Virtual Cancer Care Beyond the COVID-19 Pandemic: Patient and Staff Perspectives and Recommendations

PURPOSE

COVID-19 catalyzed rapid implementation of virtual cancer care (VC); however, work is needed to inform long-term adoption. We evaluated patient and staff experiences with VC at a large urban, tertiary cancer center to inform recommendations for postpandemic sustainment.

METHODS

All physicians who had provided VC during the pandemic and all patients who had a valid e-mail address on file and at least one visit to the Princess Margaret Cancer Centre in Toronto, Canada, in the preceding year were invited to complete a survey. Interviews and focus groups with patients and staff across the cancer center were analyzed using qualitative descriptive analysis and triangulated with survey findings.

RESULTS

Response rates for patients and physicians were 15% (2,343 of 15,169) and 41% (100 of 246), respectively. A greater proportion of patients than physicians were satisfied with VC (80.1 v 53.4%; P < .01). In addition, fewer patients than physicians felt that virtual visits were worse than those conducted in person (28.0 v 43.4%; P < .01) and that telephone and video visits negatively affected the human interaction that they valued (59.8% v 82.0%; P < .01). Major barriers to VC for patients were respect for care preferences and personal boundaries, accessibility, and equitable access. For staff, major barriers included a lack of role clarity, dedicated resources (space and technology), integration of nursing and allied health, support (administrative, clinical, and technical), and guidance on appropriateness of use.

CONCLUSION

Patient and staff perceptions and barriers to virtual care are different. Moving forward, we need to pay attention to both staff and patient experiences with virtual care since this will have major implications for long-term adoption into clinical practice.

Multimodal detection of molecular residual disease in high-risk locally advanced squamous cell carcinoma of the head and neck

Up to 30% of patients with locally advanced head and neck squamous cell carcinoma (LA-HNSCC) relapse. Molecular residual disease (MRD) detection using multiple assays after definitive therapy has not been reported. In this study, we included patients with LA-HNSCC (stage III Human Papilloma virus (HPV)-positive, III-IVB HPV-negative) treated with curative intent. Plasma was collected pre-treatment, at 4-6 weeks (FU1) and 8-12 weeks (FU2) post-treatment. Circulating tumor DNA (ctDNA) was analyzed using a tumor-informed (RaDaR®) and a tumor-naïve (CAPP-seq) assay. HPV DNA was measured using HPV-sequencing (HPV-seq) and digital PCR (dPCR). A total of 86 plasma samples from 32 patients were analyzed; all patients with at least 1 follow-up sample. Most patients were stage III HPV-positive (50%) and received chemoradiation (78%). No patients had radiological residual disease at FU2. With a median follow-up of 25 months, there were 7 clinical relapses. ctDNA at baseline was detected in 15/17 (88%) by RaDaR and was not associated with recurrence free survival (RFS). Two patients relapsed within a year after definitive therapy and showed MRD at FU2 using RaDaR; detection of ctDNA during follow-up was associated with shorter RFS (p < 0.001). ctDNA detection by CAPP-seq pre-treatment and during follow-up was not associated with RFS (p = 0.09). HPV DNA using HPV-seq or dPCR during follow-up was associated with shorter RFS (p < 0.001). Sensitivity and specificity for MRD at FU2 using RaDaR was 40% and 100% versus 20 and 90.5% using CAPP-seq. Sensitivity and specificity for MRD during follow-up using HPV-seq was 100% and 91.7% versus 50% and 100% using dPCR. In conclusion, HPV DNA and ctDNA can be detected in LA-HNSCC before definitive therapy. The RaDaR assay but not CAPP-seq may detect MRD in patients who relapse within 1 year. HPV-seq may be more sensitive than dPCR for MRD detection.

Efficacy of the Rehabilitation Planning Consult for Survivors of Head and Neck Cancer: A Phase 2 Randomized Controlled Trial

PURPOSE

Survivors of head and neck cancer may have significant lasting impairments and poor access to rehabilitation. To address this, our group developed and evaluated a rehabilitation planning consult (RPC). The RPC is conducted through an initial consultation and a single follow-up session with a rehabilitation professional. During the initial consultation, rehabilitation needs are determined and the survivor sets individualized goals and plans. They then implement their plans independently and are facilitated to evaluate and modify plans as necessary during the follow-up session.

METHODS AND MATERIALS

We used a waitlist control design to compare the proportion of participants attaining a minimally importantly different change in quality of life (QOL) on the Short Form 36 Physical Health Summary Score from baseline to 3 months after study enrollment, between patients randomized to receive (n = 77) or wait 14 ± 3 weeks to receive (n = 76) the RPC. Additional outcomes included goal attainment indicators measured using the Brief Rehabilitation Assessment for Survivors of Head and Neck Cancer (BRASH).

RESULTS

Of 153 participants recruited, 95 (62%) completed the intervention; 57 were in the immediate (RPC) group and 38 were in the waiting list control (WLC) group. No significant between-group differences were seen in the proportion of patients achieving a minimally important improvement (2.5 units) on the Physical Health Summary Score from baseline to 3 months after recruitment. No between-group differences were seen on any secondary QOL indicators. Among the 67 (RPC n = 42, WLC n = 22) participants who set individualized rehabilitation goals, BRASH scores on goal performance and satisfaction with goal performance were significantly better in the RPC group.

CONCLUSIONS

Our results suggest that the RPC may provide benefit in patients' individualized domains of choice among those who set goals, without affecting overall QOL. Future work could refine the subset of patients who benefit and explore the optimal timing and intensity of the intervention.

Women in Health and their Economic, Equity and Livelihood statuses during Emergency Preparedness and Response (WHEELER) protocol: a mixed methods study in Kenya

INTRODUCTION

Kenya reported its first COVID-19 case on 13 March 2020. Pandemic-driven health system changes followed and unforeseen societal, economic and health effects reported. This protocol aims to describe the methods used to identify the gender equality and health equity gaps and possible disproportional health and socioeconomic impacts experienced by paid and unpaid (community health volunteer) female healthcare providers in Kilifi and Mombasa Counties, Kenya during the COVID-19 pandemic.

METHODS AND ANALYSIS

Participatory mixed methods framed by gender analysis and human-centred design will be used. Research implementation will follow four of the five phases of the human-centred design approach. Community research advisory groups and local advisory boards will be established to ensure integration and the sustainability of participatory research design.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Institutional Scientific and Ethics Review Committee at the Aga Khan University and the University of Manitoba.This study will generate evidence on root cultural, structural, socioeconomic and political factors that perpetuate gender inequities and female disadvantage in the paid and unpaid health sectors. It will also identify evidence-based policy options for future safeguarding of the unpaid and paid female health workforce during emergency preparedness, response and recovery periods.

Contrast Enhanced CT Radiogenomics in a Retrospective NSCLC Cohort: Models, Attempted Validation of a Published Model and the Relevance of the Clinical Context

RATIONALE AND OBJECTIVE

To develop a radiogenomic predictive model for non-small cell lung cancer (NSCLC) patients studied through contrast enhanced chest computed tomography (CE-CT) targeting the most frequent gene alterations. M&M: A retrospective study of patients with NSCLC imaged with CE-CT before treatment and had their tumor genomics sequenced at our institution was performed. Data was gathered from their imaging studies, their electronic medical records and a web-based database search (cBioPortal.ca). All of the patient data was tabulated for analysis. Two predictive models (M1 & M2) were created using different approaches and a third model was extracted from the literature to also be tested in our population.

RESULTS

Out of 157 patients, eighty were male (51%) and 124 (79%) had a history of smoking. The three most prevalent genes were KRAS, TP53 and EGFR. The M1 radiomics-only model median AUC were 0.61 (TP53), 0.53 (KRAS) and 0.64 (EGFR) and for M1 radiomics + clinical were 0.61 (TP53), 0.61 (KRAS) and 0.80 (EGFR). The M2 radiomics-only model median AUC were 0.63 (TP53), 0.60 (KRAS) and 0.65 (EGFR) and for M2 radiomics + clinical were 0.64 (TP53), 0.62 (KRAS) and 0.81 (EGFR). The external EGFR radiomic model showed an AUC of 0.69 and 0.86 for the radiomics-only and combined radiomics + clinical respectively.

CONCLUSION

Our study was able to provide robust predictive radiomics model evaluation for the detection of TP53, KRAS and EGFR. We also compared our performance with an already published model and observed how impactful clinical variables can be on models' performance.

CLINICAL RELEVANCE STATEMENT

Identifying tumor mutations in patients that can't undergo biopsy is critical for their outcomes.

KEYPOINTS

• Tumor genomic profiling is critical for treatment selection • CE-CT radiomics produce robust predictive models comparable to those already published • Clinical variables should be considered/included in predictive models.

Multiplex proteomics in the identification of potential biomarkers of very severe sinusoidal obstruction syndrome/veno-occlusive disease (SOS/VOD) in allogeneic hematopoietic cell transplant patients treated with defibrotide

Introduction Despite well-established clinical criteria for diagnosis of SOS/VOD following allogeneic HCT, there is a lack of established diagnostic protein biomarkers. Methods Prospective samples were collected from patients with very severe SOS/VOD at diagnosis and days +3, +7, +14, and +30 post-initiation of defibrotide. Samples from age-matched controls with no VOD were collected at day +14, +30, +60, +90 and +180 following allogeneic HCT. Serum samples were analyzed for 2925 protein levels by antibody-based proximity extension assay (PEA). Mean differences in the log-transformed abundance values were compared using t-tests in a volcano plot. Results Five patients with very severe SOS/VOD and five control patients were compared. Ten proteins were identified that showed a statistically significant and log-transformed 3-fold increase in concentration. They were CALCA, CCL20, GPR37, IGFBP4, IL1RL1, SLC39A14, SPINK4, FABP3, MYL3, and CHCHD10. Four different proteins, namely CD83, LAIR2, CD7, and HEM6 showed a significant decrease with defibrotide treatment. SOS/VOD resolved in 80% (n=4) of patients, while one patient deceased due to SOS/VOD. Conclusion PEA technology identified 10 proteins that were significantly elevated in patients with very severe SOS/VOD. Prospective studies in a larger cohort using this technology may be able to conclusively identify diagnostic protein biomarkers for SOS/VOD.

Episodic disability questionnaire (EDQ) measurement properties among adults living with HIV in Canada, Ireland, United Kingdom, and United States

BACKGROUND

The Episodic Disability Questionnaire (EDQ) is a generic 35-item patient-reported outcome measure of presence, severity and episodic nature of disability. We assessed the measurement properties of the Episodic Disability Questionnaire (EDQ) with adults living with HIV.

METHODS

We conducted a measurement study with adults living with HIV in eight clinical settings in Canada, Ireland, United Kingdom, and United States. We electronically administered the EDQ followed by three reference measures (World Health Organization Disability Assessment Schedule; Patient Health Questionnaire; Social Support Scale) and a demographic questionnaire. We administered the EDQ only 1 week later. We assessed the internal consistency reliability (Cronbach's alpha; > 0.7 acceptable), and test-retest reliability (Intra Class Correlation Coefficient; > 0.7 acceptable). We estimated required change in EDQ domain scores to be 95% certain that a change was not due to measurement error (Minimum Detectable Change (MDC95%)). We evaluated construct validity by assessing 36 primary hypotheses of relationships between EDQ scores and scores on the reference measures (> 75% hypotheses confirmed indicated validity).

RESULTS

Three hundred fifty nine participants completed the questionnaires at time point 1, of which 321 (89%) completed the EDQ approximately 1 week later. Cronbach's alpha for internal consistency ranged from 0.84 (social domain) to 0.91 (day domain) for the EDQ severity scale, and 0.72 (uncertainty domain) to 0.88 (day domain) for the EDQ presence scale, and 0.87 (physical, cognitive, mental-emotional domains) to 0.89 (uncertainty domain) for the EDQ episodic scale. ICCs for test-retest reliability ranged from 0.79 (physical domain) to 0.88 (day domain) for the EDQ severity scale and from 0.71 (uncertainty domain) to 0.85 (day domain) for the EDQ presence scale. Highest precision was demonstrated in the severity scale for each domain (MDC95% range: 19-25 out of 100), followed by the presence (MDC95% range: 37-54) and episodic scales (MDC95% range:44-76). Twenty-nine of 36 (81%) construct validity hypotheses were confirmed.

CONCLUSIONS

The EDQ possesses internal consistency reliability, construct validity, and test-retest reliability, with limited precision when administered electronically with adults living with HIV across in clinical settings in four countries. Given the measurement properties, the EDQ can be used for group level comparisons for research and program evaluation in adults living with HIV.

Environment-based approaches to improve participation of young people with physical disabilities during COVID-19

AIM

To examine the effects of the Pathways and Resources for Engagement and Participation (PREP) intervention during the COVID-19 pandemic on (1) activity performance and satisfaction, and (2) motor, cognitive, and affective body functions.

METHOD

An interrupted time-series design with multiple baselines across 21 young people (13 females, eight males) aged 16 to 25 years (median = 21 years 5 months) with physical disabilities was employed. The young people engaged in an 8-week self-chosen leisure activity (e.g. football, piano, photography) at their home or community. The Canadian Occupational Performance Measure (COPM) assessed activity performance and satisfaction weekly. Mental health problems, including affective and cognitive outcomes, were assessed weekly using the Behavior Assessment System for Children, Third Edition. Motor functions (e.g. trunk control, reaching, strength) were assessed biweekly. Linear mixed-effects models were used.

RESULTS

The intervention had large effects on activity performance (0.78) and satisfaction (0.88) with clinically significant change in COPM scores (2.6 [95% confidence interval {CI}: 2.0-3.2] and 3.2 points [95% CI: 2.4-3.9] respectively). Young people without mental health problems at baseline benefited more from the intervention (p = 0.028). Improvements in at least one domain of body function occurred in 10 young people especially for motor outcomes.

INTERPRETATION

Results demonstrate the effectiveness of PREP during adverse times and suggest benefits going beyond participation, involving outcomes at the body-function level.

IVIg Use Associated with Ten-Fold Reduction of Serious Infections in Multiple Myeloma Patients Treated with Anti-BCMA Bispecific Antibodies

BCMA-targeted bispecific antibodies (BiAb) are efficacious in relapsed/refractory multiple myeloma; however, serious infections have emerged as important toxicities. In this retrospective study, we characterized all infections and their risk factors, and evaluated the impact of infection prophylaxis in patients treated with BCMA-targeted BiAbs. Among 37 patients, 15 (41%) experienced a grade 3-5 infection, with two infection-related deaths during deep remissions. Most (84%) infections occurred during disease remissions. The cumulative probability of grade 3-5 infection increased over time with no plateau. Among responders (n = 26), profound hypogammaglobulinemia occurred in 100% and continued throughout the entire duration of treatment. During periods when patients were receiving intravenous immunoglobulin (IVIg), the rate of grade 3-5 infections was 90% lower than during observation (incidence rate ratio, 0.10; 95% confidence interval, 0.01-0.80; P = 0.0307). No other risk factors for infection were identified. This study demonstrates that profound hypogammaglobulinemia is universal with BCMA-targeted BiAbs, with intravenous immunoglobulin potentially abrogating most of the infection risk.

SIGNIFICANCE

To the best of our knowledge, this is the first study to comprehensively analyze risk factors and mitigation strategies to prevent infections in myeloma patients receiving anti-BCMA bispecific antibodies. Profound and prolonged hypogammaglobulinemia was universal among responders, while immunoglobulin replacement was associated with 90% lower rates of grade 3-5 infections. See related commentary by Garfall and Stadtmauer, p. 427 . This article is featured in Selected Articles from This Issue, p. 419.

Child engagement in daily life measure V2: validation of psychometric properties for children with cerebral palsy

PURPOSE

Measurement development is a reiterative process requiring refinements and revalidation. The purpose of this study was to examine structural validity and reliability of the Child Engagement in Daily Life Measure (Version 2) for parents of children with cerebral palsy (CP) across a broader age span.

METHODS

Participants were 1054 parents of children with CP 1.5-11 years of age. Parents completed the Child Engagement in Daily Life measure that consists of the Participation in Family and Recreational Activities domain (11 items) and the Performance of Self-care Activities domain (18 items) as part of two longitudinal studies related to outcomes for children with CP.

RESULTS

Rasch analysis indicated acceptable fit of items, stable item calibration, and logical ordering of items by difficulty for both frequency of participation in family and recreational activities and performance of self-care activities. Test-retest reliability was good to excellent: ICC = 0.78 for frequency of participation, ICC = 0.68 for enjoyment of participation, and ICC = 0.97 for self-care.

CONCLUSIONS

Evidence supports reliability and validity of the Child Engagement in Daily Life Measure (Version 2) for parent-report of their children's participation in family and recreational activities and performance of self-care activities for children with CP 1.5-12 years of age.IMPLICATIONS FOR REHABILITATIONParticipation in family and recreational activities and performance of self-care activities of children with cerebral palsy can be assessed using the concise parent-report Child Engagement in Daily Life Measure V2.Knowledge of the continuum of difficulty of the frequency of participation in family and recreational activities and performance of self-care activities can assist practitioners in progressing service plans.Practitioners are encouraged to use the measure to guide discussions with parents and children on areas to focus services to support participation in family and recreational activities and performance of self-care activities.

Safety, Immunologic, and Clinical Activity of Durvalumab in Combination with Olaparib or Cediranib in Advanced Leiomyosarcoma: Results of the DAPPER Clinical Trial

PURPOSE

Non-inflamed (cold) tumors such as leiomyosarcoma do not benefit from immune checkpoint blockade (ICB) monotherapy. Combining ICB with angiogenesis or PARP inhibitors may increase tumor immunogenicity by altering the immune cell composition of the tumor microenvironment (TME). The DAPPER phase II study evaluated the safety, immunologic, and clinical activity of ICB-based combinations in pretreated patients with leiomyosarcoma.

PATIENTS AND METHODS

Patients were randomized to receive durvalumab 1,500 mg IV every 4 weeks with either olaparib 300 mg twice a day orally (Arm A) or cediranib 20 mg every day orally 5 days/week (Arm B) until unacceptable toxicity or disease progression. Paired tumor biopsies, serial radiologic assessments and stool collections were performed. Primary endpoints were safety and immune cell changes in the TME. Objective responses and survival were correlated with transcriptomic, radiomic, and microbiome parameters.

RESULTS

Among 30 heavily pretreated patients (15 on each arm), grade ≥ 3 toxicity occurred in 3 (20%) and 2 (13%) on Arms A and B, respectively. On Arm A, 1 patient achieved partial response (PR) with increase in CD8 T cells and macrophages in the TME during treatment, while 4 had stable disease (SD) ≥ 6 months. No patients on Arm B achieved PR or SD ≥ 6 months. Transcriptome analysis showed that baseline M1-macrophage and B-cell activity were associated with overall survival.

CONCLUSIONS

Durvalumab plus olaparib increased immune cell infiltration of TME with clinical benefit in some patients with leiomyosarcoma. Baseline M1-macrophage and B-cell activity may identify patients with leiomyosarcoma with favorable outcomes on immunotherapy and should be further evaluated.

Impact of 18F-DCFPyL PET/MRI in Selecting Men With Low-/Intermediate-Risk Prostate Cancer for Focal Ablative Therapies

PURPOSE

To compare the diagnostic performance of multiparametric (mp) MRI to 18F-DCFPyL PET/MRI for detecting clinically significant (cs) prostate cancer (PCa) in men with low-/intermediate-risk PCa being considered for focal ablative therapy (FT), using 2 interpretation schemes, and to assess the rate of exclusion from FT for each modality.

METHODS

This prospective study evaluated men with low- or intermediate-risk PCa, potential candidates for FT based on initial biopsy as per institutional protocol, who underwent 18F-DCFPyL PET/MRI. Each modality (mpMRI, PET/MRI using PROMISE classification [PET/MRI PROMISE], and PET/MRI considering any focal lesion on PET as positive [PETFL/MRI]) was assessed independently. All suspicious lesions underwent PET/MRI-ultrasound fusion biopsies. Diagnostic performances were calculated and compared using the exact binomial test on paired proportions.

RESULTS

Thirty-four men (median age, 64 years; interquartile range, 60-70 years) were included. Overall, 40 of 67 lesions (60%) identified on mpMRI and/or PET/MRI were malignant, and 34 of 40 lesions (85%) were csPCa (≥6 mm ISUP [International Society of Urological Pathology Grade Group] GG1 or ISUP-GG ≥2). On lesion-level analysis, for detecting csPCa, sensitivity appeared higher for PETFL/MRI than mpMRI and PET/MRI PROMISE (97% vs 76% and 79%, respectively [P = 0.02 and 0.03]), whereas specificity was lower (30% vs 85% and 88%, respectively [P < 0.001]). The calculated overall accuracy rates for PETFL/MRI, mpMRI, and PET/MRI PROMISE were 64%, 81%, and 84%, respectively. PETFL/MRI, mpMRI, and PET/MRI PROMISE excluded 10 of 34 (29%), 7 of 34 (21%), and 6 of 34 (18%) men from FT, respectively.

CONCLUSIONS

18F-DCFPyL PET/MRI excluded nearly 30% of patients with low-/intermediate-risk PCa from FT, with a potential role in decreasing selection failure. Compared with mpMRI, PET/MRI had a higher sensitivity for detecting csPCa in men who were candidates for FT.ClinicalTrials.gov identifier NCT03149861.

The association of cancer-related fatigue on the social, vocational and healthcare-related dimensions of cancer survivorship

BACKGROUND

Cancer-related fatigue (CRF) is well documented in cancer survivors, but little is known about the personal and societal impact of CRF. This study aimed to examine the impact of CRF in relation to social and vocational functioning and health care utilization in a large sample of post-treatment cancer survivors.

METHODS

We conducted a cross-sectional descriptive study of early stage breast and colorectal cancer survivors (n = 454) who were within 5 years from treatment completion. Social difficulties (SDI-21), work status, absenteeism and presenteeism (WHO-HPQ) and healthcare utilization (HSUQ) were compared in those with (CFR +) and without (CRF -) clinically significant fatigue (FACT-F ≤ 34).

RESULTS

A total of 32% met the cut-off criteria for CRF (≤ 34). Participants with CRF + had significantly higher scores on the SDI-21 across all domains and 55% of CRF + vs. 11% in CRF - was above the SDI cut-off (> 10) for significant social difficulties. Participants with CRF + were 2.74 times more likely to be unemployed or on leave (95% CI 1.62, 4.61, p < 0.001). In the subgroup of participants who were currently working (n = 249), those with CRF + reported working on average 27.4 fewer hours in the previous 4 weeks compared to CRF - (p = 0.05), and absolute presenteeism was on average 13% lower in the CRF + group (95% CI 8.0, 18.2, p < 0.001). Finally, individuals with CRF + reported significantly more physician (p < 0.001), other health care professional (p = 0.03) and psychosocial visits (p = 0.002) in the past month.

CONCLUSIONS AND IMPLICATIONS FOR CANCER SURVIVORS

CRF is associated with substantial disruption in social and work role functioning in the early transitional phase of cancer survivorship. Better management of persistent CRF and funding for the implementation of existing guidelines and recommended evidence-based interventions are urgently needed.

Evaluation of Respondent-Driven Sampling Prevalence Estimators Using Real-World Reported Network Degree

Respondent-driven sampling (RDS) is used to measure trait or disease prevalence in populations that are difficult to reach and often marginalized. The authors evaluated the performance of RDS estimators under varying conditions of trait prevalence, homophily, and relative activity. They used large simulated networks (N = 20,000) derived from real-world RDS degree reports and an empirical Facebook network (N = 22,470) to evaluate estimators of binary and categorical trait prevalence. Variability in prevalence estimates is higher when network degree is drawn from real-world samples than from the commonly assumed Poisson distribution, resulting in lower coverage rates. Newer estimators perform well when the sample is a substantive proportion of the population, but bias is present when the population size is unknown. The choice of preferred RDS estimator needs to be study specific, considering both statistical properties and knowledge of the population under study.

The role of [18F]-DCFPyL PET/MRI radiomics for pathological grade group prediction in prostate cancer

PURPOSE

To evaluate the diagnostic accuracy of [18F]-DCFPyL PET/MRI radiomics for the prediction of pathological grade group in prostate cancer (PCa) in therapy-naïve patients.

METHODS

Patients with confirmed or suspected PCa, who underwent [18F]-DCFPyL PET/MRI (n = 105), were included in this retrospective analysis of two prospective clinical trials. Radiomic features were extracted from the segmented volumes following the image biomarker standardization initiative (IBSI) guidelines. Histopathology obtained from systematic and targeted biopsies of the PET/MRI-detected lesions was the reference standard. Histopathology patterns were dichotomized as ISUP GG 1-2 vs. ISUP GG ≥ 3 categories. Different single-modality models were defined for feature extraction, including PET- and MRI-derived radiomic features. The clinical model included age, PSA, and lesions' PROMISE classification. Single models, as well as different combinations of them, were generated to calculate their performances. A cross-validation approach was used to evaluate the internal validity of the models.

RESULTS

All radiomic models outperformed the clinical models. The best model for grade group prediction was the combination of PET + ADC + T2w radiomic features, showing sensitivity, specificity, accuracy, and AUC of 0.85, 0.83, 0.84, and 0.85, respectively. The MRI-derived (ADC + T2w) features showed sensitivity, specificity, accuracy, and AUC of 0.88, 0.78, 0.83, and 0.84, respectively. PET-derived features showed 0.83, 0.68, 0.76, and 0.79, respectively. The baseline clinical model showed 0.73, 0.44, 0.60, and 0.58, respectively. The addition of the clinical model to the best radiomic model did not improve the diagnostic performance. The performances of MRI and PET/MRI radiomic models as per the cross-validation scheme yielded an accuracy of 0.80 (AUC = 0.79), whereas clinical models presented an accuracy of 0.60 (AUC = 0.60).

CONCLUSION

The combined [18F]-DCFPyL PET/MRI radiomic model was the best-performing model and outperformed the clinical model for pathological grade group prediction, indicating a complementary value of the hybrid PET/MRI model for non-invasive risk stratification of PCa. Further prospective studies are required to confirm the reproducibility and clinical utility of this approach.

1H NMR Metabolic Profiling of Synovial Fluid from Patients with Anterior Cruciate Ligament Tears and Hemarthrosis

OBJECTIVE

To compare the metabolic profiles of synovial fluid (SF) from patients with anterior cruciate ligament tears and hemarthrosis (HA) with that of normal controls, using ¹H NMR spectroscopy (NMRS).

METHODS

Synovial fluid was collected from eleven patients undergoing arthroscopic debridement within fourteen days following an anterior cruciate ligament (ACL) tear and hemarthrosis. Ten additional SF samples were obtained from the knees of osteoarthritis-free volunteers to serve as normal controls. The relative concentrations of twenty-eight endogenous SF metabolites (hydroxybutyrate, acetate, acetoacetate, acetone, alanine, arginine, choline, citrate, creatine, creatinine, formate, glucose, glutamate, glutamine, glycerol, glycine, histidine, isoleucine, lactate, leucine, lysine, phenylalanine, proline, pyruvate, threonine, tyrosine, valine, and the mobile components of glycoproteins and lipids) were evaluated using NMRS and quantified using CHENOMX metabolomics analysis software. Mean differences between groups were evaluated with t-tests controlling for multiple comparisons at an overall error rate of 0.10.

RESULTS

Statistically significant increases in the levels of glucose, choline, the branched-chain amino acids leucine, isoleucine, and valine, and the mobile components of N-acetyl glycoproteins and lipids were observed in ACL/HA SF as compared with normal controls; lactate levels were reduced.

CONCLUSIONS

Marked changes occur in the metabolic profiles of human knee fluid following ACL injury and hemarthrosis, suggestive of increased demand and accompanying inflammatory response; potentially increased lipid and glucose metabolism; and possible hyaluronan degradation within the joint following trauma.

Service user perspectives on social prescribing services for mental health in the UK: a systematic review

AIM

To thematically synthesise adult service users' perspectives on how UK-based social prescribing services support them with their mental health management.

METHODS

Nine databases were systematically searched up to March 2022. Eligible studies were qualitative or mixed methods studies involving participants aged ⩾ 18 years accessing social prescribing services primarily for mental health reasons. Thematic synthesis was applied to qualitative data to create descriptive and analytical themes.

RESULTS

51,965 articles were identified from electronic searches. Six studies were included in the review (n = 220 participants) with good methodological quality. Five studies utilised a link worker referral model, and one study a direct referral model. Modal reasons for referral were social isolation and/or loneliness (n = 4 studies). Two analytical themes were formulated from seven descriptive themes: (1) person-centred care was key to delivery and (2) creating an environment for personal change and development.

CONCLUSIONS

This review provides a synthesis of the qualitative evidence on service users' experiences of accessing and using social prescribing services to support their mental health management. Adherence to principles of person-centred care and addressing the holistic needs of service users (including devoting attention to the quality of the therapeutic environment) are important for design and delivery of social prescribing services. This will optimise service user satisfaction and other outcomes that matter to them.

Episodic Disability Questionnaire (EDQ) measurement properties among adults living with HIV in Canada, Ireland, United Kingdom, and United States

Background

The Episodic Disability Questionnaire (EDQ) is a generic 35-item patient-reported outcome measure of presence, severity and episodic nature of disability. We assessed the measurement properties of the Episodic Disability Questionnaire (EDQ) with adults living with HIV.

Methods

We conducted a measurement study with adults living with HIV in eight clinical settings in Canada, Ireland, United Kingdom, and United States. We electronically administered the EDQ followed by three reference measures (World Health Organization Disability Assessment Schedule; Patient Health Questionnaire; Social Support Scale) and a demographic questionnaire. We administered the EDQ only 1 week later. We assessed the internal consistency reliability (Cronbach's alpha; >0.7 acceptable), and test-retest reliability (Intra Class Correlation Coefficient; >0.7 acceptable). We estimated required change in EDQ domain scores to be 95% certain that a change was not due to measurement error (Minimum Detectable Change (MDC95%)). We evaluated construct validity by assessing 36 primary hypotheses of relationships between EDQ scores and scores on the reference measures (> 75% hypotheses confirmed indicated validity).

Results

359 participants completed the questionnaires at time point 1, of which 321 (89%) completed the EDQ approximately 1 week later. Cronbach's alpha for internal consistency ranged from 0.84 (social domain) to 0.91 (day domain) for the EDQ severity scale, and 0.72 (uncertainty domain) to 0.88 (day domain) for the EDQ presence scale, and 0.87 (physical, cognitive, mental-emotional domains) to 0.89 (uncertainty domain) for the EDQ episodic scale. ICCs for test-retest reliability ranged from 0.79 (physical domain) to 0.88 (day domain) for the EDQ severity scale and from 0.71 (uncertainty domain) to 0.85 (day domain) for the EDQ presence scale. Highest precision was demonstrated in the severity scale for each domain (MDC95% range: 19-25 out of 100), followed by the presence (MDC95% range: 37-54) and episodic scales (MDC95% range:44-76). Twenty-nine of 36 (81%) construct validity hypotheses were confirmed.

Conclusions

The EDQ possesses internal consistency reliability, construct validity, and test-retest reliability, with limited precision when administered electronically with adults living with HIV across in clinical settings in four countries. Given the measurement properties, the EDQ can be used for group level comparisons for research and program evaluation in adults living with HIV.

Validation of the Integrated Prediction Model algorithm for outcome of cytoreduction in advanced ovarian cancer

BACKGROUND

We previously developed the Integrated Prediction Model using a 4-step algorithm of unresectable stage IVB, patient factors, surgical resectability, and surgical complexity to predict outcome of <1 cm cytoreduction in advanced epithelial ovarian cancer, and triaged patients to neoadjuvant chemotherapy or primary cytoreductive surgery.

OBJECTIVE

To validate the Integrated Prediction Model on a retrospective cohort of patients.

METHODS

A retrospective cohort study of 107 patients with advanced ovarian cancer treated between January 2017 and September 2018 was carried out. The above mentioned 4-step algorithm determined cut-off points using the Youden Index. This validation study reports sensitivity, specificity, negative and positive predictive value on an external cohort.

RESULTS

Among 107 patients, 61 had primary surgery and 46 had neoadjuvant chemotherapy. Compared with primary surgery, patients treated with neoadjuvant chemotherapy were significantly older (63.5 vs 61, p=0.037), more likely to have stage IV disease (52% vs 18%, p<0.001), Eastern Cooperative Oncology Group (ECOG) score >1 (30% vs 11%, 0.045), lower pre-operative albumin (37 vs 40, p<0.001), and higher CA-125 (970 vs 227.5, p<0.001). They also had higher patient factors (2 vs 0, p=0.013), surgical resectability (4 vs 1, p<0.001), and anticipated surgical complexity (8 vs 5, p<0.001). There was no significant difference in outcome of cytoreduction (<1 cm residual disease: 85% for primary surgery vs 87% interval surgery, p=0.12)In this validation cohort, triaging patients with patient factors ≤2, surgical resectability score ≤5, and surgical complexity score ≤9 to primary surgery had a sensitivity of 91% for optimal cytoreduction <1 cm and a specificity of 81%. The positive predictive value, negative predictive value, and accuracy were 83%, 90%, and 86%, respectively. Application of the Integrated Prediction Model would have prevented five patients from receiving suboptimal cytoreduction and triaged them to neoadjuvant chemotherapy.

CONCLUSIONS

We validated the proposal that a triage algorithm integrating patient factors, surgical complexity, and surgical resectability in advanced ovarian cancer had high sensitivity and specificity to predict optimal cytoreduction <1 cm.

Piloting an online telecoaching community-based exercise intervention with adults living with HIV: protocol for a mixed-methods implementation science study

INTRODUCTION

Our aim is to evaluate the implementation of an online telecoaching community-based exercise (CBE) intervention with the goal of reducing disability and enhancing physical activity and health among adults living with HIV.

METHODS AND ANALYSIS

We will conduct a prospective longitudinal mixed-methods two-phased intervention study to pilot the implementation of an online CBE intervention with ~30 adults (≥18 years) living with HIV who consider themselves safe to participate in exercise. In the intervention phase (0-6 months), participants will take part in an online CBE intervention involving thrice weekly exercise (aerobic, resistance, balance and flexibility), with supervised biweekly personal training sessions with a fitness instructor, YMCA membership providing access to online exercise classes, wireless physical activity monitor to track physical activity and monthly online educational sessions on topics related to HIV, physical activity and health. In the follow-up phase (6-12 months), participants will be encouraged to continue independent exercise thrice weekly. Quantitative assessment: Bimonthly, we will assess cardiopulmonary fitness, strength, weight, body composition and flexibility, followed by administering self-reported questionnaires to assess disability, contextual factor outcomes (mastery, engagement in care, stigma, social support), implementation factors (cost, feasibility, technology), health status and self-reported physical activity. We will conduct a segmented regression analyses to describe the change in level and trend between the intervention and follow-up phases. Qualitative assessment: We will conduct online interviews with a subsample of ~10 participants and 5 CBE stakeholders at baseline (month 0), postintervention (month 6) and end of follow-up (month 12) to explore experiences, impact and implementation factors for online CBE. Interviews will be audiorecorded and analysed using content analytical techniques.

ETHICS AND DISSEMINATION

Protocol approved by the University of Toronto Research Ethics Board (Protocol # 40410). Knowledge translation will occur in the form of presentations and publications in open-access peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05006391.

A review of the impact of conductive materials on antibiotic resistance genes during the anaerobic digestion of sewage sludge and animal manure

The urgent need to reduce the environmental burden of antibiotic resistance genes (ARGs) has become even more apparent as concerted efforts are made globally to tackle the dissemination of antimicrobial resistance. Concerning levels of ARGs abound in sewage sludge and animal manure, and their inadequate attenuation during conventional anaerobic digestion (AD) compromises the safety of the digestate, a nutrient-rich by-product of AD commonly recycled to agricultural land for improvement of soil quality. Exogenous ARGs introduced into the natural environment via the land application of digestate can be transferred from innocuous environmental bacteria to clinically relevant bacteria by horizontal gene transfer (HGT) and may eventually reach humans through food, water, and air. This review, therefore, discusses the prospects of using carbon- and iron-based conductive materials (CMs) as additives to mitigate the proliferation of ARGs during the AD of sewage sludge and animal manure. The review spotlights the core mechanisms underpinning the influence of CMs on the resistome profile, the steps to maximize ARG attenuation using CMs, and the current knowledge gaps. Data and information gathered indicate that CMs can profoundly reduce the abundance of ARGs in the digestate by easing selective pressure on ARGs, altering microbial community structure, and diminishing HGT.

EPI-Net One Health reporting guideline for antimicrobial consumption and resistance surveillance data: a Delphi approach

Strategic and standardised approaches to analysis and reporting of surveillance data are essential to inform antimicrobial resistance (AMR) mitigation measures, including antibiotic policies. Targeted guidance on linking full-scale AMR and antimicrobial consumption (AMC)/antimicrobial residues (AR) surveillance data from the human, animal, and environmental sectors is currently needed. This paper describes the initiative whereby a multidisciplinary panel of experts (56 from 20 countries-52 high income, 4 upper middle or lower income), representing all three sectors, elaborated proposals for structuring and reporting full-scale AMR and AMC/AR surveillance data across the three sectors. An evidence-supported, modified Delphi approach was adopted to reach consensus among the experts for dissemination frequency, language, and overall structure of reporting; core elements and metrics for AMC/AR data; core elements and metrics for AMR data. The recommendations can support multisectoral national and regional plans on antimicrobials policy to reduce resistance rates applying a One Health approach.

Conceptualising the episodic nature of disability among adults living with Long COVID: a qualitative study

INTRODUCTION

Our aim was to describe episodic nature of disability among adults living with Long COVID.

METHODS

We conducted a community-engaged qualitative descriptive study involving online semistructured interviews and participant visual illustrations. We recruited participants via collaborator community organisations in Canada, Ireland, UK and USA.We recruited adults who self-identified as living with Long COVID with diversity in age, gender, race/ethnicity, sexual orientation and duration since initial COVID infection between December 2021 and May 2022. We used a semistructured interview guide to explore experiences of disability living with Long COVID, specifically health-related challenges and how they were experienced over time. We asked participants to draw their health trajectory and conducted a group-based content analysis.

RESULTS

Among the 40 participants, the median age was 39 years (IQR: 32-49); majority were women (63%), white (73%), heterosexual (75%) and living with Long COVID for ≥1 year (83%). Participants described their disability experiences as episodic in nature, characterised by fluctuations in presence and severity of health-related challenges (disability) that may occur both within a day and over the long-term living with Long COVID. They described living with 'ups and downs', 'flare-ups' and 'peaks' followed by 'crashes', 'troughs' and 'valleys', likened to a 'yo-yo', 'rolling hills' and 'rollercoaster ride' with 'relapsing/remitting', 'waxing/waning', 'fluctuations' in health. Drawn illustrations demonstrated variety of trajectories across health dimensions, some more episodic than others. Uncertainty intersected with the episodic nature of disability, characterised as unpredictability of episodes, their length, severity and triggers, and process of long-term trajectory, which had implications on broader health.

CONCLUSION

Among this sample of adults living with Long COVID, experiences of disability were described as episodic, characterised by fluctuating health challenges, which may be unpredictable in nature. Results can help to better understand experiences of disability among adults living with Long COVID to inform healthcare and rehabilitation.

Longitudinal study of pregnancy intention and its association with pregnancy occurrence among female sex workers in Benin and Mali

BACKGROUND

The intention of becoming pregnant has an evident impact on the prenatal and postnatal period. For female sex workers (FSWs) in West Africa, among whom pregnancies are frequent as are HIV and sexually transmitted infections, a better understanding of their pregnancy intention and its influence on pregnancy occurrence could help prevent unwanted pregnancies and adverse effects on wanted pregnancies.

METHODS

We recruited 330 FSWs in Benin and 322 in Mali and followed them for 12 months. We evaluated their pregnancy intention at recruitment and 6-month follow-up, using a multidimensional prospective measure that we developed. We assessed pregnancy occurrence with a pregnancy test and a retrospective questionnaire at 6 and 12 months. A Cox proportional hazard model was used to estimate the association between intention and pregnancy. We carried out an analysis to take losses to follow-up into account using the inverse of probability of censoring weights and a cluster analysis to corroborate that the multidimensional measure of pregnancy intention fitted the data.

RESULTS

407 FSWs were included in the first 6-month analysis and 284 at 12 months. Mean age was 30.9 years. The pregnancy intention distribution was similar between the two periods: 15.2% in the first period and 16.3% in the second had a positive intention. One out of four were ambivalent and almost 60% (57.7% and 56.3%) had a negative intention. For 38.2% of the FSWs, the intention changed between the two periods. The global incidence rate (to first event) was 19.1 pregnancies per 100 person-years. There was a borderline significant trend (p = 0.0529) of decreased pregnancy incidence with decreasing intention. Compared to positive intention, the adjusted hazard ratio (aHR) for ambivalent and negative intentions were 0.71 [95% confidence interval (95% CI) 0.32-1.60] and 0.46 (95% CI 0.21-1.01), respectively.

CONCLUSION

The level of pregnancy intention influences its occurrence among FSWs and nearly one out of six wants a baby despite working in the sex trade. Programmatically, early identification of these women could facilitate provision of quality antenatal and postnatal care. Given other health risks associated with sex work this care may decrease potential risks of adverse maternal, fetal and neonatal outcomes.

Longitudinal efficacy and toxicity of SARS-CoV-2 vaccination in cancer patients treated with immunotherapy

Despite more than 2 years having elapsed since the onset of SARS-CoV-2 pandemic, a level of hesitation around increased SARS-CoV-2 vaccine toxicity in cancer patients receiving immunotherapy (IO) remains. This hesitation stems from the idea that IO agents could elicit an overwhelming immune stimulation post vaccination and therefore increase the risk of vaccine-related toxicity. The aim of our study was to explore serological responses to SARS-CoV-2 vaccination in patients treated with IO and describe the level of immune stimulation using parameters such as blood cytokines, autoantibody levels and immune related adverse events (irAEs) post vaccination. Fifty-one evaluable patients were enrolled in this longitudinal study. Absolute levels and neutralization potential of anti-SARS-CoV-2 antibodies were not significantly different in the IO group compared to non-IO. Chemotherapy adversely affected seroconversion when compared to IO and/or targeted treatment. Following vaccination, the prevalence of grade ≥2 irAEs in patients treated with IO was not higher than the usual reported IO toxicity. We report, for the first time, that anti-SARS-CoV-2 vaccination, elicited the generation of five autoantibodies. The significantly increased autoantibodies were IgM autoantibodies against beta-2 glycoprotein (p = 0.02), myeloperoxidase (p = 0.03), nucleosome (p = 0.041), SPLUNC2 (p < 0.001) and IgG autoantibody against Myosin Heavy Chain 6 (MYH6) (p < 0.001). Overall, comprehensive analysis of a small cohort showed that co-administration of SARS-CoV-2 vaccine and IO is not associated with increased irAEs. Nevertheless, the detection of autoantibodies post anti-SARS-CoV-2 vaccination warrants further investigation (NCT03702309).

Correlates of maternal, newborn and child health services uptake, including male partner involvement: Baseline survey results from Bangladesh

South Asia bears a substantial proportion of the global maternal mortality burden, with adolescents disproportionately affected. Bangladesh has one of the highest adolescent pregnancy rates in the world, with low utilisation of maternal newborn and child health (MNCH) services. This hampers the country's efforts to achieve optimal health outcomes as envisioned by the Sustainable Development Goals. Male partner involvement is a recognised approach to optimise access to services and decision-making. In South Asia data on male involvement in MNCH service uptake is limited. Plan International's Strengthening Health Outcomes for Women and Children was implemented across four districts in Bangladesh between 2016 and 2020 and aimed to address these issues. Study results (N = 1,724) found higher maternal education levels were associated with use of MNCH services. After controlling for maternal education, service uptake was associated with male partner support level and perceived joint decision-making. The positive association between male support level and MNCH scale was robust to stratification by maternal education level, and by age group (i.e. adolescent vs. adult mothers). These findings suggest that one path for achieving optimal MNCH outcomes might be through structural-level interventions centred on women, combined with components targeting male partners or male heads of households.

Systematic development and feasibility testing of a multibehavioural digital prehabilitation intervention for patients approaching major surgery (iPREPWELL): A study protocol

Improving outcomes for people undergoing major surgery, specifically reducing perioperative morbidity and mortality remains a global health challenge. Prehabilitation involves the active preparation of patients prior to surgery, including support to tackle risk behaviours that mediate and undermine physical and mental health and wellbeing. The majority of prehabilitation interventions are delivered in person, however many patients express a preference for remotely-delivered interventions that provide them with tailored support and the flexibility. Digital prehabilitation interventions offer scalability and have the potential to benefit perioperative healthcare systems, however there is a lack of robustly developed and evaluated digital programmes for use in routine clinical care. We aim to systematically develop and test the feasibility of an evidence and theory-informed multibehavioural digital prehabilitation intervention 'iPREPWELL' designed to prepare patients for major surgery. The intervention will be developed with reference to the Behaviour Change Wheel, COM-B model, and the Theoretical Domains Framework. Codesign methodology will be used to develop a patient intervention and accompanying training intervention for healthcare professionals. Training will be designed to enable healthcare professionals to promote, support and facilitate delivery of the intervention as part of routine clinical care. Patients preparing for major surgery and healthcare professionals involved with their clinical care from two UK National Health Service centres will be recruited to stage 1 (systematic development) and stage 2 (feasibility testing of the intervention). Participants recruited at stage 1 will be asked to complete a COM-B questionnaire and to take part in a qualitative interview study and co-design workshops. Participants recruited at stage 2 (up to twenty healthcare professionals and forty participants) will be asked to take part in a single group intervention study where the primary outcomes will include feasibility, acceptability, and fidelity of intervention delivery, receipt, and enactment. Healthcare professionals will be trained to promote and support use of the intervention by patients, and the training intervention will be evaluated qualitatively and quantitatively. The multifaceted and systematically developed intervention will be the first of its kind and will provide a foundation for further refinement prior to formal efficacy testing.

CT Radiomics and Whole Genome Sequencing in Patients with Pancreatic Ductal Adenocarcinoma: Predictive Radiogenomics Modeling

We investigate whether computed tomography (CT) derived radiomics may correlate with driver gene mutations in patients with pancreatic ductal adenocarcinoma (PDAC). In this retrospective study, 47 patients (mean age 64 ± 11 years; range: 42-86 years) with PDAC, who were treated surgically and who underwent preoperative CT imaging at our institution were included in the study. Image segmentation and feature extraction was performed semi-automatically with a commonly used open-source software platform. Genomic data from whole genome sequencing (WGS) were collected from our institution's web-based resource. Two statistical models were then built, in order to evaluate the predictive ability of CT-derived radiomics feature for driver gene mutations in PDAC. 30/47 of all tumor samples harbored 2 or more gene mutations. Overall, 81% of tumor samples demonstrated mutations in KRAS, 68% of samples had alterations in TP53, 26% in SMAD4 and 19% in CDKN2A. Extended statistical analysis revealed acceptable predictive ability for KRAS and TP53 (Youden Index 0.56 and 0.67, respectively) and mild to acceptable predictive signal for SMAD4 and CDKN2A (Youden Index 0.5, respectively). Our study establishes acceptable correlation of radiomics features and driver gene mutations in PDAC, indicating an acceptable prognostication of genomic profiles using CT-derived radiomics. A larger and more homogenous cohort may further enhance the predictive ability.

COVID-19 and Cancer Patients in the Second Year of the Pandemic: Investigating Treatment Impact, Information Sources, and COVID-19-Related Knowledge, Attitudes and Practices

BACKGROUND

The novel coronavirus that has triggered the present COVID-19 pandemic continues to spread globally, resulting in widespread morbidity and mortality. Patients with cancer remain one of the most vulnerable subsets of the population to the disease. This study examined the effects of the pandemic on cancer patients' treatment, psychology, knowledge, attitudes, and practices.

METHODS

A survey was emailed to 9861 patients at a cancer centre in Toronto, Canada. Descriptive results were summarized. Qualitative feedback was coded and summarized. Regression modelling was used to explore factors associated with patient psychological well-being, knowledge, attitudes, and practices.

RESULTS

A total of 1760 surveys were completed, with a response rate of 17.8%. Most participants did not experience any pandemic-related treatment delays, and vaccination rates were high. Participants who identified themselves as non-white (OR 3.30, CI: 1.30-5.30; p ≤ 0.001), and those who referred to journal articles for information (p = 0.002) reported higher psychological impact scores. There were no significant predictors of whether participants would use personal protective equipment when leaving their homes or whether they would go to crowded places.

DISCUSSION

This study provides another snapshot of cancer patients perceptions and needs during the COVID-19 pandemic.

18F-DCFPyL PET/CT in advanced high-grade epithelial ovarian cancer: A prospective pilot study

Objectives

Glutamate carboxypeptidase-II (GCP-II), a zinc metalloenzyme that resides in cell membrane, has been reported as overexpressed in the neovasculature of ovarian cancers. The study objective was to determine whether GCP-II targeted imaging with ¹⁸F-DCFPyL PET/CT can detect disease sites in women with advanced high-grade serous ovarian cancer (HGSOC).

Materials and methods

Twenty treatment-naïve women with advanced HGSOC were recruited (median age 60 years). Prior to commencing therapy (primary cytoreductive surgery [n=9] or neoadjuvant chemotherapy [n=11]), subjects underwent routine staging with contrast-enhanced abdominopelvic CT (=CT), followed by ¹⁸F-DCFPyL PET/CT (=PET). CT and PET were reported independently using a standardized reporting template assessing 25 sites. The performance of PET was compared to CT in all subjects and to surgery and surgical histopathology in 9 patients who underwent primary cytoreductive surgery.

Results

Of the 25 sites assessed in 20 patients, CT detected disease in 292/500 (58.4%) locations and PET detected disease in 171/500 (34.2%). Compared to CT the sensitivity (95% CI) of PET to detect disease in the upper abdomen, the gastrointestinal tract or the peritoneum was 0.29 (0.20,0.40), 0.21 (0.11,0.33) and 0.74 (0.64,0.82), respectively. In the surgical cohort, 220 sites in 9 patients were evaluated. The sensitivity and specificity of CT and PET were 0.85 versus 0.54 (p<0.001) and 0.73 versus 0.93 (p<0.001), respectively.

Conclusion

Although ¹⁸F-DCFPyL has higher specificity than CT in detecting advanced HGSOC tumor sites, it detects less disease sites than CT, especially in the upper abdomen and along the gastrointestinal tract, likely limiting its clinical utility.

Clinical trial registration

ClinicalTrials.gov, NCT03811899.

The impact of an integrated, interprofessional knowledge translation intervention on access to inpatient rehabilitation for persons with cognitive impairment

Introduction

Stroke rehabilitation teams’ skills and knowledge in treating persons with cognitive impairment (CI) contribute to their reduced access to inpatient rehabilitation. This study examined stroke inpatient rehabilitation referral acceptance rates for persons with CI before and after the implementation of a multi-faceted integrated knowledge translation (KT) intervention aimed at improving clinicians’ skills in a cognitive-strategy based approach, Cognitive Orientation to daily Occupational Performance (CO-OP), CO-OP KT.

Methods

CO-OP KT was implemented at five inpatient rehabilitation centres, using an interrupted time series design and data from an electronic referral and database system called E-Stroke. CO-OP KT included a 2-day workshop, 4 months of implementation support, health system support, and a sustainability plan. A mixed effects model was used to model monthly acceptance rates for 12 months prior to the intervention and 6 months post.

Results

The dataset was comprised of 2604 pre-intervention referrals and 1354 post. In the mixed effects model, those with CI had a lower pre-intervention acceptance rate than those without. Post-intervention the model showed the acceptance rate for those with CI increased by 8.6% (p = 0.02), whereas those with no CI showed a non-significant increase of less than 1%.

Conclusions

Proportionally more persons with CI gained access to inpatient stroke rehabilitation following an integrated KT intervention.

Modelling prevalent cardiovascular disease in an urban Indigenous population

OBJECTIVE

Studies have highlighted the inequities between the Indigenous and non-Indigenous populations with respect to the burden of cardiovascular disease and prevalence of predisposing risks resulting from historical and ongoing impacts of colonization. The objective of this study was to investigate factors associated with cardiovascular disease (CVD) within and specific to the Indigenous peoples living in Toronto, Ontario, and to evaluate the reliability and validity of the resulting model in a similar population.

METHODS

The Our Health Counts Toronto study measured the baseline health of Indigenous community members living in Toronto, Canada, using respondent-driven sampling. An iterative approach, valuing information from the literature, clinical insight and Indigenous lived experiences, as well as statistical measures was used to evaluate candidate predictors of CVD (self-reported experience of discrimination, ethnic identity, health conditions, income, education, age, gender and body size) prior to multivariable modelling. The resulting model was then validated using a distinct, geographically similar sample of Indigenous people living in Hamilton, Ontario, Canada.

RESULTS

The multivariable model of risk factors associated with prevalent CVD included age, diabetes, hypertension, body mass index and exposure to discrimination. The combined presence of diabetes and hypertension was associated with a greater risk of CVD relative to those with either condition and was the strongest predictor of CVD. Those who reported previous experiences of discrimination were also more likely to have CVD. Further study is needed to determine the effect of body size on risk of CVD in the urban Indigenous population. The final model had good discriminative ability and adequate calibration when applied to the Hamilton sample.

CONCLUSION

Our modelling identified hypertension, diabetes and exposure to discrimination as factors associated with cardiovascular disease. Discrimination is a modifiable exposure that must be addressed to improve cardiovascular health among Indigenous populations.

Uncovering SARS-COV-2 vaccine uptake and COVID-19 impacts among First Nations, Inuit and Métis Peoples living in Toronto and London, Ontario

Background:

First Nations, Inuit and Métis Peoples across geographies are at higher risk of SARS-CoV-2 infection and COVID-19 because of high rates of chronic disease, inadequate housing and barriers to accessing health services. Most Indigenous Peoples in Canada live in cities, where SARS-CoV-2 infection is concentrated. To address gaps in SARS-CoV-2 information for these urban populations, we partnered with Indigenous agencies and sought to generate rates of SARS-CoV-2 testing and vaccination, and incidence of infection for First Nations, Inuit and Métis living in 2 Ontario cities.

Methods:

We drew on existing cohorts of First Nations, Inuit and Métis adults in Toronto (n = 723) and London (n = 364), Ontario, who were recruited using respondent-driven sampling. We linked to ICES SARS-CoV-2 databases and prospectively monitored rates of SARS-CoV-2 testing, diagnosis and vaccination for First Nations, Inuit and Métis, and comparator city and Ontario populations.

Results:

We found that SARS-CoV-2 testing rates among First Nations, Inuit and Métis were higher in Toronto (54.7%, 95% confidence interval [CI] 48.1% to 61.3%) and similar in London (44.5%, 95% CI 36.0% to 53.1%) compared with local and provincial rates. We determined that cumulative incidence of SARS-CoV-2 infection was not significantly different among First Nations, Inuit and Métis in Toronto (7364/100 000, 95% CI 2882 to 11 847) or London (7707/100 000, 95% CI 2215 to 13 200) compared with city rates. We found that rates of vaccination among First Nations, Inuit and Métis in Toronto (58.2%, 95% CI 51.4% to 64.9%) and London (61.5%, 95% CI 52.9% to 70.0%) were lower than the rates for the 2 cities and Ontario.

Interpretation:

Although Ontario government policies prioritized Indigenous populations for SARS-CoV-2 vaccination, vaccine uptake was lower than in the general population for First Nations, Inuit and Métis Peoples in Toronto and London. Ongoing access to culturally safe testing and vaccinations is urgently required to avoid disproportionate hospital admisson and mortality related to COVID-19 in these communities.

Implementation Outcomes Assessment of a Digital Clinical Support Tool for Intrapartum Care in Rural Kenya: Observational Analysis

Background

iDeliver, a digital clinical support system for maternal and neonatal care, was developed to support quality of care improvements in Kenya.

Objective

Taking an implementation research approach, we evaluated the adoption and fidelity of iDeliver over time and assessed the feasibility of its use to provide routine Ministry of Health (MOH) reports.

Methods

We analyzed routinely collected data from iDeliver, which was implemented at the Transmara West Sub-County Hospital from December 2018 to September 2020. To evaluate its adoption, we assessed the proportion of actual facility deliveries that was recorded in iDeliver over time. We evaluated the fidelity of iDeliver use by studying the completeness of data entry by care providers during each stage of the labor and delivery workflow and whether the use reflected iDeliver’s envisioned function. We also examined the data completeness of the maternal and neonatal indicators prioritized by the Kenya MOH.

Results

A total of 1164 deliveries were registered in iDeliver, capturing 45.31% (1164/2569) of the facility’s deliveries over 22 months. This uptake of registration improved significantly over time by 6.7% (SE 2.1) on average in each quarter-year (P=.005), from 9.6% (15/157) in the fourth quarter of 2018 to 64% (235/367) in the third quarter of 2020. Across iDeliver’s workflow, the overall completion rate of all variables improved significantly by 2.9% (SE 0.4) on average in each quarter-year (P<.001), from 22.25% (257/1155) in the fourth quarter of 2018 to 49.21% (8905/18,095) in the third quarter of 2020. Data completion was highest for the discharge-labor summary stage (16,796/23,280, 72.15%) and lowest for the labor signs stage (848/5820, 14.57%). The completion rate of the key MOH indicators also improved significantly by 4.6% (SE 0.5) on average in each quarter-year (P<.001), from 27.1% (69/255) in the fourth quarter of 2018 to 83.75% (3346/3995) in the third quarter of 2020.

Conclusions

iDeliver’s adoption and data completeness improved significantly over time. The assessment of iDeliver’ use fidelity suggested that some features were more easily used because providers had time to enter data; however, there was low use during active childbirth, which is when providers are necessarily engaged with the woman and newborn. These insights on the adoption and fidelity of iDeliver use prompted the team to adapt the application to reflect the users’ culture of use and further improve the implementation of iDeliver.

Validation of the integrated prediction model algorithm for outcome of cytoreduction in advanced ovarian cancer

5546

Background: In advanced ovarian cancer, the decision for primary cytoreductive surgery(PCS) or neoadjuvant chemotherapy(NACT) remains a challenge and may impact survival. We previously developed the integrated prediction model(IPM) using a 4-step algorithm of unresectable stage IVb, patient factors, surgical resectability and surgical complexity to predict outcome of optimal cytoreduction in advanced epithelial ovarian cancer(AEOC) and triage patients to NACT or PCS. The objective of the current study was to validate this model on a retrospective historical cohort of patients. Methods: This is a retrospective cohort study of 107 patients with AEOC treated at the Princess Margaret Cancer Centre between January 2017 and September 2018 undergoing PCS or NACT. All diagnostic imaging was retrospectively reviewed to assign surgical resectability score (SRS) for sites of disease and the surgical complexity score (SCS) for procedures anticipated to be required to achieve optimal cytoreduction based on pre-operative imaging. Those scores were modified from previously validated tools. Patient factors (PF) included age, ECOG and albumin. We previously developed an IPM algorithm to achieve outcome of optimal cytoreduction and determined cut-offs using the Youden index J. Triaging patients to PCS without stage IVb unresectable disease, PF≤ 2, SRS≤5 and SCS≤ 9 led to an 85% specificity and 75% accuracy for outcome of optimal cytoreduction < 1 cm. The current validation study was performed reporting sensitivity, specificity, negative (NPV) and positive predictive value (PPV) on an external cohort. Results: Among 107 patients, 61 had PCS and 46 had NACT followed by ICS. Patients treated with NACT were significantly older (63.5 vs 61 years, p = 0.037), more likely stage IV (52% vs 18%, p < 0.001), had a higher proportion of ECOG > 1 (30% vs 11%, 0.045), a lower pre-operative album (37 vs 40, p < 0.001) and higher CA-125 (970 vs 227.5, p < 0.001) compared to PCS. They also had higher PF (2 vs 0, p = 0.013), SRS (4 vs 1, p < 0.001) and SCS (8 vs 5, p = < 0.001). There was no significant difference in outcome of cytoreduction; the optimal cytoreduction rate was 85% vs 87%, p = 0.12 between PCS and ICS patients. In this validation cohort, triaging patients without unresectable stage IVb disease, PF≤ 2, SRS≤ 5 and SCS≤ 9 to PCS had a sensitivity of 91% to correctly identify patients who will have optimal cytoreduction of < 1 cm at PCS and a specificity of 81%. The PPV was 83%, NPV was 90% and accuracy was 86%. Application of the IPM would have prevented 5 suboptimal patients and correctly triaged them to NACT. Conclusions: We validated a triage algorithm integrating patient factors, surgical complexity and surgical resectability for patients with AEOC to achieve optimal cytoreduction at PCS with high sensitivity and specificity. This may therefore be used in a clinical setting to decide between PCS and NACT.

Clinical utility of tumor next-generational sequencing (NGS) panel testing to inform treatment decisions for patients with advanced solid tumors

3119

Background: There is limited information about the clinical utility of targeted NGS panel testing to inform decision-making for patients with advanced solid tumors. The Ontario-wide Cancer Targeted Nucleic Acid Evaluation (OCTANE) is an ongoing prospective study that enrolled over 4,500 solid tumor patients for NGS panel testing. We performed a retrospective survey of 21 medical oncologists enrolling OCTANE patients at a single academic institution to evaluate the impact of NGS testing on treatment decisions. Methods: Patients and treating oncologists were identified at the Princess Margaret Cancer Centre between 2016-2021. Tumor-only sequencing was performed using a custom hybridization capture panel of 555 cancer genes (Hi5) or a commercial 161-gene amplicon DNA/RNA panel (Oncomine Comprehensive v3). Oncologists were asked to review testing results for individual patients and complete a survey indicating whether NGS testing impacted treatment decisions. Mutations were defined as actionable based on clinical judgment and compared to classifications provided by OncoKB, an FDA-recognized precision medicine knowledgebase. The primary outcome of this study was rate of treatment change based on mutation results. Patient, test, and physician factors were evaluated for association with treatment changes using univariate analyses and a mixed effects model. Results: Two cohorts were surveyed, the first between 2017-2019 and the second in 2021. Of the 582 surveys sent, 394 (67.7%) were completed. Each physician completed a median of 19 surveys (range, 9-48). We found that 188 (47.7%) patients had a mutation classified as actionable by the oncologist, of whom 134 (71.3%) had ≥1 OncoKB-defined actionable mutation(s). 62/394 (15.7%) patients were matched to a treatment, of whom 37 were enrolled in a clinical trial, 13 received an approved drug, 4 were prescribed off-label therapy and 8 avoided ineffective treatment. 127/188 (67.5%) patients with actionable mutations did not receive treatment due to lack of available therapy, stability on current regimen, clinical deterioration or patient decision. Rate of treatment change was highest for bowel (15/37, 40.5%), breast (14/52, 27.5%), biliary tract (6/22, 27.3%) and lung (4/17, 23.5%) cancers. Treatment decisions were not associated with patient age, gender, physician clinical experience, physician gender, testing experience, OncoKB mutation level or time from biopsy to sequencing. There was no difference in overall survival between patients with matched vs. no matched treatment ( p = 0.55, median survival not reached). Conclusions: OCTANE testing led to a change in drug treatment in 15.7% of patients, supporting the clinical utility of NGS panel testing for patients with advanced solid tumors. Patient, test, and physician characteristics were not significantly associated with treatment change.

The working conditions for personal support workers in the Greater Toronto Area during the COVID-19 pandemic: a mixed-methods study

OBJECTIVE

During the height of the COVID-19 pandemic, personal support workers (PSWs) were heralded as healthcare 'heroes' as many of them cared for high-risk, vulnerable older populations, and worked in long-term care, which experienced a high number of COVID-19 outbreaks and deaths. While essential to the healthcare workforce, there is little understanding of PSW working conditions during the pandemic. The aim of our study was to examine the working conditions (including job security, work policies, and personal experiences) for PSWs in the Greater Toronto Area during the COVID-19 pandemic from the perspectives of PSWs.

METHODS

This study used a mixed-methods design. From June to December 2020, we conducted a survey of 634 PSWs to understand their working conditions during the COVID-19 pandemic. Semi-structured interviews with 31 survey respondents were conducted from February to May 2021 to understand in greater depth how working conditions were impacting the well-being of PSWs.

RESULTS

We found PSWs faced a range of challenges related to COVID-19, including anxiety about contracting COVID-19, reduced work hours, taking leaves of absences, concerns about job security, and losing childcare. While the COVID-19 pandemic highlighted the PSW workforce and their importance to the healthcare system (especially in the long-term care system), pre-existing poor work conditions of insecure jobs with no paid sick days and benefits exacerbated COVID-19-related challenges. Despite these hardships, PSWs were able to rely on their mental resilience and passion for their profession to cope with challenges.

CONCLUSION

Significant changes need to be made to improve PSW working conditions. Better compensation, increased job security, decreased workload burden, and mental health supports are needed.

Impact of 18F-DCFPyL PET on Staging and Treatment of Unfavorable Intermediate or High-Risk Prostate Cancer

Background Data regarding 2-(3-{1-carboxy-5-[(6-[¹⁸F]fluoro-pyridine 3-carbonyl)-amino]-pentyl}-ureido)-pentanedioic acid (¹⁸F-DCFPyL) PET in primary staging of prostate cancer (PCa) are limited. Purpose To compare the performance of ¹⁸F-DCFPyL PET/CT or PET/MRI (PET) with bone scan and CT with or without multiparametric MRI (hereafter, referred to as conventional imaging) in the initial staging of men with unfavorable intermediate or high-risk PCa and to assess treatment change after PET. Materials and Methods This prospective study evaluated men with biopsy-proven, untreated, unfavorable intermediate or high-risk PCa with 0 to four metastases or equivocal for extensive metastases (more than four) who underwent PET between May 2018 and December 2020. The diagnostic performance of PET in detecting pelvic nodal and distant metastases was compared with conventional imaging alone. Metastatic sites at conventional imaging and PET were compared with a composite reference standard including histopathologic analysis, correlative imaging, and/or clinical and biochemical follow-up. The intended treatment before PET was compared with the treatment plan established after performing PET. Detection rate, sensitivity, and specificity of conventional imaging and PET were compared by using McNemar exact test on paired proportions. Results The study consisted of 108 men (median age, 66 years; IQR, 61-73 years) with no metastases (n = 84), with oligometastases (four or fewer metastases; 22 men), or with equivocal findings for extensive metastases (n = 2). Detection rates at PET and conventional imaging for nodal metastases were 34% (37 of 108) and 11% (12 of 108) (P < .001), respectively, and those for distant metastases were 22% (24 of 108) and 10% (11 of 108) (P = .02), respectively. PET altered stage in 43 of 108 (40%) and treatment in 24 of 108 (22%) men. The most frequent treatment change was from systemic to local-regional therapy in 10 of 108 (9%) and from local-regional to systemic therapy in nine of 108 (8%) men. Equivocal findings were encountered less frequently with PET (one of 108; 1%) than with conventional imaging (29 of 108; 27%). Conclusion Initial staging with 2-(3-{1-carboxy-5-[(6-[¹⁸F]fluoro-pyridine 3-carbonyl)-amino]-pentyl}-ureido)-pentanedioic acid (¹⁸F-DCFPyL) PET after conventional imaging (bone scan and CT with or without multiparametric MRI) helped to detect more nodal and distant metastases than conventional imaging alone and changed treatment in 22% of men. Clinical trial registration no. NCT03535831, NCT03718260 © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Jadvar in this issue.

Implementation of a standardized voiding protocol after minimally invasive surgery: A quality improvement initiative

OBJECTIVES

To assess the effects of the implementation of a standardized voiding protocol in patients undergoing minimally invasive hysterectomy at a single cancer center in terms of the urinary tract infection (UTI) rate, time to first void, and overnight stays secondary to urinary retention.

METHODS

We enrolled 102 consecutive patients undergoing minimally invasive hysterectomy at a single cancer center during a 12-month period. A pre-intervention cohort of 100 consecutive patients was identified for comparison. A multidisciplinary team developed and implemented a standardized voiding protocol using quality improvement methodology. We compared the demographics, time to first void, rate of urinary retention, and UTI rates between the pre- and post-intervention cohorts.

RESULTS

Our intervention led to a significant reduction in the time to first void (289 min vs. 566 min; P < 0.001), rate of urinary retention (2% vs. 10%; P = 0.015), and postoperative UTI (4% vs. 8%; P = 0.249). There was a similar rate of patients going home with a Foley catheter (9% vs. 11%; P = 0.850).

CONCLUSIONS

Implementation of a standardized voiding protocol was associated with a reduction in rate of UTI, time to first void, and overnight stays secondary to urinary retention.

Precarious work among personal support workers in the Greater Toronto Area: a respondent-driven sampling study

BACKGROUND

The COVID-19 pandemic has highlighted the role of personal support workers (PSWs) in health care, as well as their work conditions. Our study aimed to understand the characteristics of the PSW workforce, their work conditions and their job security, as well as to explore the health of PSWs and the impact of precarious employment on their health.

METHODS

Our community-based participatory action research focused on PSWs in the Greater Toronto Area. We administered an online, cross-sectional survey between June and December 2020 using respondent-driven sampling. Data on sociodemographics, employment precarity, worker empowerment and health status were collected. We assessed the association between precarious employment and health using multivariable logistic regression models.

RESULTS

We contacted 739 PSWs, and 664 consented to participate. Overall, 658 (99.1%) completed at least part of the survey. Using data adjusted for our sampling approach, the participants were predominantly Black (76.5%, 95% confidence interval [CI] 68.2%-84.9%), women (90.1%, 95% CI 85.1%-95.1%) and born outside of Canada (97.4%, 95% CI 94.9%-99.9%). Most worked in home care (43.9%, 95% CI 35.2%-52.5%) or long-term care (34.5%, 95% CI 27.4%-42.0%). Although most participants had at least some postsecondary education (unadjusted proportion = 83.4%, n = 529), more than half were considered low income (55.1%, 95% CI 46.3%-63.9%). Most participants were precariously employed (86.5%, 95% CI 80.7%-92.4%) and lacked paid sick days (89.5%, 95% CI 85.8%-93.3%) or extended health benefits (74.1%, 95% CI 66.8%-81.4%). Nearly half of the participants described their health as less than very good (46.7%, 95% CI 37.9%-55.5%). Employment precarity was significantly associated with higher risk of depression (odds ratio 1.02, 95% CI 1.01-1.03).

INTERPRETATION

Despite being key members of health care teams, most PSWs were precariously employed with low wages that keep them in poverty; the poor work conditions they faced could be detrimental to their physical and mental health. Equitable strategies are needed to provide decent work conditions for PSWs and to improve their health.

Long COVID and episodic disability: advancing the conceptualisation, measurement and knowledge of episodic disability among people living with Long COVID - protocol for a mixed-methods study

INTRODUCTION

As the prevalence of Long COVID increases, there is a critical need for a comprehensive assessment of disability. Our aims are to: (1) characterise disability experiences among people living with Long COVID in Canada, UK, USA and Ireland; and (2) develop a patient-reported outcome measure to assess the presence, severity and episodic nature of disability with Long COVID.

METHODS AND ANALYSIS

In phase 1, we will conduct semistructured interviews with adults living with Long COVID to explore experiences of disability (dimensions, uncertainty, trajectories, influencing contextual factors) and establish an episodic disability (ED) framework in the context of Long COVID (n~10 each country). Using the conceptual framework, we will establish the Long COVID Episodic Disability Questionnaire (EDQ). In phase 2, we will examine the validity (construct, structural) and reliability (internal consistency, test-retest) of the EDQ for use in Long COVID. We will electronically administer the EDQ and four health status criterion measures with adults living with Long COVID, and readminister the EDQ 1 week later (n~170 each country). We will use Rasch analysis to refine the EDQ, and confirm structural and cross-cultural validity. We will calculate Cronbach's alphas (internal consistency reliability), and intraclass correlation coefficients (test-retest reliability), and examine correlations for hypotheses theorising relationships between EDQ and criterion measure scores (construct validity). Using phase 2 data, we will characterise the profile of disability using structural equation modelling techniques to examine relationships between dimensions of disability and the influence of intrinsic and extrinsic contextual factors. This research involves an academic-clinical-community partnership building on foundational work in ED measurement, Long COVID and rehabilitation.

ETHICS AND DISSEMINATION

This study was approved by the University of Toronto Research Ethics Board. Knowledge translation will occur with community collaborators in the form of presentations and publications in open access peer-reviewed journals and presentations.

Enhanced recovery after minimally invasive gynecologic oncology surgery to improve same day discharge: a quality improvement project

OBJECTIVES

Same day discharge after minimally invasive hysterectomy has been shown to be safe and feasible. We designed and implemented a quality improvement perioperative program based on early recovery after surgery principles to improve the rate of same day discharge from 30% to 75% after minimally invasive gynecologic oncology surgery over a 12 month period.

METHODS

We enrolled 102 consecutive patients undergoing minimally invasive hysterectomy at a single cancer center during a 12 month period. A pre-intervention cohort of 100 consecutive patients was identified for comparison of clinicodemographic variables and perioperative outcomes. A multidisciplinary team developed a comprehensive perioperative care program and followed quality improvement methodology. Patients were followed up for 30 days after discharge. A statistical process chart was used to monitor the effects of our interventions, and a multivariate analysis was conducted to determine factors associated with same day discharge.

RESULTS

Same day discharge rate increased from 29% to 75% after implementation (p<0.001). The post-intervention cohort was significantly younger (59 vs 62 years; p=0.038) and had shorter operative times (180 vs 211 min; p<0.001) but the two groups were similar in body mass index, comorbidity, stage, and intraoperative complications. There was no difference in 30 day perioperative complications, readmissions, reoperations, emergency department visits, or mortality. Overnight admissions were secondary to nausea and vomiting (16%), complications of pre-existing comorbidities (12%), and urinary retention (8%). On multivariate analysis, longer surgery, timing of surgery, and narcotic use on the ward were significantly associated with overnight admission. Overall, 89% of patients rated their experience as 'very good' or 'excellent', and 87% felt that their length of stay was adequate.

CONCLUSIONS

Following implementation of a perioperative quality improvement program targeted towards minimally invasive gynecologic oncology surgery, our intervention significantly improved same day discharge rates while maintaining a low 30 day perioperative complication rate and excellent patient experience.

Training programs to improve identification of sick newborns and care-seeking from a health facility in low- and middle-income countries: a scoping review

BACKGROUND

Most neonatal deaths occur in low- and middle-income countries (LMICs). Limited recommendations are available on the optimal personnel and training required to improve identification of sick newborns and care-seeking from a health facility. We conducted a scoping review to map the key components required to design an effective newborn care training program for community-based health workers (CBHWs) to improve identification of sick newborns and care-seeking from a health facility in LMICs.

METHODS

We searched multiple databases from 1990 to March 2020. Employing iterative scoping review methodology, we narrowed our inclusion criteria as we became more familiar with the evidence base. We initially included any manuscripts that captured the concepts of "postnatal care providers," "neonates" and "LMICs." We subsequently included articles that investigated the effectiveness of newborn care provision by CBHWs, defined as non-professional paid or volunteer health workers based in communities, and their training programs in improving identification of newborns with serious illness and care-seeking from a health facility in LMICs.

RESULTS

Of 11,647 articles identified, 635 met initial inclusion criteria. Among these initial results, 35 studies met the revised inclusion criteria. Studies represented 11 different types of newborn care providers in 11 countries. The most commonly studied providers were community health workers. Key outcomes to be measured when designing a training program and intervention to increase appropriate assessment of sick newborns at a health facility include high newborn care provider and caregiver knowledge of newborn danger signs, accurate provider and caregiver identification of sick newborns and appropriate care-seeking from a health facility either through caregiver referral compliance or caregivers seeking care themselves. Key components to consider to achieve these outcomes include facilitators: sufficient duration of training, refresher training, supervision and community engagement; barriers: context-specific perceptions of newborn illness and gender roles that may deter care-seeking; and components with unclear benefit: qualifications prior to training and incentives and remuneration.

CONCLUSION

Evidence regarding key components and outcomes of newborn care training programs to improve CBHW identification of sick newborns and care-seeking can inform future newborn care training design in LMICs. These training components must be adapted to country-specific contexts.

1074. The Relationship Between the Patient’s Body Mass Index and Dalbavancin’s Efficacy in the Treatment of Invasive Gram-Positive Infections

Background

Dalbavancin is a long-acting lipoglyopeptide antibiotic used in the treatment of invasive gram-positive infections. There is a lack of published research on the effect of obesity on dalbavancin’s pharmacokinetics. The primary objective was to determine if obesity correlates to clinical failure at 90 days for patients with gram-positive infections treated with dalbavancin.

Methods

This retrospective observational study reviewed the use of dalbavancin from 1/1/2015- 3/31/2021 at 2 community hospitals. Patients were included if ≥ 18 years and received at least one dose of dalbavancin as an inpatient or at an outpatient infusion center. Patients were excluded if not seen by a provider within 90 days post last infusion. The primary outcome was clinical failure (CF). CF at 90 days was a composite of one or more of the following: need for additional antibiotics, dalbavancin intolerance, hospital readmission for same indication, need for additional surgery/debridement, or death. Clinical cure (CC) was defined as not meeting the criteria for CF. Patient demographics, BMI, indication, achievement of source control, Charlson Comorbidity Index (CCM) were collected. Descriptive statistics were used. To determine if a BMI cut-point exists between CC and CF, a classification & regression tree (CART) analysis was performed.

Results

A total of 81 patients received dalbavancin with 19 patients excluded for lack of follow up. Patient demographics: mean age (SD) 45.3 (15.8) years, 50% male; CCM 2.6 (3.1). Indications included osteomyelitis n=22, endovascular n=12, diabetic foot/skin soft tissue n=9, septic joint n=8, other n=11. A total of 29 (47%) of patients were bacteremic; 34 (55%) having source control. CF occurred in 15 of 62 (24%) patients. CF was compared with weight, BMI, CCM, albumin and source control. A difference existed in the median (IQR) BMI between CF 32.5 kg/m2 (25.1 – 42.8) and CC 25.5 kg/m2 (22.1 – 28.2); p=.029. A BMI cutpoint was not identified in CART analysis.

Conclusion

There is a relationship between increased BMI and 90-day CF in patients treated with dalbavancin. A higher BMI was found among those with with CF. Future studies are necessary to determine if a BMI based weight adjustment is necessary.

Disclosures

Lisa Avery, PharmD, BCPS, BCIDP, Merck (Other Financial or Material Support, Spouse Employer)

Treatment outcomes and predictive factors in patients ≥70 years old with advanced ovarian cancer

OBJECTIVE

To evaluate treatment outcomes, survival, and predictive factors in patients ≥70 with advanced epithelial ovarian cancer (AEOC).

METHODS

A retrospective single institution cohort study of women ≥70 with Stage III-IV AEOC between 2010 and 2018. Patients had either primary cytoreductive surgery (PCS), neoadjuvant chemotherapy (NACT) with interval cytoreductive surgery (ICS), chemotherapy alone, or no treatment. Demographics, surgical outcome, complications, and survival outcome were compared between groups.

RESULTS

Among 248 patients, 69 (27.7%) underwent PCS, 99 (39.9%) had ICS, 56 (22.5%) had chemotherapy alone. Twenty-four (9.6%) remained untreated. Optimal cytoreduction (≤1 cm) was achieved in 72.4% of PCS and 77.8% of NACT/ICS (p = 0.34), without difference in grade ≥3 postoperative complications (15.9% vs. 9.1%, p = 0.37). Progression-free survival (PFS) was 23.5 months in PCS and 15.0 months in ICS patients (hazard ratio [HR]: 1.4, p = 0.041). Patients in the surgical arms, PCS or ICS, had better 2-year overall survival (OS) compared to chemotherapy alone (79%, 68%, 41%, respectively, HR: 3.58, p < 0.001). In a subgroup analysis, patients ≥80 had improved 2-year OS when treated with NACT compared to PCS (82% vs. 57%) and a trend toward improved PFS. Age, stage, and CA-125 were determinants of undergoing PCS.

CONCLUSION

In patients ≥70 with AEOC, surgery should not be deferred based on age alone. Fit, well selected patients ≥70 can benefit from PCS, while patients ≥80 might benefit from NACT over PCS.

Implementation of a restrictive opioid prescription protocol after minimally invasive gynecologic oncology surgery

OBJECTIVES

Opioids are routinely prescribed after minimally invasive gynecologic oncology surgery, with minimal data to inform the ideal dose. The aim of this study was to evaluate the impact of a restrictive opioid prescription protocol on the median morphine milligram equivalents prescribed and pain control in patients undergoing minimally invasive surgery.

METHODS

A restrictive opioid prescription protocol was implemented from January through December 2020 at a single tertiary cancer center in Ontario, Canada. Consecutive patients undergoing minimally invasive hysterectomy for suspected malignancy were included. Simultaneously, we implemented use of multimodal analgesia, patient and provider education, pre-printed standardized prescriptions, and tracking of opioid prescriptions. Total median morphine milligram equivalents prescribed were compared between pre- and post-intervention cohorts. Patients were surveyed regarding opioid use and pain control at 30 days post-surgery.

RESULTS

A total of 101 women in the post-intervention cohort were compared with 92 consecutive pre-intervention controls. Following protocol implementation, median morphine milligram equivalents prescribed decreased from 50 (range 9-100) to 25 (range 8-75) (p<0.001). In the post-intervention cohort, 75% (76/101) used 10 median morphine milligram equivalents or less and 55 patients (54%) used 0 median morphine milligram equivalent. There was no additional increase in opioid refill requests after implementation of our strategy. Overall, patients reported a median pain score of 3/10 at 30 days post-surgery; the highest pain scores and most of the pain occurred in the first week after surgery.

CONCLUSIONS

Implementation of a restrictive opioid prescription protocol led to a significant reduction in opioid use after minimally invasive gynecologic oncology surgery, with over 50% of patients requiring no opioids postoperatively.