A combined analysis of two prospective randomised studies exploring the impact of extended post-radiation temozolomide on survival outcomes in newly diagnosed glioblastoma

PURPOSE

The optimal duration of post-radiation temozolomide in newly diagnosed glioblastoma remains unclear, with no published phase III randomised trials. Standard-of-care stipulates 6 months. However, in routine care, it is often extended to 12 months, despite lacking robust supporting data.

METHODS

GEINO14-01 (Spain) and EX-TEM (Australia) studies enrolled glioblastoma patients without progression at the end of 6 months post-radiation temozolomide. Participants were randomised 1:1 to six additional months of temozolomide or observation. Primary endpoint was 6-month progression free survival from date of randomisation (6mPFS). Secondary endpoints included overall survival (OS) and toxicity. 204 patients were required to detect an improvement in 6mPFS from 50 to 60% (80% power). Neither study recruited sufficient patients. We performed a combined analysis of individual patient data.

RESULTS

205 patients were recruited: 159 in GEINO14-01 (2014-2018) and 46 in EX-TEM (2019-2022). Median follow-up was 20.0 and 14.5 months. Baseline characteristics were balanced. There was no significant improvement in 6mPFS (57.2% vs 64.0%, OR0.75, p = 0.4), nor across any subgroups, including MGMT methylated; PFS (HR0.92, p = 0.59, median 7.8 vs 9.7 months); or OS (HR1.03, p = 0.87, median 20.1 vs 19.4 months). During treatment extension, 64% experienced any grade adverse event, mainly fatigue and gastrointestinal (both 54%). Only a minority required treatment changes: 4.5% dose delay, 7.5% dose reduction, 1.5% temozolomide discontinuation.

CONCLUSION

For glioblastoma patients, extending post-radiation temozolomide from 6 to 12 months is well tolerated but does not improve 6mPFS. We could not identify any subset that benefitted from extended treatment. Six months should remain standard-of-care.

Profiles of Resilience, Distress, and Posttraumatic Growth in Parents of Children with Cancer and the Relation to Subsequent Parenting and Family Functioning

OBJECTIVE

The aim of this study was to identify patterns of distress and growth in parents of children with cancer and examine associations with subsequent parenting, parent-child relationship, and family environment.

METHODS

Participants included children with cancer history (8-17 years) stratified by time since diagnosis and their parent. At enrollment, parents (n = 254) reported depression and anxiety, and post-traumatic stress symptoms, posttraumatic growth (PTG), and benefit finding in relation to their child's cancer. Three years later, children (n = 214) reported parenting behavior, parent reactions to their distress, and family environment. Parents reported their reaction to children's distress and qualities of the parent-child relationship.

RESULTS

Latent profile analysis empirically identified 3 cross-sectional profiles using baseline data: "Resilience, High Growth" (50%), characterized by the lowest distress and the highest PTG/benefit finding; "Moderate Distress with Growth" (33%), characterized by relatively high levels of all indicators; and "Resilience, Low Growth" (17%), characterized by relatively low distress with low PTG/benefit finding. Membership in profiles was associated with parent gender; parents' stressful life events; socioeconomic status; and child diagnosis, on versus off treatment status, and treatment intensity. Parent membership in the Moderate Distress with Growth profile was generally linked with poorer parenting behavior, parent-child relationship quality, and family functioning.

CONCLUSION

The majority of parents exhibited resilience and growth. However, a subset of parents displaying moderate distress may be at risk for subsequent parenting and family functioning challenges. Findings further highlight the importance of screening for even moderate parent distress and the possible impact of parent psychosocial interventions indirectly on parenting and family functioning.

Examination of the Social Emotional Assets and Resilience Scales (SEARS) Youth Report: Factor Structure, Measurement Invariance, and Validity

The Social and Emotional Assets and Resilience Scale (SEARS) is a promising instrument for prediction of resilience in youth; however, there is limited data to support its use. The purpose of the current study was to examine the factor structure, measurement invariance, internal consistency, and validity of the SEARS-Adolescent Report in youth 8 to 20 years of age. Two hundred and twenty-five childhood cancer survivors (Mage = 15.9, SD = 4.2; 51.4% male; 74.5% White) and 122 student controls without history of significant health problems (Mage = 14.2, SD = 3.5; 54.1% female; 79.5% White) 8 to 20 years of age completed the SEARS-A. The SEARS-A was found to have an adequate factor structure and model fit (χ2 = 1215.5, p < .001; root mean square error of approximation = .057; comparative fit index = .95; standardized root mean square residual = .06) and demonstrated invariance across domains of age, health status, gender, race, and socioeconomic status (Δ comparative fit index < -0.01). It also demonstrated excellent internal reliability, criterion validity, and current validity when compared with another well-established measure of psychological adjustment. As such, the SEARS-A has potential to be a useful, valid, and psychometrically sound tool for predicting social-emotional adjustment outcomes among at-risk youth 8 to 20 years of age.

Trajectories of resilience and posttraumatic stress in childhood cancer: Consistency of child and parent outcomes

OBJECTIVE

Childhood cancer represents a potentially traumatic experience for both patients and caregivers. We examined trajectories of posttraumatic stress symptoms (PTSS) across a 5-year period in children with a history of cancer and their parents/caregivers. Medical, demographic, and dispositional variables were examined as predictors of PTSS trajectories.

METHOD

Using a longitudinal design, children with cancer history (n = 254, age 8-17 years at baseline) and one parent or caregiver (n = 255) completed measures of PTSS at baseline, and 1-, 3-, and 5-years poststudy entry. Children and caregivers completed dispositional measures including optimism, positive or negative affect, and Five-Factor Inventories. Latent class growth analysis (LCGA) was used to identify latent trajectories of PTSS, and univariate logistic regression models were conducted to predict LCGA class membership from medical, demographic, and disposition factors Results: Very similar trajectories were observed in children and caregivers, with two-class solutions providing the best fit: a "resilient" class, with low PTSS at baseline, which declined significantly over time (83.5% in children; 71.5% in parents), and an "elevated PTSS" class, which was moderately high at baseline and increased significantly over time. There was a small, but significant relationship between child and caregiver trajectories. Latent trajectories observed in children and parents were more strongly associated with dispositional variables than medical factors.

CONCLUSIONS

Resilience, depicted by low PTSS, is by far the most common outcome observed in both children and caregivers. However, the smaller subset with elevated PTSS do not show recovery over time, and are identified as a group in need of targeted interventions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

"Giving the gift of life twice": Understanding the lived experiences of parent donors and nondonors in pediatric haploidentical hematopoietic cell transplantation

BACKGROUND

The use of parental donors in pediatric haploidentical hematopoietic cell transplantation is increasing, but research on the psychosocial impact of parental donation is currently limited.

OBJECTIVES

As part of a larger study, we conducted a retrospective, qualitative analysis to explore parental perceptions of the donation process and the impact of being a donor (or nondonor) on parents' adjustment and coping with their child's transplant experience.

METHODS

Parents/caregivers of children who underwent transplantation with a parental donor or a matched unrelated donor (N = 136) participated in interviews and completed an open-ended questionnaire.

RESULTS

Six themes were identified in the data: level of understanding and satisfaction; perception of choice; preparation for donation; perceptions of donation and infusion; benefit finding; and psychological impact of transplantation. Most parents were satisfied with the information they received and reported a good understanding of transplantation and donation procedures. Parents were divided on perspectives of choice, but their responses reflect that the necessity of saving their child's life does not allow for choice. They described considerable effort to prepare for transplantation, physically, emotionally, and logistically. Parents acknowledged the psychological impact while identifying positive outcomes that resulted from their child's transplant journey.

CONCLUSIONS

Results highlight the unique experiences of parental donors and nondonors from the anticipation phase to the completion of their child's transplant. Additionally, findings inform supportive care guidance by highlighting the need to assess parental donors' emotional functioning, provide support post donation, and conduct bereavement follow-up.

Psychosocial outcomes of parents in pediatric haploidentical transplant: parental hematopoietic cell donation as a double-edged sword

Parents are increasingly used as donors for their child's haploidentical hematopoietic cell transplant, creating a dual role for parents that may increase the stress of caring for their ill child. Empiric research on the psychological adjustment of parental donors is lacking. We conducted a retrospective survey of parents (n = 136) whose child underwent transplant with a parental donor or a matched-unrelated donor, including both donor and nondonors, and both parents of survivors and bereaved. All parents completed standardized measures of quality of life, depression, anxiety, post-traumatic stress, and life satisfaction. Bereaved parents also completed measures of their grief response, while parents of survivors completed measures of the parent-child relationship. The overall sample reported psychological functioning near normative levels, but bereaved parents demonstrated significantly poorer outcomes across all measures. The effect of donor status differed by transplant outcome: for parents of survivors, donors reported better mental health than nondonors, but amongst bereaved parents, donors fared more poorly than nondonors. Bereaved donors reported greater difficulties with grief than nondonors. Results suggest that serving as donor can be a double-edged sword, acting as a protective factor when there is a successful outcome but a significant risk factor when the child does not survive.

The Influence of Early Childhood Temperament on Later Social-Emotional Functioning in Youth with Cancer

OBJECTIVE

One of the peak incidences of childhood cancer is during the early childhood years. This is also an important time for psychosocial and personality development, and it is well known that early childhood temperament influences later psychosocial functioning. However, this association has not been examined in young children with cancer.

METHODS

Parents of children with cancer (N = 39) and healthy comparisons (N = 35) completed an indicator of temperament (Children's Behavior Questionnaire) when children were young (Mage=4.99 ± 1.05 years). Five years later, parents and youth completed measures of psychosocial functioning (Mage=10.15 ± 1.10 years; Behavior Assessment Scale for Children, 2nd edition and Social Emotional Assets and Resilience Scale).

RESULTS

Parents of healthy comparisons reported that their children demonstrated greater surgency than youth with cancer; there were no differences in negative affect or effortful control. Children with cancer and healthy comparisons were rated similarly on measures of psychosocial functioning. Health status was not a significant predictor of later functioning, but socioeconomic status and temperament were. The influence of temperament was stronger for strengths-based functioning (e.g., social competence, adaptive functioning) versus distress (internalizing and externalizing problems).

CONCLUSIONS

Early childhood temperament is a strong predictor of later psychosocial functioning, regardless of health status. Findings highlight the need to consider temperament in the clinical assessment of psychosocial functioning in children with cancer. Additional research is needed to specifically assess how a diagnosis of cancer in early childhood influences temperament over time.

Family and parent-child relationship correlates of pediatric cancer survivors' substance use

OBJECTIVE

The primary aims of this research were to examine substance use among adolescent and young adult survivors of pediatric cancer (AYA survivors) and AYA without a history of chronic or life threatening illness (AYA comparisons) and to explore links between demographic, medical, caregiver-AYA, and family system factors with AYA substance use patterns.

METHODS

Participants included 289 AYA (survivors, n = 171; comparisons = 118; 51% female; M_age = 17.15, SD_age = 2.86) and their caregivers (M_age = 46.54, SD_age = 6.81; 88% mothers). AYA and caregivers completed the family environment scale, and caregivers completed the parenting relationship questionnaire at the initial assessment. Two years later, AYA completed an assessment of substance use. Chi-square and frequency analyses were used to compare differences in substance use among AYA survivors and comparisons. Multivariate analysis of variance was used to examine links between AYA substance use patterns with family and caregiver-AYA system level factors.

RESULTS

Patterns of substance use did not differ between AYA survivors and comparisons. AYA survivors were more likely to report polysubstance use if caregivers endorsed problematic caregiver-AYA relationship patterns. Family functioning and caregiver relationship patterns did not predict AYA comparison substance use.

CONCLUSION

AYA survivors were just as likely as AYA comparisons to engage in substance use, increasing their vulnerability to problematic health outcomes. Findings indicate that the role caregiver-AYA relationship patterns may have on youth at risk for substance use and potential mechanisms for future intervention.

Profiles and predictors of resilient functioning in youths with pediatric cancer history

OBJECTIVE

To identify and predict resilient functioning over time among youths with pediatric cancer experience (YPCE).

DESIGN

YPCE aged 8-17 years (N = 231) were followed prospectively for 3 years. Their psychosocial adjustment was assessed using self-report and parent-report at 1 year (T2) and 3 years (T3) post-baseline.

METHODS

Latent profile analysis identified subgroups of YPCE with different patterns of adjustment over time. Self-reported factors from baseline and T2 were examined as predictors of subgroup membership.

FINDINGS

Three subgroups of youths were found. Two exhibited average (52.5% of the sample) to better-than-average (41.3%) functioning. One subgroup (6.2%) exhibited subclinical but at-risk range of adjustment. Low optimism and low connectedness to parents and school predicted membership in this group.

CONCLUSIONS

Most YPCE exhibit resilient functioning across time. However, approximately 6% report persistent maladjustment.

IMPLICATIONS

Most YPCE are well-adjusted, but those with low optimism and poor connection to parents or school may require monitoring for psychosocial difficulties.

Centrality of the childhood cancer experience and its relation to post-traumatic stress and growth

OBJECTIVE

Event centrality, the degree to which a traumatic event is perceived as central to one's identity, has been associated with post-traumatic stress (PTS) symptoms and post-traumatic growth (PTG) outcomes in various trauma samples. Trauma frameworks are widely used to understand the psychological impact of pediatric cancer; however, event centrality has not been studied in this population. We investigated event centrality in pediatric cancer survivors and healthy comparisons, and its relation with PTS and PTG outcomes.

METHOD

Cancer survivors, age 13-23 (N = 196) and healthy comparisons (N = 131) completed the Centrality of Events Scale and PTS and PTG measures in reference to their most traumatic life event. Cancer survivors who first identified a non-cancer-related event repeated all measures in reference to cancer.

RESULTS

Centrality scores were significantly higher when referencing cancer compared to non-cancer events, even in survivors for whom cancer was not rated as most stressful (53.1%). Centrality scores for non-cancer events were not significantly different between survivors and healthy comparisons. Event centrality showed significant positive relations to both PTS and PTG outcomes.

CONCLUSION

The pediatric cancer experience is perceived as central to survivors' identity regardless of whether the experience is perceived as highly traumatic. Centrality of cancer is a significant predictor of both positive and negative psychological outcomes in cancer survivors.

Profiles of perceived social functioning in adolescent and young adult survivors of childhood cancer

OBJECTIVES

Social interaction and peer relationships are critical for development, especially for adolescents and young adults (AYA). Cancer treatment may disrupt social functioning and impact quality of life. Prior research into AYA social functioning has primarily been qualitative in nature or assessed via broad measures of functioning. Given the multi-dimensional nature of social functioning, and its importance for AYA, a person-centered approach to analyses is needed.

METHODS

AYA survivors of childhood cancer, ages 13 to 23 (n = 192, 51% male) and at least 1 year post-treatment (M = 7.35 ± 4.18 years post), completed measures to assess perceived social functioning, social support, and positive and negative affect. Caregivers also completed a measure of social functioning. Latent profile analysis was used to empirically derive profiles of perceived social functioning using the self-perception profile for adolescents (SPPA).

RESULTS

A 3-class solution provided the best fit to the data: 58.9% average, 33.7% high, and 7.5% low functioning. The average group reported mean scores that were similar to normative values available in the SPPA manual. Demographic and medical factors were unrelated to class membership. Social support and positive/negative affect differed significantly by class; caregiver-report of social functioning did not.

CONCLUSIONS

Overall, the majority of AYA survivors of childhood cancer are doing well socially, with perceived adequate social functioning associated with both high levels of social support as well as greater perceptions of positive affect. Future work is needed to elucidate longitudinal trajectories of social functioning, as well as to identify and intervene with those survivors who are struggling.

A bolt from the blue; A case report of an unusual asthma exacerbation

Background

We describe this case of a young gentleman presenting with acute dyspnoea on a background history of known, long-standing asthma. His dramatic presentation, notable for profound hypoxia and cyanosis, led to an unexpected additional diagnosis of type one congenital methaemoglobinaemia.

Case presentation

A 26-year-old Irish gentleman was transferred urgently to the emergency department resuscitation room with marked cyanosis and tachypnoea. His oxygen saturation was 70% on 100% high flow oxygen. His arterial blood gas (On Fi02 90%) demonstrated a PaO2 = 76.8 kPa, SpO2 = 99%, pCO2 = 3 kPa and pH = 7.51. A saturation gap was evident and on further analysing the arterial blood gas, the methaemoglobin level was noted to be 28%. No contributing drugs were identified. Our patient was diagnosed with type one congenital methaemoglobinaemia. He recovered well from this admission, however, has had recurrent presentations to hospital since with high methaemoglobin levels noted on each occasion.

Discussion

Congenital methemoglobinemia is a rare, often overlooked differential diagnosis in patients presenting with cyanosis and dyspnoea. This is the only case, to our knowledge, of a patient with both asthma and congenital methaemoglobinaemia. Congenital methaemoglobinaemia was first described in 1943 by Dr Deeny who described two siblings as suffering from 'Familial Idiopathic Methaemoglobinaemia'. The case we present is the first reported Irish case of congenital methaemoglobinaemia, we are aware of, since 1943.Current treatment strategies include high-flow oxygen, methylene blue infusion (contraindicated in glucose-6-phosphate-dehydrogenase deficiency) and red cell exchange transfusions in the emergency setting whilst oral ascorbic acid and riboflavin are preventative.

Posttraumatic stress in young children with cancer: Risk factors and comparison with healthy peers

OBJECTIVE

The most commonly occurring childhood cancers are diagnosed during the preschool years; yet limited psycho-oncology research has focused on this developmental time period. The primary objective was to examine rates of posttraumatic stress symptoms (PTSS) in young children with cancer and compare these findings with those of children without a history of serious illness (comparisons). The secondary aim was to examine risk and modifiable factors associated with PTSS.

METHOD

Ninety-seven caregivers of patients (n = 50) and comparisons (n = 47) aged three to six years completed diagnostic interviews for the assessment of PTSD. They also completed a survey measure of PTSS adapted from the Child Behavior Checklist (CBCL-PTSD), along with measures of their child's temperament and their own current psychological functioning.

RESULTS

On the CBCL-PTSD, no differences in PTSS were observed between children with cancer and comparisons, although many in both groups appeared at risk, with approximately 34% of children with cancer and 27% of comparisons meeting threshold scores for probable PTSD. However, using a "gold-standard" clinical-interview assessment, only three children in the patient group and no children in the comparison group met diagnostic criteria for PTSD. Parental distress and child temperament were significantly associated with PTSS scores.

CONCLUSION

Findings indicate PTSD is relatively infrequent in children with cancer, and survey measures may overestimate rates of PTSD in young children. However, other emotional or behavioral issues may be present. Ultimately, screening for potential emotional/behavioral concerns in young children with cancer is indicated, and interventions should continue to target caregiver distress.

The impact of connectedness on social functioning in youth with brain tumors

PURPOSE

Children with brain tumors (BT) are at risk for difficulties with social functioning. Research to date has focused on deficits, with no studies identifying areas of strength or resilience. Our objective was to assess the potential influence of connectedness on social functioning in youth with BT as compared with children with other cancers.

METHODS

Children with cancer (20 with BT, 33 with other diagnoses) were enrolled on a longitudinal study of psychosocial functioning. The current study included measures from time 2 (+1 year after enrollment; M_age  = 13.11 ± 2.31, M_{timesincediagnosis}  = 4.95 ± 3.74 years) and time 3 (+3 years after enrollment; M_age  = 14.98 ± 2.36, M_{timesincediagnosis}  = 6.82 ± 3.81 years). Youth completed the Hemingway Measure of Adolescent Connectedness (HMAC) at time 2. Two years later, social functioning was assessed by the self- and proxy-report versions of the Social-Emotional Assets and Resilience Scale (SEARS).

RESULTS

Youth with BT perceived that they were less connected to friends (t(50) = -2.13, P = 0.04), but similarly connected to peers as youth with other cancers. Youth with BT also demonstrated lower social functioning by self- and parent report. Connectedness to friends significantly mediated the relationship between diagnostic category and self-reported social functioning, such that youth with BT who reported being more connected to friends also indicated greater social functioning. Analyses using connectedness to peers and/or parent-reported social functioning were nonsignificant.

CONCLUSIONS

Perceiving a connection to a friend may be a protective factor that could mitigate deficits in social functioning in youth with BT. Additional research is needed to further assess the potential benefits of this construct.

Emotion Socialization in the Context of Childhood Cancer: Perceptions of Parental Support Promotes Posttraumatic Growth

Background

Examined youth’s perceptions of parental reactions to youth’s cancer and non-cancer event-related distress and the link between perceptions of parental reactions and youth posttraumatic growth (PTG).

Method

Participants included 201 youth (8–21 years) with a history of cancer. Participants self-identified their most stressful life event, which were characterized as cancer or non-cancer related, and then completed measures in reference to this event assessing (1) their perceptions of parent reactions to event-related distress and (2) PTG.

Results

Youth who identified a cancer-related event perceived their parents as reacting with more support and reassurance/distraction than those who identified a non-cancer event. Perceptions of parental support, reassurance/distraction, and magnification of youth distress were associated with more PTG, with event type (cancer vs. non-cancer) indirectly predicting PTG through perceptions of parental support.

Conclusion

Youth perceive their parents as reacting differently to cancer versus non-cancer distress, which is in turn predictive of their perceptions of growth. Findings suggest that parental support and reassurance/distraction are possible mechanisms facilitating resilience and growth in children with cancer.

Youth's Adjustment to Cancer: Examination of Patterns of Adjustment and the Role of Peer Relations

Objective

Examine unique forms of peer relations (i.e., peer group vs. friendships) in relation to patterns of youth's resilience and challenge-related growth in the context of cancer.

Methods

In all, 279 youth (cancer, n = 156; control, n = 123) completed measures of posttraumatic stress, depression, anxiety, posttraumatic growth (PTG), and perceived positive changes. Youth also reported on their peer relations. Latent profile analysis (LPA) was used to examine patterns of youth's adjustment. Peer relations were examined as predictors of youth's adjustment.

Results

LPA revealed three profiles (42.1% resilient high growth, 21.4% resilient low growth, and 36.5% mild distress with growth). Youth's peer relations, demographic factors, and disease-related factors predicted assignment to profiles. Differences in adjustment emerged depending on youth's connection with their peers versus their friends.

Summary

Peer relations serve an important role in youth's adjustment to stressful life events. Assessment of peer and friend support may provide a more nuanced understanding of adjustment processes.

[Doppler ultrasonography of the renal artery: Guidelines and predictive factors for the presence of a tight stenosis. Retrospective analysis of 450 consecutive examinations]

Duplex ultrasonography screening for renal artery stenosis has been the object of guidelines published by four societies designed to optimize the cost-effectiveness of the examination.

OBJECTIVES

To determine how well guideline indications for ultrasonography matched with requests and results in our university hospital; to determine whether compliance with guidelines was predictive of renal artery stenosis; to identify guidelines predictive of presence of stenosis; and to determine whether other predictive factors can be recognized.

MATERIAL AND METHODS

Requests and results of 450 Duplex ultrasonography examinations of the renal arteries performed from January 1st 2014 to December 31st 2015 were compared with published guidelines.

RESULTS

At least one guideline indication was identified for 212 of the 450 examinations performed (47.1%). Among these examinations, renal artery stenosis≥70% was identified in 18 patients (8.0%). No case of stenosis was identified during examinations performed outside guideline indications. Factors predictive of stenosis were: compliance with guidelines (OR=21.86 [2.88; 165.8]). Predictive guidelines were: resistant hypertension in spite of appropriate treatment (OR=3.85, [1.44; 10.33], P=0.011), accelerated hypertension (OR=7.30, [1.40; 37.99], P=0.049), sudden unexplained pulmonary edema (OR=7.30, [1.40; 37.99], P=0.049), unexplained renal insufficiency (OR=3.58, [1.37; 9.37], P=0.011), unexplained renal hypotrophy (OR=16.69, [4.38; 63.69], P<0.001), renal asymmetry (OR=4.32, [1.45; 12.85], P<0.016). No other factor was predictive of renal stenosis. These examinations had therapeutic consequences in only 50% of patients.

CONCLUSION

This study confirms the relevance of published guidelines. The diagnostic-effectiveness of Duplex ultrasonography examinations to search for renal artery stenosis depends upon compliance with these guidelines.

Clinicopathological features of squamous cell carcinoma of the oral cavity and oropharynx in young patients

Our aim was to examine the clinicopathological features of squamous cell carcinoma (SCC) of the oral cavity and oropharynx in a group of young patients who were dignosed during a 15-year period (2000-2014). Patients' clinical details, risk factors, and survival were obtained from medical records. Formalin-fixed, paraffin-embedded, tissue was tested for high-risk human papillomavirus (HPV). The results were compared with those of a matching group of older patients. We identified 91 patients who were younger than 45 years old, and the 50 youngest patients were studied in detail. The male:female ratio was 2:1, with more tumours located in the oral cavity than in the oropharynx (35 compared with 15). HPV-related SCC was restricted to the oropharynx. When matched for site, stage and HPV status, five-year overall survival was similar in young and matched older patients (log-rank test, p=0.515). Our findings suggest that young patients with oral SCC have a disease profile similar to that of older patients with the condition. It is plausible that prognostic information generally available for oral cancers is applicable to young patients with the disease.

A two phased study on health care professionals' perceptions of single or multi-use of intermittent catheters

AIMS

This two phase study aimed to explore health care professionals' teaching and prescribing practice related to intermittent catheterisation and to identify their perceptions about the possible implementation of a mixed (single and multi-use) package for intermittent catheterization.

INTRODUCTION

Single-use intermittent catheters are the norm in the UK although multi-use is common in some other countries. A recent Cochrane review found no difference in complications, including urinary tract infection rates, between those using single or multi-use catheters. A flexible option of both multi-use and single use intermittent catheters could provide users with more flexible choices in self-care. However, understanding health care professionals' perspectives is one of the keys to developing a multi-use intervention.

DESIGN

A qualitative research framework using in-depth interviews to inform an on line survey.

METHOD

In-depth interviews were conducted with health care professionals based in the UK who prescribe catheters, teach intermittent catheterisation or manage an intermittent catheterisation service. The interviewees were selected to represent a range of clinical areas, experience and professions - continence advisors, urology, multiple sclerosis (MS) and spinal cord injury specialist nurses, and General Practitioners. Following framework analysis the themes and factors identified were used to develop an on-line survey which was disseminated through health care professional networks whose members saw patients who use intermittent catheters.

RESULTS

Nineteen health care professionals participated in the telephone interviews; 206 completed the survey. A wide range of professionals in terms of experience and specialty afforded rich information regarding the contextual issues around the teaching and prescribing of intermittent catheters. The primary finding was that health care professionals were concerned about 'minimising health risk' and maximising 'normalcy' for those using intermittent self-catheterisation. Health care professionals who worked in the acute setting or had no experience of re-use were most resistant to the re-use of catheters. Professionals requested evidence that a multi-use package would not increase the risk of developing a urinary tract infection or increase the burden of use to a patient before a mixed package would be considered.

CONCLUSIONS

For multi-use to be acceptable, evidence based guidelines must be available for healthcare professionals and cleaning methods must be acceptable and safe for intermittent catheter users. Further evidence may be required to establish that a mixed catheter package is equivalent to single use only, particularly for outcomes such as urinary tract infection, urethral injury and quality of life.

RELEVANCE TO CLINICAL PRACTICE

This paper highlights that if multi-use catheters are to be successfully introduced into clinical practice, the ease of use, safety and effectiveness of the cleaning technique will need to be convincingly demonstrated by a range of well-defined users.

A minimally interactive and reproducible method for abdominal aortic aneurysm quantification in 3D ultrasound and computed tomography with implicit template deformations

The maximum diameter of abdominal aortic aneurysm (AAA) is a key quantification parameter for disease assessment. Although it is routinely measured on 2D-ultrasound images, using a volumetric approach is expected to improve measurement reproducibility. In this work, 3D-ultrasound or computed tomography imaging of patients with AAA was combined with a minimally interactive 3D segmentation based on implicit template deformation. Segmentation usability and reproducibility were evaluated on 81 patients, showing a mean measurement time of [2;8]min per case, and Dice coefficients of 0.87±0.12 for 3D-US and 0.81±0.08 for CT. Quantification parameters included a diameter measurement from 3D-US and CT volumes with respective confidence intervals of 0.51 [-2.5;3.52]mm and 1.00 [-1.68;3.67]mm. Additional volume measurements showed confidence intervals of 0.91 [-4.17;5.99]ml for 3D-US and 4.10 [-4.11;12.30]ml for CT.

Clinical characteristics and risk factors of postoperative pneumonia after hip fracture surgery: a prospective cohort study

In this study, we attempt to determine the clinical characteristic and risk factors of postoperative pneumonia (POP) after hip fracture surgery in a well-defined hip fracture cohort. We find that intrinsic factors as well as major clinical interventions were all important risk factors of POP.

INTRODUCTION

Postoperative pneumonia (POP) is one of the major complications following hip fractures surgery. However, the risk factors of POP are not well studied in hip fracture cohorts. We attempt to determine the clinical characteristic and risk factors of POP after hip fracture surgery in a well-defined hip fracture cohort.

METHODS

Datasets from a prospective hip fracture cohort study with a 2-year follow-up period, from 2000 to 2011, were reanalyzed for characteristics of POP. Multivariate Cox proportional regression was used to evaluate the association between the incidence of POP and all-cause mortality. Multivariate logistic regression was used to screen for potential risk factors of POP by analyzing demographic factors, comorbidities, major clinical interventions, and hematological parameters.

RESULTS

In 1429 patients who underwent hip surgery, the incidence of POP was 4.9 % (n = 70). All-cause mortality of patients with POP was significantly higher than that of patients without POP at 30 days (hazard ratio (HR) 3.05, 95 % confidence intervals (CI) 1.88-4.94), 1 year (HR 1.87, 95 % CI 1.41-2.48), and 2 years (HR 1.57, 95 % CI 1.23-1.99) postoperatively. Multivariate logistic regression showed that intrinsic factors (advanced age, anemia, diabetes, prior stroke, number of comorbidities, ASA score ≥III, and some laboratory biomarkers) as well as major clinical interventions were all significant risk factors for POP.

CONCLUSION

Intrinsic factors and major clinical interventions were all important risk factors of POP in patients after hip fracture surgery. Targeted preventive measures to mitigate the above risk factors may help in reducing the incidence of POP.

Mitochondrial stress-induced p53 attenuates HIF-1α activity by physical association and enhanced ubiquitination

Retrograde signaling is a mechanism by which mitochondrial dysfunction is communicated to the nucleus for inducing a metabolic shift essential for cell survival. Previously we showed that partial mtDNA depletion in different cell types induced mitochondrial retrograde signaling pathway (MtRS) involving Ca⁺² sensitive Calcineurin (Cn) activation as an immediate upstream event of stress response. In multiple cell types, this stress signaling was shown to induce tumorigenic phenotypes in immortalized cells. In this study we show that MtRS also induces p53 expression which was abrogated by Ca²⁺ chelators and shRNA mediated knock down of CnAβ mRNA. Mitochondrial dysfunction induced by mitochondrial ionophore, carbonyl cyanide m-chlorophenyl hydrazone (CCCP) and other respiratory inhibitors, which perturb the transmembrane potential, were equally efficient in inducing the expression of p53 and downregulation of MDM2. Stress-induced p53 physically interacted with HIF-1α and attenuated the latter’s binding to promoter DNA motifs. Additionally, p53 promoted ubiquitination and degradation of HIF-1α in partial mtDNA depleted cells. The mtDNA depleted cells, with inhibited HIF-1α, showed upregulation of glycolytic pathway genes, glucose transporter 1–4 (Glut1–4), phosphoglycerate kinase 1 (PGK1) and Glucokinase (GSK) but not of prolyl hydroxylase (PHD) isoforms. For the first time we show that p53 is induced as part of MtRS and it renders HIF-1α inactive by physical interaction. In this respect our results show that MtRS induces tumor growth independent of HIF-1α pathway.

Combination of red cell distribution width and American Society of Anesthesiologists score for hip fracture mortality prediction

The prognostic value of red cell distribution width (RDW) and a combination of RDW and the American Society of Anesthesiologists (ASA) score for long-term hip fracture mortality remains unknown. Our data showed that both RDW and ASA were independent risk predictors. A combination of these two parameters may provide a more powerful strategy for the prediction of hip fracture mortality.

INTRODUCTION

Red cell distribution width (RDW) has recently been suggested as an independent predictor of prognosis in a variety of disorders. The American Society of Anesthesiologists (ASA) system has been widely used to stratify patients for outcome evaluations. However, the prognostic value of RDW and a combination of RDW and the ASA score for long-term hip fracture mortality has yet to be studied.

METHODS

This prospective cohort study included 1402 subjects from 2000 to 2011 with a follow-up study over a 2 year period. Cox proportional hazards models with a bootstrap validation were used to evaluate associations of RDW, ASA, and a combination of both with long-term mortality. The global fit and the area under the receiver operating characteristic (ROC) curve (AUC) for model discrimination were further analyzed.

RESULTS

Both RDW and ASA exhibited as independent risk predictors of 2-year mortality. The population with elevation of either RDW or ASA increased the risk of mortality (bootstrap validated hazard ratio (HR) 1.971 95 % confidence interval (CI) [1.336-3.005] p < 0.01) while those with an increase in both assessments (bootstrap validated HR 2.667 95 % CI [1.526-4.515] p < 0.01) were at the highest risk for mortality. The addition of the combination of ASA and RDW improved the discrimination power of risk prediction models (AUC increased from 0.700 to 0.723, p < 0.05).

CONCLUSION

Both RDW and ASA exhibited as independent risk predictors of 2-year hip fracture mortality. The combination of these two readily available parameters may provide a more powerful and effective strategy for the assessment of all-cause mortality in hip fracture patients.

3D printed microfluidic circuitry via multijet-based additive manufacturing

The miniaturization of integrated fluidic processors affords extensive benefits for chemical and biological fields, yet traditional, monolithic methods of microfabrication present numerous obstacles for the scaling of fluidic operators. Recently, researchers have investigated the use of additive manufacturing or "three-dimensional (3D) printing" technologies - predominantly stereolithography - as a promising alternative for the construction of submillimeter-scale fluidic components. One challenge, however, is that current stereolithography methods lack the ability to simultaneously print sacrificial support materials, which limits the geometric versatility of such approaches. In this work, we investigate the use of multijet modelling (alternatively, polyjet printing) - a layer-by-layer, multi-material inkjetting process - for 3D printing geometrically complex, yet functionally advantageous fluidic components comprised of both static and dynamic physical elements. We examine a fundamental class of 3D printed microfluidic operators, including fluidic capacitors, fluidic diodes, and fluidic transistors. In addition, we evaluate the potential to advance on-chip automation of integrated fluidic systems via geometric modification of component parameters. Theoretical and experimental results for 3D fluidic capacitors demonstrated that transitioning from planar to non-planar diaphragm architectures improved component performance. Flow rectification experiments for 3D printed fluidic diodes revealed a diodicity of 80.6 ± 1.8. Geometry-based gain enhancement for 3D printed fluidic transistors yielded pressure gain of 3.01 ± 0.78. Consistent with additional additive manufacturing methodologies, the use of digitally-transferrable 3D models of fluidic components combined with commercially-available 3D printers could extend the fluidic routing capabilities presented here to researchers in fields beyond the core engineering community.

Parents of Children With Cancer: At-Risk or Resilient?

OBJECTIVE

To examine adjustment in parents of children with cancer using a design that minimizes focusing effects and allows for direct comparison with parents of healthy children.

METHOD

Parents of 305 children with cancer and a demographically similar sample of 231 parents of healthy children were evaluated using diagnostic interviews for posttraumatic stress disorder (PTSD), and questionnaire measures of posttraumatic stress symptoms (PTSS) and psychological growth (PG), as well as measures of global psychological functioning.

RESULTS

Rates of current and lifetime PTSD in parents of children with cancer were low, and did not differ from comparison parents. Likewise, levels of PTSS were not significantly different from comparison parents, but differed as a function of time since diagnosis, with parents of children who were ≥ 5 years from diagnosis reporting significantly lower PTSS than comparison parents. PG was higher in parents of children with cancer than in comparison parents regardless of time since diagnosis.

CONCLUSION

Parents of children with cancer demonstrate resilience to this challenge.

Profiles of Resilience and Growth in Youth With Cancer and Healthy Comparisons

OBJECTIVE

Inconsistent links between posttraumatic stress symptoms (PTS) and posttraumatic growth (PTG) in youth following a stressful life event have been observed in previous literature. Latent profile analysis (LPA) provides a novel approach to examine the heterogeneity of relations between these constructs.

METHOD

Participants were 435 youth (cancer group=253; healthy comparisons = 182) and one parent. Children completed measures of PTS, PTG, and a life-events checklist. Parents reported on their own PTS and PTG. LPA was conducted to identify distinct adjustment classes.

RESULTS

LPA revealed three profiles. The majority of youth (83%) fell into two resilient groups differing by levels of PTG. Several factors predicted youth's profile membership.

CONCLUSIONS

PTS and PTG appear to be relatively independent constructs, and their relation is dependent on contextual factors. The majority of youth appear to be resilient, and even those who experience significant distress were able to find benefit.

EVERSUN: a phase 2 trial of alternating sunitinib and everolimus as first-line therapy for advanced renal cell carcinoma

BACKGROUND

We hypothesised that alternating inhibitors of the vascular endothelial growth factor receptor (VEGFR) and mammalian target of rapamycin pathways would delay the development of resistance in advanced renal cell carcinoma (aRCC).

PATIENTS AND METHODS

A single-arm, two-stage, multicentre, phase 2 trial to determine the activity, feasibility, and safety of 12-week cycles of sunitinib 50 mg daily 4 weeks on / 2 weeks off, alternating with everolimus 10 mg daily for 5 weeks on / 1 week off, until disease progression or prohibitive toxicity in favourable or intermediate-risk aRCC. The primary end point was proportion alive and progression-free at 6 months (PFS6m). The secondary end points were feasibility, tumour response, overall survival (OS), and adverse events (AEs). The correlative objective was to assess biomarkers and correlate with clinical outcome.

RESULTS

We recruited 55 eligible participants from September 2010 to August 2012.

DEMOGRAPHICS

mean age 61, 71% male, favourable risk 16%, intermediate risk 84%. Cycle 2 commenced within 14 weeks for 80% of participants; 64% received ≥22 weeks of alternating therapy; 78% received ≥22 weeks of any treatment. PFS6m was 29/55 (53%; 95% confidence interval [CI] 40% to 66%). Tumour response rate was 7/55 (13%; 95% CI 4% to 22%, all partial responses). After median follow-up of 20 months, 47 of 55 (86%) had progressed with a median progression-free survival of 8 months (95% CI 5-10), and 30 of 55 (55%) had died with a median OS of 17 months (95% CI 12-undefined). AEs were consistent with those expected for each single agent. No convincing prognostic biomarkers were identified.

CONCLUSIONS

The EVERSUN regimen was feasible and safe, but its activity did not meet pre-specified values to warrant further research. This supports the current approach of continuing anti-VEGF therapy until progression or prohibitive toxicity before changing treatment.

AUSTRALIAN NEW ZEALAND CLINICAL TRIALS REGISTRY

ACTRN12609000643279.

Profiles of Connectedness: Processes of Resilience and Growth in Children With Cancer

OBJECTIVE

Identified patterns of connectedness in youth with cancer and demographically similar healthy peers.

METHOD

Participants included 153 youth with a history of cancer and 101 youth without a history of serious illness (8-19 years). Children completed measures of connectedness, posttraumatic stress symptoms (PTSS), and benefit-finding. Parents also reported on children's PTSS.

RESULTS

Latent profile analysis revealed four profiles: high connectedness (45%), low connectedness (6%), connectedness primarily to parents (40%), and connectedness primarily to peers (9%). These profiles did not differ by history of cancer. However, profiles differed on PTSS and benefit-finding. Children highly connected across domains displayed the lowest PTSS and highest benefit-finding, while those with the lowest connectedness had the highest PTSS, with moderate PTSS and benefit-finding for the parent and peer profiles.

CONCLUSION

Children with cancer demonstrate patterns of connectedness similar to their healthy peers. Findings support connectedness as a possible mechanism facilitating resilience and growth.

Child perceptions of parental care and overprotection in children with cancer and healthy children

The primary aims of this study were to: (a) examine child perceptions of overprotection; and (b) explore how these perceptions relate to child health and adjustment. Children with a prior diagnosis of cancer (n = 205) and children without a history of serious illness (n = 76) reported on parental overprotective and caring behaviors. Children with cancer were recruited from one of four strata based on the elapsed time since their cancer diagnosis (1-6 months; 6-24 months; 2-5 years; >5 years) Children also reported on symptoms of depression, anxiety, and posttraumatic stress. Children with cancer did not differ from healthy children in their perceptions of parental care or overprotection. Child distress was more strongly related to perceptions of care and overprotection than child's health status. Children with cancer do not report their parents approach to care and protection differently than children without a cancer history. These findings mirror prior research examining parental perceptions of overprotection and suggest that, despite the challenges of parenting a child with serious illness, parental protection is not significantly altered.

[Posttraumatic aneurysm of the distal radial artery leading to digital ischemia]

Distal radial artery aneurysms are rare. We relate a case of non-iatrogenic distal radial artery aneurysm in the anatomical snuffbox leading to digital ischemia in a 43-year-old man.

Life stress versus traumatic stress: The impact of life events on psychological functioning in children with and without serious illness

OBJECTIVE

To determine the differential impact of potentially traumatic events (PTEs) and other stressful life events on psychological functioning in 2 groups of children: those with cancer and those without history of serious illness.

METHOD

Children with cancer age 8-17 (n = 254) and age-, sex-, and race/ethnicity-matched controls (n = 142) completed self-report measures of stressful life events and psychological functioning. Stressful life events included those that may meet Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 2000) A1 criteria (PTEs; 9 events) and others that would likely not (other events; 21 events).

RESULTS

Children with cancer endorsed significantly more PTEs than control children. There were no differences between groups in number of other events experienced. Hierarchical regression analyses revealed that number of other events accounted for significant variance in psychological functioning, above and beyond group status, demographic factors (age and socioeconomic status), and number of PTEs.

DISCUSSION

The number of cumulative other events experienced is a significant predictor of psychological functioning in both youth with serious illness and controls. In contrast, cumulative PTEs appear to have a minor (albeit significant) impact on children's psychological functioning. Assessment of psychological functioning would benefit from a thorough history of stressful life events, regardless of their potential traumatic impact.

c-MYC is a radiosensitive locus in human breast cells

Ionising radiation is a potent human carcinogen. Epidemiological studies have shown that adolescent and young women are at increased risk of developing breast cancer following exposure to ionising radiation compared with older women, and that risk is dose-dependent. Although it is well understood which individuals are at risk of radiation-induced breast carcinogenesis, the molecular genetic mechanisms that underlie cell transformation are less clear. To identify genetic alterations potentially responsible for driving radiogenic breast transformation, we exposed the human breast epithelial cell line MCF-10A to fractionated doses of X-rays and examined the copy number and cytogenetic alterations. We identified numerous alterations of c-MYC that included high-level focal amplification associated with increased protein expression. c-MYC amplification was also observed in primary human mammary epithelial cells following exposure to radiation. We also demonstrate that the frequency and magnitude of c-MYC amplification and c-MYC protein expression is significantly higher in breast cancer with antecedent radiation exposure compared with breast cancer without a radiation aetiology. Our data also demonstrate extensive intratumor heterogeneity with respect to c-MYC copy number in radiogenic breast cancer, suggesting continuous evolution at this locus during disease development and progression. Taken together, these data identify c-MYC as a radiosensitive locus, implicating this oncogenic transcription factor in the aetiology of radiogenic breast cancer.