A new randomized clinical trial of a pilot program found that a brief in-person intervention can improve psychosocial health in a particularly vulnerable population – adolescents and young adults living with cancer.
Psychosocial stress from cancer is common and is often a major detriment to quality of life. For example, one type of stress is anxiety over how to navigate the demands of the disease. Although many programs provide some level of psychosocial support for patients and families, very few provide standardized tools to manage this stress.
The intervention, called Promoting Resilience in Stress Management, or PRISM, improved resilience and quality of life, increased hope, and lowered distress in the majority of patients.
“The experience of cancer is stressful in all realms, but we tend to focus more on physical symptoms than the equally important social and emotional challenges,” said lead study author Abby R. Rosenberg, MD, Director of Palliative Care and Resilience Research at Seattle Children’s Research Institute. “This is particularly true for adolescents and young adults who already struggle with normal developmental changes. When you throw cancer into the mix, it can become much harder.”
PRISM emerged from a theory of resilience that puts forth three sets of resources that can help manage adversity: internal resources, such as stress-management or mindfulness skills; community resources, such as social support; and existential resources, such as spirituality and the search for purpose. In prior research, the investigators found that internal and existential resources were more teachable than tapping community resources. PRISM was tested in an earlier feasibility study with young patients with either diabetes or cancer.
In this clinical trial, 100 English-speaking patients ages 12 to 25 years who were diagnosed with new or newly recurrent cancer were randomly assigned to receive PRISM or usual psychosocial care. The intervention was delivered in four 30-minute to hour-long one-on-one sessions with a trained research associate, followed by a family meeting. PRISM cultivated internal resilience resources that strengthen stress management and goal-setting, as well as existential resilience resources that strengthen cognitive reframing and meaning-making.
“Meaning-making is basically deriving some personal perspective or purpose from adversity,” said Dr. Rosenberg. “For example, we found that many young cancer patients in our study identified things for which they were grateful, despite their cancer experience.”
Regardless of which group they were in, all participants received standard psychosocial supportive care, including a dedicated social worker and access to psychologists, child-life specialists, and other experts in adolescent and young adult oncology care, as needed.
Patients completed surveys at enrollment and six months later. The authors found that the intervention improved psychosocial well-being.
Specifically, among the 74 participants who remained alive and well enough to complete the 6-month survey (36 in the intervention group and 38 in the usual care group), those who received the intervention had improvements in resilience, cancer-related quality of life, hope, and distress compared with those who received usual psychosocial care. In addition, the incidence of depression was much lower in the intervention group compared with the usual care group (6% vs. 21%).
All but four of the PRISM recipients chose to participate in the family meeting following their one-on-one skills-training sessions. “We included the family meeting because teens told us they wanted to share with their parents, and parents told us they wanted to know what their children had learned,” said Dr. Rosenberg. “While the specific impact of this meeting is yet to be determined, we hope it will guide families so that there is continued support of teen or young adult patients.”
“We need to include a much larger cultural demographic in future studies,” said Dr. Rosenberg. “Beyond that, we also need to determine if this type of intervention could translate to other centers where usual care may not be as comprehensive as what we have here.”
The investigators would also like to test PRISM in patients with advanced cancers and possibly expand to other diseases, such as cystic fibrosis.
American Society of Clinical Oncology
www.asco.org/about-asco/press-center/news-releases/resilience-intervention-improves-well-being-young-patients

A UBC Okanagan researcher has discovered a new artificial bone design that can be customized and made with a 3D printer for stronger, safer and more effective bone replacements.
Hossein Montazerian, research assistant with UBC Okanagan’s School of Engineering, has identified a way to model and create artificial bone grafts that can be custom printed. Montazerian says human bones are incredibly resilient, but when things go wrong, replacing them can be a painful process, requiring multiple surgeries.
“When designing artificial bone scaffolds it’s a fine balance between something that is porous enough to mix with natural bone and connective tissue, but at the same time strong enough for patients to lead a normal life,” says Montazerian. “We’ve identified a design that strikes that balance and can be custom built using a 3D printer.”
Traditional bone grafting is used in medicine to treat anything from traumatic fractures to defects, and requires moving bone from one part of the body to another. But Montazerian says his artificial bone grafts could be custom printed to potentially fit any patient and wouldn’t require transplanting existing bone fragments.
In his research, Montazerian analysed 240 different bone graft designs and focused on just the ones that were both porous and strong. He printed those that performed the best using a 3D printer and then ran physical tests to determine how effective they would be under load in the real world.
“A few of the structures really stood out,” Montazerian adds. “The best designs were up to 10 times stronger than the others and since they have properties that are much more similar to natural bone, they’re less likely to cause problems over the long term.”
Montazerian and his collaborators are already working on the next generation of designs that will use a mix of two or more structures.
“We hope to produce bone grafts that will be ultra-porous, where the bone and connective tissues meet and are extra-strong at the points under the most stress. The ultimate goal is to produce a replacement that almost perfectly mimics real bone.”
While his bone graft designs are well on their way, Montazerian says the technology still needs some advances before it can be used clinically. For example, he says other researchers in the field are starting to refine biomaterials that won’t be rejected by the body and that can be printed with the very fine 3D details that his designs require.
“This solution has enormous potential and the next step will be to test how our designs behave in real biological systems,” he says. “I hope to see this kind of technology clinically implemented for real patients in the near future.”

UBC’s Okanagan campus
news.ok.ubc.ca/2017/08/17/ubc-researcher-looks-to-the-future-of-bone-replacements/
 

The medical team, Cardiosos, attending the Gaes Titan Desert by Garmin endurance mountain bike race this year had point-of-care ultrasound close at hand to help them deal with injuries and medical emergencies. The race saw over 463 top-level mountain bikers cover 612 kilometres of sand dunes in Morocco over the course of six days.
Dr Marc Bausili, an anesthetist at the Sant Pau Hospital in Barcelona and a member of the Titan Desert medical team, knew what to expect: “The most frequent injuries were things like ulcerations due to friction and abrasion – dermal and cutaneous injuries from cycling in high temperatures. Then there was a lot of dehydration, fluctuating blood sugar levels, blackouts, fainting fits – the kinds of things that you’d normally expect from this type of race. We knew from our experience of similar events that, with so many participants and the technical requirements of the race, we also had to be prepared for more serious injuries and decided to take an ultrasound device with us.”
Marc uses ultrasound every day in his professional life, as he explained: “Ultrasound devices are really important for guiding analgesia and anesthesia in operating theatres, as well as for applications such as echocardiography and pulmonary echography in intensive care. For the Titan Desert, we knew we were dealing with professional cyclists from all over the world, and wanted to provide them with the best possible medical service. FUJIFILM SonoSite gave us an Edge® II system to take with us for the race, which allowed us to make quick and accurate diagnoses, and even gave us access to anesthetic guidance on the course.”
www.sonosite.com

Precision medicine has become the leading innovation of cancer treatment. Patients are routinely treated with drugs that are designed to target specific tumours and molecules. Despite the progress that has been made in targeted cancer therapies, the path has been slow and scientists have a long road ahead. In a collaborative project, researchers at the Moffitt Cancer Center and Dana-Farber Cancer Institute investigated the emerging field of radiomics has the potential to improve precision medicine by non-invasively assessing the molecular and clinical characteristics of lung tumours.
Radiomics offers scientists and clinicians a novel way to analyse individual tumours for their biology, guide cancer treatment, and predict response to therapy. Virtually every cancer patient has their tumour imaged though computed tomography (CT), magnetic resonance (MRI), and/or positron emission tomography (PET) as standard-of-care. The images allow physicians to determine the stage and location of a tumour and guide treatment decisions. But with recent advances in computer generated data and models, these images are now being used in the field of radiomics to extract high-dimensional data that can be used to guide precision medicine. By using radiomics, scientists are able to objectively quantitate different features of tumours, such as intensity, shape, size and texture. These data can then be used in combination with genetic and clinical data to predict active biological pathways, clinical outcomes, and potential effective therapies.
“The core belief of radiomics is that images aren’t pictures, they’re data. We have to treat them as data. Right now, we extract about 1300 different quantitative features from any volume of interest,” said Robert Gillies, Ph.D., chair of Moffitt’s Department of Cancer Imaging and Metabolism.
This collaboration analysed CT image features from 262 North American patients and 89 European patients with non-small cell lung cancer (NSCLC). They identified associations between the image features and molecular markers, biological pathways, and clinical outcomes. For example, they determined that certain sets of image features could predict the overall survival of NSCLC patients, while other image features could predict the stage of the tumour or the presence of biological and genetic markers that drive tumour growth. The researchers also demonstrated the clinical importance of radiomics by showing that it is possible to increase prognostic power by combining radiomic data with genetic information and clinical data.
“We already knew that radiomic algorithms have strong clinical importance; however, the biological basis for these observations remained unknown. This study now answers this key question for the first time by defining and independently validating the driving biological pathways of radiomic phenotypes” said Hugo Aerts, Ph.D., director of the Computational Imaging and Bioinformatics Laboratory and associate professor of Radiation Oncology at Harvard Medical School.
Radiomics has several advantages over other commonly used techniques that guide precision medicine. Currently, biological markers are routinely analysed with tissue biopsies that are invasive, collected only at the beginning of care, and may not accurately reflect the biology of the entire tumour. In contrast, imaging techniques are non-invasive and can provide information about the entire tumour throughout the entire course of treatment and response. Additionally, the majority of cancer patients routinely have images taken for diagnostic purposes already, making radiomics a cost-effective approach.
“This study advances the molecular knowledge of radiomic characterization of tumours, information currently not used clinically. This may provide opportunities to improve decision-support in all patients as imaging is routinely used in clinical practice as standard of care,” said Gillies.

Moffitt Cancer Center
moffitt.org/newsroom/press-release-archive/2017/new-research-shows-the-power-of-radiomics-to-improve-precision-medicine/

As more elderly patients undergo the minimally invasive heart valve procedure called Transcatheter Aortic Valve Implantation (TAVR), concerns have been raised as to what causes some to be readmitted for heart failure after the procedure.
Now, University at Buffalo researchers, working in the Gates Vascular Institute, Kaleida Health, have published a paper that identifies a new way to predict which patients may be at higher risk. Vijay S. Iyer, MD, PhD, associate professor in the UB Department of Medicine, was the principal investigator.
TAVR is a minimally invasive procedure reserved for patients who have been turned down for a traditional aortic valve replacement by open heart surgery due to serious medical co-morbidities.
“For many patients, TAVR is a life-saving and life-enhancing procedure and most see significant improvements in their symptoms,” said Bhardwaj. “However, a small percentage may not benefit adequately with the procedure. Heart failure readmission is one of the most common cardiac-related readmissions within the first year after TAVR.”
To find out what might be putting these patients at higher risk, Bhardwaj and her colleagues conducted a retrospective study on 198 patients (mean age was 82 years) who underwent TAVR from 2012-16 at the Gates Vascular Institute in Buffalo.
They focused on a measure called elevated valvuloarterial impedance, also known as Zva, which is obtained noninvasively by a cardiac ultrasound. Zva incorporates both the aortic valve stenosis and the resistance encountered by the heart due to thickening of the arteries and blood vessels for pumping blood in the body.
While Zva has been shown to have prognostic significance in TAVR patients, there was no quantifiable data as to how useful it might be in predicting heart failure, Bhardwaj explained.
“Our study was the first to evaluate the role of Zva, which can be easily obtained non-invasively for predicting heart failure readmissions,” she said. “Identifying such prognostic markers would help reduce rehospitalizations and would eventually translate into reduced health care expenditures as well.”
The UB study found that among 41 patients who were rehospitalized after TAVR, nearly twice as many patients (34.2 percent vs. 18.1 percent) with a high Zva prior to undergoing TAVR were readmitted to the hospital after TAVR because of heart failure symptoms.
Another key finding was that patients in whom the Zva either increased or remained unchanged were three times more likely (18.2 percent vs. 6.3 percent) to die within one year of the procedure.
“For that reason, we recommend that Zva should be integrated as part of routine follow up post-TAVR,” Bhardwaj said, “and should be obtained serially during follow-up echocardiograms (ultrasounds of heart) for monitoring the risk of heart failure readmissions.”
Bhardwaj and her co-authors note that Zva may also have relevance to determining who should and should not undergo TAVR in the first place.
“Our findings suggest that Zva may play a key role in patients who fail to have clinical improvement post-TAVR and will most likely not benefit from the procedure,” she said, “so Zva has prognostic implications in evaluating patients who may or may not benefit with the procedure.”
The importance of such risk stratification has a significant impact, the authors said, as hospital administrations nationwide work to minimize heart failure readmissions while trying to identify patients at higher risk to utilize more resources in the outpatient setting.
“Zva can be utilized to identify patients at high risk for readmissions and accordingly, help divert resources to these patients by establishing transitional care programmes and close cardiologist follow-up in order to avoid readmissions in hospital,” Bhardwaj concluded. “This should translate to potential cost-savings and reduced health care expenditures.”

University of Buffalohttp://tinyurl.com/ybofe59y