Risk factors for neurocognitive impairment, emotional distress, and poor quality of life in survivors of pediatric rhabdomyosarcoma: A report from the Childhood Cancer Survivor Study

BACKGROUND

Prevalence and risk of poor psychological outcomes following rhabdomyosarcoma (RMS) are not well-established.

METHODS

Participants in this cross-sectional, case-control study (n = 713 survivors, 42.5% female; mean [SD] age, 30.5 [6.6] years; n = 706 siblings, 57.2% female; mean age, 32.8,[7.9] years) completed measures of neurocognition, emotional distress, and health-related quality of life (HRQOL). Multivariable logistic regression models identified treatments, health behaviors, and chronic conditions associated with impairment.

RESULTS

Relative to siblings, more survivors reported neurocognitive impairment (task efficiency: 21.1% vs. 13.7%, emotional regulation: 16.7% vs. 11.0%, memory: 19.3% vs. 15.1%), elevated emotional distress (somatic distress: 12.9% vs. 4.7%, anxiety: 11.7% vs. 5.9%, depression: 22.8% vs. 16.9%) and poorer HRQOL (physical functioning: 11.1% vs. 2.8%, role functioning due to physical problems: 16.8% vs. 8.2%, pain: 17.5% vs. 10.0%, vitality: 22.3% vs. 13.8%, social functioning: 14.4% vs. 6.8%, emotional functioning: 17.1% vs. 10.6%). Cranial radiation increased risk for impaired task efficiency (odds ratio [OR], 2.30; 95% confidence interval [CI], 1.14-4.63), whereas chest and pelvic radiation predicted increased risk of physical functioning (OR, 2.68; 95% CI, 1.16-6.21 and OR, 3.44; 95% CI, 1.70-6.95, respectively). Smoking was associated with impaired task efficiency (OR, 2.06; 95% CI, 1.14-3.70), memory (OR, 2.23; 95% CI, 1.26-3.95), anxiety (OR, 2.71; 95% CI, 1.36-5.41) and depression (OR, 1.77; 95% CI, 1.01-3.11). Neurologic conditions increased risk of anxiety (OR, 2.30; 95% CI, 1.04-5.10), and hearing conditions increased risk of depression (OR, 1.79; 95% CI, 1.05-3.03). Neurologic and hearing conditions, respectively, were associated with impaired memory (OR, 2.44; 95% CI, 1.20-4.95 and OR, 1.87; 95% CI, 1.05-3.35) and poor health perception (OR, 2.62; 95% CI, 1.62-1.28 and OR, 2.33; 95% CI, 1.34-4.06).

CONCLUSIONS

RMS survivors are at significant risk for poor psychological outcomes. Advancing therapies for local control, smoking cessation, and managing chronic medical conditions may mitigate poor outcomes following RMS.

1894. Antimicrobial Stewardship in the Intensive Care Unit: Survey of Critical Care and Infectious Diseases Physicians

Background

One aim of antimicrobial stewardship programs is to combat climbing rates of antibiotic resistance. Typically coordinated by Infectious Diseases (ID) physicians, such programs have decreased costs, resistance rates and secondary infections. A point of contention is whether ID or Critical Care (CC) physicians should manage the antibiotics prescribed to critically ill patients in the Intensive Care Unit (ICU). We surveyed ID and CC physicians regarding their perspectives on ICU antimicrobial stewardship and collaborations.

Methods

In 2017, CC and ID fellows and attendings completed an online survey that included 17 Likert-scaled items (1 = strongly disagree to 5 = strongly agree) measuring views on ICU antibiotic stewardship. Principal components analysis (PCA) was used for data reduction. Multivariable linear regression models explored variables associated with outcomes measuring physicians’ views on which specialty should guide antibiotic stewardship and the value of clinical collaborations in the ICU.

Results

Of 334 physicians, 71% were attendings (vs. fellows) and 61% were ID (vs. CC) specialists. From the PCA, 3 factors emerged measuring views about: (1) the specialty that should serve as ICU antibiotic stewards (Cronbach’s α = 0.71; higher scores indicate ID physicians should be stewards); (2) ICU clinical collaborations (α = 0.60; higher scores indicate greater value of collaboration); and (3) ICU decision-making insecurity (α = 0.45; higher scores indicate greater insecurity). In the regression models (n = 309), CC physicians and those placing lower value on ICU collaborations reported greater agreement that ID physicians should be the primary ICU stewards; women and physicians reporting greater ICU decision-making insecurity and less agreement that ID physicians should be ICU antibiotic stewards reported greater value of clinical collaborations.

Conclusion

CC physicians favor ID specialists to assume ICU antibiotic stewardship.

Disclosures

All authors: No reported disclosures.

North American survey on the post-neuroimaging management of children with mild head injuries

OBJECTIVEThere remains uncertainty regarding the appropriate level of care and need for repeating neuroimaging among children with mild traumatic brain injury (mTBI) complicated by intracranial injury (ICI). This study's objective was to investigate physician practice patterns and decision-making processes for these patients in order to identify knowledge gaps and highlight avenues for future investigation.METHODSThe authors surveyed residents, fellows, and attending physicians from the following pediatric specialties: emergency medicine; general surgery; neurosurgery; and critical care. Participants came from 10 institutions in the United States and an email list maintained by the Canadian Neurosurgical Society. The survey asked respondents to indicate management preferences for and experiences with children with mTBI complicated by ICI, focusing on an exemplar clinical vignette of a 7-year-old girl with a Glasgow Coma Scale score of 15 and a 5-mm subdural hematoma without midline shift after a fall down stairs.RESULTSThe response rate was 52% (n = 536). Overall, 326 (61%) respondents indicated they would recommend ICU admission for the child in the vignette. However, only 62 (12%) agreed/strongly agreed that this child was at high risk of neurological decline. Half of respondents (45%; n = 243) indicated they would order a planned follow-up CT (29%; n = 155) or MRI scan (19%; n = 102), though only 64 (12%) agreed/strongly agreed that repeat neuroimaging would influence their management. Common factors that increased the likelihood of ICU admission included presence of a focal neurological deficit (95%; n = 508 endorsed), midline shift (90%; n = 480) or an epidural hematoma (88%; n = 471). However, 42% (n = 225) indicated they would admit all children with mTBI and ICI to the ICU. Notably, 27% (n = 143) of respondents indicated they had seen one or more children with mTBI and intracranial hemorrhage demonstrate a rapid neurological decline when admitted to a general ward in the last year, and 13% (n = 71) had witnessed this outcome at least twice in the past year.CONCLUSIONSMany physicians endorse ICU admission and repeat neuroimaging for pediatric mTBI with ICI, despite uncertainty regarding the clinical utility of those decisions. These results, combined with evidence that existing practice may provide insufficient monitoring to some high-risk children, emphasize the need for validated decision tools to aid the management of these patients.

Evaluating the utility and accuracy of a reverse telephone directory to identify the location of survey respondents

PURPOSE

To investigate the utility and positional accuracy of a reverse telephone directory to enhance geocoding using self-reported street addresses.

METHODS

This cross-sectional study used 2001 self-reported survey data from 2636 participants in three Missouri areas. When available, street addresses were appended to participant telephone numbers using a reverse telephone directory. The odds of finding a telephone number in the reverse directory and the positional accuracy between self-reported addresses and those obtained from the reverse directory were calculated. We also determined the quality of self-reported address information and that obtained by means of the reverse telephone directory.

RESULTS

Rural respondents, younger respondents, women, African Americans, and respondents with less than a high school education were less likely to have their telephone number present in the reverse directory. Using the reverse directory increased the overall percentage of respondents whose addresses were geocoded from 51.5% to 72.0%. Eighty-one percent of addresses were geocoded to the same US Census Block Group and 89% were geocoded to the same Census Tract as the self-reported addresses.

CONCLUSIONS

The street address of survey participants obtained through the reverse directory can be used to augment the unknown location of telephone survey respondents but specific groups of people are less likely to be found in the directory.

The Full Potential of Breast Cancer Screening Use to Reduce Mortality has not yet been Realized in the United States

OBJECTIVE

Breast cancer mortality has been declining in European countries and the United States since the early 1990s. Based on breast cancer screening programs in western European countries, the reduction in mortality results from a predictable pattern of increasing early-stage and subsequent declining incidence of late-stage cancers. The purpose of this study was to determine whether changes in the incidence of early-stage and late-stage breast cancers has occurred in the United States to suggest that a reduction in breast cancer mortality is the result of screening.

METHOD

The analyses are based on women 50-69 years of age using 1990-1998 Surveillance, Epidemiology, and End Results data. Five indicators that are precursors to reductions in mortality are described: in situ breast cancer, T1 tumors (< 2 cm), stage II-IV tumors, lymph node-positive cancers, and locally advanced breast cancers (LABC).

RESULTS

The rate of in situ tumors increased from 37.8 to 67.0 per 100,000 population and that of T1 tumors increased from 143.5 to 163.5 per 100,000 population during 1990-1998. The rates of stage II-IV tumors, lymph node-positive cancers, and LABC remained unchanged at about 120 per 100,000, 76 per 100,000, and 17 per 100,000 population, respectively.

CONCLUSIONS

Although there has been an increase in early-stage breast cancers (in situ and T1 tumors), the prerequisite decline in late-stage cancers has not yet occurred in the United States--a pattern that was observed in European studies. Possible explanations include the lack of widespread mammography use during the 1980s and, therefore, insufficient elapsed time since mammography use has become more widespread.

Compliance with universal precautions among emergency department personnel caring for trauma patients

STUDY OBJECTIVE

Emergency department personnel are at high risk of occupational infection with bloodborne pathogens. The objective of this study was to observe and analyze the use of barrier precautions among ED personnel caring for trauma patients.

METHODS

This observational study used videotapes of trauma cases seen at an urban Level I trauma center. Study participants were ED and trauma team personnel. Trained observers scored breaks in the use of barrier precautions during the first 15 minutes of 88 videotaped Level I trauma cases. "Major" breaks were scored when ED personnel performed invasive procedures without gloves, mask, gown, and adequate eye protection. "Minor" breaks were scored when ED personnel were adjacent to a trauma patient (within 1 m) without wearing these items.

RESULTS

We observed 1 or more major breaks in 33.6% of 304 invasive procedures. The most common major break was failure to wear a mask (32.2% of procedures), followed by inadequate eyewear (22.2%), no gown (5.6%), and no gloves (3.0%). We observed minor breaks during 55.5% of 752 patient encounters. Large and statistically significant variations were seen in use rates of barrier precautions among different groups of personnel; surgery residents were most likely to use precautions, whereas attending surgeons were least likely.

CONCLUSION

Compliance with universal precautions is poor in this high-risk clinical setting. These data provide a baseline for measuring the effectiveness of interventions to improve compliance. Videotaped observations are a novel and effective tool in this setting.