A focused ethnography of a Child and Adolescent Mental Health Service: factors relevant to the implementation of a depression trial

BACKGROUND

Prior to commencing a randomised controlled trial, we conducted a focused ethnography to ensure that the trial was well suited to the proposed setting.

METHODS

A six-month observation of a Child and Adolescent Mental Health Service site in the North-East of England was undertaken to observe the site procedures, staff culture and patient care pathways. During this period, documentary data were collected and interviews were conducted with key informants to provide insight into staff perceptions of the proposed trial. The data were coded using thematic analysis and the resulting themes were verified by a second coder.

RESULTS

Seventeen documents were collected, 158 h of observation and six formal staff interviews were undertaken. Four themes emerged from the data; non-clinically orientated variation in practice, diagnosis, capacity and staff economy. Non-clinically orientated variation in practice occurred when staff decisions were based upon resource availability rather than on clinical judgement. Diagnosis demonstrated differing staff confidence in making diagnoses and in the treatment of patients who had received a diagnosis. Capacity consisted of the time to attend training and the psychological capacity to consider or incorporate learning into practice. Staff economy was characterised by staff changes and shortages. There was significant interaction between the themes, with staff economy emerging as a central barrier to research. The results directly informed adaptations to the trial protocol.

CONCLUSIONS

An ethnographic approach has provided important insights into the individual, practical and organisational boundaries into which a trial would need to be implemented.

Abstract P6-11-08: Safety and efficacy results from phase I study of BYL 719 plus nab-paclitaxel in HER 2 negative metastatic breast cancer

Introduction

Mutations/deregulations in the phosphatidylinositol-3-kinase (PI3K) pathway are common in breast cancer, Inhibition of the PI3K pathway is recognized as a promising target for the treatment of breast cancer. Although taxanes are effective early on in advanced stage breast cancer, resistance often develops. It has been demonstrated that activation of the PI3K/AKT pathway confers resistance to paclitaxel, and in preclinical models, concomitant inhibition of the PI3K pathway enhances the efficacy of taxanes. BYL719 is a potent oral, class I PI3K inhibitor which strongly inhibits the PI3K alpha isoforms and is significantly less active against the other class I isoforms. Targeting the alpha isoform of PI3K is expected to improve the therapeutic window over inhibitors with less isoform specificity. Nab-Paclitaxel is a solvent-free, nanoparticle, albumin-based paclitaxel which takes advantage of the antitumor activity of paclitaxel while decreasing the toxicities typically associated with the solvent (Cremophor) used to administer the most common formulation of paclitaxel.

Methods

A 3+3 dose-escalation design evaluated three dose levels of BYL719 (250mg, 300mg, and 350mg) administered PO once daily (D1-28) with nab-Paclitaxel (100 mg/m2 intravenously D 1, 8, 15) every 28 days in patients with metastatic HER 2 negative breast cancer. The aims of the study were to 1) determine the recommended phase II dose (RPTD) of BYL719 + nab-Paclitaxel, 2) assess pharmacokinetics of BYL and nab-paclitaxel, and 3) assess preliminary efficacy.

Results

10 patients were enrolled at 3 dose levels of BYL719 and 3 patients were enrolled in expansion cohort at the RPTD of BYL719 of 350 mg PO daily plus nab-paclitaxel 100mg/m2 (D 1, 8, 15). Median age was 61years; 54% (7/13) of patients were hormone receptor positive and 46% (6/13) triple negative. 85% (11/13) had visceral disease, 69% (9/13) had received prior chemotherapy for metastatic disease and 85% (11/13) had received prior taxane in adjuvant/metastatic setting. There were no DLTs in the three cohorts and the MTD of BYL was not reached. Hyperglycemia (G3:31%, G4:0%) and neutropenia (G3:15%, G4:8%), were the most common grade 3/4 adverse events. There were no Grade 3/4 diarrhea or rash. Best overall response for 12 patients was 58% (7/12) (complete response=1, partial response=6), and an additional 33% (4/12) demonstrated stable disease. Objective responses were noted in both hormone positive and triple negative disease. Median duration of response is 6.5 months (range 2-14 months). No pharmacokinetic interactions were detected when BYL and nab-paclitaxel were co-administered.

Discussion:

This phase I study demonstrates that combination of BYL719 and nab-paclitaxel was well tolerated and shows encouraging efficacy in metastatic HER2 negative breast cancer. Enrollment in the phase II portion of the trial at the RPTD (BYL719 350mg PO daily plus nab-paclitaxel 100mg/m2 D1,8,15 every 28 days) continues. Ongoing analysis of PI3K pathway alterations in tumor and cfDNA will be correlated with clinical response.

Citation Format: Sharma P, Abramson VG, O'Dea A, Lewis S, Scott JN, Ward J, De Jong JA, Lehn C, Brown AR, Williamson SK, Perez RP, Komiya T, Godwin AK, Reed GA, Khan QJ. Safety and efficacy results from phase I study of BYL 719 plus nab-paclitaxel in HER 2 negative metastatic breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-11-08.

Abstract P4-17-01: YSC's "shady pink elephant” end of life series

Background

Young Survival Coalition (YSC) is the premier organization dedicated to the critical issues confronted by young women diagnosed with breast cancer.Young women diagnosed with metastatic breast cancer (YWMBC) in particular, face unique concerns. As a result of a large survey to its metastatic constituency from September 2013 through February 2014, YSC gained important information about the lack of knowledge and education when it comes to end of life (EOL) planning and decisions. The survey was a result of YSC's Research Think Tank, which included a metastasis work group that identified the psychosocial needs of YWMBC as a priority.

Based on the results of this survey which showed 71% of YWMBC had not made EOL plans, YSC decided that offering education and tools regarding EOL was an important intervention to offer. In doing so, young women affected by breast cancer, young adult cancer survivors, co-survivors and healthcare providers will be better prepared to have difficult conversations by allowing stigma to be removed, intentions to be shared, and plans to be made, all to honor the young woman's wishes.

Methods

YSC created a three part end-of-life series called the “Shady Pink Elephant.” (hereinafter “Series”) Each part featured a subject matter expert and was offered as a Facebook event where the speaker was live-streamed and recorded. YSC also offered free continuing education credits for nurses and social workers. The recorded events are stored on YSC's YouTube channel as enduring material. The three parts include: (a) The Research and Benefit of Introducing Palliative Care Early; (b) Let's Have Dinner and Talk about Death; and (c) The “Nuts and Bolts” of End of Life Planning. YSC collaborated with the University of Louisville and received IRB approval to study the entire series as intervention. The study is in process and will conclude later in 2016.

Results

Nine participated in Series Part One of the live event. For Series Part Two, 31 participated in the live event. In the third and final part, 33 participated in the live event. The three parts housed on YSC's YouTube channel have been viewed a total of 747 times to date: 411 views for part one, 156 views for part two and 180 for part three. Thirty-three sought continuing education credit. Fourteen social workers and 5 nurses contacted the approving organization to receive continuing education credit for Series Part One, and 10 social workers and 1 nurse contacted the approving organization to receive continuing education credit for Series Part Three.

Conclusions

Live-streamed, recorded Facebook events are a novel and forward-thinking mode of programmatic offering. YSC learned through this process that live-streamed events are a feasible way to offer programming that reaches a larger and broader audience of young women affected by breast cancer and their loved ones.

Citation Format: Esser MR, Rowe J, Schapmire T, Lewis S. YSC's "shady pink elephant” end of life series [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-17-01.

Abstract P6-06-01: The changing paradigm of hereditary cancer testing: Comparison of tests in 497 women with breast cancer evaluated at an NCI designated cancer center

The Hereditary Cancer Program at Vanderbilt-Ingram Cancer Center (VICC) was established in mid-2012 and provides cancer genetic services to patients and family members who are at risk for family cancer syndromes. During this time, the testing paradigm has markedly shifted from testing a small number of genes to a larger multi-gene set.

HYPOTHESIS AND METHODS:

We hypothesized that multi-gene testing would identify a higher rate of pathogenic mutations in breast cancer patients than the standard BRCA1/2 testing paradigm. To test this notion, we examined the records of 641 women with breast cancer seen in our clinic from July 2012 through Dec 2014 and tabulated the test outcome in women tested for BRCA1/2 only and women who had multi-gene panels. Patient characteristics were compared between the two groups.

RESULTS: Excluding 17 (3%) women with a known familial mutation and the 127 (20%) women who did not proceed with testing, 497 women had usual Sanger BRCA1/2 (189; 38%) or a multi-gene NGS testing (308; 62%). 40 (13%) women were found to have a pathogenic mutation using the multi-gene panel compared to 13 (6%) women who had a restricted BRCA1/2 sequencing (P=0.035, Fishers Exact Test). The 13 women with Sanger BRCA1/2 were younger at diagnosis (40.6 vs 48 yrs) and more likely to have triple negative (TN) disease (38% vs 18%) compared to the 40 women diagnosed with multi-gene panels. TN disease was not confined to BRCA1 carriers, however, as 3 of 7 TN patients had a mutation in BRCA2, PALB2, and ATM, respectively. Thus, 29% (2/7) of our triple negative patients would not have been identified without multi-gene panels. In addition to BRCA1 (6; 15%) and BRCA2 (5; 12.5%), 6 women had mutations in ATM (15%), 7 in CHEK2 (17.5%), 6 in MUTYH (15%), 4 in PALB2 (10%), 2 in TP53 (5%), and 1 each in FANCC, PMS2, RAD51D and XRCC2 (2.5% each). 105 patients (35%) who did not have a deleterious mutation on a multi-gene panel were found to have one or more variants of uncertain significance (VUS) compared to 4 patients who underwent BRCA1/2 testing alone (4/189; 2%). There was a significant difference between providers when ordering hereditary cancer testing, with MD or NP ordering panel testing at a greater rate compared to Genetic Counselors (72% vs 53%; P< 0.0001).

CONCLUSION: We have examined the outcomes of genetic tests for 497 women with breast cancer during a time of great change in the approach to testing. Our study supports the paradigm that multi-gene panels will identify additional pathogenic mutations in genes other than BRCA1/2, which could increase clinical efficiency and improve patient outcomes. However, our study also found a high VUS rate in this group of patients, which will require additional clinical time to track for potential changes in pathogenicity. Future studies will focus on potential differences in management for patients found to have alterations on multi-gene tests.

Citation Format: Wiesner GL, Lewis S, Holt J, Morgan RH, Riddle DA, Trump SA, McReynolds K. The changing paradigm of hereditary cancer testing: Comparison of tests in 497 women with breast cancer evaluated at an NCI designated cancer center. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-06-01.

The influence of mothers' and fathers' sensitivity in the first year of life on children's cognitive outcomes at 18 and 36 months

BACKGROUND

There has been increasing interest in the relative effects of mothers' and fathers' interactions with their infants on later development. However to date there has been little work on children's cognitive outcomes.

METHODS

We examined the relative influence of fathers' and mothers' sensitivity during interactions with their children at the end of the child's first year (10-12 months, n = 97), on child general cognitive development at 18 months and language at 36 months.

RESULTS

Both parents' sensitivity was associated with cognitive and language outcomes in univariate analyses. Mothers' sensitivity, however, appeared to be associated with family socio-demographic factors to a greater extent that fathers' sensitivity. Using path modelling the effect of paternal sensitivity on general cognitive development at 18 months and language at 36 months was significantly greater than the effect of maternal sensitivity, when controlling for socio-demographic background. In relation to language at 36 months, there was some evidence that sensitivity of one parent buffered the effect of lower sensitivity of the other parent.

CONCLUSIONS

These findings suggest that parental sensitivity can play an important role in children's cognitive and language development, and that higher sensitivity of one parent can compensate for the lower sensitivity of the other parent. Replication of these findings, however, is required in larger samples.

The effectiveness of tobacco control television advertisements in increasing the prevalence of smoke-free homes

BACKGROUND

There is considerable evidence that tobacco control mass media campaigns can change smoking behaviour. In the UK, campaigns over the last decade have contributed to declines in smoking prevalence and been associated with falls in cigarette consumption among continuing smokers. However, it is less evident whether such campaigns can also play a role in changing smokers' behaviour in relation to protecting others from the harmful effects of their smoking in the home. We investigated whether exposure to English televised tobacco control campaigns, and specifically campaigns targeting second hand smoking, is associated with smokers having a smoke-free home.

METHODS

We used repeated cross-sectional national survey data on 9872 households which participated in the Health Survey for England between 2004 and 2010, with at least one adult current smoker living in the household. Exposure to all government-funded televised tobacco control campaigns, and to those specifically with a second hand smoking theme, was quantified in Gross Rating Points (GRPs), an average per capita measure of advert exposure where 100 GRPs indicates 100 % of adults exposed once or 50 % twice. Our outcome was self-reported presence of a smoke-free home (where no one smokes in the home on most days). Analysis used generalised additive models, controlling for individual factors and temporal trends.

RESULTS

There was no association between monthly televised campaigns overall and the probability of having a smoke-free home. However, exposure to campaigns specifically targeting second hand smoke was associated with increased odds of a smoke-free home in the following month (odds ratio per additional 100 GRPs, 1.07, 95 % CI 1.01 to 1.13), though this association was not seen at other lags. These effects were not modified by socio-economic status or by presence of a child in the home.

CONCLUSIONS

Our findings provide tentative evidence that mass media campaigns specifically focussing on second hand smoke may be effective in reducing smoking in the home, and further evaluation of campaigns of this type is needed. General tobacco control campaigns in England, which largely focus on promoting smoking cessation, do not impact on smoke-free homes over and above their direct effect at reducing smoking.

The 2011-2014 prevalence of eosinophilic oesophagitis in the elderly amongst 10 million patients in the United States

BACKGROUND

Eosinophilic oesophagitis (EoE) is primarily diagnosed by clinicians. There are less than a handful of epidemiological studies in EoE that have included elderly patients (>65 years).

AIM

To determine the prevalence of elderly subjects among EoE patients and compare their clinical presentation, associated conditions and treatment modalities with adult and paediatric EoE patients.

METHODS

A large nationwide database (Explorys) between January 2011 and January 2014 was used. The term 'Eosinophilic Oesophagitis' was used in the Explorys search tool. The patient population was divided into three groups, Paediatric (<18 years), Adult (18-65 years) and Elderly (>65 years).

RESULTS

We identified 4840 patients coded as EoE. The total estimated prevalence was 50.6 cases per 100 000 patients (0.05%). A total of 360 cases (7.44%) were elderly patients with an estimated prevalence rate of 18.6 cases per 100 000. Across all age groups, the majority of EoE patients were Caucasians and males. A significantly greater proportion of older patients had concomitant GERD. Dysphagia was the most common symptom among elderly EoE patients as compared with the paediatric EoE patients (P < 0.001). The proportion of elderly EoE patients with food allergies or asthma was significantly lower as compared with paediatric and adult EoE patients (P < 0.001). Oesophageal dilation and/or proton pump inhibitor treatment were the most commonly used therapeutic modalities in elderly EoE patients.

CONCLUSION

Eosinophilic oesophagitis is uncommon in elderly subjects and the clinical presentation is markedly different as compared with adults or the paediatric population.

The relationship between length of Barrett's oesophagus mucosa and body mass index

BACKGROUND

Length of Barrett's oesophagus (BE) is a risk factor for oesophageal cancer. The underlying mechanisms that determine BE length are nor fully known.

AIM

To determine if there is a correlation between obesity and length of BE.

METHODS

Using a population-based study, 381 patients diagnosed with Barrett's oesophagus between 1999 and 2013 were included. Body mass index (BMI) at the time of BE diagnosis was calculated. Upper endoscopy reports were reviewed to obtain the length of BE. Spearman's correlation coefficient was performed to assess the strength of the relationship between Barrett's length and BMI. A multivariate logistic regression analysis was conducted to further examine the association between BMI and length of BE.

RESULTS

The adjusted odds ratio for each five-point increase in BMI was 1.5 (95% CI 1.24-1.81, P < 0.001). The mean BMI was significantly higher in patients with long segment BE as compared to patients with short segment BE (32.7 vs. 30.3, P = 0.001). There was also a positive trend in long segment BE as patients entered into higher BMI categories (Z = 4.25, P < 0.001). There was a significant correlation between BMI and length of BE (r = 0.25, P < 0.0001).

CONCLUSION

The study demonstrated a correlation between BMI and the length of Barrett's oesophagus mucosa. Thus, increased BMI is associated with longer segment of Barrett's oesophagus.

Assessing the impact of evolving evidence in renal cell carcinoma treatment: an update of the Renal Cell Carcinoma Appropriateness-based Treatment Toolkit (ReCATT)

The appropriateness of the numerous therapeutic options available for patients with advanced or metastatic renal cell carcinoma (RCC) was evaluated in 2011, using the RAND/University of California, Los Angeles (UCLA) appropriateness methodology to match treatment suitability to a range of patient scenarios. However, the RCC therapeutic area evolves rapidly and a body of new clinical data has accrued in the intervening years; as a result the exercise was repeated in 2013 using the same methodology, expert panel and patient scenarios. The aim of the updated assessment was to update the guidance to clinicians and use it to develop an interactive web-based application, the Renal Cell Carcinoma Appropriateness-based Treatment Toolkit (ReCATT). This round of assessment achieved greater concordance concerning the appropriateness of treatments/interventions for the clinical scenarios tested; this higher level of agreement is likely to reflect the body of scientific evidence accrued since the previous assessment exercise. Many of the areas of disagreement in 2011 related to the suitability of pazopanib or sunitinib treatment; in the 2013 assessment both agents were considered appropriate treatment options for many of the clinical scenarios assessed. Uncertain scenarios often are related to the optimal management of metastatic RCC with clear cell histology. The use of the RAND/UCLA RCC assessment findings to develop the ReCATT support tool will help to disseminate expert opinion concerning best treatment practice and guide the clinical management of RCC patients treated in the community setting.

Effectiveness of tobacco control television advertisements with different types of emotional content on tobacco use in England, 2004-2010

AIM

To examine the effects of tobacco control television advertisements with positive and negative emotional content on adult smoking prevalence and cigarette consumption.

DESIGN

Analysis of monthly cross-sectional surveys using generalised additive models.

SETTING

England.

PARTICIPANTS

60 000 adults aged 18 years or over living in England and interviewed in the Opinions and Lifestyle Survey from 2004 to 2010.

MEASUREMENTS

Current smoking status, daily cigarette consumption, tobacco control gross rating points (GRPs-a measure of per capita advertising exposure), cigarette costliness, concurrent tobacco control policies, sociodemographic variables.

RESULTS

After adjusting for cigarette costliness, other tobacco control policies and individual characteristics, we found that a 400-point increase in positive emotive GRPs was associated with 7% lower odds of smoking (odds ratio (OR) 0.93, 95% CI 0.87 to 0.98) 1 month later and a similar increase in negative emotive GRPs was significantly associated with 4% lower odds of smoking (OR 0.96, 95% CI 0.92 to 0.999) 2 months later. An increase in negative emotive GRPs from 0 to 400 was also associated with a significant 3.3% (95% CI 1.1 to 5.6) decrease in average cigarette consumption. There was no evidence that the association between positive emotive GRPs and the outcomes differed depending on the intensity of negative emotive GRPs (and vice versa).

CONCLUSIONS

This is the first study to explore the effects of campaigns with different types of emotive content on adult smoking prevalence and consumption. It suggests that both types of campaign (positive and negative) are effective in reducing smoking prevalence, whereas consumption among smokers was only affected by campaigns evoking negative emotions.