Palliative Care Always as a massive open online course (MOOC) to build primary palliative care in a global audience

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Background: Primary palliative care (PC) is critical to improve access to PC from the point of diagnosis. Still, barriers exist to providing primary PC worldwide, including a lack of awareness, time, and training. Interactive online learning experiences can help overcome these. This project describes a massive open online course (MOOC)--Palliative Care Always--designed to build primary PC skills in a global audience. Methods: A team of PC providers and online instructional experts developed 12 modules that included: patient scenes, brief lectures, empathy exercises, and Google Hangout discussions. Course objectives included awareness of PC, practicing effective communication skills, basic symptom assessment and management. The target audience included oncology clinicians; secondary audience included patients and families. The MOOC launched January-April 2016. Participant engagement, satisfaction and self-reported knowledge were assessed through pre- and post-surveys. Multiple choice assessments captured knowledge gain. Follow-up assessments will be distributed three months post-MOOC. Results: By April 2016, the course reached 1,300 participants from 91 countries. 54% were from the US, followed by India, Brazil, and Canada. 76% were healthcare professionals, the majority being nurses (40%), physicians (19%) and social workers (13%). The remaining 24% included patient, caregivers, and others interested in PC. Top reasons for enrolling were interest in PC, personal growth and job relevance. On average, 27% of enrollees actively engaged week-over-week. Eighty-six percent of respondents were “very satisfied” with the amount learned, and over 50% cited learning “a great deal” in: communicating difficult news, goals of care, psychosocial and hospice care. 93% cited being “very likely” to recommend the course. Conclusions: Interactive MOOC experiences have the potential to build PC awareness, primary skills and global PC networks. Upcoming iterations will incorporate: accommodations for varying levels of PC knowledge; additional opportunities for interaction between participants, including social networks; blended learning; and evaluation of impact on practice and healthcare outcomes.

Quantitative Evaluation of Medial Temporal Lobe Morphology in Children with Febrile Status Epilepticus: Results of the FEBSTAT Study

BACKGROUND AND PURPOSE

The pathogenesis of febrile status epilepticus is poorly understood, but prior studies have suggested an association with temporal lobe abnormalities, including hippocampal malrotation. We used a quantitative morphometric method to assess the association between temporal lobe morphology and febrile status epilepticus.

MATERIALS AND METHODS

Brain MR imaging was performed in children presenting with febrile status epilepticus and control subjects as part of the Consequences of Prolonged Febrile Seizures in Childhood study. Medial temporal lobe morphologic parameters were measured manually, including the distance of the hippocampus from the midline, hippocampal height:width ratio, hippocampal angle, collateral sulcus angle, and width of the temporal horn.

RESULTS

Temporal lobe morphologic parameters were correlated with the presence of visual hippocampal malrotation; the strongest association was with left temporal horn width (P < .001; adjusted OR, 10.59). Multiple morphologic parameters correlated with febrile status epilepticus, encompassing both the right and left sides. This association was statistically strongest in the right temporal lobe, whereas hippocampal malrotation was almost exclusively left-sided in this cohort. The association between temporal lobe measurements and febrile status epilepticus persisted when the analysis was restricted to cases with visually normal imaging findings without hippocampal malrotation or other visually apparent abnormalities.

CONCLUSIONS

Several component morphologic features of hippocampal malrotation are independently associated with febrile status epilepticus, even when complete hippocampal malrotation is absent. Unexpectedly, this association predominantly involves the right temporal lobe. These findings suggest that a spectrum of bilateral temporal lobe anomalies are associated with febrile status epilepticus in children. Hippocampal malrotation may represent a visually apparent subset of this spectrum.

Liposomal Doxorubicin in Breast Cancer

Drug-delivery carriers represent an important step in the development of targeted therapy. Encapsulation of drug into liposomes represents such a carrier, and helps to minimize side effects of conventional doxorubicin by improving the tumor-specific biodistribution profile. We review the development of the two liposomal doxorubicin formulations, pegylated liposomal doxorubicin and liposomal-encapsulated doxorubicin citrate from reconstitution and comparative pharmacokinetics to pivotal Phase III trials, with special emphasis in breast cancer. The relative differences in the toxicity profile can be attributed to their differences in the liposomal formulations. Areas of special interest include the reduction in cardiac toxicities and the improved efficacy, such as in the treatment of ovarian cancer. These improvements have also increased the potential of these liposomal formulations of doxorubicin for combination and sequencing with other biological and cytotoxic agents for clinical benefit.

Interstitial lung disease in systemic sclerosis: An HRCT-clinical correlative study

Purpose: To evaluate high-resolution CT (HRCT) parameters of inflammation and fibrosis in systemic sclerosis (SSc), for correlation with lung function, skin scores and exercise tolerance.

Material and Methods: 45 SSc patients (40 women, 48.5±13.4 years), underwent thoracic HRCT, lung function assessment, and modified Rodnan skin scores. Exercise tolerance was also graded. HRCT were scored for extent of 4 HRCT patterns of interstitial lung disease (ILD): ground glass opacification (GGO), reticular, mixed and honeycomb pattern in each lobe. Total HRCT score, inflammation index (GGO and mixed score) and fibrosis index (reticular and honeycomb scores) were correlated with lung function and clinical parameters.

Results: ILD was present in 39/45 (86.7%) patients. Abnormal (<80% predicted) forced vital capacity (FVC), total lung capacity (TLC) and carbon monoxide diffusion factor (DLco) were detected in 30%, 22% and 46% of patients. Total HRCT score correlated with FVC ( r=−0.43, p=0.008), FEV1 (forced expiratory volume) ( r=–0.37, p=0.03), TLC ( r=–0.47, p=0.003), and DLCO ( r=–0.43, p=0.008); inflammatory index with DLCO ( r=–0.43, p=0.008) and exercise tolerance ( r=–0.39, p < 0.05); and fibrosis index with FVC ( r=–0.31, p=0.05) and TLC ( r=–0.38, p=0.02). Higher total HRCT score, and inflammation and fibrosis indices were found in patients with abnormal lung function.

Conclusion: Qualitative HRCT is able to evaluate inflammation and fibrosis, showing important relationships with diffusion capacity and lung volume, respectively.

Reducing the percent of ICU deaths of patients with advanced cancer at Stanford

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Background: Intensive care at the end of life, for patients with advanced cancer can compromise quality of life and result in excessive costs for patients and their families. In 2014, 40% of patients with solid tumors admitted to the Stanford Health Care ICU died with advanced stage disease. Sixty-five percent of the patients with advanced stage saw palliative care (PC) < 7 days of life. The aim was to decrease the percent of advanced solid tumor ICU deaths by 25%, through early palliative care intervention. Methods: The current process was analyzed through mapping and a cause and effect diagram. The outcome measure was defined as percentage of patients with advanced solid tumors dying in ICU. A key intervention was the development of criteria designed to trigger an earlier PC referral for patients with stage III-IV lung/pancreatic cancer. PC referral triggers included: 2+ lines of prior chemotherapy with life expectancy < 6 months or refractory disease, hospitalization within prior 30 days, > 7days of hospitalization, uncontrolled symptoms. ICU trainees were to contact the primary oncologists and discuss the role of PC consultation for patients who met the criteria. A balance measure was developed to assess if primary oncologists were contacted. Charts of patients admitted to the ICU 2 weeks pre- and post-implementation were reviewed. Results: During the pre-PDSA cycle, 13 patients with cancer were admitted to the ICU while 10 were admitted post-PDSA cycle. Primary oncologists of the patients with advanced cancer who met our criteria were contacted in similar rate pre- and post-PDSA (39% vs 40%). PC consultation was also similar for pre- and post-PDSA cycles (31% vs 30%). The percent of ICU deaths of patients in the pre-PDSA was 22% and 22% in the post-PDSA cycles. Conclusions: The percentage of deaths in the ICU for patients with advanced cancer met our target goal of 25% reduction from the baseline. However, the improvement was independent of our intervention, given the timing and short interval. The percent of PC consults for patients meeting the criteria did not change. Data from subsequent PDSA cycles and a SPC chart will be reported in the conference.

Abstract P5-08-17: A study of c-Jun N-terminal kinase (JNK) and c-Jun as biomarkers in early breast cancer

Background

The AP-1 transcription factor c-Jun is a key downstream target of c-Jun N-terminal kinase (JNK) which mediates intracellular signalling associated with a variety of cellular functions. The JNK pathway in breast cancer (BC) can be attenuated via loss of function mutations in MAPK kinases as well as via PIK3CA mutations; however, there is contradictory information about the role of JNK pathway and its clinical implications in BC.

Methods

In the current study, the clinicopathological implications of JNK and JUN mRNA expressions were evaluated in multiple independent BC datasets: a) Training-set (Uppsala cohort; n=249), b) Test-set (human genome atlas database; n=540), c) External validation-set (METABRIC cohort; n=1952) and d) Multicentre pooled databases (n=5530). The clinicopathological associations of their phosphorylated proteins (p-Jnk and p-c-Jun) were assessed in the Nottingham Tenovus Primary BC Series (n= 1650) and in an ER negative cohort (n=450).

Results

Both JNK and c-JUN mRNA high expressions were significantly associated with PAM50-Luminal A and ER+/HER2-/low proliferation molecular BC subtypes, tubular/lobular types, and integrative molecular clusters 4 (IntClust.4), ps&lt;0.001. Whereas BC that had both low JNK and c-JUN mRNA, were significantly associated with large tumour size, high grade, absence of hormonal receptors (HR), HER2 overexpression, PAM50 HER2 and PAM50 Basal molecular subtypes, and IntClust.1, 9 and 10 BCs; ps&lt;0.001.

There was a significant positive correlations between p-Jnk and p-c-Jun protein levels (p&lt;0.0001), however; our data suggested that differential p-Jnk/p-c-Jun expression may influence BC phenotypes. BC with p-Jnk-ve/p-c-Jun-ve were associated with the most aggressive phenotypes including largest tumour size, highest grade, lympho-vascular invasion, absence of HR, basal-like-phenotype, HER2 overexpression, and loss of double strand , single stand and base excision DNA repair proteins (ps&lt;0.0001). In addition p-Jnk-ve/ pc-Jun-ve phenotype was associated with the lowest levels of p-38, ATF2, and p-ATF2; ps&lt;0.001. Interestingly, low levels of either c-JUN-mRNA or pc-Jun protein, was associated with, PAM50-luminal B, epithelial mesenchymal transition and TP53 mutation and loss of its downstream proteins such as MDM2, MDM4, Bcle2 and p21; ps&lt;0.05.

JNK+ (mRNA and p-Jnk) and c-JUN+ (mRNA and p-c-Jun) individually were associated with prolonged BC specific survival (ps&lt;0.001). Multivariate cox regression models that included other validated prognostic factors and therapies revealed that c-JUN-mRNA (Uppsala: p=0.005 and METABIRIC: p=0.036) and p-c-Jun (HR: 0.69; 95% CI = 0.55-0.88; p=0.002) were independently associated with clinical outcome. Furthermore, in ER+ high risk BC, exposure to tamoxifen was associated with decreased risk of death from BC in those patients with p-c-Jun-ve BC (HR: 0.65; 95% CI: 0.45-0.95; p=0.025).

Conclusion

JNK and c-JUN mRNA as well as p-Jnk and p-c-Jun protein levels are associated with luminal BC, with p-c-Jun being found to be an independent prognostic factor. The interaction between p-Jnk, p-c-Jun and TP53 mutation could predict response to endocrine therapy in ER+ BC. The role of the transcriptionally active form of c-JUN warrants further investigation with regard to its role in BC.

Citation Format: Palmieri C, Rudraraju B, Giannoudis A, Moore D, Shaw J, Chan S, Ellis IO, Caldas C, Coombes RC, Carroll JS, Ali S, Abdel-Fatah TMA. A study of c-Jun N-terminal kinase (JNK) and c-Jun as biomarkers in early breast cancer. [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 P5-08-17.

Preliminary results of using inertial sensors to detect dementia- related wandering patterns

We present a solution for detecting dementia-related travel patterns using only inertial sensors. The results and lessons learnt from the experiments on dementia and non-dementia subjects are reported.

A randomised trial of secondary prophylaxis using granulocyte colony-stimulating factor ('SPROG' trial) for maintaining dose intensity of standard adjuvant chemotherapy for breast cancer by the Anglo-Celtic Cooperative Group and NCRN

BACKGROUND

Guidelines on the use of haematopoietic colony-stimulating factors for patients having adjuvant chemotherapy for breast cancer are designed to minimise the risk of neutropaenic infection (Smith TJ, Khatcheressian J, Lyman GH et al. Update of recommendations for the use of white blood cell growth factors: an evidence-based clinical practice guideline. J Clin Oncol 2006; 3: 187-205; Aapro MS, Bohlius J, Cameron DA et al. Effect of primary prophylactic G-CSF use on systemic therapy administration for elderly breast cancer patients. Breast Cancer Res Treat 2011; 47: 8-32; Carlson RW, Allred DC, Anderson BO et al. Breast cancer. Clinical practice guidelines in oncology. J Natl Compr Canc Netw 2009; 7: 122-192). Non-randomised data suggest that the achievement of planned dose intensity (DI) may have an important effect on survival. This trial compared the effects of granulocyte colony-stimulating factor, GCSF, against standard management following a first neutropaenic event (NE) in achieving planned DI.

PATIENTS AND METHODS

Adult patients receiving adjuvant or neoadjuvant chemotherapy were randomised following a first NE, defined as hospitalisation due to neutropaenic fever, an absolute neutrophil count (ANC) ≤1.5 × 10(9)/l requiring treatment delay or dose reduction of 15% or more of planned dose. The study was initially planned to enrol 816 patients to detect a difference of 10%. This was difficult to achieve in the timeframe and the trial size was amended. Thus, 407 patients were randomly assigned to filgrastim for 7 days or pegfilgrastim versus standard care. The amended study was designed to have 80% power to detect an absolute difference of 14% of planned DI between the two groups.

RESULTS

Most regimens were anthracycline-based many of which included a sequential taxane and/or were in clinical trials. Around 82.7% had an NE in the first three cycles. A total of 401 had calculable relative dose intensity (RDI) data. A target of 85% planned RDI was achieved in only 50% of patients in the control arm compared with 75% in the GCSF arm (P < 0.0001). A secondary end point revealed a reduction in post-randomisation NEs, 65.7% controls versus 18.2% with GCSF.

CONCLUSIONS

Secondary intervention with GCSF showed a statistically significant improvement in the achievement of adequate RDI in non-intensive regimens. This may have important clinical implications for outcome.