Making informed choices on incorporating chemoprevention into carE (MiCHOICE, SWOG 1904): Design and methods of a cluster randomized controlled trial

INTRODUCTION

Women with atypical hyperplasia (AH) or lobular carcinoma in situ (LCIS) have a significantly increased risk of breast cancer, which can be substantially reduced with antiestrogen therapy for chemoprevention. However, antiestrogen therapy for breast cancer risk reduction remains underutilized. Improving knowledge about breast cancer risk and chemoprevention among high-risk patients and their healthcare providers may enhance informed decision-making about this critical breast cancer risk reduction strategy.

METHODS/DESIGN

We are conducting a cluster randomized controlled trial to evaluate the effectiveness and implementation of patient and provider decision support tools to improve informed choice about chemoprevention among women with AH or LCIS. We have cluster randomized 26 sites across the U.S. through the SWOG Cancer Research Network. A total of 415 patients and 200 healthcare providers are being recruited. They are assigned to standard educational materials alone or combined with the web-based decision support tools. Patient-reported and clinical outcomes are assessed at baseline, after a follow-up visit at 6 months, and yearly for 5 years. The primary outcome is chemoprevention informed choice after the follow-up visit. Secondary endpoints include other patient-reported outcomes, such as chemoprevention knowledge, decision conflict and regret, and self-reported chemoprevention usage. Barriers and facilitators to implementing decision support into clinic workflow are assessed through patient and provider interviews at baseline and mid-implementation.

RESULTS/DISCUSSION

With this hybrid effectiveness/implementation study, we seek to evaluate if a multi-level intervention effectively promotes informed decision-making about chemoprevention and provide valuable insights on how the intervention is implemented in U.S.

CLINICAL SETTINGS

TRIAL REGISTRATION

NCT04496739.

Associations between anterior knee pain and 2-year patellofemoral cartilage worsening: The MOST study

OBJECTIVE

Anterior knee pain (AKP) is associated with patellofemoral osteoarthritis (PFOA), but longitudinal studies are lacking. If AKP precedes PFOA, it may create an opportunity to identify and intervene earlier in the disease process. The purpose of this study was to examine the longitudinal relation of AKP to worsening patellofemoral (PF) cartilage over two years.

DESIGN

Participants were recruited from the Multicenter Osteoarthritis Study, a longitudinal study of individuals with or at risk for knee osteoarthritis (OA). Exclusion criteria included bilateral knee replacements, arthritis other than OA, and radiographic PFOA. At baseline, participants completed a knee pain map questionnaire and underwent knee magnetic resonance imaging (MRI). Imaging was repeated at 2-year follow-up. Exposure was presence of frequent AKP. Outcome was worsening cartilage damage in the PF joint defined as increase in MRI Osteoarthritis Knee Score from baseline to 2 years. Log-binomial models were used to calculate risk ratios (RR).

RESULTS

One knee from 1083 participants (age 56.7 ± 6.6 years; body mass index 28.0 ± 4.9 kg/m2) was included. Frequent AKP and frequent isolated AKP were present at baseline in 14.5% and 3.6%, respectively. Frequent AKP was associated with an increased risk (RR: 1.78, 95% confidence interval: 1.21, 2.62) of 2-year worsening cartilage damage in the lateral PF compartment. No association was found between frequent AKP and worsening in the medial PF joint.

CONCLUSION

Frequent AKP at baseline was associated with worsening cartilage damage in the lateral PF joint over 2 years.

1058 ESTABLISHING A VIRTUAL MULTIDISCIPLINARY TEAM MEETING FOR CARE HOME RESIDENTS IN NEWCASTLE-UPON-TYNE

Introduction

Care home (CH) residents are frail with complex physical and mental health needs. Healthcare provided is often by different organisations and fragmented. Optimising quality of life and reducing avoidable hospital attendance is crucial. The Newcastle Specialist Care Home Support Team (SCHST) provides care for 2,482 residents across 55 Newcastle CHs. Between April 2019–2020, there were 2,428 unplanned hospital attendances in this cohort. SCHST looked to establish multidisciplinary team (MDT) meetings to streamline care by collaboration and integrating pre-existing services. We aimed to establish weekly virtual MDT meetings to facilitate coordinated care for CH residents, reduce unplanned hospital attendances and improve communications between services, reducing need for additional referrals.

Method

Members identified to comprise the MDT included SCHST staff, Geriatricians, Old Age Psychiatrists, Pharmacists and GPs. Weekly meetings via Microsoft Teams were established, with the SCHST undertaking initial assessments of those referred. Management plans were formulated and actioned with feedback to GPs, CH staff and relatives. Residents were either discharged, planned for MDT re-review, or planned for in-person CH review. Interventions include medications optimisation, CH staff education, psychiatric and comprehensive geriatric assessments.

Results

From April-Nov 2021, 77 residents were referred to MDT. The number of reviews ranged from 1–6 (median = 2). All residents received an initial assessment by SCHST, with only 18 requiring in-person geriatrician input. Analysis of 22 residents showed fewer unplanned admissions in the 6 months following MDT review, compared to 6 months before. (Pre-MDT median 2 (range 0–6); post-MDT 0 (0–9); p < 0.05).

Conclusion

Preliminary data suggest that the virtual Care Home MDT may reduce the number of unplanned hospital admissions of care home residents, with less than one quarter requiring face-to-face geriatrician reviews. The CH MDT has shown to provide effective delivery of care, whilst reducing workload and improving efficiency, through collaborative interdisciplinary working.

Impact of left heart disease risk factors on risk stratification and treatment response in pulmonary arterial hypertension

Background

Contemporary registries have documented a change in the epidemiology of PAH patients displaying increasing co-morbidities associated with left heart disease (LHD). These patients are often excluded from randomized clinical trials. It is unclear whether the presence of LHD comorbidities may adversely impact the accuracy of risk stratification and response to PAH therapy.

Method

Data was extracted from the Pulmonary Hypertension Society of Australia and New Zealand registry for incident patients with a diagnosis with idiopathic/heritable/toxin-induced (I/H/D)-PAH and connective tissue disease (CTD) associated PAH from 2011 - 2020. Patients without available medication and follow up data were excluded. We used the AMBITION trial exclusion criteria to define the subpopulation with LHD risk factors and haemodynamic phenotype (PAH-rLHD).

Results

489 patients (I/H/D-PAH=251, CTD-PAH=238) were included in our analysis, with 103 (21.0%) fulfilling the definition of PAH-rLHD (34 had ≥3 risk factors for left heart disease (rLHD-hypertension, diabetes, obesity or ischaemic heart disease) and 76 had borderline haemodynamics (mean capillary wedge pressure 13–15 with pulmonary vascular resistance <500 dynes sec/cm5) including 7 who met both criteria). Compared to classical PAH, patients with PAH-rLHD were older at diagnosis (66±13 vs 58±19, p<0.001), had lower pulmonary vascular resistance (PVR: 393±266 vs 708±391, p=0.031) but worse exercise capacity (6MWD: 286±130m vs 327±136m, p=0.005). PAH-rLHD were more likely to be started on initial monotherapy, compared with “classical” PAH (73% vs 56%, p=0.002). In the monotherapy groups, endothelin receptor antagonists (ERA) were used in 73% PAH-rLHD, compared with 66% in classical PAH group. Both groups exhibited similar response to both mono- and combination therapy with commensurate improvements in WHO functional class (mean change 0.3±0.6 vs 0.3±0.8, p=0.443) and 6-minute walk distance (mean change 44±82 vs 48±101, p=0.723). There was no difference in survival between classical PAH and PAH-rLHD (log rank, p=0.29). The REVEAL 2.0 risk score effectively discriminated risk in both populations at baseline and first follow up (classical PAH: baseline C statistic 0.750, follow up 0.774 and PAH-rLHD: baseline C statistic 0.756, follow up 0.791).

Conclusion

Despite lower PVR at diagnosis, PAH-rLHD patients and “classical” PAH demonstrate similar response to first-line therapy with similar long term survival. The REVEAL 2.0 risk score can be effectively applied to the subpopulation of PAH-rLHD in real life clinical practice.

Funding Acknowledgement

Type of funding sources: None.

Maritime Interfacility Transport of Two Laboring Mothers - A Case Report

Background: Interfacility transport of laboring mothers is an infrequent endeavor associated with additional risk in the best of circumstances. Case Presentation: We report on a case where two laboring mothers were transported at night via fireboat, resulting in the delivery of one child while underway and delivery of another soon after arrival at the receiving facility. Conclusions: The objective of this case report is to describe the decision-making process and medical care for these two mothers during a nontraditional EMS transport.

Striving for perfection, accepting the reality: A reflection on adherence to airway clearance and inhalation therapy for paediatric patients with chronic suppurative lung disease

Non-adherence to prescribed treatment is considered the foremost cause of treatment failure in chronic medical conditions. Airway clearance techniques (ACT) play a key role in the management of chronic suppurative lung disease yet, along with inhaled therapies such as nebulised antibiotics, adherence to these is often lower than to other treatments. In this review we discuss methods of monitoring adherence to these therapies and potential barriers and outline suggestions for improving adherence in the paediatric population.

Chlamydia psittaci infection as a cause of respiratory disease in neonatal foals

BACKGROUND

During 2016-2018, 15 critically ill neonatal foals with acute respiratory distress associated with Chlamydia psittaci infection were presented to three referral hospitals in New South Wales. Chlamydia psittaci has not previously been associated with the development of neonatal respiratory disease.

OBJECTIVES

To investigate and describe the clinical features and outcome of C. psittaci infection in neonatal foals.

STUDY DESIGN

Multicentre retrospective case series.

METHODS

The clinical, clinicopathological, necropsy and histological features of 15 foals with confirmed C. psittaci infection were reviewed and reported.

RESULTS

Thirteen foals with C. psittaci infection died or were subjected to euthanasia within 36 h of hospitalisation and two foals survived to discharge. Findings during post-mortem examination of nonsurviving foals included bronchopneumonia, pulmonary congestion, hepatic congestion and hepatic inflammation. Detection of C. psittaci was achieved using polymerase chain reaction (PCR) testing of swabs of nasal secretions (4/6) and rectal mucosa (5/7) from live foals, lung tissues of foals at necropsy (11/14) and foetal membranes (4/5).

MAIN LIMITATIONS

Small numbers of confirmed cases of neonatal C. psittaci infection and inconsistent sampling methods.

CONCLUSIONS

Chlamydia psittaci should be considered a differential diagnosis for neonatal foals with signs of severe systemic disease, including equine neonatal acute respiratory distress syndrome (EqNARDS). Chlamydia psittaci is a zoonotic pathogen and a personal protective equipment (PPE) should be worn for the management of foals with suspected or confirmed infection.

A Geospatial Analysis of Adult Major Trauma Transit Time in Dublin

Aims To estimate ambulance transit time of Major Trauma patients from scene to Emergency Department (ED) in order to inform future trauma network design. Methods Dublin Fire Brigade data was analysed and each Major Trauma incident was mapped. Actual distance and time to the receiving ED was measured and estimates of distances and times from each of these incidents to any ED in Dublin (any potential Major Trauma Centre) were formulated using Google Maps in Internet Explorer 11. Results Adult trauma (n=500) was evenly distributed throughout Dublin. The median transit time to each ED varied from 5 to 8 minutes with a longest time of 26 minutes. The calculated median transit time from an incident to any ED was 18 minutes with a maximum estimated transit time of 40 minutes. Conclusion The data demonstrated that all patients could get to any Dublin ED with a median time of 18 minutes and within the internationally recommended transfer time of 45 minutes to a Major Trauma Centre.

Infection and inflammation in induced sputum from preschool children with chronic airways diseases

BACKGROUND

We hypothesized airway inflammation can be detected non-invasively by induced sputum (IS) or peripheral blood eosinophilia, and IS can detect bacterial and viral infection in preschool children with airway disease, with results comparable to broncho-alveolar lavage (BAL).

METHODS

Preschool children with cystic fibrosis, recurrent wheeze, or wet cough underwent IS with nebulized hypertonic saline, chest physiotherapy, and oropharyngeal suction. Samples were analyzed for inflammation by cytology and bacterial culture, viral detection by PCR. Results were compared to BAL and blood in a sub-group undergoing clinically indicated bronchoscopy.

RESULTS

64 children (median age 33 [7-76] months) underwent IS without adverse events. IS was obtained from 61/64. Twenty out of sixty-four underwent BAL and IS, no IS was obtained in 2/23. Thirteen out of twenty-one (62%) had matching bacteria and viruses, 4/21 had positive BAL bacterial growth with negative IS, and 3/21 had negative BAL growth with positive IS. 67% of sputum samples were processed for cytology, 46% had <80% squamous cells; the proportion of squamous cells reduced with increasing age (r = -0.55, P < 0.01). IS was significantly more neutrophilic and less eosinophilic than BAL; 2/21 IS samples contained eosinophils compared to 17/23 BAL. There was a positive correlation between blood and BAL eosinophilia (r = 0.75, P < 0.01).

CONCLUSION

IS from preschool children can be used to assess infection. BAL and IS culture concurred in approximately two-thirds. However, inflammation was measureable in only one-third of IS samples and the cell differential was predominantly neutrophilic compared to BAL. Blood eosinophils may provide a better reflection of lower airway eosinophilia in this age group. Pediatr Pulmonol. 2016;51:778-786. © 2015 WileyPeriodicals, Inc.