Single Institution Preliminary Evaluation of a National Study for the Development of Daily Online Magnetic Resonance Image Guided Radiotherapy

PURPOSE/OBJECTIVE(S)

A 4-stage non-comparative prospective feasibility study to assess and develop imaging protocols for MRIgRT was opened at the first two centers using MR Linac technology in the UK. The primary aims of this study were to determine a) the acceptability of MR images for target and organ at risk delineation and registration; b) inter/intra observer registration and delineation variation. This work reports on the initial results from a single center.

MATERIALS/METHODS

In June 2019, following ethical and regulatory approvals the 2nd UK centre began study recruitment as follows: Stage A: non-patient volunteer imaging to determine sequence suitability for normal tissue in 6 anatomical sites (head & neck (H&N), chest wall/breast, lung/esophagus, abdomen, male and female pelvis). Volunteers were recruited in cohorts of 3 participants per region, and image quality was assessed by 3 independent observers using a visual guidance assessment tool (VGA). Stage B: the most suitable sequences defined in stage A used to assess the visibility of targets/normal tissues in patient volunteers using the same methods as in stage A. Stage C: patient volunteers were imaged using sequences selected from stage B to determine inter and intra observer segmentation and registration variation. Stage D recruitment of patient and non-patient volunteers for further image develop and refinement of MRIgRT workflows. All participants completed experience questionnaires to optimize workflows. Participants were asked to undergo 1-12 imaging sessions, lasting no more than 60.

RESULTS

To date 151 participants (61 non-patients; 90 patients) have undergone 231 imaging sessions. From stage B, vendor provided, in-workflow sequences have been agreed from 47 completed VGAs by prioritizing high scores in either the tumor (e.g., lung) or organs at risk (e.g., cervix). T2w 3D sequences scored best in cervix, pancreas, prostate, bladder, liver, soft-tissue metastases and rectal cancers; T1w 3D sequences for H&N, and patient a specific approach for lung. No suitable sequences have been selected for partial breast. Research sequences (e.g., diffusion weighted or motion corrected imaging) have been agreed or are in development in stages C & D for H&N, cervix, bladder and prostate cancers. The mean interobserver (n = 8) vector variation in 5 H&N patients was largest (3.6mm) using T1-CT boney registrations and smallest (2.1mm) using T1-T1 soft-tissue registrations (mean observer match confidence 3.7/5). Analyses using MR to CT, MR to MR and CT to CT registrations in lung, pancreas, cervix, bladder, and prostate have also been completed. Interobserver delineation studies are on-going.

CONCLUSION

Using a 4-stage non-comparative prospective feasibility study has facilitated clinical implementation MRIgRT of multiple treatment sites at our institution.

Barriers and facilitators to conducting radiotherapy clinical trials: Findings from a UK survey

INTRODUCTION

As an essential component of service delivery, radiotherapy clinical trials were championed within the NHS England service specifications. A call for a 15% increase in research and clinical trial activity, alongside a demand for equity of access for patients with cancer subsequently ensued. National understanding of current radiotherapy clinical trials operational practices is absent, but essential to help establish the current provision required to support the development of a strategic plan for implementation of NHS England's specifications.

METHODS

A cross-sectional survey was developed by a multi-disciplinary team and distributed to therapeutic radiography clinical trial leads across the UK to ascertain the current provision of radiotherapy clinical trials only, including workforce resources and the trials management processes to establish a benchmark and identify potential barriers, enablers, and opportunities to increase access to clinical trials.

RESULTS

Thirty-two complete responses were obtained equating to 49% of the total UK NHS departments and 74% of those departments invited. Four key findings were identified: 1) research strategy and systems, 2) participation and activity in radiotherapy clinical trials, 3) access to clinical trials at alternative departments and 4) facilitators & barriers. Overarchingly a lack of radiotherapy clinical trials strategy or supported processes were apparent across the UK, aggravating existing barriers to trial activity.

CONCLUSION

It is essential for radiotherapy clinical trials to be embedded in to departmental and Trust strategy, this will help to ensure the processes and resources required for trial delivery are not only in place, but also recognised as imperative and important for patients with cancer as radiotherapy treatment delivery.

IMPLICATIONS FOR PRACTICE

Failure to address the barriers or build upon the facilitators may result in UK radiotherapy departments facing challenges in achieving the 15% increase in radiotherapy clinical trial activity.

Use of the HOME Inventory with Families of Young Visually Impaired Children

The study reported here examined the usefulness of the Infant-Toddler and the Early Childhood forms of the HOME Inventory as applied to children who are visually impaired. The results indicated that families of children with visual impairments scored about the same as did families in the norm groups.

Introducing magnetic resonance imaging into the lung cancer radiotherapy workflow - An assessment of patient experience

INTRODUCTION

Magnetic resonance imaging (MRI) offers superior soft tissue contrast to computed tomography (CT), the current standard imaging modality for planning radiotherapy treatment. Improved soft tissue contrast could reduce uncertainties in identifying tumour and surrounding healthy tissues, potentially leading to improved outcomes in patients with lung cancer. This study explored patient experience of MR treatment planning scans in addition to a CT scan.

METHODS

Participants were recruited to the 'Magnetic Resonance Imaging for the Delineation of Organs At Risk and Target Volumes in Lung Cancer Patients (MR-Lung)' study at a UK specialist cancer centre. Participants completed their standard of care radiotherapy planning CT scan and two additional MRI scans. Baseline and post-scan questionnaires were completed assessing anxiety and claustrophobia. Motion artefact during MRI was assessed by a modified visual grading analysis. Sixteen participants completed semi-structured interviews; transcripts were analysed thematically.

RESULTS

29 people (66% female; aged 54-89 years) participated. Nineteen participants completed all imaging and 10 participants withdrew before completion. There was minimal adverse impact on state and scan-specific anxiety levels from completing the MRI scans. Completers experienced significantly less scan-specific anxiety during MRI 1 compared to non-completers (U = 33, z = -1.98, p < 0.05). 78% of those who withdrew during or post MRI 1 were positioned 'arms up'. Motion artefact negatively impacted image quality in 34% of scans. Participants commonly reported concerns during MRI; noise, claustrophobia and pain in upper limbs.

CONCLUSION

Two thirds of participants tolerated two additional MR scans with minimal adverse impact on anxiety levels.

IMPLICATIONS FOR PRACTICE

Patient arm positioning and comfort ought to be considered when introducing MR-Linac systems. A screening tool to identify those at high risk of non-completion should be developed.

The projected costs and benefits of a supervised injection facility in Seattle, WA, USA

BACKGROUND

As one strategy to improve the health and survival of people who inject drugs, the King County Heroin & Opioid Addiction Task Force recommended the establishment of supervised injection facilities (SIF) where people can inject drugs in a safe and hygienic environment with clinical supervision. Analyses for other sites have found them to be cost-effective, but it is not clear whether these findings are transferable to other settings.

METHODS

We utilized local estimates and other data sources deemed appropriate for our setting to implement a mathematical model that assesses the impact of a hypothetical SIF on overdose deaths, non-fatal overdose health service utilization, skin and soft tissue infections, bacterial infections, viral infections, and enrollment in medication assisted treatment (MAT). We estimated the costs and savings that would occur on an annual basis for a small-scale pilot site given current overdose rates, as well as three other scenarios of varying scale and underlying overdose rates.

RESULTS

Assuming current overdose rates, a hypothetical Seattle SIF in a pilot phase is projected to annually reverse 167 overdoses and prevent 6 overdose deaths, 45 hospitalizations, 90 emergency department visits, and 92 emergency medical service deployments. Additionally, the site would facilitate the enrollment of 41 SIF clients in medication assisted treatment programs. These health benefits correspond to a monetary value of $5,156,019. The annual estimated cost of running the SIF is $1,222,332. The corresponding cost-benefit ratio suggests that the pilot SIF would generate $4.22 for every dollar spent on SIF operational costs. The pilot SIF is projected to save the healthcare system $534,453. If Seattle experienced elevated overdose rates and Seattle SIF program were scaled up, the health benefits and financial value would be considerably greater.

CONCLUSION

This analysis suggests that a SIF program in Seattle would save lives and result in considerable health benefits and cost savings.

Caloric requirement for refeeding inpatients with anorexia nervosa: the contribution of anxiety exercise, and cigarette smoking

BACKGROUND

Refeeding inpatients with anorexia nervosa (AN) is costly, stressful, and can precipitate the refeeding syndrome. Caloric intake is usually increased gradually from a low starting point until a steady weight gain is achieved. There is no reliable equation that predicts the number of calories required for a weight gain. It was our clinical suspicion that anxiety, exercise, and cigarette smoking might increase the caloric need for refeeding.

METHOD

We conducted an observational cohort study of 17 females with AN admitted to an inpatient eating disorder unit for refeeding. We estimated the energy intake by observation, the caloric expenditure due to exercise with a triaxial accelerometer, the number of cigarettes smoked by history, and the anxiety by the Beck Anxiety Inventory (BAI).

RESULTS

Neither anxiety, exercise, or cigarette smoking predicted the caloric requirement for refeeding, individually or in combination.

DISCUSSION

Our data suggest that the caloric requirement for weight gain during refeeding is not predicted by the patient's anxiety, exercise or smoking habits. The standard methods of estimating caloric requirements for refeeding remain indirect calorimetry and previous history.

Health status of preterm low-birth-weight infants. Comparison of maternal reports

BACKGROUND

Developers of measures of child health status have documented acceptable reliability and some validity, but less attention has been paid to the concurrent and predictive validity of these measures.

METHODS

We examined the concurrent and predictive validity of the RAND General Health Rating Index, the Stein-Jessop Functional Status II-R, and the mother's global assessment of her child's health on a 5-point scale, in a sample of preterm low-birth-weight children (n = 608) who were followed up as controls in the Infant Health and Development Program. We compared maternal-reported measures assessed at 24 months with other measures of growth, morbidity, functioning, and health care utilization assessed concurrently and at 36 months in bivariate and multivariate analyses.

RESULTS

After controlling for other factors, the RAND General Health Rating Index and the Stein-Jessop Functional Status II-R were unrelated to the growth, utilization, or functioning measures. The RAND General Health Rating Index was significantly, but weakly, related to future morbidity. The mother's global perception of health was significantly related to outpatient utilization and behavior problems.

CONCLUSIONS

Clinicians may find that maternal assessment of overall child health is a sensitive but nonspecific indicator of the mother's concern. For researchers, none of these measures seems likely to serve as a proxy for health care utilization or morbidity in studies of other phenomena, or as an indicator of detailed health outcomes.

Home environment and adaptive social behavior among premature, low birth weight children: alternative models of environmental action

Used data from 465 premature, low birth weight children representing three major sociocultural groups (Caucasian, African American, Hispanic) to examine the relation between children's home environments and their adaptive social behavior. Results showed low to moderate associations between scores on the HOME Inventory at 1 and 3 years and scores on two measures of adaptive social behavior at 30 to 36 months, the Adaptive Social Behavior Inventory, and observations of mother-child interaction in a structured laboratory situation. Results indicated that responsive, nurturant care at both 1 and 3 years are related to child adaptive social behavior, as are cognitively stimulating experiences and materials. However, canonical correlational analysis indicated that only Acceptance and Variety of Experience, measured at age 3, and Variety of Experience measured at age 1 accounted for independent amounts of variance in adaptive social behavior as perceived by mothers. Also, only sociocultural group status and Learning Materials at 36 months contributed to the prediction of persistence and enthusiasm as observed in the laboratory setting.

A multifaceted intervention for infants with failure to thrive. A prospective study

OBJECTIVE

To determine whether a multifaceted intervention decreased the incidence of failure to thrive (FTT) in a group of preterm infants with low birth weights and improved the 3-year intelligence, health, growth, and behavior status of the children with FTT.

DESIGN

Three-year, prospective, randomized, clinical trial.

SETTING

Eight large university hospital sites throughout the United States.

SAMPLE

Nine hundred fourteen preterm infants with low birth weights who were born at the sites and met study criteria.

INTERVENTION

Home visits weekly during the first year of life and biweekly thereafter until the age of 3 years to provide family support and implement two curricula; and attendance at a child development center from 12 months until 3 years of age, 5 days a week, to deliver an early childhood educational intervention.

RESULTS

The incidence of FTT did not differ between the treatment and control groups (20% vs 22%). Overall, children with FTT in the treatment group were not different from children with FTT in the follow-up group on any of the outcome variables. However, after controlling for other factors, treatment group membership significantly contributed to the prediction model of 36-month IQ (P = .005) for the children with FTT. In addition, children with FTT in the intervention group with higher compliance demonstrated higher 3-year IQ and better behavior scores than the children with FTT in the low-compliance group.

CONCLUSIONS

The intervention did not change the incidence of FTT or the 3-year outcomes in this low-birth-weight, preterm cohort. After controlling for multiple independent variables, marked effects on 3-year IQ were noted. In addition, these beneficial effects were most pronounced in families that were most complaint with the intervention.

A reexamination of the association between HOME scores and income

This study, which represents another look at the relationship between the HOME Inventory and income, uses data from the Infant Health and Development Program (IHDP), a multisite, longitudinal study of low-birth-weight preterm infants. Two versions of the HOME Inventory were used: The Infant/Toddler (IT-HOME), at 12 months of age, and the Early Childhood (EC-HOME), at 36 months of age. Predictor variables were income, ethnicity, maternal education, parity, gestational age, marital status, maternal age, and site. HOME scores were positively correlated with income. However, after controlling for the other variables in the models, the portion of the variance in HOME scores uniquely explained by income was quite low (IT-HOME, 5.1%; EC-HOME, 4.2%). Finally, the relationship between HOME scores and four child characteristics (cognitive development, growth, maladaptive behavior, and social competence) measured when the child was 36 months old were investigated using correlation. The results indicated that the quality of the home environment, as measured by the HOME Inventory, is related to children's development.

A factor analytic study of the infant-toddler and early childhood versions of the HOME Inventory administered to white, black, and Hispanic american parents of children born preterm

Factor analyses were performed on the Infant-Toddler and the Early Childhood versions of the HOME Inventory for 3 groups (blacks, whites, and Hispanics) of premature, low-birthweight children. Participants lived in 8 different U.S. cities. On the IT-HOME, 5 factors were originally retained for each group using the principal factors method of extraction. Factor structures for blacks and whites were similar, accounting for 85% and 75% of the variance, respectively. The structure for Hispanics was somewhat different; a 7-factor solution accounting for 65% of the variance was most interpretable. For the EC-HOME, 6 factors were retained for both black and white groups, accounting for 80% and 73% of the variance, respectively. For Hispanics, an 8-factor solution accounted for 59% of the variance. The factor structures for blacks and whites were largely in agreement with the current organization of items into subscales. The fit for Hispanics was not quite as good, but most factors also corresponded to current subscales.

Early indications of resilience and their relation to experiences in the home environments of low birthweight, premature children living in poverty

The caregiving environment experienced by 243 premature, low birthweight (LBW) children living in poverty was examined to determine whether the quality of care such children receive affords them some measure of protection from the generally deleterious consequences of poverty and prematurity. Only 26 children were identified as functioning in the normal range for cognitive, social/adaptive, health, and growth parameters at age 3. These children, who showed early signs of resiliency, differed from nonresilient children in that they were receiving more responsive, accepting, stimulating, and organized care. They were also living in safer, less crowded homes. 6 "protective" aspects of caregiving were identified and used as part of a cumulative protection index. Children with less than 3 protective aspects of caregiving present at age 1 had only a 2% probability of being resilient, and only a 6% probability if fewer than 3 were present at age 3. Overall, premature LBW children born into conditions of poverty have a very poor prognosis of functioning within normal ranges across all the dimensions of health and development assessed. However, those raised in a setting with 3 or more protective factors were more likely to show early signs of resiliency.

Risk factors and outcomes for failure to thrive in low birth weight preterm infants

OBJECTIVE

To determine the epidemiology, clinical characteristics, and outcomes for low birth weight (LBW) infants with growth deficiency, or failure to thrive (FTT, the term commonly used by pediatric providers to describe growth deficiency or faltering in early childhood).

DESIGN

Three-year prospective cohort study with matched case-control study of outcomes.

SETTING

Eight large university hospital sites throughout the United States.

SAMPLE

914 LBW infants inborn at the sites and meeting study criteria.

RESULTS

FTT was a common condition in this cohort, with 180 (19.7%) of 914 LBW infants meeting case criteria by 30 months. New cases of FTT peaked at 8 months gestation-corrected age. In addition to expected differences in growth between infants with and without FTT, infants with FTT had lower developmental indices and less stimulating home environments. At 36 months, FTT infants had lower IQ scores and were much smaller than infants without FTT.

CONCLUSIONS

Growth deficiency, or FTT, is a common clinical condition for those involved in the follow-up care of LBW infants. Worse cognitive and growth outcomes were observed for those meeting the restrictive case criteria employed in this study. More than 80% of the cases in this LBW cohort did not involve any chronic medical disorders, but several biological and environmental differences were found between those who developed FTT and those who did not.

Low-birth-weight infants born to adolescent mothers. Effects of coresidency with grandmother on child development

OBJECTIVE

To explore the impact of young maternal age, coresidency with infant's grandmother, and other familial and environmental factors on development of low-birth-weight (LBW) infants.

DESIGN

Prospective cohort analyses.

SETTING

Eight medical institutions in different geographical locations participating in the Infant Health and Development Program.

PARTICIPANTS

Control population of 272 LBW, preterm infants enrolled in the Infant Health and Development Program born to mothers aged 15 to 24 years.

MAIN OUTCOME MEASURE

Child cognitive, behavioral, and health outcomes at 36 months' gestation-corrected age.

RESULTS

Maternal age was not significantly related to child development. Coresidence with infant's grandmother was associated with improved cognitive and health outcomes. Maternal ethnicity, maternal verbal ability, and other environmental factors were also associated with child outcomes.

CONCLUSIONS

Findings of this study support the need for programs that include the extended family of at-risk infants, providing education and literacy skills to the mothers and encouraging participation of all care givers of the child.