Locoregional control and toxicity following high-dose hypofractionated and accelerated palliative radiotherapy regimens in breast cancer

AIMS

For patients with locally advanced primary/recurrent breast cancer, radiotherapy is an effective treatment for locoregional control. 36 Gy in 6 Gy once-weekly fractions is a commonly used schedule, but there are no data comparing local control and toxicity between 36 Gy delivered once-weekly versus accelerated schedules of multiple 6 Gy fractions per week. This retrospective study compared local control rates and acute and late toxicity in patients undergoing 30-36 Gy in 6 Gy fractions over 6 weeks versus more accelerated schedules over 2-3 weeks for an unresected breast cancer.

MATERIALS AND METHODS

Patients who received 30-36 Gy in 6 Gy fractions to an unresected breast cancer ± involved lymph nodes between December 2011 and August 2020 were identified. Patients were grouped into once-weekly versus accelerated fractionation schedules. Response rates, local control and toxicity data were analysed.

RESULTS

In total, 109 patients were identified. The median follow-up duration was 46 months. Forty-seven patients (43%) received once-weekly fractions and 62 patients (57%) received accelerated fractionation schedules. There were no significant differences in baseline tumour characteristics between the groups. Eighty-seven per cent of patients had an objective (complete or partial) response (81% in the once-weekly group; 91% in the accelerated group). The median time to local progression was 23.5 months overall (95% confidence interval 17.8-29.2); 23.5 months (95% confidence interval 18.8-28.1) in the once-weekly group and 19.0 months (95% confidence interval 7.0-31.1) in the accelerated group (P = 0.99). Acute toxicity of any grade occurred in 75% of patients (76% in the once-weekly group; 74% in the accelerated group) and grade 3 toxicity occurred in 7% of patients (7% in the once-weekly group; 8% in the accelerated group). There were no associations between the groups and acute or late toxicity grade (P = 0.78 and P = 0.26, respectively), although one grade 4 late toxicity (skin radionecrosis) occurred in a patient who received five fractions a week and therefore this regimen is not recommended. Study limitations included a lack of statistical power analysis, the necessary grouping of all accelerated patients for analysis and a high rate of censored data.

CONCLUSION

There were no apparent differences in response rate, time to local progression or toxicity between patients who received 30-36 Gy in 6 Gy fractions once-weekly compared with twice-weekly as palliative treatment for locally advanced breast cancer. This regimen appears to be a safe alternative and may be preferred by patients.

P046 A review and retrospective case series of paediatric Sjögren’s syndrome from Southern Africa

Background

Paediatric Sjögren’s syndrome (pSS) is an uncommon autoimmune paediatric disease, rarely reported in children in Africa. It remains an important consideration in a child with parotid swelling. Here, we present a retrospective case-series of four patients from a paediatric rheumatology clinic in South Africa and discuss some of the difficulties of diagnosis in our context.

Methods

We performed a retrospective analysis of patients who attend the Red Cross War Memorial Hospital Paediatric Rheumatology clinic between 2010 and 2019.

Result

The four patients diagnosed with Sjögren’s all had varied presentations and disease courses. There were 3 females and 1 male and the ages at diagnosis ranged from 6 to 19 years old. The time to diagnosis was prolonged and ranged from 1 month to 10 years. Two patients with primary pSS presented with extra-articular manifestations of arthritis, abdominal pain and fatigue, followed by dry mouth, dry eyes, parotid swelling and and suggestive histopathology. The remaining 2 patients had a secondary pSS due to juvenile onset SLE and tuberculosis respectively.

Conclusion

In less resourced settings the diagnosis of pSS is often delayed. Both patients with primary pSS had preceding extra-glandular manifestations. In less resourced settings, infectious diseases may present as pSS and associated rheumatic diseases causing secondary pSS must be considered.

Psychosocial outcomes of peer support for patients with an inherited cardiac condition

Funding Acknowledgements

Type of funding sources: None.

Introduction

Inherited cardiac conditions (ICCs) are feared for their risk of sudden death. Individuals are often young and diagnosed after the sudden death of an apparently healthy family member. A diagnosis can have a profound psychological impact and negative effect on quality of life. Uncertainty surrounding the natural history of some diseases causes anxiety and concern about existing children or starting a family. Necessary lifestyle adjustments are often associated with a sense of isolation during social engagement with peers. Psychological support for such patients is scarce. However, a specialist nurse led peer group support within the ICC service may improve psychological outcomes and empower patients to support others. 

Purpose

To determine the effect of a nurse led peer support group on subjective psychological symptoms for patients with ICCs.

Methods

A pilot specialist nurse support group was established in February 2020 including 30 patients with ICCs. This consisted of a meeting in person followed by 6 subsequent 2 monthly online video meetings. Each session lasted 2 hours and included a talk by a healthcare professional on an ICC related topic, followed by an open forum for group discussion facilitated by the specialist nurse. An online social media chat forum was also developed. After 1 year, a bespoke questionnaire was distributed to all participants enquiring about the effect of group support on anxiety level, sense of isolation, knowledge about their condition and empowerment to support themselves and others. 

Results

21 (70%) patients aged between 20 and 65 years old (mean age 49) responded. Diagnoses included Brugada syndrome, arrhythmogenic cardiomyopathy, dilated cardiomyopathy, hypertrophic cardiomyopathy and long QT syndrome. All participants agreed that the group provided a comfortable platform to ask questions about their condition. 95% of participants were keen to know more about their condition after diagnosis of which 86% agreed that knowledge about their condition had improved since joining the group. 90% of participants experienced anxiety related to their condition before joining the group of which 76% reported reduced levels since joining. 76% felt isolated after their diagnosis of which 86% reported that these feelings had lessened since joining the group. 86% of the group agreed that group discussion empowered them and helped them support other affected individuals. 

Conclusion

A pilot study support group for patients with ICCs reduced anxiety and sense of isolation, improved knowledge, and sense of empowerment and willingness to support other patients in ≥ 80% of attendees. There is potential that patient support groups can be kick started by specialist nurses and subsequently allowed to run by patients themselves. Apart from improving psychological outcomes, such practice may reduce the workload for the ICC multidisciplinary team.

Polymeric Ligand-Mediated Regioselective Bonding of Plasmonic Nanoplates and Nanospheres

Nanoparticle (NP) clusters are attractive for many applications, but controllable and regioselective assembly of clusters remains challenging. This communication reports a strategy to precisely assemble Ag nanoplates (NP-As) and Au nanospheres (NP-Bs) grafted with copolymer ligands into defined AB_x clusters with controlled coordination number (x) and orientation of the NPs. The directional bonding of shaped NPs relies on the stoichiometric reaction of complementary reactive groups on copolymer ligands. The x value of NP clusters can be tuned from 1 to 4 by varying the number ratio of reactive groups on single NP-Bs to NP-As. The regioselective bonding of nanospheres to the edge or face of a central nanoplate is governed by the steric hindrance of copolymeric ligands on the nanoplate. The clusters exhibit distinctive plasmonic properties that are dependent on the bonding modes of NPs. This study paves a route to fabricating nanostructures with high precision and complexity for applications in plasmonics, catalysis, and sensing.

Adaptation to Brightness Perception in Patients Implanted With a Small Aperture

PURPOSE

Small apertures are successfully used to extend depth of focus in presbyopic patients implemented either as corneal inlays or intraocular lenses. The use of small apertures reduces retinal illuminance. In this study, we quantify the relative perceived brightness in the 2 eyes of patients implanted monocularly with a small-aperture inlay.

DESIGN

Prospective case series.

METHODS

We used a binocular adaptive optics vision simulator to determine the relative perceived brightness. Four patients implanted monocularly with the KAMRA corneal inlay (1.6 mm) and a group of control subjects participated in the study. The projected pupil on the eye implanted with the inlay alternated in diameter between 0 and 2.5 mm (effective 1.6 mm) to eliminate potential for light to project around the periphery of the inlay while the corresponding fellow eye projected pupil alternated between 0 and 3.0 mm or 0 and 4.0 mm at a frequency of 1 Hz. Alternation on both eyes was synchronized so that only 1 eye at a time had a nonblocked pupil. At equal transmittance, a flickering was perceived. Patients' task consisted of modifying the transmittance of the pupil corresponding to the fellow eye until the perceived flickering, owing to the different perceived brightness, was minimized. This equalizing transmittance (ET) value indicates the relative perceived brightness.

RESULTS

In the KAMRA's patients, ET was found to be greater than expected considering the difference in pupil sizes and the Stiles-Crawford effect, showing an enhanced a greater brightness perception in the eye with the small aperture in comparison with the fellow eye. Compared with the control subjects, this difference was on average bigger by a factor of ×1.42.

CONCLUSIONS

Patients implanted with the small-aperture corneal inlay exhibited an enhanced brightness perception with the eye implanted, in comparison with their untreated fellow eye. The amount of this increase is much larger than what could be expected owing to the Stiles-Crawford effect and was probably attributable to a neural adaptation process. This phenomenon could explain a reported equalization of brightness between eyes in patients with unilateral inlays and implies that the expected reduction of brightness may have a less significant impact on these patients, as expected.

The prevalence of community programmes and policies to prevent childhood obesity in a diverse sample of US communities: the Healthy Communities Study

INTRODUCTION

This manuscript describes the prevalence and attributes of community programmes and policies (CPPs) to address childhood obesity documented as occurring in 130 diverse US communities.

METHODS

Key informant interviews (N = 1420) and document abstraction were used to identify and characterize CPPs to promote physical activity and healthy nutrition occurring during a 10-year retrospective study period. Data were collected in 2013-2015 and analysed in 2016.

RESULTS

Across all 130 communities, 9681 distinct CPPs were reported as occurring by key informants. Of these, 5574 (58%) focused on increasing physical activity, 2596 (27%) on improving nutrition and 1511 (16%) on both behaviours. The mean number of CPPs per community was 74.0, with a range of 25 to 295 across all communities. Most CPPs occurred more than once (63%) and on average lasted 6.1 years. The greatest number of reported CPPs occurred in school settings (44%).

CONCLUSIONS

Communities showed a wide range of investment in the amount of CPPs occurring in settings that affect opportunities for children to engage in physical activity and healthy nutrition. The pattern of implementation of CPPs showed variation over time, with an increase in more recent years. This observational study provides new and valuable information about what US communities are doing to prevent childhood obesity.

The longitudinal relationship between community programmes and policies to prevent childhood obesity and BMI in children: the Healthy Communities Study

BACKGROUND

Although a national epidemic of childhood obesity is apparent, how community-based programmes and policies (CPPs) affect this outcome is not well understood.

OBJECTIVES

This study examined the longitudinal relationship between the intensity of CPPs in 130 communities over 10 years and body mass index (BMI) of resident children. We also examined whether these relationships differ by key family or community characteristics.

METHODS

Five thousand one hundred thirty-eight children in grades K-8 were recruited through 436 schools located within 130 diverse US communities. Measures of height, weight, nutrition, physical activity and behavioural and demographic family characteristics were obtained during in-home visits. A subsample of families consented to medical record review; these weight and height measures were used to calculate BMI over time for 3227 children. A total of 9681 CPPs were reported during structured interviews of 1421 community key informants, and used to calculate a time series of CPP intensity scores within each community over the previous decade. Linear mixed effect models were used to assess longitudinal relationships between childhood BMI and CPP intensity.

RESULTS

An average BMI difference of 1.4 kg/m² (p-value < 0.01) was observed between communities with the highest and lowest observed CPP intensity scores, after adjusting for community and child level covariates. BMI/CPP relationships differed significantly by child grade, race/ethnicity, family income and parental education; as well as community-level race/ethnicity.

CONCLUSIONS

These results indicate that, over time, more intense CPP interventions are related to lower childhood BMI, and that there are disparities in this association by sociodemographic characteristics of families and communities.

Characterizing the recovery trajectories of knee range of motion for one year after total knee replacement

Design: Retrospective analysis of routinely collected clinical data. Objective: This study modeled the recovery in knee flexion and extension range of motion (ROM) over 1 year after total knee replacement (TKR). Background: Recovery after TKR has been characterized for self-reported pain and functional status. Literature describing target knee ROM at different follow-up periods after TKR is scarce. Methods: Data were extracted for patients who had undergone TKR at a tertiary care hospital at 2, 8, 12, 26, and 52 weeks after TKR. A linear mixed-effects growth model was constructed that investigated the following covariates age, sex, pre-TKR range, body mass index, duration of symptoms, and their interaction with weeks post TKR. Results: Of the 559 patients included (age 64.8 ± 8.5 years), 370 were women and 189 were men. Knee ROM showed the greatest change during the first 12 weeks after TKR, plateauing by 26 weeks. For an average patient, knee flexion increased from approximately 100º 2 weeks post TKR to 117º 52 weeks post TKR. Knee extension increased from approximately 3º knee flexion 2 weeks post TKR to 1º flexion 52 weeks post TKR. Conclusions: The results showed that the maximum gains in knee ROM should be expected within the first 12 weeks with small changes occurring up to 26 weeks after TKR. In addition, age and presurgery knee ROM are associated with the gains in knee ROM and should be factored into the estimation of expected knee ROM at a given follow-up interval after TKR.

The Effects of Scaphoid and Colles Casts on Hand Function

Although necessary for bone healing, immobilisation temporarily prevents hand function and may necessitate corrective physiotherapy later. Scaphoid and Colles casts are both commonly used to immobilize scaphoid fractures. Non-union rates are comparable with both casts. The Scaphoid cast incorporates the thumb, whereas the Colles cast leaves the thumb free. We compared the effect of the two casts on hand function in 20 healthy right-hand-dominant volunteers using the Jebsen–Taylor Hand Function Test. Data were obtained through a mixed between and within subject design. Both casts prolonged the time taken to complete the hand function test compared to controls. Testing in the Scaphoid cast took significantly longer than in the Colles cast.

Reliability, validity, and responsiveness of the Western Ontario and McMaster Universities Osteoarthritis Index for elderly patients with a femoral neck fracture

BACKGROUND

The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) has been extensively evaluated in groups of patients with osteoarthritis, yet not in patients with a femoral neck fracture. This study aimed to determine the reliability, construct validity, and responsiveness of the WOMAC compared with the Short Form-12 (SF-12) and the EuroQol 5D (EQ-5D) questionnaires for the assessment of elderly patients with a femoral neck fracture.

METHODS

Reliability was tested by assessing the Cronbach alpha. Construct validity was determined with the Pearson correlation coefficient. Change scores were calculated from ten weeks to twelve months of follow-up. Standardized response means and floor and ceiling effects were determined. Analyses were performed to compare the results for patients less than eighty years old with those for patients eighty years of age or older.

RESULTS

The mean WOMAC total score was 89 points before the fracture in the younger patients and increased from 70 points at ten weeks to 81 points at two years postoperatively. In the older age group, these scores were 86, 75, and 78 points. The mean WOMAC pain scores before the fracture and at ten weeks and two years postoperatively were 92, 76, and 87 points, respectively, in the younger age group and 92, 84, and 93 points in the older age group. Function scores were 89, 68, and 79 points for the younger age group and 84, 71, and 73 points for the older age group. The Cronbach alpha for pain, stiffness, function, and the total scale ranged from 0.83 to 0.98 for the younger age group and from 0.79 to 0.97 for the older age group. Construct validity was good, with 82% and 79% of predefined hypotheses confirmed in the younger and older age groups, respectively. Responsiveness was moderate. No floor effects were found. Moderate to large ceiling effects were found for pain and stiffness scales at ten weeks and twelve months in younger patients (18% to 36%) and in the older age group (38% to 53%).

CONCLUSIONS

The WOMAC showed good reliability, construct validity, and responsiveness in both age groups of elderly patients with a femoral neck fracture who had been physically and mentally fit before the fracture. The instrument is suitable for use in future clinical studies in these populations.

CLINICAL RELEVANCE

The results are based on two clinical trials. The questionnaires used concern pure, clinically relevant issues (ability to walk, climb stairs, etc.). Moreover, the results can be used for future research comparing clinical outcomes (or treatments) for populations with a femoral neck fracture.

Molecular characterisation of 'strangles' outbreaks in the UK: the use of M-protein typing of Streptococcus equi ssp. equi

REASONS FOR PERFORMING STUDY

Strangles is the most commonly diagnosed and important infectious disease of horses worldwide. Very little is known about the temporo-spatial and molecular epidemiology of strangles. The disease is not notifiable in the UK and there are few published data on the geographical locations of outbreaks.

OBJECTIVE

To investigate whether typing of a surface protein (SeM) of Streptococcus equi ssp. equi (S. equi), the causative agent of strangles, is a useful epidemiological tool.

METHODS

The variable region of the SeM gene was amplified from 145 isolates of S. equi by PCR and sequenced. Different SeM gene alleles were assigned based on the SeM database, grouped into phylogenetic clusters using split decomposition analysis and plotted against the submitting veterinary practices.

RESULTS

In this study 21 S. equi SeM alleles were found, including 9 previously unidentified alleles and representing 4 phylogenetic groups. S. equi containing SeM alleles 9 and 7 were the most commonly isolated and there was a high number of low frequency alleles. The occurrence of an outbreak cluster in the north-west of the UK is also reported.

CONCLUSIONS

Strangles outbreaks can be differentiated on the basis of their SeM allele sequences. The data provide further evidence of SeM mutation leading to the emergence of novel, but related SeM alleles that are geographically linked. Sequencing of the SeM gene is a useful tool for the elucidation of strangles epidemiology at a regional and a national level.

POTENTIAL RELEVANCE

This technique may allow differentiation or linkage of strangles outbreaks and as such may be an effective tool for local as well as national and international disease surveillance.

Cost effectiveness of atorvastatin in patients with type 2 diabetes mellitus: a pharmacoeconomic analysis of the collaborative atorvastatin diabetes study in the belgian population

BACKGROUND AND OBJECTIVE

Patients with type 2 diabetes mellitus have a high risk of developing cardiovascular (CV) disease. The clinical benefit of use of statins in patients with type 2 diabetes has been demonstrated in several randomized, controlled trials, including the CARDS clinical trial. Based on the clinical CARDS data, the favourable cost effectiveness of atorvastatin 10 mg in patients with type 2 diabetes has been demonstrated in countries such as the UK and France. This study aimed to estimate the cost effectiveness in the Belgian setting of atorvastatin 10 mg compared with no treatment for the primary prevention of CV events in type 2 diabetes patients without a history of CV disease.

METHODS

A Markov model with 1-year cycles was developed to simulate the CV event and death risk according to the therapeutic approach initiated. The transition probabilities for CV events in the 'no statin treatment' group were derived from the risk equations reported from the large UKPDS. Risk reductions from the CARDS clinical trial were used to adjust these CV event probabilities in the atorvastatin 10 mg treatment group. The characteristics of type 2 diabetes patients without a CV history were derived from the Belgian OCAPI survey. The public healthcare payers' perspective was taken into account for costing. The direct medical costs of CV events were based on the Public Health Authorities' hospital database for acute care costs and on the literature for the follow-up costs. The impact on the reimbursement system of generic entry to the market was considered in the drug cost. Costs were valued as at year 2009; costs and outcomes were discounted at 3% and 1.5%, respectively.

RESULTS

Based on a 5-year time horizon, atorvastatin was demonstrated to be cost effective with an incremental cost/quality-adjusted life-year (QALY) of euro 16,681. Over a lifetime horizon (25 years), atorvastatin was demonstrated to be a cost-saving therapeutic intervention. At a threshold of euro 30,000/QALY, atorvastatin had a 98.8% probability of being cost effective.

CONCLUSION

Compared with 'no treatment', use of atorvastatin 10 mg as a primary prevention intervention in Belgian type 2 diabetes patients not only improves CV outcomes, but also appears to be cost saving over a lifetime horizon.

Ways of coping with cystic fibrosis: implications for treatment adherence

PURPOSE

How individuals cope with aspects of cystic fibrosis (CF) has the potential to influence their self management and the course of their disease. To evaluate how individuals cope with CF, a disease specific coping scale was developed and validated. A second objective of the work was to examine the relationship between coping styles and treatment adherence.

METHODS

The development of the coping scale constituted a longitudinal design. A cross-sectional questionnaire design was used to examine the coping-adherence relationship. The development and validation of the coping scale comprised three phases: (1) Initially, 60 patients were interviewed to identify CF concerns. From this information a list of 23 concerns were recorded; (2) Eighty-three patients were interviewed to identify CF coping responses. For each concern, they were asked what they did or thought to ease the worry. A list of 24 coping strategies were recorded that formed a comprehensive set of items as to how people with CF act, feel and think about aspects of their disease; and (3) Further development and testing of the questionnaire involved 174 patients completing the measure. Four distinct ways of coping with CF were identified by factor analysis. These were termed optimistic acceptance, hopefulness, distraction and avoidance. The cronbach alpha coefficients were 0.74 (optimistic acceptance), 0.69 (hopefulness). 0.71 (distraction) and 0.76 (avoidance). To evaluate the relationship between coping and treatment adherence 60 patients completed the CF Coping Questionnaire and the Manchester Adult Cystic Fibrosis Compliance Questionnaire.

RESULTS

Compared with patients who were non-adherent, those who were adherent scored higher on the optimistic acceptance scale (physiotherapy p < 0.05, enzymes p < 0.003, vitamins p < 0.05) and hopefulness scale (physiotherapy p < 0.002, enzymes p < 0.001). Those who were partially adherent reported using distraction as a way of coping to a greater extent than adherent or non-adherent patients (all p's < 0.05). Non-adherent patients used avoidance strategies to a greater extent than those who were adherent (physiotherapy p < 0.05, enzymes p < 0.04), although interestingly, adherence with exercise was associated with avoidant coping (p < 0.004).

CONCLUSIONS

The degree of adherence to treatments was influenced by a person's style of coping. The identification of effective coping strategies to aid both long-term psychological and clinical well-being should improve the management of non-adherence.