Locoregional Control Benefit of a Tumor Bed Boost for Ductal Carcinoma In Situ (DCIS)

PURPOSE/OBJECTIVE(S)

Radiotherapy (RT) following breast conserving surgery (BCS) for ductal carcinoma in situ (DCIS) reduces invasive and in situ recurrences. Whereas landmark studies suggest that a tumor bed boost improves local control for invasive breast cancer, the benefit in DCIS remains less certain. We evaluated outcomes of DCIS patients treated with or without a boost and hypothesized that a tumor bed boost would improve locoregional control rates.

MATERIALS/METHODS

The study cohort comprised patients with DCIS who underwent BCS at our institution from 2004-2018. Clinicopathologic features, treatment parameters and outcomes were ascertained from medical records. Patient and tumor characteristics were evaluated relative to outcomes using univariable and multivariable Cox models. Recurrence-free survival (RFS) estimates were generated using the Kaplan Meier method.

RESULTS

We identified 1675 patients who underwent BCS for DCIS (median age 56 [interquartile range (IQR) 49, 64]). Boost RT was employed in 68% of cases (n = 1146) and endocrine therapy in 32% (n = 536). At a median follow-up of 4.2 years (IQR 1.4, 7.0), we observed 61 locoregional recurrence events (56 local, 5 regional) and 21 deaths. Univariable logistic regression demonstrated that boost RT was more common among younger patients (p<0.001) with positive/close margins (p<0.001), and with larger tumors (p<0.001) of higher grade (p = 0.025). The 10-year RFS rate was 88.8% among those receiving a boost and 84.3% among those without a boost (p = 0.3), and neither univariable nor multivariable analyses revealed an association between boost RT and locoregional recurrence.

CONCLUSION

Among patients with DCIS who underwent BCS, use of a tumor bed boost was not associated with locoregional recurrence or RFS. Despite a preponderance of adverse features among the boost cohort, outcomes were similar to those not receiving a boost, suggesting that a boost may mitigate risk of recurrence among patients with high-risk features. Ongoing studies will elucidate the extent to which a tumor bed boost influences disease control rates.

Risk of Radiation-Associated Secondary Malignancies among Patients with Breast Cancer Harboring TP53 Germline Variants

PURPOSE/OBJECTIVE(S)

Radiation-associated malignancies are rare and poorly understood. TP53 encodes a multifunctional protein that maintains genome integrity and is the most common somatically mutated gene in cancer. Germline pathogenic variants of TP53 predispose carriers to several cancers comprising the Li-Fraumeni syndrome. It is hypothesized that carriers are also at increased risk of radiotherapy (RT)-associated secondary malignancies; however, reports are mixed. We evaluated the risk of secondary malignancies after breast RT among patients with Li-Fraumeni syndrome.

MATERIALS/METHODS

This multi-institutional cohort study included carriers of TP53 germline variants who underwent surgical treatment for breast cancer between 1980 and 2020. Patients were stratified based on germline TP53 classification (pathogenic variants [PV] vs variants of uncertain significance [VUS]). The primary outcome of interest was the cumulative incidence risk of developing an in-field secondary cancer after radiotherapy for primary breast carcinoma.

RESULTS

Ninety-one patients (57 PV and 34 VUS) were evaluated with a median age of 36 years (interquartile range [IQR] 31, 42) and a median follow up of 7.9 years (IQR 4.7, 14.4). Among those with PV who received RT (n = 22), 4 secondary non-breast cancers developed in the radiation field (15-year cumulative incidence 19% [95% CI: 4-43%]), whereas, among those with PV who did not receive RT (n = 35), 0 secondary non-breast cancers were observed in the treated breast (15-year cumulative incidence 0%; p = 0.043). We observed 3 radiation-associated sarcomas among patients with PV who received RT (15-year risk 12% [95% CI 2-33%]) compared with 0 among those who did not receive RT (p = 0.08). No RT-associated sarcomas were observed among 18 patients with TP53 VUS who received RT. RT was not associated with overall survival, despite higher T and N breast cancer stage among those receiving RT (p = 0.33). As expected, patients with PV were more likely than those with VUS to develop any secondary cancer following breast cancer treatment (15-year risk: 54% [95% CI: 33-72%] vs. 14% [95% CI: 3-36%]).

CONCLUSION

Carriers of pathogenic variants of TP53 are at elevated risk of developing secondary malignancies after breast cancer treatment. This population is at particular risk of developing in-field secondary cancers following RT. This iatrogenic risk must be weighed against the anticipated therapeutic benefit of tumor control. Shared decision making is crucial in the radiotherapeutic management of breast cancer patients harboring the Li-Fraumeni syndrome.

Accelerated Partial Breast Irradiation (APBI) For HER2+ Early-Stage Breast Cancer

PURPOSE/OBJECTIVE(S)

Historically, HER2+ breast cancer exhibited poor outcomes and, hence, has not been well-studied among trials of accelerated partial breast irradiation (APBI). We hypothesized that in contemporary practice with effective HER2-targeted agents, patients with HER2+ breast cancer now have excellent disease control and survival outcomes when treated with adjuvant APBI.

MATERIALS/METHODS

Using a prospectively-maintained institutional database, we identified all HER2+ breast cancer patients treated with breast conserving surgery (BCS) and adjuvant APBI from 2000 - 2022. Salient clinicopathologic parameters were collected, as were receipt of systemic and endocrine therapies. All patients received external beam APBI to a total dose of 40Gy in 10 daily fractions over 2 weeks. We analyzed outcomes including local recurrence (LR), regional recurrence, distant recurrence, and death. Cumulative incidence functions were calculated to estimate the incidence of LR with the competing risk of death. All statistical analyses were performed in R version 4.2.2.

RESULTS

The study cohort comprised 52 patients with HER2+ breast cancer (median age 64 years; range 44-87). Nearly all had T1 tumors (98%; median size 15 mm; range 1 - 21 mm). Approximately 10% had multifocal disease, with one exhibiting suspicion for lymphovascular invasion. Most patients had ER+ disease (88%). All patients had negative final surgical margins. Nearly all underwent sentinel node biopsy (94%), with the remainder undergoing no surgical axillary evaluation. 42 (81%) received chemotherapy, 40 (77%) endocrine therapy, and 42 (81%) HER2-directed therapy, most commonly trastuzumab. At 143.8 person-years of follow-up (range 7 - 226 months for each patient), we observed two LR events, at 14 and 26 months, yielding a 2-year LR rate of 3.8%. No regional or distant recurrences were observed, nor were any contralateral invasive breast cancer events or breast-specific mortality events. Two deaths were noted in the cohort, both without evidence of disease.

CONCLUSION

Among a cohort of HER2+ early-stage breast cancer patients managed with BCS and APBI, we observed a 2-year LR rate of 3.8% with no regional or distant recurrences, and excellent overall survival. These findings merit longer term follow-up among larger cohorts, although are thus far consistent with the results of contemporary randomized trials of APBI unselected for HER2-status.

Harnessing Electronic Patient-Reported Outcomes (ePRO) in Routine Care to Promote Clinical Trial Enrollment: A Randomized Study

PURPOSE/OBJECTIVE(S)

Only approximately 5% of adult cancer patients participate in clinical trials. While collection of patient-reported outcomes (PRO) is now routine in clinical trials, their role in actively improving care is evolving, particularly in radiation oncology. At our single multi-site institution, weekly electronic patient reported outcomes (ePRO) questionnaires regarding acute toxicity are routinely sent to all patients undergoing breast radiation We hypothesized that using ePROs to prompt recruitment to a clinical trial assessing a supportive intervention would increase enrollment.

MATERIALS/METHODS

An automated weekly query of ePRO survey responses was generated to identify patients with moderate or greater fatigue, the primary eligibility criterion for an ongoing randomized clinical trial testing an integrative medicine intervention. 23 radiation oncologists treating breast cancer were randomized to have their patients potentially eligible by ePRO receive a direct portal message about the trial, or to usual care (physician-based referral). Physician randomization was stratified by patient caseload and assigned in a 1:1 ratio. Secondarily, every other patient in the portal message group was assigned to receive the message either from their radiation oncologist or integrative medicine. Statistical analysis included two-sample, two-sided proportion tests.

RESULTS

From September 5, 2022, to December 19, 2022, among 776 patients completing ePROs during radiation treatment, 252 patients (32%) screened positive for fatigue. Of those who screened positive, 135 were randomized to the ePRO-prompted portal message group and 117 to the usual care group (physician-based referral). Among patients in the portal message group, 52 responded (39%) and 27 enrolled (20%), compared to 1 patient referred (0.8%) and 0 enrolled with physician-based referral alone (p < 0.001). In the portal message group, there were 21 responses (30%) and 12 enrollments (17%) among those messaged by their radiation oncologist, compared to 31 responses (48%) and 15 enrollments (23%) among those messaged by integrative medicine. When evaluating the source of the portal message, there was a significant difference in response rate favoring integrative medicine (p = 0.03), but no difference in enrollments (p = 0.39).

CONCLUSION

Utilization of ePROs to prompt recruitment to a trial testing a symptom intervention resulted in increased enrollment compared to standard physician-based referral, suggesting a promising new role for ePROs. Importantly, messaging from the supportive care service directly did not result in a difference in enrollments and may help reduce oncology physician-level barriers to studies testing supportive interventions. Future directions should investigate this method to reduce disparities in patients enrolling on clinical trials and facilitate access to symptom support services in routine cancer care.

The Presence of Extensive Lymphovascular Invasion (LVI) is Associated with Higher Risk of Recurrence in Curatively Treated Breast Cancer Patients

PURPOSE/OBJECTIVE(S)

Lymphovascular invasion (LVI) is a pathological feature seen in breast cancer that may be an important step in cancer metastasis. Multiple datasets have demonstrated a correlation between LVI and local-regional recurrence (LRR). Whether the extent of LVI is an incremental determinant of LRR risk is unknown. We describe clinical outcomes in women with invasive breast cancer stratified by: 1) absence of LVI (neg), 2) LVI focal or suspicious (FS-LVI), 3) usual (non-extensive) LVI (LVI) and 4) extensive LVI (E-LVI).

MATERIALS/METHODS

Between December 2009 and August 2021, there were 8,837 patients with early-stage breast cancer (T1-2 and N0-2a) were treated with curative intent and were evaluable. Clinical-pathological details were abstracted by retrospective review. The description of LVI was abstracted from pathology reports. Recurrence and survival outcomes were compared based on the extent of LVI.

RESULTS

Of the 8837 patients studied, 5584 were neg, 461 had FS-LVI, 2315 had LVI, and 477 had E-LVI. The E-LVI cohort had baseline characteristics suggestive of higher risk such as younger median age, higher proportion of grade 3, more nodal positivity, more mastectomy (67% vs 48%), and higher use of chemotherapy compared to LVI. The cumulative incidence of LRR and DM was highest in the E-LVI group. Using LVI as the reference, the presence of E-LVI, age, tumor size, ER status, grade, mastectomy, and close/positive margins were independent variables for LRR on Cox multivariable regression (Table 1). To assess the effect with an alternate statistical method, we created propensity matched cohorts (matched for age, size, receptors, grade, surgery type, margins and chemotherapy/RT use); a statistical difference in OS was noted between groups with LVI vs E-LVI (HR 1.44 (CI 1.06-1.96, p = 0.018), but not in LRR (HR 1.31 (CI 0.87-1.97, p = 0.2) or DM (HR 1.16 (CI 0.88-1.53, p = 0.3).

CONCLUSION

Our work suggests that patients with E-LVI are at a higher risk for LRR compared to patients with usual LVI, despite maximal standard of care treatment. This is important because E-LVI can be determined from breast specimens, and may help define indications for RNI/PMRT when nodal information is not available.

Oncotype Recurrence Score (RS) at the Extremes of Tumor Size: Which Drives Clinical Outcomes?

PURPOSE/OBJECTIVE(S)

Tumor size is an established and independent risk factor for local-regional recurrence (LRR) and distant recurrence (DM). More recently, the recurrence score calculated from a 21-gene expression assay (Oncotype DXTM, Exact Sciences) has also been correlated with LRR and DM. We sought to determine the impact of the interaction between tumor size and Oncotype RS, particularly when the variables are in discrepancy with each other. More specifically, we evaluated clinical outcomes in patients with small tumors (≤1 cm) and high RS (≥26) and, separately, in patients with large tumors (>5 cm) with low RS.

MATERIALS/METHODS

Between 2008 and 2020, 310 patients were identified retrospectively as having been treated for early-stage, hormone-receptor positive, Her2-negative breast cancers with tumor size ≤1 cm that were node-negative and had RS ≥ 26 at our institution. In addition, 64 patients were identified with tumor size >5 cm and RS < 26 (irrespective of nodal status). Locoregional recurrence rates (LRR) and invasive recurrence rates (composite of LRR and distant recurrence) were estimated using the Kaplan-Meier method.

RESULTS

Patient characteristics are shown in Table 1. In the group of patients with small tumors and high RS, the 5- and 10-year invasive recurrence rates with 95% CI were 8% (4.2-12) and 17% (8.2-26). The 5- and 10-year locoregional recurrence rates with 95% CI were 5.8% (2.7-8.8) and 15% (6.2-23). In the group of patients with large tumors and low RS, 10-year rates could not be estimated with the available data. The 5- and 8-year invasive recurrence rates with 95% CI were 3.2% (0-7.5) and 3.2% (0-7.5). The 5- and 8-year locoregional recurrence rates with 95% CI were 1.6% (0-4.7) and 1.6% (0-4.7).

CONCLUSION

Our findings suggest that patients with small tumors and high RS are at a higher risk for LRR compared to the average ≤1 cm node-negative breast cancer based on published data on the effect of tumor size on LRR and DM. Similarly, tumors larger than 5 cm with low RS appear to behave indolently and in a manner consistent with more favorable risk (despite their large size). These findings may have important implications for the tailoring of local-regional treatment strategies.

Emotion regulation and combat severity differentiates PTSD diagnostic status among veterans

OBJECTIVE

This study examined whether posttraumatic stress disorder (PTSD) diagnostic groups in veterans were differentiated by combat severity and specific avoidance and approach-related emotion regulation (ER) strategies.

METHOD

In a cohort study, 725 participants (Mage = 58.39, SD = 11.27, 94.5% male, 58.2% White) recruited from VHA facilities completed the Clinician Administered PTSD Scale (CAPS), Combat Exposure Scale (CES), and Emotion Regulation Questionnaire (ERQ). Participants were categorized into three PTSD groups: Current, Remitted, and Never.

RESULTS

Multinomial logistic regressions adjusting for age, sex, and race, showed combat severity significantly differentiated all groups from each other (ps < .001). Specifically, combat severity was significantly associated with increased odds of Current PTSD versus Remitted (OR: 1.02, 95% CI [1.01, 1.05]) and Never PTSD (OR: 1.14, [1.12, 1.17]) and odds of Remitted compared with Never PTSD (OR: 1.11, [1.09, 1.14]). Suppression, but not reappraisal, was significantly associated with increased odds of Current PTSD compared with Remitted (OR: 1.15, [1.06, 1.24]) and Never PTSD (OR: 1.14, [1.06, 1.22]; ps < .001). Lower reappraisal was only significantly associated with the likelihood of Remitted PTSD compared with Never PTSD (OR: 0.93, [0.88, 0.99], p = .03).

CONCLUSIONS

Increasing levels of combat severity differentiated veterans with current, remitted, and no history of PTSD, suggesting screening for severity of combat may be helpful. Greater habitual suppression distinguished current versus non-current PTSD status, whereas only less reappraisal distinguished non-current groups from each other. Lower suppression may be an important treatment target for veterans with moderate and high combat severity. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Identifying correlates of suicide ideation during the COVID-19 pandemic: A cross-sectional analysis of 148 sociodemographic and pandemic-specific factors

The coronavirus disease 2019 (COVID-19) pandemic has created a global health crisis, with disproportionate effects on vulnerable sociodemographic groups. Although the pandemic is showing potential to increase suicide ideation (SI), we know little about which sociodemographic characteristics or COVID-19 experiences are associated with SI. Our United States-based sample (n = 837 adults [mean age = 37.1 years]) completed an online survey during August-September 2020. The study utilized an online convenience sample from a prior study, which was enriched for exposure to trauma and experiences of posttraumatic stress symptoms. We assessed SI using the Beck Depression Inventory-II. Traditional (i.e., logistic regression) and machine learning (i.e., LASSO, random forest) methods evaluated associations of 148 self-reported COVID-19 factors and sociodemographic characteristics with current SI. 234 participants (28.0%) reported SI. Twenty items were significantly associated with SI from logistic regression. Of these 20 items, LASSO identified seven sociodemographic characteristics (younger age, lower income, single relationship status, sexual orientation other than heterosexual as well as specifically identifying as bisexual, non-full-time employment, and living in a town) and six COVID-19 factors (not engaging in protective COVID-19 behaviors, receiving mental health treatment (medication and/or psychotherapy) due to the COVID-19 pandemic, socializing during the pandemic, losing one's job due to COVID-19, having a friend with COVID-19, and having an acquaintance with COVID-19) associated with SI. Random forest findings were largely consistent with LASSO. These findings may inform multidisciplinary research and intervention work focused on understanding and preventing adverse mental health outcomes such as SI during and in the aftermath of the pandemic.

Anhedonia in Anxiety Disorders

Humans, like other animals, are fundamentally motivated to pursue rewarding outcomes and avoid aversive ones. Anxiety disorders are conceptualized, defined, and treated based on heightened sensitivity to perceived aversive outcomes, including imminent threats as well as those that are uncertain yet could occur in the future. Avoidance is the central strategy used to mitigate anticipated aversive outcomes - often at the cost of sacrificing potential rewards and hindering people from obtaining desired outcomes. It is for these reasons that people are often motivated to seek treatment. In this chapter, we consider whether and how anhedonia - the loss of interest in pursuing and/or reduced responsiveness to rewarding outcomes - may serve as a barrier to recovering from clinically impairing anxiety. Increasingly recognized as a prominent symptom in many individuals with elevated anxiety, anhedonia is not explicitly considered within prevailing theoretical models or treatment approaches of anxiety. Our goal, therefore, is to review what is known about anhedonia within the anxiety disorders and then integrate this knowledge into a functional perspective to consider how anhedonia could maintain anxiety and limit treatment response. Our overarching thesis is that anhedonia disrupts the key processes that are central to supporting anxiety recovery. We end this chapter by considering how explicitly targeting anhedonia in treatment can optimize outcomes for anxiety disorders.

Reducing Barriers to Behavioral Treatments for Insomnia: A Qualitative Examination of Veterans' Perspectives of BBTI

Objective: Although behavioral treatments are recommended for treating insomnia disorder, these treatments are not the most commonly provided treatments due to numerous barriers (e.g., treatment length, time limitations). Brief Behavioral Treatment for Insomnia (BBTI) was developed, in part, to help overcome these barriers. The purpose of the current study was to qualitatively examine the treatment experiences of veterans with insomnia disorder participating in BBTI.Methods: All veterans (n=46) who were randomized to receive BBTI as part of a randomized clinical trial participated in 10-20 minute semi-structured interviews one week after completing treatment. Rapid analysis procedures were used for qualitative analysis.Results: Thirteen qualitative themes were identified: BBTI provided veterans with the skills they believed they needed to continue improving independently post-treatment; beginning BBTI with in-person sessions was valued; phone sessions helped participation; veterans did not perceive that they could cover the same content during phone and in-person sessionsl; materials could be more portable; BBTI created accountability; BBTI required discipline and willingness; BBTI facilitated buy-in; BBTI was aligned with military culture; loved ones could provide important support; BBTI could be improved with more personalization; BBTI challenged expectations of mental health; and BBTI improved awareness of health behaviors beyond sleep.Conclusions: BBTI was successful in overcoming barriers to behavioral insomnia treatment and interviews identified critical treatment aspects that should be maintained to preserve acceptability (e.g., in-person session first). Areas in which BBTI did not fully meet the needs of veterans and targets for improvement (e.g., ameliorating understanding and expectations of phone sessions) were also identified.

Physical Disability and Psychedelic Therapies: An Agenda for Inclusive Research and Practice

Over the past decade, there has been an increase in the number of clinical trials for psychedelic therapies as treatments for a wide range of psychiatric conditions. We are concerned that research organizations overseeing these trials have neglected the inclusion of individuals with physical and sensory disabilities. We suggest that psychedelic research organizations should prioritize and plan for the inclusion of individuals with physical and sensory disabilities to address the mental health burdens they confront. Not doing so risks reinforcing structural ableism in healthcare: the discriminatory manifestation of lowered expectations toward people with disabilities on the part of medical providers. Drawing on scholarship from disability studies and medical ethics, we offer four recommendations for disability inclusion in research. We recognize particular populations shoulder significant mental health burdens; these populations deserve priority and should be given a range of accommodations. We emphasize the need for extensive disability awareness training for those facilitating psychedelic therapies and encourage psychedelic researchers and therapists to exercise cultural humility toward individuals with physical and sensory disabilities. This article should be the impetus for further scholarship and debate about how psychedelic research and therapies can be made accessible to members of disability communities who might benefit.

Psilocybin for Trauma-Related Disorders

Posttraumatic stress disorder (PTSD) is a debilitating, chronic disorder and efficacy rates of current PTSD treatments are underwhelming. There is a critical need for innovative approaches. We provide an overview of trauma and PTSD and cite literature providing converging evidence of the therapeutic potential of psilocybin for PTSD. No study to date has investigated psilocybin or psilocybin-assisted psychotherapy (PAP) as treatments for PTSD. An open-label study in traumatized AIDS survivors found that PAP reduced PTSD symptoms, attachment anxiety, and demoralization. Several PAP trials show preliminary efficacy in facilitating confronting traumatic memories, decreasing emotional avoidance, depression, anxiety, pessimism, and disconnection from others, and increasing acceptance, self-compassion, and forgiveness of abusers, all of which are relevant to PTSD recovery. There is also early evidence that other classic psychedelics may produce large reductions in PTSD symptoms in combat veterans. However, this body of literature is small, mechanisms are not yet well understood, and the risks of using psychedelic compounds for trauma-related disorders need further study. In sum, evidence supports further investigation of PAP as a radically new approach for treating PTSD.

Association Between Responsibility for the Death of Others and Postdeployment Mental Health and Functioning in US Soldiers

IMPORTANCE

Rates of suicidal thoughts and behaviors (STBs) in US soldiers have increased sharply since the terrorist attacks on September 11, 2001, and postdeployment posttraumatic stress disorder (PTSD) remains a concern. Studies show that soldiers with greater combat exposure are at an increased risk for adverse mental health outcomes, but little research has been conducted on the specific exposure of responsibility for the death of others.

OBJECTIVE

To examine the association between responsibility for the death of others in combat and mental health outcomes among active-duty US Army personnel at 2 to 3 months and 8 to 9 months postdeployment.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study obtained data from a prospective 4-wave survey study of 3 US Army brigade combat teams that deployed to Afghanistan in 2012. The sample was restricted to soldiers with data at all 4 waves (1-2 months predeployment, and 2-3 weeks, 2-3 months, and 8-9 months postdeployment). Data analysis was performed from December 12, 2020, to April 23, 2021.

MAIN OUTCOMES AND MEASURES

Primary outcomes were past-30-day PTSD, major depressive episode, STBs, and functional impairment at 2 to 3 vs 8 to 9 months postdeployment. Combat exposures were assessed using a combat stress scale. The association of responsibility for the death of others during combat was tested using separate multivariable logistic regression models per outcome adjusted for age, sex, race and ethnicity, marital status, brigade combat team, predeployment lifetime internalizing and externalizing disorders, and combat stress severity.

RESULTS

A total of 4645 US soldiers (mean [SD] age, 26.27 [6.07] years; 4358 men [94.0%]) were included in this study. After returning from Afghanistan, 22.8% of soldiers (n = 1057) reported responsibility for the death of others in combat. This responsibility was not associated with any outcome at 2 to 3 months postdeployment (PTSD odds ratio [OR]: 1.23 [95% CI, 0.93-1.63]; P = .14; STB OR: 1.19 [95% CI, 0.84-1.68]; P = .33; major depressive episode OR: 1.03 [95% CI, 0.73-1.45]; P = .87; and functional impairment OR: 1.12 [95% CI, 0.94-1.34]; P = .19). However, responsibility was associated with increased risk for PTSD (OR, 1.42; 95% CI, 1.09-1.86; P = .01) and STBs (OR, 1.55; 95% CI, 1.03-2.33; P = .04) at 8 to 9 months postdeployment. Responsibility was not associated with major depressive episode (OR, 1.30; 95% CI, 0.93-1.81; P = .13) or functional impairment (OR, 1.13; 95% CI, 0.94-1.36; P = .19). When examining enemy combatant death only, the pattern of results was unchanged for PTSD (OR, 1.44; 95 CI%, 1.10-1.90; P = .009) and attenuated for STBs (OR, 1.46; 95 CI%, 0.97- 2.20; P = .07).

CONCLUSIONS AND RELEVANCE

This cohort study found an association between being responsible for the death of others in combat and PTSD and STB at 8 to 9 months, but not 2 to 3 months, postdeployment in active-duty soldiers. The results suggest that delivering early intervention to those who report such responsibility may mitigate the subsequent occurrence of PTSD and STBs.

Feasibility of youth empowerment initiative for identifying never- and under-immunized children

Background

One-in-every 5 children globally remains deprived of life-saving vaccines. We developed and implemented the Adolescent Health and Leadership Program (AHLP) among school girls from grades 8-10 (Kiran Sitaras (KSs); Shining Stars) to provide them with soft skills and community mobilization skills and equipping them to become community advocates for immunization. We evaluated the feasibility of KS community mobilization through validating KSs' ability to accurately identify and link never- and under-immunized children with immunization services.

Methods

We implemented a mixed-methods study in six public schools located in peri-urban areas of Karachi, Pakistan. After the development and roll-out of AHLP in schools, KSs conducted door-to-door visits in their neighborhoods to identify never-and under-immunized children. This was followed by verification visits by field staff to establish accuracy and immunization camps to vaccinate never- and under-immunized children identified by KSs.

Results

From January 28 to February 22, 2020, 591 KSs visited 10,330 households, screened 3,295 under-2 children and identified 7.5% (247/3,295) never- and 27.0% (889/3,295) under-immunized children, with an accuracy of 90.4% and 49.6%, respectively. In January 2021, 291 never- and under-immunized children were invited to immunization camps, of which 28.9% (84/291) received vaccinations, while 57.0% (166/291) did not respond to the invite and 14.1% (41/291) were deemed ineligible (illness, overage, etc.).

Conclusions

We demonstrated the feasibility of empowering adolescent girls to boost immunization uptake in LMIC settings. Engaging young women from within the community provides an organic and sustainable solution for promoting immunization coverage and equity today and ensuring they will continue to champion the cause in their capacity as tomorrow's mothers. We are actively scaling-up our solution across the country to create a force of 100,000+ KSs to magnify our efforts.

Key messages

The Kiran Sitara initiative, via its community-centered approach, leverages the force of adolescent school girls to boost demand and referrals for immunization in unreached geographical pockets. The Kiran Sitara initiative utilizes the power of youth engagement to identify never- and under-immunized children, and subsequently increase vaccine-uptake.

Feasibility of an artificially intelligent vaccines chatbot in Pakistan: A mixed methods evaluation

Background

Despite free vaccination services, gaps in information access impede immunization uptake in low and middle-income countries (LMICs), including Pakistan. We developed Bablibot (Babybot), a local-language, text-based chatbot to connect caregivers with immunization-related information in real-time, and evaluated its feasibility and acceptability in resolving immunization-related queries among Karachi's low-income communities.

Methods

We developed Bablibot using Natural Language Processing (NLP), Machine Learning, and Human in the Loop features. We conducted a sequential mixed-methods pilot in Karachi where caregivers were recruited when visiting selected immunization centers for any childhood vaccine except Measles 2 (last vaccine visit) or were informed through targeted text messages. We assessed Bablibot's feasibility and acceptability through user-engagement metrics and thematic analysis of qualitative interviews conducted with 20 pilot participants.

Results

Between March 9, 2020 and April 15, 2021, Bablibot accrued 677 users and participated in 874 conversations. Of 2,202 pilot-enrolled caregivers, 210 (10%) interacted with the bot; other 467 users were not pilot participants. Most queries were about due dates (25%; 221/874), delaying vaccination (17%; 146/874), or side-effect management (16%;137/874). The conversations now constitute a valuable training database for future local-language bots. Over 90% (277/307) of responses to text-based exit surveys indicated user satisfaction. Qualitative analysis showed caregivers appreciate Bablibot's convenience, reliability, and responsiveness.

Conclusions

Our results demonstrate the feasibility and acceptability of local-language NLP chatbots in providing immunization information. Text-based chatbots can minimize workload on helpline operators, in addition to quickly resolving queries that otherwise lead to delay or default. Bablibot's conversation data provides learning infrastructure for future health-related bots.

Key messages

An AI-based NLP chatbot is a feasible and acceptable intervention for providing immunization-related information to large number of caregivers 24/7 in limited resource setting. By serving as a remote, low-cost and confidential bi-directional channel, chatbots can address gaps in information access, especially for women, and have long term impact on immunization uptake.

1-year impact of COVID-19 on childhood immunizations in Pakistan: analysis of &gt; 3.7 million children

 

Covid-19 has universally disrupted primary health care, but routine childhood immunizations are one the most affected services. We analyzed big data in vaccines for measuring the 1-year impact of Covid-19 on outline childhood immunizations for the 48 million population in the Sindh province of Pakistan. We extracted and analyzed >3.7m real-time immunization records of 0-23 months old children from the Sindh Government's Electronic Immunization Registry (EIR). Using a 6-month baseline preceding the COVID-19 lockdown, we quantified the lockdown's (March 23-May 9, 2020) impact on daily immunization rates by geographical area and the change in coverage rates at the one-year mark since the lockdown. The lockdown resulted in 53% drop in the number of immunizations. The impact in rural areas as more than in urban areas (54.9% decline vs 47.5% decline from baseline), and slums had a slightly larger decrease in immunization coverage than non-slum areas (53.8% vs. 51.3%). Of 1,246,321 children who missed immunizations during first year of the pandemic, 76% of these children were eventually vaccinated by the end of March 2021. Similarly, of the 417,553 children who had dropped out during the initial 7-week national lockdown (March 23-May 10, 2020), 79% were immunized by March 2021. Our analysis of EIR data shows that the catch-up and recovery of coverage rates have primarily been driven through intensive outreach vaccination efforts instead of an increase in demand. One year since the onset of the pandemic, the average daily immunization doses administered through outreach increased by 121 percent above baseline estimates. In contrast, vaccines administered at immunization clinics were still 22 percent below baseline. The example of Pakistan shows LMICs can successfully deploy mitigation strategies to catch up with missed children during Covid-19 and sustain routine childhood immunizations to close immunity gaps.

Key messages

Although the lockdown resulted in a 53% drop in immunizations, at the 1-year mark since the pandemic started, 76% of children who missed immunizations are vaccinated.

Pakistan data shows LMICs can rectify routine immunization coverage and immunity gaps and rebound successfully to their pre-COVID-19 coverage rates.

Automated chest radiography and mass systematic screening for tuberculosis

BACKGROUND: Systematic screening for TB using automated chest radiography (ACR) with computer-aided detection software (CAD4TB) has been implemented at scale in Karachi, Pakistan. Despite evidence supporting the use of ACR as a pre-screen prior to Xpert^® MTB/RIF diagnostic testing in presumptive TB patients, there has been no data published on its use in mass screening in real-world settings.METHOD: Screening was undertaken using mobile digital X-ray vehicles at hospital facilities and community camps. Chest X-rays were offered to individuals aged ≥15 years, regardless of symptoms. Those with a CAD4TB score of ≥70 were offered Xpert testing. The association between Xpert positivity and CAD4TB scores was examined using data collected between 1 January and 30 June 2018 using a custom-built data collection tool.RESULTS: Of the 127 062 individuals screened, 97.2% had a valid CAD4TB score; 11 184 (9.1%) individuals had a CAD4TB score ≥70. Prevalence of Xpert positivity rose from 0.7% in the <50 category to 23.5% in the >90 category. The strong linear association between CAD4TB score and Xpert positivity was found in both community and hospital settings.CONCLUSION: The strong association between CAD4TB scores and Xpert positivity provide evidence that an ACR-based pre-screening performs well when implemented at scale in a high-burden setting.

Expressive suppression and cognitive reappraisal in veterans with PTSD: Results from the mind your heart study

OBJECTIVE

This study examined whether expressive suppression (ES), a maladaptive regulation strategy, was more strongly associated with PTSD diagnosis and symptom clusters in veterans than cognitive reappraisal (CR), an adaptive regulation strategy.

METHOD

In a cohort study, 746 participants recruited from VHA facilities completed Clinician Administered PTSD Scale-IV, Emotion Regulation Questionnaire, and Patient Health Questionnaire. Participants were categorized into groups: Current, Remitted/Lifetime, and Never PTSD.

RESULTS

One-way ANOVA revealed significant differences between Current PTSD and both Remitted and Never PTSD for ES, but not CR. The Remitted and Never PTSD groups did not vary significantly from each other and were collapsed into one group for regressions. Adjusting for sex, race, employment, and comorbid depression, binary logistic regression showed ES, but not CR, was associated with increased likelihood of Current PTSD (p < .001, OR: 1.43). ES was also significantly associated with increased odds of meeting criteria for all symptom clusters (ps < 0.001). CR was not significantly associated with meeting criteria for Current PTSD or any symptom cluster.

LIMITATIONS

Cross-sectional design and use of self-report limit causality inferences that can be drawn.

CONCLUSIONS

ES is associated with increased odds of Current PTSD diagnosis and symptom clusters. Veterans in the Remitted and Never PTSD groups did not differ significantly. Greater suppression of emotional expression is more strongly linked with PTSD criteria in veterans than decreased cognitive reappraisal.

Introducing new and repurposed TB drugs: the endTB experience

In 2015, the initiative Expand New Drug Markets for TB (endTB) began, with the objective of reducing barriers to access to the new and repurposed TB drugs. Here we describe the major implementation challenges encountered in 17 endTB countries. We provide insights on how national TB programmes and other stakeholders can scale-up the programmatic use of new and repurposed TB drugs, while building scientific evidence about their safety and efficacy. For any new drug or diagnostic, multiple market barriers can slow the pace of scale-up. During 2015-2019, endTB was successful in increasing the number of patients receiving new and repurposed TB drugs in 17 countries. The endTB experience has many lessons, which are relevant to country level introduction of new TB drugs, as well as non-TB drugs and diagnostics. For example: the importation of TB drugs is possible even in the absence of registration; emphasis on good clinical monitoring is more important than pharmacovigilance reporting; national guidelines and expert committees can both facilitate and hinder innovative practice; clinicians use new and repurposed TB drugs when they are available; data collection to generate scientific evidence requires financial and human resources; pilot projects can drive national scale-up.

Feasibility of implementing Integrated Management of Childhood Illnesses through Mobile Technology

Background

The Integrated Management of Childhood Illnesses (IMCI) strategy was launched by WHO and partners in 1995 to reduce child mortality by enhancing frontline health workers' (FHWs) ability to diagnose and manage childhood illnesses, and strengthen overall health systems. However, although IMCI is associated with decreased child mortality, numerous studies have shown its impact has been limited due to persistent barriers to implementation.

Methods

We developed a digitized version of IMCI (eIMCI) using Android technology to overcome implementation problems, including poor protocol compliance, lengthy trainings, paper-based data collection, and gaps in the referral system. The feasibility and efficacy of eIMCI was assessed through a mixed-methods pilot study encompassing baseline and end-line surveys, interviews, and Focus Group Discussions, in a low-resource rural district of Punjab, Pakistan. During the 8 weeks of deployment, a total of 1,978 children were enrolled in the eIMCI application by 10 participating FHWs, and 47 electronic referrals were generated.

Results

Preliminary outcomes showed reduced disease occurrence (for example, diarrhea decreased from 48% at baseline to 29% at endline), increased adherence to IMCI protocol, and strengthened health system linkages (facility referrals increased from 5% at baseline to 45% at endline). FHWs reported enhanced performance, as well as an improved community response to their services.

Discussion

Indicating the feasibility and efficacy of eIMCI deployment in a low-resource setting, evidence from the pilot demonstrates the benefit of digitizing the IMCI protocol. eIMCI is a digital health solution with the potential to significantly reduce child mortality and improve service delivery and performance of FHWs.

Key messages

eIMCI is a feasible solution for the implementation of IMCI strategy in developing countries and demonstrates increased compliance and enhanced performance by the frontline health workers. Implementation of eIMCI can result in a significant reduction in child morbidity and mortality via timely referrals of patients and reduced disease occurrence.

Real-time immunization trends in under-2 children in Pakistan: insights from big data analysis

Background

Despite the provision of free-of-cost vaccines in Pakistan, fully immunized child (FIC) coverage in Sindh province remains low at 49%. In 2012, we developed and piloted the Zindagi Mehfooz (Safe Life; ZM) Digital Immunization Registry, an Android-based platform that enables vaccinators to enroll and track child level immunization data of children in the catchment population. In 2017, ZM was scaled-up across Sindh province and is currently being used by 2,284 vaccinators across 1,526 facilities serving &gt;48 million (m) population.

Methods

All children under-2 years of age visiting EPI centers are enrolled. At enrollment, caregiver and child bio-data and child immunization history are recorded, and the child is provided with a unique Quick Response (QR) code for identification. For follow-up immunization visits, 3 SMS reminders are sent to caregivers, and upon immunization, child history is retrieved by scanning the QR code and vaccination record updated. ZM allows real-time access to data and generation of monitoring reports. Data from ZM was used to calculate coverage rates, timeliness, and trends for immunization coverage in Sindh.

Results

From Oct'17 to Dec'19, more than 2.4m children and 0.8m women were enrolled in the Registry, while &gt;17m immunizations were administered. The FIC coverage in 12-23 months old children has increased from 49% (at baseline) to 57% for children enrolled in ZM. Additionally, pentavalent-3 coverage increased from 59% to 68%.

Discussion

ZM demonstrates the potential of DIRs to improve immunization outcomes within low-resource settings by enabling better child tracking and a higher retention rate. Additionally, the big dataset provides the opportunity to identify real-time trends and provides actionable data for evidence-based decision making.

Key messages

ZM Immunization Registry has strengthened the current EPI program through increased FIC coverage and timeliness through better tracking of children and increased retention. Big Data from ZM can be used to analyze immunization trends of global relevance, and guide strategic policy decisions for improving immunization coverage and equity, based on actionable data insights.

Using mobile immunization vans to cover under-served populations in hard-to-reach areas

Background

In Pakistan, only 66% of children receive their basic vaccinations. However, the figure masks significant inequalities in vaccine coverage between urban and rural residences, slums and areas distantly located from EPI centers. Frequent outbreaks of vaccine-preventable diseases such as polio and measles, in urban cities like Karachi, signal the need for expanding vaccine services to underserved areas. In Apr'19, we introduced the Mobile Immunization Van initiative in Karachi in collaboration with EPI Sindh. Currently, two vans are deployed in hard-to-reach areas and slums to immunize under-2 children for routine vaccines.

Methods

Before the van visit, mobilization efforts are conducted in targeted areas to encourage caretakers to bring their child for vaccination. On the day of visit, the van is parked at a central location, and announcements are played on a loudspeaker to attract caregivers. All vaccinations are administered in the van, and entries are recorded in Government's Digital Immunization Registry along with GIS coordinates of immunized children. The data is then automatically transferred on to a web-dashboard for analysis and tracking.

Results

From Apr'19 to Jan'20, the vans have vaccinated 2,867 children, out of which 50% had never been immunized prior to the van visit. Of those who received their follow-up vaccines from the van, 80% were at least 4 weeks beyond from their vaccine due date. GIS analysis of van data confirmed that immunizations were conducted in slums, and areas distantly located from EPI centers. Moreover, compared to government outreach activity, proportion of BCG, Penta3 and Measles1 administrations in slums was higher through the vans by 5%, 6%, and 4% respectively.

Conclusions

The vans provide an opportunity for immunizing never-vaccinated children and children defaulting on their vaccine schedule, from the most vulnerable geographies, while simultaneously enrolling them in the Government's EPI Program for effective tracking.

Key messages

The mobile vans help achieve universal immunization coverage through provision of vaccine services in slum and rural hard-to-reach areas with limited access to government-provided services. The mobile vans help vaccinate and capture never-immunized children into the Government’s EPI records, reducing the number of children missed through routine services.

Assessment of immunization service delivery in Pakistan: A cross-sectional survey of health facilities

Background

Routine childhood immunization coverage in Pakistan remains sub-par, in part, due to the poor quality of service delivery. This study aims to summarize the quality of immunization centers throughout the Sindh province, Pakistan, by assessing all Government vaccination facilities and their associated health workers.

Methods

A health facility and worker assessment survey adapted from tools developed by BASICS and EPI-Sindh was used to record facility infrastructure, processes, and human resources. Using expert panel ranking, we developed critical criteria to indicate items immunization centers need to be operational (vaccinator, a cold box or refrigerator, and vaccine supplies) as well as high, low, and moderate function requirements and their respective scores.

Results

Out of 1396 centers assessed, 1236 (88.5%) were operational, while 1209 (86.6%) offered immunization services. Only 793 (66.0%) of the functional immunization facilities met the critical criteria. The average scores for high, moderate, and low function requirements were significantly lower for centers that did not meet the critical criteria. Of 2,153 healthcare workers interviewed, 1874 (87.1%) were vaccinators. 1805 (96.3%), 1655 (88.3%), and 1387 (74.0%) were trained in vaccination, cold chain, and inventory, respectively.

Discussion

One out of three immunization centers in Sindh lack the critical components essential for quality vaccination services. Health workers have adequate training and experience, suggesting that sub-optimal vaccination center quality is due to inadequate infrastructure and inefficient processes. Our study presents innovative and critical research findings with high-impact policy implications for identifying and addressing gaps to improve vaccination uptake within an LMIC setting.

Key messages

Every 2 out of 5 facilities in Sindh Province lacked essential equipment for immunizations such as vaccines, vaccinator and cold box for vaccination. In all health facilities, the health workers appear sufficiently trained, indicating that poor quality may be due to missing infrastructure and inefficient processes in resource-constrained settings.

Evaluating mobile conditional cash transfers for improving immunization coverage in Pakistan

Background

Despite progress in increasing immunization coverage, poor uptake of vaccines remains a challenge, particularly in LMICs. In part, this is due to the poor socio-economic status of caregivers, lack of motivation, and parental procrastination. While there is evidence that large (≥100 USD) incentives can overcome these problems, research on small incentives that are more appropriate for an LMIC setting is sparse. Our study addresses this gap by evaluating the impact of small (≤12 USD) CCTs in increasing immunization coverage for children under the age of two.

Methods

A 2-year program utilizing two small incentive schemes of different amounts (high: USD9; low: USD5) was implemented in Shikarpur District, Pakistan. Caregivers (with children 0-24 months) visiting any of the 33 study immunization centers were given the opportunity to enroll. All consenting parent-child pairs were randomized in one of the two incentive schemes and incentives were disbursed following each immunization visit, using mobile money. A baseline and end-line survey was conducted to evaluate changes in pre-post coverage.

Results

A total of 63,336 participants were enrolled between March 2016 - April 2018, of which 41,483 were randomized in the high or low incentive schemes (remaining caregivers were enrolled in the no-incentive group). Results show a 13% and 28% increase in age-appropriate coverage for Measles-1 (M1) and fully immunized children (FIC) compared to the baseline (FIC:16%, M1: 38%). There was no difference in M1 coverage between the high and low incentive schemes.

Discussion

Small CCTs have induced positive behavioral change and are a powerful tool for improving immunization coverage and compliance within LMICs.

Key messages

Small mobile conditional cash transfers (USD&lt;12) can serve as nudges to parents and lead to behavioral shifts resulting in improved immunization outcomes for children. There was no significant difference in outcomes between high and low incentives, indicating that small mobile conditional cash transfers were equally effective in improving immunization coverage.

Evaluating small conditional cash transfers to improve vaccine coverage and timeliness in Pakistan

Background

Low immunization coverage rates have prompted the need to design effective demand-side interventions to improve uptake. Simple SMS reminders and large (≥USD 100) incentives have been demonstrated to effectively increase immunization coverage. However, research on small incentives (≤USD 15) for immunization is sparse and there is uncertainty regarding the optimal structure of incentives in terms of size, schedule, and design.

Methods

A 12-arm randomized controlled trial is being conducted in Karachi, Pakistan with 10 incentive arms of varying size (amount), schedules (progressivity) and design (certainty of payment), an exclusive SMS arm and control arm. The incentives are provided through two mechanisms: mobile air time and mobile-money through a mobile-money provider. Children were enrolled when they presented to the study sites for either BCG, Penta-1, or Penta-2 vaccine.

Results

A total of 11,197 children were enrolled between Nov 2017 and Oct 2018 with approximately 800 children in each incentive arm and 1600 and 1599 in SMS and Control arm, respectively. As of Jan 09, 2020, Penta-3 and Measles-1 coverage are lowest in the control arm (71% and 60% respectively) and highest in the high-flat-lottery arm (78% and 69% respectively) with uniformly progressing incentive amounts along the immunization schedule.

Discussion

Interim results suggest that small mobile-based incentives coupled with SMS reminders can significantly improve immunization coverage in children. The final analysis will provide robust evidence of this impact and provide policy implications for the most optimal incentive structure that can build caregiver demand for effectively increasing child immunization in an LMIC setting.

Key messages

Small incentives (USD&lt;15) coupled with simple SMS reminders can improve immunization coverage and timeliness in low resource settings in an inexpensive, logistically simple way. The study will provide experimental evidence on optimal incentive design, structure, and size of small incentives for a cost-effective approach to increase immunization coverage and timeliness.

Empowering adolescent girls and creating lifelong champions to improve immunization coverage

Background

Despite the global imperative to 'leave no child behind', one in every 5 children remain deprived of life-saving vaccines. Low immunization coverage is in part due to the weak linkages between community and health system, inaccessibility of outsiders to closely-knit societies and low parental awareness regarding immunizations. The Kiran Sitara (Shining Stars; KS) Adolescent Health and Leadership Program (AHLP), was implemented using adolescent girls (Kiran Sitaras-KSs) as the agents of change, who by virtue of belonging to the community were able to cause a ripple effect in boosting uptake for WHO-recommended immunizations for children under 2 years of age. Our research evaluated the feasibility of the KS community mobilization and validated KS's ability to accurately identify under-immunized and zero-dose (never-vaccinated) children.

Methods

AHLP was implemented in grades 8-10 of two public secondary schools in Shikarpur and Lakhi Town, Pakistan. From April-May, 2017, a door-to-door survey was conducted by KSs followed by visits of trained staff to verify the immunization statuses identified by KSs.

Results

KSs (N = 45) screened 207 children and identified under-immunized and zero-dose children with an accuracy of 74% and 94% respectively.

Conclusions

Our strategy of mobilizing girls from within the communities provides a promising avenue to provide immunization services in high-risk areas that cannot be penetrated through conventional mechanisms. We are actively scaling-up our sustainable solution by implementing AHLP in 250+ schools and creating a force of 100,000+ KSs who can promote health equity today and champion the cause in their capacity as tomorrow's mothers.

Key messages

The Kiran Sitara initiative via its community-centered approach leverages the force of adolescent school girls to boost demand and provide referrals for immunization in unreached geographical pockets. The Kiran Sitara initiative utilizes the power of youth engagement to identify zero-dose and under-immunized children, link them to immunization services and improve knowledge among caregivers.

Combat-Related Posttraumatic Stress Disorder and Comorbid Major Depression in U.S. Veterans: The Role of Deployment Cycle Adversity and Social Support

Posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) commonly co-occur in combat veterans, and this comorbidity has been associated with higher levels of distress and more social and economic costs compared to one disorder alone. In a secondary analysis of a multisite randomized controlled trial of a sample of veterans with combat-related PTSD, we examined the associations among pre-, peri-, and postdeployment adversity, social support, and clinician-diagnosed comorbid MDD. Participants completed the Deployment Risk and Resilience Inventory and the Beck Depression Inventory-II as well as structured clinical interviews for diagnostic status. Among 223 U.S. veterans of the military operations in Iraq and Afghanistan (86.9% male) with primary combat-related PTSD, 69.5% had current comorbid MDD. After adjustment for sex, a linear regression model indicated that more concerns about family disruptions during deployment, f² = 0.065; more harassment during deployment, f² = 0.020; and lower ratings of postdeployment social support, f² = 0.154, were associated with more severe self-reported depression symptoms. Interventions that enhance social support as well as societal efforts to foster successful postdeployment reintegration are critical for reducing the mental health burden associated with this highly prevalent comorbidity in veterans with combat-related PTSD.

Examining the impact of different types of military trauma on suicidality in women veterans

Suicide rates amongst women veterans are significantly higher than rates for their civilian counterparts. However, risk factors for suicide among women veterans remain unclear. The current study examined the impact of exposure to a number of military stressors (e.g., perceived life threat, killing in combat, military sexual trauma) on suicidal ideation (SI) in women veterans. A total of 403 women veterans responded to mailed self-report surveys, 383 (ages 24-70 years) returned fully completed surveys and were included in analyses, and 16% of those included endorsed current SI. Rates of endorsement for military stressors were as follows: 43% being wounded, 34% loss of someone close, 36% perceived life threat, 30% witnessing a killing or injury, 4% seeing injured or dead bodies, 4% killing in combat, 65% military sexual harassment, and 33% military sexual assault. A logistic regression analysis was conducted with all of the military stressors entered simultaneously to determine the effect on SI. Life threat and sexual harassment had the strongest associations with SI compared to other military stressors. These findings suggest that particular military stressors may play an especially important role in SI in women veterans. Implications and future research considerations are discussed.

Sex Differences in the Association between Heavy Drinking and Behavioral Distress Tolerance and Emotional Reactivity Among Non-Depressed College Students

Background

Heavy episodic drinking (HED) is a common behavior among college students that is associated with severe negative consequences. Negative reinforcement processes have been applied to elucidate mechanisms underlying relationships between consumption of alcohol and the desire to alleviate negative feelings. Distress tolerance (DT) and emotional reactivity are two mechanisms that are consistent with the self-medication model that may contribute to HED. The current study investigated relationships between DT, emotional reactivity, defined as frustration reactivity and irritability reactivity, and HED in a non-depressed college population. Given differential patterns of consumption and motivation for drinking between males and females, sex differences were also examined.

Short Summary

The study examined two constructs consistent with negative reinforcement processes, behavioral distress tolerance (DT) and emotional reactivity (frustration reactivity and irritability reactivity), to explain heavy episodic drinking (HED) among non-depressed college students. Behavioral DT and frustration reactivity independently predicted HED. Higher HED was associated with higher frustration reactivity and lower behavioral DT in women, but nor in men.

Methods

One-hundred-ten college students without depressive symptoms completed alcohol use measures and the Paced Auditory Serial Attention Task (PASAT-C) to assess behavioral DT and emotional reactivity.

Results

DT and frustration reactivity independently predicted HED. The association between DT and HED was moderated by sex such that higher levels of DT predicted higher HED among females, but not among males. Higher frustration reactivity scores were associated with a greater number of HED.

Conclusions

Results provide supporting evidence that DT and emotional reactivity are distinct factors, and that they predict HED independently. Results underscore the importance of examining sex differences when evaluating the association between HED and negative reinforcement processes in this population.

Abstract OT2-04-01: Phase III trial to determine if chest wall and regional nodal radiotherapy (CWRNRT) post mastectomy (Mx) or the addition of RNRT to whole breast RT post breast-conserving surgery (BCS) reduces invasive breast cancer recurrence-free interval (IBCR-FI) in patients (pts) with pathologically positive axillary (PPAx) nodes who are ypN0 after neoadjuvant chemotherapy (NC): NRG Oncology/NSABP B-51/RTOG 1304

This phase III post-NC trial evaluates if CWRNRT post-Mx or whole breast irradiation (WBI) with RNRT after BCS significantly reduces the IBCR-FI rate in pts with PPAx nodes that are pathologically negative after NC. Secondary aims are OS, LRR-FI, DR-FI, DFS-DCIS, second primary cancer, and comparison of RT effect on cosmesis in reconstructed Mx pts. Correlative science examines RT effect by tumor subtype, molecular outcome predictors for residual disease, and predictors for the degree of reduction in loco-regional recurrence.

Methods: Clinical T1-3, N1 IBC PPAx nodes (FNA or core needle biopsy) pts complete ≥8 weeks of NC (anthracycline and/or taxane). HER2+ pts receive anti-HER2 therapy. Following NC, BCS or Mx, sentinel node biopsy (≥2 nodes) and/or Ax dissection with histologically negative nodes is performed. ER/PR and HER-2neu status before NC is required. Pts may receive appropriate adjuvant systemic therapy. Radiation credentialing with a facility questionnaire/case benchmark is required. Random assignment for Mx pts is to no CWRNRT or CWRNRT and for BCS pts to WBI or WBI+RNRT.

Statistics: 1,636 pts are to be enrolled over 5 yrs (definitive analysis at 7.5 yrs). Study is powered at 80% to test that RT reduces the annual hazard rate of events for IBCR-FI by 35% for an absolute risk reduction of 4.6% (5-yr cumulative rate). Intent-to-treat analysis with 3 interim analyses (43, 86, and 129 events) and a 4th/final analysis at 172 events. Pt-reported outcomes focusing on RT effect will be provided by 736 pts before random assignment and at 3, 6, 12, and 24 mos. Accrual as of 6-21-18 is 967 (59.11%).

Contacts: Protocol: CTSU member website https://www.ctsu.org. Questions: NRG Oncology Pgh Clin Coord Dpt: 1-800-477-7227 or ccd@nsabp.org. Pt entry: OPEN at https://open.ctsu.org or the OPEN tab on CTSU member website.

NCT01872975

Support: U10 CA-2166; -180868, -180822; 189867; Elekta

Citation Format: Mamounas EP, Bandos H, White JR, Julian TB, Khan AJ, Shaitelman SF, Torres MA, Vicini FA, Ganz PA, McCloskey SA, Paik S, Gupta N, Li XA, DiCostanzo DJ, Curran WJ, Wolmark N. Phase III trial to determine if chest wall and regional nodal radiotherapy (CWRNRT) post mastectomy (Mx) or the addition of RNRT to whole breast RT post breast-conserving surgery (BCS) reduces invasive breast cancer recurrence-free interval (IBCR-FI) in patients (pts) with pathologically positive axillary (PPAx) nodes who are ypN0 after neoadjuvant chemotherapy (NC): NRG Oncology/NSABP B-51/RTOG 1304 [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT2-04-01.

The Association between Distress Tolerance and Alcohol Related Problems: The Pathway of Drinking to Cope

Binge drinking (BD) and alcohol related problems (ARP) are highly prevalent among college students. However, current models examining ARP suggest drinking quantity only accounts for a portion of the variance, suggesting other variables contribute to ARP. Distress tolerance (DT), or the ability to withstand negative affect, is associated with alcohol misuse and may be an important mechanism related to ARP. However, studies have reported inconsistent findings on this association, which may be due to the use of only global scores to measure DT rather than specific DT components. Furthermore, the mechanisms underlying this association remain unknown. Drinking to cope with negative affect has been associated with both DT and ARP, suggesting it may be a mechanism explaining the relationship between DT and ARP. The current study examined the association between specific proposed DT components (i.e., tolerance, absorption, appraisal, and regulation) and drinking to cope and ARP in 147 college students who BD. A hierarchical linear regression was performed in order to examine which DT component best predicted ARP. Four follow-up mediation models were then tested to examine whether drinking to cope mediated the relationship between each DT component and ARP. Appraisal of DT was the only DT component that significantly predicted ARP, in the model controlling for drinking quantity and sex differences. Drinking to cope mediated the relationship between ARP and tolerance, absorption, and regulation, but not appraisal of DT. Implications for furthering our understanding of DT and treatment of BD as it relates to DT are explored.

UK families with children with rare chromosome disorders: Changing experiences of diagnosis and counselling (2003-2013)

The latest United Kingdom (UK) strategy for rare diseases emphasises the need to empower affected populations to improve diagnosis, intervention, and coordination of care. Families who have a child with a rare chromosome disorder (RCD) are a challenging group to include. We report the findings of 2 large-scale surveys, undertaken by the UK RCD Support Group Unique, of these families' experiences over a 10-year period. Seven stages of the patient journey were examined. From pre-testing, through diagnosis, genetics consultation, clinical follow-up and peer support. Overall, 1158 families replied; 36.4% response rate (2003) and 53.6% (2013). Analysis of responses identifies significant differences (P < .001) over time with a decrease in results reported face to face (76%-62%), doubling by telephone (12%-22%), improved explanation of chromosome disorder (57%-75%), and increased signposting to peer support group (34%-62%). However, conduct of the consultation raises a number of important questions. Overall, 28 aspects of the patient journey are recognised as requiring improvement; only 12/28 are currently incorporated in UK service specifications. Involvement of RCD families has identified key service improvements. This approach can empower those affected by such extremely rare disorders, and also enable professionals to design improved services in partnership with "expert families." Further surveys are planned.

Sugar before bed: a simple dietary risk factor for caries experience

Clinical care pathways have placed renewed emphasis on caries risk assessment and the ability to predict and prevent further disease. With diet considered a key factor in the development of caries, the level of caries risk posed by dietary habits, such as the frequency of intake and timing of free sugars is questioned.

OBJECTIVE

To identify reliable and simple dietary risk factors for caries experience.

RESEARCH DESIGN

A cross-sectional observational study of a convenience sample with data gained from clinical examinations, questionnaire and a 24 hour dietary-recall interview.

PARTICIPANTS

128 subjects aged 11-12 from comprehensive schools in Greater Manchester and Newcastle upon-Tyne, UK.

OUTCOME MEASURES

free sugars consumed between meals, before bed and total % of total free sugars consumed were assessed from dietary assessments led by a dietitian. D4-6MFT was generated with a caries threshold of ICDAS stage 4 from clinical examinations.

RESULTS

Analysis revealed no significant differences in caries experience when looking specifically at caries into dentine, referred to as the cavity group (split at D4-6MFT), between high and low deprivation, consumption of free sugars between meals and free sugars (%). The consumption of free sugars within the hour before bed revealed a statistically significant difference between the cavity/no cavity groups (p=0.002). Logistic regression analysis on the cavity/no cavity groups revealed an odds ratio of 2.4 (95%CI 1.3,4.4) for free sugars consumption before bedtime.

CONCLUSIONS

The study suggests that the consumption of free sugars before bedtime may be an important risk factor for adolescent caries into dentine experience.

Abstract OT2-03-01: NRG oncology/NSABP B-51/RTOG 1304: A phase III superiority clinical trial designed to determine if chest wall and regional nodal radiotherapy (CWRNRT) post mastectomy (Mx) or the addition of RNRT to breast RT post breast-conserving surgery (BCS) will reduce invasive cancer events in patients (pts) with positive axillary (Ax) nodes and convert to ypN0 after neoadjuvant chemotherapy (NC)

Background:

This phase III post-NC trial evaluates if CWRNRT post Mx or whole breast irradiation (WBI) with RNRT after BCS significantly reduces the invasive breast cancer recurrence-free interval (IBC-RFI) rate in pts presenting with positive Ax nodes that are pathologically negative after NC. Secondary aims are OS, LRRFI, DRFI, DFS-DCIS, and second primary cancer, as well as comparing RT effect on cosmesis in reconstructed Mx pts.

Correlative science studies examine RT effect by tumor subtype, molecular outcome predictors for residual disease pts, and predictors for the degree of reduction in loco-regional recurrence.

Methods:

Clinical T1-3, N1 IBC pts with positive Ax nodes (FNA or core needle biopsy) complete ≥8 wks of NC (anthracycline and/or taxane). HER2-positive pts receive anti-HER2 therapy (tx). After NC, BCS or Mx is performed with a sentinel node biopsy (≥2 nodes) and/or Ax dissection with histologically negative nodes. ER/PR and HER2 neu status before NC is required. Pts receive required systemic tx. Radiation credentialing with a facility questionnaire and a case benchmark is required. Randomization for Mx pts is to no CWRNRT or CWRNRT and for BCS pts to WBI or WBI+RNRT.

Statistics:

1636 pts to be enrolled over 5 yrs with definitive analysis at 7.5 yrs. Study is powered at 80% to test that RT reduces the annual hazard rate of events for IBCR-FI by 35% for an absolute risk reduction in the 5-yr cumulative rate of 4.6%. Intent-to-treat analysis with 3 interim analyses at 43, 86, and 129 events, with a 4th/final analysis at 172 events will occur. Accrual as of 6/13/16 is 356. Pt-reported outcomes focusing on RT effect will be obtained from 736 pts before randomization and at 3, 6, 12, and 24 months.

Contacts:

Protocol: CTSU member website https://www.ctsu.org. Questions: NRG Oncology Pgh Clin Coord Dpt: 1-800-477-7227 or ccd@nsabp.org. Pt entry: OPEN at https://open.ctsu.org or the OPEN tab on CTSU member website.

Support: U10 CA-2166; -180868, -180822; -189867; Elekta.

Citation Format: Mamounas EP, Bandos H, White JR, Julian TB, Khan AJ, Shaitelman SF, Torres MA, Vicini FA, Ganz PA, McCloskey SA, Paik S, Gupta N, Li XA, DiCostanzo DJ, Curran, Jr WJ, Wolmark N. NRG oncology/NSABP B-51/RTOG 1304: A phase III superiority clinical trial designed to determine if chest wall and regional nodal radiotherapy (CWRNRT) post mastectomy (Mx) or the addition of RNRT to breast RT post breast-conserving surgery (BCS) will reduce invasive cancer events in patients (pts) with positive axillary (Ax) nodes and convert to ypN0 after neoadjuvant chemotherapy (NC) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT2-03-01.

Cerebro-cerebellar Resting-State Functional Connectivity in Children and Adolescents with Autism Spectrum Disorder

BACKGROUND

The cerebellum plays important roles in sensori-motor and supramodal cognitive functions. Cellular, volumetric, and functional abnormalities of the cerebellum have been found in autism spectrum disorders (ASD), but no comprehensive investigation of cerebro-cerebellar connectivity in ASD is available.

METHODS

We used resting-state functional connectivity magnetic resonance imaging in 56 children and adolescents (28 subjects with ASD, 28 typically developing subjects) 8-17 years old. Partial and total correlation analyses were performed for unilateral regions of interest (ROIs), distinguished in two broad domains as sensori-motor (premotor/primary motor, somatosensory, superior temporal, and occipital) and supramodal (prefrontal, posterior parietal, and inferior and middle temporal).

RESULTS

There were three main findings: 1) Total correlation analyses showed predominant cerebro-cerebellar functional overconnectivity in the ASD group; 2) partial correlation analyses that emphasized domain specificity (sensori-motor vs. supramodal) indicated a pattern of robustly increased connectivity in the ASD group (compared with the typically developing group) for sensori-motor ROIs but predominantly reduced connectivity for supramodal ROIs; and 3) this atypical pattern of connectivity was supported by significantly increased noncanonical connections (between sensori-motor cerebral and supramodal cerebellar ROIs and vice versa) in the ASD group.

CONCLUSIONS

Our findings indicate that sensori-motor intrinsic functional connectivity is atypically increased in ASD, at the expense of connectivity supporting cerebellar participation in supramodal cognition.

High tuberculosis prevalence in children exposed at home to drug-resistant tuberculosis

SETTING

Urban Karachi, Pakistan.

OBJECTIVE

To describe the yield of a contact investigation protocol implemented among children living with drug-resistant tuberculosis (DR-TB) patients.

DESIGN

We implemented a contact investigation protocol in households of DR-TB patients treated at the Indus Hospital, Karachi, between January 2008 and April 2011. This included a detailed history and physical examination, tuberculin skin test, chest radiograph, smear microscopy and culture of sputum or gastric aspirate specimens, and drug susceptibility testing. Treatment supporters who visited DR-TB patients at home referred all child contacts for baseline evaluation and performed monthly assessments. We evaluated two age groups: 1) children aged <5 years, and 2) those aged 5-14 years.

RESULTS

Among 133 children aged <15 years in 40 households, 40.4% (51/125) were moderately to severely underweight (weight-for-age Z-score <-2). Overall, 7.5% (10/133) had TB disease. This proportion was 6.5% (2/31) in those aged <5 years and 7.8% (8/102) in those aged 5-14 years. Seven (7/10) were smear-positive, and 4/10 had culture-confirmed multidrug-resistant Mycobacterium tuberculosis

CONCLUSION

We detected a high prevalence of TB in children who live with DR-TB patients, regardless of the age of the child. Child contacts of DR-TB patients are a high-yield population for detecting TB cases.

Identification of Chili leaf curl virus Causing Leaf Curl Disease of Petunia in Oman

Petunias (Petunia × hybrida) are the most important ornamental plants in Oman. In 2012, petunias were observed in public parks and airport landscape in Dhofar region with symptoms of upward leaf curling, yellowing and vein clearing, and size reduction in leaves. Almost all plants in the surveyed landscape showed high infestation of Bemisia tabaci and symptoms that suggested infection with a begomovirus. Six symptomatic samples were collected from three different sites. All symptomatic samples were found PCR-positive with diagnostic primers for begomovirus (3) when DNA extracted from infected leaves was used as template. Nucleic acids extracted from the symptomatic leaves were used to amplify circular DNA molecules by rolling circle amplification method. The amplified concatameric products were digested with restriction enzyme PstI, which yielded a product ∼2.8 kb in size. The putative begomovirus fragment was cloned and sequenced in both orientations. Partial sequences of six clones were 99 to 100% similar and thus only two clones, PT-2 and PT-3, were fully sequenced. The whole genomes of both clones were 2,761 bp, and both were deposited in GenBank under accession numbers HF968755 and HF968756 for the isolates PT-2 and PT-3, respectively. Both sequences had six open reading frames; Rep, TrAP, REn, and C4 genes in complementary sense; and CP and V2 genes in virion-sense, typical of the begomovirus genome organization. Upon alignment, the two sequences showed 99.4% nucleotide identity with each other, thus representing isolates of a single begomovirus species. BlastN comparison showed PT-2 and PT-3 from petunia were 94 to 95% identical to the sequences of ChCLV from Oman (JN604490 to JN604500), which were obtained from other hosts. ClustalV multiple sequence alignment showed that isolates PT-2 and PT-3 shared maximum sequence identity of 93.3 and 92.8%, respectively, with an isolate of ChLCV-OM (JN604495). According to ICTV rules for begomoviruses, PT-3 should be considered to be a new strain of ChLCV-OM and PT-2 a variant of the already existing ChLCV-OM strain. We propose the name for this new strain as the "Petunia strain" of Chili leaf curl virus (ChLCV-Pet). Two infectious clones were constructed from the PT-2 and PT-3 sequences, clones as 1.75-genome sequences in a binary vector, suitable for agroinfection to confirm their infectivity. Both clones, PT-2 and PT-3, produced typical leaf curl disease symptoms upon inoculation on petunia 18 days post inoculation. The presence of the same virus in symptomatic field infected and inoculated petunia was confirmed by Southern blot using 650 bp DIG labeled probe prepared from CP region of PT-3 isolate. ChLCV-OM, a monopartite begomovirus, is widely associated with leaf curl disease of tomato and pepper in Oman, with its origin traced to the Indian subcontinent (2). Identification of a new strain of ChLCV from petunia provides evidence of an ongoing rapid evolution of begomoviruses in this region. Although petunia has been tested as an experimental host for some begomoviruses (1,4), this is the first report of petunia as natural host for ChLCV, a begomovirus previously reported in tomato and pepper in Oman. References: (1) Cui et al. J. Virol. 78:13966, 2004. (2) Khan et al. Virus Res. 177:87, 2013. (3) Khan et al. Plant Dis. 97:1396, 2013. (4) Urbino et al. Arch. Virol. 149:417, 2003.

Basal subtype, as approximated by triple-negative phenotype, is associated with locoregional recurrence in a case-control study of women with 0-3 positive lymph nodes after mastectomy

PURPOSE

Basal subtype, as approximated by the triple-negative phenotype (ER-PR-Her2-), has correlated with higher LRR in recent studies. Indications for postmastectomy RT (PMRT) in women with 0-3 positive lymph nodes remain unclear. We evaluated the importance of biologic subtype in a cohort of women with LRR after mastectomy.

METHODS

We identified 22 women with 0-3 positive lymph nodes at our institution who were initially treated with mastectomy (without post-mastectomy radiation), suffered LRRs, and had paraffin-embedded tissue blocks from the primary mastectomy specimen available for staining. None of these women received PMRT. We case-control matched these to 29 women with 0-3 positive nodes who had mastectomy (no PMRT) and remained without evidence of disease at last follow-up and had available primary specimens for processing. We matched controls for age (±3 years) and follow-up duration (<5 year vs. more). Paraffin-embedded specimens were used to construct a triple-redundant tissue microarray. We used conditional logistic regressions to study the association between each predictor and LRR. Results were summarized based on odds ratio (OR).

RESULTS

On univariate analysis, ER+, PR+, or the combination was strongly associated with lower odds of LRR. Basal subtype, as approximated by ER-PR-Her2- (TN), was associated with higher LRR (OR 8.5, p = 0.048). Use of chemotherapy also was associated with lower LRR (OR 0.126, p = 0.0073).

CONCLUSIONS

Our data are concordant with reports from others demonstrating that TN phenotype is associated with higher LRR and can be considered along with other predictors of LRR when selecting women for PMRT.

A Distinct Strain of Chickpea chlorotic dwarf virus Infecting Pepper in Oman

During a field survey in 2011, pepper (Capsicum annum) plants showing symptoms suggestive of geminivirus infection were observed in three fields in the Al-Sharqiya region of Oman. Symptoms observed included upward leaf curling leading to cupping and stunting with 15 to 25% disease incidence in surveyed fields. Total DNA was extracted from the leaves of seven symptomatic plants and subjected to rolling circle amplification (RCA). The RCA product was digested with several restriction endonucleases to obtain unit length of ~2.6 to 2.8, typical of geminivirus. Out of seven samples, only four yielded a product of ~2.6 kb in size by KpnI digestion. The fragments were cloned in pUC19 and sequenced. The partial sequences of four isolates were >95% identical to each other at the nucleotide (nt) level and thus only one isolate (P-25) was fully sequenced, determined to be 2,572 nt in length, and its sequence deposited in GenBank (KF111683). The P-25 sequence showed a genome organization typical of a mastrevirus, with four open reading frames (ORFs), two in virion-sense and two in complementary-sense. The virion and complementary-sense ORFs were separated by a long intergenic region, containing a predicted hairpin structure with the nonanucleotide sequence (TAATATTAC) in the loop, and a short intergenic region. An initial comparison to all sequences in the NCBI database using BlastN showed the isolate to have the highest level of sequence identity with isolates of the dicot-infecting mastrevirus Chickpea chlorotic dwarf virus (CpCDV). Subsequent alignments of all available CpCDV isolates using the species demarcation tool (2) showed the isolate P-25 to share between 83.6 and 90.3% identity to isolates of CpCDV available in databases, with the highest (90.3%) to CpCDV strain A originating from Syria (FR687959) (3). Amino acid sequence comparison showed that the predicted proteins encoded by the four ORFs of P-25 (coat protein [CP], movement protein [MP], replication associated protein A [RepA], and RepB) share 91.5, 88.2, 89.1, and 90.8% amino acid sequence identity, respectively, with the homologous proteins of the CpCDV isolate from Syria. Based on the recently revised mastreviruses species and strain demarcation criteria (78 and 94% whole genome nt identity, respectively) proposed by Muhire et al. (2), the results indicate that isolate P-25 represents a newly identified strain (strain F) of CpCDV. The presence of CpCDV in symptomatic pepper plants was further confirmed by Southern blot hybridization technique using digoxygenin (DIG) labeled probe prepared from CpCDV isolate P-25. The genus Mastrevirus consists of geminiviruses with single component genomes that are transmitted by leafhoppers. Mastreviruses have so far only been identified in the Old World and infect either monocotyledonous or dicotyledonous plants (1). To our knowledge, this is the first report of a mastrevirus on the Arabian Peninsula and the first record of pepper as host of CpCDV. Recently, several begomoviruses of diverse geographic origins have been found infecting vegetable crops in Oman. The propensity of geminiviruses to evolve through recombination may lead to evolution of recombinant CpCDV with new host adaptability. Due to extensive agricultural/travel links of Oman with rest of the world, there exists high probability for the spread of this virus. References: (1) M. I. Boulton. Physiol. Mol. Plant Pathol. 60:243, 2002. (2) B. Muhire et al. Arch. Virol. 158:1411, 2013 (3) H. Mumtaz et al. Virus Genes 42:422, 2011.

A Distinct Strain of Tomato leaf curl Sudan virus Causes Tomato Leaf Curl Disease in Oman

Tomato leaf curl disease (ToLCD) is a significant constraint for tomato production in the Sultanate of Oman. The disease in the north of the country has previously been shown to be caused by the monopartite begomoviruses (family Geminiviridae) Tomato yellow leaf curl virus and Tomato leaf curl Oman virus. Many tomato plants infected with these two viruses were also found to harbor a symptom enhancing betasatellite. Here an analysis of a virus isolated from tomato exhibiting ToLCD symptoms originating from south and central Oman is reported. Three clones of a monopartite begomovirus were obtained. One of the clones was shown to be infectious to tomato and Nicotiana benthamiana and to induce symptoms typical of ToLCD. Analysis of the cloned sequences show them to correspond to isolates of Tomato leaf curl Sudan virus (ToLCSDV), a virus that occurs in Sudan and Yemen. However, the sequences showed less than 93% nucleotide sequence identity to previously characterized ToLCSDV isolates, indicating that the viruses represent a distinct strain of the species, for which we propose the name "Oman" strain (ToLCSDV-OM). Closer analysis of the sequences showed them to differ from their closest relative, the "Tobacco" strain of ToLCSDV originating from Yemen, in three regions of the genome. This suggests that the divergence of the "Oman" and "Tobacco" strains has occurred due to recombination. Surprisingly, ToLCSDV-OM was not found to be associated with a betasatellite, even though the isolates of the other ToLCSDV strains have been shown to be. The significance of these findings and the possible reasons for the distinct geographic distributions of the tomato-infecting begomoviruses within Oman are discussed.

Abstract P4-16-09: Dosimetric feasibility and acute toxicity in a prospective trial of ultra-short course accelerated partial breast irradiation (APBI) using a multi-lumen balloon brachytherapy device

Background: Shorter courses of APBI with novel fractionation schedules are being investigated; a large randomized trial from Europe has recently shown the safety and efficacy of a single-fraction adjuvant approach (with limited follow-up). We designed a prospective trial to identify and address the potential radiobiological and logistical limitations of single-fraction, intraoperative APBI.

Methods: We designed a single-arm, multi-institutional, prospective phase II trial that sequentially treats three cohorts of women (each n=30) with three progressively hypofractionated schedules. Eligible women were age ≥ 50 years with unifocal invasive or in situ tumors ≤ 3.0 cm, excised with negative margins, and with negative lymph nodes and positive hormone-receptors. Using a reference schedule of 60 Gy delivered in 2 Gy fractions, and assuming tumor parameters: a/b = 4 Gy; a = 0.27 Gy-1, and repopulation parameters of: Teff = 26 days; delay time = 0 days, the reference tumor BED is ∼ 86 Gy4. We began with a schedule of 4 fractions of 7 Gy delivered twice-daily using a Contura MLB multi-lumen device. We defined very conservative dosimetric criteria for acceptability: maximum skin and rib dose to not exceed 100% of prescription dose, and V150 and V200 to not exceed 40 cc and 10 cc, respectively. Subsequent schedules are 3 fractions of 8.25 Gy and 2 fractions of 10.25 Gy, both delivered over 2 days. The primary endpoint is to exclude a local failure rate exceeding 10% with the upper limit of a 95% confidence interval.

Results: A total of 30 patients have been enrolled at the 7 Gy × 4 fractions dose-level and followed for a minimum of 6 months. The median skin dose as a percent of prescription dose (PD) was 84% (40–100) and the median rib dose was 71% (16–119). 96% of the PTV_eval received a median of 95% of PD (range 85–103). The V150 (range 14–48cc) and V200 (range 0–29cc) criteria were met in all cases. One breast infection occurred and was treated; 2 cases of symptomatic fat necrosis and 2 cases of symptomatic seromas occurred. No acute toxicities greater than CTCAE grade 2 have been observed.

Conclusion: Short-course APBI is dosimetrically feasible using the Contura MLB and appears to be tolerable in terms of acute toxicities. Our approach is based on well-defined radiobiological parameters and allows for an abbreviated course of treatment that is guided by full pathological review and the ability to objectively achieve and validate acceptable dosimetric criteria in each case. We have opened enrollment to the next schedule of 8.25 Gy for three fractions.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-16-09.

Identification of Cotton leaf curl Gezira virus in Papaya in Oman

Papaya is an important fruit crop in Oman covering some 130 ha with an annual production of 20 tonnes. In 2011, during surveys of farms in the Quriyat region of Oman, papaya plants were found severely affected by leaf curl disease. Leaves with severe curling, vein darkening, and vein thickening were collected for study. Disease incidence ranged from 30 to 50%, particularly in fields with young papaya. A begomovirus (family Geminiviridae) was suspected as the causal agent based on symptoms (1) and the presence of whiteflies in the field. Samples (four to five) were collected from three farms. Total nucleic acids extracted from symptomatic leaves using the CTAB method were used as templates to amplify circular DNAs using Φ29 DNA polymerase and products were digested with restriction enzymes to identify fragments of 2.6 to 2.8 kb typical of geminiviruses. PstI yielded a fragment of ~1.8 kb when the digested product was analyzed by electrophoresis on a 1% agarose gel. The fragment was cloned and sequenced using primer walking strategy in both directions. The sequencing confirmed the exact size (1,764 bp) and the sequence was deposited in GenBank (HE800524). The viral sequence from Oman (isolate Pap-2) showed four open reading frames (ORFs) in the complementary sense (replication associated protein [Rep] gene, the C2 gene, the replication enhancer protein [REn] gene, and the C4 gene) and the virion-sense ORFs (V1 and V2) were missing in the sequence. An initial comparison to NCBI database sequences using BLAST showed the clone from Oman had the highest level of sequence identity to Cotton leaf curl Gezira virus (CLCuGeV) (FJ868828) cloned from okra in Sudan. Subsequent pair wise sequence comparison was done using ClustalV algorithm. Full length sequences of CLCuGeV from database were trimmed according to the size and genomic coordinates of Pap-2 isolate. The Pap-2 isolate sequence was found to have 83.3 to 95.1% sequence identity to CLCuGeV sequences with maximum value to the Sudan isolate. Amino acid sequence comparison showed that the four predicted proteins (Rep, C2, REn, and C4) encoded by the Pap-2 isolate shared 95.3%, 97.8%, 97.7%, and 87.6% sequence identity, respectively, with the homologous proteins of CLCuGeV-SD (FJ868828). The absence of virion-sense protein sequences indicated it to be a subgenomic molecule of CLCuGeV. According to the recommendations of International Committee on Taxonomy of Viruses, these results indicate that the virus identified in association with papaya leaf curl disease in Oman is a variant of CLCuGeV. CLCuGeV is a begomovirus of African origin which is distinct from the begomoviruses of the Middle East and Asia. To our knowledge, this is the first report of CLCuGeV, or any other cotton infecting begomovirus, from papaya in Oman. The presence of a recombinant fragment of CLCuGeV in a Tomato yellow leaf curl virus isolate from Iran (2), and the association of CLCuGeV with cotton in Pakistan (3) and hollyhock in Jordan (GU945265) suggests this virus has moved into the Middle East and Asia from Africa. The identification of CLCuGeV in Oman shows the widespread occurrence of this virus species. This discovery is important since Oman, and other countries in the area, are a hub of international trade and travel, particularly by air and sea, meaning that the virus could spread further. References: (1) R. W. Briddon and P. G. Markham. Virus Res. 71:151, 2000. (2) P. Lefeuvre et al. PLoS Pathog. 6:e1001164, 2010. (3) M. N. Tahir et al. PLoS ONE 6:e20366, 2011.

Predictors of delayed culture conversion in patients treated for multidrug-resistant tuberculosis in Pakistan

Culture conversion is an interim monitoring tool for treatment of multidrug-resistant tuberculosis (MDR-TB). We evaluated the time to and predictors of culture conversion in pulmonary MDR-TB patients enrolled in the community-based MDR-TB management program at the Indus Hospital in Karachi, Pakistan. Despite strict daily directly observed therapy, monthly food incentives and patient counseling, the median time to culture conversion was 196 days (range 32-471). The cumulative probabilities of culture conversion by 2, 4, 6 and 12 months were respectively 6%, 33%, 47%, and 73%. Smoking, high smear grade at baseline and previous use of second-line drugs delayed culture conversion.

Six-year analysis of treatment-related toxicities in patients treated with accelerated partial breast irradiation on the American Society of Breast Surgeons MammoSite Breast Brachytherapy registry trial

BACKGROUND

The American Society of Breast Surgeons (ASBrS) enrolled women in a registry trial to prospectively study patients treated with the MammoSite RTS device. This report presents 6-year data on treatment-related toxicities from the trial.

METHODS

A total of 1449 primary early-stage breast cancers were treated with accelerated partial breast irradiation (APBI) using the MammoSite device (34 Gy in 10 fractions) in 1440 women. Of these, 1255 case (87%) had invasive breast cancer (IBC) (median size = 10 mm) and 194 cases (13%) had ductal carcinoma in situ (DCIS) (median size = 8 mm). Median follow-up was 59 months. Fisher exact test was performed to correlate categorical covariates with toxicity.

RESULTS

Breast seromas were reported in 28% of cases (35.5% with open cavity and 21.7% with closed cavity placement). Also, 13% of all treated breasts developed symptomatic seromas, and 77% of these seromas developed during the 1st year after treatment. There were 172 cases (11.9%) that required drainage to correct. Use of chemotherapy and balloon fill >50 cc were associated with the development of symptomatic seromas. Also, 2.3% of patients developed fat necrosis (FN). The incidence of FN during years 1 and 2 were 0.9% and 0.8%, respectively. Seroma formation, use of hormonal therapy, breast infection, and A/B cup size were associated with fat necrosis. There were 138 infections (9.5%) recorded; 98% occurred during the 1st year after treatment. Chemotherapy and seroma formation were associated with the development of infections.

CONCLUSIONS

Treatment-related toxicities 6 years after treatment with APBI using the MammoSite device are similar to those reported with other forms of APBI with similar follow-up.

WHO guidelines for the programmatic management of drug-resistant tuberculosis: 2011 update

The production of guidelines for the management of drug-resistant tuberculosis (TB) fits the mandate of the World Health Organization (WHO) to support countries in the reinforcement of patient care. WHO commissioned external reviews to summarise evidence on priority questions regarding case-finding, treatment regimens for multidrug-resistant TB (MDR-TB), monitoring the response to MDR-TB treatment, and models of care. A multidisciplinary expert panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to develop recommendations. The recommendations support the wider use of rapid drug susceptibility testing for isoniazid and rifampicin or rifampicin alone using molecular techniques. Monitoring by sputum culture is important for early detection of failure during treatment. Regimens lasting ≥ 20 months and containing pyrazinamide, a fluoroquinolone, a second-line injectable drug, ethionamide (or prothionamide), and either cycloserine or p-aminosalicylic acid are recommended. The guidelines promote the early use of antiretroviral agents for TB patients with HIV on second-line drug regimens. Systems that primarily employ ambulatory models of care are recommended over others based mainly on hospitalisation. Scientific and medical associations should promote the recommendations among practitioners and public health decision makers involved in MDR-TB care. Controlled trials are needed to improve the quality of existing evidence, particularly on the optimal composition and duration of MDR-TB treatment regimens.