Biomechanical parameters of the golf swing associated with lower back pain: A systematic review

Low back pain (LBP) is the most common injury in golfers of all abilities. The primary aim of this review was to improve understanding of human golf swing biomechanics associated with LBP. A systematic review using the PRISMA guidelines was performed. Nine studies satisfying inclusion criteria and dually reporting golf swing biomechanics and LBP were identified. Human golf swing biomechanics potentially associated with LBP include: reduced lumbar flexion velocity; reduced transition phase length; reduced lumbar torsional load; earlier onset of erector spinae contraction; increased lumbar lateral flexion velocity; reduced or greater erector spinae activity; and earlier onset of external oblique contraction. These potential associations were undermined by a very limited and conflicting quality of evidence, study designs which introduced a severe potential for bias and a lack of prospective study design. There is no conclusive evidence to support the commonly held belief that LBP is associated with "poor" golf swing technique. The potential associations identified should be further investigated by prospective studies of robust design, recruiting participants of both sexes and dexterities. Once firm associations have been identified, further research is required to establish how this knowledge can be best integrated into injury prevention and rehabilitation.

Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

A systematic review and meta-analysis of global and social functioning among people at risk of bipolar disorder

BACKGROUND

Functional status could predict development of bipolar disorder (BD) or have clinical significance. The relationship between BD risk and functioning is poorly understood. We undertook a systematic review examining the global and social functioning of those at risk for BD.

METHODS

We examined observational studies comparing a risk sample with healthy controls or full-threshold BD participants, using measures of global or social functioning. Risk status included family history of BD, meeting risk criteria, or having prodromal symptomatology, or premorbid functioning of persons with BD. Medline, PsycINFO, and Embase were searched. The Newcastle-Ottawa Scale for Cross-Sectional Studies was used to assess quality. Meta-analyses were performed where possible.

RESULTS

7215 studies were screened and 40 studies were included (8474 participants). Risk samples had poorer functioning than controls, and superior functioning to participants with BD. Meta-analysis indicated poorer global functioning among persons with familial risk compared to healthy controls (mean global functional difference: 5.92; 95 % confidence interval: 7.90, 3.95; mean premorbid functioning difference: 2.31; 95 % confidence interval: 0.70, 3.92). Studies with higher proportions of female participants had slightly poorer global functioning. High heterogeneity was attributable functional measures and potentially functionally differential subgroups within the risk samples.

LIMITATIONS

Broader measures of functioning, such as neurocognition and behavioural measures, were excluded. Measures of global functioning are limited by conflating functioning and symptoms.

CONCLUSIONS

Functioning in the BD risk populations is intermediate to that of healthy controls and persons with BD, indicating their value in definitions of BD risk, in itself a likely heterogeneous state.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Healthcare use by children in North West London 2015-2019 by deprivation and integrated care access

Background

England has a health system offering universal coverage, but disparities in healthcare use are increasing. Between 2007-2017, children living in more deprived areas had higher rates of unplanned care (Emergency Department (ED) attendance and hospital admissions), whereas children from less deprived areas had higher rates of planned care (General Practitioner (GP) contact and outpatient appointments). More detailed research to find solutions for this divergent pattern is required.

Aim

To assess the rates of GP contact, outpatient appointments, hospital admissions and ED attendance in North West London, by Index of Multiple Deprivation (IMD) decile of home postcode and access to an integrated care service providing linked care between multiple child health professionals ‘Connecting Care for Children (CC4C)', for children aged 0-18 years between 2015-2019.

Methods

Retrospective analysis of a de-identified database of integrated care records for 495,357 children.

Results

Children from the most deprived decile had higher rates of emergency admissions (0.070 per child per year vs. overall mean 0.040), elective admissions (0.076 vs. 0.032), ED attendances (0.754 vs. 0.358) and outpatient appointments (1.702 vs. 0.756) between 01.01.2015- 31.12.2019. Children from the least deprived decile had the second highest rates of outpatient appointments (0.911 vs. 0.756) and GP contact (8.192 vs. 5.390) between 01.01.2015- 31.12.2019. Children with access to the CC4C service, despite being from more deprived backgrounds, had lower rates of emergency admissions (0.028 vs. 0.037) compared to patients with access to usual care. P values &lt;0.001 in all cases.

Conclusions

Greater deprivation was linked to higher rates of emergency admissions, but this was partially mitigated by access to more integrated healthcare models. Children from the least deprived decile continued to have disproportionately higher use of planned care.

Key messages

• Despite universal health coverage, children from more deprived areas continue to have disproportionately higher use of unplanned care.

• Further research is required to explore whether integrated care solutions can reduce the burden on unplanned health services and inequalities in access to care.

TRENDS IN HIV CARE OUTCOMES AMONG ADULTS AND ADOLESCENTS IN THE U.S. SOUTH, 2015-2019

PURPOSE

HIV disparities continue to persist in the southern United States and among some populations. Early HIV diagnosis, prompt linkage to care, and viral suppression among persons with HIV in the South, in particular the Deep South, are critical to reduce disparities and achieve national prevention goals.

METHODS

Estimated annual percent changes were calculated to assess trends during 2015-2019 in percentage distributions for stage of disease at the time of diagnosis, linkage to HIV medical care, and viral suppression.

RESULTS

Among 95,488 persons with HIV diagnosed in the South (Deep South: 81,848; Other South:13,640), the overall percentage that received a diagnosis classified as stage 0 increased 9.0%, stages 1-2 increased 1.8%, linkage to HIV care increased 2.9%, and viral suppression increased 5.9%. Changes in care outcomes among American Indian/Alaska Native persons and persons with infection attributed to injection drug use were minimal.

CONCLUSIONS

To reach the goals of Ending the HIV Epidemic (EHE) and other federal initiatives, efforts need to focus on prevention and care among persons residing in the South. Addressing factors such as stigma and discrimination and elimination of barriers to HIV testing, care, and treatment are needed to effectively address these disparities in HIV-related care outcomes.

MEdication Management in older people with Intellectual Disabilities (MEMID): a scoping review

Introduction

Globally, around 1 in 100 adults have intellectual disabilities (ID) (synonymous with learning disability in the UK) (1) yet their needs in terms of healthcare in general and medication management in particular, are under-researched. People with ID have more comorbidities compared with those without ID and around one third of older people (≥ 50 years) with ID (OPwID) have two or more chronic conditions, putting them at risk of polypharmacy (use of multiple medicines) (2).

Aim

To undertake a scoping review to gather evidence on the barriers and facilitators in the medication management of OPwID from a multi-stakeholder (patient, carer and healthcare professional) perspective.

Methods

Standard scoping review methods were used. Electronic databases (Medline, PsycINFO) were searched from 2011-2021 using a range of search terms. Studies were included if they involved: OPwID without dementia (all types); healthcare professionals or caregivers caring for individuals with ID; problems related to medication use. The review was restricted to studies in the English language.

The PRISMA-ScR checklist and reporting standards was used to conduct and report the review. Independent duplicate screening and data extraction was undertaken. The quality of studies was not formally assessed. A narrative synthesis was conducted to summarise the results and included barriers and facilitators associated with medicines management from patients’/carers’ and professionals’ perspectives.

Results

Eight studies were included, of which seven used qualitative methods. The majority of studies were undertaken in Europe ((the Netherlands (2), Norway (1), Belgium (1), UK (3)) and one was conducted in the US.

Patients/carers reported several barriers/facilitators:

The most cited barriers to medication management of OPwID from professionals’ perspective included: limited knowledge of, and training about, ID; nonadherence to guideline recommendation; and lack of coordination between different professionals in multidisciplinary teams.

Conclusion/Discussion

The review was restricted to two databases and the English language due to resource- and time-constraints. All the included studies were conducted in developed countries with different healthcare settings/practice. As such, the findings might not be generalisable to other less/under-developed countries or settings.

There is limited empirical evidence regarding the medication management of OPwID, in particular, facilitators to medicines management from professionals’ perspective. OPwID are a highly vulnerable population for whom medications have an important role in managing their multiple morbidities. This review highlights an evidence gap regarding the medication management of these individuals. The results will be used to inform the development of personalised intervention(s) to improve the safe and effective use of medication in this population.

References

(1) Maulik PK, Mascarenhas MN, Mathers CD, Dua T, Saxena S. Prevalence of intellectual disability: a meta-analysis of population-based studies. Res Dev Disabil. 2011 Mar 1;32(2):419-36.

(2) Hermans H, Evenhuis HM. Multimorbidity in older adults with intellectual disabilities. Res Dev Disabil. 2014;35(4):776–83.

A national initiative to promote public involvement in medicine safety in Scotland: the use of a population survey to identify candidate behaviours for intervention development

Introduction

Medicines are the most commonly used healthcare intervention (1). Every medicine has benefits and harms. One of the five objectives of the WHO Global Patient Safety campaign, Medication Without Harm, is to “empower patients, families and their carers to become actively involved and engaged in treatment or care decisions, ask questions, spot errors and effectively manage their medications” (2). Effective strategies are needed to promote greater public involvement in the safe and effective use of medicines.

Aim

The aim of this study was to explore the prevalence of public behaviour in terms of information-/advice-seeking about medicines in general, newly prescribed medicines, and pain management including their use of oral, over-the-counter (OTC) analgesics. The survey also included exploration of self-reported behaviour regarding their use of pharmacies and OTC analgesics.

Methods

A cross-sectional online survey of 1000 adults (aged &gt;16years) in Scotland was undertaken in collaboration with Ipsos MORI. The content was informed by a multi-stakeholder prioritisation event (held in November 2019) and supplemented with information from earlier studies, including national surveys using Citizen Panels. The following themes were included in the questionnaire:

The data were input online by respondents then cleaned and weighted by Ipsos Mori using random iterative method (RIM) weighting to the known offline population proportions for age, gender, region and working status. All data were analysed and presented using descriptive statistics.

Results

Most respondents (78%, n=777) had used a pharmacy in the previous 12 months to obtain a prescription medicine and slightly fewer (61%, n=610) to obtain an OTC medicine. Low levels of information- and advice-seeking were reported especially on receipt of new prescription medicines.

Few (5%) respondents ‘always’ discussed their new prescription medicine with pharmacy staff and 29% reported ‘never’ engaging in this behaviour. Older people (&gt; 35 years) were less likely to engage in this behaviour. Up to 65% of respondents reported ‘always’ engaging with specific aspects of the appropriate use of OTC analgesics e.g. appropriate dose.

Potentially unsafe behaviours were identified with medicine disposal. Nearly one third (29%) of respondents considered waste bin disposal to be of low or no harm, and 19% considered disposal of medicines via the toilet/sink to be of low/no harm.

Conclusion

Despite the extensive use of pharmacies, low levels of information-/advice-seeking were reported especially on receipt of new prescription medicines. Potentially unsafe behaviours were also identified with medicine use and disposal. The key determinants of these behaviours will be explored in more detail and theory-based interventions will be developed and tested to evaluate their effect.

Respondent opinion (positively or negatively) regarding their perceptions regarding community pharmacies and/or pharmacy personnel could have been influenced by the increased use and/or awareness of community pharmacy services due to the pandemic.

References

(1) National Institute for Health and Care Excellence. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. NICE Guidelines [NG5]. 2015. https://www.nice.org.uk/guidance/ng5 (accessed 13/10/2021).

(2) Medication without harm - Global patient safety challenge on medication safety. Geneva: World Health Organization, 2017. Licence: CCBY-NC-SA3.0IGO.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Communicating During an HIV Outbreak Among People Who Inject Drugs-West Virginia 2019

In 2019, the West Virginia Bureau for Public Health (WV BPH), Cabell-Huntington Health Department (CHHD), and CDC collaborated to respond to an HIV outbreak among people who inject drugs (PWID). CDC, WV BPH, and CHHD formed a cross-agency communications team to establish situational awareness, identify knowledge gaps, and establish key audiences for messages, including the general population, PWID, and clinical and social service providers. The team disseminated up-to-date information about the outbreak, and prioritized messages addressing stigma related to drug use, syringe services programs, and HIV. Messages were continually updated to address the evolving situation and to resonate with local values. Messages were disseminated via advertisements, local news media, and directly to PWID, people experiencing homelessness, and providers. The response supplemented CHHD's assets, including strong relationships and community knowledge, with staff capacity and expertise from state and federal agencies. This collaborative approach is a useful model to address communication needs.

In situ evaluation of contact stiffness in a slip interface with different roughness conditions using ultrasound reflectometry

Understanding the dynamic condition of the interface between a railway wheel and rail is important to reduce the risks and consider the effectiveness of countermeasures for tribological problems. Traditionally the difficulty in obtaining accurate non-destructive interfacial measurements has hindered systematic experimental investigations. Recently, an ultrasound reflectometry technique has been developed as a direct observation method of a rolling–sliding interface; however, the topography dependence under the high contact pressures in a wheel–rail contact has not been clarified. For this reason, a novel in situ measurement of the contact stiffness using ultrasound reflectometry was carried out for three different levels of roughness. A contact pressure equivalent to that in a wheel–rail interface was achieved by using a high-pressure torsion test approach. The dynamic change of contact stiffness with slip was measured using ultrasound and the influence of roughness was investigated. The measured changes were validated using a newly developed numerical simulation, and mechanisms to explain the observed behaviour were proposed in terms of fracture and plastic deformation of the asperity bonds. These findings could help in understanding the traction characteristics for different roughness conditions and also assist in understanding damage mechanisms better, such as wear and rolling contact fatigue.

Response to a Large HIV Outbreak, Cabell County, West Virginia, 2018-2019

INTRODUCTION

In January 2019, the West Virginia Bureau for Public Health detected increased HIV diagnoses among people who inject drugs in Cabell County. Responding to HIV clusters and outbreaks is 1 of the 4 pillars of the Ending the HIV Epidemic in the U.S. initiative and requires activities from the Diagnose, Treat, and Prevent pillars. This article describes the design and implementation of a comprehensive response, featuring interventions from all pillars.

METHODS

This study used West Virginia Bureau for Public Health data to identify HIV diagnoses during January 1, 2018-October 9, 2019 among (1) people who inject drugs linked to Cabell County, (2) their sex or injecting partners, or (3) others with an HIV sequence linked to Cabell County people who inject drugs. Surveillance data, including HIV-1 polymerase sequences, were analyzed to estimate the transmission rate and timing of infections using molecular clock phylogenetic analysis. Federal, state, and local partners designed and implemented a comprehensive response during January 2019-October 2019.

RESULTS

Of 82 people identified in the outbreak, most were male (60%), were White (91%), and reported unstable housing (80%). In a large molecular cluster containing 56 of 60 (93%) available sequences, 93% of inferred transmissions occurred after January 1, 2018. HIV testing, HIV pre-exposure prophylaxis, and syringe services were rapidly expanded, leading to improved linkage to HIV care and viral suppression.

CONCLUSIONS

Evidence of rapid transmission in this outbreak galvanized robust collaboration among federal, state, and local partners, leading to critical improvements in HIV prevention and care services. HIV outbreak response requires increased coordination and creativity to improve service delivery to people affected by rapid HIV transmission.

HIV Cluster and Outbreak Detection and Response: The Science and Experience

The Respond pillar of the Ending the HIV Epidemic in the U.S. initiative, which consists of activities also known as cluster and outbreak detection and response, offers a framework to guide tailored implementation of proven HIV prevention strategies where transmission is occurring most rapidly. Cluster and outbreak response involves understanding the networks in which rapid transmission is occurring; linking people in the network to essential services; and identifying and addressing gaps in programs and services such as testing, HIV and other medical care, pre-exposure prophylaxis, and syringe services programs. This article reviews the experience gained through 30 HIV cluster and outbreak responses in North America during 2000-2020 to describe approaches for implementing these core response strategies. Numerous jurisdictions that have implemented these response strategies have demonstrated success in improving outcomes related to HIV care and viral suppression, testing, use of prevention services, and reductions in transmission or new diagnoses. Efforts to address important gaps in service delivery revealed by cluster and outbreak detection and response can strengthen prevention efforts broadly through multidisciplinary, multisector collaboration. In this way, the Respond pillar embodies the collaborative, data-guided approach that is critical to the overall success of the Ending the HIV Epidemic in the U.S. initiative.

Improving provider, patient and health systems outcomes: a qualitative analysis of Project ECHO

Background

Project ECHO (Extension for Community Healthcare Outcomes) is an internationally recognised tele-mentoring intervention that has been implemented in over 40 countries. The model connects specialist healthcare providers (hubs) with providers in primary and community practice (spokes), often in rural and isolated areas.

Objectives

Project ECHO aims to improve healthcare provider's skills, confidence and knowledge, and to create a community of practitioners using the hub and spoke model. Analysing interview data from 27 Project ECHO network leads and participants in Northern Ireland, this study sought to assess the impact of Project ECHO on improving provider, patient and health system outcomes.

Results

Having access to a specialist, a space to share experiences, and being able to disseminate up-to-date best practice were all cited as improving provider knowledge. Providers described improved outcomes for patients such as receiving a new treatment or an efficient referral. Providers reported being more confident in managing patients and thus were less likely to refer unnecessarily, and links between providers at primary and secondary levels being improved. ECHO was deemed an acceptable methodology in terms of format and in improving access to education and training by removing geographic barriers and reducing time barriers.

Conclusions

This is one of the first studies to qualitatively analyse outcomes across a number of different ECHO networks, and involving both health and social care networks. The results indicate the benefit of ECHO in improving provider, patient and healthcare outcomes. This has implications for future resourcing decisions, particularly within the context of COVID-19 in which virtual and online training is necessitated by social distancing requirements. This study has implications for wider international contexts in which ECHO may be piloted to address similar challenges.

Key messages

Participants across our study described Project ECHO as having a positive impact on provider, patient and health systems outcomes.

Project ECHO was described as an acceptable approach to training and education that improved access through removing geographic barriers.

Case report: NTRK1-rearranged cervical sarcoma with fibrosarcoma like morphology presenting in a 13-year-old managed with a neo-adjuvant TRK-inhibitor and surgical excision

•

NTRK fusion-positive fibrosarcoma like tumour of the cervix in a paediatric patient.

•

Fertility sparing surgery achieved with the use of a neo-adjuvant TKi.

•

Identifying NTRK fusions may afford conservative treatment options in these tumours.

This case report reviews the case of a 13-year-old patient who presented with a 9 cm NTRK1-rearranged cervical sarcoma with fibrosarcoma like morphology. At presentation the lesion filled her vagina and pelvis and any attempt at surgical removal would have been morbid and led to loss of fertility. These neoplasms are extremely rare with 18 cases of the uterine cervix reported in the literature, none of which have occurred in a paediatric patient, and none of whom have received neo-adjuvant therapy prior to excision. Based upon evidence that has shown good tolerability and responses of paediatric NTRK fusion-positive solid tumours to TRK inhibitors, both in the neo-adjuvant and upfront setting, this patient was managed with neo-adjuvant entrectinib. Following a dramatic reduction in tumour size confirmed by imaging, she underwent conservative fertility sparing surgery with final histopathology showing no residual disease.

Risk factors for persistent abnormality on chest radiographs at 12-weeks post hospitalisation with PCR confirmed COVID-19

Background

The long-term consequences of COVID-19 remain unclear. There is concern a proportion of patients will progress to develop pulmonary fibrosis. We aimed to assess the temporal change in CXR infiltrates in a cohort of patients following hospitalisation for COVID-19.

Methods

We conducted a single-centre prospective cohort study of patients admitted to University Hospital Southampton with confirmed SARS-CoV2 infection between 20th March and 3rd June 2020. Patients were approached for standard-of-care follow-up 12-weeks after hospitalisation. Inpatient and follow-up CXRs were scored by the assessing clinician for extent of pulmonary infiltrates; 0–4 per lung (Nil = 0, < 25% = 1, 25–50% = 2, 51–75% = 3, > 75% = 4).

Results

101 patients with paired CXRs were included. Demographics: 53% male with a median (IQR) age 53.0 (45–63) years and length of stay 9 (5–17.5) days. The median CXR follow-up interval was 82 (77–86) days with median baseline and follow-up CXR scores of 4.0 (3–5) and 0.0 (0–1) respectively. 32% of patients had persistent CXR abnormality at 12-weeks. In multivariate analysis length of stay (LOS), smoking-status and obesity were identified as independent risk factors for persistent CXR abnormality. Serum LDH was significantly higher at baseline and at follow-up in patients with CXR abnormalities compared to those with resolution. A 5-point composite risk score (1-point each; LOS ≥ 15 days, Level 2/3 admission, LDH > 750 U/L, obesity and smoking-status) strongly predicted risk of persistent radiograph abnormality (0.81).

Conclusion

Persistent CXR abnormality 12-weeks post COVID-19 was common in this cohort. LOS, obesity, increased serum LDH, and smoking-status were risk factors for radiograph abnormality. These findings require further prospective validation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-021-01750-8.

Increasing Capacity to Detect Clusters of Rapid HIV Transmission in Varied Populations-United States

Molecular cluster detection analyzes HIV sequences to identify rapid HIV transmission and inform public health responses. We describe changes in the capability to detect molecular clusters and in geographic variation in transmission dynamics. We examined the reporting completeness of HIV-1 polymerase sequences in quarterly National HIV Surveillance System datasets from December 2015 to December 2019. Priority clusters were identified quarterly. To understand populations recently affected by rapid transmission, we described the transmission risk and race/ethnicity of people in clusters first detected in 2018–2019. During December 2015 to December 2019, national sequence completeness increased from 26% to 45%. Of the 1212 people in the 136 clusters first detected in 2018–2019, 69% were men who have sex with men (MSM) and 11% were people who inject drugs (PWID). State-by-state analysis showed substantial variation in transmission risk and racial/ethnic groups in clusters of rapid transmission. HIV sequence reporting has increased nationwide. Molecular cluster analysis identifies rapid transmission in varied populations and identifies emerging patterns of rapid transmission in specific population groups, such as PWID, who, in 2015–2016, comprised only 1% of people in such molecular clusters. These data can guide efforts to focus, tailor, and scale up prevention and care services for these populations.

A systematic review of pharmacist-led audit and feedback interventions to influence prescribing behaviour in general practice settings

Introduction

Audit and Feedback (A&F) involves measuring data about practice, comparing it with clinical guidelines, professional standards or peer performance, and then feeding back the data to individuals/groups of health professionals to encourage change in practice (if required). A 2012 Cochrane review (1) found A&F was effective in changing health professionals’ behaviour and suggested that the person who delivers the A&F intervention influences its effect. Increasingly, pharmacists work in general practice and often have responsibility for medication review and repeat prescriptions. The effectiveness of pharmacist-led A&F in influencing prescribing behaviour is uncertain.

Aim

This secondary analysis from an ongoing update of the original Cochrane review aims to identify and describe pharmacist-led A&F interventions and evaluate their impact on prescribing behaviour in general practice compared with no intervention.

Methods

This sub-review is registered with PROSPERO: CRD42020194355 and complies with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (2). For the updated Cochrane review, the Cochrane Effective Practice and Organization of Care Group searched MEDLINE (1946 to present), EMBASE, CINAHL and Cochrane Library (March 2019) to identify randomised trials featuring A&F interventions. For this sub-review, authors screened titles and abstracts (May 2020) to identify trials involving pharmacist-led A&F interventions in primary care, extracted data, and assessed risk of bias (RoB) in eligible studies. Review results are summarised descriptively. Heterogeneity will be assessed and a random-effects meta-analysis is planned. Publication bias for selected outcomes and the certainty of the body of evidence will be evaluated and presented. Sub-group analyses will be conducted.

Results

Titles and abstracts of 295 studies identified for inclusion in the Cochrane A&F review update were screened. Eleven studies (all cluster-randomised trials) conducted in 9 countries (Denmark, Italy, Netherlands, Norway, Republic of Ireland, UK, Australia, Malaysia, USA) were identified for inclusion (Figure 1). Six studies had low RoB, two had high risk due to dissimilarities between trial arms at baseline and/or insufficient detail about randomisation, and three studies had unclear RoB. Studies examined the effect of A&F on prescribing for specific conditions (e.g. hypertension), medications (e.g. antibiotics), populations (e.g. patients &gt;70), and prescribing errors (e.g. inappropriate dose). The pharmacist delivering A&F was a colleague of intervention participants in five studies. Pharmacists’ levels of skill and experience varied; seven studies reported details of pharmacist training undertaken for trial purposes. A&F interventions in nine studies demonstrated changes in prescribing, including reductions in errors or inappropriate prescribing according to the study aims and smaller increases in unwanted prescribing compared with the control group. Data analyses are ongoing (results will be available for the conference).

Conclusion

The preliminary results demonstrate the effectiveness of pharmacist-led A&F interventions in different countries and health systems with influencing prescribing practice to align more closely with guidance. Studies measured different prescribing behaviours; meta-analysis is unlikely to include all 11 studies. Further detailed analysis including feedback format/content/frequency and pharmacist skill level/experience, work-base (external/internal to recipients), will examine the impact of specific features on intervention effectiveness.

References

1. Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012(6):CD000259.

2. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097.

"What counts can't always be measured": a qualitative exploration of general practitioners' conceptualisation of quality for community pharmacy services

Background

The expansion of community pharmacy services is one solution to relieve pressure on general practice in the United Kingdom (UK). There is a paucity of research of general practitioners’ (GPs’) perspectives of quality of care in the community pharmacy sector.

The purpose of this study was to explore GPs’:

Conceptualisation of quality for community pharmacy services, including the management of acute (low acuity) conditions and defining indispensable aspects of the patient experience (‘always events’)

Opinions regarding whether and how to measure quality in the community pharmacy sector

Method

Semi-structured interviews were conducted with GPs in the UK. GPs were recruited using the snowballing technique and professional networks. Interviews were audio-recorded, transcribed and analysed using an interpretive approach.

Results

Interviews were completed with 20 GPs from Scotland (n = 8) and England (n = 12). Multidimensional and inter-related concepts of quality were identified; most dimensions related to patient benefit, as well as impact on GP workload or other health service provision. Interviewees cautioned that “what counts can’t always be measured”. GPs’ expectations of quality often mirrored those of their own sector, but were ambivalent about the adoption of a quality outcome framework-type approach. Pharmacist involvement was expected to ensure quality in the management of ‘acute consultations’, however, GPs lacked awareness of community pharmacy personnel type, roles and training. Interviewees’ perceptions of quality varied by pharmacy type; independent pharmacies were sometimes associated with higher quality service delivery than larger chain organisations.

Conclusions

Quality frameworks for community pharmacy services could be partly informed by GP experience and expectations, but need to be contextual to reflect differences between both settings. The importance of person-centred care, consistency and continuity was emphasised together with the need for competent personnel and privacy of interactions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-020-01319-2.

Population estimate and rate of increase of southern right whales Eubalaena australis in southeastern Australia

In Australian waters, southern right whales Eubalaena australis form 2 genetically distinct populations that have shown contrasting patterns of recovery since whaling ceased: a western population in South Australia and Western Australia and an eastern population in southeastern Australia (Tasmania, Victoria and New South Wales). Here, we provide an abundance estimate derived from a breeding female superpopulation mark-recapture model for the southeastern southern right whale population. The population comprises 268 individuals (68 breeding females) and has increased at a rate of 4.7% per annum between 1996 and 2017. There has been no significant change in the annual abundance of mother-calf pairs sighted at the only calving ground (Logans Beach in Victoria) over the last 3 decades. The total number of southern right whales (i.e. all adults and calves) using the southeastern Australian coastline has increased by 7% since 1985. Unlike the population estimate (which was restricted to breeding females sighted prior to the post-breeding southward migration), this estimate is likely to include transiting whales from the southwestern population. The theoretical population model predicts 19 breeding females at Logans Beach in 2018 and 28 in 2028; the actual number of breeding females, as of 2018, is 14. This study provides the first complete estimate of population size and rate of increase of southern right whales along the southeastern Australian coastline. This knowledge is critical for assessing population status and recovery of southern right whales in Australia. It provides a basis for monitoring persistence and responses of the population to environmental stressors.

Assurance Enzyme Immunoassay for Detection of Enterohemorrhagic Escherichia coli 0157:H7 in Selected Foods: Collaborative Study

Five foods types were analyzed by the Assurance EHEC (Escherichia coli 0157:H7) enzyme immunoassay (EIA) and by the Bacteriological Analytical Manual (BAM) culture method. Each sample of each food type at each inoculation level was simultaneously analyzed by both methods. A total of 21 laboratories representing state and federal government agencies and private industry in the United States and Canada participated. Samples were inoculated with E. coli 0157:H7, except for one lot of poultry that was naturally contaminated. A total of 1304 samples and controls were analyzed and confirmed, of which 473 were positive and 818 were negative by both methods. Thirteen samples were positive by BAM but negative by EIA. Because of the study design, it was not possible for the BAM method to produce false-negative or falsepositive results. The Assurance method for detection of E. coli OI57:H7 in selected foods has been adopted first action by AOAC INTERNATIONAL.

Visual Immunoprecipitate Assay (VIP) for Detection of Enterohemorrhagic Escherichia coli (EHEC) 0157:H7 in Selected Foods: Collaborative Study

Five foods representative of a variety of food products were analyzed by the Visual Immunoprecipitate Assay (VIP) and the Bacteriological Analytical Manual (BAM) culture method for the presence of Escherichia coli 0157: H7. A total of 21 laboratories representing state and federal government agencies, as well as private industry, in the United States and Canada participated. Food types were inoculated with strains of E. coli 0157:H7, with the exception of one lot of poultry, which was naturally contaminated. During this study, a total of 1377 samples and controls were analyzed and confirmed, of which 508 were positive and 867 were negative by both methods. Two samples were positive by BAM and negative by VIP. Because of the study design, it was not possible for the BAM method to produce false-negative or false-positive results. The VIP assay for detection of EHEC in selected foods has been adopted first action by AOAC INTERNATIONAL.

Novel Method for Rapid Detection of Spatiotemporal HIV Clusters Potentially Warranting Intervention

Rapid detection of increases in HIV transmission enables targeted outbreak response efforts to reduce the number of new infections. We analyzed US HIV surveillance data and identified spatiotemporal clusters of diagnoses. This systematic method can help target timely investigations and preventive interventions for maximum public health benefit.

Prevalence of Sun Protection Use and Sunburn and Association of Demographic and Behaviorial Characteristics With Sunburn Among US Adults

Importance

Monitoring sun protection and sunburn over time at the population level can provide valuable information about progress toward skin cancer prevention goals and inform future intervention efforts.

Objective

To examine the prevalence of sun protection use (shade, sunscreen, and clothing) and sunburn and the association between sunburn and individual characteristics and health behaviors in the US population.

Design, Setting, and Participants

In this cross-sectional study using a nationally representative sample of 31 162 US adults from the 2015 National Health Interview Survey-Cancer Control Supplement, household interviews of civilian, noninstitutionalized US adults were conducted throughout 2015 in person and completed on the telephone when necessary. Data analysis was performed from August 16, 2016, to September 6, 2017.

Main Outcomes and Measures

The prevalence of sunburn and use of sun protection and their association with demographic characteristics, sun sensitivity, and health-related behaviors and conditions using multivariable logistic regression modeling.

Results

A total of 31 162 respondents (mean [SD] age, 47.0 [0.36] years; 13 932 male [44.7%] and 17 230 female [55.3%]) were included in the analyses, with 34.2% experiencing sunburn in 2015. Sunburn prevalence was higher among younger age groups (51.2% in adults 18-29 years old; 95% CI, 48.8%-53.7%), non-Hispanic white individuals (42.5%; 95% CI, 41.2%-43.9%), and those with sun-sensitive skin (50.2%). However, sunburn was also prevalent among black (13.2%; 95% CI, 11.6%-15.1%) and Hispanic (29.7%; 95% CI, 27.6%-31.9%) individuals, demographic groups that are often considered to be at low risk of skin cancer. The most frequent sun protection behaviors were staying in the shade (37.1%; 95% CI, 36.3%-38.0%) and using sunscreen (31.5%; 95% CI, 30.7%-32.3%) followed by wearing long clothing to the ankles (28.4%; 95% CI, 27.6-29.1). Sun avoidance behaviors (seeking shade and not going in the sun) were significantly (39.5% vs 35.1%; P < .001) associated with a lower prevalence of sunburn. Those who used self-applied sunless tanning products (45.0% of users vs 36.1% of nonusers; P < .001), those who engaged in aerobic activity (37.9% of aerobic exercisers vs 32.8% of non-aerobic exercisers; P < .001), binge drinkers (45.1% of binge drinkers vs 35.0% of non-binge drinkers; P < .001), and overweight or obese individuals (37.9% of overweight or obese individuals vs 34.4% of non-overweight or obese individuals; P < .001) were more likely to experience sunburn compared with the respective comparison groups.

Conclusions and Relevance

Sun sensitivity was significantly associated with a higher sunburn prevalence, independent of race/ethnicity, suggesting a need to consider sun sensitivity when identifying target demographic groups for sun safety interventions. Efforts to improve vigilance and consistency with use of sun protection are needed. In addition, those who engage in physical activity, use sunless tanners, or use sunscreen for tanning purposes may require additional intervention strategies to address the unique barriers they face in staying adequately protected.

Shade as an Environmental Design Tool for Skin Cancer Prevention

Little work has been done to explore the use of shade for skin cancer prevention in the context of the built environment. In an effort to address this gap and draw attention to the intersection between architectural and public health practice, we reviewed research on shade design, use, and policies published from January 1, 1996, through December 31, 2017. Our findings indicate that various features influence the sun-protective effects of shade, including the materials, size, shape, and position of the shade structure; the characteristics of the surrounding area; and weather conditions. Limited research suggests that shade provision in outdoor spaces may increase shade use. Shade audit and design tools are available to inform shade planning efforts. Shade policies to date have mostly been setting specific, and information on the implementation and effects of such policies is limited. Integrating shade planning into community design, planning, and architecture may have a substantial impact and will require a multidisciplinary approach.

Medical assistance in dying for cancer patients one year after legalization: a collaborative approach at a comprehensive cancer centre

Medical assistance in dying (maid) is a new medical service in Canada. Access to maid for patients with advanced cancer can be daunting during periods of declining health near the end of life. In this report, we describe a collaborative approach between the centralized coordination service and a regional cancer centre as an effective strategy for enabling interdisciplinary care delivery and enhancing patient-centred care at the end of the patient's cancer journey.

Improving Information and Support for Metastatic Breast Cancer in Nigeria

Background: Breast cancer is a global health problem of the 21th century. In developing countries, it is the third most common cause of death after infectious, parasitic, and cardiovascular diseases. Experience of late stage cancer carries a high emotional burden, due to poor outcomes and lack of comprehensive care. Currently in Nigeria, most cancer patients are looked after almost solely by their primary clinical oncologists, with minimal psychological and social care. There is a great need to broaden the care to include the psychosocial component now, considered a priority in clinical practice guidelines worldwide. Aim: To assess distress levels and improve quality of life of metastatic breast cancer patients through a continued support group system and psychotherapy. Produce field-tested audio-visual community education, psychosocial support and advocacy materials aimed at improving early diagnosis and reducing breast cancer death. Methods: This is a mixed-methods design study including a prepost design and qualitative focus group discussions. The study will enroll all consecutive patients in advanced stages 3 and 4 of their illness who consent to be included in the study until the estimated sample size of about 100 for the given period of the study is attained. The knowledge and attitude questionnaires, quality of life instruments as well as the distress thermometer will be administered to the patients to ascertain both their levels at baseline presentation as well as identify those who may benefit from psychotherapy. The eligible (stage 3 and 4) patients will be exposed to group psychosocial supportive interventions for three months before reassessment of the baseline parameters to ascertain the value of these interventions for the patients. Breast cancer education tools will be developed during the group interactions and construct validated with nonbreast cancer patients in the community. Results from focus group discussions will be used to triangulate the findings from the other aspects of the study. Data will be analyzed both descriptively and inferentially. Results: Progress to date includes obtaining ethical committee approval for the study protocol with the registration number NHREC/05/01/2008a from the UI/UCH Joint Research Ethics Committee. The research nurses have been trained in distress assessment. Their sociodemographic characteristics, knowledge and attitudes in regard of cancer, distress states, effects of the various psychological and social interventions on the patients and advocacy tools from the group therapy will be the products of this research. Conclusion: The results of this work will be used to advance cancer care and promote advocacy in the UCH and other similar cancer care settings in Nigeria and other developing countries.

31 A multi-site retrospective case note review for clinical practices of constipation in specialist palliative care settings

Background

Constipation is a common symptom for patients receiving palliative care. Whilst national clinical guidelines are available on the management of constipation for people with advanced cancer in specialist palliative care (SPC) settings questions exist around clinical practice and the extent to which the guidelines are implemented in practice. This study examine current clinical practice for management of constipation for patients with advanced cancer in SPC settings.

Methods

A multi-site retrospective case-note review was conducted consisting of 150 patient case-notes from three SPC units across the United Kingdom between August 2016 and May 2017. Descriptive statistics were used to compare clinical practices to national policy guidelines for constipation.

Results

A physical exam and bowel history was recorded for 109 patients (73%). Whilst the Bristol Stool Chart was used frequently across sites (96%) involvement of the multidisciplinary team varied. Almost a third of patient charts (27%) recorded no evidence of non-pharmacological management strategies. Pharmacological management was recorded frequently with sodium docusate or senna as the preferred laxatives across all sites however 33% of patient charts recorded no information on the titration of laxatives. There were no consistent management strategies recorded for opioid induced constipation or bowel obstruction

Conclusion

Assessment and management of constipation in SPC settings is highly variable. Variations in assessment; limited use of non-pharmacological and preventative strategies and absence of consistent strategies for opioid induced constipation or bowel obstruction are evident. Further education is needed to equip HCPs with the necessary knowledge and skills to assess and manage constipation.

References

. Friedrichsen M, Erichsen E. The lived experience of constipation in cancer patients in palliative hospital-based home care. Int J Palliat Nurs [Internet] 2004;10(7):321–5. Available from: http://search.ebscohost.com/login.aspx?direct=true&profile=ehost&scope=site&authtype=crawler&jrnl?=13576321&A?N=13991056&h=XKMF4r08srZuhDY0j7C95oLLyYKNHUcvoeEuhyXNnsIM2BI%2BEhmcY1pPP%2BN1pvrMzQ9Bn9b5j45X6WzyBRydEA%3D%3D&crl=c [Accessed: 21 August 2017]

. Gilbert EH, et al. Chart reviews in emergency medicine research: Where are the methods?Annals of Emergency Medicine1996;27(3):305–8. Available at: http://www.ncbi.nlm.nih.gov/pubmed/8599488 [Accessed: 17 May 2018]

. National Clinical Effectiveness Committee. Management of constipation in adult patients receiving palliative care national clinical guideline No. 10November 2015.

. Tvistholm N, Munch L, Danielsen AK. Constipation is casting a shadow over everyday life? A systematic review on older people’s experience of living with constipation [Internet]. Journal of Clinical Nursing2017;26:902–14. Available from: http://doi.wiley.com/10.1111/jocn.13422 [Accessed: 21 August 2017]

. Wickson-griffiths A, et al.Revisiting retrospective chart review: An evaluation of nursing home palliative and end-of-life care research. Palliative Medicine Care2014;1(2):8. Available at: www.symbiosisonlinepublishing.com [Accessed: 23 November 2017]

32 Examining the key factors impacting on the implementation of an educational program on constipation in specialist palliative care

Introduction

Constipation is one of the most common symptoms in patients in specialist palliative care (SPC) settings and can cause considerable physical psychological and social suffering for the patient and their family. Due to the high variability in constipation assessment and management in SPC settings questions exist around how to implement an educational program in practice to address this clinical gap.

Aim

To develop and test the feasibility and acceptability of a novel educational intervention for HCPs to manage constipation experienced by people in SPC settings.

Method

Using the MRC framework for complex interventions and guided by the consolidated framework for implementation research an online resource was developed considering the content context and processes for implementation.

Results

Assessment prevention and management were identified as the core aspects. Six sessions with theoretical content application to practice and reflection through interacting with colleagues were developed in line with the best available evidence. Incentives including an educational bursary and alignment with revalidation and support from senior management champions and the research team were identified as key elements needed successful implementation. Funding IT infrastructure and attitudes to the content have been flagged as potential barriers to success.

Conclusion

A six week blended program covering the key concepts for assessment and management of constipation in palliative care has been created. Content evidence from the literature and empirical data on the preferred structure and method of delivery as well as key considerations of the contextual factors have been identified as key factors for implementation.

References

. Craig P, et al.Developing and evaluating complex interventions: The new medical research council guidance. BMJ Clinical Research Ed2008;337(October):a1655. Available at: http://discovery.ucl.ac.uk/168426/

. Damschroder LJ, et al. Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science2009;4(50).

. Friedrichsen M, Erichsen E. The lived experience of constipation in cancer patients in palliative hospital-based home care. Int J Palliat Nurs [Internet] 2004;10(7):321–5. Available from: http://search.ebscohost.com/login.aspx?direct=true&profile=ehost&scope=site&authtype=crawler&jrnl?=13576321&AN=13991056&h=XKMF4r08srZuhDY0j7C95oLLyYKNHUcvoeEuhyXNnsIM2BI%2BEhmcY1pPP%2BN1pvrMzQ9Bn9b5j45X6WzyBRydEA%3D%3D&crl=c [Accessed: 2017 August 21]

. Tvistholm N, Munch L, Danielsen AK. Constipation is casting a shadow over everyday life? A systematic review on older people’s experience of living with constipation [Internet]. Journal of Clinical Nursing2017;26:902–14. Available from: http://doi.wiley.com/10.1111/jocn.13422 [Accessed: 2017 August 21]

Assessment of trends in cervical cancer screening rates using healthcare claims data: United States, 2003-2014

Improved understanding of the natural history of cervical cancer has led to changes in screening recommendations, including the addition of the human papillomavirus (HPV) testing as an option in routine screening. Most studies of screening trends have used national self-reported survey data. To better understand recent trends in cervical cancer screening, including cytology (Papanicolaou, or Pap, tests) and human papillomavirus co-tests (HPV + Pap test), we used healthcare claims data to examine screening practices and trends. We analyzed screening among commercially-insured females ages 18-65 during 2005-2014 who were continuously enrolled during three or more contiguous calendar years, to identify those who received cervical cancer screening with a Pap test or co-test. We examined screening prevalence by age group and year. During the latter years of our study period, screening prevalence (regardless of screening method) declined significantly for women in all age groups examined. Despite declines in overall screening, the prevalence of co-testing increased in all age groups except those aged 18-20. In 2014, women aged 30-39 had the highest overall screening uptake (77.5%) and the highest use of co-testing (44.4%); this group also had the lowest overall declines in screening over the time period (-4.5%). These screening measures from healthcare claims were lower than self-reported screening from national surveys of the general population. More research to explore the reasons for these differences is needed to ensure that women are receiving appropriate screening, and to better understand why screening prevalence is declining among this population of commercially insured women.

Abstract PD8-03: ESR1 gene fusions drive endocrine therapy resistance and metastasis in breast cancer

Background. Dysregulation of the estrogen receptor gene (ESR1) is an established mechanism of inducing endocrine therapy resistance. We previously discovered a chromosomal translocation event generating an estrogen receptor gene fused in-frame to C-terminal sequences of YAP1 (ESR1-YAP1) that contributed to endocrine therapy resistance in estrogen receptor positive (ER+) breast cancer models. This study compares functional, transcriptional, and pharmacological properties of additional ESR1 gene fusion events of both early stage (ESR1-NOP2) late stage (ESR1-YAP1 and ESR1-PCDH11x) breast cancers to gain a better understanding of therapeutic resistance and metastasis. Understanding the role of ESR1 fusions in inducing metastasis is critical, since the primary cause of death in breast cancer patients is through metastasis to distant sites.

Methods. RNA-seq screens identified ESR1 fusions from early and late stage, endocrine therapy resistant breast tumor samples. Functional experiments were conducted using ER+ breast cancer cell lines, xenograft, and PDX models to test the ability of ESR1 fusions to induce therapeutic resistance and metastasis. ChIP-seq and RNA-seq were performed to examine transcriptional properties and differential gene expression induced by the fusions which directed subsequent pharmacological experiments with a CDK4/6 inhibitor.

Results. ESR1-YAP1 and ESR1-PCDH11x promoted estrogen-independent and fulvestrant-resistant growth in vitro and induced greater tumor growth and increased metastatic capacity to the lungs of xenografted mice. In contrast, the ESR1-NOP2 fusion was sensitive to low estrogen conditions in vitro, and did not promote tumor growth. RNA-seq profiling revealed E2F targets pathway as the most highly enriched pathway induced by the ESR1 fusions. IHC revealed higher levels of pRb in ESR1-YAP1 and ESR1-PCDH11x xenograft tumors and subsequent CDK4/6 inhibition completely blocked tumor growth in an ESR1-YAP1 PDX model. Integrating RNA-seq with ChIP-seq data, we discovered a set of EMT and metastasis genes bound by all ESR1 fusions and WT-ER, but whose expression was strongly and uniquely up-regulated only by the ESR1-YAP1 and ESR1-PCDH11x fusions. These studies also revealed gained sites bound only by the ESR1-YAP1 and ESR1-PCDH11x fusions, not bound by WT-ER nor ESR1-NOP2. Genes mapping to these sites have a role in metastatic biology and were highly up-regulated by the YAP1 and PCDH11x fusions, potentially mediated by long range transcriptional activation.

Conclusion. ESR1-YAP1 and ESR1-PCDH11x are driver fusions that occur in drug-resistant, advanced stage breast cancer and are a new class of recurrent somatic mutation that can cause acquired endocrine therapy resistance, yet can be treated with CDK4/6 inhibition. These driver fusions also confer increased metastatic ability through their ability to drive expression of genes that contribute to EMT and metastasis. In contrast, ESR1-NOP2 did not produce functional protein and appears to be a passenger event. These studies may provide pre-clinical rationale for targeting ESR1 translocated breast tumors, since the presence of an ESR1 driver fusion places a patient in a therapeutic category where none of the currently available endocrine therapies are likely to be effective.

Citation Format: Lei JT, Shao J, Zhang J, Iglesia M, Chan DW, Cao J, Anurag M, Singh P, Haricharan S, Kavuri SM, Matsunuma R, Schmidt C, Kosaka Y, Crowder R, Hoog J, Phommaly C, Goncalves R, Ramalho S, Rodrigues-Peres RM, Lai W-C, Hampton O, Rogers A, Tobias E, Parikh P, Davies S, Ma C, Suman V, Hunt K, Watson M, Hoadley KA, Thompson A, Perou CM, Creighton CJ, Maher C, Ellis MJ. ESR1 gene fusions drive endocrine therapy resistance and metastasis in 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 PD8-03.

Cervical cancer survival in the United States by race and stage (2001-2009): Findings from the CONCORD-2 study

BACKGROUND

Overall, cervical cancer survival in the United States has been reported to be among the highest in the world, despite slight decreases over the last decade. Objective of the current study was to describe cervical cancer survival trends among US women and examine differences by race and stage.

METHODS

This study used data from the CONCORD-2 study to compare survival among women (aged 15-99 years) diagnosed in 37 states covering 80% of the US population. Survival was adjusted for background mortality (net survival) with state- and race-specific life tables and was age-standardized with the International Cancer Survival Standard weights. Five-year survival was compared by race (all races, blacks, and whites). Two time periods, 2001-2003 and 2004-2009, were considered because of changes in how the staging variable was collected.

RESULTS

From 2001 to 2009, 90,620 women were diagnosed with invasive cervical cancer. The proportion of cancers diagnosed at a regional or distant stage increased over time in most states. Overall, the 5-year survival was 63.5% in 2001-2003 and 62.8% in 2004-2009. The survival was lower for black women versus white women in both calendar periods and in most states; black women had a higher proportion of distant-stage cancers.

CONCLUSIONS

The stability of the overall survival over time and the persistent differences in survival between white and black women in all US states suggest that there is a need for targeted interventions and improved access to screening, timely treatment, and follow-up care, especially among black women. Cancer 2017;123:5119-37. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

Counseling on Sun Protection and Indoor Tanning

BACKGROUND

The US Preventive Services Task Force recommends clinical counseling for individuals ages 10 to 24 years to decrease skin cancer risk.

METHODS

A national, random sample of US American Academy of Pediatrics members practicing primary care in 2002 (response rate 55%) and 2015 (response rate 43%). Surveys explored attitudes and experiences regarding sun protection counseling; indoor tanning questions were added in 2015. χ² tests compared demographics and counseling responses across years, and multivariable logistic regression models examined counseling predictors.

RESULTS

More pediatricians in 2015 (34%) than in 2002 (23%) reported discussing sun protection during recent summer months with ≥75% of patients. This pattern held across all patient age groups (each P <.001). Female and suburban pediatricians counseled more; those in the South and West counseled less. More pediatricians in 2015 than in 2002 named time as a barrier. Sun protection ranked lowest among preventive topics in both years. In 2015, approximately one-third of pediatricians reported discussing indoor tanning at least once with 10 to 13 year-old patients; approximately half discussed this with older adolescents. Most (70%) did not know if their states had laws on minors' indoor tanning access; those stating they knew whether a law existed counseled more.

CONCLUSIONS

Although improved, sun protection counseling rates remain low. Indoor tanning counseling can be improved. Because early-life exposure to UV radiation increases risk and clinician counseling can positively impact prevention behaviors, pediatricians have an important role in skin cancer prevention; counseling may save lives. Time constraints remain a barrier.