Examining the implementation of a community paediatric clinic in a socially disadvantaged Irish community: A retrospective process evaluation

BACKGROUND

Understanding interventions and their implementation is essential for improving community initiatives. Kidscope is a community paediatric development clinic providing free health and developmental assessment and onward referral for children aged zero to six years in an urban area of southern Ireland where many children experience complex needs. Established in 2010, Kidscope developed an inter-disciplinary, multi-agency community team by drawing on the strengths of local services and practitioners to deliver holistic approaches to child health and development. Recent studies examining stakeholder engagement and Kidscope outcomes highlighted the need to examine implementation to better understand the processes and mechanisms of the clinic and how events have affected outcomes.

METHODS

Guided by the UK Medical Research Council Framework for Developing and Evaluating Complex Interventions, this study used a post-hoc qualitative process evaluation study design with multiple data sources; stakeholder perspectives (interviews, focus group, questionnaires) and document analysis (annual reports, meeting minutes, work plans). A diverse set of research questions were developed in conjunction with a Patient and Public Involvement Group. Guiding frameworks supported thematic analysis of primary data, document analysis of secondary data, and triangulation of findings across datasets.

RESULTS

Data analysis yielded 17 themes and 18 sub-themes. Successful implementation hinged on developing a coalition of linked practitioners and services whose skills were utilised and enhanced within Kidscope to deliver a high-quality healthcare model to vulnerable children and families. Relational and multi-disciplinary working, innovative approaches to implementation and sustainability, training and education provision, and the accessible community location were among the mechanisms of change resulting in improved child, family, practitioner, and system-level outcomes. External factors such as COVID-19 and deficits in Ireland's disability services posed significant barriers to fidelity.

CONCLUSION

This study provides evidence of the processes, mechanisms, and model of care employed by a community-based paediatric clinic to successfully engage society's most vulnerable families and promote health equity. This study makes an important contribution to the field of implementation research by offering an example of a robust approach to conceptualising and measuring implementation outcomes of community healthcare initiative in a changing, real-world context.

Parent perspectives of engaging with a community paediatric clinic with linked child development supports in a disadvantaged area of Ireland

Parent experiences of child health services can be used to understand their value and optimise the support provision to families during critical developmental periods. A gap in the literature exists regarding parental perspectives of linked child development supports, particularly in disadvantaged areas. This study examined parent experiences of the impact and value of a community paediatric clinic (Kidscope) with linked, multi-agency supports in a disadvantaged area of Ireland. Using a qualitative analysis design, 10 parents participated in one-to-one interviews. A Community Advisory Group consulted on interview schedules. Data was thematically analysed in line with Braun & Clarke's Framework. Five themes and twenty-two sub-themes emerged. Kidscope's linked, multi-agency approach was valuable for engaging families, addressing developmental delay, supporting readiness for education, and developing parent-child relationships. Relational working and a child and family centred model of care empowered parents to become active agents in children's health. Coronavirus disease 2019, national deficits in healthcare, and staff turnover impeded service delivery. Kidscope and linked supports work in partnership to disrupt the impact exclusion from healthcare has on vulnerable children and families. This study provides evidence of an effective integrated paediatric service delivery model designed around vulnerable children and families and highlights areas for improvement.

Did COVID-19 Have an Impact on Incident Leaning? Implications for Patient Safety

PURPOSE/OBJECTIVE(S)

The Ottawa Hospital's Radiation Oncology program maintains the Incident Learning System (ILS) - a quality assurance program that consists of report submissions of errors and near misses arising from all major domains of radiation. In March 2020, the department adopted workflow changes to optimize patient and provider safety during the COVID-19 pandemic. The purpose of this study was to analyze the number and type of ILS submissions pre- and post-pandemic precautions to assess the impact of COVID-19-related workflow changes.

MATERIALS/METHODS

ILS data was collected over seven one-year time periods between March 2016 and February 2023, where COVID-19-related workflow changes were initiated March 2020, and lifted in March 2022. All incidents in the system were previously investigated as per clinical practice. Incidents were analyzed for the number of reports submitted and number of actual versus potential incidents as compared to previous years. Origin and detection domains were tabulated for each period under consideration, as were the root causes of the incidents.

RESULTS

With the onset of COVID-19-related workflow changes, the total number of ILS submissions were reduced by 25%. Similarly, there were 30% fewer ILS submissions per number of treatment courses compared to pre-pandemic data. There was also an increase in the proportion of "treatment planning" ILS submissions and a 50% reduction in the proportion of "decision to treat" ILS submissions compared to previous years. Root cause analysis revealed there were more incidents attributable to "poor, incomplete, or unclear documentation" during the pandemic years. In the most recent year, as COVID-19 workflow changes have eased, the total number of ILS submissions has returned to the pre-pandemic baseline average.

CONCLUSION

During the pandemic years, workflow and staffing changes were associated with a decrease in the number of ILS submissions indicating less engagement with a vital component of quality assurance and therefore patient safety. In addition, significant changes observed regarding the types of submissions reported during the pandemic years are reflective of the unique challenges encountered during pandemic precautions. Continued engagement with ILS reporting is essential to the continued safety of the radiation oncology program, particularly during the dynamic COVID-19 pandemic or other periods of rapid change within a program.

Safety and management of niraparib monotherapy in ovarian cancer clinical trials

Niraparib is a poly (ADP-ribose) polymerase inhibitor that has shown a significant improvement in progression-free survival irrespective of biomarker status in patients with advanced epithelial ovarian cancer. This review focuses on the adverse events associated with niraparib and their management to maintain efficacy of niraparib treatment and improve quality of life for patients. In five trials assessing efficacy of niraparib in patients with advanced epithelial ovarian cancer (PRIMA, NOVA, NORA, QUADRA, and PRIME), treatment-emergent adverse events of any grade were reported in nearly all patients (≥99%) receiving niraparib; the events were grade ≥3 in 51-74% of patients. Across all lines of therapy, treatment-emergent adverse events led to dose interruptions in 62-80% of patients receiving niraparib and dose reductions in 47-71%. Hematologic events were most frequently reported, including thrombocytopenia, anemia, and neutropenia. Common non-hematologic events included gastrointestinal events, which were generally low grade (<5% were grade ≥3). Clinical strategies to manage these and other events, such as fatigue and insomnia, cognitive behavioral therapy and pharmacologic agents, are summarized. Once-daily niraparib dosing may be advantageous for some patients for many reasons, including night-time dosing which may help alleviate gastrointestinal symptoms. An individualized starting dose (determined by baseline body weight and platelet count) of niraparib demonstrated an improved safety profile while maintaining efficacy. Patients receiving the niraparib individualized starting dose had fewer grade ≥3 adverse events, dose interruptions, and dose reductions than patients receiving a fixed starting dose. The safety profile of niraparib across five pivotal studies in advanced epithelial ovarian cancer was consistent across multiple lines of treatment, including as maintenance therapy in first-line and recurrent settings and as treatment in heavily pre-treated patients. Long-term safety data from the NOVA trial confirmed that, with appropriate and early dose modifications, niraparib is well tolerated.

Exploring Undergraduate Medical Student Experiences of Training Within a Community-Based Paediatric Clinic

Background

Undergraduate medical education in Ireland comprises of clinical training largely within teaching hospitals, with less emphasis on training in community settings. Studies show a move beyond traditional models of training is needed, particularly in the domain of community child health. A multi-agency, inter-disciplinary community paediatric clinic was established in a disadvantaged area of southern Ireland. Kidscope provides health and developmental assessment for children aged 0-6 years and acts as a training clinic for medical students who complete a one day placement during the final year of their undergraduate medical degree. The aim of this study was to capture student experiences and to understand the perceived impact of community-based training on undergraduate medical education.

Methods

A descriptive study design was used. Research tools included a mixed-methods online questionnaire and qualitative reflective essays. Microsoft Excel generated descriptive statistics from quantitative questionnaire responses. Braun and Clarke's framework guided thematic analysis of qualitative data. Data integration and reporting were conducted in line with mixed-methods research design standards.

Results

Fifty-two medical students consented to participate. Thirty-two (62%) responded to the online questionnaire. Twenty reflective essays were randomly selected. Ninety-four percent felt the clinic provided an opportunity to apply knowledge and skills, 96% reported the experience strongly improved their understanding of child health and development, and 90% reported the experience was extremely valuable to their overall learning. Qualitative analysis showed engagement with a vulnerable population in the community increased student knowledge, informed practice, and heightened awareness of social deprivation and its impact on child development.

Conclusion

Exposure to a community-based paediatric clinic influenced undergraduate medical student training through experiential and transformative learning. Our experience of teaching clinical skills in the community could be replicated across medical fields to the benefit of the wider community.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-022-01699-3.

Sustainable Development Goals in Ireland: How Public Health Nurses Are Contributing Through Engagement in an Interagency Community Pediatric Clinic

Introduction

United Nations Sustainable Development Goals (SDGs) were adopted as a plan of action for people, planet, and prosperity by 2030. SDG 3 aims to ensure healthy lives and promote well-being for all ages, and other goals focus on reduction of inequality, abolition of poverty, decent work for all, and building effective, accountable, and inclusive institutions. A community pediatric clinic, Kidscope, was established in a vulnerable Irish community offering free developmental assessment and onward referral of children 0 to 6 years. The Kidscope model involves multiagency input with local public health nurses (PHNs) acting as fundamental partners in the provision of specialist early years support to vulnerable children and families. This study evaluates PHN involvement in Kidscope in the context of SDGs.

Objective

To record and understand PHN roles within Kidscope and to capture their contribution to achieving SDGs in a disadvantaged Irish community.

Methods

Qualitative stakeholder analysis and mapping design. Snowball sampling identified participants. Data collection involved scoping interviews, questionnaires, one-to-one interviews, and a focus group. A Stakeholder Matrix Table was developed in line with the guiding framework. Transcripts were thematically analyzed.

Results

PHNs are key stakeholders in Kidscope contributing to clinic development, delivery, and sustainability. Six themes were identified: lead referrers, in-clinic support, learning and education, child and family follow-up, specialist early years role, and partnership working. PHNs contribute to six SDGs through the Kidscope model.

Conclusion

PHNs are fundamental partners in achieving SDGs in a disadvantaged Irish community through ameliorating childhood developmental delay by intercepting the gap within Ireland's early intervention system and disrupting the impact exclusion to healthcare has on vulnerable children and their families. Findings underscore a shift from the current "cradle to grave" model of working toward a specialist early years PHN role.

Community paediatric clinics and their role in supporting developmental outcomes and services for children living in disadvantaged communities

Children living in disadvantaged communities have substantially increased risk for deleterious health and developmental outcomes. A considerable proportion of developmental delay is avoidable; however if children do not receive appropriate treatment within this critical period, damage can be irreparable. Community paediatric clinics provide medical and developmental assessment; deliver health promotion services, counselling, and advice to caregivers; and referral to services. The aim of this study was to systematically search, appraise, and synthesise the literature exploring the role of community paediatric clinics in supporting developmental outcomes and services for children living in disadvantaged communities. Electronic databases were searched using a carefully developed search strategy. Validated tools and appropriate guidelines assessed quality and confidence in evidence. Data analysis and mixed-methods synthesis was guided by the Segregated Framework for Mixed-Method Systematic Reviews. Eighteen studies were selected for inclusion. Areas of emphasis in the literature include the identification and monitoring of developmental delay; engagement of vulnerable families; relational working with children, families, and local services; referral to early intervention services; parental empowerment, practitioner capacity building; and tackling barriers to healthcare access. Through use of a child and family-centred model of care, community paediatric clinics can better meet the needs of vulnerable populations.

British Gynaecological Cancer Society (BGCS) cervical cancer guidelines: Recommendations for practice

Cervix cancer in many countries is declining and screening programmes and immunisation will reduce the incidence in the next few decades. This guideline attempts to cover management of invasive disease reflecting diagnosis and imaging including new imaging and sentinel lymph node biopsies. Smaller volume disease is usually managed surgically whereas advanced disease is treated with (chemo)- radiation. It also includes discussion of fertility sparing procedures. Practices are changing frequently for all aspects of care usually in attempts to reduce complications and improve quality of life. The management of advanced disease is treated by chemotherapy and the use of newer agents is also discussed. Other sections discuss specialist situations such as cancer in pregnancy, rare cervical tumours, late effects and supportive measures and fertility preserving approaches.

British Gynaecological Cancer Society (BGCS) vulval cancer guidelines: Recommendations for practice

The purpose of this guideline is to collate evidence and propose evidence-based guidelines for the diagnosis and management of adult patients with vulva carcinoma treated in the UK. Malignant melanoma may present via similar routes and will be discussed. The reader is referred to the Ano-uro-genital Mucosal Melanoma Full Guideline [1] for more detailed recommendations. The management of vulval sarcoma is outside of the scope of this guideline. For further information, including details of guideline development and GRADE of recommendations, please see BGCS website for details (https://www.bgcs.org.uk/professionals/guidelines-for-recent-publications/).

The impact of a complex workplace dietary intervention on Irish employees' off-duty dietary intakes

A paucity of evidence exists regarding the impact of workplace dietary interventions on employees' off-duty dietary intakes. This study assessed the impact of workplace dietary interventions that included nutrition education and environmental dietary modification both alone and in combination on employees' dietary intakes inside (on-duty) and outside (off-duty) of work. A pre-post study on employees' on and off-duty dietary intakes was undertaken. Data were obtained from a complex workplace dietary intervention study (Food Choice at Work Trial). Four manufacturing workplaces were allocated to: Control (n = 111), nutrition education (n = 226), environmental dietary modification (n = 113) and nutrition education and environmental dietary modification combined (n = 400) (2013-14). Seven- to nine-month follow-up data were obtained for 517 employees (61% response) [Control (n = 67), Education (n = 107), Environment (n = 71) and Combined (n = 272)]. Dietary intakes were measured using 24-h dietary recalls. Differences between on and off-duty mean dietary intakes were compared and regression analyses adjusted for potential confounders. Significant reductions in on-duty intakes of total fat (-14.2 g/day, p = 0.000), saturated fat (-7 g/day, p = 0.000), salt (-1.4 g/day, p = 0.000) and total sugars (-8.9 g/day, p = 0.003) were observed in the Combined and in the Environment [total fat (-11.4 g/d, p = 0.017) and saturated fat (-8.8 g/day, p = 0.000)]. In the Combined, significant changes were also observed in off-duty intakes of total fat (-10.0 g/day, p = 0.001), saturated fat (-4.2 g/day, p = 0.001), salt (-0.7 g/day, p = 0.020) and total sugars (-8.1 g/day, p = 0.020). Food service can have a positive impact in our everyday environments, including inside and outside of work. Dietary interventions combining nutrition education and environmental dietary modification can improve employees' on and off-duty dietary intakes.

British Gynaecological Cancer Society recommendations and guidance on patient-initiated follow-up (PIFU)

The National Cancer Survivorship Initiative through the National Health Service (NHS) improvement in the UK started the implementation of stratified pathways of patient-initiated follow-up (PIFU) across various tumor types. Now the initiative is continued through the Living With and Beyond Cancer program by NHS England. Evidence from non-randomized studies and systematic reviews does not demonstrate a survival advantage to the long-established practice of hospital-based follow-up regimens, traditionally over 5 years. Evidence shows that patient needs are inadequately met under the traditional follow-up programs and there is therefore an urgent need to adapt pathways to the needs of patients. The assumption that hospital-based follow-up is able to detect cancer recurrences early and hence improve patient prognosis has not been validated. A recent survey demonstrates that follow-up practice across the UK varies widely, with telephone follow-up clinics, nurse-led clinics and PIFU becoming increasingly common. There are currently no completed randomized controlled trials in PIFU in gynecological malignancies, although there is a drive towards implementing PIFU. PIFU aims to individualize patient care, based on risk of recurrence and holistic needs, and optimizing resources. The British Gynaecological Cancer Society wishes to provide the gynecological oncology community with guidance and a recommendations statement regarding the value, indications, and limitations of PIFU in endometrial, cervical, ovarian, and vulvar cancers in an effort to standardize practice and improve patient care.

Expert recommendations on the management of hypertension in patients with ovarian and cervical cancer receiving bevacizumab in the UK

Bevacizumab is an anti-vascular endothelial growth factor monoclonal antibody that may prolong survival in ovarian and cervical cancer when given in combination with chemotherapy. It works by blocking the signalling pathways that are required for tumour angiogenesis, potentially limiting the cancer’s ability to grow and spread. Hypertension is a known side effect of all angiogenesis inhibitors and could lead to interruption or premature discontinuation of effective anti-cancer treatment. Hypertension may also act as a barrier to the initiation of such treatment. In this review, we aim to present clear and practical recommendations on the management of blood pressure in ovarian and cervical cancer patients before, during and after bevacizumab treatment. This guidance covers considerations before initiating bevacizumab therapy and recommendations on the management of patients who develop hypertension, or who experience worsening of pre-existing hypertension, during bevacizumab treatment, and once the course of bevacizumab has been completed. These recommendations were developed collaboratively by a group of clinicians, comprising cardiologists, oncologists, a general practitioner and specialist oncology nurses, with expertise and practical experience in either oncology or hypertension. The aim of these recommendations is to support oncologists with hypertension assessment and management to facilitate starting or continuing bevacizumab.

Pilot evaluation of an adolescent risk and injury prevention programme incorporating curriculum and school connectedness components

School connectedness is an important protective factor for adolescent risk-taking behaviour. This study examined a pilot version of the Skills for Preventing Injury in Youth (SPIY) programme, combining teacher professional development (PD) for increasing school connectedness (connectedness component) with a risk and injury prevention curriculum for early adolescents (curriculum component). A process evaluation was conducted on the connectedness component, involving assessments of programme reach, participant receptiveness and initial use, and a preliminary impact evaluation was conducted on the combined connectedness and curriculum programme. The connectedness component was well received by teacher participants, who saw benefits for both themselves and their students. Classroom observation also showed that teachers who received PD made use of the programme strategies. Grade 8 students who participated in the SPIY programme were less likely to report violent behaviour at 6-month follow-up than were control students, and trends also suggested reduced transport injuries. The results of this research support the use of the combined SPIY connectedness and curriculum components in a large-scale effectiveness trial to assess the impact of the programme on students' connectedness, risk-taking and associated injuries.

PROSPER: a randomised comparison of surgical treatments for rectal prolapse

AIM

Rectal prolapse is a profoundly disabling condition, occurring mainly in elderly and parous women. There is no accepted standard surgical treatment, with previous studies limited in methodological quality and size. PROSPER aimed to address these deficiencies by comparing the relative merits of different procedures.

METHOD

In a pragmatic, factorial (2 × 2) design trial, patients could be randomised between abdominal and perineal surgery (i), and suture vs resection rectopexy for those receiving an abdominal procedure (ii) or Altemeier's vs Delorme's for those receiving a perineal procedure (iii). Primary outcome measures were recurrence of the prolapse, incontinence, bowel function and quality of life scores (Vaizey, bowel thermometer and EQ-5D) measured up to 3 years.

RESULTS

Two hundred and ninety-three patients were recruited: 49 were randomised between surgical approaches (i); 78 between abdominal procedures (ii); and 213 between perineal procedures (iii). Recurrence rates were higher than anticipated, but not significantly different in any comparison: Altemeier's vs Delorme's 24/102 (24%) and 31/99 (31%) [hazard ratio (HR) 0.81; 95% CI 0.47, 1.38; P = 0.4]; resection vs suture rectopexy 4/32 (13%) and 9/35 (26%) (HR 0.45; 95% CI 0.14, 1.46; P = 0.2); perineal vs abdominal 5/25 (20%) and 5/19 (26%) (HR 0.83; 95% CI 0.24, 2.86; P = 0.8). Vaizey, bowel thermometer and EQ-5D scores were not significantly different in any of the comparisons.

CONCLUSION

No significant differences were seen in any of the randomised comparisons, although substantial improvements from baseline in quality of life were noted following all procedures.

Abstract S4-4: SECRAB: The Optimal SEquencing of Adjuvant Chemotherapy (CT) and RAdiotherapy (RT) in Early Breast Cancer (EBC), Results of a UK Multicentre Prospective Randomised Trial

Background: The optimal sequence of CT and RT for women with EBC has yet to be defined. SECRAB aimed to determine i) if synchronous (Syn) CT-RT improves loco-regional relapse rates (LRR) and ii) whether the treatments could be given together without increased toxicity or compromising the dose intensity of either CT or RT. The first endpoint of this study is presented in this abstract. Methods: SECRAB was a prospective, randomised trial comparing sequential (Seq) to Syn CT-RT. Permitted RT schedules included 40Gy/15F over 3 weeks, 45Gy/20F over 4 weeks and 50Gy/25F over 5 weeks. Syn RT was administered between cycles 2 and 3 for CMF or 5 and 6 for anthracycline-CMF. Syn patients treated using 15F were treated predominantly using a sandwich schedule while those receiving &gt;15F were treated concurrently with CT. Seq RT was delivered on CT completion. Key eligibility criteria were completely excised EBC, fit for and requiring adjuvant CT and RT. The trial was powered to produce a definitive event driven analysis: 150 loco-regional relapses having 85% power to detect 4% 2-sided differences in the primary endpoint of overall LRR. Results: Between Jul 98 and Mar 04, 2296 women were randomised. Baseline characteristics were well balanced. 63% of patients were node positive indicating a high risk population. 2 patients did not receive CT and 23 did not receive RT. 5 patients in the latter group had a loco-regional relapse prior to planned RT (Seq n=3). With a median follow-up of 8.8 years there were 93 and 76 loco-regional relapses in the Seq and Syn arms and 5-year LRR were 7.4% (95% CI 5.9-9.1) and 5.4% (95% CI 4.2-7.0) respectively. There was no significant difference in overall LRR (HRSyn 0.82; 95% CI 0.6-1.1; p=0.19). There was a trend for benefit for Syn treatment which was consistent across different subgroups (grade, lymph node status, tumour size, vascular invasion and excision margin). In an unplanned subgroup analysis, a trend for benefit for Syn treatment was seen predominantly in patients with the presence of lymphovascular invasion (LRR 11.9% Seq vs 8.2% Syn) and also in patients with 0 and 1-3 positive nodes (LRR 7.8% Seq vs 5.2% Syn) but not in those with 4 or more positive nodes. Similar rates were observed for distant recurrences (22.2% vs 22.2%), contralateral recurrences (2.9% vs 2.7%), and new primary cancers (2.9% vs 2.6%) in the Seq and Syn arms respectively. There was also no significant difference in overall survival which was 83% and 82% in the Syn and Seq arms respectively at 5-years (HRSyn 0.99; 95% CI 0.8-1.2; p=0.87). Modest differences in acute skin toxicity and telangiectasia were observed between the two study arms. There was no difference in other late toxicities. The second primary endpoint of safety, toxicity and dose intensity is described in detail elsewhere (abstract no 850168). Conclusions: SECRAB is the largest sequencing trial in EBC to date. Delivering Syn CT-RT using CMF or anthracycline-CMF and a 3 weekly RT fractionation shortens the overall treatment time. Although not statistically significant there was a trend to improved locoregional control with Syn treatment.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr S4-4.

Abstract P4-11-05: Acute and Late Toxicity Results from the SECRAB Trial: The Optimal SEquencing of Adjuvant Chemotherapy (CT) and RAdiotherapy (RT) in Early Breast Cancer (EBC)

Background: SECRAB is a large multicentre randomised controlled trial designed to determine the optimal sequence of CT and RT for women with EBC. The second objective of this trial was to determine if CT and RT treatment modalities could be given together without increased toxicity or compromising either modality. See abstract no 851519 for details of CT and RT scheduling.

Methods: Data on acute skin reaction was collected on completion of RT and graded as mild, moderate or severe. Late toxicity data was collected annually and included lymphoedema, telangiectasia, severe subcutaneous fibrosis, brachial plexopathy, rib fracture, ischaemic heart disease, symptomatic lung fibrosis, and clinical radiation pneumonitis.

Results: Between Jul 98 and Mar 04, 2296 women were randomised. Acute toxicity data was collected on 2267 patients who received RT. The distribution of RT schedules was balanced across treatment arms, with the majority of patients (67%) receiving 40Gy/15F (15F). Significantly more patients in the Syn arm experienced a delay of &gt;10 days in CT delivery (11% vs 5%, p &lt; 0.0001). Very few patients experienced a &gt;7 days delay in RT in either arm (Syn n=12 vs Seq n=3). In a sub-set of 880 patients dose intensity of CT was not significantly different between the two arms. Percentage skin toxicities for the Syn and Seq arms respectively were: None 22.9 vs 36.3; Mild 52.4 vs 48.1; Moderate 20.2 vs 13.6; Severe 3.8 vs 1.1. A significantly (p &lt; 0.001) higher proportion of patients on the Syn arm suffered a moderate or severe skin reaction compared to those on the Seq arm. An unplanned exploratory analysis by duration of RT showed that patients receiving &gt;15F (45Gy/20F or 50Gy/25F) had a significantly worse acute skin reaction than those receiving 15F (25% vs 16%, p=&lt;0.001). 5 patients on the Syn arm were admitted to hospital as a result of a severe RT reaction, 3 received &gt;15F. Acute radiation pneumonitis was 0.3% in both arms (n=5 in total). Percentage late toxicities for the Syn and Seq arms respectively were not significantly different for: moderate/severe lymphoedema 6.1 (n=70) vs 5.5 (n=64); severe subcutaneous fibrosis 1.3 (n= 15) vs 0.6 (n=7); brachial plexopathy 0.2 (n=2) vs 0.1 (n=1); rib fracture 0.6 (n=7) vs 0.4 (n=5); ischaemic heart disease 0.4 (n=5) vs 0.4 (n=2); symptomatic lung fibrosis 0.3 (n=15) vs 0.3 (n=7); and late clinical radiation pneumonitis 0.1 (n=1) vs 0.1 (n=1). Howevermoderate/severe telangiectasia was 2.5% vs 1.3% in the Syn and Seq arms respectively (p =0.05). This difference was not seen in patients receiving 15F.

Conclusions: The delivery of Syn CT-RT in the adjuvant treatment of EBC is associated with an increase in acute skin toxicity however the percentage of severe reactions is less than 5%. These skin reactions were seen predominantly in patients treated with concurrent RT (&gt;15F). An increase in late skin telangiectasia was also seen in patients receiving &gt;15F. There was no difference in other late toxicities recorded. Syn CT-RT is feasible in the adjuvant treatment of EBC and does not result in a reduction in dose intensity of delivered CT. The optimal schedule is 40Gy/15F which is now the standard regime used in the UK.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-11-05.

Rapid testing for group B streptococcus during labour: a test accuracy study with evaluation of acceptability and cost-effectiveness

OBJECTIVE

To determine the accuracy, acceptability and cost-effectiveness of polymerase chain reaction (PCR) and optical immunoassay (OIA) rapid tests for maternal group B streptococcal (GBS) colonisation at labour.

DESIGN

A test accuracy study was used to determine the accuracy of rapid tests for GBS colonisation of women in labour. Acceptability of testing to participants was evaluated through a questionnaire administered after delivery, and acceptability to staff through focus groups. A decision-analytic model was constructed to assess the cost-effectiveness of various screening strategies.

SETTING

Two large obstetric units in the UK.

PARTICIPANTS

Women booked for delivery at the participating units other than those electing for a Caesarean delivery.

INTERVENTIONS

Vaginal and rectal swabs were obtained at the onset of labour and the results of vaginal and rectal PCR and OIA (index) tests were compared with the reference standard of enriched culture of combined vaginal and rectal swabs.

MAIN OUTCOME MEASURES

The accuracy of the index tests, the relative accuracies of tests on vaginal and rectal swabs and whether test accuracy varied according to the presence or absence of maternal risk factors.

RESULTS

PCR was significantly more accurate than OIA for the detection of maternal GBS colonisation. Combined vaginal or rectal swab index tests were more sensitive than either test considered individually [combined swab sensitivity for PCR 84% (95% CI 79-88%); vaginal swab 58% (52-64%); rectal swab 71% (66-76%)]. The highest sensitivity for PCR came at the cost of lower specificity [combined specificity 87% (95% CI 85-89%); vaginal swab 92% (90-94%); rectal swab 92% (90-93%)]. The sensitivity and specificity of rapid tests varied according to the presence or absence of maternal risk factors, but not consistently. PCR results were determinants of neonatal GBS colonisation, but maternal risk factors were not. Overall levels of acceptability for rapid testing amongst participants were high. Vaginal swabs were more acceptable than rectal swabs. South Asian women were least likely to have participated in the study and were less happy with the sampling procedure and with the prospect of rapid testing as part of routine care. Midwives were generally positive towards rapid testing but had concerns that it might lead to overtreatment and unnecessary interference in births. Modelling analysis revealed that the most cost-effective strategy was to provide routine intravenous antibiotic prophylaxis (IAP) to all women without screening. Removing this strategy, which is unlikely to be acceptable to most women and midwives, resulted in screening, based on a culture test at 35-37 weeks' gestation, with the provision of antibiotics to all women who screened positive being most cost-effective, assuming that all women in premature labour would receive IAP. The results were sensitive to very small increases in costs and changes in other assumptions. Screening using a rapid test was not cost-effective based on its current sensitivity, specificity and cost.

CONCLUSIONS

Neither rapid test was sufficiently accurate to recommend it for routine use in clinical practice. IAP directed by screening with enriched culture at 35-37 weeks' gestation is likely to be the most acceptable cost-effective strategy, although it is premature to suggest the implementation of this strategy at present.

Epithelial ovarian cancer: role of pegylated liposomal Doxorubicin in prolonging the platinum-free interval and cancer antigen 125 trends during treatment

BACKGROUND

Epithelial ovarian cancer's response to platinum retreatment depends on the duration of response to first-line platinum therapy. Platinum-free interval predicts subsequent platinum sensitivity and is a prognostic factor. Little has been published on the effect of pegylated liposomal doxorubicin (PLD) in the prolongation of treatment-free interval.

METHODS

Patients treated with PLD were reviewed to assess response to platinum retreatment after PLD and to establish the use of cancer antigen 125 (Ca125) trends. All patients treated with PLD had progressed within 12 months of prior platinum therapy. Cancer antigen 125 fluctuations were categorized as the variances from the baseline (+/-10%, +/-10%-25%, and >25%). The response to chemotherapy was defined as Ca125 reduction from the baseline of more than 50%, clinical, or radiological response.

RESULTS

Fifty-nine women were identified. The response rate (RR) to PLD was 28.9%, and the median overall survival from PLD initiation was 62 weeks. The number of women demonstrating more than 25% reduction in Ca125 from the baseline increased progressively with each cycle; at cycle 2, 11%; cycle 3, 18%; cycle 4, 22%; and cycle 5, 27% (trend significant between cycles 2 and 4, P = 0.004). Fifteen patients were re-treated with platinum after progression after PLD with 80% (12/15) of the patients responding. The RR to platinum retreatment after PLD compares favorably with the historical data on the response to second-line platinum retreatment.

CONCLUSIONS

The sole use of early Ca125 trends in PLD treatment before cycle 4 may result in an erroneous discontinuation of PLD in potential responders. Retreatment with platinum after PLD may yield a good RR in selected patients even those with disease progression within 12 months after prior platinum treatment.

A process evaluation of an injury prevention school-based programme for adolescents

A process evaluation provides critical information that can inform the design and implementation of a programme. This study sought to provide examples of how to operationalize a process evaluation of an effective programme (Skills for Preventing Injury in Youth). A comprehensive definition of process evaluation was used which included assessing dose, adherence, quality of process, participant responsiveness and programme differentiation. Dose was assessed through teacher and student ratings as well as independent observations. Reports from an observer were used to assess adherence to programme objectives, the quality of process including interactive delivery and programme differentiation. Participant responsiveness was assessed quantitatively and qualitatively with students providing greater depth to the findings. Findings regarding dose varied and suggested different sources of reports provided supplementary information. The findings also suggested that independent observations are an important tool for process evaluation and identified challenges for programme designers regarding interactive material. Overall, the research indicated that a comprehensive definition of process evaluation could be operationalized and provided an understanding of an application of a process evaluation to an injury prevention programme. Continued development of process evaluations will enable a better understanding of the conduct of interventions and maximize the likely effect of such interventions.

Modular endoprosthetic replacement for tumours of the proximal femur

Endoprosthetic replacement of the proximal femur may be required to treat primary bone tumours or destructive metastases either with impending or established pathological fracture. Modular prostheses are available off the shelf and can be adapted to most reconstructive situations for this purpose. We have assessed the clinical and functional outcome of using the METS (Stanmore Implants Worldwide) modular tumour prosthesis to reconstruct the proximal femur in 100 consecutive patients between 2001 and 2006. We compared the results with the published series for patients managed with modular and custom-made endoprosthetic replacements for the same conditions. There were 52 males and 48 females with a mean age of 56.3 years (16 to 84) and a mean follow-up of 24.6 months (0 to 60). In 65 patients the procedure was undertaken for metastases, in 25 for a primary bone tumour, and in ten for other malignant conditions. A total of 46 patients presented with a pathological fracture, and 19 presented with failed fixation of a previous pathological fracture. The overall patient survival was 63.6% at one year and 23.1% at five years, and was significantly better for patients with a primary bone tumour than for those with metastatic tumour (82.3% vs 53.3%, respectively at one year (p = 0.003)). There were six early dislocations of which five could be treated by closed reduction. No patient needed revision surgery for dislocation. Revision surgery was required by six (6%) patients, five for pain caused by acetabular wear and one for tumour progression. Amputation was needed in four patients for local recurrence or infection. The estimated five-year implant survival with revision as the endpoint was 90.7%. The mean Toronto Extremity Salvage score was 61% (51% to 95%). The implant survival and complications resulting from the use of the modular system were comparable to the published series of both custom-made and other modular proximal femoral implants. We conclude that at intermediate follow-up the modular tumour prosthesis for proximal femur replacement provides versatility, a low incidence of implant-related complications and acceptable function for patients with metastatic tumours, pathological fractures and failed fixation of the proximal femur. It also functions as well as a custom-made endoprosthetic replacement.

Selective axillary node sampling and radiotherapy to the axilla in the management of breast cancer

AIMS

Axillary treatment for patients with early-stage breast cancer can be associated with considerable morbidity. Techniques, such as axillary node sampling (ANS) and, more recently, sentinel node biopsy, in combination with radiotherapy have the potential to reduce toxicity. A retrospective review of axillary treatment in patients with early-stage breast cancer treated at our institution between 1997 and 2003 was carried out to assess the outcome and morbidity of ANS in combination with radiotherapy.

MATERIALS AND METHODS

The treatment policy was to carry out four-node, Edinburgh-style ANS except in those cases with either palpably enlarged nodes or cytological confirmation of involvement or with clinically obvious node involvement at surgery when level 2 axillary node clearance (ANC) was carried out. Patients with involved nodes after ANS received postoperative axillary radiotherapy.

RESULTS

In total, 381 patients were included, 331 received ANS and 50 received ANC. The median follow-up was 6.5 years and overall survival at 5 years was 84%. Pathologically involved nodes were found in 152/331 (50%) ANS patients and 43/50 (86%) ANC patients. The rate of local recurrence (breast or chest wall) at 5 years was 4% (95% confidence interval 1-17%) in the ANC group and 2% (95% confidence interval 1-4%) in the ANS group. The nodal recurrence rate of those undergoing ANS was 3% (11/331) compared with 6% (3/50) for those treated by ANC. The rate of clinically significant lymphoedema at 5 years was significantly higher (P=0.01) in the ANC arm: 18% (95% confidence interval 9-32%) compared with 5% (95% confidence interval 3-8%) in those treated by ANS. Thirty-one cases received additional supraclavicular fossa irradiation because of the involvement of more than four nodes on ANS, which may not have been available with sentinel node biopsy and has implications for current practice.

CONCLUSIONS

Selective ANS with the removal of a minimum of four nodes guides optimal locoregional treatment with good local control rates, low overall morbidity and may obviate the need for a second surgical procedure.

Worsening of macrophage activation syndrome in a patient with adult onset Still's disease after initiation of etanercept therapy

The macrophage activation syndrome (MAS) is a rare, potentially fatal, clinical syndrome, which has been described in childhood rheumatic disorders. MAS is defined by a prolonged period of fevers, pancytopenia, and hypertriglyceridemia (with or without hypofibrinogenemia). Histopathological examination of bone marrow, spleen, or lymph nodes shows hemophagocytosis by mononuclear phagocytes. In patients with Still's disease, observed triggering events for MAS have included both infectious processes and pharmacological agents, such as parenteral gold and nonsteroidal anti-inflammatory drugs. We report the case of a young woman with adult-onset Still's disease (AOSD), complicated by an Epstein-Barr virus infection and subsequent MAS, whose course worsened after administration of the soluble tumor necrosis factor-alpha receptor, etanercept. Subsequent treatment with pulse corticosteroids and cyclosporine A induced a dramatic clinical improvement. Treatment data regarding the use of etanercept in AOSD are lacking; given our experience and recent reports in children with Still's disease, we would suggest caution using this agent in patients with AOSD, particularly when complicated by MAS.

Methylation of the ESR1 CpG island in the colorectal mucosa is an 'all or nothing' process in healthy human colon, and is accelerated by dietary folate supplementation in the mouse

ESR1 is frequently silenced by CGI (CpG island) methylation, both in human colorectal tumours and, in an age-dependent manner, in healthy mucosa. It is not clear, however, whether methylation of individual cytosines occurs randomly within the epithelial genome, or preferentially within individual cells as an 'all-or-nothing' phenomenon. CGI methylation can be quantified in human DNA residues recovered from faecal samples. We used bisulphite genomic sequencing of human DNA from this source and from a colorectal cancer cell line (SW48) to show that the ESR1 CGI is methylated in an allele-specific manner. This provides support for the 'all or none' mechanism for methylation of this gene, and shows how age-dependent methylation of the ESR1 CGI leads rapidly to silencing of the gene within the cells, and hence the colonic crypt within which it occurs. Preliminary studies with a rodent model suggest the rate of age-dependent methylation of ESR1 is modifiable by dietary folate.

Adrenalitis in the non-obese diabetic mouse

The non-obese diabetic (NOD) mouse is a model of spontaneous type-1 diabetes used in the field of diabetes research. This study looked at the adrenal glands of NOD and control mice both indirectly in vivo for hormone secretion, and directly in vitro for histological examination. Adrenal glands were taken from NOD mice, of both sexes, at different ages and corticosterone and adrenocorticotropic hormone (ACTH) plasma levels evaluated by radioimmunoassay. There was evidence of lymphocytic infiltration of the adrenal glands, which however, was not accompanied by changes in corticosterone levels. There was a reduction in ACTH levels with age (R2 = 0.98). Mice from other strains (TFW, CBA and Balb/c) showed no lymphocytic infiltration in the adrenal glands and had lower levels of corticosterone than NOD mice of similar ages, but the differences were not significant. In conclusion, since the NOD mouse shows histological signs of adrenalitis, thyroiditis, sialitis and parathyroiditis, this animal can be regarded as a model to investigate mechanisms involved in diffuse lymphocytic infiltration of peripheral endocrine glands (polyendocrine autoimmunity). In addition, if diabetes in the NOD mouse is the result of a polyendocrine disorder rather than a process specific for diabetes, then this finding may have implications for attempts to prevent type-1 diabetes in humans.