Implementing an Evidence-Based, Asthma Decision Support Tool for Children Younger Than 5 Years Old

INTRODUCTION

Asthma is underdiagnosed, particularly for children younger than 5 years old. Clinical practice guidelines have been shown to improve asthma diagnosis and management, but are underutilized. This evidence-based practice project aimed to develop, implement, and evaluate a three-page decision support tool (DST) to improve the asthma diagnosis process among children younger than 5 years old.

METHODS

This project used a pre-experimental design and was conducted in a pediatric primary care setting with a predominantly South Asian population. The authors analyzed the utilization of the DST as well as the end-users' perception of the tool.

RESULTS

Despite above-average results in the end-users' usability scale, the DST had poor utilization.

DISCUSSION

Implementation of the DST is recommended at similar pediatric primary care sites. The EBP Project team recommends translating the DST to the electronic health record and improving the roles of the champion.

Abstract P3-08-07: Distinct biological signatures describe differences in BRCA mutated subgroups

Background: BRCA mutated (BRCA+) breast cancers are expected to have increased activation of Homologous Recombination Deficiency (HRD) and altered DNA damage repair pathways when compared to BRCA wildtype (BRCA-). To better understand differences in these populations, biological patterns and immune responses to BRCA+ breast cancers were evaluated. The primary aim of our study was to use novel gene expression tools to assess early stage breast cancers with and without germline BRCA mutations, and within distinct BRCA+ subgroups.

Methods: We identified 124 early stage untreated breast cancers with and without BRCA mutations (n = 62 and 62, respectively). Our BRCA- group was matched by hormone receptor (HR) status, age, and stage to the BRCA+ group. The NanoString Breast Cancer 360 panel was applied to RNA isolated from 80 breast tumors (BRCA+ = 39; BRCA- = 41). The BRCA+ group had a BRCA1+ subgroup (n=17) and a BRCA2+ subgroup (n=22).

Results: There was a significant increase in two BC360 signatures in both the BRCA1+ and BRCA2+ tumors compared with the BRCA- population: Prosigna™Risk of Recurrence (ROR) score [BRCA1+: HR: 1.142 (95% CI 1.019, 1.279), p=0.02; BRCA2+: HR: 1.321 (95% CI 1.190, 1.466), p<0.001] and HRD [BRCA1+: HR: 3.576 (95% CI 2.174, 5.880), p=0.02; BRCA2+: HR: 1.801 (95% CI 1.142, 2.840), p<0.001]. BRCA1+ tumors had lower expression of ESR1 [p=0.03], PGR [p=0.02], ER signaling [p<0.001], and differentiation [p=0.005]; while BRCA2+ tumors had lower expression of stroma markers [p=0.02] and inflammatory chemokines [p=0.001]. The two BRCA+ subgroups had distinct molecular subtype correlation trends that were highly significant. BRCA1+ tumors were positively associated with a basal subtype [p<0.001], whereas this association was not significant for BRCA2+ tumors. BRCA2+ tumors were associated with an increase in luminal B subtype [p=0.05]. All BRCA+ tumors had a decrease in luminal A subtype correlation [BRCA1+: p<0.001; BRCA2+: p=0.002]. In addition to the BC360 signatures, a differential analysis of all genes in the BC360 panel revealed more single gene differences in BRCA2+ than BRCA1+ tumors when compared to BRCA- tumors.

Conclusions: In early stage BRCA+ breast cancer, tumors have higher ROR and increased HRD signature scores compared to BRCA- tumors. Furthermore, BRCA1+ and BRCA2+ tumors have both signature and single gene expression differences when compared to BRCA- tumors, indicating distinct subgroup-related biology. The greater correlation of BRCA1+ tumors with basal-like biology and BRCA2+ tumors with aggressive hormonal biology confirms these trends. Distinctions in hormone receptor signaling, DNA-damage pathways, and microenvironment/inflammatory features between BRCA1 and BRCA2 associated cancers suggest a need for different prevention and therapeutic strategies for each of these breast cancer subtypes. The unique biological patterns identified here should be further evaluated as predictive or prognostic tools that could be translated into clinical care for early stage BRCA+ patients.

Citation Format: Force J, Plichta J, Stashko I, Kimmick G, Westbrook K, Sammons S, Hwang S, Hyslop T, Kauff N, Castellar E, Nair S, Weinhold K, Davis S, Mashadi-Hossein A, Brauer HA, Marcom PK. Distinct biological signatures describe differences in BRCA mutated subgroups [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-08-07.

Guselkumab for the Treatment of Moderate-to-Severe Plaque Psoriasis During Induction Phase: A Systematic Review and Network Meta-Analysis

Background:

Guselkumab is an interleukin-23 inhibitor indicated for treatment of moderate-to-severe plaque psoriasis.

Objective:

The objective was to determine the relative efficacy and safety of guselkumab compared to other biologics.

Methods:

A systematic review was performed to identify randomized controlled trials (RCTs). Bayesian network meta-analyses (NMAs) were conducted using meta-regression analyses that adjusted for cross-trial differences and risk differences. The primary outcome was Psoriasis Area and Severity Index (PASI) 90 response. Other efficacy and safety outcomes were considered. Several meta-regressions were performed to account for variations in patient and study characteristics: baseline risk adjustment (ie, control group response), prior biologic use, duration of psoriasis, weight, age, race, and baseline PASI/dermatology life quality index scores. The best-fitting model using predefined criteria was selected.

Results:

Forty-five RCTs were identified. Patient and study characteristics differed between RCTs as reflected in variations in control group response. Both the baseline risk-adjusted NMA and the risk-difference NMA fit the data best and suggested guselkumab has one of the highest PASI 90 responses. Pairwise comparisons from the baseline risk-adjusted PASI 90 NMA suggested guselkumab has comparable efficacy with ixekizumab (relative risk [RR]: 0.999, 95% credible intervals [CrIs]: 0.89-1.13) and brodalumab (RR: 1.04, 95% CrIs: 0.91-1.17) and superior efficacy versus all other treatments in the network (RR range, 1.20 to 43.22). Guselkumab was superior or comparable to other therapies for other efficacy outcomes and had a more favorable safety profile than most.

Conclusions:

Guselkumab has one of the highest PASI 90 responses among psoriasis treatments; similar findings were observed for other efficacy outcomes. Guselkumab has a favorable benefit–risk balance compared to moderate-to-severe psoriasis therapies.

Unique Partnership to Roll Out Cancer Awareness and Screening Program for High-Risk Population in Maharashtra

Background and context: India is one of the few countries to have National Cancer Control Program and emphasis is given on tobacco related cancers because of high prevalence of such practices in India. As per the Global Adult survey 2016 around 30% of Indian population consume tobacco in any other form. Bus drivers, conductors and support staff of two leading public transport companies will be targeted by Indian Cancer Society as they are among high risk population with huge percentage of employees addicted with tobacco. Through this unique partnership, Indian Cancer Society (ICS) will promote tobacco deaddiction, cancer awareness and early detection of cancer among their staff. Aim: ICS is aiming at reaching out to around 1.20 Lakh bus drivers, conductors and support staff through this project in the span of 2 years. Strategy/Tactics: Cancer awareness will be created among targeted as well as general population by means of posters, banners, IEC leaflets. Depot managers will be sensitized about cancer, ill effects of tobacco consumption and importance of early detection. All eligible employees will be screened for commonest cancers in India like oral, breast, cervical and prostate. Tobacco deaddiction activities like support group meetings, experience sharing activities, role plays etc. will be organized for employees to facilitate tobacco deaddiction. Program/Policy process: Baseline survey was conducted for the sample size of 1000 employees in the month of March 2018 to assess their knowledge, attitude and practices related to tobacco addiction and cancer awareness. BCC and IEC activities will be planned based on the findings of baseline survey. Customized cancer screening packages will be developed based on the age and risk profile of employees. Support group meetings will be organized for employees with tobacco addiction. Outcomes: In the tenure of 2 years, cancer awareness will be created among 1.20 Lakh bus drivers, conductors and support staff. 75%–80% of these population will undergo cancer screening. General population residing in 30 districts of Maharashtra will be reached out through the cancer awareness drive organized at bus depots. Burden on the health system of these two transport companies will be reduced due to improved knowledge and health practices among their staff. Conclusion: With mandatory CSR, the private sector is keen on focusing on diseases with measurable outcome. Partnerships between government and NGOs can provide opportunities for private sector to collaborate; to reduce the burden of cancer through awareness and facilitate early detection thus improving chance of cure. This PPP model will provide structured quality cancer screening facility to identified high risk population and will facilitate early cancer detection. Best practices will be imbibed and tobacco deaddiction activities will be sustained beyond the project period.

An Eye Opener: Lessons Learnt in Retinoblastoma Awareness and Screening Program

Background: Retinoblastoma is most common intraocular malignancy of infancy. Globally screening is recommended for ‘at risk’ children. Despite knowing this, Indian Cancer Society undertook general screening at behest of a corporate donor. Scenario in India is challenging as children at rural, urban slums are not routinely screened for any of eye disease. ICS implemented the pilot project among underprivileged children with primary aim of spreading awareness and improve the ocular health. Though expected outcome was zero retinoblastoma suspect cases; based on past projects it was expected that other eye conditions like squint, cataract etc. would be identified in a few. Aim: To screen 4500 children below 4 years of age at Indian rural and suburban slum areas. To create awareness about retinoblastoma and other eye conditions in community. Methods: Locations were identified where literacy, awareness, immunization coverage were low. Partners were selected a team of experts (ocular oncologists, pediatric ophthalmologists, optometrists, paramedical staff) were deployed for implementation. For awareness, all parents coming for the immunization, Aaganwadis and preschools etc. were given a talk on the importance of child eye screening and various disease which can be detected and prevented through simple eye examination. Special community level programs planned to create awareness about retinoblastoma and early childhood eye screening. Brochures and pamphlets were to be given in the vernacular language of the region. Screening for retinoblastoma was planned in 2 phases, those found to have positive red reflex in stage 1 are subjected to dilation, after obtaining consent from the parents. Proformas were filled in and treatment was given as per the pediatric eye disease identified. Results: In 5 months 2450 children were screened, at tribal area and in suburban slum areas. Awareness sessions were conducted for 348 mothers in batches at the tribal area and similarly for mothers and teachers at Anganwadi, schools. None of the parents/teachers were aware about cancer of eye. A thorough eye check-up was done based on the suggestions of the American Association of Pediatric eye diseases and special attention was given to tests such as Bruckners test. Number of children suspected of retinoblastoma was nil, however, 6% children were found to have other eye conditions such as congenital cataract, corneal opacity, refractive errors, squints and ptosis in the tribal area and project is ongoing in suburban area. Treatment was given as per the protocol for same. Conclusion: Screening for retinoblastoma for not at risk children is not recommended. Main aim for implementing retinoblastoma awareness program is to integrate it with immunization or nutritional program in India. This would ensure standardized ocular care. Challenges are numerous, such as lack of infrastructure, poor literacy rates, low income levels. Yet, innovative strategies are needed for better impact of awareness programs.

Navigating Muddy Waters: Clearing Waves While Keeping Ourselves Afloat

Background and context: As the oldest cancer-related nongovernmental organization in Malaysia, the National Cancer Society of Malaysia regularly receives proposals for collaborations. While many are mutually beneficial, some are “risky”. Examples include partnerships with fast food companies, health supplements which benefits are vastly exaggerated, or fundraisers being held at bars or pubs. While these campaigns are accepted norms within the region, they might not conform to the standards of more mature markets. As we are expected to promote these activities or products on our digital media accounts, we risk overcrowding our pages, or being perceived as endorsing a product or behavior. Aim: Keeping donors happy while maintaining credibility Strategy/Tactics: The current strategy for NCSM's digital outreach is to focus on education/awareness instead of marketing. Also, we match the campaign's values with that of NCSM when deciding whether to promote it. When promoting a campaign, we stay neutral or personalise the donation. Above all, we play “devil's advocate”, focus on the impact of the funds raised, and stay firm on our decision. Program/Policy process: Out of 12 social media posts each week, no more than 2 is on marketing campaigns. Donors, instead of the product, are featured in a personalised “Why I Give” post. At times, we also prioritize well-meaning campaigns over others. For fundraisers held in bars/pubs, we ask for compromises (e.g., to ban smoking in the area for a short time, or that we do not promote the alcohol manufacturer). We are also proactive in checking the promotional content and insist that the donor remove any unproven information. Outcomes: NCSM's Facebook page grew organically (without ad buys) from 4000 in 2016 to 15,000 in 2017. We have about 60 new followers each week, negligible “unfollows” even on marketing-heavy times, and a minimum reach of 15,000 people. Education content is more popular (2300 reach per post versus 400); the same trend is observed for personalised versus product-based posts (3700 vs 400). To date, we have good relationships with our donors, and have not received comments on any partnerships. What was learned: It's intention, and not visual or monetary value, that counts: our audiences are more appreciative of quality content, even if marketing/product posts might look better. Also, staff and survivors can sense sincere donors, which makes a difference in our promotional efforts (positive versus matter-of-fact tones). Well-meaning donors do adhere to our promotion guidelines, and do agree to not being promoted. In addition, featuring donors is a great way to publicise an activity without mentioning the product. Most importantly, being able to justify collaborations within the organization protects its integrity and credibility.

Mxra8 is a receptor for multiple arthritogenic alphaviruses

Arthritogenic alphaviruses comprise a group of enveloped RNA viruses that are transmitted to humans by mosquitoes and cause debilitating acute and chronic musculoskeletal disease 1 . The host factors required for alphavirus entry remain poorly characterized 2 . Here we use a genome-wide CRISPR-Cas9-based screen to identify the cell adhesion molecule Mxra8 as an entry mediator for multiple emerging arthritogenic alphaviruses, including chikungunya, Ross River, Mayaro and O'nyong nyong viruses. Gene editing of mouse Mxra8 or human MXRA8 resulted in reduced levels of viral infection of cells and, reciprocally, ectopic expression of these genes resulted in increased infection. Mxra8 bound directly to chikungunya virus particles and enhanced virus attachment and internalization into cells. Consistent with these findings, Mxra8-Fc fusion protein or anti-Mxra8 monoclonal antibodies blocked chikungunya virus infection in multiple cell types, including primary human synovial fibroblasts, osteoblasts, chondrocytes and skeletal muscle cells. Mutagenesis experiments suggest that Mxra8 binds to a surface-exposed region across the A and B domains of chikungunya virus E2 protein, which are a speculated site of attachment. Finally, administration of the Mxra8-Fc protein or anti-Mxra8 blocking antibodies to mice reduced chikungunya and O'nyong nyong virus infection as well as associated foot swelling. Pharmacological targeting of Mxra8 could form a strategy for mitigating infection and disease by multiple arthritogenic alphaviruses.

Irg1 expression in myeloid cells prevents immunopathology during M. tuberculosis infection

Nair et al. define a key role for Irg1 in minimizing the pathological immune response associated with Mtb infection. Using Irg1^−/− and Irg1^fl/fl conditional mice, detailed immune cell analysis, and transcriptional profiling, their data supports a model where Irg1 expression in myeloid cell subsets tempers inflammation and controls the recruitment and infection of neutrophils during Mtb infection.

Immune-Responsive Gene 1 (Irg1) is a mitochondrial enzyme that produces itaconate under inflammatory conditions, principally in cells of myeloid lineage. Cell culture studies suggest that itaconate regulates inflammation through its inhibitory effects on cytokine and reactive oxygen species production. To evaluate the functions of Irg1 in vivo, we challenged wild-type (WT) and Irg1^−/− mice with Mycobacterium tuberculosis (Mtb) and monitored disease progression. Irg1^−/−, but not WT, mice succumbed rapidly to Mtb, and mortality was associated with increased infection, inflammation, and pathology. Infection of LysM-Cre Irg1^fl/fl, Mrp8-Cre Irg1^fl/fl, and CD11c-Cre Irg1^fl/fl conditional knockout mice along with neutrophil depletion experiments revealed a role for Irg1 in LysM⁺ myeloid cells in preventing neutrophil-mediated immunopathology and disease. RNA sequencing analyses suggest that Irg1 and its production of itaconate temper Mtb-induced inflammatory responses in myeloid cells at the transcriptional level. Thus, an Irg1 regulatory axis modulates inflammation to curtail Mtb-induced lung disease.

Squamous cell carcinoma of the upper aerodigestive tract in exclusive smokers, chewers, and those with no habits

BACKGROUND

Tobacco consumption is the major risk factor for developing head and neck squamous cell cancer (SCC). The site of development of HNSCC may depend on the way the tobacco is consumed. While laryngeal cancers are more common among smokers, oral cancers are more common among tobacco chewers. Since the use of smokeless tobacco is increasing, it is important to know whether this difference is restricted only to site wise distribution or it has other clinical and pathological implications.

PATIENTS AND METHODS

We analyzed a prospectively collected dataset of HNSCC patients other than nasopharyngeal cancers attending our outpatient department at a single unit of the head and neck services at Tata Memorial Hospital, Mumbai, India, between January 2010 and September 2011. There were 747 eligible patients and were divided into three groups: Those with chewing as the only habit (chewers), those with smoking as the only habit (smokers), and those with no habits. Patients with regular use of alcohol were excluded from the study. The clinical and pathological parameters were analyzed.

RESULTS

Of the 747 patients, the tobacco chewers formed 69.3% followed by smokers (19.5%) and patients with no habits (11.1%). Majority of smokers were men (98%). Site distribution revealed patients with chewing as the only habit had oral cancers (most commonly gingivobuccal complex cancers) as the most common site and those with smoking as the only habit had larynx as the most common site. In patients with no habits, oral tongue was found to be the most common site. No statistically significant pathological differences were observed in between these groups in patients who underwent surgery (n = 366) at the initial modality of treatment.

CONCLUSIONS

There is a direct relationship between the form of tobacco use and site of appearance of HNSCC. However, there are no differences in clinical or pathological parameters between HNSCC caused by tobacco chewing or tobacco smoking.