Use of a standardized asthma severity score to determine emergency department disposition for paediatric asthma: A cohort study

Consensus outcomes between health professionals and parents for oral corticosteroids in treating preschool wheeze: a multi-national survey and nominal group technique study

OBJECTIVE

To obtain priority consensus for outcome measures of oral corticosteroid treatment of preschool wheeze that represent stakeholder groups.

DESIGN

(1) A systematic review to identify a set of outcome measures; (2) an international survey for healthcare professionals (HCPs) and a nominal group meeting with parents; (3) a final consensus nominal group meeting with key HCPs (trial investigators and paediatric emergency medicine clinicians) and the same parent group.

MAIN OUTCOME MEASURES

Consensus priority of treatment outcome measures, outcome minimal clinically important differences (MCIDs) and level of concerns about adverse effects.

RESULTS

Through an iterative process engaging HCPs and parents, the final consensus on a primary outcome was Wheezing Severity Score (WSS). Secondary outcomes prioritised as a revisit to general practice/emergency department, rehospitalisation, length of hospital stay (LOS), time back to normal, doses of short-acting beta-agonists and additional steroid course. Compared with placebo, clinicians considered the median MCID change in WSS at 4 and 12 hours as 40% (IQR 29-51%) and 50% (37-63%) and 5 hours (4-6 hours) for LOS, and 2 days (2-3 days) for a time back to normal. Parents identified MCIDs which were frequently longer than physiologically observed impacts in trials. Concerns about multiple steroid doses were most prevalent.

CONCLUSIONS

Stakeholders prioritised change in WSS as the most favourable outcome measure. Our study demonstrated the potential of parent/patient engagement in co-creating patient research outcomes. Incorporating this result in the design of future clinical research will provide a more holistic assessment of the impact of treatment while ensuring relevant primary research outcomes.

Management strategies and clinical outcomes in breast cancer patients who develop left ventricular dysfunction during trastuzumab therapy

BACKGROUND

Trastuzumab reduces risk of breast cancer recurrence but carries risk of cardiotoxicity that may be reversible upon treatment cessation and institution of left ventricular (LV) enhancement therapies (LVETx). We assessed management patterns of trastuzumab-induced cardiotoxicity (TIC) in a contemporary real-world setting.

METHODS

We reviewed charts of all breast cancer patients who received adjuvant trastuzumab in British Columbia between January 2010 and December 2013, spanning the opening of a cardio-oncology clinic. LV dysfunction (LVD) was classified as minimal (LVEF nadir 45-49%), mild (40-44%) or moderate-severe (< 40%). Charts were reviewed for baseline characteristics, management strategies, and outcomes. Multivariable analysis was performed to identify patient characteristics associated with trastuzumab completion and cardiology referral.

RESULTS

Of 967 patients receiving trastuzumab, 171 (17.7%) developed LVD, including 114 patients (11.8%) with LVEF declines of ≥10 to < 50%. Proportions of patients receiving cardiology referrals and LVETx increased and wait times to consultation decreased after a dedicated cardio-oncology clinic opened. LVETx was used more frequently in patients with moderate-severe LVD compared to minimal or mild LVD. Factors associated with completion of trastuzumab included mastectomy (OR 5.1, 95% CI 1.1-23.0) and proximity to quaternary care centre (OR 7.7, 95% CI 2.2-26.2). Moderate-severe LVD was associated with a lower probability of completing trastuzumab (OR 0.07 vs. minimal LVD, 95% CI 0.01-0.74). Factors associated with cardiology referral included heart failure symptoms (OR 8.0, 95% CI 1.5-42.9), proximity to quaternary care centre (OR 6.8, 95% CI 1.3-34.2), later year of cancer diagnosis (OR 2.4 per year, 95% CI 1.4-4.3), node-positive disease (OR 0.18, 95% CI 0.06-0.56), mastectomy (OR 0.05, 95% CI 0.01-0.52), and minimal LVD (OR 0.14, 95% CI 0.05-0.46). LVEF recovered to > 50% in 90.7% of patients.

CONCLUSIONS

Management strategies in patients with TIC are associated with cancer characteristics and severity of cardiotoxicity. Access to dedicated cardio-oncology clinics may facilitate optimal care of this complex patient population.