.9%) and London (61.5%, 95% CI 52.9% to 70.0%) were lower than the rates for the 2 cities and Ontario.

Interpretation:

Although Ontario government policies prioritized Indigenous populations for SARS-CoV-2 vaccination, vaccine uptake was lower than in the general population for First Nations, Inuit and Métis Peoples in Toronto and London. Ongoing access to culturally safe testing and vaccinations is urgently required to avoid disproportionate hospital admisson and mortality related to COVID-19 in these communities.

Implementation Outcomes Assessment of a Digital Clinical Support Tool for Intrapartum Care in Rural Kenya: Observational Analysis

Background

iDeliver, a digital clinical support system for maternal and neonatal care, was developed to support quality of care improvements in Kenya.

Objective

Taking an implementation research approach, we evaluated the adoption and fidelity of iDeliver over time and assessed the feasibility of its use to provide routine Ministry of Health (MOH) reports.

Methods

We analyzed routinely collected data from iDeliver, which was implemented at the Transmara West Sub-County Hospital from December 2018 to September 2020. To evaluate its adoption, we assessed the proportion of actual facility deliveries that was recorded in iDeliver over time. We evaluated the fidelity of iDeliver use by studying the completeness of data entry by care providers during each stage of the labor and delivery workflow and whether the use reflected iDeliver’s envisioned function. We also examined the data completeness of the maternal and neonatal indicators prioritized by the Kenya MOH.

Results

A total of 1164 deliveries were registered in iDeliver, capturing 45.31% (1164/2569) of the facility’s deliveries over 22 months. This uptake of registration improved significantly over time by 6.7% (SE 2.1) on average in each quarter-year (P=.005), from 9.6% (15/157) in the fourth quarter of 2018 to 64% (235/367) in the third quarter of 2020. Across iDeliver’s workflow, the overall completion rate of all variables improved significantly by 2.9% (SE 0.4) on average in each quarter-year (P<.001), from 22.25% (257/1155) in the fourth quarter of 2018 to 49.21% (8905/18,095) in the third quarter of 2020. Data completion was highest for the discharge-labor summary stage (16,796/23,280, 72.15%) and lowest for the labor signs stage (848/5820, 14.57%). The completion rate of the key MOH indicators also improved significantly by 4.6% (SE 0.5) on average in each quarter-year (P<.001), from 27.1% (69/255) in the fourth quarter of 2018 to 83.75% (3346/3995) in the third quarter of 2020.

Conclusions

iDeliver’s adoption and data completeness improved significantly over time. The assessment of iDeliver’ use fidelity suggested that some features were more easily used because providers had time to enter data; however, there was low use during active childbirth, which is when providers are necessarily engaged with the woman and newborn. These insights on the adoption and fidelity of iDeliver use prompted the team to adapt the application to reflect the users’ culture of use and further improve the implementation of iDeliver.

Validation of the integrated prediction model algorithm for outcome of cytoreduction in advanced ovarian cancer

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Background: In advanced ovarian cancer, the decision for primary cytoreductive surgery(PCS) or neoadjuvant chemotherapy(NACT) remains a challenge and may impact survival. We previously developed the integrated prediction model(IPM) using a 4-step algorithm of unresectable stage IVb, patient factors, surgical resectability and surgical complexity to predict outcome of optimal cytoreduction in advanced epithelial ovarian cancer(AEOC) and triage patients to NACT or PCS. The objective of the current study was to validate this model on a retrospective historical cohort of patients. Methods: This is a retrospective cohort study of 107 patients with AEOC treated at the Princess Margaret Cancer Centre between January 2017 and September 2018 undergoing PCS or NACT. All diagnostic imaging was retrospectively reviewed to assign surgical resectability score (SRS) for sites of disease and the surgical complexity score (SCS) for procedures anticipated to be required to achieve optimal cytoreduction based on pre-operative imaging. Those scores were modified from previously validated tools. Patient factors (PF) included age, ECOG and albumin. We previously developed an IPM algorithm to achieve outcome of optimal cytoreduction and determined cut-offs using the Youden index J. Triaging patients to PCS without stage IVb unresectable disease, PF≤ 2, SRS≤5 and SCS≤ 9 led to an 85% specificity and 75% accuracy for outcome of optimal cytoreduction < 1 cm. The current validation study was performed reporting sensitivity, specificity, negative (NPV) and positive predictive value (PPV) on an external cohort. Results: Among 107 patients, 61 had PCS and 46 had NACT followed by ICS. Patients treated with NACT were significantly older (63.5 vs 61 years, p = 0.037), more likely stage IV (52% vs 18%, p < 0.001), had a higher proportion of ECOG > 1 (30% vs 11%, 0.045), a lower pre-operative album (37 vs 40, p < 0.001) and higher CA-125 (970 vs 227.5, p < 0.001) compared to PCS. They also had higher PF (2 vs 0, p = 0.013), SRS (4 vs 1, p < 0.001) and SCS (8 vs 5, p = < 0.001). There was no significant difference in outcome of cytoreduction; the optimal cytoreduction rate was 85% vs 87%, p = 0.12 between PCS and ICS patients. In this validation cohort, triaging patients without unresectable stage IVb disease, PF≤ 2, SRS≤ 5 and SCS≤ 9 to PCS had a sensitivity of 91% to correctly identify patients who will have optimal cytoreduction of < 1 cm at PCS and a specificity of 81%. The PPV was 83%, NPV was 90% and accuracy was 86%. Application of the IPM would have prevented 5 suboptimal patients and correctly triaged them to NACT. Conclusions: We validated a triage algorithm integrating patient factors, surgical complexity and surgical resectability for patients with AEOC to achieve optimal cytoreduction at PCS with high sensitivity and specificity. This may therefore be used in a clinical setting to decide between PCS and NACT.

Clinical utility of tumor next-generational sequencing (NGS) panel testing to inform treatment decisions for patients with advanced solid tumors

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Background: There is limited information about the clinical utility of targeted NGS panel testing to inform decision-making for patients with advanced solid tumors. The Ontario-wide Cancer Targeted Nucleic Acid Evaluation (OCTANE) is an ongoing prospective study that enrolled over 4,500 solid tumor patients for NGS panel testing. We performed a retrospective survey of 21 medical oncologists enrolling OCTANE patients at a single academic institution to evaluate the impact of NGS testing on treatment decisions. Methods: Patients and treating oncologists were identified at the Princess Margaret Cancer Centre between 2016-2021. Tumor-only sequencing was performed using a custom hybridization capture panel of 555 cancer genes (Hi5) or a commercial 161-gene amplicon DNA/RNA panel (Oncomine Comprehensive v3). Oncologists were asked to review testing results for individual patients and complete a survey indicating whether NGS testing impacted treatment decisions. Mutations were defined as actionable based on clinical judgment and compared to classifications provided by OncoKB, an FDA-recognized precision medicine knowledgebase. The primary outcome of this study was rate of treatment change based on mutation results. Patient, test, and physician factors were evaluated for association with treatment changes using univariate analyses and a mixed effects model. Results: Two cohorts were surveyed, the first between 2017-2019 and the second in 2021. Of the 582 surveys sent, 394 (67.7%) were completed. Each physician completed a median of 19 surveys (range, 9-48). We found that 188 (47.7%) patients had a mutation classified as actionable by the oncologist, of whom 134 (71.3%) had ≥1 OncoKB-defined actionable mutation(s). 62/394 (15.7%) patients were matched to a treatment, of whom 37 were enrolled in a clinical trial, 13 received an approved drug, 4 were prescribed off-label therapy and 8 avoided ineffective treatment. 127/188 (67.5%) patients with actionable mutations did not receive treatment due to lack of available therapy, stability on current regimen, clinical deterioration or patient decision. Rate of treatment change was highest for bowel (15/37, 40.5%), breast (14/52, 27.5%), biliary tract (6/22, 27.3%) and lung (4/17, 23.5%) cancers. Treatment decisions were not associated with patient age, gender, physician clinical experience, physician gender, testing experience, OncoKB mutation level or time from biopsy to sequencing. There was no difference in overall survival between patients with matched vs. no matched treatment ( p = 0.55, median survival not reached). Conclusions: OCTANE testing led to a change in drug treatment in 15.7% of patients, supporting the clinical utility of NGS panel testing for patients with advanced solid tumors. Patient, test, and physician characteristics were not significantly associated with treatment change.

The working conditions for personal support workers in the Greater Toronto Area during the COVID-19 pandemic: a mixed-methods study

OBJECTIVE

During the height of the COVID-19 pandemic, personal support workers (PSWs) were heralded as healthcare 'heroes' as many of them cared for high-risk, vulnerable older populations, and worked in long-term care, which experienced a high number of COVID-19 outbreaks and deaths. While essential to the healthcare workforce, there is little understanding of PSW working conditions during the pandemic. The aim of our study was to examine the working conditions (including job security, work policies, and personal experiences) for PSWs in the Greater Toronto Area during the COVID-19 pandemic from the perspectives of PSWs.

METHODS

This study used a mixed-methods design. From June to December 2020, we conducted a survey of 634 PSWs to understand their working conditions during the COVID-19 pandemic. Semi-structured interviews with 31 survey respondents were conducted from February to May 2021 to understand in greater depth how working conditions were impacting the well-being of PSWs.

RESULTS

We found PSWs faced a range of challenges related to COVID-19, including anxiety about contracting COVID-19, reduced work hours, taking leaves of absences, concerns about job security, and losing childcare. While the COVID-19 pandemic highlighted the PSW workforce and their importance to the healthcare system (especially in the long-term care system), pre-existing poor work conditions of insecure jobs with no paid sick days and benefits exacerbated COVID-19-related challenges. Despite these hardships, PSWs were able to rely on their mental resilience and passion for their profession to cope with challenges.

CONCLUSION

Significant changes need to be made to improve PSW working conditions. Better compensation, increased job security, decreased workload burden, and mental health supports are needed.

Impact of 18F-DCFPyL PET on Staging and Treatment of Unfavorable Intermediate or High-Risk Prostate Cancer

Background Data regarding 2-(3-{1-carboxy-5-[(6-[¹⁸F]fluoro-pyridine 3-carbonyl)-amino]-pentyl}-ureido)-pentanedioic acid (¹⁸F-DCFPyL) PET in primary staging of prostate cancer (PCa) are limited. Purpose To compare the performance of ¹⁸F-DCFPyL PET/CT or PET/MRI (PET) with bone scan and CT with or without multiparametric MRI (hereafter, referred to as conventional imaging) in the initial staging of men with unfavorable intermediate or high-risk PCa and to assess treatment change after PET. Materials and Methods This prospective study evaluated men with biopsy-proven, untreated, unfavorable intermediate or high-risk PCa with 0 to four metastases or equivocal for extensive metastases (more than four) who underwent PET between May 2018 and December 2020. The diagnostic performance of PET in detecting pelvic nodal and distant metastases was compared with conventional imaging alone. Metastatic sites at conventional imaging and PET were compared with a composite reference standard including histopathologic analysis, correlative imaging, and/or clinical and biochemical follow-up. The intended treatment before PET was compared with the treatment plan established after performing PET. Detection rate, sensitivity, and specificity of conventional imaging and PET were compared by using McNemar exact test on paired proportions. Results The study consisted of 108 men (median age, 66 years; IQR, 61-73 years) with no metastases (n = 84), with oligometastases (four or fewer metastases; 22 men), or with equivocal findings for extensive metastases (n = 2). Detection rates at PET and conventional imaging for nodal metastases were 34% (37 of 108) and 11% (12 of 108) (P < .001), respectively, and those for distant metastases were 22% (24 of 108) and 10% (11 of 108) (P = .02), respectively. PET altered stage in 43 of 108 (40%) and treatment in 24 of 108 (22%) men. The most frequent treatment change was from systemic to local-regional therapy in 10 of 108 (9%) and from local-regional to systemic therapy in nine of 108 (8%) men. Equivocal findings were encountered less frequently with PET (one of 108; 1%) than with conventional imaging (29 of 108; 27%). Conclusion Initial staging with 2-(3-{1-carboxy-5-[(6-[¹⁸F]fluoro-pyridine 3-carbonyl)-amino]-pentyl}-ureido)-pentanedioic acid (¹⁸F-DCFPyL) PET after conventional imaging (bone scan and CT with or without multiparametric MRI) helped to detect more nodal and distant metastases than conventional imaging alone and changed treatment in 22% of men. Clinical trial registration no. NCT03535831, NCT03718260 © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Jadvar in this issue.

Implementation of a standardized voiding protocol after minimally invasive surgery: A quality improvement initiative

OBJECTIVES

To assess the effects of the implementation of a standardized voiding protocol in patients undergoing minimally invasive hysterectomy at a single cancer center in terms of the urinary tract infection (UTI) rate, time to first void, and overnight stays secondary to urinary retention.

METHODS

We enrolled 102 consecutive patients undergoing minimally invasive hysterectomy at a single cancer center during a 12-month period. A pre-intervention cohort of 100 consecutive patients was identified for comparison. A multidisciplinary team developed and implemented a standardized voiding protocol using quality improvement methodology. We compared the demographics, time to first void, rate of urinary retention, and UTI rates between the pre- and post-intervention cohorts.

RESULTS

Our intervention led to a significant reduction in the time to first void (289 min vs. 566 min; P < 0.001), rate of urinary retention (2% vs. 10%; P = 0.015), and postoperative UTI (4% vs. 8%; P = 0.249). There was a similar rate of patients going home with a Foley catheter (9% vs. 11%; P = 0.850).

CONCLUSIONS

Implementation of a standardized voiding protocol was associated with a reduction in rate of UTI, time to first void, and overnight stays secondary to urinary retention.

Precarious work among personal support workers in the Greater Toronto Area: a respondent-driven sampling study

BACKGROUND

The COVID-19 pandemic has highlighted the role of personal support workers (PSWs) in health care, as well as their work conditions. Our study aimed to understand the characteristics of the PSW workforce, their work conditions and their job security, as well as to explore the health of PSWs and the impact of precarious employment on their health.

METHODS

Our community-based participatory action research focused on PSWs in the Greater Toronto Area. We administered an online, cross-sectional survey between June and December 2020 using respondent-driven sampling. Data on sociodemographics, employment precarity, worker empowerment and health status were collected. We assessed the association between precarious employment and health using multivariable logistic regression models.

RESULTS

We contacted 739 PSWs, and 664 consented to participate. Overall, 658 (99.1%) completed at least part of the survey. Using data adjusted for our sampling approach, the participants were predominantly Black (76.5%, 95% confidence interval [CI] 68.2%-84.9%), women (90.1%, 95% CI 85.1%-95.1%) and born outside of Canada (97.4%, 95% CI 94.9%-99.9%). Most worked in home care (43.9%, 95% CI 35.2%-52.5%) or long-term care (34.5%, 95% CI 27.4%-42.0%). Although most participants had at least some postsecondary education (unadjusted proportion = 83.4%, n = 529), more than half were considered low income (55.1%, 95% CI 46.3%-63.9%). Most participants were precariously employed (86.5%, 95% CI 80.7%-92.4%) and lacked paid sick days (89.5%, 95% CI 85.8%-93.3%) or extended health benefits (74.1%, 95% CI 66.8%-81.4%). Nearly half of the participants described their health as less than very good (46.7%, 95% CI 37.9%-55.5%). Employment precarity was significantly associated with higher risk of depression (odds ratio 1.02, 95% CI 1.01-1.03).

INTERPRETATION

Despite being key members of health care teams, most PSWs were precariously employed with low wages that keep them in poverty; the poor work conditions they faced could be detrimental to their physical and mental health. Equitable strategies are needed to provide decent work conditions for PSWs and to improve their health.

Long COVID and episodic disability: advancing the conceptualisation, measurement and knowledge of episodic disability among people living with Long COVID - protocol for a mixed-methods study

INTRODUCTION

As the prevalence of Long COVID increases, there is a critical need for a comprehensive assessment of disability. Our aims are to: (1) characterise disability experiences among people living with Long COVID in Canada, UK, USA and Ireland; and (2) develop a patient-reported outcome measure to assess the presence, severity and episodic nature of disability with Long COVID.

METHODS AND ANALYSIS

In phase 1, we will conduct semistructured interviews with adults living with Long COVID to explore experiences of disability (dimensions, uncertainty, trajectories, influencing contextual factors) and establish an episodic disability (ED) framework in the context of Long COVID (n~10 each country). Using the conceptual framework, we will establish the Long COVID Episodic Disability Questionnaire (EDQ). In phase 2, we will examine the validity (construct, structural) and reliability (internal consistency, test-retest) of the EDQ for use in Long COVID. We will electronically administer the EDQ and four health status criterion measures with adults living with Long COVID, and readminister the EDQ 1 week later (n~170 each country). We will use Rasch analysis to refine the EDQ, and confirm structural and cross-cultural validity. We will calculate Cronbach's alphas (internal consistency reliability), and intraclass correlation coefficients (test-retest reliability), and examine correlations for hypotheses theorising relationships between EDQ and criterion measure scores (construct validity). Using phase 2 data, we will characterise the profile of disability using structural equation modelling techniques to examine relationships between dimensions of disability and the influence of intrinsic and extrinsic contextual factors. This research involves an academic-clinical-community partnership building on foundational work in ED measurement, Long COVID and rehabilitation.

ETHICS AND DISSEMINATION

This study was approved by the University of Toronto Research Ethics Board. Knowledge translation will occur with community collaborators in the form of presentations and publications in open access peer-reviewed journals and presentations.

Enhanced recovery after minimally invasive gynecologic oncology surgery to improve same day discharge: a quality improvement project

OBJECTIVES

Same day discharge after minimally invasive hysterectomy has been shown to be safe and feasible. We designed and implemented a quality improvement perioperative program based on early recovery after surgery principles to improve the rate of same day discharge from 30% to 75% after minimally invasive gynecologic oncology surgery over a 12 month period.

METHODS

We enrolled 102 consecutive patients undergoing minimally invasive hysterectomy at a single cancer center during a 12 month period. A pre-intervention cohort of 100 consecutive patients was identified for comparison of clinicodemographic variables and perioperative outcomes. A multidisciplinary team developed a comprehensive perioperative care program and followed quality improvement methodology. Patients were followed up for 30 days after discharge. A statistical process chart was used to monitor the effects of our interventions, and a multivariate analysis was conducted to determine factors associated with same day discharge.

RESULTS

Same day discharge rate increased from 29% to 75% after implementation (p<0.001). The post-intervention cohort was significantly younger (59 vs 62 years; p=0.038) and had shorter operative times (180 vs 211 min; p<0.001) but the two groups were similar in body mass index, comorbidity, stage, and intraoperative complications. There was no difference in 30 day perioperative complications, readmissions, reoperations, emergency department visits, or mortality. Overnight admissions were secondary to nausea and vomiting (16%), complications of pre-existing comorbidities (12%), and urinary retention (8%). On multivariate analysis, longer surgery, timing of surgery, and narcotic use on the ward were significantly associated with overnight admission. Overall, 89% of patients rated their experience as 'very good' or 'excellent', and 87% felt that their length of stay was adequate.

CONCLUSIONS

Following implementation of a perioperative quality improvement program targeted towards minimally invasive gynecologic oncology surgery, our intervention significantly improved same day discharge rates while maintaining a low 30 day perioperative complication rate and excellent patient experience.

Training programs to improve identification of sick newborns and care-seeking from a health facility in low- and middle-income countries: a scoping review

BACKGROUND

Most neonatal deaths occur in low- and middle-income countries (LMICs). Limited recommendations are available on the optimal personnel and training required to improve identification of sick newborns and care-seeking from a health facility. We conducted a scoping review to map the key components required to design an effective newborn care training program for community-based health workers (CBHWs) to improve identification of sick newborns and care-seeking from a health facility in LMICs.

METHODS

We searched multiple databases from 1990 to March 2020. Employing iterative scoping review methodology, we narrowed our inclusion criteria as we became more familiar with the evidence base. We initially included any manuscripts that captured the concepts of "postnatal care providers," "neonates" and "LMICs." We subsequently included articles that investigated the effectiveness of newborn care provision by CBHWs, defined as non-professional paid or volunteer health workers based in communities, and their training programs in improving identification of newborns with serious illness and care-seeking from a health facility in LMICs.

RESULTS

Of 11,647 articles identified, 635 met initial inclusion criteria. Among these initial results, 35 studies met the revised inclusion criteria. Studies represented 11 different types of newborn care providers in 11 countries. The most commonly studied providers were community health workers. Key outcomes to be measured when designing a training program and intervention to increase appropriate assessment of sick newborns at a health facility include high newborn care provider and caregiver knowledge of newborn danger signs, accurate provider and caregiver identification of sick newborns and appropriate care-seeking from a health facility either through caregiver referral compliance or caregivers seeking care themselves. Key components to consider to achieve these outcomes include facilitators: sufficient duration of training, refresher training, supervision and community engagement; barriers: context-specific perceptions of newborn illness and gender roles that may deter care-seeking; and components with unclear benefit: qualifications prior to training and incentives and remuneration.

CONCLUSION

Evidence regarding key components and outcomes of newborn care training programs to improve CBHW identification of sick newborns and care-seeking can inform future newborn care training design in LMICs. These training components must be adapted to country-specific contexts.

1074. The Relationship Between the Patient’s Body Mass Index and Dalbavancin’s Efficacy in the Treatment of Invasive Gram-Positive Infections

Background

Dalbavancin is a long-acting lipoglyopeptide antibiotic used in the treatment of invasive gram-positive infections. There is a lack of published research on the effect of obesity on dalbavancin’s pharmacokinetics. The primary objective was to determine if obesity correlates to clinical failure at 90 days for patients with gram-positive infections treated with dalbavancin.

Methods

This retrospective observational study reviewed the use of dalbavancin from 1/1/2015- 3/31/2021 at 2 community hospitals. Patients were included if ≥ 18 years and received at least one dose of dalbavancin as an inpatient or at an outpatient infusion center. Patients were excluded if not seen by a provider within 90 days post last infusion. The primary outcome was clinical failure (CF). CF at 90 days was a composite of one or more of the following: need for additional antibiotics, dalbavancin intolerance, hospital readmission for same indication, need for additional surgery/debridement, or death. Clinical cure (CC) was defined as not meeting the criteria for CF. Patient demographics, BMI, indication, achievement of source control, Charlson Comorbidity Index (CCM) were collected. Descriptive statistics were used. To determine if a BMI cut-point exists between CC and CF, a classification & regression tree (CART) analysis was performed.

Results

A total of 81 patients received dalbavancin with 19 patients excluded for lack of follow up. Patient demographics: mean age (SD) 45.3 (15.8) years, 50% male; CCM 2.6 (3.1). Indications included osteomyelitis n=22, endovascular n=12, diabetic foot/skin soft tissue n=9, septic joint n=8, other n=11. A total of 29 (47%) of patients were bacteremic; 34 (55%) having source control. CF occurred in 15 of 62 (24%) patients. CF was compared with weight, BMI, CCM, albumin and source control. A difference existed in the median (IQR) BMI between CF 32.5 kg/m2 (25.1 – 42.8) and CC 25.5 kg/m2 (22.1 – 28.2); p=.029. A BMI cutpoint was not identified in CART analysis.

Conclusion

There is a relationship between increased BMI and 90-day CF in patients treated with dalbavancin. A higher BMI was found among those with with CF. Future studies are necessary to determine if a BMI based weight adjustment is necessary.

Disclosures

Lisa Avery, PharmD, BCPS, BCIDP, Merck (Other Financial or Material Support, Spouse Employer)

Treatment outcomes and predictive factors in patients ≥70 years old with advanced ovarian cancer

OBJECTIVE

To evaluate treatment outcomes, survival, and predictive factors in patients ≥70 with advanced epithelial ovarian cancer (AEOC).

METHODS

A retrospective single institution cohort study of women ≥70 with Stage III-IV AEOC between 2010 and 2018. Patients had either primary cytoreductive surgery (PCS), neoadjuvant chemotherapy (NACT) with interval cytoreductive surgery (ICS), chemotherapy alone, or no treatment. Demographics, surgical outcome, complications, and survival outcome were compared between groups.

RESULTS

Among 248 patients, 69 (27.7%) underwent PCS, 99 (39.9%) had ICS, 56 (22.5%) had chemotherapy alone. Twenty-four (9.6%) remained untreated. Optimal cytoreduction (≤1 cm) was achieved in 72.4% of PCS and 77.8% of NACT/ICS (p = 0.34), without difference in grade ≥3 postoperative complications (15.9% vs. 9.1%, p = 0.37). Progression-free survival (PFS) was 23.5 months in PCS and 15.0 months in ICS patients (hazard ratio [HR]: 1.4, p = 0.041). Patients in the surgical arms, PCS or ICS, had better 2-year overall survival (OS) compared to chemotherapy alone (79%, 68%, 41%, respectively, HR: 3.58, p < 0.001). In a subgroup analysis, patients ≥80 had improved 2-year OS when treated with NACT compared to PCS (82% vs. 57%) and a trend toward improved PFS. Age, stage, and CA-125 were determinants of undergoing PCS.

CONCLUSION

In patients ≥70 with AEOC, surgery should not be deferred based on age alone. Fit, well selected patients ≥70 can benefit from PCS, while patients ≥80 might benefit from NACT over PCS.