Medication use among children with asthma in East Harlem

PURPOSE

To examine daily use of antiinflammatory medication among children with asthma in East Harlem, where hospitalization rates for asthma are among the highest in the United States.

METHODS

We analyzed parent/guardian reports of medications used by children with current asthma (defined as physician diagnosis and wheezing during the previous 12 months) identified from a cross-sectional survey conducted in 2 elementary schools.

RESULTS

From an overall sample of 1319 children, 298 with current asthma were included in this analysis. Most of those with asthma were Puerto Rican (136 [46%]) or black (98 [33%]), 168 (57%) were boys, and the median age was 8 years old. Overall, 65 (22%) were using antiinflammatory medication on a daily basis. A subgroup of 107 children with asthma had been hospitalized during the previous 12 months or had used beta(2)-agonist on a daily basis, suggesting persistent or severe asthma. Of these 107 children, 42 (39%) were taking antiinflammatory medication on a daily basis. Multivariate analysis of these 107 children revealed that daily use of antiinflammatory medication was associated with using a spacer tube (adjusted odds ratio [AOR]: 3. 08; 95% confidence interval [CI]: 1.27,7.47) and having seen a physician in the past 6 months (AOR: 3.46; CI: 1.01,11.9). Compared with Puerto Ricans, blacks (AOR:.32; CI:.12,.89) or children of other races/ethnicities (AOR:.27; CI:.09,.85) were less likely to use antiinflammatory medication on a daily basis.

CONCLUSION

Daily use of antiinflammatory medication for children with persistent or severe asthma in East Harlem was underused. Differences in access to care may explain some findings; however, reasons for ethnic differences in use remain unclear. Both community interventions and additional provider education are needed.

Caudate blood flow and volume are reduced in HIV+ neurocognitively impaired patients

OBJECTIVE

To evaluate the effects of HIV-associated neurocognitive impairment on caudate blood flow and volume.

METHODS

The authors performed continuous arterial spin labeled MRI on 42 HIV+ patients (23 subsyndromic and 19 HIV neurosymptomatic) on highly active antiretroviral therapy and 17 seronegative controls. They compared caudate blood flow and volume among groups.

RESULTS

A stepwise decrease in both caudate blood flow and volume was observed with increasing HIV-associated neurocognitive impairment. Compared with seronegative controls, baseline caudate blood flow was reduced in HIV+ neurosymptomatic patients (p = 0.001) with a similar decreasing trend for subsyndromic HIV+ patients (p = 0.070). Differences in caudate volume were observed only for neurosymptomatic HIV+ patients compared with controls (p = 0.010). A Jonckheere-Terpstra test for trends was significant for both caudate blood flow and volume for each of the three subgroups. Pearson product moment correlation coefficients were not significant between caudate blood flow and volume for each group.

CONCLUSIONS

Decreasing trends in caudate blood flow and volume were associated with significantly increasing HIV-associated neurocognitive impairment (HNCI), with the greatest decreases observed for more severely impaired patients. However, reductions in caudate blood flow and volume were poorly correlated. Changes in residual caudate blood flow may act as a surrogate biomarker for classifying the degree of HNCI.

Cortical and subcortical afferent connections of a posterior division of feline area 7 (area 7p)

Area 7 of the cat, as identified cytoarchitecturally, includes cortex both on the middle suprasylvian gyrus and on the anterior lateral gyrus. The aim of the experiments reported here was to determine whether within this zone there are subdivisions with qualitatively different patterns of afferent connectivity. Deposits of distinguishable retrograde tracers were placed at 29 sites in and around area 7 of 15 cats; cortical and subcortical telencephalic structures were then scanned for retrograde labeling. Our results indicate that cortex on the anterior lateral gyrus, although often included in area 7, is indistinguishable on connectional grounds from adjacent somesthetic cortex (area 5b). Cortex with strong links to visual, oculomotor, and association areas is confined to the middle suprasylvian gyrus and the adjacent lateral bank of the lateral sulcus. We refer to this discrete, connectionally defined zone as posterior area 7 (area 7p). Area 7p receives input from visual areas 19, 20a, 20b, 21a, 21b, AMLS, ALLS, and PLLS; from frontal oculomotor cortex (areas 6m and 6l); and from cortical association areas (posterior cingulate cortex, the granular insula, the posterior ectosylvian gyrus, and posterior area 35). Thalamic projections to area 7p arise from three specific nuclei (pulvinar; nucleus lateralis intermedius, pars caudalis; nucleus ventralis anterior) and from the intralaminar complex (nuclei centralis lateralis, paracentralis and centralis medialis). Neurons in a division of the claustrum immediately beneath the somatosensory and visual zones project to area 7p. Within area 7p, anterior-posterior regional differentiation is present, as indicated by the spatial ordering of projections from cingulate and frontal cortex, the thalamus, and the claustrum. Area 7p, as delineated by connectional analysis in this study, resembles cortex of the primate inferior parietal lobule both in its location relative to other cortical districts and in its pattern of neural connectivity.

A controlled trial of fluoxetine in nondepressed patients with Huntington's disease

To examine the antidepressant specificity of fluoxetine in Huntington's disease (HD), we carried out a randomized, double-blind, placebo-controlled trial of this medication in nondepressed HD patients. Thirty patients with early HD who were depressed (Hamilton Depression Inventory < 16) were randomized to placebo (N = 13) or fluoxetine 20 mg/day (N = 17) and were followed up for 4 months. Outcome measures included changes in total functional capacity (TFC) and in standardized neurological, cognitive, and behavioral ratings. After adjustment for the higher education level found in the placebo group at baseline, no differences between the treatment groups were found in TFC, neurological, or cognitive ratings. Fluoxetine-treated patients did show a slight reduction in agitation and in the need for routine. Although fluoxetine may be a useful antidepressant in depressed HD patients, it failed to exert substantial clinical benefits in nondepressed HD patients.

The use of molecular imaging combined with genomic techniques to understand the heterogeneity in cancer metastasis

Tumour heterogeneity has, in recent times, come to play a vital role in how we understand and treat cancers; however, the clinical translation of this has lagged behind advances in research. Although significant advancements in oncological management have been made, personalized care remains an elusive goal. Inter- and intratumour heterogeneity, particularly in the clinical setting, has been difficult to quantify and therefore to treat. The histological quantification of heterogeneity of tumours can be a logistical and clinical challenge. The ability to examine not just the whole tumour but also all the molecular variations of metastatic disease in a patient is obviously difficult with current histological techniques. Advances in imaging techniques and novel applications, alongside our understanding of tumour heterogeneity, have opened up a plethora of non-invasive biomarker potential to examine tumours, their heterogeneity and the clinical translation. This review will focus on how various imaging methods that allow for quantification of metastatic tumour heterogeneity, along with the potential of developing imaging, integrated with other in vitro diagnostic approaches such as genomics and exosome analyses, have the potential role as a non-invasive biomarker for guiding the treatment algorithm.

Osimertinib and anti-HER3 combination therapy engages immune dependent tumor toxicity via STING activation in trans

Over the past decade, immunotherapy delivered novel treatments for many cancer types. However, lung cancer still leads cancer mortality, and non-small-cell lung carcinoma patients with mutant EGFR cannot benefit from checkpoint inhibitors due to toxicity, relying only on palliative chemotherapy and the third-generation tyrosine kinase inhibitor (TKI) osimertinib. This new drug extends lifespan by 9-months vs. second-generation TKIs, but unfortunately, cancers relapse due to resistance mechanisms and the lack of antitumor immune responses. Here we explored the combination of osimertinib with anti-HER3 monoclonal antibodies and observed that the immune system contributed to eliminate tumor cells in mice and co-culture experiments using bone marrow-derived macrophages and human PBMCs. Osimertinib led to apoptosis of tumors but simultaneously, it triggered inositol-requiring-enzyme (IRE1α)-dependent HER3 upregulation, increased macrophage infiltration, and activated cGAS in cancer cells to produce cGAMP (detected by a lentivirally transduced STING activity biosensor), transactivating STING in macrophages. We sought to target osimertinib-induced HER3 upregulation with monoclonal antibodies, which engaged Fc receptor-dependent tumor elimination by macrophages, and STING agonists enhanced macrophage-mediated tumor elimination further. Thus, by engaging a tumor non-autonomous mechanism involving cGAS-STING and innate immunity, the combination of osimertinib and anti-HER3 antibodies could improve the limited therapeutic and stratification options for advanced stage lung cancer patients with mutant EGFR.

An internet-delivered self-management programme for bipolar disorder in mental health services in Ireland: Results and learnings from a feasibility trial

Bipolar disorder (BD) is a chronic condition that requires continued care. Psychological interventions are recommended by clinical guidelines but there are treatment barriers that prevent patients to access these services. Internet-delivered self-management interventions are promising alternatives to improve treatment accessibility in patients with BD. Several studies indicate that these interventions are acceptable and beneficial for patients with BD, but no studies have been conducted in routine care settings. This trial aimed to examine the feasibility, acceptability, and preliminary efficacy of implementing an internet-delivered, clinician-supported intervention for BD as an adjunct to treatment as usual at two secondary-care services in Ireland. This study used an uncontrolled design with mixed-methods evaluation. Feasibility and acceptability were assessed in terms of recruitment, use of the intervention, and satisfaction from both clinicians and patients' perspectives. Personal recovery, quality of life, and severity of symptoms were measured at baseline and post-intervention. Fifteen patients signed consent and used the programme for 10 weeks. Usage of the intervention was adequate with high frequency of tool usage. There was a significant improvement in patients' sense of personal recovery (z = 2.38, p = .017). The intervention was found acceptable and easy-to-use; however, implementation barriers will need to be overcome for scaling the intervention. This is the first study testing the feasibility of a digital intervention for patients with BD in public mental health services in Ireland. More research is needed in order to increase the understanding of how to promote the integration and the uptake of digital interventions for individuals with BD.

The challenges of integrating molecular imaging into the optimization of cancer therapy

We review novel, in vivo and tissue-based imaging technologies that monitor and optimize cancer therapeutics. Recent advances in cancer treatment centre around the development of targeted therapies and personalisation of treatment regimes to individual tumour characteristics. However, clinical outcomes have not improved as expected. Further development of the use of molecular imaging to predict or assess treatment response must address spatial heterogeneity of cancer within the body. A combination of different imaging modalities should be used to relate the effect of the drug to dosing regimen or effective drug concentration at the local site of action. Molecular imaging provides a functional and dynamic read-out of cancer therapeutics, from nanometre to whole body scale. At the whole body scale, an increase in the sensitivity and specificity of the imaging probe is required to localise (micro)metastatic foci and/or residual disease that are currently below the limit of detection. The use of image-guided endoscopic biopsy can produce tumour cells or tissues for nanoscopic analysis in a relatively patient-compliant manner, thereby linking clinical imaging to a more precise assessment of molecular mechanisms. This multimodality imaging approach (in combination with genetics/genomic information) could be used to bridge the gap between our knowledge of mechanisms underlying the processes of metastasis, tumour dormancy and routine clinical practice. Treatment regimes could therefore be individually tailored both at diagnosis and throughout treatment, through monitoring of drug pharmacodynamics providing an early read-out of response or resistance.

Dropout From an Internet-Delivered Cognitive Behavioral Therapy Intervention for Adults With Depression and Anxiety: Qualitative Study

BACKGROUND

Treatment dropout continues to be reported from internet-delivered cognitive behavioral therapy (iCBT) interventions, and lower completion rates are generally associated with lower treatment effect sizes. However, evidence is emerging to suggest that completion of a predefined number of modules is not always necessary for clinical benefit or consideration of the needs of each individual patient.

OBJECTIVE

The aim of this study is to perform a qualitative analysis of patients' experiences with an iCBT intervention in a routine care setting to achieve a deeper insight into the phenomenon of dropout.

METHODS

A total of 15 purposively sampled participants (female: 8/15, 53%) from a larger parent randomized controlled trial were interviewed via telephone using a semistructured interview schedule that was developed based on the existing literature and research on dropout in iCBT. Data were analyzed using a descriptive-interpretive approach.

RESULTS

The experience of treatment leading to dropout can be understood in terms of 10 domains: relationship to technology, motivation to start, background knowledge and attitudes toward iCBT, perceived change in motivation, usage of the program, changes due to the intervention, engagement with content, experience interacting with the supporter, experience of web-based communication, and termination of the supported period.

CONCLUSIONS

Patients who drop out of treatment can be distinguished in terms of their change in motivation: those who felt ready to leave treatment early and those who had negative reasons for dropping out. These 2 groups of participants have different treatment experiences, revealing the potential attributes and nonattributes of dropout. The reported between-group differences should be examined further to consider those attributes that are strongly descriptive of the experience and regarded less important than those that have become loosely affiliated.

Lifestyle correlates of Carpal Tunnel Syndrome

The potential for predicting membership in a Carpal Tunnel Syndrome group (CTS) vs. a non-CTS group was evaluated for five psychological variables (i.e., life events stress, perceived stress, self-management habits, cognitive self-control skills, and lifestyle organization) and three physical variables (i.e., general physical symptoms, suspected medical risk for CTS, and generic musculoskeletal problems). The subjects included 50 pairs of workers, with each pair having one worker who had CTS and the other who had not. A logistic regression analysis indicated that five of the measures (three psychological and two physical) were significant single model predictors of membership in CTS and non-CTS groups. The most efficient multifactor model in predicting CTS appeared to be a combination of measures reflecting generic musculoskeletal problems and lifestyle organization.

Validity and reliability of eye healthcare professionals in the assessment of glaucoma - a systematic review

OBJECTIVE(S)

To explore the validity and reliability of eye healthcare professionals with different levels of training in diagnosing and/or identifying glaucomatous progression.

CLINICAL RELEVANCE

Substantial pressure is being placed on our current eye healthcare workforce by chronic diseases such as glaucoma. Shared care schemes and role expansion of professionals other than ophthalmologists are being proposed to alleviate this pressure. A sound evidence base is imperative to determine whether other allied health professionals are skilled and clinically competent, when it comes to taking on these new roles in glaucoma management.

METHODS

A systematic review of research articles identified in MEDLINE, CINAHL, Embase, Scopus and Cochrane Library was performed. Studies which investigated rater reliability of various health professionals in diagnosing and/or identifying glaucoma progression against a reference standard were included.

RESULTS

Of the 4088 publications identified by the initial database search, 32 met the inclusion criteria. The majority of studies demonstrated positive results, with most finding moderate to substantial agreement for inter- and intra-rater reliability across all testing modalities. The eye health professionals with ophthalmology training consistently attained the greatest agreement. When allied health professionals with different levels of training were compared, those who had completed residency training were significantly better than those who had not.

CONCLUSION

The studies included in this review show promising results, including those raters without ophthalmology training. A lack of power calculations, unequal sample sizes in some studies and the diversity of the testing procedures used make it difficult to make sound inferences.

'Joining the Dots: Linking Prenatal Drug Exposure to Childhood and Adolescence' - research protocol of a population cohort study

INTRODUCTION

Prenatal drug exposure (PDE) is one of the most important causes of child harm, but comprehensive information about the long-term outcomes of the families is difficult to ascertain. The Joining the Dots cohort study uses linked population data to understand the relationship between services, therapeutic interventions and outcomes of children with PDE.

METHODS AND ANALYSIS

Information from routinely collected administrative databases was linked for all births registered in New South Wales (NSW), Australia between 1 July 2001 and 31 December 2020 (n=1 834 550). Outcomes for seven mutually exclusive groups of children with varying prenatal exposure to maternal substances of addiction, including smoking, alcohol, prescription/illicit drugs and neonatal abstinence syndrome will be assessed. Key exposure measures include maternal drug use type, maternal social demographics or social determinants of health, and maternal physical and mental health comorbidities. Key outcome measures will include child mortality, academic standardised testing results, rehospitalisation and maternal survival. Data analysis will be conducted using Stata V.18.0.

ETHICS AND DISSEMINATION

Approvals were obtained from the NSW Population and Health Services Research Ethics Committee (29 June 2020; 2019/ETH12716) and the Australian Capital Territory Health Human Research Ethics Committee (11 October 2021; 2021-1231, 2021-1232, 2021-1233); and the Aboriginal Health and Medical Research Council (5 July 2022; 1824/21), and all Australian educational sectors: Board of Studies (government schools), Australian Independent Schools and Catholic Education Commission (D2014/120797). Data were released to researchers in September 2022. Results will be presented in peer-reviewed academic journals and at international conferences. Collaborative efforts from similar datasets in other countries are welcome.

Abstract P2-10-29: Time dependent breast cancer metastasis prediction using novel biological imaging, clinico-pathological and genomic data combined with Bayesian modeling to reduce over-fitting and improve on inter-cohort reproducibility

Background: Breast cancer heterogeneity demands that prognostic models must be biologically driven and recent clinical evidence indicates that future prognostic signatures need evaluation in the context of early versus late metastatic risk prediction. The aim of our work was to identify biologically validated quantitative imaging parameters with improved correlation to clinical outcome, and to address some of the remaining obstacles for a truly robust prognostic model in clinical use.

Method: We identified 4 seed proteins (ezrin/radixin/moesin-cofilin), along with several kinases as biologically relevant subnetwork of proteins that control tumor cell motility and metastasis. Patient-derived breast cancer tumour samples were used to perform a combination of imaging methods such as Fluoresecence lifetime imaging microscopy, automated segmentation and co-localisation intensity analysis. A complexity optimized Bayesian proportional hazard regression model was performed on a total of 419 breast cancer patients to validate time dependent predictions using traditional clinicopathological, genomic and our novel optical imaging-derived parameters. An independent dataset of 300 patient samples from the Leeds Institute of Molecular Medicine is currently being evaluated, representing a large cross centre validation of our integrated model.

Results: We demonstrate that the traditional gold standard clinico-pathological variables are poor predictors for patients that survive long periods, and that their predictive significance (in terms of hazard ratios) varies significantly between two temporal cohorts where the adjuvant treatments are vastly different. Moreover, we investigate the predictive accuracy of a combined imaging/clinicopathological model compared with genomic/clinicopathological models. We demonstrate how to reduce over-fitting to help improve the performance of prognostic models. Results of an integrated model combining genomic and imaging parameters are still awaited.

Discussion: We have produced the first optical imaging-derived multivariate tumour metastatic signature, which measures underlying key biological variables involved in regulating cancer cell motility. Using Bayesian proportional hazards regression in a time-dependent manner, we highlight the inadequacies of existing prediction tools and present a model combining the clinicopathological parameters with our imaging-based metastatic signature, as an integrative reproducible prognostic tool across different temporal cohorts.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-10-29.

Pushing through the Barriers: Peer Advice to Increase Physical Activity and Reduce Dementia Risk from Participants in a Massive Open Online Alzheimer's Focused Course

BACKGROUND

Engagement in physical activity is associated with reduced dementia risk but insufficient physical activity is a global trend.

OBJECTIVES

We aimed to explore what advice might be offered to others to increase physical activity and to identify enablers and barriers to physical activity for adults interested in dementia prevention and participating in a massive open online course.

PARTICIPANTS

Two thousand, one hundred and thirty-two participants contributed to an online discussion forum.

DESIGN

Analysis was conducted using Topic modelling analysis followed by thematic analysis.

RESULTS

The themes generated from the discussion posts included time constraints, poor health and lack of motivation as barriers to physical activity, and social interaction, incidental activities, and dog ownership as enablers. Peer advice was frequently suggested around scheduling physical activity into the day and joining a friend or organised activity.

CONCLUSION

This online discussion forum uniquely captured ideas from a large, diverse group of participants. Future research may benefit from further examining the role of discussion forums and peer advice in dementia risk reduction initiatives.

Abstract P5-01-01: Lymphoid tissue inducer cells: Identification of a novel immune cell within the breast tumour microenvironment and its role in promoting tumour cell invasion

Within breast cancers, trans-endothelial migration of tumour cells through lymphatic vessels is the first step to tumour dissemination and lympho-vascular invasion has been shown to stratify breast cancer phenotypes into distinct prognostic groups. The exact molecular mechanisms mediating tumor cell entry and persistence within the lymphatic system remain unclear. Lymphoid tissue inducer (LTi) cells are members of the emerging family of retinoic acid related orphan receptor (ROR)gt+ innate lymphoid cells (ILCs), and their interaction with stromal cells induces production by the stromal cells of VEGF-C and “lymphoid” chemokines, essential for lymphoid organogenesis. We hypothesized that tumour cells manipulate the normal processes that govern chemokine-dependent, trans-lymphatic migration of immune cells, including LTi cells; shaping its microenvironment. Results: We analyzed the expression of lymphoid chemokines genes (CXCL12, CXCL13, CCL19, CCL20 and CCL21) and their corresponding receptors (CXCR4, CXCR5, CCR6 and CCR7) within the METABRIC (Molecular Taxonomy of Breast Cancer International Consortium) Tissue Bank. An unsupervised hierarchical cluster analysis revealed co-expression of these genes, categorizing breast tumors as relatively high/low expressors. Tumors exhibiting relatively high expression of these genes were found to be enriched for “basal-like” breast cancers according to PAM50 intrinsic subtype assignments. Immunofluorescence of the primary tumour sections identified cells that were comparable in phenotype to LTi cells. In a blinded study, we observed that patients with high LTi counts within the tumour microenvironment were also likely to have a gene expression corresponding to high expression for the lymphoid chemokines. IHC for the lymphatic marker, podoplanin found that the LTi count correlated with both an increased lymphatic vessel density and tumor invasion into lymphatic vessels. Within the basal and HER2+ve subtypes, patients with more than 4 lymph nodes were found to exhibit higher numbers of intratumoural LTi cells. In vitro studies, alongside multi-photon in vivo imaging were performed to investigate the interaction between intra-tumoural LTi and mesenchymal stromal cells. CXCL13 was shown to be essential for LTi clustering around stromal cells in vitro, and, the administration of a blocking antibody in vivo delayed the onset of lymph node metastasis in a murine mammary tumour (4T1.2) model. CXCLl3 has been identified as having independent prognostic significance in breast cancer, but we and others report that breast cancer cell lines are not the source of CXCL13. We show that an increase in stromal CXCL13 concentration within the tumour microenvironment following LTi recruitment promotes an EMT phenotype in the 4T1.2 cancer cell line, possibly via activation of the RANKL/RANK axis promoting tumorigenesis. We report for the first time, the identification of LTi cells within the human breast cancer tumour microenvironment and propose a pivotal role for these cells, through stromal cell interactions in the tumour microenvironment, in facilitating lymphatic invasion of tumour cells by modulation of the local lymphoid chemokine profile.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-01-01.

How audit can improve provision of in-patient pain services

Clinical governance makes it necessary for the cycle of clinical audit to be refined, encouraging a continuous process of quality improvement. This is achieved through the monitoring of practice and benchmarking, and supported by continuing practice development. Reliable information is essential if pain services are to be improved in line with patients' needs.

The transition to managed care: experiences of planned parenthood patients

A review of the findings from a 1996 survey of women visiting a Planned Parenthood clinic reveals that some members of managed care organizations (MCOs) may not be receiving appropriate preventive services and information from their primary care providers. This article details the results of a survey of 115 women who attended a Planned Parenthood of New York City clinic for reproductive health services. Based on these survey findings, the authors provide recommendations for MCOs and traditional providers of reproductive health to improve service delivery.