P09.04.B The importance of treatment tolerability for people with glioma: registry review and qualitative findings from the COBra Study

Background

Gliomas are the commonest form of primary brain tumour, accounting for 80% of malignant brain tumours. Gliomas represent a heterogeneous group of cancers with variable outcomes, traditionally graded from I to IV (least to most aggressive). The poor prognosis of some glioma patients and high symptom burden has led to a growing emphasis on their quality of survival. Maintaining cognitive function, physical function and other health-related quality of life aspects throughout the disease trajectory are key considerations, particularly for patients with aggressive forms of glioma. It is therefore important that glioma intervention studies collect data aligned with patient priorities that enables assessment of the net clinical benefit of treatments and facilitates informed decision-making. In particular, and of increasing recognition, is the importance of monitoring the incidence of adverse events during and after the course of an intervention, and understanding their impact upon patients, and patients’ own assessment of, tolerability.

Material and Methods

A trial registry review, a systematic review of the qualitative literature and semi-structured interviews with patients and caregivers were undertaken. Outcomes were extracted from these sources to formulate a longlist during the development of a core outcome set for glioma interventional trials (the COBra study).

Results

The registry review (n=91), systematic review (n=21) and semi-structured interviews (n=19) identified many important outcomes and concepts, one of which was tolerability. Tolerability, adverse events, toxicity or safety was reported to be collected as an outcome in 46 trials. Outcomes related to tolerability were identified from 7 articles included in the systematic review. Themes related to tolerability emerged from the qualitative interviews. These included tolerability of side effects of treatment; trade-offs of side effects versus potential benefits in deciding on, and willingness to, undertake further treatment; and self-directed strategies for coping.

Conclusion

There is a growing acknowledgement of the importance of treatment tolerability in the wider field of cancer research. In glioma research specifically, its significance is yet to be reflected in outcomes collected in trials. Our qualitative findings indicate tolerability is of high significance to patients and those close to them. Participants reported how their preconceptions and experience of tolerability influenced treatment decisions and treatment uptake. However, outcomes related to tolerability were collected in just over half of trials in our sample. Tolerability and items relating to the patients’ experience of adverse events should be collected and reported in trial findings to reflect patients’ priorities and enable informed treatment decisions.

Using group concept mapping software to develop a conceptual framework of left ventricular assist device recipients' experiences

Background

Advanced Heart failure (AHF) carries a high mortality rate. Heart transplantation is one therapeutic option, but low donation rates limits its availability. A left ventricular assist device (LVAD) is an alternative therapy which helps relieve symptoms, while improving prognosis and quality of life. However, lack of donors also means that the LVAD becomes a destination therapy by default.(1) Living with an LVAD requires significant psychological, social and physical adaptation for the recipients' and their families.(2) Patient reported outcome measures (PROMs) are one way of capturing these concerns and ongoing problems. Discussions with a patient and public involvement group found a range of issues not currently captured by available PROMS.

Aim

To develop a conceptual framework which reflects the experiences of LVAD recipients' and evaluate their importance for inclusion in PROMs using a research web platform.

Method

Participants were recruited from a regional transplant centre which covers a wide geographical area in the UK. Ethical approval was obtained and participants were recruited through routine LVAD clinics. Group concept mapping (GCM) is a semi-quantitative mixed methods approach that can be used to capture and quantify recipients' experiences.(3) Groupwisdom concept mapping software was used as the electronic data collection platform.(4) GCM consists of 3 stages: statement generation, thematic statement sorting, and rating statements for importance, relevance and frequency of impact. Multidimensional scaling and hierarchical cluster analysis produces visual representations of recipients' experiences as a points and cluster map, and scoring of statements produces relative importance of items across the clusters.

Results

18 LVAD recipients consented to take part. 101 items and 9 clusters were generated. Clusters represented: Activities; Partner/family dependency; Travel; Mental well-being; LVAD challenges; Equipment and clothing; Physical and cognitive limitations; Restrictions, and LVAD positives. LVAD Positives and LVAD restrictions were rated high for frequency, relevance and importance. Physical and cognitive limitations was rated high for importance and frequency. Equipment was rated high for relevance and frequency, and Challenges was rated high for relevance.

Conclusion

GCM and the online software is a useful tool for developing a conceptual framework and mapping key areas of importance for LVAD recipients, especially, when prioritising important patient reported outcome domains for use in clinical practice, future research and design evolution. Using an electronic platform allowed us to reach participants dispersed over a wide geographical area.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): British Heart FoundationNational Institute for Health Research Cluster Rating Map for Importance

The effect of deep muscle relaxation on the force required during Latissimus Dorsi dissection for breast reconstructive surgery: results of a prospective, double-blinded observational pilot study

BACKGROUND

The use of neuromuscular blocking agents has previously been suggested to facilitate the dissection of the latissimus dorsi muscle during breast reconstructive surgery. The aim of this study was to quantify the influence of deep muscle relaxation on the force required to lift the latissimus dorsi muscle during flap preparation.

METHODS

After ethics approval and written informed consent 15 patients scheduled for elective breast reconstruction with a latissimus dorsi pedicled flap (muscle flap, not myocutaneous flap) under general anaesthesia were prospectively included. Midway through the muscle dissection a sterile cotton tape was slung around the mid portion of the muscle and connected with a sterile strain gauge stably positioned just above the patient. Thereafter, the muscle was lifted by moving the strain gauge vertically upwards until a muscle tension similar to that created manually during muscle dissection was achieved. The force (N) and distance required to tension the muscle were recorded and the tension released. In a randomized and blinded crossover design either rocuronium (0.6 mg.kg-1) or normal saline were given intravenously, and the tension protocol was repeated 2 min after each drug administration.

RESULTS

Muscle relaxation significantly reduced the force for flap tensioning (median [percentiles] - 22 [-32/-13] %; P = 0.011) in 10/15 patients. However, in the remaining 5 patients no significant effect was measured. Normal saline had no effect on the measured force.

CONCLUSIONS

Deep muscle relaxation significantly reduces the force required to manually elevate the latissimus dorsi muscle during its dissection in the majority of but not all patients.

TRIAL REGISTRATION

The study was retrospectively registered on [17.6.2014] with the Australian and New Zealand Clinical Trials Registry. ACTRN12614000637640.

Descriptive analysis of a 1:1 physiotherapy outpatient intervention post primary lumbar discectomy: one arm of a small-scale parallel randomised controlled trial across two UK sites

OBJECTIVE

There is a lack of high-quality evidence for physiotherapy post lumbar discectomy. Substantial heterogeneity in treatment effects may be explained by variation in quality, administration and components of interventions. An optimised physiotherapy intervention may reduce heterogeneity and improve patient benefit. The objective was to describe, analyse and evaluate an optimised 1:1 physiotherapy outpatient intervention for patients following primary lumbar discectomy, to provide preliminary insights.

DESIGN

A descriptive analysis of the intervention embedded within an external pilot and feasibility trial.

SETTING

Two UK spinal centres.

PARTICIPANTS

Participants aged ≥18; post primary, single level, lumbar discectomy were recruited.

INTERVENTION

The intervention encompassed education, advice, mobility and core stability exercises, progressive exercise, and encouragement of early return to work/activity. Patients received ≤8 sessions for ≤8 weeks, starting 4 weeks post surgery (baseline).

OUTCOMES

Blinded outcome assessment at baseline and 12 weeks (post intervention) included the Roland Morris Disability Questionnaire. STarT Back data were collected at baseline. Statistical analyses summarised participant characteristics and preplanned descriptive analyses. Thematic analysis grouped related data.

FINDINGS

Twenty-two of 29 allocated participants received the intervention. STarT Back categorised n=16 (55%) participants 'not at low risk'. Physiotherapists identified reasons for caution for 8 (36%) participants, commonly risk of overdoing activity (n=4, 18%). There was no relationship between STarT Back and physiotherapists' evaluation of caution. Physiotherapists identified 154 problems (mean (SD) 5.36 (2.63)). Those 'not at low risk', and/or requiring caution presented with more problems, and required more sessions (mean (SD) 3.14 (1.16)).

CONCLUSIONS

Patients present differently and therefore require tailored interventions. These differences may be identified using clinical reasoning and outcome data.

TRIAL REGISTRATION NUMBER

ISRCTN33808269; post results.

The use of qualitative methods to inform Delphi surveys in core outcome set development

Background

Core outcome sets (COS) help to minimise bias in trials and facilitate evidence synthesis. Delphi surveys are increasingly being used as part of a wider process to reach consensus about what outcomes should be included in a COS. Qualitative research can be used to inform the development of Delphi surveys. This is an advance in the field of COS development and one which is potentially valuable; however, little guidance exists for COS developers on how best to use qualitative methods and what the challenges are. This paper aims to provide early guidance on the potential role and contribution of qualitative research in this area. We hope the ideas we present will be challenged, critiqued and built upon by others exploring the role of qualitative research in COS development.

This paper draws upon the experiences of using qualitative methods in the pre-Delphi stage of the development of three different COS. Using these studies as examples, we identify some of the ways that qualitative research might contribute to COS development, the challenges in using such methods and areas where future research is required.

Results

Qualitative research can help to identify what outcomes are important to stakeholders; facilitate understanding of why some outcomes may be more important than others, determine the scope of outcomes; identify appropriate language for use in the Delphi survey and inform comparisons between stakeholder data and other sources, such as systematic reviews. Developers need to consider a number of methodological points when using qualitative research: specifically, which stakeholders to involve, how to sample participants, which data collection methods are most appropriate, how to consider outcomes with stakeholders and how to analyse these data. A number of areas for future research are identified.

Conclusions

Qualitative research has the potential to increase the research community’s confidence in COS, although this will be dependent upon using rigorous and appropriate methodology. We have begun to identify some issues for COS developers to consider in using qualitative methods to inform the development of Delphi surveys in this article.

Development of an optimised 1:1 physiotherapy intervention post first-time lumbar discectomy: a mixed-methods study

OBJECTIVES

To develop an optimised 1:1 physiotherapy intervention that reflects best practice, with flexibility to tailor management to individual patients, thereby ensuring patient-centred practice.

DESIGN

Mixed-methods combining evidence synthesis, expert review and focus groups.

SETTING

Secondary care involving 5 UK specialist spinal centres.

PARTICIPANTS

A purposive panel of clinical experts from the 5 spinal centres, comprising spinal surgeons, inpatient and outpatient physiotherapists, provided expert review of the draft intervention. Purposive samples of patients (n=10) and physiotherapists (n=10) (inpatient/outpatient physiotherapists managing patients with lumbar discectomy) were invited to participate in the focus groups at 1 spinal centre.

METHODS

A draft intervention developed from 2 systematic reviews; a survey of current practice and research related to stratified care was circulated to the panel of clinical experts. Lead physiotherapists collaborated with physiotherapy and surgeon colleagues to provide feedback that informed the intervention presented at 2 focus groups investigating acceptability to patients and physiotherapists. The focus groups were facilitated by an experienced facilitator, recorded in written and tape-recorded forms by an observer. Tape recordings were transcribed verbatim. Data analysis, conducted by 2 independent researchers, employed an iterative and constant comparative process of (1) initial descriptive coding to identify categories and subsequent themes, and (2) deeper, interpretive coding and thematic analysis enabling concepts to emerge and overarching pattern codes to be identified.

RESULTS

The intervention reflected best available evidence and provided flexibility to ensure patient-centred care. The intervention comprised up to 8 sessions of 1:1 physiotherapy over 8 weeks, starting 4 weeks postsurgery. The intervention was acceptable to patients and physiotherapists.

CONCLUSIONS

A rigorous process informed an optimised 1:1 physiotherapy intervention post-lumbar discectomy that reflects best practice. The developed intervention was agreed on by the 5 spinal centres for implementation in a randomised controlled trial to evaluate its effectiveness.

Fatigue, psychological and cognitive impairment following transient ischaemic attack and minor stroke: a systematic review

Transient ischaemic attack (TIA) and minor stroke are characterized by short-lasting symptoms; however, anecdotal and empirical evidence suggests that these patients experience ongoing cognitive/psychological impairment for which they are not routinely treated. The aims were (i) to investigate the prevalence and time course of fatigue, anxiety, depression, post-traumatic stress disorder(PTSD) and cognitive impairment following TIA/minor stroke; (ii) to explore the impact on quality of life (QoL), change in emotions and return to work; and (iii) to identify where further research is required and potentially inform an intervention study. A systematic review of MEDLINE, EMBASE, PSYCINFO, CINAHL, the Cochrane libraries and the grey literature between January 1993 and April 2013 was undertaken. Literature was screened and data were extracted by two independent reviewers. Studies were included of adult TIA/minor stroke participants with any of the outcomes of interest: fatigue, anxiety, depression, PTSD, cognitive impairment, QoL, change in emotions and return to work. Random-effects meta-analysis pooled outcomes by measurement tool. Searches identified 5976 records, 289 were assessed for eligibility and 31 studies were included. Results suggest high levels of cognitive impairment and depression post-TIA/minor stroke which decreased over time. However, frequencies varied between studies. Limited information was available on anxiety, PTSD and fatigue. Meta-analysis revealed that the measurement tool administered influenced the prevalence of cognitive impairment: Mini-Mental State Examination 17% [95% confidence interval (CI) 7, 26]; neuropsychological test battery 39% (95% CI 28, 50); Montreal Cognitive Assessment 54% (95% CI 43, 66). There is evidence to suggest that TIA/minor stroke patients may experience residual impairments; however, results should be interpreted with caution because of the few high quality studies. Notwithstanding, it is important to raise awareness of potential subtle but meaningful residual impairments.

Fear of falling, fracture history, and comorbidities are associated with health-related quality of life among European and US women with osteoporosis in a large international study

We studied 7,897 women with postmenopausal osteoporosis to assess factors that influence health-related quality of life (HRQoL). An increased number of comorbidities, fear of falling, and previous vertebral fracture were associated with significant reductions in HRQoL. Understanding the factors that affect HRQoL may improve management of these patients.

INTRODUCTION

HRQoL is impaired in women treated for postmenopausal osteoporosis (PMO). The objective of this study was to examine the relationship between clinical characteristics, comorbidities, medical history, patient demographics, and HRQoL in women with PMO.

METHODS

Baseline data were obtained and combined from two large and similar multinational observational studies: Prospective Observational Scientific Study Investigating Bone Loss Experience in Europe (POSSIBLE EU®) and in the US (POSSIBLE US™) including postmenopausal women in primary care settings initiating or switching bone loss treatment, or who had been on bone loss treatment for some time. HRQoL measured by health utility scores (EQ-5D™) were available for 7,897 women (94 % of study participants). The relationship between HRQoL and baseline clinical characteristics, medical history and patient demographics was assessed using parsimonious, multivariable, mixed-model analyses.

RESULTS

Median health utility score was 0.80 (interquartile range 0.69-1.00). In multivariable analyses, young age, low body mass index, previous vertebral fracture, increased number of comorbidities, high fear of falling, and depression were associated with reduced HRQoL. Regression-based model estimates showed that previous vertebral fracture was associated with lower health utility scores by 0.08 (10.3 %) and demonstrated the impact of multiple comorbidities and of fear of falling on HRQoL.

CONCLUSIONS

In this large observational study of women with PMO, there was substantial interindividual variability in HRQoL. An increased number of comorbidities, fear of falling, and previous vertebral fracture were associated with significant reductions in HRQoL.

Implantation of cardiac resynchronization therapy systems in the CARE-HF trial: procedural success rate and safety

AIMS

To assess procedural characteristics and adjudicated procedure-related (<or=30 days) major adverse events among patients who underwent cardiac resynchronization therapy (CRT) implantation in the CARE-HF study. The CARE-HF study shows that CRT improves symptoms and reduces morbidity and mortality in New York Heart Association (NYHA) class III/IV chronic heart failure (CHF) patients. However, safe and proper implantation of pacing systems remains key to effective CRT delivery.

METHODS AND RESULTS

Generalized linear modeling was used to examine the relationships between first implant success/failure and: NYHA class; beta-adrenergic blocker use; underlying ischemic vs. non-ischemic heart disease; history of coronary artery bypass graft or valve surgery; left ventricular (LV) end-diastolic volume<or=vs. >300 cm(3); and, influence of the participating study-centres. Implantation was attempted in 404/409 patients assigned to CRT, and in 65/404 patients assigned to medical therapy. Among these 469 patients, 450 (95.9%) received a successfully implanted and activated device. Complications occurred within 24 h in 47 patients (10.0%), mainly lead dislodgments (n = 10, 2.1%) and coronary sinus dissection/perforation (n = 10, 2.1%), and between 24 h and 30 days in 26 patients (5.5%), mainly lead dislodgment (n = 13, 2.8%). Mean LV lead stimulation threshold was significantly higher than at the right atrium or right ventricle, though remained stable, delivering effective, and reliable CRT. Implanting experience was the only predictor of procedural outcome.

CONCLUSION

Transvenous CRT system implantation, using a CS lead designed for long-term LV pacing, was safe and reliable. As implanting centres become more experienced, this success rate is expected to increase further.

A controlled trial of a school-based intervention to improve asthma management

The present study investigated schools as an appropriate context for an intervention designed to produce clinical and psychological benefits for children with asthma. A total of 193 out of 219 (88.1%) children with asthma (aged 7-9 yrs) from 23 out of 24 (95.8%) schools completed the study. Intervention schools received a staff asthma-training session, advice on asthma policy, an emergency beta2-agonist inhaler with spacer and whole-class asthma workshops. Nonintervention schools received no asthma-related input. Intervention children required less general practitioner-prescribed preventer medication despite no differences in symptom control compared with the nonintervention asthmatic group. Increased peer knowledge of asthma may have mediated improved active quality of life in the intervention group, together with increased self-esteem in young females. Those females not receiving the intervention, but identified as being asthmatic within the classroom, and thus possibly stigmatised, reported decreased self-esteem. Lower self-esteem in young males was associated with pet ownership. No change was found in staff knowledge, the establishment of asthma policies or school absences which were low even before intervention. In conclusion, a whole-school intervention can improve the health of children with asthma when followed with support for all children but effects are likely to be modified by sex and the home environment.

Hemifacial microsomia: progress in understanding the genetic basis of a complex malformation syndrome

Hemifacial microsomia (HFM) is a common birth defect involving first and second branchial arch derivatives. The phenotype is extremely variable. In addition to craniofacial anomalies there may be cardiac, vertebral and central nervous system defects. The majority of cases are sporadic, but there is substantial evidence for genetic involvement in this condition, including rare familial cases that exhibit autosomal dominant inheritance. As an approach towards identifying molecular pathways involved in ear and facial development, we have ascertained both familial and sporadic cases of HFM. A genome wide search for linkage in two families with features of HFM was performed to identify the disease loci. In one family data were highly suggestive of linkage to a region of approximately 10.7 cM on chromosome 14q32, with a maximum multipoint lod score of 3.00 between microsatellite markers D14S987 and D14S65. This locus harbours the Goosecoid gene, an excellent candidate for HFM based on mouse expression and phenotype data. Coding region mutations were sought in the familial cases and in 120 sporadic cases, and gross rearrangements of the gene were excluded by Southern blotting. Evidence for genetic heterogeneity is provided by the second family, in which linkage was excluded from this region.

A simian human immunodeficiency virus with a nonfunctional Vpu (deltavpuSHIV(KU-1bMC33)) isolated from a macaque with neuroAIDS has selected for mutations in env and nef that contributed to its pathogenic phenotype

Previous studies have shown that passage of nonpathogenic SHIV-4 through a series of macaques results in the selection of variants of the virus that are capable of causing rapid subtotal loss of CD4(+) T cells and AIDS within 6-8 months following inoculation into pig-tailed macaques. Using a pathogenic variant of SHIV-4 known as SHIV(KU-1bMC33), we reported that a mutant of this virus with the majority of the vpu deleted was still capable of causing profound CD4(+) T cell loss and neuroAIDS in pig-tailed macaques (McCormick-Davis et al., 2000, Virology 272, 112-116). In this study, we have analyzed the tissue-specific changes in the env and nef in one macaque that developed neuroAIDS (macaque 50 O) and in three macaques that developed only a moderate or no significant loss of CD4(+) T cells and no neurological disease (macaques 50 Y, 20220, 20228) following inoculation with DeltavpuSHIV(KU-1bMC33). Sequence analysis of the gp120 region of env isolated from lymphoid tissues (lymph node and spleen) of macaques 50 Y, 20220, and 20228 revealed no consensus amino acid substitutions. In contrast, analysis of the gp120 sequences isolated from lymphoid and CNS tissues (parietal cortex, basal ganglia, and pons) of macaque 50 O revealed numerous amino acid substitutions. The significance of the amino acid substitutions in gp120 was supported by neutralization assays which showed that the virus isolated from the lymph node of macaque 50 O was neutralization resistant compared to the parental SHIV(KU-1bMC33). Analysis of changes in the nef gene from macaque 50 O revealed in-frame deletions in Nef that ranged from 4 to 13 amino acids in length, whereas the nef genes isolated from the other three macaques revealed no deletions or consensus amino acid substitutions. Inoculation of the virus isolated from the lymph node of the macaque which developed neuroAIDS, SHIV(50OLNV), into four pig-tailed macaques resulted in a severe loss of the circulating CD4(+) T cells within 2 weeks postinoculation, which was maintained for up to 20 weeks postinoculation, confirming that this virus had indeed become more pathogenic in pig-tailed macaques. Taken together, these observations suggest that DeltavpuSHIV(KU-1bMC33) has a low pathogenic phenotype in macaques but that individual pig-tailed macaques can select for additional mutations within the Env and Nef which can compensate for the lack of an intact Vpu and ultimately increase its pathogenicity.

Labiomental intertrigo. An indication for orthognathic surgery

Severe skeletal retrognathia may lead to a pronounced labiomental fold. When severe the labiomental fold may result in intertrigo, which is chronic and symptomatic. This problem can be managed by orthodontics and orthodontic surgery to reposition the jaw at a more anterior direction, thus creating a normal lip posture and a normal labiomental fold.

Dominantly inherited cleft lip and palate in two families

Two families with non-syndromic cleft lip and cleft palate are described. The linear pattern of inheritance through several generations is difficult to explain by conventional multifactorial models. The pedigrees strengthen the suggestion that a dominantly inherited mutation exists with a major influence on clefting of the lip and palate alone.