Abstract 1725: Tissue-based biomarker analysis of DLBCL using multiplex immunofluorescence AQUA (Automated Quantitative Analysis) algorithms

Purpose: Deeper understanding of immune landscape of DLBCL tumor microenvironment is critical for exploration and development of next generation immunotherapies. Although conventional immunohistochemical (IHC) analysis can provide information on the immune landscape or target expression, it is generally limited to single marker analysis. Advantages of multiplex fluorescence IHC (mFIHC) include the ability to assess different cell types, their spatial relationship as well as variable antigen expression on tumor cells. As such, we developed quantitative mFIHC panels using AQUA® (Automated Quantitative Analysis) technology to evaluate T and B cell populations and their functional status to generate detailed spatial information of immune checkpoint (IC) markers. mFIHC combined with hypothesis driven spatial profiling algorithms (e.g., AQUA Technology) were found to provide the most powerful predictors of immunotherapies in a systematic meta-analyses of over 8000 patients treated with PD1/L1 pathway blockers (Lu et al., JAMA Oncol 2019). Implementation of mFIHC coupled with robust image analysis may provide great insight into DLBCL immune surveillance, mechanism of resistance and patient stratification.

Study Design: We designed two novel mFIHC assays to (1) characterize various B cell populations (CD19, CD20, CD22, PAX5, CD3, TIM3), and (2) evaluate T cell functional status (CD8, Granzyme B, PD1, PDL1, TIM3, Tumor). We successfully validated clinical grade mFIHC assays using automated staining (Leica Bond RX), imaging (Vectra Polaris) and analyses (AQUA Technology) workflow.

Results: Sensitivity, accuracy and specificity were confirmed for all mFIHC assays on known positive and negative controls. Excellent reproducibility (less than 35% CV) and precision were observed across instruments, operators and independent experiments for all markers. Between these two panels, over 200 unique parameters were evaluated. The prevalence of CD19, CD20, CD22, and PAX5 ranged from 30% to >90% positive for the DLBCL samples tested and were overall highly concordant with each other.

Conclusion: The validated mFIHC assays examine B cell antigen expression in DLBCL and their interaction with CD3+ T cells and further characterize CD8+ T cells and immune checkpoint expression. These panels may be used to further understand the complex immune cell and tumor cell spatial biology in the context of clinical trials.

Citation Format: James Paul Santos, Jacob Levy, Kristen Ruma, David Yang, Steve Woolfenden, Jimmie Lim, Xun Li, Ariana Valencia, James Deeds, Ramu Thiruvamoor, Xin Li, Emmanuel Pacia, Margaret McLaughlin, Thai Tran, Sarah Choi, Jennifer Bordeaux. Tissue-based biomarker analysis of DLBCL using multiplex immunofluorescence AQUA (Automated Quantitative Analysis) algorithms [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 1725.

Model-based dose selection to inform translational clinical oncology development of WNT974, a first-in-class Porcupine inhibitor

WNT974 is a potent, selective, and orally bioavailable first‐in‐class inhibitor of Porcupine, a membrane‐bound O‐acyltransferase required for Wnt secretion, currently under clinical development in oncology. A phase I clinical trial is being conducted in patients with advanced solid tumors. During the dose‐escalation part, various dosing regimens, including once or twice daily continuous and intermittent dosing at a dose range of 5–45 mg WNT974 were studied, however, the protocol‐defined maximum tolerated dose (MTD) was not established based on dose‐limiting toxicity. To assist in the selection of the recommended dose for expansion (RDE), a model‐based approach was utilized. It integrated population pharmacokinetic (PK) modeling and exposure–response analyses of a target‐inhibition biomarker, skin AXIN2 mRNA expression, and the occurrence of the adverse event, dysgeusia. The target exposure range of WNT974 that would provide a balance between target inhibition and tolerability was estimated based on exposure–response analyses. The dose that was predicted to yield an exposure within the target exposure range was selected as RDE. This model‐based approach integrated PK, biomarker, and safety data to determine the RDE and represented an alternative as opposed to the conventional MTD approach for selecting an optimal biological dose. The strategy can be broadly applied to select doses in early oncology trials and inform translational clinical oncology drug development.

"Watch Me Grow- Electronic (WMG-E)" surveillance approach to identify and address child development, parental mental health, and psychosocial needs: study protocol

Background

The COVID-19 pandemic and the associated economic recession has increased parental psychosocial stress and mental health challenges. This has adversely impacted child development and wellbeing, particularly for children from priority populations (culturally and linguistically diverse (CALD) and rural/regional communities) who are at an already increased risk of health inequality. The increased mental health and psychosocial needs were compounded by the closure of in-person preventive and health promotion programs resulting in health organisations embracing technology and online services. Watch Me Grow- Electronic (WMG-E) – developmental surveillance platform- exemplifies one such service.

WMG-E was developed to monitor child development and guide parents towards more detailed assessments when risk is identified. This Randomised Controlled Trial (RCT) aims to expand WMG-E as a digital navigation tool by also incorporating parents’ mental health and psychosocial needs. Children and families needing additional assessments and supports will be electronically directed to relevant resources in the ‘care-as-usual’ group. In contrast, the intervention group will receive continuity of care, with additional in-person assessment and ‘warm hand over’ by a ‘service navigator’ to ensure their needs are met.

Methods

Using an RCT we will determine: (1) parental engagement with developmental surveillance; (2) access to services for those with mental health and social care needs; and (3) uptake of service recommendations. Three hundred parents/carers of children aged 6 months to 3 years (recruited from a culturally diverse, or rural/regional site) will be randomly allocated to the ‘care-as-usual’ or ‘intervention’ group. A mixed methods implementation evaluation will be completed, with semi-structured interviews to ascertain the acceptability, feasibility and impact of the WMG-E platform and service navigator.

Conclusions

Using WMG-E is expected to: normalise and de-stigmatise mental health and psychosocial screening; increase parental engagement and service use; and result in the early identification and management of child developmental needs, parental mental health, and family psychosocial needs. If effective, digital solutions such as WMG-E to engage and empower parents alongside a service navigator for vulnerable families needing additional support, will have significant practice and policy implications in the pandemic/post pandemic period.

Trial registration

The trial (Protocol No. 1.0, Version 3.1) was registered with ANZCTR (registration number: ACTRN12621000766819) on July 21st, 2021 and reporting of the trial results will be according to recommendations in the CONSORT Statement.

The Quality of Care for Australian Children with Autism Spectrum Disorders

Knowledge about the quality of care delivered to children with autism spectrum disorders (ASD) in relation to that recommended by clinical practice guidelines (CPGs) is limited. ASD care quality indicators were developed from CPGs and validated by experts, then used to assess the quality of care delivered by general practitioners (GPs) and pediatricians in Australia. Data were retrospectively collected from the medical records of 228 children (≤ 15 years) with ASD for 2012-2013. Overall quality of care was high, but with considerable variation among indicators, and between GPs and pediatricians-e.g., GPs were less likely to complete the assessment care bundle (61%; 95% CI 21-92). Findings highlight potential areas for improvement in the need for standardized criteria for diagnosis.

A PDGFRα-driven mouse model of glioblastoma reveals a stathmin1-mediated mechanism of sensitivity to vinblastine

Glioblastoma multiforme (GBM) is an aggressive primary brain cancer that includes focal amplification of PDGFRα and for which there are no effective therapies. Herein, we report the development of a genetically engineered mouse model of GBM based on autocrine, chronic stimulation of overexpressed PDGFRα, and the analysis of GBM signaling pathways using proteomics. We discover the tubulin-binding protein Stathmin1 (STMN1) as a PDGFRα phospho-regulated target, and that this mis-regulation confers sensitivity to vinblastine (VB) cytotoxicity. Treatment of PDGFRα-positive mouse and a patient-derived xenograft (PDX) GBMs with VB in mice prolongs survival and is dependent on STMN1. Our work reveals a previously unconsidered link between PDGFRα activity and STMN1, and highlight an STMN1-dependent cytotoxic effect of VB in GBM.

Predictors of developmental surveillance completion at six months of age in south western Sydney

BACKGROUND

While developmental surveillance programs promote early identification of child developmental problems, evidence has indicated suboptimal uptake. This study aimed to identify predictors of developmental surveillance completion at 6 months postpartum.

METHODS

Questionnaires were administered to the parents of 510 infants who were born in south western Sydney, Australia over a 22-month period. Attendance for developmental screening and completion of the Parents' Evaluation of Developmental Status (PEDS) at 6 months postpartum were modelled separately using multivariable logistic regression.

RESULTS

Developmental surveillance attendance was predicted by higher levels of maternal education, annual income and being informed about checks. PEDS completion at 6 months of age was predicted by higher income and being informed, as well as being married, employed, speaking English at home, full-term birth and the professional status of the practitioner completing the check.

CONCLUSIONS

Barriers to developmental surveillance included low socioeconomic status, linguistic diversity and possible gaps in parental knowledge and professional education. Developmental surveillance rates may be increased by the addition of targeted parental and professional support within current universal frameworks.

Abstract 2140: Dual Wnt and EGFR-MAPK dependency of BRAFV600E-mutant colorectal cancer

Aberrant Wnt pathway activation due to inactivating mutations in the gene encoding RNF43 (an E3 ubiquitin ligase that promotes degradation of the Wnt receptors Frizzled and LRP6) may contribute to the unresponsiveness of BRAFV600E-mutant colorectal cancer (CRC) to BRAF inhibitors. Analysis of The Cancer Genome Atlas (TCGA) CRC data set reveals a striking co-occurrence of the BRAFV600E mutation and truncating mutations in RNF43. RNF43 mutations are likely to be functionally significant, as RNF43 mutations and mutations in the β-catenin destruction complex component APC are almost completely mutually exclusive. The vast majority of BRAFV600E;RNF43-mutant CRCs are hypermutable [microsatellite instability (MSI)-high phenotype]. The mismatch repair deficiency in these tumors may directly contribute to RNF43 mutagenesis, as RNF43 mutations tend to be small insertions/deletions in homopolymeric tracts. To determine if RNF43 mutations confer Wnt dependency in BRAFV600E-mutant CRC, we treated three BRAFV600E;RNF43-mutant CRC patient-derived xenograft (PDX) models with the porcupine inhibitor WNT974 (formerly LGK974), which blocks the palmitoylation and secretion of Wnt ligands. Single agent WNT974 anti-tumor activity was observed in 2/3 PDX models, and correlated with decreased tumor cell proliferation and mucinous differentiation. Single agent anti-tumor activity with the BRAF inhibitor LGX818 was also observed in 2/3 PDX models. No single agent anti-tumor activity was observed with the EGFR inhibitor cetuximab. The double combinations of WNT974+LGX818 and LGX818+cetuximab, and the triple combination of WNT974+LGX818+cetuximab were efficacious in all three BRAFV600E;RNF43-mutant CRC PDX models. In summary, the Wnt pathway and the EGFR-MAPK pathway may jointly promote tumorigenesis of BRAFV600E-mutant CRC, providing a strong rationale to treat patients with BRAFV600E-mutant CRCs harboring upstream Wnt pathway mutations with combinations of WNT974, LGX818 and/or cetuximab.

Citation Format: Youzhen Wang, Michael Palmer, Savina Jaeger, Linda Bagdasarian, Shumei Qiu, Steve Woolfenden, Ronald Meyer, Guizhi Yang, John Green, Shifeng Pan, Jun Liu, Hui Gao, Z. Alexander Cao, Andrea Myers, Margaret E. McLaughlin. Dual Wnt and EGFR-MAPK dependency of BRAFV600E-mutant colorectal cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 2140. doi:10.1158/1538-7445.AM2015-2140

Developmental vulnerability--don't investigate without a model in mind

Children who are developmentally vulnerable are at risk of a difficult start to school, and ongoing educational challenges which may adversely impact on long term health outcomes. Clinicians, researchers and service providers need a thorough understanding of both risk and protective factors and their complex interplay to understand their impact on early childhood development, in order to plan effective and comprehensive prevention and interventions strategies. In this opinion piece we recommend that investigation of developmental vulnerability should only proceed if underpinned by both a theoretical model through which the interaction between risk and protective factors may be investigated, and analytical models that are appropriate to assess these impacts.

ROS1 signaling regulates epithelial differentiation in the epididymis

The initial segment (IS) of the epididymis plays an essential role in male fertility. The IS epithelium is undifferentiated and nonfunctional at birth. Prior to puberty, the epithelium undergoes differentiation that leads to the formation of a fully functional organ. However, the mechanistic details of this program are not well understood. To explore this further, we used genetic engineering to create a kinase dead allele of the ROS1 receptor tyrosine kinase in mice and studied the effects of ROS1 tyrosine kinase activity on the differentiation of the IS epithelium. We show that the expression and activation of ROS1 coincides with the onset of differentiation and is exclusively located in the IS of the maturing and adult mouse epididymides. Here we demonstrate that the differentiation of the IS is dependent on the kinase activity of ROS1 and its downstream effector MEK1/2-ERK1/2 signaling axis. Using genetic engineering, we show that germ line ablation of ROS1 kinase activity leads to a failure of the IS epithelium to differentiate, and as a consequence sperm maturation and infertility were dramatically perturbed. Pharmacological inhibition of ROS1 kinase activity in the developing epididymis, however, only delayed differentiation transiently and did not result in infertility. Our results demonstrate that ROS1 kinase activity and the ensuing MEK1/2-ERK1/2 signaling are necessary for the postnatal development of the IS epithelium and that a sustained ablation of ROS1 kinase activity within the critical window of terminal differentiation abrogate the function of the epididymis and leads to sterility.

Acquired MET expression confers resistance to EGFR inhibition in a mouse model of glioblastoma multiforme

Glioblastoma multiforme (GBM) is an aggressive brain tumor for which there is no cure. Overexpression of wild-type epidermal growth factor receptor (EGFR) and loss of the tumor suppressor genes Ink4a/Arf and PTEN are salient features of this deadly cancer. Surprisingly, targeted inhibition of EGFR has been clinically disappointing, demonstrating an innate ability for GBM to develop resistance. Efforts at modeling GBM in mice using wild-type EGFR have proven unsuccessful to date, hampering endeavors at understanding molecular mechanisms of therapeutic resistance. Here, we describe a unique genetically engineered mouse model of EGFR-driven gliomagenesis that uses a somatic conditional overexpression and chronic activation of wild-type EGFR in cooperation with deletions in the Ink4a/Arf and PTEN genes in adult brains. Using this model, we establish that chronic activation of wild-type EGFR with a ligand is necessary for generating tumors with histopathological and molecular characteristics of GBMs. We show that these GBMs are resistant to EGFR kinase inhibition and we define this resistance molecularly. Inhibition of EGFR kinase activity using tyrosine kinase inhibitors in GBM tumor cells generates a cytostatic response characterized by a cell cycle arrest, which is accompanied by a substantial change in global gene expression levels. We demonstrate that an important component of this pattern is the transcriptional activation of the MET receptor tyrosine kinase and that pharmacological inhibition of MET overcomes the resistance to EGFR inhibition in these cells. These findings provide important new insights into mechanisms of resistance to EGFR inhibition and suggest that inhibition of multiple targets will be necessary to provide therapeutic benefit for GBM patients.

Chronic activation of wild-type epidermal growth factor receptor and loss of Cdkn2a cause mouse glioblastoma formation

Glioblastoma multiforme (GBM) is characterized by overexpression of epidermal growth factor receptor (EGFR) and loss of the tumor suppressors Ink4a/Arf. Efforts at modeling GBM using wild-type EGFR in mice have proven unsuccessful. Here, we present a unique mouse model of wild-type EGFR-driven gliomagenesis. We used a combination of somatic conditional overexpression and ligand-mediated chronic activation of EGFR in cooperation with Ink4a/Arf loss in the central nervous system of adult mice to generate tumors with the histopathologic and molecular characteristics of human GBMs. Sustained, ligand-mediated activation of EGFR was necessary for gliomagenesis, functionally substantiating the clinical observation that EGFR-positive GBMs from patients express EGFR ligands. To gain a better understanding of the clinically disappointing EGFR-targeted therapies for GBM, we investigated the molecular responses to EGFR tyrosine kinase inhibitor (TKI) treatment in this model. Gefitinib treatment of primary GBM cells resulted in a robust apoptotic response, partially conveyed by mitogen-activated protein kinase (MAPK) signaling attenuation and accompanied by BIM(EL) expression. In human GBMs, loss-of-function mutations in the tumor suppressor PTEN are a common occurrence. Elimination of PTEN expression in GBM cells posttumor formation did not confer resistance to TKI treatment, showing that PTEN status in our model is not predictive. Together, these findings offer important mechanistic insights into the genetic determinants of EGFR gliomagenesis and sensitivity to TKIs and provide a robust discovery platform to better understand the molecular events that are associated with predictive markers of TKI therapy.

The novel Hsp90 inhibitor NXD30001 induces tumor regression in a genetically engineered mouse model of glioblastoma multiforme

Glioblastoma multiforme (GBM) has an abysmal prognosis. We now know that the epidermal growth factor receptor (EGFR) signaling pathway and the loss of function of the tumor suppressor genes p16Ink4a/p19ARF and PTEN play a crucial role in GBM pathogenesis: initiating the early stages of tumor development, sustaining tumor growth, promoting infiltration, and mediating resistance to therapy. We have recently shown that this genetic combination is sufficient to promote the development of GBM in adult mice. Therapeutic agents raised against single targets of the EGFR signaling pathway have proven rather inefficient in GBM therapy, showing the need for combinatorial therapeutic approaches. An effective strategy for concurrent disruption of multiple signaling pathways is via the inhibition of the molecular chaperone heat shock protein 90 (Hsp90). Hsp90 inhibition leads to the degradation of so-called client proteins, many of which are key effectors of GBM pathogenesis. NXD30001 is a novel second generation Hsp90 inhibitor that shows improved pharmacokinetic parameters. Here we show that NXD30001 is a potent inhibitor of GBM cell growth in vitro consistent with its capacity to inhibit several key targets and regulators of GBM biology. We also show the efficacy of NXD30001 in vivo in an EGFR-driven genetically engineered mouse model of GBM. Our findings establish that the Hsp90 inhibitor NXD30001 is a therapeutically multivalent molecule, whose actions strike GBM at the core of its drivers of tumorigenesis and represent a compelling rationale for its use in GBM treatment.

A Cre/LoxP conditional luciferase reporter transgenic mouse for bioluminescence monitoring of tumorigenesis

Genetically engineered, Cre/LoxP-conditional mouse models of cancer are designed to investigate the genetic contributors of tumorigenesis and are well suited to assess therapeutic treatment responses. The capacity to serially visualize tumor burden in a noninvasive fashion would greatly strengthen their applications. We report the generation of a bioluminescent reporter strain that allows monitoring of tumor development in preexisting conditional mouse tumor models. We demonstrate that, in a Cre-dependent glioblastoma multiforme model, tumor initiation and progression is readily monitored over time and that luminescent output is related to tumor volume. Our results show that this reporter strain may be combined with various Cre/loxP mouse tumor models to allow for noninvasive longitudinal monitoring of tumor growth and therapeutic response in vivo.

Epigenetic regulation of c-ROS receptor tyrosine kinase expression in malignant gliomas

The proto-oncogene tyrosine kinase c-ROS is an orphan receptor whose normal expression pattern is tightly spatio-temporally restricted during development. In glioma, c-ROS mRNA expression is frequently ectopically up-regulated. In this study, we determined by immunohistochemical means that c-ROS receptor protein is present in 25% of low-grade and 30% of malignant glioma tumor samples from tissue microarrays. We then explored the molecular basis for the up-regulation of c-ROS expression in these tumors. We identified and characterized the c-ROS gene promoter region and report that the ectopic expression of c-ROS in tumors is tied to hypomethylation of a CpG island in the c-ROS promoter. Bisulfite sequencing analysis in glioma tumor samples revealed that demethylation of the CpG island (-384 to -132 bp) correlated with c-ROS expression. Moreover, c-ROS expression could be activated by treatment of c-ROS-negative cells with the demethylating agent 5-aza-2'-deoxycytidine. These results establish a strong link between c-ROS promoter demethylation and gain of c-ROS expression and function in glioma. Our data suggest that epigenetic activation of c-ROS represents an important oncogenic mechanism for glioma initiation and progression and suggest that cautionary measures in the clinical use of 5-aza-dC for the treatment of glioma be taken into consideration. [Cancer Res 2009;69(6):2180-4].

Household interventions for prevention of domestic lead exposure in children

BACKGROUND

Lead poisoning is associated with physical, cognitive and neurobehavioral impairment in children and many household interventions to prevent lead exposure have been trialled.

OBJECTIVES

To determine the effectiveness of household interventions in preventing or reducing lead exposure in children as measured by reductions in blood lead levels and/or improvements in cognitive development.

SEARCH STRATEGY

Trials were identified through electronic searches of CENTRAL 2006 (Issue 1), MEDLINE 1966 to March 2006, and thirteen other electronic databases and contacting experts to find unpublished studies.

SELECTION CRITERIA

Randomised and quasi randomised trials of household educational or environmental interventions to prevent lead exposure in children where at least one standardised outcome measure was reported.

DATA COLLECTION AND ANALYSIS

Two reviewers independently reviewed all eligible studies for inclusion, assessed study quality and extracted data. Triallists were contacted to obtain missing information.

MAIN RESULTS

Twelve studies (2239 children) were included. All studies reported blood lead level outcomes and none reported on cognitive or neurobehavioural outcomes. Studies were subgrouped according to their intervention type. Meta-analysis of both continuous and dichotomous data was performed for subgroups where appropriate. Educational interventions were not effective in reducing blood lead levels (continuous: WMD 0.13, 95% CI -0.30, 0.56, I2 = 41.6; dichotomous >/= 10 microg/dL (>/= 0.48 micromol/l): RR 1.02 (95% CI 0.79, 1.30, I2 = 0); dichotomous >/= 15 microg/dL (>/=0.72 micromol/l): RR 0.60, 95% CI 0.33, 1.09, I2 = 0). Meta-analysis of the dichotomous data for the dust control subgroup found no evidence of effectiveness. The studies using soil abatement (removal and replacement) and combination intervention groups were not able to be meta-analysed due to substantial differences between studies.

AUTHORS' CONCLUSIONS

Currently there is no evidence of effectiveness for household interventions for education or dust control measures in reducing blood lead levels in children as a population health measure. There is insufficient evidence for soil abatement or combination interventions. Further trials are required to establish the most effective intervention for prevention of lead exposure. Key elements should include longer term follow up and measures of compliance as well as performing trials in developing countries and differing socio-economic groups in developed countries.

The presentation of aggressive children and adolescents to emergency departments in Western Sydney

AIM

To examine the utilization characteristics of children and adolescents with aggression presenting to emergency departments (ED) in Western Sydney.

METHODS

Retrospective chart review of children and adolescents who presented with aggression to five non-psychiatric emergency departments over a 5-year period. Data were linked with the National Coroner's Information System Database.

RESULTS

There were 279 index presentations by children and adolescents (66% male) with aggression. One hundred and seventeen (42%) were 14 years or under. The majority presented after working hours and/or on weekends (62%). Fifty-three percent of presentations had a self-harm component. In 26% of presentations, there was no documentation of mental health involvement. Children were discharged in 62% of presentations. Sixty-eight (24%) children and adolescents subsequently re-presented on 135 occasions with self-harm and/or aggression over the 5-year period. Four (1%) adolescents died.

CONCLUSION

A presentation to an ED with aggression by a child or adolescent is an indicator of significant psychosocial dysfunction. These children and adolescents present when services are least accessible and are at risk of re-presentation and death. To address this issue, systems need to be developed that facilitate collaboration between EDs and child and adolescent mental health services.

Barriers to immunization: attitudes of general practitioners to varicella, the disease and its vaccine

OBJECTIVES

To investigate the attitudes of general practitioners (GPs) to varicella disease and varicella vaccine.

METHODS

A cross-sectional questionnaire was mailed to GPs in Fairfield (located in the south-western suburbs of Sydney, NSW, Australia) to identify attitudes about varicella vaccine, previous experience with varicella disease and the likelihood of prescribing varicella vaccine.

RESULTS

Of 239 questionnaires issued, 160 were returned (67%). The majority (72%) of respondents agreed that varicella vaccine should become part of the immunization schedule. However 12% of GPs did not support vaccination for varicella as they considered it to be a benign self-limiting disease. Respondents who had experience with varicella complications were significantly more likely to recommend universal vaccination (OR 3.36; 95% confidence interval (CI) 1.38-8.19) whereas those respondents who were concerned about side effects of the vaccine were less likely to recommend universal vaccination (OR 0.31; CI 0.15-0.63).

CONCLUSIONS

The majority of GPs are receptive to varicella vaccination becoming part of the immunization schedule. Experience with varicella complications is associated with recommending universal varicella vaccination. General practitioners in this cohort do not consider varicella to be a benign disease, but they are concerned about possible unknown side effects of the vaccine. Public health measures for introducing universal vaccination need to address these concerns.

Parental use of a paediatric emergency department as an ambulatory care service

OBJECTIVE

This qualitative study explored the parental attitudes, perceptions and beliefs that play a role in the use of a tertiary paediatric emergency department (PED) when a child has a non-urgent illness.

METHOD

Semi-structured, in-depth interviews of 25 parents of children with non-urgent illnesses were conducted in the waiting room of a tertiary PED in Western Sydney in 1998. Inductive analysis was used to identify dominant themes.

RESULTS

Parents used their own system of triage to choose the appropriate service for their sick child. The perceived expertise of the tertiary PED, access and parental expectations all appeared to be major factors in parental use of a PED.

CONCLUSIONS

The parental choice to attend a PED is a dynamic, complex and unique process and the parental views that underpin this process often diverge from those of health professionals about the most 'appropriate' use of a PED.

IMPLICATIONS

A clearer understanding by health professionals of the factors influencing parental choice will promote more effective collaboration with parents and ultimately assist in the decision on the best management option for sick children.