The development and implementation of the Northern Health lung cancer digital care pathway: a case study in service change

This case study details the approach utilised to establish an easy to use, accessible and sustainable method for routine collection of Patient Reported Outcome Measures for patients newly diagnosed with lung cancer. We sought to enhance communication with patients and their families, particularly around shared decision making, their quality of life and symptoms, as well as the impacts of their care or treatment. We detail the co-design methodology utilised with consumers and healthcare providers to develop and implement a multi-lingual, fully automated digital care pathway which has been proven to be highly impactful and powerful for both healthcare providers working within the service and consumers enrolled within the digital pathway. This innovative initiative has changed the practice of the lung cancer service across a health service. Furthermore, its success has evolved the organisational strategy, to embed 'Outcomes for Impact' across the health service.

Validation of the psychosocial consequences of screening in lung cancer questionnaire in the international lung screen trial Australian cohort

BACKGROUND

Evaluation of psychosocial consequences of lung cancer screening with LDCT in high-risk populations has generally been performed using generic psychometric instruments. Such generic instruments have low coverage and low power to detect screening impacts. This study aims to validate an established lung cancer screening-specific questionnaire, Consequences Of Screening Lung Cancer (COS-LC), in Australian-English and describe early results from the baseline LDCT round of the International Lung Screen Trial (ILST).

METHODS

The Danish-version COS-LC was translated to Australian-English using the double panel method and field tested in Australian-ILST participants to examine content validity. A random sample of 200 participants were used to assess construct validity using Rasch item response theory models. Reliability was assessed using classical test theory. The COS-LC was administered to ILST participants at prespecified timepoints including at enrolment, dependent of screening results.

RESULTS

Minor linguistic alterations were made after initial translation of COS-LC to English. The COS-LC demonstrated good content validity and adequate construct validity using psychometric analysis. The four core scales fit the Rasch model, with only minor issues in five non-core scales which resolved with modification. 1129 Australian-ILST participants were included in the analysis, with minimal psychosocial impact observed shortly after baseline LDCT results.

CONCLUSION

COS-LC is the first lung cancer screening-specific questionnaire to be validated in Australia and has demonstrated excellent psychometric properties. Early results did not demonstrate significant psychosocial impacts of screening. Longer-term follow-up is awaited and will be particularly pertinent given the announcement of an Australian National Lung Cancer Screening Program.

TRIAL REGISTRATION

NCT02871856.

Functionality and Quality of Asthma mHealth Apps and Their Consistency With International Guidelines: Structured Search and Evaluation

BACKGROUND

Asthma is a chronic respiratory disorder requiring long-term pharmacotherapy and judicious patient self-management. Few studies have systematically evaluated asthma mobile health (mHealth) apps for quality and functionality; however, none have systematically assessed these apps for their content alignment with international best practice guidelines.

OBJECTIVE

This review aims to conduct a systematic search and evaluation of current mHealth apps in the Australian marketplace for their functionality, quality, and consistency with best practice guidelines.

METHODS

The most recent Global Initiative for Asthma (GINA) guidelines were reviewed to identify key recommendations that could be feasibly incorporated into an mHealth app. We developed a checklist based on these recommendations and a modified version of a previously developed framework. App stores were reviewed to identify potential mHealth apps based on predefined criteria. Evaluation of suitable apps included the assessment of technical information, an app quality assessment using the validated Mobile App Rating Scale (MARS) framework, and an app functionality assessment using the Intercontinental Medical Statistics Institute for Health Informatics (IMS) Functionality Scoring System. Finally, the mHealth apps were assessed for their content alignment with the GINA guidelines using the checklist we developed.

RESULTS

Of the 422 apps initially identified, 53 were suitable for further analysis based on inclusion and exclusion criteria. The mean number of behavioral change techniques for a single app was 3.26 (SD 2.27). The mean MARS score for all the reviewed apps was 3.05 (SD 0.54). Of 53 apps, 27 (51%) achieved a total MARS score of ≥3. On average, the reviewed apps achieved 5.1 (SD 2.79) functionalities on the 11-point IMS functionality scale. The median number of functionalities identified was 5 (IQR 2-7). Overall, 10 (22%) of the 45 apps with reviewer consensus in this domain provided general knowledge regarding asthma. Of 53 apps, skill training in peak flow meters, inhaler devices, recognizing or responding to exacerbations, and nonpharmacological asthma management were identified in 8 (17%), 12 (25%), 11 (28%), and 14 (31%) apps, respectively; 19 (37%) apps could track or record "asthma symptoms," which was the most commonly recorded metric. The most frequently identified prompt was for taking preventive medications, available in 9 (20%) apps. Five (10%) apps provided an area for patients to store or enter their asthma action plan.

CONCLUSIONS

This study used a unique checklist developed based on the GINA guidelines to evaluate the content alignment of asthma apps. Good-quality asthma apps aligned with international best practice asthma guidelines are lacking. Future app development should target the currently lacking key features identified in this study, including the use of asthma action plans and the deployment of behavioral change techniques to engage and re-engage with users. This study has implications for clinicians navigating the ever-expanding mHealth app market for chronic diseases.

TRIAL REGISTRATION

PROSPERO CRD42021269894; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=269894.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/33103.

Early outcomes following the implementation of a specialised pleural disease service

BACKGROUND

Pleural effusion is a common cause of hospitalisation and a poor prognostic marker that is associated with morbidity and mortality. The evaluation and management of pleural effusion may be performed more effectively by a specialised pleural disease service (SPDS).

AIMS

To evaluate the impact of a SPDS established in 2017 at a 400-bed metropolitan hospital in Victoria, Australia.

METHODS

A retrospective observational study was undertaken comparing outcomes of individuals with pleural effusions. People with pleural effusion were identified using administrative data. Two 12-month time periods were compared, 2016 (Period 1, before SPDS) and 2018 (Period 2, after SPDS).

RESULTS

Period 1 had n = 76 and Period 2 had n = 96 individuals with pleural effusion receiving intervention. Age (69.8 ± 17.6 vs 71.8 ± 15.8), gender and Charlson Comorbidity Index (4.9 ± 2.8 vs 5.4 ± 3.0) were similar across both periods. Utilisation of point-of-care ultrasound for pleural procedures increased from Period 1 to 2, 57.3-85.7% (P < 0.001). There was a reduction in median days from admission to intervention (3.8-2.1 days, P = 0.048) and pleural-related re-intervention rate (32% vs 19%, P = 0.032). Pleural fluid testing was more consistent with recommendations (16.8% vs 43.2%, P < 0.001). Overall, there was no difference in the median length of stay (7.9 vs 6.4 days, P = 0.23), pleural-related readmissions (11% vs 16%, P = 0.69) or mortality (17.1% vs 15.6%, P = 0.79). Procedural complications were similar between the two periods.

CONCLUSIONS

The introduction of a SPDS was associated with increased point-of-care ultrasound utilisation for pleural procedures, shorter delays to intervention and improved standardisation of tests on pleural fluid.

Prevalence of subclinical lung cancer detected at autopsy: a systematic review

BACKGROUND

Lung cancer screening in high-risk populations with low-dose computed tomography is supported by international associations and recommendations. Overdiagnosis is considered a risk of screening with associated harms. The aim of this paper is to determine the prevalence of subclinical lung cancer diagnosed post-mortem to better understand the reservoir of subclinical lung cancer.

METHODS

We searched EMBASE, PubMed, and MEDLINE databases from inception until March 2022 with no language restrictions. We considered all studies with ≥100 autopsies in adults. Two reviewers independently assessed eligibility of studies, extracted data, and assessed risk of bias of included studies. We performed a meta-analysis using a random-effects model for prevalence of subclinical lung cancer diagnosed post-mortem with sensitivity and subgroup analyses.

RESULTS

A total of 13 studies with 16 730 autopsies were included. Pooled prevalence was 0.4% (95% CI 0.20 to 0.82%, I2 = 84%, tau2 = 1.19, low certainty evidence,16 730 autopsies). We performed a sensitivity analysis excluding studies which did not specify exclusion of children in their cohort, with a pooled prevalence of subclinical lung cancer of 0.87% (95% CI 0.48 to 1.57%, I2 = 71%, tau2 = 0.38, 6998 autopsies, 8 studies).

CONCLUSIONS

This is the first published systematic review to evaluate the prevalence of post-mortem subclinical lung cancer. Compared to autopsy systematic reviews in breast, prostate and thyroid cancers, the pooled prevalence is lower in lung cancer for subclinical cancer. This result should be interpreted with caution due to the included studies risk of bias and heterogeneity, with further high-quality studies required in target screening populations.

COVID-19 infection among patients with cancer in Australia from 2020 to 2022: a national multicentre cohort study

Background

The global COVID-19 pandemic disproportionately affected certain populations and its management differed between countries. This national study describes characteristics and outcomes of COVID-19 in patients with cancer in Australia.

Methods

We performed a multicentre cohort study of patients with cancer and COVID-19 from March 2020 to April 2022. Data were analysed to determine varying characteristics between cancer types and changes in outcomes over time. Multivariable analysis was performed to determine risk factors associated with oxygen requirement.

Findings

620 patients with cancer from 15 hospitals had confirmed COVID-19. There were 314/620 (50.6%) male patients, median age 63.5 years (IQR 50-72) and majority had solid organ tumours (392/620, 63.2%). The rate of COVID-19 vaccination (≥1 dose) was 73.4% (455/620). Time from symptom onset to diagnosis was median 1 day (IQR 0-3), patients with haematological malignancy had a longer duration of test positivity. Over the study period, there was a significant decline in COVID-19 severity. Risk factors associated with oxygen requirement included male sex (OR 2.34, 95% CI 1.30-4.20, p = 0.004), age (OR 1.03, 95% CI 1.01-1.06, p = 0.005); not receiving early outpatient therapy (OR 2.78, 95% CI 1.41-5.50, p = 0.003). Diagnosis during the omicron wave was associated with lower odds of oxygen requirement (OR 0.24, 95% CI 0.13-0.43, p < 0.0001).

Interpretation

Outcomes from COVID-19 in patients with cancer in Australia over the pandemic have improved, potentially related to changing viral strain and outpatient therapies.

Funding

This study was supported by research funding from MSD.

Thunderstorm asthma in seasonal allergic rhinitis: The TAISAR study

BACKGROUND

Asthma epidemics associated with thunderstorms have had catastrophic effects on individuals and emergency services. Seasonal allergic rhinitis (SAR) is present in the vast majority of people who develop thunderstorm asthma (TA), but there is little evidence regarding risk factors for TA among the SAR population.

OBJECTIVE

We sought to identify risk factors for a history of TA and hospital presentation in a cohort of individuals with SAR.

METHODS

This multicenter study recruited adults from Melbourne, Australia, with a past diagnosis of TA and/or self-reported SAR. Clinical information, spirometry results, white blood cell count, ryegrass pollen-specific (RGP-sp) IgE concentration, and fractional exhaled nitric oxide were measured to identify risk factors for a history of TA in individuals with SAR.

RESULTS

From a total of 228 individuals with SAR, 35% (80 of 228) reported SAR only (the I-SAR group), 37% (84 of 228) reported TA symptoms but had not attended hospital for treatment (the O-TA group), and 28% (64 of 228) had presented to the hospital for TA (the H-TA group). All patients in the H-TA group reported a previous asthma diagnosis. Logistic regression analysis of factors associated with O-TA and H-TA indicated that lower FEV1 value and an Asthma Control Questionnaire score higher than 1.5 were associated with H-TA. Higher blood RGP-sp IgE concentration, eosinophil counts, and fractional exhaled nitric oxide level were significantly associated with both O-TA and H-TA. Receiver operating curve analysis showed an RGP-sp IgE concentration higher than 10.1 kU/L and a prebronchodilator FEV1 value of 90% or lower to be biomarkers of increased H-TA risk.

CONCLUSION

Clinical tests can identify risk of a history of TA in individuals with SAR and thereby inform patient-specific treatment recommendations.

Functionality and Quality of Asthma mHealth Apps and Their Consistency With International Guidelines: Protocol for a Systematic Search and Evaluation of Mobile Apps

Background

Asthma is a chronic respiratory disorder that requires long-term pharmacotherapy and patient empowerment to manage the condition and recognize and respond to asthma exacerbations. Mobile health (mHealth) apps represent a potential medium through which patients can improve their ability to self-manage their asthma. Few studies have conducted a systematic evaluation of asthma mobile apps for quality and functionality using a validated tool. None of these reviews have systematically assessed these apps for their content and evaluated them against the available international best practice guidelines.

Objective

The objective of this study is to conduct a systematic search and evaluation of adult-targeted asthma mHealth apps. As part of this review, the potential of an mHealth app to improve asthma self-management and the overall quality of the app will be evaluated using the Mobile App Rating Scale framework, and the quality of the information within an app will be evaluated using the current Global Initiative for Asthma guidelines as a reference.

Methods

A stepwise methodological approach was taken in creating this review. First, the most recent Global Initiative for Asthma guidelines were independently reviewed by 2 authors to identify key recommendations that could be feasibly incorporated into an mHealth app. A previously developed asthma assessment framework was identified and was modified to suit our research and ensure that all of these identified recommendations were included. In total, 2 popular app stores were reviewed to identify potential mHealth apps. These apps were screened based on predefined inclusion and exclusion criteria. Suitable apps were then evaluated. Technical information was obtained from publicly available information. The next step was to perform an app quality assessment using the validated Mobile App Rating Scale framework to objectively determine the quality of an app. App functionality was assessed using the Intercontinental Medical Statistics Institute for Health Informatics Functionality Scoring System. Finally, the mHealth apps were assessed using our developed checklist.

Results

Funding has been received for the project from the Respiratory Department at Northern Health, Victoria. Three reviewers have been recruited to systematically evaluate the apps. The results of this study are expected in 2022.

Conclusions

To our knowledge, this review represents the first study to examine all mHealth apps available in Australia that are targeted to adults with asthma for their functionality, quality, and consistency with international best practice guidelines. Although this review will only be conducted on mHealth apps available in Australia, many apps are available worldwide; thus, this study should be largely generalizable to other English-speaking regions and users. The results of this review will help to fill gaps in the literature and assist clinicians in providing evidence-based advice to patients wishing to use mHealth apps as part of their asthma self-management.

Trial Registration

PROSPERO 269894; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=269894

International Registered Report Identifier (IRRID)

PRR1-10.2196/33103

Missed diagnosis or misdiagnosis: How often do hospitalised patients with a diagnosis of chronic obstructive pulmonary disease (COPD) have spirometry that supports the diagnosis?

BACKGROUND

Chronic obstructive pulmonary disease is one of the most common clinical diagnoses among hospital inpatients. Diagnosis requires the demonstration of post-bronchodilator airflow obstruction. However, it is uncertain how often spirometry results are available at the time a diagnostic label of COPD is applied.

AIM

To identify how frequently spirometry results were available following an inpatient admission with a clinical diagnosis of COPD, and to determine how often the available spirometry results supported a clinical diagnosis of COPD. Inhaler prescription, at discharge, was also evaluated to determine one of the potential implications of diagnostic inaccuracy.

METHODS

A single centre retrospective observational study was undertaken at a 400-bed metropolitan health service between October 2016 and March 2018.

RESULTS

A total of 2239 inpatient separations occurred in 1469 individuals who had a clinical diagnosis of COPD during the study. Spirometry results were not available in 43.6% (n = 641) of those with a diagnosis of COPD. A further 19.7% (n = 289) had spirometry results available at the time of admission, that did not demonstrate fixed airflow obstruction. The available prescribing data (n = 443) demonstrated that inhaled medications were prescribed in a similar pattern, regardless of the availability of spirometry, or whether the results supported a clinical diagnosis of COPD.

CONCLUSIONS

Inpatients with a clinical diagnosis of COPD frequently did not have supportive spirometry results that confirmed the diagnosis or had results inconsistent with COPD. Misdiagnosis and inappropriate prescribing require further attention to improve the quality of care in this setting. This article is protected by copyright. All rights reserved.

Improving access to ward-based respiratory failure management: a case study in the development of a respiratory care unit at an Australian metropolitan health service

This case study describes the implementation of a ward-based respiratory care unit to improve access to specialised respiratory failure management at an Australian metropolitan health service. Using a case study approach, we describe the conception, development and implementation of a respiratory care unit within a previously inexperienced ward. Key barriers and facilitators are explored and the importance of a safety culture and an aspiration for continuous quality improvement are detailed. Three key aspects of implementation were identified: physical environment, expertise and governance. Continuous review of clinical and quality data was also considered critical to success. Stakeholder engagement was identified as both a barrier and facilitator to successful implementation. Early success was demonstrated through increased utilisation of respiratory interventions but with less utilisation of the intensive care unit and no apparent deterioration in clinical outcomes. Successful implementation of ward-based management of respiratory failure can be undertaken within non-tertiary settings but requires a comprehensive plan. Essential aspects include the support of clinical champions, early and continuous stakeholder engagement and an aspirational culture of safety and continuous quality improvement. What is known about the topic? Non-invasive ventilation and high-flow oxygen therapy are now established as key treatments in the management of acute respiratory failure. Access to these treatments is often limited to critical care locations (emergency department, intensive care unit (ICU) and operating theatre), but ward-based use can be safe and effective when applied with appropriate clinical policies, expertise and staffing. What does this paper add? This report describes the successful and rapid development of a specialised respiratory care unit within an inexperienced ward at an Australian metropolitan health service. Prior to development of the unit, the health service only provided non-invasive ventilation and high-flow oxygen therapy within critical care locations. Successful implementation was associated with increased utilisation of these therapies with significantly less ICU utilisation and no apparent deterioration in outcomes. What are the implications for practitioners? An explanation of a model for implementation is provided that may help health services improve access to complex respiratory failure management outside of critical care locations. Key factors in the success of the model are identified and examined.

The impact of perceived risk, screening eligibility and worry on preference for lung cancer screening: a cross-sectional survey

Lung cancer screening is effective at reducing lung cancer deaths when individuals at greatest risk are screened. Recruitment initiatives target all current and former smokers, of whom only some are eligible for screening, potentially leading to discordance between screening preference and eligibility in ineligible individuals. The objective of the present study was to identify factors associated with preference for screening among ever-smokers. Ever-smokers aged 55-80 years attending outpatient clinics at three Australian hospitals were invited. The survey recorded: 1) demographics; 2) objective lung cancer risk and screening eligibility using the Prostate Lung Colon Ovarian 2012 risk model; and 3) perceived lung cancer risk, worry about and seriousness of lung cancer using a validated questionnaire. Multivariable ordinal logistic regression identified predictors of screening preference. The survey was completed by 283 individuals (response rate 27%). Preference for screening was high (72%) with no significant difference between low-dose computed tomography screening-eligible and -ineligible individuals (77% versus 68%, p=0.11). Worry about lung cancer (adjusted-proportional odds ratio (adj-OR) 1.31, 95% CI 1.08-1.58; p=0.007) and perceived seriousness of lung cancer (adj-OR 1.31, 95% CI 1.05-1.64; p=0.02) were associated with higher preference for lung cancer screening while screening eligibility was not. The concept of "early detection" was the most important driver to have screening while practical obstacles like difficulty travelling to the scan or taking time off work were the least important barriers to screening. Most current or former smokers prefer to undergo screening. Worry about lung cancer and perceived seriousness of the diagnosis are more important drivers for screening preference than eligibility status.

Low rates of eligibility for lung cancer screening in patients undergoing computed tomography coronary angiography

Incidental findings, including pulmonary nodules, on computed tomography coronary angiography (CTCA) are common. Previous authors have suggested CTCA could allow opportunistic screening for lung cancer, though the lung cancer risk profile of this patient group has not previously been established. Smoking histories of 229 patients undergoing CTCA at two tertiary hospitals were reviewed and only 25% were current or former smokers aged 55-80 years old. Less than half of this group were eligible for screening based on the PLCO_m2012 risk model. We conclude that routine screening in the form of full thoracic field imaging, of individuals undergoing CTCA is not appropriate as it would likely result in net harm.

Matching-adjusted indirect comparison of efficacy in patients with moderate-to-severe plaque psoriasis treated with ixekizumab vs. secukinumab

BACKGROUND

Head-to-head randomized studies comparing ixekizumab and secukinumab in the treatment of psoriasis are not available.

OBJECTIVES

To assess efficacy and quality of life using matching-adjusted indirect comparisons for treatment with ixekizumab vs. secukinumab.

METHODS

Psoriasis Area and Severity Index (PASI) improvement of at least 75%, 90% and 100% and Dermatology Life Quality Index (DLQI) 0/1 response rates for approved dosages of ixekizumab (160 mg at Week 0, then 80 mg every two weeks for the first 12 weeks) and secukinumab (300 mg at Weeks 0, 1, 2, 3 and 4, then 300 mg every 4 weeks) treatment were compared using data from active (etanercept and ustekinumab) and placebo-controlled studies. Comparisons were made using the Bucher (BU) method and two modified versions of the Signorovitch (SG) method (SG total and SG separate). Subsequently, results based on active treatment common comparators were combined using generic inverse-variance meta-analysis.

RESULTS

In the meta-analysis of studies with active comparators, PASI 90 response rates were 12·7% [95% confidence interval (CI) 5·5-19·8, P = 0·0005], 10·0% (95% CI 2·1-18·0, P = 0·01) and 11·2% (95% CI 3·2-19·1, P = 0·006) higher and PASI 100 response rates were 11·7% (95% CI 5·9-17·5, P < 0·001), 12·7% (95% CI 6·0-19·4, P < 0·001) and 13·1% (95% CI 6·3-19·9, P < 0·001) higher for ixekizumab compared with secukinumab using BU, SG total and SG separate methods. PASI 75 results were comparable when SG methods were used and favoured ixekizumab when the BU method was used. Week 12 DLQI 0/1 response rates did not differ significantly.

CONCLUSIONS

Ixekizumab had higher PASI 90 and PASI 100 responses at week 12 compared with secukinumab using adjusted indirect comparisons.

Venous thromboembolism management practices and knowledge of guidelines: a survey of Australian haematologists and respiratory physicians

BACKGROUND

Current international clinical practice guidelines do not adequately address all clinical scenarios in the management of venous thromboembolism (VTE), and no comprehensive Australian guidelines exist.

AIMS

To identify areas of uncertainty in VTE management and whether self-reported practice is consistent with guidelines.

METHODS

We conducted an Australian cross-sectional online survey consisting of 53 questions to investigate doctors' VTE management practices. The survey was distributed to consultant and trainee/registrar haematologists and respiratory physicians with the aid of participating medical societies.

RESULTS

A total of 71 haematologists and 110 respiratory physicians responded to the survey. The majority of survey respondents were 31-50-years old and worked in teaching hospitals and in the acute care setting. Under-treatment was reported for high-risk pulmonary embolism (PE) and duration of anticoagulation for first-episode unprovoked PE (32 and 83% respectively). Over-treatment was reported in areas of thrombolysis for intermediate-risk PE (16%) and duration of anticoagulation for first-episode provoked PE (41%). Uncertainty and variations in doctors' management approaches were also found.

CONCLUSION

This survey demonstrated significant over-treatment, under-treatment and variability in the practice of VTE management. The findings highlight the need for the development and implementation of national guidelines for the management of VTE in Australia.

Surgery for limited-stage small-cell lung cancer

BACKGROUND

Current treatment guidelines for limited-stage small-cell lung cancer (SCLC) recommend concomitant platinum-based chemo-radiotherapy plus prophylactic cranial irradiation, based on the premise that SCLC disseminates early, and is chemosensitive. However, although there is usually a favourable initial response, relapse is common and the cure rate for limited-stage SCLC remains relatively poor. Some recent clinical practice guidelines have recommended surgery for stage 1 (limited) SCLC followed by adjuvant chemotherapy, but this recommendation is largely based on the findings of observational studies.

OBJECTIVES

To determine whether, in patients with limited-stage SCLC, surgical resection of cancer improves overall survival and treatment-related deaths compared with radiotherapy or chemotherapy, or a combination of radiotherapy and chemotherapy, or best supportive care.

SEARCH METHODS

We performed searches on CENTRAL, MEDLINE, Embase, CINAHL, and Web of Science up to 11 January 2017. We handsearched review articles, clinical trial registries, and reference lists of retrieved articles.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with adults diagnosed with limited-stage SCLC, confirmed by cytology or histology, and radiological assessment, considered medically suitable for resection and radical radiotherapy, which randomised participants to surgery versus any other intervention.

DATA COLLECTION AND ANALYSIS

We imported studies identified by the search into a reference manager database. We retrieved the full-text version of relevant studies, and two review authors independently extracted data. The primary outcome measures were overall survival and treatment-related deaths; and secondary outcome measures included loco-regional progression, quality of life, and adverse events.

MAIN RESULTS

We included three trials with 330 participants. We judged the quality of the evidence as very low for all the outcomes. The quality of the data was limited by the lack of complete outcome reporting, unclear risk of bias in the methods in which the studies were conducted, and the age of the studies (> 20 years). The methods of cancer staging and types of surgical procedures, which do not reflect current practice, reduced our confidence in the estimation of the effect.Two studies compared surgery to radiation therapy, and in one study chemotherapy was administered to both arms. One study administered initial chemotherapy, then responders were randomised to surgery versus control; following, both groups underwent chest and whole brain irradiation.Due to the clinical heterogeneity of the trials, we were unable to pool results for meta-analysis.All three studies reported overall survival. One study reported a mean overall survival of 199 days in the surgical arm, compared to 300 days in the radiotherapy arm (P = 0.04). One study reported overall survival as 4% in the surgical arm, compared to 10% in the radiotherapy arm at two years. Conversely, one study reported overall survival at two years as 52% in the surgical arm, compared to 18% in the radiotherapy arm. However this difference was not statistically significant (P = 0.12).One study reported early postoperative mortality as 7% for the surgical arm, compared to 0% mortality in the radiotherapy arm. One study reported the difference in mean degree of dyspnoea as -1.2 comparing surgical intervention to radiotherapy, indicating that participants undergoing radiotherapy are likely to experience more dyspnoea. This was measured using a non-validated scale.

AUTHORS' CONCLUSIONS

Evidence from currently available RCTs does not support a role for surgical resection in the management of limited-stage small-cell lung cancer; however our conclusions are limited by the quality of the available evidence and the lack of contemporary data. The results of the trials included in this review may not be generalisable to patients with clinical stage 1 small-cell lung cancer carefully staged using contemporary staging methods. Although some guidelines currently recommend surgical resection in clinical stage 1 small-cell lung cancer, prospective randomised controlled trials are needed to determine if there is any benefit in terms of short- and long-term mortality and quality of life compared with chemo-radiotherapy alone.

Continuous dosing versus interrupted therapy with ixekizumab: an integrated analysis of two phase 3 trials in psoriasis

Background

Continuous treatment is recommended for patients with moderate‐to‐severe psoriasis; however, treatment may need to be interrupted in routine clinical practice.

Objective

To assess outcomes in patients continuously treated with ixekizumab versus those who interrupted therapy and were subsequently retreated with ixekizumab (IXE).

Methods

This analysis used data pooled from two phase 3 trials, UNCOVER‐1 and UNCOVER‐2. Patients were randomized to placebo (PBO), IXE every 4 (Q4W) or IXE every 2 weeks (Q2W) for 12 weeks. Patients with a static Physician's Global Assessment (sPGA) 0, 1 at Week 12 were rerandomized to IXEQ4W, IXE every 12 weeks (not presented) or PBO. We examined outcomes in patients who were continuously treated (IXEQ2W/IXEQ4W; IXEQ4W/IXEQ4W) or withdrawn (IXEQ2W/PBO; IXEQ4W/PBO), and in patients who were withdrawn and retreated with IXEQ4W for 24 weeks after disease relapse (sPGA ≥3).

Results

A total of 1226 treated patients achieved an sPGA 0, 1 at Week 12 and entered the maintenance phase; of these patients, 402 and 416 were rerandomized to PBO and IXEQ4W, respectively. Among patients interrupting treatment, 157 (82.2%) of IXEQ4W/PBO and 176 (83.4%) of IXEQ2W/PBO had an sPGA ≥3 by Week 60; median time to relapse was approximately 20 weeks irrespective of induction dose. At Week 60, continuously treated patients maintained high levels of PASI and sPGA responses (90.0% PASI 75 IXEQ2W/IXEQ4W; 81.9% sPGA 0, 1 IXEQ2W/IXEQ4W, non‐responder imputation). After 24 weeks of retreatment with IXEQ4W (IXEQ2W/PBO/IXEQ4W and IXEQ4W/PBO/IXEQ4W), 87.0% (107 of 123) and 95.1% (97 of 102) (observed), respectively, of patients recaptured PASI 75 and 70.7% (104 of 147) and 82.3% (107 of 130) (observed) recaptured an sPGA 0, 1. Overall, adverse events in continuously treated and retreated patients were comparable.

Conclusion

High levels of response were sustained with continuous ixekizumab treatment through 60 weeks. Most patients who were withdrawn experienced disease relapse, and most of those patients recaptured response after 24 weeks of retreatment.

Diagnostic Utility of Bronchial Brush-Tip Washings for the Immunohistochemical Assessment of Peripheral Lung Lesions

OBJECTIVES

Immunohistochemistry (IHC) is an important component of lung cancer diagnosis and management, although performance can be limited due to tissue availability. We describe a novel technique for processing brush-tip washings (BTW) and evaluate the feasibility of IHC testing on these samples.

STUDY DESIGN

All patients who had cell blocks (CB) created from BTW following bronchoscopic investigation of peripheral lung lesions were included. CB were assessed for adequate material before undergoing IHC staining.

RESULTS

75 patients were included in the study, with bronchoscopic diagnosis of malignancy achieved in 77%. Sixty-seven samples (89%) had sufficient cells for diagnosis on CB and 56 of these (84%) proved amenable to IHC. CB created from BTW were the sole specimens available for IHC subtyping in 7 patients (9%).

CONCLUSIONS

CB are easily created from BTW and are a simple method for increasing the diagnostic utility of bronchoscopic specimens without increasing the risk or duration of bronchoscopy. IHC can be easily performed in a high proportion of cases, increasing the likelihood of accurate sub-typing of tumours following diagnostic bronchoscopy.

Sequential multimodality bronchoscopic investigation of peripheral pulmonary lesions

Multiple guidance modalities may be combined during bronchoscopic investigation of peripheral pulmonary lesions (PPLs). The relative contribution of each modality to diagnostic performance remains uncertain.Endobronchial ultrasound (EBUS) with virtual bronchoscopy (VB) was routinely performed, with electromagnetic navigation (EMN) utilised only where EBUS was unable to locate PPLs or where the probe was adjacent to the lesion and on-site cytologic examination was nondiagnostic.236 consecutive patients with 245 PPLs had lesion size 22.8±12.4 mm (mean±sd). PPLs were localised using EBUS+VB alone in 188 (77%) and was diagnostic in 134 of these (71.3%). EBUS localisation was predicted by PPL size (23.7±10.5 versus 19.7±9.8 mm, p=0.003), but not by bronchus sign, PPL-hilum distance or PPL-pleura distance. EMN in 57 patients achieved EBUS localisation in a further 17 patients (30.9%), improving overall visualisation yield to 85%. Nine of these 57 procedures achieved a definitive diagnosis (16%), improving overall diagnostic yield to 58.4%. Probe position and lesion type influenced overall diagnostic yield. Sensitivity for diagnosis of lung cancer was 70% (131/188; 95% CI 63-76%).Localisation rate and diagnostic sensitivity of radial probe EBUS+VB alone for diagnosis of PPLs is high. EBUS localisation rates and procedural yield are improved only modestly (by 8% and 4%, respectively) with addition of EMN. Sampling following EMN should include all available methods to maximise diagnostic yield.

Experimental heart failure modelled by the cardiomyocyte-specific loss of an epigenome modifier, DNMT3B

Differential DNA methylation exists in the epigenome of end-stage failing human hearts but whether it contributes to disease progression is presently unknown. Here, we report that cardiac specific deletion of Dnmt3b, the predominant DNA methyltransferase in adult mouse hearts, leads to an accelerated progression to severe systolic insufficiency and myocardial thinning without a preceding hypertrophic response. This was accompanied by widespread myocardial interstitial fibrosis and myo-sarcomeric disarray. By targeted candidate gene quantitative RT-PCR, we discovered an over-activity of cryptic splice sites in the sarcomeric gene Myh7, resulting in a transcript with 8 exons missing. Moreover, a region of differential methylation overlies the splice site locus in the hearts of the cardiac-specific conditional knockout (CKO) mice. Although abundant and complex forms of alternative splice variants have been reported in diseased hearts and the contribution of each remains to be understood in further detail, our results demonstrate for the first time that a link may exist between alternative splicing and the cardiac epigenome. In particular, this gives the novel evidence whereby the loss of an epigenome modifier promotes the development and progression of heart disease.

Teriparatide versus alendronate for treating glucocorticoid-induced osteoporosis: an analysis by gender and menopausal status

SUMMARY

The effects of teriparatide versus alendronate were compared by gender and menopausal status in patients with glucocorticoid-induced osteoporosis. At 18 months, increases in lumbar spine BMD were significantly greater in the teriparatide versus alendronate group in postmenopausal women (7.8% versus 3.7%, p < 0.001), premenopausal women (7.0% versus 0.7%, p < 0.001), and men (7.3% versus 3.7%, p = 0.03).

INTRODUCTION

In patients with glucocorticoid-induced osteoporosis (GIO), teriparatide significantly increased bone mineral density (BMD) and decreased vertebral fractures compared with alendronate. We examined effects of teriparatide versus alendronate by gender and menopausal status.

METHODS

This was a multicenter, randomized, double-blind study of teriparatide 20 microg/day versus alendronate 10 mg/day in patients with GIO (277 postmenopausal women, 67 premenopausal women, 83 men). Primary outcome was change in lumbar spine BMD. Secondary outcomes included change in hip BMD, change in bone biomarkers, fracture incidence, and safety.

RESULTS

At 18 months, mean percent increases from baseline in lumbar spine BMD were significantly greater in the teriparatide versus alendronate group in postmenopausal women (7.8% versus 3.7%, p < 0.001), premenopausal women (7.0% versus 0.7%, p < 0.001), and men (7.3% versus 3.7%, p = 0.03). Radiographic vertebral fractures occurred in one teriparatide (one postmenopausal) and ten alendronate patients (six postmenopausal, four men), and nonvertebral fractures occurred in 12 teriparatide (nine postmenopausal, two premenopausal, one man) and eight alendronate patients (six postmenopausal, two men). The proportion of patients reporting adverse events in teriparatide versus alendronate groups was consistent across subgroups.

CONCLUSION

Among men and pre- and postmenopausal women with GIO, lumbar spine BMD increased more in patients receiving teriparatide compared with alendronate.

Added risk and inverse estimation for count responses in reproductive aquatic toxicology studies

One of the experimental designs used to evaluate the toxicity of certain chemicals in aquatic organisms focuses on reproductive output. Toxic effects are manifested through a reduced level of reproduction in exposed organisms. Historically, evaluating risks in this context has focused on changes in the mean reproduction in a population of organisms. In this paper, we focus on the toxic effects at the level of the individual organism. This new method for count responses involves added risk, the probability of the production of young being suppressed below certain specified levels in individuals exposed to a particular concentration level relative to the probability of that level of suppression in control organisms. This probability serves as the basis of the individual-based risk estimation procedures. In particular, inverse estimation of the concentration associated with a specified added risk and estimates of the added risk associated with a particular concentration are discussed in the context of a negative binomial regression model. Confidence intervals are constructed for both of these quantities using the delta method. These methods are illustrated with a study of an aquatic organism, Ceriodaphnia dubia, exposed to the herbicide nitrofen.

Pharmacist as a provider of oncology ambulatory care services

The services provided by a pharmacist to ambulatory oncology patients is described. The pharmacist takes drug histories, monitors drug therapy, gives patient discharge consultations and acts in cooperation with local physicians and the medical staff in providing chemotherapy to cancer patients for home administration. The pharmacist also provides inservice education and acts as a consultant to the medical, nursing and pharmacy staffs.