Telehealth as a Strategy for Health Equity: A Scoping Review of Telehealth in India During and Following the COVID-19 Pandemic for People with Disabilities.

Introduction: Telehealth in India is growing rapidly and represents a strategy to promote affordable, inclusive, timely and safe access to healthcare. Yet there is a risk that telehealth increases inequity due to the digital divide and existing poor health literacy. Methods: A scoping review was conducted to explore use of telehealth in India during and following the COVID-19 pandemic by people with disabilities to inform strategies to increase equity of telehealth for people with disabilities. Of 1966 studies from the initial search in four databases and three specific telehealth journals, 20 sources met the inclusion criteria, limited to a focus on physical disability in India. Results: Findings showed examples of how people with disabilities can exercise increased control in the timing of appointments, convenience of receiving services from home and not having to travel to clinics or hospitals, and platform preference through tools and applications already familiar to them. Carers and families of people with disabilities were described as highly valued stakeholders with important roles in the uptake and effectiveness of telehealth for people with disabilities. The identified benefits of telehealth resulted in high levels of user satisfaction due to increased control and convenience, however, systemic barriers for accessibility remain. Conclusion: This review suggested that if telehealth is not designed intentionally to change the status quo for people with disabilities and prioritize equity, then the benefits may not be sustainable. Recommendations for telehealth India are provided, based on both findings from the literature and analysis of results.

A scoping assessment of dental services at designated head and neck cancer centres in Ontario, Canada.

BACKGROUND: Dentists serve a crucial role in managing treatment complications for patients with head and neck cancer, including post-radiation caries and oral infection. To date, dental services for head and neck cancer patients in Ontario, Canada have not been well characterized and considerable disparities in allocation, availability, and funding are thought to exist. The current study aims to describe and assess the provision of dental services for head and neck cancer patients in Ontario. METHODS: A mixed methods scoping assessment was conducted. A purposive sample of dentist-in-chiefs at each of Ontario's 9 designated head and neck cancer centres (tertiary centres which meet provincially-set quality and safety standards) was invited to participate. Participants completed a 36-item online survey and 60-minute semi-structured interview which explored perceptions of dental services for head and neck cancer patients at their respective centres, including strengths, gaps, and inequities. If a centre did not have a dentist-in-chief, an alternative stakeholder who was knowledgeable on that centre's dental services participated instead. Thematic analysis of the interview data was completed using a mixed deductive-inductive approach. RESULTS: Survey questionnaires were completed at 7 of 9 designated centres. A publicly funded dental clinic was present at 5 centres, but only 2 centres provided automatic dental assessment for all patients. Survey data from 2 centres were not captured due to these centres' lack of active dental services. Qualitative interviews were conducted at 9 of 9 designated centres and elicited 3 themes: (1) lack of financial resources; (2) heterogeneity in dentistry care provision; and (3) gaps in the continuity of care. Participants noted concerning under-resourcing and limitations/restrictions in funding for dental services across Ontario, resulting in worse health outcomes for vulnerable patients. Extensive advocacy efforts by champions of dental services who have sought to mitigate current disparities in dentistry care were also described. CONCLUSIONS: Inequities exist in the provision of dental services for head and neck cancer patients in Ontario. Data from the current study will broaden the foundation for evidence-based decision-making on the allocation and funding of dental services by government health care agencies.

A Primed Neutrophil Subset Predicts the Risk of Bloodstream Infections in Allogeneic Hematopoietic Stem-Cell Transplant Patients: A Prospective Study.

BACKGROUND: Bloodstream infections (BSIs) are the most common infectious complication in patients who receive allogeneic hematopoietic stem-cell transplants (allo-HSCTs). Polymorphonuclear neutrophils (PMNs) are quantified to monitor the susceptibility to BSIs; however, their degree of activation is not. We previously identified a population of primed PMNs (pPMNs) with distinct markers of activation representing approximately 10% of PMNs in circulation. In this study, we investigate whether susceptibility to BSIs is related to the proportion of pPMNs rather than strictly PMN counts. METHODS: In this prospective observational study, we used flow cytometry to assess pPMNs in blood and oral rinse samples collected from patients receiving an allo-HSCT over the course of their treatment. We used the proportion of pPMNs in the blood on day 5 post-transplant to categorize patients into a high- or a low-pPMN group (>10% or <10% pPMNs). These groups were then used as a predictor of BSIs. RESULTS: A total of 76 patients were enrolled in the study with 36 in the high-pPMN group and 40 in the low-pPMN group. Patients in the low-pPMN group had lower expression of PMN activation and recruitment markers and displayed a delay in PMN repopulation of the oral cavity after the transplant. These patients were more susceptible to BSIs compared with patients in the high-pPMN group with an odds ratio of 6.5 (95% confidence interval, 2.110-25.07; P = .002). CONCLUSIONS: In patients who receive an allo-HSCT, having <10% pPMNs early in the post-transplant phase can be an independent predictor of BSI in allo-HSCT patients.

A Systematic Review of Decision Aids in Hematologic Malignancies: What Are Currently Available and What Are We Missing?

BACKGROUND: Patient decision aids (PDAs) are tools designed to facilitate decision-making. In this systematic review, we summarized existing studies on the development and evaluation of PDAs for patients with hematologic malignancies. PATIENTS AND METHODS: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched for articles in PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. We included studies, abstracts, and clinical trial protocols available in English involving PDAs for patients age ≥18 diagnosed with a hematologic malignancy and/or their caregivers. Data were summarized using descriptive statistics. RESULTS: Of the 5281 titles/abstracts screened, 15 were included: 1 protocol, 7 abstracts, and 7 full-texts. Six were PDA developmental studies, 6 were pilot studies, and 3 were randomized trials. PDA formats included electronic with web content, videos, and/or audio, questionnaires, bedside instruments, and a combination of various formats. Average participant age ranged from 36.0 to 62.4 years. Patients and caregivers identified efficacy, adverse effects, cost, and quality of life as important decision-making factors. PDAs were associated with increased knowledge and patient satisfaction as well as decreased decisional conflict and attitudinal barriers. Research on PDAs for adult patients with hematologic malignancies and their caregivers is limited. Among the studies, PDAs appear to support patients in shared decision-making. CONCLUSION: While current literature examining the use of PDAs for adults with hematologic malignancies is limited, the positive impact of PDAs on shared decision-making and patient outcomes warrants additional research in this field.

Detecting dental caries on oral photographs using artificial intelligence: A systematic review.

OBJECTIVES: This systematic review aimed at evaluating the performance of artificial intelligence (AI) models in detecting dental caries on oral photographs. METHODS: Methodological characteristics and performance metrics of clinical studies reporting on deep learning and other machine learning algorithms were assessed. The risk of bias was evaluated using the quality assessment of diagnostic accuracy studies 2 (QUADAS-2) tool. A systematic search was conducted in EMBASE, Medline, and Scopus. RESULTS: Out of 3410 identified records, 19 studies were included with six and seven studies having low risk of biases and applicability concerns for all the domains, respectively. Metrics varied widely and were assessed on multiple levels. F1-scores for classification and detection tasks were 68.3%-94.3% and 42.8%-95.4%, respectively. Irrespective of the task, F1-scores were 68.3%-95.4% for professional cameras, 78.8%-87.6%, for intraoral cameras, and 42.8%-80% for smartphone cameras. Limited studies allowed assessing AI performance for lesions of different severity. CONCLUSION: Automatic detection of dental caries using AI may provide objective verification of clinicians' diagnoses and facilitate patient-clinician communication and teledentistry. Future studies should consider more robust study designs, employ comparable and standardized metrics, and focus on the severity of caries lesions.

Putting the system in systemic racism: A systems thinking approach to advancing equity.

Generations of scholars and activists have argued that racial inequities emerge not only because of racist ideologies but also from a hierarchical system of racial oppression. This theoretical tradition has highlighted numerous ways in which systemic racism manifests itself, from racist policies to differential access to material conditions and power. However, given that by definition systemic racism is focused on systems, theories of systemic racism would be more comprehensive and actionable by drawing on scholarship related to systems thinking. Systems thinking is a conceptual orientation that aims to understand how different types of systems function over time. This paper builds on the work of previous scholars to propose a systems thinking approach to understand and strategically disrupt racist systems. We provide a typology of system characteristics (organized into the categories of paradigms, structures, elements, and feedback loops) that together can be used to help understand the operation of systemic racism in different system contexts. The paper also provides an approach to identify and strategically target multiple system leverage points to simultaneously disrupt the status quo of racial inequity and promote the emergence of conditions enabling racial equity. This systems thinking approach can be used to guide learning and action within an ongoing process of antiracist praxis.

Medical students and residents appreciate ebooks' convenience, but prefer the print book reading experience.

BACKGROUND: Increasingly, libraries buy medical monographs as ebooks, but that may not be what medical students and residents want. Some studies have shown that they prefer print books for some types of reading. On the other hand, for participants in distributed medical programs, ebooks are more accessible. OBJECTIVES: To determine whether medical students and residents at an institution with a distributed medical education program prefer medical ebooks or print books. METHODS: In February 2019, 844 medical students and residents were invited to complete an online questionnaire on their format preferences. RESULTS: Two hundred thirty-two students and residents responded. Most preferred electronic format for reading a few pages, but print for entire books. Respondents preferred ebooks because they were immediately available, searchable and could be used on the go, and print books because they strained users' eyes less, facilitated absorption of the text and could be held in users' hands. The location of respondents and year of study had little effect on responses. DISCUSSION: Libraries should consider buying quick reference and large, heavy textbooks as ebooks and pocket-sized or shorter, single-topic titles, in print format. CONCLUSIONS: Libraries have a responsibility to make both print and ebooks available to their users.

Evaluating the association of frailty with communication about aging-related concerns between older patients with advanced cancer and their oncologists.

BACKGROUND: A geriatric assessment (GA) intervention improves communication about aging-related concerns, but its effect on communication in patients with various levels of frailty is unknown. METHODS: This was a secondary analysis of a nationwide trial of patients aged ≥70 years with incurable cancer and impairment on 1 or more GA domains (ClinicalTrials.gov Identifier NCT02107443; principal investigator Supriya G. Mohile). Practice sites were randomized to either the GA-intervention or usual care. Frailty was assessed with a deficit accumulation index (range, 0-1), and patients were stratified as robust (0 to <0.2), prefrail (0.2 to <0.35), or frail (≥0.35). The clinic visit after the GA-intervention was audio-recorded, transcribed, and coded to evaluate the number and quality of conversations about aging-related concerns. Linear mixed models examined differences in the number and quality of conversations within and between arms. All P values were 2-sided. RESULTS: Patients (n = 541) were classified as robust (27%), prefrail (42%), or frail (31%). In the usual care arm, frail patients (vs robust ones) engaged in more aging-related conversations (adjusted mean difference, 1.73; 95% confidence interval [CI], 0.59-2.87), conversations of higher quality (difference, 1.12; 95% CI, 0.24-2.0), and more discussions about evidence-based recommendations (difference, 0.71; 95% CI, 0.04-1.38; all P values ≤ .01). Similarly, in the GA intervention arm, frail patients (vs robust ones) engaged in more aging-related conversations (difference, 2.49; 95% CI, 1.51-3.47), conversations of higher quality (difference, 1.31; 95% CI, 0.56-2.06), and more discussions about evidence-based recommendations (difference, 0.87; 95% CI, 0.32-1.42; all P values ≤ .01). Furthermore, the GA-intervention significantly improved the number and quality of conversations in all patients: robust, prefrail, and frail (all P values ≤ .01). CONCLUSIONS: Patients with higher degrees of frailty and those exposed to the GA-intervention had more and higher quality conversations about aging-related concerns with oncologists. LAY SUMMARY: A geriatric assessment (GA) intervention improves communication about aging-related concerns, but its effect on communication in patients with various levels of frailty is unknown. This study conducted a secondary analysis of a nationwide trial of patients aged ≥70 years with incurable cancer and 1 or more GA domain impairments. Patients were stratified as robust, prefrail, or frail. The number and quality of conversations about aging-related concerns that occurred during the clinic visit after the GA-intervention were determined. Patients with higher degrees of frailty and those in the GA intervention arm had more and higher quality conversations about aging-related concerns with oncologists.

The Effect of Intensity-Modulated Radiotherapy to the Head and Neck Region on the Oral Innate Immune Response and Oral Microbiome: A Prospective Cohort Study of Head and Neck Tumour Patients.

Neutrophils, also known as polymorphonuclear leukocytes (PMNs), form a significant component of the innate host response, and the consequence of the interaction between the oral microbiota and PMNs is a crucial determinant of oral health status. The impact of radiation therapy (RT) for head and neck tumour (HNT) treatment on the oral innate immune system, neutrophils in particular, and the oral microbiome has not been thoroughly investigated. Therefore, the objective of this study was to characterize RT-mediated changes in oral neutrophils (oPMNs) and the oral microbiome in patients undergoing RT to treat HNTs. Oral rinse samples were collected prior to, during and post-RT from HNT patients receiving RT at Dental Oncology at Princess Margaret Cancer Centre. The oPMNs counts and activation states were analysed using flow cytometry, and the oral microbiome was analysed using 16S rRNA gene sequencing. Statistically significant (p < 0.05) drops in oPMN counts and the activation states of the CD11b, CD16, CD18, CD64 and H3Cit markers from pre-RT to post-RT were observed. Moreover, exposure to RT caused a significant reduction in the relative abundance of commensal Gram-negative bacteria and increased the commensal Gram-positive microbes. Ionizing radiation for the treatment of HNTs simultaneously decreased the recruitment of oPMNs into the oral cavity and suppressed their activation state. The oral microbiome composition post-RT was altered significantly due to RT which may favour the colonization of specific microbial communities unfavourable for the long-term development of a balanced oral microbiome.

A comparative study of medical ebook and print book prices.

BACKGROUND: Although most medical libraries buy ebooks, there has been little discussion of the comparative costs of medical ebooks and print books. OBJECTIVES: To determine whether individually purchased medical ebooks cost more or less, on average, than the same titles in print format and, if so, to calculate the price differential. METHODS: The author searched the platform of monograph vendor YBP for the 1095 titles in the 'Clinical Medicine' category of Doody's Core Titles 2018 edition. For each title, the print price and the lowest ebook price were noted; the ratio of ebook price to print book price for each title was then calculated. RESULTS: On average, ebooks cost 2.20 times more than their print equivalents, though the size of the price differential varied greatly with the publisher. For some publishers, ebooks cost nearly the same amount as print books, while for others, ebooks cost three or even four times as much as the print. DISCUSSION: The greater price of some ebooks may make them unaffordable for libraries or mean that those titles cannot be purchased as ebooks even when that format would be preferred. CONCLUSIONS: Buying ebooks, at least on a title-by-title basis, can be very costly for medical libraries.

THE PROCESS OF DEVELOPING CONSENSUS GUIDELINES BY DENTAL ONCOLOGISTS FOR PRE-RADIOTHERAPY DENTAL CARE IN HEAD AND NECK CANCER PATIENTS USING THE MODIFIED DELPHI TECHNIQUE.

BACKGROUND: There is a range of pre-radiation therapy (RT) dental care strategies used to prevent the side effects associated with the use of RT in the treatment of head and neck cancer. However, there is a paucity of evidence-based, prospectively tested clinical practice guidelines for dentists to utilize in the provision of care prior to RT. PURPOSE: The aim of this study is to describe the process of creating consensus guidelines for dental care in head and neck cancer patients undergoing RT using the Modified Delphi Technique. PROCEDURE: We invited 44 dental oncologists to participate as panelists in the study. Three rounds of iterative structured surveys were completed within eight months, followed by a virtual meeting to conclude the modified Delphi process. Questions were divided into six main domains and patients were categorized as low, moderate, and high-risk based on factors identified by panelists and agreed upon during the first round. The threshold value set for each round of the Delphi process was a 70% response rate and 75% Consensus level. FINDINGS: Eighteen panelists out of the forty-four (41% overall response rate) completed the study. The number of questions that achieved the set consensus level in rounds 1,2,3 and the virtual meeting were 24%, 62%,61% and 81%, respectively. A confidence level of 95% and a response rate of >75% were reached throughout the process. CONCLUSION: Consensus was attained in most of the questions in all domains, which will be utilized to develop guidelines for dental care in head and neck cancer patients before the commencement of RT.

More than noise: context-dependent luminance contrast discrimination in a coral reef fish (Rhinecanthus aculeatus).

Achromatic (luminance) vision is used by animals to perceive motion, pattern, space and texture. Luminance contrast sensitivity thresholds are often poorly characterised for individual species and are applied across a diverse range of perceptual contexts using over-simplified assumptions of an animal's visual system. Such thresholds are often estimated using the receptor noise limited model (RNL). However, the suitability of the RNL model to describe luminance contrast perception remains poorly tested. Here, we investigated context-dependent luminance discrimination using triggerfish (Rhinecanthus aculeatus) presented with large achromatic stimuli (spots) against uniform achromatic backgrounds of varying absolute and relative contrasts. 'Dark' and 'bright' spots were presented against relatively dark and bright backgrounds. We found significant differences in luminance discrimination thresholds across treatments. When measured using Michelson contrast, thresholds for bright spots on a bright background were significantly higher than for other scenarios, and the lowest threshold was found when dark spots were presented on dark backgrounds. Thresholds expressed in Weber contrast revealed lower thresholds for spots darker than their backgrounds, which is consistent with the literature. The RNL model was unable to estimate threshold scaling across scenarios as predicted by the Weber-Fechner law, highlighting limitations in the current use of the RNL model to quantify luminance contrast perception. Our study confirms that luminance contrast discrimination thresholds are context dependent and should therefore be interpreted with caution.

Information service in head and neck cancer care-a qualitative study.

AIM: We aimed to understand how information was delivered to head and neck (H&N) cancer patients and describe the perceptions of the H&N patients concerning information delivery. METHODOLOGY: This qualitative investigation was a part of our larger quantitative study that was conducted with H&N cancer patients at two academic hospitals in Montreal. After obtaining the ethical approval, a purposeful sample of participants was recruited from the main study until the content of the information gathered reached saturation. Data were collected by observing the information delivery and interviewing the study participants and Nurse Pivots. All observations and interviews were audiotaped. Data were transcribed verbatim; transcripts were developed, audited, and subjected to a thematic analysis. RESULTS: Eleven H&N patients participated in the study. We found that the doctors were the main source of information at both hospitals; one hospital delivered information systematically to every patient using a multimedia-based information disseminating tool while the second hospital delivered information verbally in an ad hoc manner. Those who received information using the multimedia tool understood what was said to them and were better prepared for the next step, while those who received information verbally did not retain much, were confused, and expressed dissatisfaction. CONCLUSIONS: Although the doctors were the main source of information, patients experience difficulties in understanding what was said to them. Comprehensive information together with audiovisuals, when provided to H&N cancer patients based on their needs, seems to improve their understanding of their cancer and prepare them for their treatment.

Sexual Motives in Heterosexual Women With and Without Sexual Difficulties.

Previous research indicates that women with sexual problems may have different reasons for engaging in sex than women who are not experiencing sexual problems. The current study investigated whether reasons for sex differed by women reporting high versus low overall sexual functioning, as assessed by the Female Sexual Function Index (FSFI) (Rosen et al., 2000). As low desire and inability to achieve orgasm are the two most commonly reported sexual problems for women, the study also investigated whether women with and without problems specifically related to sexual desire or orgasm cited different reasons for sex. The sample consisted of 446 heterosexual women between the ages of 18 and 61 who completed an online questionnaire assessing reasons for sex and sexual functioning. Women with low sexual functioning overall were more likely to endorse insecurity reasons for sex, while women with high sexual functioning overall were more likely to endorse physical reasons for sex. Women experiencing low desire specifically were less likely to endorse emotional and physical reasons for sex than women without desire difficulties. Women experiencing orgasm difficulties specifically were more likely to endorse insecurity reasons for sex than women without orgasm difficulties. The variance accounted for was low in all cases. This research offers insights into the important but limited role sexual functioning may play in the broader context of women's sexual motivations.

The importance of leisure reading to health sciences students: results of a survey.

OBJECTIVE: To determine what value health sciences students place on leisure reading, whether they prefer to read online or in print, what the principal barriers are to their reading and whether they wish to have a leisure reading collection at their health sciences library. METHODS: In October 2010, a link to a survey was sent to all 1800 students in health sciences professional programmes at the author's institution. RESULTS: Two hundred and thirteen students (11.8%) responded. Most felt that leisure reading had helped in their development as health professionals and increased their empathy. They listed many benefits of reading, such as improved understanding of minority groups, reduced stress, and improved thinking and communication skills. The majority preferred to read books and magazines in print, while the largest number preferred reading newspapers in print as well. Lack of time, fatigue and the expense of purchasing reading materials were the greatest barriers to reading. A majority of students were in favour of having a leisure reading collection set up at their library. CONCLUSIONS: Leisure reading was valued by the respondents, who felt it provided personal and professional benefits. However, many indicated that circumstances made it difficult to participate in leisure reading.

Socioeconomic status and nonadherence to antihypertensive drugs: a systematic review and meta-analysis.

BACKGROUND: Although conventional wisdom suggests that low socioeconomic status (SES) is a robust predictor of medication nonadherence, the strength of this association remains unclear. OBJECTIVES: 1) To estimate the proportion of studies that identified SES as a potential risk indicator of nonadherence, 2) to describe the type of SES measurements, and 3) to quantify the association between SES and nonadherence to antihypertensive pharmacotherapy. METHODS: A systematic review and meta-analysis research design was used. We searched multiple electronic databases for studies in English or French examining nonadherence to antihypertensive medications measured by electronic prescription databases where explanatory factors were considered. Two authors independently assessed quality, described the SES measure(s), and recorded its association with nonadherence to antihypertensives. A random-effects model meta-analysis was performed, and heterogeneity was examined by using the I(2) statistic. RESULTS: Fifty-six studies with 4,780,293 subjects met the inclusion criteria. Twenty-four of these studies (43%) did not report any SES measures. When it was reported (n = 32), only seven (13%) examined more than one component but none performed a multidimensional assessment. Most of the studies relied on income or income-related measures (such as prescription-drug benefits or co-payments) (27 of 32 [84%]). Meta-analysis could be quantified in 40 cohorts reported in 30 studies. Overall, the pooled adjusted risk estimate for nonadherence according to SES (high vs. low) was 0.89 (95% confidence interval 0.87-0.92; I(2) = 95%; P < 0.001). Similar patterns were observed in all subgroups examined. CONCLUSIONS: Published studies have not found a strong association between low SES and nonadherence to antihypertensive medications. However, important limitations in the assessment of SES can be identified in virtually all studies. Future studies are required to ascertain whether a stronger association is observed when SES is determined by comprehensive measures.

Leisure reading collections in academic health sciences and science libraries: results of visits to seven libraries.

OBJECTIVE: To visit leisure reading collections in academic science and health sciences libraries to determine how they function and what role they play in their libraries. METHODS: The author visited seven libraries with leisure reading collections and carried out a semistructured interview with those responsible either for selection of materials or for the establishment of the collection. RESULTS: These collections contained a variety of materials, with some libraries focusing on health-science-related materials and others on providing recreational reading. The size of the collections also varied, from 186 to 9700 books, with corresponding differences in budget size. All collections were housed apart, with the same loan period as the regular collection. No collections contained electronic materials. Although there was little comparable statistical data on usage, at the six libraries at which active selection was occurring, librarians and library staff felt that the collection was well used and felt that it provided library users with benefits such as stress relief and relaxation and exposure to other perspectives. CONCLUSION: Librarians and library staff at the libraries that undertook active selection felt that their leisure reading collection was worthwhile. It would be interesting for future work to focus on the user experience of such collections.

Prognostic awareness and willingness to explore prognosis in older adults with cancer.

INTRODUCTION: Prognostic awareness varies widely among older adults with cancer. Accurate prognostic awareness helps to ensure delivery of care that is aligned with the patient's goals. Understanding factors associated with poor prognostic awareness in older adults with cancer may help identify which patients may need interventions to improve prognostic awareness. In this study, we assessed factors associated with poor prognostic awareness in older adults with cancer. MATERIALS AND METHODS: We conducted a cross-sectional analysis of older patients with cancer referred to a geriatric oncology clinic at the University of Rochester. We provided paper questionnaires for patients to complete prior to their clinic assessment. Questionnaires asked patients to estimate their overall life expectancy and the life expectancy of a person of the same age with normal health. Prognostic awareness was considered poor if patients estimated living at least as long as a person of the same age with normal health. We assessed independent demographic and clinical variables (age, sex, race, income, religion, living situation, education, marital status, and cancer type and stage), aging-related factors (comorbidities, cognition, depression, social support, nutritional status, and physical function), and willingness to discuss prognosis. Factors significant at p ≤ 0.15 on bivariate analyses were included in the multivariable logistic regression model. RESULTS: We included 257 patients; the mean age was 80 years (standard deviation [SD] 6.8, range 55-97), 37% were female, 71% were White, and 44% were married. Nearly two-thirds of patients (62%) had poor prognostic awareness: 7% estimated they would live longer than and 55% estimated they would live as long as a person of the same age with normal health. Half (49%) were willing to discuss prognosis, 29% were not, and 22% did not answer. On multivariable analysis, factors associated with poor prognostic awareness were older age [one-year increase; adjusted odds ratio (AOR) 1.07, 95% confidence interval (CI) 1.02-1.12], race other than White (AOR 2.35, 95% CI 1.09-5.06), unwillingness to discuss prognosis (AOR 3.33, 95% CI 1.54-7.18), and stage I-III cancer (vs. stage IV, AOR 3.83, 95% CI 1.8-8.17). DISCUSSION: In a cohort of older patients with cancer, approximately two-thirds had poor prognostic awareness. Older age, race other than White, stage I-III cancer, and unwillingness to discuss prognosis were associated with higher odds of poor prognostic awareness. Interventions aiming to improve patients' prognostic awareness may need to gauge patients' willingness to discuss prognosis.

Development and Standardization of an Osteoradionecrosis Classification System in Head and Neck Cancer: Implementation of a Risk-Based Model.

PURPOSE: Osteoradionecrosis of the jaw (ORN) can manifest in varying severity. The aim of this study is to identify ORN risk factors and develop a novel classification to depict the severity of ORN. METHODS: Consecutive patients with head and neck cancer (HNC) treated with curative-intent intensity-modulated radiation therapy (IMRT) (≥45 Gy) from 2011 to 2017 were included. Occurrence of ORN was identified from in-house prospective dental and clinical databases and charts. Multivariable logistic regression model was used to identify risk factors and stratify patients into high-risk and low-risk groups. A novel ORN classification system was developed to depict ORN severity by modifying existing systems and incorporating expert opinion. The performance of the novel system was compared with 15 existing systems for their ability to identify and predict serious ORN event (jaw fracture or requiring jaw resection). RESULTS: ORN was identified in 219 of 2,732 (8%) consecutive patients with HNC. Factors associated with high risk of ORN were oral cavity or oropharyngeal primaries, received IMRT dose ≥60 Gy, current/ex-smokers, and/or stage III to IV periodontal condition. The ORN rate for high-risk versus low-risk patients was 12.7% versus 3.1% (P < .001) with an AUC of 0.71. Existing ORN systems overclassified serious ORN events and failed to recognize maxillary ORN. A novel ORN classification system, ClinRad, was proposed on the basis of vertical extent of bone necrosis and presence/absence of exposed bone/fistula. This system detected serious ORN events in 5.7% of patients and statistically outperformed existing systems. CONCLUSION: We identified risk factors for ORN and proposed a novel ORN classification system on the basis of vertical extent of bone necrosis and presence/absence of exposed bone/fistula. It outperformed existing systems in depicting the seriousness of ORN and may facilitate clinical care and clinical trials.

Prevention and Management of Osteoradionecrosis in Patients With Head and Neck Cancer Treated With Radiation Therapy: ISOO-MASCC-ASCO Guideline.

PURPOSE: To provide evidence-based recommendations for prevention and management of osteoradionecrosis (ORN) of the jaw secondary to head and neck radiation therapy in patients with cancer. METHODS: The International Society of Oral Oncology-Multinational Association for Supportive Care in Cancer (ISOO-MASCC) and ASCO convened a multidisciplinary Expert Panel to evaluate the evidence and formulate recommendations. PubMed, EMBASE, and Cochrane Library databases were searched for randomized controlled trials and observational studies, published between January 1, 2009, and December 1, 2023. The guideline also incorporated systematic reviews conducted by ISOO-MASCC, which included studies published from January 1, 1990, through December 31, 2008. RESULTS: A total of 1,539 publications were initially identified. There were 487 duplicate publications, resulting in 1,052 studies screened by abstract, 104 screened by full text, and 80 included for systematic review evaluation. RECOMMENDATIONS: Due to limitations of available evidence, the guideline relied on informal consensus for some recommendations. Recommendations that were deemed evidence-based with strong evidence by the Expert Panel were those pertaining to best practices in prevention of ORN and surgical management. No recommendation was possible for the utilization of leukocyte- and platelet-rich fibrin or photobiomodulation for prevention of ORN. The use of hyperbaric oxygen in prevention and management of ORN remains largely unjustified, with limited evidence to support its practice.Additional information is available at www.asco.org/head-neck-cancer-guidelines.