Incidence and risk factors for alopecia in survivors of critical illness: A multi-centre observational study

PURPOSE

To investigate the incidence, nature and risk factors for patient-reported alopecia in survivors of critical illness.

MATERIALS AND METHODS

A multi-centre, mixed methods observational study in the intensive care units (ICU) of ten hospitals in Wales. All patients with an ICU stay of 5 days or more, able to give consent were included. Demographic variables and risk factors were collected. A pre-designed survey was completed at three months post-ICU discharge. Statistical analysis included numbers and percentages (categorical variables) and medians and interquartile ranges (continuous variables). Comparisons between patients with and without alopecia were made using Fisher's Exact test (categorical variables) and Mann Whitney U test (continuous variables). Multivariate logistic regression analysis was used to determine the risk factors for alopecia.

RESULTS

The survey was completed by 123 patients with alopecia reported in 44 (36%) patients. The only risk factor for alopecia on analysis was sepsis / septic shock (p < .001; OR: 5.1, 95%CI: 2.1-12.4).

CONCLUSIONS

Limited research exists examining the incidence, nature and risk factors for patient-reported alopecia in adult survivors of critical illness. The results of this study highlight the need to discuss the potential for alopecia with survivors of critical illness, who had sepsis / septic shock.

Reduction in surgical site infections in the Southern Cross Hospitals network, 2004-2015: successful outcome of a long-term surveillance and quality improvement project

AIM

To report on the reduction in the surgical site infection (SSI) rate in the Southern Cross Hospitals network over a 12-year period, 2004-2015, following active surveillance and quality improvement actions.

METHODS

Ten hospitals in the network performed prospective SSI surveillance using standard definitions across a range of ten surgical procedure groups. Data was manually collected on a standardised form and entered into a bespoke database. Information collected included timing and dose of surgical antibiotic prophylaxis, type of surgical site skin preparation used, and patient information on smoking, diabetes and body mass index (BMI). Patients were contacted 30 days after their elective surgery to detect SSIs presenting after discharge from hospital. Surveillance results were widely reported to infection control and clinical review committees. Quality improvement activities to increase use of best practice interventions for surgical antibiotic prophylaxis and alcohol-based skin preparations were initiated during the surveillance period.

RESULTS

42,792 procedures performed in ten hospitals were analysed. There were 932 (2.2%) SSIs. The SSI rate decreased from 3.5% in 2004 to 1.2% in 2015, r-0.865, p=<0.0001, a decrease of 59%, approximately 5% a year. Rates decreased in seven of the 10 hospitals, p≤0.02 for each, and in five of the ten procedure groups, p≤0.02 for each. Diabetic patients, odds ratio (OR) 1.4 (95% confidence interval (CI) 1.1-1.9), obese patients (BMI>30), OR 2.0 (95% CI 1.6-2.4), and those with a surgical risk score of ≥1 OR 1.3 (95% CI 1.1-1.6) had higher SSI rates. These three patient risk factors increased during the 12-year period. The use of alcohol-based skin preparations increased during the period from 63% to 84% in the first two and last two years respectively, p<0.0001. Use of an alcohol-based skin preparation was associated with a reduction in SSIs OR 0.54 (95% CI 0.47-0.62). On time prophylaxis improved from 72% to 95% over the 12 years, p<0.0001, and on time prophylaxis was associated with a reduction in SSIs, OR=0.62 (95% CI 0.51-0.75). The use of 2g doses of cefazolin increased significantly after 2010, p<0.0001. The most common cause of SSI was Staphylococcus aureus which was present in 54% of cases with a positive culture.

CONCLUSIONS

This long-term surveillance and quality improvement programme has made a significant contribution to the overall reduced rate of SSIs in Southern Cross Hospitals. This reduction occurred despite patient risk factors for SSI increasing. Further reduction is possible with higher adherence to best practice and interventions aimed at reducing S. aureus SSIs.

Efficient Synthesis of Immunomodulatory Drug Analogues Enables Exploration of Structure-Degradation Relationships

The immunomodulatory drugs (IMiDs) thalidomide, pomalidomide, and lenalidomide have been approved for the treatment of multiple myeloma for many years. Recently, their use as E3 ligase recruiting elements for small-molecule-induced protein degradation has led to a resurgence in interest in IMiD synthesis and functionalization. Traditional IMiD synthesis follows a stepwise route with multiple purification steps. Herein we describe a novel one-pot synthesis without purification that provides rapid access to a multitude of IMiD analogues. Binding studies with the IMiD target protein cereblon (CRBN) reveals a narrow structure-activity relationship with only a few compounds showing sub-micromolar binding affinity in the range of pomalidomide and lenalidomide. However, anti-proliferative activity as well as Aiolos degradation could be identified for two IMiD analogues. This study provides useful insight into the structure-degradation relationships for molecules of this type as well as a rapid and robust method for IMiD synthesis.

Abstract OT1-06-01: OPTIMA: A prospective randomized trial to validate the predictive utility and cost-effectiveness of gene expression test-directed chemotherapy decisions in early breast cancer

Background: Multi-parameter gene expression assays (MPAs) are widely used to estimate individual patient residual risk in hormone-sensitive HER2-negative node-negative early breast cancer, allowing patients with low risk to safely avoid chemotherapy. Evidence for MPA use in node-positive breast cancer is limited. OPTIMA (Optimal Personalised Treatment of early breast cancer usIng Multi-parameter Analysis) aims to validate MPA's as predictors of chemotherapy sensitivity in a largely node-positive breast cancer population.

Methods: OPTIMA is a partially blinded multi-center, phase 3 randomized controlled trial with an adaptive two-stage design. The main eligibility criteria are women or men aged 40 or older with resected ER-positive, HER2-negative breast cancer and up to 9 involved axillary lymph nodes. Randomization is to standard management (chemotherapy and endocrine therapy) or to MPA-directed treatment. Those with a “high risk” tumor MPA score receive standard management whilst those at “low risk” are treated with endocrine therapy alone. The preliminary phase (OPTIMA prelim) evaluated the performance of several MPAs to select a test to be used in the main efficacy trial based on economic analysis, and assessed the feasibility and acceptability of a large UK trial. OPTIMA prelim used Oncotype DX as the primary discriminator; the main trial will use Prosigna (PAM50) with Prosigna Score ≤60 defined as “low-risk”. The co-primary outcomes are (1) Invasive Disease Free Survival (IDFS) and (2) cost-effectiveness of test-directed therapy. Secondary outcomes include IDFS in “low-risk” patients, quality of life and additional survival measures. An integrated qualitative recruitment study will identify and address challenges to recruitment and informed consent. Tumor blocks from all consenting participants will be banked allowing the performance of alternative MPA technologies to be evaluated. Recruitment of 4500 patients will permit demonstration of 3% non-inferiority of test-directed treatment, with 5% significance and 85% power, assuming 3 years follow-up and a control arm 5-year IDFS of at least 85%. The addition of patients from OPTIMA prelim will allow non-inferiority to be assessed with 2.5% significance.

Results: OPTIMA-prelim recruited 412 patients in 23 months from 35 sites with a 47% acceptance rate. The main study opened in January 2017. Early progress indicates that the recruitment target is achievable in the intended 46-month timescale through the participation of &gt;100 sites

Conclusion: OPTIMA, as one of two large scale prospective trials validating the use of test-guided chemotherapy decisions in node-positive early breast cancer, is expected to have a global impact on breast cancer treatment. Experience from OPTIMA prelim showed that patient advocate support and close engagement with sites will aid trial success.

Funding: The project is funded in the UK by the NIHR HTA Programme (10/34/501). Views expressed are those of the authors and not those of the HTA Programme, NIHR, NHS or the DoH.

Citation Format: Stein RC, Makris A, Hughes-Davies L, Macpherson IR, Hall PS, Cameron DA, Earl HM, Pinder SE, Poole CJ, Rea DW, McIntosh S, Harmer V, Morgan A, Rooshenas L, Conefrey C, Donovan JL, Hulme C, McCabe C, Stallard N, Campbell A, Higgins H, Bartlett JMS, Marshall A, Dunn JA. OPTIMA: A prospective randomized trial to validate the predictive utility and cost-effectiveness of gene expression test-directed chemotherapy decisions in early breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT1-06-01.

'What gets measured gets managed': revisiting the indicators for maternal and newborn health programmes

Background

The health of women and children are critical for global development. The Sustainable Development Goals (SDG) agenda and the Global Strategy for Women’s, Children’s, and Adolescent’s Health 2016–2030 aim to reduce maternal and newborn deaths, disability, and enhancement of well-being. However, information and data on measuring countries’ progress are limited given the variety of methodological challenges of measuring care around the time of birth, when most maternal and neonatal deaths and morbidities occur.

Main body

In 2015, the World Health Organization launched Mother and Newborn Information for Tracking Outcomes and Results (MoNITOR), a technical advisory group to WHO. MoNITOR comprises 14 independent global experts from a variety of disciplines selected in a competitive process for their technical expertise and regional representation. MoNITOR will provide technical guidance to WHO to ensure harmonized guidance, messages, and tools so that countries can collect useful data to track progress toward achieving the Sustainable Development Goals.

Short conclusion

Ultimately, MoNITOR will provide technical guidance to WHO to ensure harmonized guidance, messages, and tools so that countries can collect useful data to track progress toward achieving the Sustainable Development Goals.

Adjuvant endocrine therapy after breast cancer: a qualitative study of factors associated with adherence

INTRODUCTION

Despite evidence of the efficacy of adjuvant endocrine therapy (AET) in reducing the risk of recurrence and mortality after treatment for primary breast cancer, adherence to AET is suboptimal. This study aimed to explore factors that influence adherence and nonadherence to AET following breast cancer to inform the development of supportive interventions.

METHODS

Interviews were conducted with 32 women who had been prescribed AET, 2-4 years following their diagnosis of breast cancer. Both adherers (n=19) and nonadherers (n=13) were recruited. The analysis was conducted using the Framework approach.

RESULTS

Factors associated with adherence were as follows: managing side effects including information and advice on side effects and taking control of side effects, supportive relationships, and personal influences. Factors associated with nonadherence were as follows: burden of side effects, feeling unsupported, concerns about long-term AET use, regaining normality, including valuing the quality of life over length of life, and risk perception.

CONCLUSION

Provision of timely information to prepare women for the potential side effects of AET and education on medication management strategies are needed, including provision of timely and accurate information on the efficacy of AET in reducing breast cancer recurrence and on potential side effects and ways to manage these should they arise. Trust in the doctor-patient relationship and clear patient pathways for bothersome side effects and concerns with AET are important. Training and education on AET for GPs should be considered alongside novel care pathways such as primary care nurse cancer care review and community pharmacist follow-up.

Management of hot flushes in UK breast cancer patients: clinician and patient perspectives

INTRODUCTION

Menopausal problems are among the most prevalent and distressing problems following breast cancer treatment, with 70% women experiencing hot flushes and night sweats (HFNS). A working party was set up to support the development of new research into the management of these problems.

METHODS

We conducted surveys to explore the need as perceived by women with breast cancer and establish current UK management practices. A patient survey was conducted through a charity, Breast Cancer Care, and a health professional survey via the UK Breast Intergroup. The HFNS Problem Rating Scale was used, as well as specific questions addressing the aims of the study.

RESULTS

Six hundred and sixty-five patients responded and 185 health professionals. Twenty-eight percent women had considered stopping adjuvant endocrine treatment because of HFNS, yet 34% had never been asked about HFNS by any health professional. The most commonly offered interventions were SSRIs, such as venlafaxine, yet only 25% patients had been offered these drugs. Cognitive behavioural therapy was rarely suggested (2%) despite good evidence.

DISCUSSION

This study shows a lack of coherence in the management of HFNS in breast cancer survivors, which may lead to reduced adherence to adjuvant therapy. There is an urgent need to develop guidelines to support management of HFNS after breast cancer.

Value of Information Analysis of Multiparameter Tests for Chemotherapy in Early Breast Cancer: The OPTIMA Prelim Trial

BACKGROUND

Precision medicine is heralded as offering more effective treatments to smaller targeted patient populations. In breast cancer, adjuvant chemotherapy is standard for patients considered as high-risk after surgery. Molecular tests may identify patients who can safely avoid chemotherapy.

OBJECTIVES

To use economic analysis before a large-scale clinical trial of molecular testing to confirm the value of the trial and help prioritize between candidate tests as randomized comparators.

METHODS

Women with surgically treated breast cancer (estrogen receptor-positive and lymph node-positive or tumor size ≥30 mm) were randomized to standard care (chemotherapy for all) or test-directed care using Oncotype DX™. Additional testing was undertaken using alternative tests: MammaPrint^TM, PAM-50 (Prosigna^TM), MammaTyper^TM, IHC4, and IHC4-AQUA™ (NexCourse Breast™). A probabilistic decision model assessed the cost-effectiveness of all tests from a UK perspective. Value of information analysis determined the most efficient publicly funded ongoing trial design in the United Kingdom.

RESULTS

There was an 86% probability of molecular testing being cost-effective, with most tests producing cost savings (range -£1892 to £195) and quality-adjusted life-year gains (range 0.17-0.20). There were only small differences in costs and quality-adjusted life-years between tests. Uncertainty was driven by long-term outcomes. Value of information demonstrated value of further research into all tests, with Prosigna currently being the highest priority for further research.

CONCLUSIONS

Molecular tests are likely to be cost-effective, but an optimal test is yet to be identified. Health economics modeling to inform the design of a randomized controlled trial looking at diagnostic technology has been demonstrated to be feasible as a method for improving research efficiency.

Review of systematic reviews of non-pharmacological interventions to improve quality of life in cancer survivors

OBJECTIVES

Over two million people in the UK are living with and beyond cancer. A third report diminished quality of life.

DESIGN

A review of published systematic reviews to identify effective non-pharmacological interventions to improve the quality of life of cancer survivors.

DATA SOURCES

Databases searched until May 2017 included PubMed, Cochrane Central, EMBASE, MEDLINE, Web of Science, the Cumulative Index to Nursing and Allied Health Literature, and PsycINFO.

STUDY SELECTION

Published systematic reviews of randomised trials of non-pharmacological interventions for people living with and beyond cancer were included; included reviews targeted patients aged over 18. All participants had already received a cancer diagnosis. Interventions located in any healthcare setting, home or online were included. Reviews of alternative therapies or those non-English reports were excluded. Two researchers independently assessed titles, abstracts and the full text of papers, and independently extracted the data.

OUTCOMES

The primary outcome of interest was any measure of global (overall) quality of life.

ANALYTICAL METHODS

Quality assessment assessing methdological quality of systematic reviews (AMSTAR) and narrative synthesis, evaluating effectiveness of non-pharmacological interventions and their components.

RESULTS

Of 14 430 unique titles, 21 were included in the review of reviews. There was little overlap in the primary papers across these reviews. Thirteen reviews covered mixed tumour groups, seven focused on breast cancer and one focused on prostate cancer. Face-to-face interventions were often combined with online, telephone and paper-based reading materials. Interventions included physical, psychological or behavioural, multidimensional rehabilitation and online approaches. Yoga specifically, physical exercise more generally, cognitive behavioural therapy (CBT) and mindfulness-based stress reduction (MBSR) programmes showed benefit in terms of quality of life.

CONCLUSIONS

Exercise-based interventions were effective in the short (less than 3-8 months) and long term. CBT and MBSR also showed benefits, especially in the short term. The evidence for multidisciplinary, online and educational interventions was equivocal.

Psychometric properties of the Beliefs about Medicine Questionnaire-adjuvant endocrine therapy (BMQ-AET) for women taking AETs following early-stage breast cancer

This study evaluated the Beliefs about Medicine Questionnaire to explore adherence to adjuvant endocrine therapy after treatment for breast cancer (BMQ-AET). Factor structure of the BMQ-AET was explored alongside internal consistency, convergent validity and acceptability. The BMQ-AET Specific Scale fitted the original 10 item model. Internal consistency of the BMQ-AET was much improved compared to the original BMQ and convergent validity showed predicted direction of correlation, although correlation with BMQ-AET concerns scale was low. Acceptability was good. The evaluation of the BMQ-AET is encouraging, and could facilitate future research around adherence to AET.

Hit-and-run epigenetic editing prevents senescence entry in primary breast cells from healthy donors

Aberrant promoter DNA hypermethylation is a hallmark of cancer; however, whether this is sufficient to drive cellular transformation is not clear. To investigate this question, we use a CRISPR-dCas9 epigenetic editing tool, where an inactive form of Cas9 is fused to DNA methyltransferase effectors. Using this system, here we show simultaneous de novo DNA methylation of genes commonly methylated in cancer, CDKN2A, RASSF1, HIC1 and PTEN in primary breast cells isolated from healthy human breast tissue. We find that promoter methylation is maintained in this system, even in the absence of the fusion construct, and this prevents cells from engaging senescence arrest. Our data show that the key driver of this phenotype is repression of CDKN2A transcript p16 where myoepithelial cells harbour cancer-like gene expression but do not exhibit anchorage-independent growth. This work demonstrates that hit-and-run epigenetic events can prevent senescence entry, which may facilitate tumour initiation.

“Although aberrant promoter DNA hypermethylation is a hallmark of cancer, it is not clear whether it is sufficient to drive transformation. Here, the authors use CRISPR-dCas9 to perform hit-and-run epigenetic editing, which prevents senescence entry in primary breast cells from healthy donors.”

Atypical Callosal Morphology in Developmental Language Disorder

Introduction

Developmental language disorder (DLD) is common, yet the neurobiology of DLD is poorly understood. A key hypothesis suggests atypical functional lateralization of language, which might be accompanied structurally by a deficit in inter-hemispheric connectivity of language-related regions. Indeed, aberrations of the corpus callosum have been associated with language deficits in children with frank neurological lesions and/or born pre-term. In contrast, studies examining the corpus callosum in children with DLD remain elusive.

Objective

We aimed to expand this largely understudied field by comparing callosal morphology between 17 children with DLD and 17 typically developing children carefully matched for sex and age.

Methods

We analyzed high-resolution structural magnetic resonance imaging data applying a well-validated computational approach, which captures the thickness of the corpus callosum with a high regional specificity at 100 equidistant points.

Results

As shown in Fig. 1, we observed a significantly thinner corpus callosum, particularly in the splenium, in children with DLD compared to typically developing controls (DLD < CTL).

Conclusions

These findings indicating pronounced aberrations in the brain's largest whiter matter tract make an important contribution to an understudied field of research and support the theory that DLD is accompanied by atypical lateralization of language function.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Development and Testing of a Cognitive Behavioral Therapy Resource for Children's Dental Anxiety

Cognitive Behavioral Therapy (CBT) is an evidence-based treatment for dental anxiety; however, access to therapy is limited. The current study aimed to develop a self-help CBT resource for reducing dental anxiety in children, and to assess the feasibility of conducting a trial to evaluate the treatment efficacy and cost-effectiveness of such an intervention. A mixed methods design was employed. Within phase 1, a qualitative "person-based" approach informed the development of the self-help CBT resource. This also employed guidelines for the development and evaluation of complex interventions. Within phase 2, children, aged between 9 and 16 y, who had elevated self-reported dental anxiety and were attending a community dental service or dental hospital, were invited to use the CBT resource. Children completed questionnaires, which assessed their dental anxiety and health-related quality of life (HRQoL) prior to and following their use of the resource. Recruitment and completion rates were recorded. Acceptability of the CBT resource was explored using interviews and focus groups with children, parents/carers and dental professionals. For this analysis, the authors adhered to the Mixed Methods Appraisal Tool criteria. There were 24 families and 25 dental professionals participating in the development and qualitative evaluation of the CBT resource for children with dental anxiety. A total of 56 children agreed to trial the CBT resource (66% response rate) and 48 of these children completed the study (86% completion rate). There was a significant reduction in dental anxiety (mean score difference = 7.7, t = 7.9, df = 45, P < 0.001, Cohen's d ES = 1.2) and an increase in HRQoL following the use of the CBT resource (mean score difference = -0.03, t = 2.14, df = 46, P < 0.05, Cohen's d ES = 0.3). The self-help approach had high levels of acceptability to stakeholders. These findings provide preliminary evidence for the effectiveness and acceptability of the resource in reducing dental anxiety in children and support the further evaluation of this approach in a randomized control trial. Knowledge Transfer Statement: This study details the development of a guided self-help Cognitive Behavioral Therapy resource for the management of dental anxiety in children and provides preliminary evidence for the feasibility and acceptability of this approach with children aged between 9 and 16 y. The results of this study will inform the design of a definitive trial to examine the treatment- and cost-effectiveness of the resource for reducing dental anxiety in children.