Survival Outcomes of Extensive Stage Small Cell Lung Cancer Patients Treated with Consolidative Thoracic Radiotherapy at a Tertiary Cancer Center

PURPOSE/OBJECTIVE(S)

Most small cell lung cancer cases present as Stage IV (M1) or extensive stage (ES-SCLC), which are defined as tumor extending outside the hemithorax without a tolerable radiation portal. The CREST trial demonstrated improved local control with a modest overall survival (OS) benefit at the 2-year secondary endpoint of 14% survival with consolidative thoracic radiotherapy (CTRT) compared to 3% without CTRT. Low toxicity rates were also observed. This study reports our institutional ES-SCLC experience for patients treated with CTRT.

MATERIALS/METHODS

A retrospective review was conducted on ES-SCLC patients treated with CTRT at our institution between 2014 and 2019. CTRT was defined as ≥30 Gy of thoracic radiotherapy. OS and tolerability of treatment were assessed in this population. Chemotherapy details were also captured. OS rate was determined using the Kaplan-Meier method and the time from start of CTRT to last date of follow-up or death. CTRT tolerability was determined using incidence and grade of esophagitis and radiation pneumonitis as per CTCAE v5.

RESULTS

We identified 100 ES-SCLC patients treated with any thoracic RT at our institute, of which 45 received thoracic RT for palliative intent or with <30 Gy. The remaining 55 patients received ≥30 Gy CTRT and were included for analysis. The median age was 65.1 years (range 46.6-86.9) and 36 (65%) were male. The median follow-up for this sample was 0.8 (range 0.03-4.2) years. Median chemotherapy cycles were 6 (range 1-6), most receiving ≥4 cycles (87%) and completing chemotherapy prior to CTRT initiation (91%) with a minority concurrently receiving chemotherapy and CTRT (9%). Platinum chemotherapy was the most common (96%) with 2 patients receiving etoposide alone (4%). The most common CTRT regimens were 30 Gy in 10 fractions (80%) followed by 40 Gy in 15 fractions (9%) and 45 Gy in 30 twice-daily fractions (7%). Most patients (67%) were treated with IMRT/VMAT technique, while the remaining (33%) patients were treated with 3DCRT. The median survival time was 1.3 years with 1- and 2-year OS of 57.2% (CI 44.0 - 74.3%) and 26.1% (CI 12.9 - 52.7%), respectively. CTRT was well tolerated with no grade 4+ toxicities. The most common toxicity was esophagitis with 21 patients (39%), of which 15 were G1 (28%) and 6 were G2 (11%). Radiation pneumonitis was present in 5 patients (9.2%) with 1 G1 (2%), 3 G2 (6%), and 1 G3 (2%) cases.

CONCLUSION

Consolidative TRT for ES-SCLC in this institutional series was at least as good as the reported CREST outcome with modest acute toxicities in this cohort. Disease burden at diagnosis, chemotherapy response, patterns of failure, and subsequent therapies will be further investigated.

Clinical Acceptability of Artificial Intelligence-Screened Interstitial Lung Disease (AI-ILD) in Lung Cancer Patients Treated with Radiotherapy

PURPOSE/OBJECTIVE(S)

Patients with interstitial lung disease (ILD) treated with thoracic radiotherapy (RT) are at greater risk of pulmonary toxicity. Automatic universal screening for ILD allows radiation oncologists (ROs) to risk stratify patients and implement necessary modifications to their respiratory monitoring or treatment. Automatic screening however may affect RO workload and so it is imperative to assess the clinical acceptability of this tool.

MATERIALS/METHODS

We have developed a machine learning algorithm to identify patients who are at high risk of having ILD based on RT planning computed tomography (CT) images. A quality improvement (QI) project was initiated to test feasibility and acceptability of the machine learning algorithm. If positive, the results of the machine learning algorithm were made available to ROs via structured electronic reporting. ROs were prompted to review the patient and consider expert radiologist consultation if thought appropriate. All electronic surveys and qualitative comments were summarized to describe clinical acceptability. Expert radiologist established gold standard ILD status of all patients on the study. A formal review of RO feedback was collected for all screen-positive, true-positive cases.

RESULTS

Two hundred forty cases were screened of which 45 were flagged as AI-ILD positive and the responsible RO notified. Of these 45 screen-positive cases, all continued on to RT except for 3 patients with tumor progression. From these 45, 24 surveys were completed, 21 had no prior suspicion of ILD. There were 7 true-positives, of which 1 had a survey response. Based on the survey responses, 88% of cases underwent review by the responsible RO. In 16 cases this automatic notification prompted case consultation with an expert radiologist. Expert review was performed from 10 minutes up to 53 hours after the email prompt to the radiologist, with median response time of 1.5 hours. In the 7 screen-positive, true-positive cases, only 2 were not previously known to the responsible RO. In the two cases where true-positive ILD status was previously unknown, one was a mild case of ILD and the other had previously received thoracic RT at this institution without ILD being identified, in both cases the ROs were grateful that this diagnosis was identified prior to treatment. RO confidence in the machine learning prediction was moderate due to the high proportion of false positives.

CONCLUSION

Based on available survey results, more than 75% of the screen-positive cases were reviewed by the responsible RO and two-thirds of these involved expert radiology input. RO feedback was generally positive and this tool was rated as a net benefit despite the high rate of false-positives and the need for clarification.

One Year Radiographic Response Following Prostrate SBRT: An Exploratory Analysis of a Phase III Randomized Trial

PURPOSE/OBJECTIVE(S)

Radiographic MRI response following prostate radiotherapy, particularly stereotactic body radiotherapy (SBRT), remains poorly understood. Our objective was to describe radiographic changes to the prostate gland and prostate tumor following SBRT of men treated on a prospective, randomized trial.

MATERIALS/METHODS

MIRAGE (NCT04384770) is a single center, randomized phase III trial of patients receiving either CT or MRI guided SBRT for localized prostate cancer. Patients underwent pre-treatment and annual post-treatment MRIs, in addition to routine PSA surveillance. Outcomes reported include percent gland shrinkage, percent PSA response at one year, and presence of residual tumor based on radiographic interpretation. Patient characteristics were compared via two-sample t-test or Fischer's exact test. Both univariate and multivariable logistical analysis were employed to identify potential clinical predictors of residual tumor on 1-year follow up MRI.

RESULTS

This study cohort included 94 eligible patients with baseline characteristics in Table 1. Residual lesions were seen in 13 patients (14%), 5/27 (18.5%) treated without ADT and 8/67 (12%) with ADT. PSA ablation was deep, with a 79% median decrease without ADT and 98% median decrease with ADT. Patients receiving ADT showed more gland shrinkage (17% vs. 34% shrinkage, p = 0.0001), while radiographic non-responders and responders experienced similar gland shrinkage (median 21% vs 29% shrinkage, p > 0.05). No significant clinical predictors of residual tumor were identified on univariate and multivariate analysis. No patient had any clinical or biochemical evidence of failure.

CONCLUSION

A total of 14% of patients were found to have residual tumor detected on MRI one year after SBRT. These data highlight the protracted nature of radiographic tumor response to radiation therapy, even with ablative radiation techniques. The analysis is limited by the lack of biopsy data to quantify whether visualized residual tumor harbor active cancer.

Focal Brachytherapy for Localized Prostate Cancer: Systematic Review and Meta-Analysis

PURPOSE/OBJECTIVE(S)

Advances in image-guided brachytherapy have increased the interest in focal brachytherapy (F-BT) approaches to optimize disease control, while reducing the toxicities associated whole gland treatments for prostate cancer (PCa). In this study we performed a systematic review to report biochemical control (BC), and genitourinary (GU) and gastrointestinal (GI) toxicity rates in patients with localized prostate cancer treated with F-BT as a definitive or salvage modality.

MATERIALS/METHODS

This project was registered in the PROSPERO database (ID CRD42022320921). A comprehensive literature search was conducted in Cochrane Central databases, Cochrane Database of Systematic Reviews, Embase Classic +Embase, and Medline ALL, all from the OvidSP platform and Web of Science from Clarivate, from each database's inception to July 2022. Search was restricted to English and included terms: focal brachytherapy/prostate cancer, partial brachytherapy/prostate cancer. In total, 14862 articles were identified. Manuscripts that not related to focal or partial prostate brachytherapy, review papers and studies not reporting BC were excluded. After eliminating duplicates, and studies deemed irrelevant by consensus among three independent reviewers, 44 articles remained for in-depth review and data extraction.

RESULTS

Thirty studies that included BC outcomes were included for this analysis, comprising 1556 patients treated with F-BT for PCa. Of these, 1094 (70%) and 462 (30%) underwent F-BT as definitive monotherapy or salvage, respectively; while 585 (38%) and 971 (62%) received HDR or LDR, respectively. For F-BT as monotherapy, the most commonly prescribed dose for HDR was 19 Gy in 1 fraction (range 19-24 Gy), and for LDR, 145 Gy (90-160Gy). Whereas for salvage F-BT, most common dose schedule of HDR was 19Gy in 1 fraction (19-27GY) and LDR 145Gy (144-145Gy). BC random effects estimate for F-BT monotherapy at 1-, 2-, 3-, and 5-years were 100% (P = 1.0), 96% (P = 0.45), 91% (P = 0.45) and 87% (P< 0.01), respectively. Whereas BC random effects estimate for salvage at 1-, 2-, 3-, and 5-years were 91% (P = 0.86), 68% (0.17), and 57% (P = 0.20), respectively. GI and GU grade 3-4 crude toxicity rates for monotherapy and salvage ranged from 0-3.33% and 0-17%, respectively.

CONCLUSION

Over the last decade, there has been increasing interest in F-BT approaches, both as monotherapy and in the salvage setting. BC and toxicity profiles of F-BT appear favorable, and future studies directly comparing with whole-gland treatments are warranted.

MR-Guided HDR Brachytherapy Boost in Localized Prostate Cancer - Results of a Phase II Trial

PURPOSE/OBJECTIVE(S)

Dose escalation in localized prostate cancer using brachytherapy combined with external beam radiation (EBRT) has demonstrated improved biochemical control compared to EBRT alone. However, ultrasound guided LDR brachytherapy might be associated with increased GU toxicity. We report the results of a prospective study of MR-guided HDR brachytherapy (MRgHDR) in combination with EBRT for localized prostate cancer.

MATERIALS/METHODS

Intermediate- (IR) and high-risk (HR) prostate cancer patients were eligible. Patients received either 15Gy single fraction or 10Gy x 2 fractions using MRgHDR technique, followed by EBRT (37.5 Gy, [prostate only] -IR or 45-46 Gy - [prostate + pelvic nodes] -HR). Toxicity (CTCAE v4) and HRQoL (EPIC) were recorded at 1, 3 and 6 months, then at 1, 2, 3, and 5 years. Androgen deprivation therapy (ADT) was used according to the appropriate disease risk category. Biochemical failure was defined according to Phoenix definition (nadir+2).

RESULTS

From 2010-2018, 120 patients were enrolled, 53 (44%) had IR and 67 (56%) had HR disease. Median age was 69 years (range, 46-78), median PSA was 12.1 ng/ml (3.2-148). ADT was used in 84 (70%) of patients, of whom 51 (60%) patients received <1 year and 33 (40%) received >1 year of ADT. A single fraction of 15Gy was given to 94 patients (78%) and the remaining 26 patients (22%) received 10Gy x 2 fractions. EBRT dose was 37.5Gy in 52 (43%) patients while 67 (56%) received 45-46Gy. One patient received only the first fraction of 10Gy, declined the second fraction and subsequently received 60Gy EBRT to the prostate. The median follow up was 58 months (11-134). Overall, 5-year biochemical control was 90% while it was 95% and 86% for IR and HR, respectively. At 5 years 7% patient had nodal or distant relapse or both. While the 5-yr distant control rates were 95% and 91% in the IR, HR, respectively. Acute grade ≥2 GU and GI toxicity was 6.7% and 5% respectively. Acute toxicity trended back to baseline by 6 months in all patients except one. Late grade ≥ 2 GU and GI worst toxicity was seen in 10% and 4.2%, respectively. As with acute toxicity, late toxicity tended to improve over time. Only one patient experienced severe toxicity (Grade 3 GU - frequency) at 6 months but subsequently this resolved. HRQol will be reported separately.

CONCLUSION

MRgHDR brachytherapy boost in conjunction with EBRT provides comparable biochemical outcomes compared to the literature. Severe toxicity rates were minimal. Further follow-up will determine if these outcomes are sustained.

Stereotactic Ablative Radiotherapy for Oligo-Progressive Cancers: Results of the Randomized Phase II STOP Trial

PURPOSE/OBJECTIVE(S)

In the metastatic setting, there is uncertain benefit to localized eradication of one or more lesions that are progressing despite systemic therapy. This randomized phase II trial examined if patients with ≤5 sites of oligoprogression benefited from the addition of stereotactic ablative radiotherapy (SABR) to standard of care (SOC) systemic therapy.

MATERIALS/METHODS

Eligibility criteria included age ≥18 years, ECOG performance status 0-2, and oligoprogressive disease, defined as 1-5 lesions actively progressing while on systemic therapy. Patients were required to have at least 3 months of disease stability/response on systemic therapy prior to oligoprogression. After stratifying by type of systemic therapy (cytotoxic vs. non-cytotoxic), patients were randomized 2:1 to SABR to all progressing lesions plus SOC (SABR arm) vs. SOC alone (SOC arm). The trial began exclusive to non-small cell lung cancer but did not meet accrual goals and was expanded in 2019 to include all non-hematologic malignancies. The primary endpoint was progression-free survival (PFS). Secondary endpoints included overall survival (OS), lesional control, quality of life (QOL), toxicity, and duration of current systemic agent post-SABR.

RESULTS

Between February 2017 and June 2021, 90 patients with 125 oligoprogressive metastases were enrolled across 8 Canadian institutions, with 59 patients randomized to SABR and 31 to SOC. Median age was 67 years (IQR: 61-73 years) and 39 (43%) were female. The most common primary sites were lung (44% of patients), genitourinary (23%) and breast (13%), with the most common oligo-progressive locations being lung (43%), bone (19%), lymph nodes (14%), and liver (13%). In the SABR arm, the most common fractionations were 35 Gy/5 (38% of lesions) and 50 Gy/5 (18%). Protocol adherence in the SOC arm was suboptimal: 3 patients (10%) withdrew immediately after randomization, and 7 additional patients (23%) received high-dose or ablative therapies. Median follow-up was 31 months. There was no difference in PFS between arms (median PFS 8.4 months in the SABR arm vs. 4.3 months in the SOC arm; however, the curves cross and 2-year PFS was 9% vs. 24% respectively, p = 0.91). Median OS was 31.2 months vs. 27.4 months, respectively (p = 0.22). Lesional control with SABR was 71% vs. 39% with SOC (p = 0.002). Median duration of post-randomization first-line systemic therapy was 10.3 months vs. 7.6 months, respectively (p = 0.71). Treatment was well-tolerated with 2 (3.4%) grade 3 treatment-related toxicities in the SABR arm and no grade 4/5 related events in either arm. QOL did not differ between arms.

CONCLUSION

Despite being a well-tolerated treatment providing superior lesional control, SABR for oligoprogression did not improve PFS or OS. Results may have been impacted by withdrawals and desire for ablative treatments on the SOC arm, and this lack of equipoise may make accrual to phase III trials difficult, although larger studies in select sub-populations are desired. (NCT02756793).

Assessment of Precision Irradiation in Early Non-Small Cell Lung Cancer and Interstitial Lung Disease (ASPIRE-ILD): Primary Analysis of a Phase II Trial

PURPOSE/OBJECTIVE(S)

The use of stereotactic ablative radiotherapy (SABR) in patients with fibrotic interstitial lung disease (ILD) has been associated with an increased risk of toxicity, but patients with ILD and lung cancer may have no other options for curative-intent treatment. The goal of the ASPIRE-ILD trial was to assess the benefits and toxicities of SABR in patients with fibrotic ILD.

MATERIALS/METHODS

We enrolled patients with fibrotic ILD and a diagnosis of T1-2N0 NSCLC who were not candidates for surgery. All patients were centrally reviewed prior to enrollment to confirm the presence and subtype of ILD. After stratification by the ILD-GAP score (a measure of ILD severity and prognosis), patients were treated with SABR to a dose of 50 Gy in 5 fractions EOD (BED = 100 Gy10), with a built-in de-escalation protocol in case of unacceptable toxicity. The primary endpoint was overall survival (OS), powered to distinguish 1-year OS >70% vs. an unacceptable rate of ≤50%. Secondary endpoints included toxicity (CTC-AE version 4.0), progression-free survival (PFS), local control (LC), patient-reported outcomes (FACT-L quality of life and cough severity), and changes in pulmonary function tests (PFTs). The study pre-specified that SABR would be considered worthwhile if median OS was >1 year, with a grade 3-4 toxicity risk <35% and a grade 5 toxicity risk <15%. Target accrual was 39 treated patients.

RESULTS

Thirty-nine patients were enrolled and treated with SABR between March 2019 and January 2022, all to a dose of 50 Gy in 5 fractions, at 5 institutions in Canada and 1 in Scotland. Median age was 78 years (interquartile range: 67-83), 59% were male, and 92% had a history of smoking (median 43 pack-years). At baseline, 70% reported dyspnea, median FEV1 was 80% predicted and median DLCO was 49% predicted. ILD-GAP scores were as follows: ≤2 (i.e., best ILD status): n = 14; 3-5: n = 23; ≥6 (i.e., worst ILD status): n = 2. Median follow-up was 19 months. OS at 1-year was 78.9% (p<0.001 by binomial test vs. the unacceptable rate). Median OS was 25 months, median PFS was 19 months, and 2-year LC was 92%. AE rates (possibly, probably or definitely related) were as follows (highest grade per patient): grade 1-2: n = 12 (31%); grade 3: n = 4 (10%); grade 4; n = 0; grade 5 n = 3 (7.7%, all due to respiratory deterioration). AE rates did not differ by ILD-GAP category or ILD subtype. FACT-L scores trended downward over time (p = 0.07), and cough severity scale scores worsened over time (p = 0.02). Comparing last-available PFTs with baseline, DLCO declined (median: -4%; p = 0.046), FVC trended downward (median: -2.5%; p = 0.11), and FEV1 remained stable (median change: 0%).

CONCLUSION

The use of SABR in patients with ILD met the pre-specified acceptability thresholds for both toxicity and efficacy, supporting the use of SABR for curative-intent treatment after a careful discussion of risks and benefits. Further studies exploring pharmacologic options to reduce toxicity may be beneficial in this population. ().

Association of Artificial Intelligence-Screened Interstitial Lung Disease with Radiation Pneumonitis and Mortality in Locally Advanced Non-Small Cell Lung Cancer

PURPOSE/OBJECTIVE(S)

Radiation pneumonitis (RP) is a common and dose-limiting toxicity following radiotherapy for non-small cell lung cancer (NSCLC). Patients with interstitial lung disease (ILD) are believed to be at increased risk of developing complications including RP, ILD progression, or death. An automated method to identify patients prior to radiotherapy at high risk of developing toxicities or death may allow clinicians to mitigate risk through informed treatment planning and careful patient monitoring.

MATERIALS/METHODS

All locally advanced NSCLC patients treated with definitive radiation from 2006-2021 with a minimum 1 year of follow-up were assessed. RP and mortality data were prospectively collected and retrospectively reviewed. A convolutional neural network (CNN) was previously developed and validated to identify patients with radiographic ILD using planning computed tomography (CT) images, with an accuracy of 0.82. Planning CT scans for the retrospective cohort were used as input to the CNN, with artificial intelligence-screened ILD (AI-ILD) score as an output. AI-ILD scores above our established threshold were labeled as AI-ILD+. The association between AI-ILD score, AI-ILD+/-, mean lung dose (MLD), and the primary outcome of grade ≥2 (G2+) RP or mortality, as well as the secondary outcomes of G2+ RP and mortality were assessed using Wilcoxon rank sum test, univariate and multivariable logistic regression, and Kaplan-Meier survival analysis.

RESULTS

Of 799 patients reviewed, 745 eligible patients were included in the analysis; grade 0-5 RP was reported in 51.3%, 27.1%, 16.9%, 4.0%, 0.1%, and 0.5% of patients respectively. Overall, 22.9% of patients were AI-ILD+, and therefore at high risk (>20% chance) of having true ILD. On UVA, AI-ILD score, AI-ILD+ and MLD were significantly associated with the primary outcome of G2+ RP or mortality, as well as the secondary outcome of mortality. However, only MLD was significantly associated with the secondary outcome of G2+ RP. On MVA, both AI-ILD+ (OR 1.42, 95% CI 1.02-1.97, p = 0.04) and MLD (OR 1.13, 95% 1.05-1.21, p = 0.008) were significantly associated with G2+ RP or mortality. On Kaplan-Meier analysis, the median toxicity-free survival (TFS) time for AI-ILD+ and AI-ILD- patients were 1.7 and 3.4 years respectively, with a 2-year TFS of 48.3% vs. 59.3% (log-rank test: p = 0.02). There was no significant difference in rates of G2+ RP.

CONCLUSION

The AI-ILD algorithm can detect high risk patients with significantly decreased TFS following definitive treatment for NSCLC. AI-ILD classification was not associated with a significant difference in rates of RP when accounting for MLD. Future work will focus on improving the classification algorithm, expert radiologist validation of this dataset, and exploring reasons for the mortality difference in AI-ILD+ patients.

Long-Term Biochemical Control of a Prospective Cohort of Prostate Cancer Patients Treated With Interstitial Brachytherapy Versus Radical Prostatectomy

AIMS

To report long-term oncological outcomes of men treated prospectively as part of the American College of Surgeons Oncology Group phase III Surgical Prostatectomy Versus Interstitial Radiation Intervention Trial (SPIRIT) at our institution.

MATERIALS AND METHODS

In 2003-2004, patients eligible for SPRIT attended a multidisciplinary educational session, following which they could choose radical prostatectomy, low dose rate brachytherapy (LDR-BT) or randomisation to SPIRIT. Biochemical failure was determined by the accepted definitions of a prostate-specific antigen (PSA) level ≥0.2 ng/ml after radical prostatectomy and the Phoenix definition of PSA ≥2 ng/ml above the nadir after LDR-BT. A sensitivity analysis, using a PSA >0.5 ng/ml to define biochemical failure after LDR-BT and a threshold PSA ≥0.2 ng/ml, was carried out to test the robustness of the results. To account for the competing risk of death, Gray's test was used to test the equality of the cumulative incidence function of biochemical failure between treatment groups. The Kaplan-Meier method was used to estimate overall survival and prostate cancer-specific survival. A P-value ≤0.05 was considered statistically significant.

RESULTS

Of 156 patients, 100 received LDR-BT (15 after randomisation) and 56 underwent radical prostatectomy (15 after randomisation). The median follow-up was 12.6 and 14.7 years for LDR-BT and radical prostatectomy, respectively. The median age was 60 years; the median pre-treatment PSA was 5.5 (interquartile range 4.3-7.1). No significant differences in patient characteristics were found between groups. Two patients received adjuvant radiotherapy after radical prostatectomy. The cumulative incidence function of biochemical failure was 0%, 1.1% and 2.4% at 5, 10 and 15 years, respectively, in the LDR-BT arm versus 8.5%, 15.8% and 15.8% in the radical prostatectomy arm (P < 0.001). These results were consistent when varying the definition of biochemical failure defined as PSA ≥0.5 ng/ml (P = 0.01). At 15 years, overall survival was higher in patients treated with radical prostatectomy compared with those treated with LDR-BT; however, no statistical difference was found in prostate cancer-specific survival.

CONCLUSION

In low-risk prostate cancer patients, LDR-BT offers excellent long-term oncological outcomes comparable with radical prostatectomy, in addition to the previously reported advantage for LDR-BT in urinary and sexual quality of life domains and patient satisfaction.

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

Background

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

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

Methods

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

Conclusions

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

Trial registration

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

Surgical wound infection prevention using topical negative pressure therapy on closed abdominal incisions - the 'SWIPE IT' randomized clinical trial

BACKGROUND

Surgical site infections (SSIs) are the most common cause of healthcare-associated infections in surgical patients. It is unclear whether incisional negative pressure wound therapy (NPWT) can reduce the risk of SSIs in patients after open abdominal surgery.

METHODS

A prospective, non-blinded multi-centre randomized controlled trial (RCT) was performed to evaluate the incidence of SSI post-laparotomy using incisional NPWT compared with a standard dressing. The primary outcome was the rate of superficial SSI.

RESULTS

A total of 124 patients (61 patients in the NPWT arm and 63 patients in the control arm) were included. One hundred and nine (87.9%) patients underwent colorectal surgery; 61 patients (49.2%) had emergency surgery. There were more superficial SSIs in the control group than in the NPWT group, although not statistically significant (20.6% vs 9.8%, P=0.1). Upon multiple logistic regression analysis, control dressings were associated with increased risk of superficial SSI although again, not statistically significant (odds ratio (OR) 2.41, 95% confidence interval (CI) 0.81-7.17, P=0.11). There was no superficial non-SSI related wound dehiscence in the NPWT group compared with 9.5% in the control group (P=0.03). There was no difference in postoperative complications (P=0.15), nor in other wound complications (P=0.79).

CONCLUSION

NPWT was not associated with decreased superficial SSI in this RCT. However, there was a statistically significant reduction in superficial wound dehiscence with NWPT dressings. The results of this study should be included in meta-analyses for better evaluation of NPWT on closed abdominal incisions.

Protective effect of fennel, and its major component trans-anethole against social isolation induced behavioral deficits in rats

Social isolation damages the nervous system by weakening the antioxidant system and leading to behavioral disorders. Fennel (Foeniculum vulgare Mill.) is an herbal plant that has antioxidant and neuroprotective properties. The objective of this study was to evaluate the effect of fennel methanol extract and its major component trans-anethole on spatial learning and memory, anxiety and depression in male rats exposed to social isolation stress.Rats were divided into six groups of Control (C), Fennel (F), trans-Anethole (A), Isolation, Isolation-F and Isolation-A. The rats were kept in the cage alone for 30 days to induce isolation. Fennel extract (150 mg/kg) and trans-anethole (80 mg/kg) were also gavaged during this period. At the end of the course, spatial learning and memory, anxiety and depression were measured by Morris water maze (MWM), elevated plus maze (EPM) and forced swimming test (FST), respectively.Learning and memory were impaired in isolated rats. Swimming time and distance to reach the hidden platform in these animals increased compared with controls (P < 0.05). In the EPM test, the percentage of open arm entries and open arm time also decreased significantly in the Isolation group (P < 0.01). The immobilization time in FST also increased significantly in these animals compared with the Control group (P < 0.001). Fennel and trans-anethole were both able to eliminate these changes in isolated rats.It is concluded that fennel and its major component, trans-anethole are suitable candidates for the prevention and treatment of stress-induced neurological disorders.

0628 An Observational Report of Clinical Outcomes Among Veterans with Obstructive Sleep Apnea Treated with Hypoglossal Nerve Stimulation

Introduction

The efficacy of positive airway pressure (PAP) therapy in the management of obstructive sleep apnea (OSA) is limited by inadequate patient adherence. Hypoglossal nerve stimulation (HNS) is an FDA approved PAP-alternate surgical treatment option that is available for patients with poor PAP tolerance. The purpose of this pilot study was to review outcome measures and adherence data for patients treated with HNS therapy in a military veteran population.

Methods

Methodology involved a retrospective chart review of 30 PAP intolerant cases referred for HNS treatment over the course of 2 years. The inclusion criteria were Body Mass Index (BMI) &lt; 35 kg/m2, Apnea Hypopnea Index (AHI) of 15-65/hour and drug induced sleep endoscopy (DISE) showing antero-posterior pharyngeal collapse. Qualified veterans proceeded to HNS implantation. Variables for analysis included BMI, Epworth sleep scale (ESS), DISE results, pre- and post-treatment AHI and adherence data.

Results

Of the 30 veterans, 17 proceeded to DISE. 15 had partial or complete AP collapse and 2 had concentric collapse. 12 veterans proceeded to HNS implantation. 6 veterans who completed HNS titration studies showed an average improvement of 77% from baseline AHI. There was significant decrease in mean AHI from 43.95/hour to 10.52/hour. The mean ESS decreased from 13 to 11. The mean compliance was 6.66 hours/night.

Conclusion

This limited veteran observational study supports that HNS is an effective treatment option for the management of PAP-intolerant patients with OSA. Our preliminary data suggests improved treatment adherence. Future prospective large-scale cohort studies should be considered.

Support

The authors declare no conflicts of interest nor any financial support

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

An expert consensus for the management of chronic hepatitis B in Asian Americans

BACKGROUND

Hepatitis B virus (HBV) infection is common with major clinical consequences. In Asian Americans, the HBsAg carrier rate ranges from 2% to 16% which approximates the rates from their countries of origin. Similarly, HBV is the most important cause of cirrhosis, hepatocellular carcinoma (HCC) and liver related deaths in HBsAg positive Asians worldwide.

AIM

To generate recommendations for the management of Asian Americans infected with HBV.

METHODS

These guidelines are based on relevant data derived from medical reports on HBV from Asian countries as well as from studies in the HBsAg positive Asian Americans. The guidelines herein differ from other recommendations in the treatment of both HBeAg positive and negative chronic hepatitis B (CHB), in the approach to HCC surveillance, and in the management of HBV in pregnant women.

RESULTS

Asian American patients, HBeAg positive or negative, with HBV DNA levels >2000 IU/mL (>10⁴ copies/mL) and ALT values above normal are candidates for anti-viral therapy. HBeAg negative patients with HBV DNA >2000 IU/mL and normal ALT levels but who have either serum albumin <3.5 g/dL or platelet count <130 000 mm³ , basal core promoter (BCP) mutations, or who have first-degree relatives with HCC should be offered treatment. Patients with cirrhosis and detectable HBV DNA must receive life-long anti-viral therapy. Indications for treatment include pregnant women with high viraemia, coinfected patients, and those requiring immunosuppressive therapy. In HBsAg positive patients with risk factors, life-long surveillance for HCC with alpha-fetoprotein (AFP) testing and abdominal ultrasound examination at 6-month intervals is required. In CHB patients receiving HCC treatments, repeat imaging with contrast CT scan or MRI at 3-month intervals is strongly recommended. These guidelines have been assigned to a Class (reflecting benefit vs. risk) and a Level (assessing strength or certainty) of evidence.

CONCLUSIONS

Application of the recommendations made based on a review of the relevant literature and the opinion of a panel of Asian American physicians with expertise in HBV treatment will inform physicians and improve patient outcomes.

Taking culture seriously: Can we improve the developmental health and well-being of Australian Aboriginal children in out-of-home care?

BACKGROUND

Children in out-of-home care have well-documented health and developmental needs. Research suggests that Aboriginal children in care have unmet health and intervention needs. In metropolitan Sydney, Kari Aboriginal Resources Inc. (KARI), an Aboriginal organization, provides support to indigenous children in care, including clinical assessment and intervention. We wanted to determine the health and developmental needs of a subset of children in out-of-home care with KARI, who had been in stable care for at least a year. We wanted to identify child, carer, and intervention characteristics that contributed to children doing well. We also wanted to identify enablers and barriers to providing culturally competent intervention.

METHODS

We used mixed methods. From the KARI clinic database over the past 3 years, we identified children who had been in stable care with KARI for >12 months. We compared clinical measures and outcomes for these children with results from previous audits. We carried out a group discussion and key informant interviews with therapists and caseworkers to identify risk and resilience factors for each child, as well as enablers and barriers to culturally competent intervention.

RESULTS

The health and developmental profile of the 26 children identified as being in stable care was similar to that of previous audits. Most (88%) were getting speech pathology intervention; one third were getting occupational therapy and psychological intervention; most children and their carers attended cultural programmes. The majority of children (25/26) improved in their developmental health. Caseworkers and therapists identified risk and resilience factors related to child, carer, and home characteristics. They also identified elements of good practice; systemic issues prevented some interventions from being carried out.

CONCLUSIONS

There are challenges delivering a trauma-informed, culturally respectful service to Aboriginal children in out-of-home care in an urban setting, but it can be done if attention is paid to culture and the enablers and barriers are identified.