Oral Cavity Cancers: Ethnic Differences in Radiotherapy Outcomes in a Majority South Asian Leicester Community

AIMS

Squamous cell carcinoma oral cavity cancers (SCCOCCs) have a higher reported incidence in South Asian countries. We sought to compare presenting stage and outcome by ethnicity in patients with SCCOCC treated with radical radiotherapy in a single centre in the UK.

MATERIALS AND METHODS

All patients with SCCOCC treated with radical radiotherapy at an oncology department in Leicester (UK) between 2011 and 2017 were identified. Baseline demographic, clinical data and 2-year treatment outcomes were reported.

RESULTS

Of the 109 patients included, 40 were South Asian and 59 were non-South Asian. South Asians had significantly poorer 2-year disease-free survival compared with non-South Asians (54.6% versus 73%, P = 0.01).

CONCLUSION

Our analysis suggests that South Asians with SCCOCC have poorer outcomes despite a younger age and similar disease characteristics. Environmental, social factors and differing biology of disease may be responsible and further research is required to inform targeted interventions.

Implementation of the HOME core outcome set for clinical trials of atopic eczema-barriers and opportunities: the HOME IX meeting report

The Harmonising Outcome Measures for Eczema (HOME) initiative established a core outcome set (COS) for atopic eczema (AE) clinical trials in 2019. This set encompasses four core outcome domains and corresponding measurement instruments: clinical signs (EASI), patient-reported symptoms (POEM and NRS 11 point for worst itch over the last 24 h), quality of life (DLQI/CDLQI/IDQoLI), and long-term control (Recap or ADCT). Following its roadmap, the HOME initiative is now focused on supporting implementation of the COS. To identify barriers and facilitators to implementation of the COS, and to guide the effort to promote COS uptake, a virtual consensus meeting was held over 2 days (September 25-26, 2021) attended by 55 participants (26 healthcare professionals, 16 methodologists, 5 patients, 4 industry representatives, and 4 students). Implementation themes were identified by a pre-meeting survey distributed to HOME members, presentations, and whole-group discussion. Participants were divided into five multi-professional small groups which ranked their top 3 most important themes, followed by whole-group discussion and anonymous consensus voting (consensus criteria: < 30% disagreement). Three most important implementation themes were identified and agreed upon: (1) awareness and stakeholder engagement, (2) universal applicability of the COS, and (3) ensuring minimum administrative burden. Working groups to address these issues are now a priority for the HOME initiative. The results from this meeting will inform the development of a HOME Implementation Roadmap in an effort to support other COS groups planning for effective implementation of their core sets.

POS1052 DEVELOPING EVIDENCE-BASED PATIENT FOCUSED LEARNING MATERIALS TO SUPPORT HEALTH BEHAVIOUR CHANGE FOR PEOPLE LIVING WITH PSORIATIC ARTHRITIS

Background

Psoriatic arthritis (PsA) is a complex condition that requires high levels of self-management from those living with the condition. It is associated with many comorbidities, including depression, metabolic syndrome, and increased cardiovascular disease risk and can adversely affect quality of life. There is growing evidence that people living with psoriatic arthritis (PsA) are more likely to be overweight, consume alcohol above recommended levels, smoke, be affected by poor sleep, fatigue, anxiety, and take insufficient exercise for healthy living. These modifiable health behaviours further increase the already known risk of cardiovascular morbidity and mortality. These issues are not systematically addressed in routine clinical care due to low confidence in effective delivery and time constraints.

Objectives

To co-develop evidence-based patient-focused learning materials to support healthy lifestyle changes for people living with PsA.

Methods

The development of the materials was overseen by a steering group of people living with PsA, psychologists, rheumatologists, and researchers. The COM-B model was used in the development of the materials, and they are designed around motivational interviewing principles. Firstly, a systematic literature review was performed to establish the evidence for the current burden and potential interventions aimed at these issues in PsA. These included diet, weight, alcohol, smoking, exercise, anxiety, depression, and stress. An initial focus group of people living with PsA was used to identify priority behaviours and ideas for content.

The steering group developed draft materials, and we partnered with a design agency to create engaging materials. They developed a website and downloadable postcards. A second focus made up of people living with PsA was held for people to give their views on the draft content for the materials and initial design ideas. A third focus group was held with people living with PsA and a fourth with clinicians to refine the design materials and ensure they were accessible, interesting, and helpful to initiate and maintain change. A final evaluation survey was performed to review the draft website before launching the final materials. The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) approved the final materials.

Results

Following the steering and focus groups’ input, 15 candidate topics were prioritised (Table 1). A website and downloadable postcards summarising each of the topics were developed by the design team and refined following feedback from the patient focus groups. An example of the postcard for ‘keeping active’ can be found in Figure 1. The resources are free to use and can be accessed at https://www.informatree.org.

Table 1.Topics1Pain2Fatigue3Healthcare appointments4Tobacco5Different treatments6Alcohol7Work8Social support9Food and weight10Sleep11Keeping active12Mood13Intimacy14Travel15Using treatmentsFigure 1.

During the development of the website and downloadable postcards, particular attention was paid to making the material as accessible and as friendly as possible for patients.

Conclusion

This project created patient-focused information to support behaviour change in clinical practice. It addresses common concerns of people living with PsA about how they may optimise their health by providing practical and brief interventions to challenge and support them to make personal changes. Future research is needed to test the impact of the resource.

Acknowledgements

This research project was funded by a Medical Education Grant from Pfizer. SK was funded by Cancer Research UK (grant C49297/A27294).

Disclosure of Interests

Louise Hailey: None declared, Christine Bundy Consultant of: Over the last 3 years, I have received funds for consultancy from the following pharmaceutical companies: Abbvie, Almirall, Amgen (was Celgene), Beiersdorf, Janssen, Novartis, Pfizer, UCB., Grant/research support from: Over the last 3 years, I have received funds for research and honoraria from the following pharmaceutical companies: Abbvie, Almirall, Amgen (was Celgene), Beiersdorf, Janssen, Novartis, Pfizer, UCB., Laura Howells: None declared, Shona Kirtley: None declared, Sam Martin: None declared, Denis O’Sullivan: None declared, Ingrid Steinkoenig: None declared, Melissa Stepney: None declared, Laura Coates Speakers bureau: LCC has been paid as a speaker for AbbVie, Amgen, Biogen, Celgene, Eli Lilly, Galapagos, Gilead, GSK, Janssen, Medac, Novartis, Pfizer and UCB.

, Consultant of: LCC has worked as a paid consultant for AbbVie, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Eli Lilly, Gilead, Galapagos, Janssen, Moonlake, Novartis, Pfizer and UCB., Grant/research support from: LCC has received grants/research support from AbbVie, Amgen, Celgene, Eli Lilly, Janssen, Novartis, Pfizer and UCB.

How has the COVID-19 pandemic affected eczema self-management and help seeking? A qualitative interview study with young people and parents/carers of children with eczema

Background

Eczema can have a considerable impact on quality of life. Treatments can improve this, but management is complex. Barriers to eczema self‐management may be impacted upon by environmental context, such as the COVID‐19 pandemic.

Objectives

To explore experiences of eczema, self‐management, and accessing healthcare and advice during the COVID‐19 pandemic among young people with eczema and parents/carers of children with eczema.

Methods

Qualitative semi‐structured interviews were carried out with 36 participants recruited from general practices as part of randomised controlled trials of online eczema resources.

Results

Changes to everyday life—Periods of staying at home due to the pandemic alter the burden of eczema, with reports of an improved routine and application of topical treatments for many, but difficulties with handwashing for others. Parents/carers reported improved eczema control due to closures of educational settings. Young people reported higher stress that may have triggered eczema flare‐ups. Changes to access to advice and treatment—There was a reluctance to seek medical appointments in a non‐emergency situation. Participants reported a lack of trust in the outcome of telephone consultations because health professionals were unable to see or feel the skin. Delays or difficulties when obtaining appointments and treatments caused frustration. Access to an online eczema resource was reported to have extra value in the context of the pandemic.

Conclusion

Changes to lifestyle and access to healthcare during the pandemic have affected eczema and self‐management. Healthcare settings may want to consider providing extra reassurance around remote consultations.

Do patient characteristics matter when calculating sample size for eczema clinical trials?

Background

The Patient‐Oriented Eczema Measure (POEM) is the core outcome instrument recommended for measuring patient‐reported atopic eczema symptoms in clinical trials. To ensure that the statistical significance of clinical trial results is meaningful, trials are often designed by specifying the target difference in the primary outcome as part of the sample size calculation. One method used to specify the target difference is a score that corresponds to a standardized effect size.

Objectives

to assess how the standardized effect size of POEM scores vary across age, gender, ethnicity and disease severity.

Methods

This study combined data from five UK‐based randomized clinical trials of eczema treatments in order to assess differences in self‐reported eczema symptoms (POEM) corresponding to a standardized effect size (0.5 SD of baseline POEM scores) across age, gender, ethnicity and disease severity.

Results

POEM scores corresponding to 0.5 SD_(baseline) were remarkably consistent across participants of varying ages, gender, ethnicity and disease severity from datasets of five UK trials in children (range 2.99–3.45).

Conclusions

This study provides information that can support those designing clinical trials to determine their sample size and can aid individuals interpreting trial results. Further exploration of differences in populations beyond the United Kingdom is needed.

OVPSYCH2: A randomized controlled trial of psychological support versus standard of care following chemotherapy for ovarian cancer

BACKGROUND

Fear of disease progression (FOP) is a rational concern for women with Ovarian Cancer (OC) and depression is also common. To date there have been no randomized trials assessing the impact of psychological intervention on depression and FOP in this patient group.

PATIENTS AND METHODS

Patients with primary or recurrent OC who had recently completed chemotherapy were eligible if they scored between 5 and 19 on the PHQ-9 depression and were randomized 1:1 to Intervention (3 standardized CBT-based sessions in the 6-12 weeks post-chemotherapy) or Control (standard of care). PHQ-9, FOP-Q-SF, EORTC QLQ C30 and OV28 questionnaires were then completed every 3 months for up to 2 years. The primary endpoint was change in PHQ-9 at 3 months. Secondary endpoints were change in other scores at 3 months and all scores at later timepoints.

RESULTS

182 patients registered; 107 were randomized; 54 to Intervention and 53 to Control; mean age 59 years; 75 (70%) had completed chemotherapy for primary and 32 (30%) for relapsed OC and 67 patients completed both baseline and 3-month questionnaires. Improvement in PHQ-9 was observed for patients in both study arms at three months compared to baseline but there was no significant difference in change between Intervention and Control. A significant improvement on FOP-Q-SF scores was seen in the Intervention arm, whereas for those in the Control arm FOP-Q-SF scores deteriorated at 3 months (intervention effect = -4.4 (-7.57, -1.22), p-value = 0.008).

CONCLUSIONS

CBT-based psychological support provided after chemotherapy did not significantly alter the spontaneously improving trajectory of depression scores at three months but caused a significant improvement in FOP. Our findings call for the routine implementation of FOP support for ovarian cancer patients.

Thematic synthesis of the experiences of people with hidradenitis suppurativa: a systematic review

BACKGROUND

Although hidradenitis suppurativa (HS) is known to affect quality of life, little summative knowledge exists on how HS impacts people living with the condition.

OBJECTIVES

To synthesize experiences of people with HS within published qualitative research.

METHODS

Searches on databases MEDLINE, PsycINFO, Embase and CINAHL were conducted on 17 April 2020. Two independent reviewers screened 5512 publications. Study quality was assessed using the National Institute for Health and Care Excellence quality appraisal checklist for qualitative studies. Thematic synthesis generated descriptive and analytic themes.

RESULTS

Fourteen studies were included: four studies fulfilled most quality criteria, eight fulfilled some quality criteria, and two fulfilled few quality criteria. There were three final themes. (i) Putting the brakes on life. The physical, psychological and social consequences of HS resulted in people missing out on multiple life events. This could have a cumulative effect that influences the trajectory of someone's life. (ii) A stigmatized identity: concealed and revealed. People try to conceal their HS, visually and verbally, but this results in anticipation and fear of exposure. Social support and psychological acceptance helped people cope. Connecting to others with HS may have a specific role in preserving a positive self-identity. (iii) Falling through the cracks. Delayed diagnosis, misdiagnosis and lack of access to care were reported. People felt unheard and misunderstood by healthcare professionals, and healthcare interactions could enhance feelings of shame.

CONCLUSIONS

There need to be improvements to clinical care to allow people with HS to live their life more fully.

Measurement properties of patient-reported outcome measures for eczema control: a systematic review

Atopic eczema (herein referred to as 'eczema') is a skin disease characterized by remitting and relapsing symptoms. The Harmonising Outcome Measures for Eczema (HOME) initiative was developed to establish a core outcome set (COS) for eczema to be measured for all future eczema trials. The core outcome set for atopic eczema clinical trials includes the domain for patient-reported eczema control, but a review of the validation of available eczema control instruments was lacking. We aimed to review the literature and systematically assess the measurement properties of validated patient-reported outcome instruments that capture eczema control. PubMed and Ovid EMBASE were searched up to 24 January 2020 for any study that reported on PROM instrument development or validation. The COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) criteria were used to assess the quality of eligible studies. We screened 12 036 titles and abstracts and 58 full texts. A total of 12 papers were included, reporting on seven PROMS. These were assessed with respect to development, reliability, construct validity and responsiveness. Two instruments, Recap of Atopic Eczema (RECAP) and the Atopic Dermatitis Control Tool (ADCT), have been developed and validated to a sufficient standard to support their recommendation as patient-reported outcome instruments for measuring control of atopic eczema as part of the HOME Core Outcome Set.

Recommended core outcome instruments for health-related quality of life, long-term control and itch intensity in atopic eczema trials: results of the HOME VII consensus meeting

Background

The Harmonising Outcome Measures for Eczema (HOME) initiative has established a core outcome set of domains for atopic eczema (AE) clinical trials. Previous consensus meetings have agreed on preferred instruments for clinician‐reported signs (Eczema Area and Severity Index, EASI) and patient‐reported symptoms (Patient‐Oriented Eczema Measure, POEM). This paper reports consensus decisions from the HOME VII meeting.

Objectives

To complete the core outcome set for AE by agreeing on core outcome instruments for the domains of quality of life (QoL), long‐term control and itch intensity.

Methods

A face‐to‐face consensus meeting was held in Tokyo, Japan (8–10 April 2019) including 75 participants (49 healthcare professionals/methodologists, 14 patients, 12 industry representatives) from 16 countries. Consensus decisions were made by presentations of evidence, followed by whole and small group discussions and anonymous voting using predefined consensus rules.

Results

It was agreed by consensus that QoL should be measured using the Dermatology Life Quality Index (DLQI) for adults, the Children’s Dermatology Life Quality Index (CDLQI) for children and the Infant’s Dermatology Quality of Life Index (IDQoL) for infants. For long‐term control, the Recap of Atopic Eczema (RECAP) instrument or the Atopic Dermatitis Control Test (ADCT) should be used. Consensus was not reached over the frequency of data collection for long‐term control. The peak itch numerical rating scale (NRS)‐11 past 24 h was recommended as an additional instrument for the symptom domain in trials of older children and adults. Agreement was reached that all core outcome instruments should be captured at baseline and at the time of primary outcome assessment as a minimum.

Conclusions

For now, the core outcome set for clinical trials in AE is complete. The specified domains and instruments should be used in all new clinical trials and systematic reviews of eczema treatments.

What is already known about this topic?

Core outcomes sets improve the design and reporting of clinical trials, reduce selective outcome reporting bias and facilitate meta‐analysis of results in systematic reviews.

The HOME core outcome set for eczema recommends the inclusion of four core domains in all atopic eczema trials: clinician‐reported signs, patient‐reported symptoms, health‐related quality of life (HrQoL) and long‐term control.

Clinician‐reported signs should be captured using the Eczema Area and Severity Index (EASI) and patient‐reported symptoms using the Patient‐Oriented Eczema Measure (POEM).

What does this study add?

The HOME core outcome set is now complete and recommended core outcome instruments have been agreed on for all four domains.

Core outcome instruments for HrQoL: Dermatology Life Quality Index (DLQI) for adults, Children’s Dermatology Life Quality Index (CDLQI) for children and Infant’s Dermatology Quality of Life Index (IDQoL) for infants.

Core outcome instruments for long‐term control: either the Recap of Atopic Eczema (RECAP) or the Atopic Dermatitis Control Test (ADCT).

In addition, itch intensity should be measured using the peak NRS‐11 past 24 h for trials including older children and adults.

What are the clinical implications of this work?

If all future trials of eczema treatments include the HOME core outcome instruments, then trial results will be more readily incorporated into meta‐analyses in systematic reviews and clinical care will be informed by the best available evidence.

Linked Comment: D.F. Murrell and C.F. Paul. Br J Dermatol 2021; 185:13–14.

Recommended core outcome instruments for health-related quality of life, long-term control and itch intensity in atopic eczema trials: results of the HOME VII consensus meeting

BACKGROUND

The Harmonising Outcome Measures for Eczema (HOME) initiative has established a core outcome set of domains for atopic eczema clinical trials. Previous consensus meetings have agreed upon preferred instruments for clinician-reported signs (Eczema Area and Severity Index - EASI) and patient-reported symptoms (Patient-Oriented Eczema Measure - POEM). This paper reports consensus decisions from the HOME VII meeting.

OBJECTIVE

To complete the core outcome set for atopic eczema by agreeing upon core outcome instruments for the domains of quality of life, long-term control and itch intensity.

METHODS

Face-to-face consensus meeting held in Tokyo, Japan (8th to 10th April, 2019) including 74 participants (47 healthcare professionals/methodologists, 14 patients, 13 industry representatives), from 16 countries. Consensus decisions were made by presentations of evidence, followed by whole and small group discussions and anonymous voting using pre-defined consensus rules.

RESULTS

It was agreed by consensus that quality of life should be measured using the Dermatology Life Quality Index (DLQI) for adults, the Children's Dermatology Life Quality Index (CDLQI) for children, and the Infant's Dermatology Quality of Life Index (IDQoL) for infants. For long-term control, the Recap of Atopic Eczema (RECAP) instrument or the Atopic Dermatitis Control Test (ADCT) should be used. Consensus was not reached over the frequency of data collection for long-term control. The peak itch numerical rating scale(NRS)-11 past 24 hours was recommended as an additional instrument for the symptom domain in trials of older children and adults. Agreement was reached that all core outcome instruments should be captured at baseline and at the time of primary outcome assessment as a minimum.

CONCLUSIONS

For now, the core outcome set for clinical trials in atopic eczema is complete. The specified domains and instruments should be used in all new clinical trials and systematic reviews of eczema treatments.

Defining and measuring 'eczema control': an international qualitative study to explore the views of those living with and treating atopic eczema

Background

Atopic eczema (also known as eczema) is a chronic, inflammatory skin condition that often afflicts patients’ health and well‐being. The Harmonising Outcome Measures for Eczema (HOME) initiative recommends that ‘long‐term control of eczema’ is measured in all clinical trials 3 months or longer in duration. However, little has been published on what eczema control means to those living with or treating atopic eczema.

Objectives

To (i) develop understanding of what eczema control means to patients, carers and clinicians and (ii) explore the feasibility and acceptability of different ways of measuring eczema control in the long term.

Methods

Online focus groups explored patients/carers experiences in the UK, the United States, the Netherlands, France, Sweden and Japan, and an international online survey gathered views of clinicians. The framework method was used to analyse the focus groups, and thematic analysis was used to analyse survey data. All findings were integrated into a theoretical framework to create overarching themes that cut across these diverse groups.

Results

Eight focus groups with patients (16 years+) and eight groups with carers of children took place (N = 97). Sixty‐two people took part in the survey. Eczema control was described as a multifaceted construct involving changes in disease activity, the treatment and management of the condition and psychological, social and physical functioning. Patient/carer measurement allows personal accounts and frequent measurement, whilst clinician measurement was deemed less subjective. The burden on patients/carers and issues for analysing and interpreting data should be considered.

Conclusions

This study formed the basis of judging the content validity and feasibility of measurement instruments/methods to assess control of eczema in clinical trials. This online approach to an international qualitative study is an example of how core outcome set developers with limited resources can engage with multiple stakeholder groups on an international basis to inform consensus meeting discussions.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Engaging Men in Psychosocial Cancer Support

Background: Despite increasing rates of cancer survivorship, there is still evidence to suggest men are less likely to access information services, health services and cancer screening. Men may be more reticent to express their emotions in relation to health and specifically in relation to cancer; and so it is important to ensure that services offer different routes to inclusion. Maggie´s ( www.maggiescentres.org ) is an innovative, multidisciplinary, health professional led model of holistic supportive cancer care, widely regarded as an exemplar of best practice in cancer rehabilitation and supported self-management. In 2017 Maggie´s received 249,247 visits across their network of twenty-three centres in the UK, Hong Kong and Tokyo. One of the key challenges for Maggie´s and others is to develop sustainable, innovative and equitable approaches to supportive care. Aim: To explore whether male-specific facilitated support groups provide a constructive environment within which men can engage with health professional led holistic cancer services. Methods: Men (n=39) with a range of cancers (including curative and noncurative) from varied socioeconomic backgrounds, attending male-specific facilitated support groups at eight Maggie's Centres in the UK completed questionnaires to give feedback on the social, emotional, practical and informational support the groups aim to provide. A smaller subset of group members (n=12) participated in focus group discussions to capture themes about why men attend the groups. The group facilitators were interviewed to provide observations about the impact of the groups on both the participants and themselves. Results: Men in the facilitated support groups report high levels of satisfaction in relation to practical (94.8%), emotional (95.2%) and social (90.47%) and informational support (92.50%). Thematic analysis of the smaller subset of focus group data suggest reasons why men attend male-specific support groups including “reducing isolation and developing a sense of belonging”, “creating shared experience and understanding”, “safely expressing emotion”, “protecting loved ones from distress” and “use of male specific language and humor”. Conclusion: Globally, the supportive care needs of men affected by cancer are changing but the Maggie´s model of care offers valuable lessons that can be generalized across varied support settings to meet these emerging needs. The current study underlines the importance of engaging and supporting men throughout the cancer experience through the use of professionally facilitated support groups that discuss themes tailored to the challenges the men face and maximize the opportunity for acceptable social support. Further controlled longitudinal research is required to build on these findings.

Enhancing Quality of Life Through an Innovative, Multidisciplinary Model of Supportive Cancer Care and Rehabilitation

Background: Advancements in diagnosis and cancer treatment mean survival rates have improved but as a consequence many people are living with the adverse physical effects of complex treatments, financial hardship, work and relationship stress, and fear of recurrence. Person-centered, holistic care is required to help people maximize all aspects of their quality of life when living with and beyond their cancer, but debate continues around which models are economically sustainable and effective in achieving the desired outcomes. Maggie's ( www.maggiescentres.org ) is an innovative, multidisciplinary model of holistic supportive cancer care, widely regarded as an exemplar of best practice in cancer rehabilitation and supported self-management. In 2017 Maggie's received 249,247 visits across the network of centres in the UK, Hong Kong and Tokyo. The Maggie's program is designed to incorporate evidence based psychoeducation techniques delivered by multidisciplinary oncology professionals; offer personalised and understandable treatment and lifestyle information; and maximize the opportunity for social-support. Outcome evaluation is embedded within the model of care. Aim: To illustrate the holistic Maggie's model using outcome data from “Managing Stress” and “Living with and after Prostate Cancer (LWAPC)” courses to provide examples of the impact Maggie´s makes in enhancing quality of life. Methods: A subset of participants in “Managing Stress” and “Living with and after Prostate Cancer” courses across the network of UK Maggie´s Centres completed pre and post course standardized questionnaires. Results: Participants in “Managing Stress” found significant improvements in overall psychological well-being and quality of life (QoL) (t(40)=3.28, P = .002) and significant improvements in their ability to tolerate uncertainty (t(47) = 3.23, P = .002). Participants in the LWAPC found significant improvements in overall prostate cancer specific QoL ( t(37)=3.603, P = .001), general well-being ( t(37)=2.61, P = .013), and emotional well-being ( t(37)=2.62, P = .013). Also, significant reductions were found in overall negative appraisal of life (t(52)=2.96, P = .005), overall health worries (t(52) 2.28, P = 0.27), worries about the future (t(52) = 2.85, P = .006) and uncertainty (t(52) = 3.89, P < .001). Conclusion: Globally, the supportive care needs of people affected by cancer are changing but the Maggie's model of care offers valuable lessons that can be generalized across varied support settings to meet these emerging needs.

The Relationship Between Psychological Flexibility, Value-Based Living and Emotional Well-Being in People Affected by Cancer

Background: Receiving a cancer diagnosis can have detrimental effects on an individual's psychological flexibility (ability to adapt constructively to reality), emotional well-being and ability to live aligned with personal values, for example, in relationships and work. Higher levels of psychological flexibility and emotional well-being are associated with better quality of life and lower psychological cancer-related distress. In turn, value-based living is positively associated with psychological flexibility and emotional well-being. There is, however, limited research specifically exploring the relationship between value-based living and emotional well-being within individuals affected by cancer. Maggie's Centres ( www.maggiescentres.org ) offer an innovative, multidisciplinary model of holistic supportive cancer care, widely regarded as an exemplar of best practice in cancer rehabilitation and supported self-management. In 2017 Maggie's received 249,247 visits across the network of Centres in the UK, Hong Kong and Tokyo. Principles of ACT (acceptance and commitment therapy) are incorporated within the program of individual support, psychoeducational courses and groups to help people maximize their quality of life. Aim: To explore the associations between psychological flexibility, value-based living and emotional well-being in individuals affected by cancer. Methods: Sixty-five people, affected by a cancer diagnosis personally or in a family member, were recruited from four UK Maggie's Centres. Participants completed standardized questionnaires measuring psychological flexibility, valued-based living and emotional well-being. Results: Moderate positive associations were found between emotional well-being and psychological flexibility (r=.4750), as well as emotional well-being and valued-living (r=.37983). Psychological flexibility was also positively associated with valued living (r=.443474). Multiple regression analysis revealed a significant model (F(5,54)=9.35, P < .001), accounting for 41.4% of the variance in emotional well-being (adjusted R2 = .414). Both psychological flexibility (b=.357, P = .002) and valued-living (b=.337, P = .004) were predictors of emotional well-being across all ages, gender and time since diagnosis. Conclusion: The study provides support for the positive associations between psychological flexibility, valued-living and emotional well-being and indicates that psychological flexibility and valued-living may be predictors of emotional well-being. This was a small observational study, so conclusions about causation or change over time cannot be made. Longitudinal intervention studies need to explore the potential impact valued-living and psychological flexibility may have on emotional well-being in those affected by cancer, and so contribute to understanding the potential importance of encouraging valued-living as a therapeutic tool within cancer care.

Report from the fifth international consensus meeting to harmonize core outcome measures for atopic eczema/dermatitis clinical trials (HOME initiative)

This is the report from the fifth meeting of the Harmonising Outcome Measures for Eczema initiative (HOME V). The meeting was held on 12-14 June 2017 in Nantes, France, with 81 participants. The main aims of the meeting were (i) to achieve consensus over the definition of the core domain of long-term control and how to measure it and (ii) to prioritize future areas of research for the measurement of the core domain of quality of life (QoL) in children. Moderated whole-group and small-group consensus discussions were informed by presentations of qualitative studies, systematic reviews and validation studies. Small-group allocations were performed a priori to ensure that each group included different stakeholders from a variety of geographical regions. Anonymous whole-group voting was carried out using handheld electronic voting pads according to predefined consensus rules. It was agreed by consensus that the long-term control domain should include signs, symptoms, quality of life and a patient global instrument. The group agreed that itch intensity should be measured when assessing long-term control of eczema in addition to the frequency of itch captured by the symptoms domain. There was no recommendation of an instrument for the core outcome domain of quality of life in children, but existing instruments were assessed for face validity and feasibility, and future work that will facilitate the recommendation of an instrument was agreed upon.

How should minimally important change scores for the Patient-Oriented Eczema Measure be interpreted? A validation using varied methods

Background

The Patient‐Oriented Eczema Measure (POEM), scored 0–28, is the core outcome instrument recommended for measuring patient‐reported atopic eczema symptoms in clinical trials. To date, two published studies have broadly concurred that the minimally important change (MIC) of the POEM is three points. Further assessment of the MIC of POEM in different populations, and using a variety of methods, will improve interpretability of the POEM in research and clinical practice.

Objectives

To calculate the smallest detectable change in the POEM and estimate the MIC of the POEM using a variety of methods in a trial dataset of children with moderate‐to‐severe atopic eczema.

Methods

This study used distribution‐based and anchor‐based methods to calculate the MIC of the POEM in children with moderate‐to‐severe eczema.

Results

Data were collected from 300 children. The smallest detectable change was 2·13. The MIC estimates were 1·07 (using 0·2 SD of baseline POEM scores) and 2·68 (using 0·5 SD of baseline POEM scores) based on distribution‐based methods; were 3·09–6·13 based on patient‐/parent‐reported anchor‐based methods; and were 3·23–5·38 based on investigator‐reported anchor‐based methods.

Conclusions

We recommend the following thresholds be used to interpret changes in POEM scores: ≤ 2, unlikely to be a change beyond measurement error; 2·1–2·9, a small change detected that is likely to be beyond measurement error but may not be clinically important; 3–3·9, probably a clinically important change; ≥ 4, very likely to be a clinically important change.

What's already known about this topic?

The Patient‐Oriented Eczema Measure (POEM) is recommended as the core outcome instrument for measuring patient‐reported symptoms in eczema clinical trials.

Two previous studies have examined the minimally important change (MIC) of the POEM; one in children with mild eczema and another in adults with very severe eczema.

These previous studies both concluded that the MIC in POEM is around three points.

What does this study add?

This study explored the impact of different methodologies for calculating the MIC of the POEM in children with moderate‐to‐severe eczema.

A change in POEM of less than two points is likely to be below the smallest detectable change (i.e. below measurement error) for the scale.

The MIC varied considerably depending on the method used, but a change in POEM score below three points is unlikely to be a clinically important change.

What are the clinical implications of this work?

This study aids sample size calculations for clinical trials and helps researchers, clinicians and patients to interpret changes in POEM scores in clinical trials and routine monitoring of eczema in clinical practice.

https://doi.org/10.1111/bjd.16611 available online

https://goo.gl/Uqv3dl

Development, reliability and validity of the Diabetes Illness Representations Questionnaire: four studies with adolescents

AIMS

This article reports on the development and validity of a Diabetes-specific Illness Representations Questionnaire (DIRQ) to assess all five dimensions of an individual's perception of diabetes, for adolescents with Type 1 diabetes mellitus.

METHODS

There were two development studies. Study 1: participants (n = 115) completed a questionnaire assessing perceptions of the consequences of diabetes and the effectiveness of treatment, along with a questionnaire assessing self-care. Study 2: participants (n = 79) completed a questionnaire assessing their identity, timeline and causal beliefs, along with a diabetes self-efficacy and barriers to adherence questionnaire. Subsequently there were two validation studies. Study 3: participants (n = 44 adolescents and 28 parents) completed the DIRQ and questionnaires assessing their self-care and psychological well-being. Glycaemic control was assessed through retrieval of routine assay results. Study 4: participants (n = 70) completed the DIRQ and questionnaires to assess their psychological well-being, with glycaemic control assessed through retrieval of routine assay results.

RESULTS

The development studies suggest that the perceived consequences of diabetes consist of two subscales, perceived threat and perceived impact, and provide further support for the distinction between treatment effectiveness to control diabetes and treatment effectiveness to prevent complications. Along with the validation studies, the results indicate that the questionnaire scales showed good internal consistency and construct validity through their associations with measures of self-care and psychological well-being.

CONCLUSION

The data reported here suggest that the DIRQ has the potential to be a useful tool for clinical assessment and evaluating the impact of psycho-educational and medical interventions.

A randomized control trial of the effect of negotiated telephone support on glycaemic control in young people with Type 1 diabetes

AIM

To evaluate changes in self-efficacy for self-management in young people with Type 1 diabetes participating in a "Negotiated Telephone Support" (NTS) intervention developed using the principles of problem solving and social learning theory.

METHODS

One-year RCT with 79 young people (male 39; mean age +/- sd 16.5 +/- 3.2 years, duration 6.7 +/- 4.4 years, HbA(1c) 8.6 +/- 1.5%) randomized into: Group 1 (control group), continued routine management, n = 28; Group 2, continued routine management with NTS, n = 25; Group 3, annual clinic with NTS, n = 26.

OUTCOME MEASURES

HbA(1c), self-efficacy, barriers to adherence, problem solving, and diabetes knowledge.

RESULTS

There were no differences between the groups at baseline. Participants in Groups 2 and 3 received an average of 16 telephone calls/year (range 5-19), median duration 9 min (2-30), with a median interval of 3 weeks (1-24) between calls. Significant correlations were found between age and average length of call (r = 0.44, P < 0.01) and frequency of contact (r = 0.36, P < 0.05). Social and school topics were discussed frequently. After 1 year, while the participants in the two intervention groups showed significant improvements in self-efficacy (P = 0.035), there was no difference in glycaemic control in the three groups. Barriers to insulin use adherence were a significant predictor of HbA(1c) (P < 0.001) after controlling for baseline.

CONCLUSIONS

NTS is an effective medium to deliver a simple theory-based psychological intervention to enhance self-efficacy for diabetes self-management. Reduced clinic attendance, combined with NTS, did not result in a deterioration of HbA(1c). Intensive personal support needs to be combined with intensive diabetes therapy to improve glycaemic control in this age group.

The potential for CYP2D6 inhibition screening using a novel scintillation proximity assay-based approach

High throughput inhibition screens for human cytochrome P450s (CYPs) are being used in preclinical drug metabolism to support drug discovery programs. The versatility of scintillation proximity assay (SPA) technology has enabled the development of a homogeneous high throughput assay for cytochrome P450 2D6 (CYP2D6) inhibition screen using [O-methyl-(14)C]dextromethorphan as substrate. The basis of the assay was the trapping of the O-demethylation product, [(14)C]HCHO, on SPA beads. Enzyme kinetics parameters V(max) and apparent K(m), determined using pooled human liver microsomes and microsomes from baculovirus cells coexpressing human CYP2D6 and NADPH-cytochrome P450 reductase, were 245 pmol [(14)C]HCHO/min/mg protein and 11 microM, and 27 pmol [(14)C]HCHO/min/pmol and 1.6 microM, respectively. In incubations containing either pooled microsomes or recombinant CYP2D6, [(14)C]dextromethorphan O-demethylase activity was inhibited in the presence of quinidine (IC(50) = 1.0 microM and 20 nM, respectively). By comparison, inhibitors selective for other CYP isoforms were relatively weak (IC(50) > 25 microM). In agreement, a selective CYP2D6 inhibitory monoclonal antibody caused greater than 90% inhibition of [(14)C]dextromethorphan O-demethylase activity in human liver microsomes, whereas CYP2C9/19- and CYP3A4/5-selective antibodies elicited a minimal inhibitory effect. SPA-based [(14)C]dextromethorphan O-demethylase activity was also shown to correlate (r(2) = 0.6) with dextromethorphan O-demethylase measured by high-performance liquid chromatography in a bank of human liver microsomes (N = 15 different organ donors). In a series of known CYP2D6 inhibitors/substrates, the SPA-based assay resolved potent inhibitors (IC(50) < 2 microM) from weak inhibitors (IC(50) >or= 20 microM). It is concluded that the SPA-based assay described herein is suitable for CYP2D6 inhibition screening using either native human liver microsomes or cDNA-expressed CYP2D6.

Development and optimisation of an improved derivatisation procedure for the determination of avermectins and milbemycins in bovine liver

A robust procedure has been developed to overcome the instability problems experienced with the fluorescent derivative of eprinomectin. The procedure involves addition of acetic acid, together with the typical reagents methylimidazole and trifluoroacetic anhydride, to produce a fluorescent molecule that can be determined by high performance liquid chromatography (HPLC) with fluorescence detection. Derivatisation is completed in 30 min at 65 degrees C. This derivatisation procedure was shown to be suitable, also, for the related compounds, moxidectin, abamectin, doramectin and ivermectin. A multi-residue method for these compounds in bovine liver has been developed using the derivatisation procedure. Samples are extracted with acetonitrile; followed by clean-up on deactivated alumina and C18 solid phase extraction (SPE) cartridges. The method was validated using bovine liver fortified at levels of 4 and 20 micrograms kg-1 with the drugs. The mean recovery ranged between 73 and 97%. The intra- and inter-assay variations showed relative standard deviations typically of < 6% and < 14%, respectively. The limit of quantitation of the method is 2 micrograms kg-1 (ppb).

Miniaturization of a hepatitis C virus RNA polymerase assay using a -102 degrees C cooled CCD camera-based imaging system

Innovations in detection technologies have allowed us to develop a novel assay in 1536-well plate format and assess the advantages of screen miniaturization compared with conventional high-throughput compound screening in 96- or 384-well plates. An HCV RNA polymerase assay has been miniaturized in 1536-well plates by using a new detection technology known as LEADseeker homogeneous imaging system. It uses a -102 degrees C cooled charge-coupled device (CCD) camera and newly designed scintillation proximity microparticles. The miniaturized assay used europium-doped streptavidin-coated yttrium oxide (YO(x)) or polystyrene (PS) microspheres to capture biotin-labeled [(3)H]RNA product transcripts. Beads in proximity to the radioisotope convert the emitted beta(-) particles into photons having wavelengths in the red region of the visible spectrum, optimal for detection by the CCD camera. Because the camera collects light from all wells of the plate simultaneously, 1536-well plates are imaged as rapidly as 384-well plates, on the order of 10 min per plate. The assay has a signal to background of approximately 20-fold, satisfactory for high-throughput robotics screening. The enzyme kinetics and potency of a known inhibitor were similar to those obtained from the conventional assay using scintillation proximity assay (SPA) beads and a scintillation plate counter. Furthermore, the newly developed microbeads (emitting at 610 to 620 nm) are less prone to quenching effects caused by yellow-colored compounds, than conventional SPA beads or scintillation fluid (emitting at 400 to 480 nm region). Thus, the LEADseeker imaging system is a useful new tool for miniaturization of assays for high-throughput screening.

Characterization of metabolites of the chemopreventive agent curcumin in human and rat hepatocytes and in the rat in vivo, and evaluation of their ability to inhibit phorbol ester-induced prostaglandin E2 production

Curcumin, the yellow pigment in turmeric, has been shown to prevent malignancies in a variety of tissues in rodents, especially in the intestinal tract. Pharmacological activities of curcumin in cells in situ germane to chemoprevention, such as inhibition of expression of cyclooxygenase-2 (COX-2), require drug concentrations in the 10(-5) - 10(-4) M range. The systemic bioavailability of curcumin is low, so that its pharmacological activity may be mediated, in part, by curcumin metabolites. To investigate this possibility, we compared curcumin metabolism in human and rat hepatocytes in suspension with that in rats in vivo. Analysis by high-performance liquid chromatography with detection at 420 and 280 nm permitted characterization of metabolites with both intact diferoylmethane structure and increased saturation of the heptatrienone chain. Chromatographic inferences were corroborated by mass spectrometry. The major metabolites in suspensions of human or rat hepatocytes were identified as hexahydrocurcumin and hexahydrocurcuminol. In rats, in vivo, curcumin administered i.v. (40 mg/kg) disappeared from the plasma within 1 h of dosing. After p.o. administration (500 mg/kg), parent drug was present in plasma at levels near the detection limit. The major products of curcumin biotransformation identified in rat plasma were curcumin glucuronide and curcumin sulfate whereas hexahydrocurcumin, hexahydrocurcuminol, and hexahydrocurcumin glucuronide were present in small amounts. To test the hypothesis that curcumin metabolites resemble their progenitor in that they can inhibit COX-2 expression, curcumin and four of its metabolites at a concentration of 20 microM were compared in terms of their ability to inhibit phorbol ester-induced prostaglandin E2 (PGE2) production in human colonic epithelial cells. Curcumin reduced PGE2 levels to preinduction levels, whereas tetrahydrocurcumin, previously shown to be a murine metabolite of curcumin, hexahydrocurcumin, and curcumin sulfate, had only weak PGE2 inhibitory activity, and hexahydrocurcuminol was inactive. The results suggest that (a) the major products of curcumin biotransformation by hepatocytes occur only at low abundance in rat plasma after curcumin administration; and (b) metabolism of curcumin by reduction or conjugation generates species with reduced ability to inhibit COX-2 expression. Because the gastrointestinal tract seems to be exposed more prominently to unmetabolized curcumin than any other tissue, the results support the clinical evaluation of curcumin as a colorectal cancer chemopreventive agent.

Multi-residue analysis of avermectins and moxidectin by ion-trap LC-MSn

A multi-residue method was developed and validated for the quantitation and confirmation of avermectins and moxidectin residues in bovine liver. Target analytes were extracted from liver homogenate using C8 solid phase cartridges, chromatographed under basic pH conditions in order to promote the formation of analyte anions, and detected by ion-trap mass spectrometry (MS) in negative ion mode using an atmospheric pressure chemical ionization interface (APCI). The method provided detection capabilities (CC beta, where beta = 0.05) for eprinomectin, abamectin, doramectin, moxidectin and ivermectin of 3.1, 3.2, 2.2, 4.0 and 3.2 ng g-1 liver respectively, well below their respective maximum residue limits (MRLs). The critical concentrations for MRL compliance (CC alpha, where alpha = 0.01) were 840, 28, 130, 130 and 130 ng g-1 respectively. Analysis of liver fortified at the appropriate MRLs gave recoveries (% +/- RSD) of 70.9 +/- 11.6 (n = 14), 69.1 +/- 3.9 (n = 13), 65.9 +/- 6.4 (n = 19), 69.7 +/- 9.3 (n = 19) and 73.2 +/- 10.5 (n = 19), respectively, for each analyte. Calibration curves fitted a second order polynomial function (R2 > or = 0.9978) over a wide range of concentrations (0 to 10,000 ng ml-1). The detection of two daughter-ions for each analyte allowed for quantitation and the confirmation of identity. The method is suitable for application in European Union statutory veterinary drug residue surveillance programmes, since it fulfills appropriate analytical criteria, and has the particular advantage of enabling high throughput multi-residue quantitation and confirmation of the target analytes.

Inhibition of cyclo-oxygenase 2 expression in colon cells by the chemopreventive agent curcumin involves inhibition of NF-kappaB activation via the NIK/IKK signalling complex

Colorectal cancer is a major cause of cancer deaths in Western countries, but epidemiological data suggest that dietary modification might reduce these by as much as 90%. Cyclo-oxygenase 2 (COX2), an inducible isoform of prostaglandin H synthase, which mediates prostaglandin synthesis during inflammation, and which is selectively overexpressed in colon tumours, is thought to play an important role in colon carcinogenesis. Curcumin, a constituent of turmeric, possesses potent anti-inflammatory activity and prevents colon cancer in animal models. However, its mechanism of action is not fully understood. We found that in human colon epithelial cells, curcumin inhibits COX2 induction by the colon tumour promoters, tumour necrosis factor alpha or fecapentaene-12. Induction of COX2 by inflammatory cytokines or hypoxia-induced oxidative stress can be mediated by nuclear factor kappa B (NF-kappaB). Since curcumin inhibits NF-kappaB activation, we examined whether its chemopreventive activity is related to modulation of the signalling pathway which regulates the stability of the NF-kappaB-sequestering protein, IkappaB. Recently components of this pathway, NF-kappaB-inducing kinase and IkappaB kinases, IKKalpha and beta, which phosphorylate IkappaB to release NF-kappaB, have been characterised. Curcumin prevents phosphorylation of IkappaB by inhibiting the activity of the IKKs. This property, together with a long history of consumption without adverse health effects, makes curcumin an important candidate for consideration in colon cancer prevention.

Melanin as an adsorbent for drug residues

The binding of seven veterinary drugs (clenbuterol, chlorpromazine, diethylstilbestrol, 19-nortestosterone, salbutamol, salicylic acid and trenbolone) to melanin from Sepia officinalis was investigated. Basic and hydrophobic drugs were the most strongly bound. Desorption by ethanol was complete for neutral drugs but only partial for the basic drugs, which suggests that binding of the latter involves an ionic component. A method of synthesizing melanin in an immobilized form (melanin-PS) on the surface of porous silica was developed. When the drug binding properties of melanin-PS were investigated, its capacity to bind the basic drug clenbuterol was found to be higher (5.9 nmol mg-1) than that for the neutral hydrophobic drug 19-nortestosterone (0.56 nmol mg-1); for both drugs the attainment of binding equilibrium with melanin-PS was relatively rapid (< 5 min). By virtue of its binding kinetics, high capacity and mechanical robustness, melanin-PS offers potential for use in chromatography or solid-phase extraction and may additionally enable modelling of drug-melanin interactions.

Cognitive therapy for depression with individuals with intellectual disabilities

The increase in research into psychopathology in people with intellectual disability has recently spread to include depression. Several reports have appeared on the assessment of depression in the client group and there is a pressing need for research into treatment of depression in people with intellectual disability. The present paper reviews cognitive behaviour therapy for depression and reports on its adaptation for people with intellectual disability. Two case studies of individuals with mild intellectual disability illustrate the clinical applications. All the elements of cognitive behaviour therapy for depression were maintained and simplified. Both subjects were able to monitor their feelings of depression and subject 2 monitored the frequency of suicidal thoughts. Improvements were seen in both cases on the Zung Depression Inventory and daily monitoring of depressive feelings.

Acute cadmium fume poisoning. Five cases with one death from renal necrosis

This paper describes the accidental poisoning of five workers by cadmium fume. The men were dismantling a frame of girders in a confined space by cutting bolts with an oxyacetylene burner. They were unaware at the time that the bolts were cadmium-plated or that this presented a serious industrial hazard. The paper sets out to give an appreciation of acute cadmium poisoning, the characteristics and uses of cadmium, and a review of the literature. The clinical picture of these cases is described, with the pathology of the fatal case which showed severe pulmonary oedema, alveolar metaplasia of the lung, and bilateral cortical necrosis of the kidneys. The lungs contained 0·25 g. cadmium oxide (CdO) per 100 g. wet specimen. An attempted estimation of the fatal dose of CdO fume is made. From the post-mortem findings, using an assumption that 11% of inhaled CdO will be retained in the lungs, approximately 51·7 mg. CdO fume must have been inhaled by the fatal case. As he worked for five hours with a probable ventilatory rate of 20 l./min. the concentration of CdO in the air breathed would be of the order of 8·6 mg./m.³. An estimation of the dose from a study of the working conditions proved unsatisfactory due to certain variables listed in the text.

Diabetes mellitus treated with chlorpropamide and tolbutamide. A four-year clinical study

The findings in 676 patients treated with tolbutamide and chlorpropamide for periods of up to four years are presented. Only small differences between the results obtained with the two drugs were found. In twenty patients treatment was discontinued because of intercurrent disease or because of side effects. There were sixty-seven primary failures (10 per cent). Of the remaining 589, there were sixty-six secondary failures (11 per cent), fifty-eight achieved fair control (10 per cent) and 465 good control (79 per cent). Satisfactory results were obtained most often in patients weighing between 85 per cent and 115 per cent of their standard weight, in those over forty-five years of age, and in those who had not previously required insulin. The mean body weight of the patients increased by 1.3 per cent while they were receiving sulfonylureas. Needle core liver biopsies were obtained from eight patients. Four of these were normal, three showed focal collections of chronic inflammatory cells, and one showed early portal cirrhosis.