Implementation Outcomes of Strategies to Promote Short-Course Radiation for Nonspine Bone Metastases in an Academic-Community Partnership: Survey Results from the ALIGNMENT Trial

PURPOSE/OBJECTIVE(S)

Local treatment of nonspine bone metastases has become increasingly complex, resulting in physician practice variability nationwide. The purpose of this study was to assess physician perceptions of 3 implementation strategies to promote adoption of short course radiotherapy (RT) for nonspine bone metastases.

MATERIALS/METHODS

ALIGNMENT ("Alliance Group for Bone Metastasis") was a multi-institutional stepped wedge cluster randomized implementation trial testing strategies to increase use of ≤5 fractions for nonspine bone metastases conducted across 3 clinical sites in an academic-community partnership. Strategies included a) multidisciplinary consensus guidelines, b) e-Consults, an email-based consultation platform, and c) personalized audit and feedback (A&F) reports with peer comparison. Using the Proctor et al. framework and validated questions from Weiner et al., physician surveys were used to assess each strategy's usefulness, acceptability (i.e., "I welcome [strategy]"), appropriateness (i.e., "[strategy] seems like a good match"), and feasibility (i.e., "[strategy] seems implementable" or "easy to use"). Survey responses were anonymized, so Fisher's Exact test was used to compare proportions with significance set at p<0.05.

RESULTS

Overall, 29 of 38 and 30 of 38 physicians participated in the pre- and post-implementation surveys, respectively, with 80% completing both. Pre-implementation, guidelines was most often ranked 1st in terms of usefulness (61%), followed by eConsults (38%) and A&F (3%). Post-implementation, guidelines and eConsults had the most and least favorable acceptability, appropriateness, and feasibility scores, respectively (Table), with 77% of physicians being likely to recommend the guidelines to other oncologists. In contrast, while 43% of physicians reported having at least 1 difficult clinical question regarding bone metastases during the study, only 33% of physicians preferred eConsults, while 50% preferred reaching out to a friend/colleague. Lastly, although A&F had the lowest perceived usefulness pre-implementation, A&F had the greatest increase in acceptability (72%→90%; p = 0.10), appropriateness (66%→90%; p = 0.03) feasibility ("implementable": 59%→93%, p = 0.002; "easy to use": 45%→93%, p<0.001).

CONCLUSION

In this multicenter trial, all strategies were acceptable, appropriate, and feasible, with guidelines and A&F showing the most favorable outcomes post-implementation. While guidelines were assessed as the most useful, A&F had significant increases in appropriateness and feasibility.

A39 HEALTHY FIRST-DEGREE RELATIVES FROM MULTIPLEX FAMILIES VERSUS SIMPLEX HARBOR A HIGHER RISK OF DEVELOPING CROHN'S DISEASE AND ARE ASSOCIATED WITH SUBCLINICAL INFLAMMATION AND ALTERED MICROBIOME COMPOSITION

Background

Healthy individuals within families with multiple affected members (multiplex families) with Crohn’s disease (CD) have a notably high risk of developing CD. No large prospective pre-disease cohort has assessed differences in preclinical intestinal inflammation, permeability, fecal microbiome, and genetics in healthy at-risk subjects from multiplex families.

Purpose

We aimed to assess differences in subclinical gut inflammation, genetic risk, gut barrier function, and fecal microbiota composition between first-degree relatives (FDRs) from families with 2 or more affected members (multiplex) and families with only one affected member (simplex). Also, we aimed to assess the risk of future CD onset in subjects from multiplex versus simplex families.

Method

We utilized the GEM Project cohort of healthy FDRs of CD patients. Subclinical gut inflammation was assessed using fecal calprotectin (FCP) at recruitment. Gut barrier function was assessed using the lactulose-to-mannitol ratio (LMR). For assessment of the CD-related genetic risk, CD-polygenic risk scores (CD-PRS) were calculated. Microbiome composition was assessed by sequencing fecal 16S ribosomal RNA. Generalized estimating equations logistic regression and LEfSe (PMID: 21702898) were used to assess the associations between multiplex status and different outcomes. A Cox proportional hazards model was used to assess time-related risk of future onset of CD.

Result(s)

4385 subjects were included. Median age was 17 [IQR 12-24] years, 52.9% were female, 69.4% were siblings and 30.6% were offspring. 4052 (92.4%) and 333 (7.6 %) were simplex and multiplex subjects, respectively. After adjusting for age, sex, family size, and relation to proband, multiplex status was significantly associated with higher baseline FCP (p=0.038), but was not associated with either baseline LMR or CD-PRS (p=0.19 and p=0.33, respectively).

We found no significant differences in alpha diversity (Shannon index) (p=0.57) between simplex and multiplex subjects. Beta diversity analysis assessed by the Bray-Curtis dissimilarity index did not reveal significant differences (R2=3e-04, p=0.607). The genera Eisenbergiella, Eggerthellaceae uncultured, and Morganella, were significantly more abundant in multiplex subjects, whereas Lachnospira, Sutterella, Lachnospiraceae_NK4A136_group, and Lachnospiraceae_UCG_004 less abundant.

The risk of CD onset was significantly higher in multiplex subjects. In multivariable analysis, multiplex status at recruitment was associated with increased risk of CD onset (adjusted HR 3.41, 95% CI 1.70-6.87, p=0.00055), after adjusting for demographics, FCP, LMR, and CD-PRS.

Conclusion(s)

Multiplex status compared to simplex is associated with a 3.4-fold increased risk of CD onset, a higher FCP, and fecal bacterial composition. A comprehensive assessment of environmental factors that increase CD risk in multiplex families remains to be elucidated in future studies.

Disclosure of Interest

None Declared

Prognostic Factors in Metastatic Cutaneous Squamous Cell Carcinoma of the Head and Neck

Metastatic cutaneous squamous cell carcinoma (SCC) of the head and neck poses a significant therapeutic challengedue to its aggressive biologic behavior. We conducted a retrospective study of71 patients—58 men and 13 women, aged 28 to 88 years (mean: 71)—who had been treated atour university-affiliated tertiary care medical center for metastatic cutaneous SCCover a 15-year period. In addition to demographic data, we compiled and analyzed information on tumor characteristics, the site and extent of metastasis, treatment, follow-up, and outcome. Among the tumor factors, poorly differentiated carcinoma was an independent predictor of poorer disease-free survival, and olderage was found to be an independent predictor of poorer overall survival. We found no significant difference in disease-free or disease-specific survival among patients with parotid involvement, neck involvement, or both. In our series, the site of nodal involvement appeared to have no prognostic significance in patients with metastatic cutaneous SCC of the head and neck.

Environmental governance in China: Interactions between the state and "nonstate actors"

In the West, limited government capacity to solve environmental problems has triggered the rise of a variety of "nonstate actors" to supplement government efforts or provide alternative mechanisms for addressing environmental issues. How does this development - along with our efforts to understand it - map onto environmental governance processes in China? China's efforts to address environmental issues reflect institutionalized governance processes that differ from parallel western processes in ways that have major consequences for domestic environmental governance practices and the governance of China "going abroad." China's governance processes blur the distinction between the state and other actors; the "shadow of the state" is a major factor in all efforts to address environmental issues. The space occupied by nonstate actors in western systems is occupied by shiye danwei ("public service units"), she hui tuanti ("social associations") and e-platforms, all of which have close links to the state. Meanwhile, international NGOs and multinational corporations are also significant players in China. As a result, the mechanisms of influence that produce effects in China differ in important ways from mechanisms familiar from the western experience. This conclusion has far-reaching implications for those seeking to address global environmental concerns, given the importance of China's growing economy and burgeoning network of trade relationships.

Prognostic factors in metastatic cutaneous squamous cell carcinoma of the head and neck

Metastatic cutaneous squamous cell carcinoma (SCC) of the head and neck poses a significant therapeutic challenge due to its aggressive biologic behavior. We conducted a retrospective study of 71 patients-58 men and 13 women, aged 28 to 88 years (mean: 71)-who had been treated at our university-affiliated tertiary care medical center for metastatic cutaneous SCC over a 15-year period. In addition to demographic data, we compiled and analyzed information on tumor characteristics, the site and extent of metastasis, treatment, follow-up, and outcome. Among the tumor factors, poorly differentiated carcinoma was an independent predictor of poorer disease-free survival, and older age was found to be an independent predictor of poorer overall survival. We found no significant difference in disease-free or disease-specific survival among patients with parotid involvement, neck involvement, or both. In our series, the site of nodal involvement appeared to have no prognostic significance in patients with metastatic cutaneous SCC of the head and neck.

Post-laryngectomy voice rehabilitation: comparison of primary and secondary tracheoesophageal puncture

BACKGROUND

Voice restoration following total laryngectomy is an important part of patients' rehabilitation and long-term quality of life.

OBJECTIVES

To evaluate the long-term outcome of indwelling voice prostheses inserted during (primary procedure) or after (secondary procedure) total laryngectomy.

METHODS

The study group included 90 patients who underwent total laryngectomy and tracheoesophageal puncture (TEP) with placement of voice prosthesis at a tertiary medical center during the period 1990-2008. Background, clinical and outcome data were collected by medical file review. Findings were compared between patients in whom TEP was performed as a primary or a secondary procedure.

RESULTS

TEP was performed as a primary procedure in 64 patients and a secondary procedure in 26. Corresponding rates of satisfactory voice rehabilitation were 84.4% and 88.5% respectively. There was no association of voice quality with either receipt of adjuvant radiation/chemoradiation or patient age. The average lifetime of the voice prosthesis was 4.2 months for primary TEP and 9.06 months for secondary TEP (P= 0.025).

CONCLUSIONS

Primary TEP provides almost immediate and satisfactory voice rehabilitation. However, it is associated with a significantly shorter average prosthesis lifetime than secondary TEP. Chemoradiotherapy and patient age do not affect voice quality with either procedure.

Obstructive sleep apnea after radial forearm free flap reconstruction of the oral tongue

OBJECTIVES/HYPOTHESIS

To determine whether radial forearm free flap reconstruction of the tongue after partial glossectomy is associated with obstructive sleep apnea.

STUDY DESIGN

Retrospective case series.

METHODS

Fifteen patients (5 men, 10 women) treated for tongue cancer in 2006-2010 by partial glossectomy and immediate radial forearm free flap reconstruction completed the Epworth Sleepiness Scale and underwent polysomnographic studies. Background, clinical, and pathologic data were collected from the medical files.

RESULTS

Mean ± SD age of the study group was 57 ± 19 years; body mass index, 24 ± 4; follow-up, 5.6 ± 2.8 years. Mean ± SD Epworth scale score was 8.18 ± 6.18 (normal, <8). Disordered sleep was documented in 11 patients, of whom 8 (53.3% of the cohort) had OSA (5 mild, 2 moderate, 1 severe). The OSA rate was significantly higher than reported in the general population (P = 0.001).

CONCLUSION

Patients after partial glossectomy and radial forearm free flap reconstruction appear to be at high risk of obstructive sleep apnea. Testing for OSA should be considered in these patients.

Cancer of the head and neck region in solid organ transplant recipients

BACKGROUND

Solid organ recipients are at an increased risk of developing various malignancies. We investigated the incidence, clinical features, and outcome of patients diagnosed with head and neck cancer after organ transplantation.

METHODS

A retrospective analysis was undertaken of patients who underwent solid organ transplantation (kidney, liver, lung, heart) treated at our institution from 1992 to 2010.

RESULTS

Of 2817 organ recipients, 175 patients (6.1%) developed 391 head and neck malignancies. Cutaneous malignancies were the most common (93%): squamous cell carcinoma (SCC; 51%) and basal cell carcinoma (BCC; 42%). The average interval from transplantation to diagnosis of head and neck malignancy was 7.3 years, with liver recipients diagnosed earlier. Eighteen percent of patients presented with an aggressive pattern of head and neck cancer, including 24% of patients with cutaneous SCC.

CONCLUSION

Organ transplantation recipients are at a higher risk to develop head and neck cancer with an aggressive behavior characterized by multiple recurrences and decreased survival.

Cost-effectiveness analysis of primary arthroscopic stabilization versus nonoperative treatment for first-time anterior glenohumeral dislocations

PURPOSE

The purpose of this study was to compare the cost-effectiveness of initial observation versus surgery for first-time anterior shoulder dislocation.

METHODS

The clinical scenario of first-time anterior glenohumeral dislocation was simulated using a Markov model (where variables change over time depending on previous states). Nonoperative outcomes include success (no recurrence) and recurrence; surgical outcomes include success, recurrence, and complications of infection or stiffness. Probabilities for outcomes were determined from published literature. Costs were tabulated from Medicare Current Procedural Terminology data, as well as hospital and office billing records. We performed microsimulation and probabilistic sensitivity analysis running 6 models for 1,000 patients over a period of 15 years. The 6 models tested were male versus female patients aged 15 years versus 25 years versus 35 years.

RESULTS

Primary surgery was less costly and more effective for 15-year-old boys, 15-year-old girls, and 25-year-old men. For the remaining scenarios (25-year-old women and 35-year-old men and women), primary surgery was also more effective but was more costly. However, for these scenarios, primary surgery was still very cost-effective (cost per quality-adjusted life-year, <$25,000). After 1 recurrence, surgery was less costly and more effective for all scenarios.

CONCLUSIONS

Primary arthroscopic stabilization is a clinically effective and cost-effective treatment for first-time anterior shoulder dislocations in the cohorts studied. By use of a willingness-to-pay threshold of $25,000 per quality-adjusted life-year, surgery was more cost-effective than nonoperative treatment for the majority of patients studied in the model.

LEVEL OF EVIDENCE

Level II, economic and decision analysis.

Laryngeal carcinoma in nonsmoking patients

OBJECTIVES

Smoking is a known risk factor for laryngeal carcinoma. We sought to describe the clinicopathologic characteristics and outcomes of nonsmoking patients with laryngeal carcinoma.

METHODS

Of 1,443 patients treated for laryngeal carcinoma between 1960 and 2006, 55 (3.8%) were nonsmokers: 40 (73%) had never smoked and 15 (27%) had stopped smoking 12 years or more before diagnosis. Patient characteristics and outcomes were reviewed.

RESULTS

The study group consisted of 87% men; the mean age at diagnosis was 67 years. All lesions but one were located in the glottis. The 5-year survival rate for the whole group was 85%. Most tumors were detected early. Of 38 patients (69%) with stage T1 disease, there was no significant difference in prognostic features between those who had never smoked and those who had smoked in the past.

CONCLUSIONS

Fewer than 5% of patients with laryngeal carcinoma were nonsmokers. Like smokers, this subgroup was characterized by a male predominance and an approximate age at diagnosis in the seventh decade. Unlike smokers, nonsmokers show a greater predilection for glottic rather than supraglottic disease. There was no difference in prognosis between smokers and nonsmokers, regardless of whether they had smoked in the past.

A biodegradable button to augment suture attachment in rotator cuff repair

Recent experimental studies suggest that the use of suture anchors for rotator cuff tear (RCT) repair transfers the "weak link" to the suture-tendon interface where failure occurs as the sutures cut through the tendon. The purpose of this study was to evaluate the effect of using a suture augmentation button on the fixation strength of rotator cuff tendon repair. A 1.5 cm by 2 cm defect was created in the supraspinatus tendon of seven cadaveric shoulder pairs and two suture anchors inserted in each humerus for suture attachment. For one of each pair, the defect was repaired with sutures placed in a horizontal mattress configuration. The other side was repaired with the sutures being passed through low profile, bioabsorbable buttons placed on the bursal tendon surface prior to knot tying. The supraspinatus tendon was cyclically loaded at a physiologic rate and load (33 mm/sec and 180 N, respectively). The number of loading cycles was recorded when the specimens developed 0.75 cm and 1.5 cm gaps at the repair site. The specimens were then tested to failure. Specimens in the unaugmented group developed 0.75 cm and 1.5 cm gaps at an average of 135 cycles and 362 cycles, respectively. The button augmented group developed these gaps at average of 420 cycles and 708 cycles, respectively. These differences were statistically significant (p < 0.05). The gaps progressively increased in all specimens, which eventually failed by suture cutting through tendon in all specimens. This study demonstrates that in vitro, suture augmentation with a low profile, bioabsorbable button provides significantly enhanced fixation when using suture anchors to repair torn rotator cuff tendon. This device may be a useful adjunct to current methods of rotator cuff repair.

Expression of MMP-9, TIMP-1, CD-34 and factor-8 as prognostic markers for squamous cell carcinoma of the tongue

Squamous cell carcinoma (SCC) of the tongue is characterized by an unpredictable course, ranging from relatively benign to a high degree of locally aggressive growth and metastasis. Treatment guidelines have been developed according to TNM stage, but they do not always accurately predict clinical outcome. The aim of the present study was to evaluate the expression of the matrix metalloproteinases (MMPs) that degrade the extracellular matrices, their inhibitors (TIMPs), and angiogenic factors (factor-8 and CD-34) in tumor cells and to correlate these findings with the clinicopathological features and patient outcome. Tissue specimens from 23 patients with primary SCC of the tongue were immunohistochemically stained for these markers. High expressions of MMP-9 and TIMP-1 were detected in 60.9% and 65.2% of the specimens, respectively. Tumor invasion to adjacent muscle, lymph node metastasis, and disease status at the end of follow-up were positively correlated with the microvessel count using the CD-34 marker, but not with high expression of MMP-9 or TIMP-1. Expression of MMP-9 and TIMP-1 fails to predict aggressiveness in SCC of the tongue. However, the degree of vascularization in tumor tissue is indicative of disease aggressiveness and might be used as a basis for patient selection for more intensive therapy.

Sentinel node guided surgery for melanoma in the head and neck region

Sentinel lymph node biopsy may be more technically challenging for melanoma of the head and neck compared with other locations because of the complex lymphatic drainage patterns. This study demonstrates the value of sentinel node biopsy for head and neck melanoma, and highlights the associated difficulties. Thirty consecutive patients with primary cutaneous melanoma of the head and neck (n=26) or draining to the neck (n=4) underwent preoperative lymphoscintigraphy. This was followed by intraoperative lymphatic mapping using blue dye alone (n=8) or in combination with a hand-held gamma probe (n=22) and sentinel lymphadenectomy. Modified neck dissection was performed in all patients with positive sentinel nodes. The study population had a male predominance (73%). Most lesions were nodular and were not ulcerated. In two patients (6.2%) preoperative lymphoscintigraphy failed to demonstrate the draining nodes, which were retrieved by surgery, and in two patients (6.2%) the sentinel node was not found at surgery despite preoperative visualization. Overall, the sentinel node was identified 93% of the time: in seven out of eight cases (88%) using blue dye alone, and in 21 out of 22 cases (96%) using a combination of blue dye and gamma probe. Four out of 28 basins were deemed positive for metastases. Twenty-three of the 24 patients with negative sentinel nodes were free of disease at a median of 31 months (range 9-91 months). There was one false-negative case salvaged by surgery. The sentinel node technique is technically demanding but advantageous for most patients with head and neck melanoma. Identification rates seem to be better when preoperative lymphoscintigraphy is combined with intraoperative blue dye mapping and a hand-held gamma probe. The relative contribution of each component could not be determined.

Transoral reconstruction of the mobile tongue, using radial forearm free flap

Tongue resection has significant influence on the patient's quality of life, because it interferes with masticatory and speech functions and affects facial aesthetics. To avoid the disadvantages of the traditional lip-splitting used to approach partial tongue reconstruction for resection (40% of the tongue or more), we recommend a completely transoral approach, with the radial forearm free flap as a donor flap. Between 1999-2001, the suggested technique was applied in 11 patients with squamous-cell carcinoma of the mobile tongue. A follow-up of 6-30 months showed good to excellent oral function, with preservation of tongue volume, motion, and facial aesthetics. This approach seems to be preferable over the lip-split approach for the reconstruction of mobile tongue defects.

Revision parathyroidectomy guided by intraoperative radionuclide imaging

BACKGROUND

Technetium-99m sestamibi scintigraphy has become one of the most popular techniques for localization of the parathyroid gland after failure of primary neck exploration.

OBJECTIVE

To examine the efficacy of sestamibi with the hand-held gamma ray detecting probe for the identification of parathyroid adenomas during revision parathyroidectomy.

METHODS

We reviewed six cases of probe-assisted neck exploration for parathyroid lesions following unsuccessful primary exploration.

RESULTS

In all cases the pathologic glands were successfully detected and removed.

CONCLUSIONS

With careful planning, a gamma ray detecting probe can be used optimally 2-3 hours after technetium-99m sestamibi injection. The probe is efficient, easy and convenient to use.

Invasive meningococcal disease: patient and strain characteristics set new challenge for prevention and control

Differences in the course of invasive meningococcal disease, in prevalence, case-to-carrier ratio, geographical pattern, age distribution and antibiotic resistance have been related to major serogroups and their serotypes. The relationships between Neisseria meningitidis serogroups and clinical manifestation, outcome and patient characteristics are assessed. All hospitalized patients in six major hospitals in central Israel with a verified meningococcal disease during 1990-1994 were included (n = 66). Their personal and clinical data and the results of bacteriological and serological tests of their blood and cerebrospinal fluid (CSF) were recorded. Meningococci were isolated from both blood and CSF, from blood alone, and from CSF alone in 60.6%, 18.2%, and 21.2% of the cases, respectively. The highest proportion of isolations were from infants < 1 year (34.8%), followed by children aged 1 to 5 years (25.8%). Serogroup B prevailed in 62.1%, while groups C and W135 accounted for 28.8% and 9.1%, respectively. Serogroup B predominated in children < 1 year, while in patients aged 5-22 years, C strains were the major pathogen (P < 0.001). Serogroup B accounted for 93% of the cases of meningitis, 58% of meningococcemia and 42% of fulminant meningococcemia, while group C strains were the major cause of fulminant meningococcemia (50%). The overall case fatality rate was 7.6%: fulminant meningococcemia 8.3%, and meningococcemia 10%. It was concluded that N. meningitidis group C continues to account for almost a third of the cases of meningococcal disease and is the major cause of fulminant meningococcemia.

Identification of an immunologically important hypervariable domain of major outer surface protein A of Borrelia burgdorferi

The gene for the major outer surface protein A (OspA) from several clinically obtained strains of Borrelia burgdorferi, the cause of Lyme disease, has been cloned, sequenced, and expressed in Escherichia coli by using a T7-based expression system (J. J. Dunn, B. N. Lade, and A. G. Barbour, Protein Expr. Purif. 1:159-168, 1990). All of the OspAs have a single conserved tryptophan at residue 216 or, in some cases, 217; however, the region of the protein flanking the tryptophan is hypervariable, as determined by a moving-window population analysis of ospA from 15 European and North American isolates of B. burgdorferi. Epitope-mapping studies using chemically cleaved OspA and a TrpE-OspA fusion have indicated that this hypervariable region is important for immune recognition. Biophysical analysis, including fluorescence and circular dichroism spectroscopy, have indicated that the conserved tryptophan is buried in a hydrophobic environment. Polar amino acid side chains flanking the tryptophan are likely to be exposed to the hydrophilic solvent. The hypervariability of these solvent-exposed amino acid residues may contribute to the antigenic variation in OspA. To test this, we have performed site-directed mutagenesis to replace some of the potentially exposed amino acid side chains in the B31 protein with the analogous residues of a Borrelia garinii strain, K48. The altered proteins were then analyzed by Western blot (immunoblot) with monoclonal antibodies which bind OspA on the surface of the intact B31 spirochete. Our results indicate that specific amino acid changes near the tryptophan can abolish the reactivity of OspA to these monoclonal antibodies, which is an important consideration in the design of vaccines based on recombinant OspA.

Virus-associated colitis in homosexual men: two case reports

Two homosexual men with colitis are described. In each case there was evidence of viral infection of the colon. One patient developed toxic megacolon that responded to conservative therapy. The other patient had proctosigmoiditis and opportunistic infections that eventually led to his death. An intensive search for viruses should be made in all homosexual men with proctitis and/or colitis.