Guidelines for Ethical Review of Qualitative Research

In recognition of the important ethical issues posed by qualitative research in health care, the authors present key questions to aid ethical review. The purpose is to assist lay and professional members of research ethics committees in their assessment of applications involving qualitative research methods and to inform researchers intending to submit such applications for ethical approval. For the benefit of those less familiar with this type of research, the authors include an overview of different types of qualitative research, together with an explanation of terms commonly used by qualitative researchers.

One-stop microvascular screening service: an effective model for the early detection of diabetic peripheral neuropathy and the high-risk foot

AIMS

To evaluate the feasibility of a one-stop microvascular screening service for the early diagnosis of diabetic distal symmetrical polyneuropathy, painful distal symmetrical polyneuropathy and the at-risk diabetic foot.

METHODS

People with diabetes attending retinal screening in hospital and community settings had their feet examined by a podiatrist. Assessment included: Toronto Clinical Neuropathy Score evaluation; a 10-g monofilament test; and two validated, objective and quick measures of neuropathy obtained using the point-of-care devices 'DPN-Check', a hand-held device that measures sural nerve conduction velocity and amplitude, and 'Sudoscan', a device that measures sudomotor function. The diagnostic utility of these devices was assessed against the Toronto Clinical Neuropathy Score as the 'gold standard'.

RESULTS

A total of 236 consecutive people attending the retinal screening service, 18.9% of whom had never previously had their feet examined, were evaluated. The prevalence of distal symmetrical polyneuropathy, assessed using the Toronto Clinical Neuropathy Score, was 30.9%, and was underestimated by 10-g monofilament test (14.4%). The prevalence of distal symmetrical polyneuropathy using DPN-check was 51.5% (84.3% sensitivity, 68.3% specificity), 38.2% using Sudoscan foot electrochemical skin conductance (77.4% sensitivity, 68.3% specificity), and 61.9% using abnormality in either of the results (93.2% sensitivity, 52.8% specificity). The results of both devices correlated with Toronto Clinical Neuropathy Score (P<0.001). A new diagnosis of painful distal symmetrical polyneuropathy was made in 59 participants (25%), and 56.6% had moderate- or high-risk foot. Participants rated the service very highly.

CONCLUSIONS

Combined, eye, foot and renal screening is feasible, has a high uptake, reduces clinic visits, and identifies painful distal symmetrical polyneuropathy and the at-risk foot. Combined large- and small-nerve-fibre assessment using non-invasive, quantitative and quick point-of-care devices may be an effective model for the early diagnosis of distal symmetrical polyneuropathy.

Surgical re-excision vs. observation for histologically dysplastic naevi: a systematic review of associated clinical outcomes

BACKGROUND

The management of histologically dysplastic naevi (HDN) with re-excision vs. observation remains controversial because of lack of evidence about associated melanoma outcomes.

OBJECTIVES

To assess published data on the development of biopsy-site primary cutaneous melanoma among biopsy-proven HDN managed with either re-excision or observation.

METHODS

A systematic review of all published data: a total of 5293 records were screened, 18 articles were assessed in full text and 12 studies met inclusion criteria. No controlled trials were identified.

RESULTS

Most studies (11 of 12, 92%) were retrospective chart reviews, and one was both a cross-sectional and cohort study. Many studies (nine of 12, 75%) had no head-to-head comparison groups and either only reported HDN that were re-excised or observed. A total of 2673 (1535 observed vs. 1138 re-excised) HDN of various grades were included. Follow-up varied between 2 weeks and 30 years. Nine studies reported that no melanomas developed. Eleven biopsy-site melanomas developed across three of the studies, six among observed lesions (0·39%) and five among re-excised lesions (0·44%).

CONCLUSIONS

Based upon the available evidence the rates of biopsy-site primary melanoma were similarly low among observed lesions and re-excised lesions. This suggests that HDNs can be observed with minimal adverse melanoma-associated outcomes. However, all included articles were of low quality and further prospective trials could better guide clinical decision making.

Abstract P2-02-14: Circulating tumor DNA predicts clinical outcome in early stage triple negative breast cancer

Background- Triple negative breast cancer (TNBC) is the most aggressive subtype of breast cancer as these patients have the highest risk of recurrence and death. Only 35% of TNBC patients achieve a pathologic complete response (pCR) following neoadjuvant chemotherapy. Patients who do not achieve pCR have a 27% risk of distant recurrence and ultimate death at 3 years compared to 9% for pCR. Unidentified micrometastases are responsible for ultimate overt progression and death. Developing strategies to identify patients with minimal residual disease following curative treatment is an unmet need. Circulating tumor DNA (ctDNA) can characterize and monitor advanced cancers. In this study, we sought to assess if ctDNA can predict clinical outcome in TNBC.

Methods-Biospecimens were obtained from patients with stages II and III TNBC enrolled on a neoadjuvant trial (NCT02124902). Patients have a research biopsy and plasma for ctDNA collected at baseline, cycle 1 day 3, definitive surgery for those with residual disease, and at recurrence for those who relapse. Plasma for ctDNA is also collected every 6 months for 5 years after treatment. Patients receive docetaxel and carboplatin every 3 weeks X 6 cycles. Surgery is 3-5 weeks after chemotherapy. Six patients' serial tumor samples and germline DNA were studied by whole exome sequencing. The median sequencing depth was 90.13x. Sequencing was performed on samples with high cellularity (≥50%). All 6 patients also had serial ctDNA analyzed using Swift Biosciences Accel-Amplicon™ 56G Oncology Panel v2. After identifying somatic mutations in each breast tumor series, we determined the subset of mutations that intersected with the regions targeted by the Swift 56 gene panel. We then evaluated whether corresponding mutations could be detected in ctDNA, and if ctDNA predicted clinical outcome.

Results-Four of the 6 patients were non-pCR with residual disease following chemotherapy. We identified 627 somatic variants by exome analysis that were called by at least two somatic variant callers and passed additional quality filtering steps. Of these, 10 variants overlapped with the Swift panel. TP53 variants were identified in all 6 patients' tumor tissue samples. At least one TP53 variant was identified in 4 patients' baseline pre-chemotherapy ctDNA samples. Both pCR patients had either no detectable ctDNA TP53 mutations (NTN007-ref. in baseline tumor tissue was 19.58% variant allele frequency [VAF]); or clearance of ctDNA following chemotherapy from 4.45% VAF at baseline to 0.06% following chemotherapy (NTN004-ref. in baseline tumor tissue 37.34% VAF). Three non-PCR patients had persistent TP53 mutations in ctDNA during the treatment course. One non-pCR patient did not have detectable mutations in ctDNA. The only patient with recurrent disease whose ctDNA TP53 mutation persisted during the treatment course (baseline VAF-1.65%, cycle 1 day 3-0.78%, definitive surgery-0.09%), was found to have a higher ctDNA VAF at recurrence (29.55%).

Conclusion-In this pilot study, mutation tracking by ctDNA is sensitive and distinguishes pCR from non-pCR in TNBC patients receiving neoadjuvant chemotherapy. ctDNA also identifies recurrence following curative therapy. Evaluating ctDNA as a biomarker of outcome in TNBC is warranted.

Citation Format: Ademuyiwa F, Feng Y-Y, Skidmore Z, Kunisaki J, Walker J, Fulton R, Krysiak K, Skinner T, Weilbaecher K, Ma C, Griffith O, Griffith M. Circulating tumor DNA predicts clinical outcome in early stage triple negative 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 P2-02-14.

[Acupuncture covered by statutory health insurance in Germany : An observational study based on claims data]

BACKGROUND

The coverage for acupuncture for chronic lower back or knee pain by the statutory health insurance was introduced in 2007. The aim of this study was to investigate characteristics of patients and providers of acupuncture and temporal and regional trends in the utilization of acupuncture.

METHODS

This retrospective observational study used anonymized statutory health insurance claims data from a sample of roughly four million subjects. The sample is representative of the German population regarding age and gender in 2013.

RESULTS

Lower back pain was the most common coded indication (86%) for billing acupuncture. Women were more often treated with acupuncture than men; the mean age was 61.1 years. For 63% acupuncture was billed in 2014 for the first time, 37% already had an acupuncture treatment in 2012 or 2013. Premature termination (<6 sessions) was observed in 14% of all insurants receiving acupuncture for the first time in 2014 for knee pain and in 21% of those with back pain. Overall there was a statistically significant decrease in the utilization of acupuncture from 2008 to 2015. Regional differences between East and West Germany and city states were observed. Half of all acupuncture treatments in 2014 were provided by 11% of all physicians who billed acupuncture at least once.

DISCUSSION

Higher utilization of acupuncture by women reflects the epidemiology of back and knee pain and their preference for alternative complementary medicine. On the one hand, the large proportion of patients treated repeatedly with acupuncture suggests perceived benefits. On the other hand, provision of acupuncture services is decreasing continuously and a relevant proportion of subjects are terminating treatment prematurely.

Correction to: Abstracts : 29th European Congress of Pathology

Due to an error with the registration system, the following abstract was regrettably omitted from the Poster Sessions. The abstract should have been included as PS-10-021 and displayed on page S166.

Does regional loss of bone density explain low trauma distal forearm fractures in men (the Mr F study)?

The pathogenesis of low trauma wrist fractures in men is not fully understood. This study found that these men have lower bone mineral density at the forearm itself, as well as the hip and spine, and has shown that forearm bone mineral density is the best predictor of wrist fracture.

INTRODUCTION

Men with distal forearm fractures have reduced bone density at the lumbar spine and hip sites, an increased risk of osteoporosis and a higher incidence of further fractures. The aim of this case-control study was to investigate whether or not there is a regional loss of bone mineral density (BMD) at the forearm between men with and without distal forearm fractures.

METHODS

Sixty-one men with low trauma distal forearm fracture and 59 age-matched bone healthy control subjects were recruited. All subjects underwent a DXA scan of forearm, hip and spine, biochemical investigations, health questionnaires, SF-36v2 and Fracture Risk Assessment Tool (FRAX). The non-fractured arm was investigated in subjects with fracture and both forearms in control subjects.

RESULTS

BMD was significantly lower at the ultradistal forearm in men with fracture compared to control subjects, in both the dominant (mean (SD) 0.386 g/cm² (0.049) versus 0.436 g/cm² (0.054), p < 0.001) and non-dominant arm (mean (SD) 0.387 g/cm² (0.060) versus 0.432 g/cm² (0.061), p = 0.001). Fracture subjects also had a significantly lower BMD at hip and spine sites compared with control subjects. Logistic regression analysis showed that the best predictor of forearm fracture was ultradistal forearm BMD (OR = 0.871 (0.805-0.943), p = 0.001), with the likelihood of fracture decreasing by 12.9% for every 0.01 g/cm² increase in ultradistal forearm BMD.

CONCLUSIONS

Men with low trauma distal forearm fracture have significantly lower regional BMD at the ultradistal forearm, which contributes to an increased forearm fracture risk. They also have generalised reduction in BMD, so that low trauma forearm fractures in men should be considered as indicator fractures for osteoporosis.