Primary Intraosseous Spindle Cell Rhabdomyosarcoma: A Case Report in an Unusual Location.

Spindle cell/sclerosing rhabdomyosarcoma is an infrequent subtype of rhabdomyosarcoma according to the World Health Organization Classification of Soft Tissue and Bone Tumours, which includes a novel category of intraosseous spindle-cell rhabdomyosarcomas (ISCRMS) with EWSR1:: or FUS::TFCP2 fusions. We report a case of ISCRMS with EWSR1::TFCP2 fusion presenting in the femur mimicking osteosarcoma in this unusual primary location. We present an 18-year-old male with relapsed widely metastatic sarcoma, morphologically identical to osteosarcoma responding poorly to chemotherapy, initially presenting in the distal femur. Sections showed a high-grade malignant neoplasm with sheets of epithelioid and spindled cells without obvious rhabdomyoblastic differentiation morphologically containing focal areas resembling new bone/osteoid formation. Molecular sequencing identified t(12;22) EWSR1::TFCP2. The tumor cells were diffusely positive for pancytokeratin, MyoD1, and ALK by retrospective immunohistochemistry. Desmin and SATB2 were focally positive. Myogenin was negative, and INI-1 expression was retained. ISCRMS commonly involves craniofacial and pelvic bones, but rarely originates in long bones, as in this case. Initially, osteosarcoma was the primary diagnostic consideration based on distal long bone location, patient age, and evidence of osteoid formation. Distinction between the two entities may be nearly impossible on morphologic grounds alone, which presents a diagnostic pitfall without molecular or extensive immunoprofiling data.

Comparing internal versus external carotid artery branch delivery of intraarterial chemotherapy for the treatment of retinoblastoma.

PURPOSE: The goal of this study was to compare the efficacy of intraarterial chemotherapy (IAC) for retinoblastoma delivered via the ophthalmic artery (OA) division of the internal carotid artery (ICA) versus alternative branches of the external carotid artery (ECA). METHODS: We performed a retrospective chart review of patients receiving IAC for retinoblastoma at a single institution. Subjects were divided into three groups: those that received IAC solely through the OA branch of the ICA, those that initially received IAC through the OA branch of the ICA but were later switched to the ECA, and those that only received IAC through the ECA. The main outcomes compared included globe salvage rate and reduction in tumor thickness and size. RESULTS: A total of 30 eyes from 26 patients were included. A total of 91 (58%) sessions of IAC were performed through the OA division of the ICA and 65 (42%) were performed through branches of the ECA. Eleven eyes (37%) solely received IAC through the OA branch of the ICA, 16 eyes (53%) were converted to ECA treatment, and 3 eyes solely received IAC through branches of the ECA. Statistical analysis did not show any significant difference in globe salvage rate or reduction in tumor thickness and size. CONCLUSION: The use of alternative approaches for IAC when the OA branch of the ICA catheterization is not feasible allows for safe continued delivery of highly effective IAC, leading to similar outcomes in terms of globe salvage and reduction in tumor size.

Neuropsychological assessment in pediatric oncology survivorship care: utilization of services, results of evaluation, and educational and behavioral health outcomes.

PURPOSE: Neuropsychological evaluation has become a standard component of long-term follow-up care for survivors of pediatric cancer. The purpose of the present study was to examine access to, and benefits of, neuropsychological evaluation for survivors. METHODS: A retrospective chart review was conducted on cancer survivors who were referred for neuropsychological evaluation from a multidisciplinary long-term follow-up (LTFU) clinic approximately 5 years following treatment cessation. Descriptive statistics were calculated, and t-tests and chi-square analyses were utilized to examine variables that may impact survivors' access to neuropsychological services. RESULTS: One hundred seven survivors between 6 and 26 years old were referred for a neuropsychological evaluation. Referred male patients were less likely than female patients to schedule an evaluation. Consultation with a neuropsychologist in the LTFU clinic was related to more referrals but did not improve attrition rates (55%). Twenty-four percent of evaluated patients displayed severe cognitive impairment and 75% were diagnosed with a psychological disorder. Utilization of educational and behavioral health services did not significantly change following evaluation. CONCLUSION: Survivors' utilization of neuropsychological services is lower for males than females. The presence of a neuropsychologist in a multidisciplinary team clinic can improve identification of survivors that may benefit from neuropsychological evaluation. Many survivors did not receive recommended services, suggesting patients and families may need additional supports following evaluation. Future research should focus on improving survivors' access to neuropsychological services and identifying barriers to receiving recommended services.

Appraisal of Washington State workers' compensation-based return-to-work programs and suggested system improvements: A survey of workers with permanent impairments.

BACKGROUND: Following a work-related permanent impairment, injured workers commonly face barriers to safe and successful return to work (RTW). Examining workers' experiences with the workers' compensation (WC) system could highlight opportunities to improve RTW outcomes. Objectives included summarizing workers': (1) appraisal of several WC-based RTW programs, and (2) suggestions for vocational rehabilitation and WC system improvements to promote safe and sustained RTW. METHODS: In telephone interviews, 582 Washington State workers with work-related permanent impairments were asked whether participation in specified WC-based RTW programs helped them RTW and/or stay at work. Suggestions for program and system improvements were solicited using open-ended questions; qualitative content analysis methods were used to inductively code responses. RESULTS: Most respondents reported positive impacts from RTW program participation; for example, 62.5% of vocational rehabilitation participants reported it helped them RTW, and 51.7% reported it helped them stay at work. Among 582 respondents, 28.0% reported that no change was needed to the WC system, while 57.6% provided suggestions or critiques. Reduce delays/simplify process/improve efficiency was the most frequent WC system theme-mentioned by 34.9%. Among 120 vocational rehabilitation participants, 35.8% reported that no change was needed to vocational rehabilitation, while 46.7% (N = 56) provided suggestions or critiques. More worker choice/input into the vocational retraining plan was the most frequent vocational rehabilitation theme-mentioned by 33.9%. CONCLUSIONS: This study's findings suggest that there is substantial room for improvement in workers' experience with the WC system. In addition, injured workers' feedback may reflect opportunities to reduce administrative burden and to improve worker health and RTW outcomes.

Workplace improvements to support safe and sustained return to work: Suggestions from a survey of workers with permanent impairments.

BACKGROUND: Roughly 10% of occupational injuries result in permanent impairment. After initial return to work (RTW), many workers with permanent impairments face RTW interruption due to reinjury, unstable health, disability, and layoff. This study used open-ended survey data to: (1) explore workplace factors identified by workers as important levers for change, some of which may previously have been unrecognized; and (2) summarize workers' suggestions for workplace improvements to promote sustained RTW and prevent reinjury. METHODS: This study included data from workers' compensation claims and telephone surveys of 582 Washington State workers who had RTW after a work-related injury involving permanent impairment. The survey was conducted in 2019, about a year after claim closure. We used qualitative content analysis methods to inductively code open-ended survey responses. RESULTS: The most frequent themes were: safety precautions/safer workplace (18.1%), adequate staffing/appropriate task distribution (16.2%), and safety climate (14.1%). Other frequent themes included ergonomics, rest breaks, job strain, predictability and flexibility in work scheduling practices, employer response to injury, social support, communication, and respect. Many workers reported that they were not listened to, or that their input was not sought or valued. Workers often linked communication deficiencies to preventable deficiencies in safety practices, safety climate, and RTW practices, and also to lack of respect or distrust. In counterpoint, nearly one-third of respondents reported that no change was needed to their workplace. CONCLUSIONS: Policies and interventions targeting worker-suggested workplace improvements may promote safe and sustained RTW, which is essential for worker health and economic stability.

The role of nonstandard and precarious jobs in the well-being of disabled workers during workforce reintegration.

BACKGROUND: Nonstandard employment arrangements are becoming increasingly common and could provide needed flexibility for workers living with disabilities. However, these arrangements may indicate precarious employment, that is, employment characterized by instability, powerlessness, and limited worker rights and benefits. Little is known about the role of nonstandard and precarious jobs in the well-being of disabled persons during workforce reintegration after permanent impairment from work-related injuries or illnesses. METHODS: We used linked survey and administrative data for a sample of 442 Washington State workers who recently returned to work and received a workers' compensation permanent partial disability award after permanent impairment from a work-related injury. Multivariable logistic regression models were used to examine associations between nonstandard employment and outcomes related to worker well-being and sustained employment. We also examined associations between a multidimensional measure of precarious employment and these outcomes. Secondarily, qualitative content analysis methods were used to code worker suggestions on how workplaces could support sustained return to work (RTW). RESULTS: Workers in: (1) nonstandard jobs (compared with full-time, permanent jobs), and (2) precarious jobs (compared with less precarious jobs) had higher adjusted odds of low expectations for sustained RTW. Additionally, workers in precarious jobs had higher odds of reporting fair or poor health and unmet need for disability accommodation. Workers in nonstandard and precarious jobs frequently reported wanting safer and adequately staffed workplaces to ensure safety and maintain sustained employment. CONCLUSIONS: Ensuring safe, secure employment for disabled workers could play an important role in their well-being and sustained RTW.

Geographic differences in receipt of addictions treatment in a national sample of patients with alcohol use disorders from the U.S. Veterans Health Administration.

Background: In the United States, alcohol use disorder (AUD) is common and costly but substantially undertreated. Rurality is an important determinant of health that may influence receipt of evidence-based alcohol-related care. In a large, national sample of Veterans Health Administration (VA) patients with AUD with documented and non-Hispanic Black, Hispanic, or non-Hispanic White race/ethnicity, we examine whether meeting national Healthcare Effectiveness Data and Information Set (HEDIS) quality measures for specialty addictions care and receiving evidence-based medications for AUD differs across patients living in urban, large rural, and small rural areas. Methods: VA electronic health record data were used to identify all patients with AUD documented in Fiscal Year 2012. Rurality was measured using a three-category rural and urban commuting area (RUCA) classification linked to patient zip code. Logistic regression models with clustered standard errors-iteratively adjusted for hypothesized confounders-were used to estimate the likelihood and marginal probabilities of receiving care for patients living in small and large rural areas, relative to urban areas. Primary outcomes included HEDIS initiation (any visit within 14 days of initial AUD visit after a 60-day period of no treatment), HEDIS engagement (2 or more AUD visits within 30 days of HEDIS initiation visit) and having any filled prescription for AUD medications (naltrexone, disulfiram, acamprosate, or topiramate). Results: For all outcomes, patients living in large and small rural areas had a lower likelihood of receiving evidence-based AUD treatment than patients living in urban areas (all p-values < 0.05); differences in marginal probabilities across groups were relatively small. Conclusions: In this national sample of VA patients with AUD, those living in more rural areas were less likely to receive evidence-based treatment for AUD than those living in urban areas. Further research is needed to investigate strategies to increase receipt of specialty care and pharmacotherapy in more rural areas.

Implementation of Opioid Safety Efforts: Influence of Academic Detailing on Adverse Outcomes Among Patients in the Veterans Health Administration.

BACKGROUND: The Veterans Health Administration (VA) implemented academic detailing (AD) to support safer opioid prescribing and overdose prevention initiatives. METHODS: Patient-level data were extracted monthly from VA's electronic health record to evaluate whether AD implementation was associated with changes in all-cause mortality, opioid poisoning inpatient admissions, and opioid poisoning emergency department (ED) visits in an observational cohort of patients with long-term opioid prescriptions (≥45-day supply of opioids 6 months prior to a given month with ≤15 days between prescriptions). A single-group interrupted time series analysis using segmented logistic regression for mortality and Poisson regression for counts of inpatient admissions and ED visits was used to identify whether the level and slope of these outcomes changed in response to AD implementation. RESULTS: Among 955 376 unique patients (19 431 241 person-months), there were 53 369 deaths (29 025 pre-AD; 24 344 post-AD), 1927 opioid poisoning inpatient admissions (610 pre-AD; 1317 post-AD), and 408 opioid poisoning ED visits (207 pre-AD; 201 post-AD). Immediately after AD implementation, there was a 5.8% reduction in the odds of all-cause mortality (95% confidence interval [CI]: 0.897, 0.990). However, patients had a significantly increased incidence rate of inpatient admissions for opioid poisoning immediately after AD implementation (incidence rate ratio = 1.523; 95% CI: 1.118, 2.077). No significant differences in ED visits for opioid poisoning were observed. CONCLUSIONS: AD was associated with decreased all-cause mortality but increased inpatient hospitalization for opioid poisoning among patients prescribed long-term opioids. Mechanisms via which AD's efforts influenced opioid-related outcomes should be explored.

Scleral ectasia stabilization following intra-arterial chemotherapy in an eye with recurrent retinoblastoma.

Purpose: To report a case of recurrent retinoblastoma following transpupillary thermotherapy (TTT) with development of scleral ectasia, as well as their successful treatment with intra-arterial chemotherapy. Observations: A 15-month-old girl with bilateral retinoblastoma presented with recurrent retinoblastoma and associated scleral ectasia with concern for extraocular extension after receiving multiple round of systemic chemotherapy and TTT. Given her negative systemic evaluation, decision was made to pursue intra-arterial chemotherapy. After completion of six rounds of 3-agent intra-arterial chemotherapy, the recurrent retinoblastoma had completely regressed and the scleral ectasia had improved and fibrosed. Conclusions and importance: The sclera is classically viewed as hyperthermy-resistant to TTT. Here, we describe scleral ectasia due to aggressive TTT with recurrence of the retinoblastoma. Our treatment with intra-arterial chemotherapy not only caused complete regression of the recurrent retinoblastoma, but it also contributed to the stabilization and improvement of the weakened scleral.

Workplace Wellness Program Interest and Barriers Among Workers With Work-Related Permanent Impairments.

BACKGROUND: Nearly half of U.S. workers have access to workplace wellness programs (WWPs), 58% of workers with access participate. The aim of this study was to assess interest in WWP participation and identify reasons for lack of interest among workers with work-related permanent impairments-a population at elevated risk of adverse health outcomes. METHODS: Workers who returned to work after a work-related permanent impairment were interviewed 11 to 15 months after workers' compensation claim closure. Qualitative content analysis methods were used to code open-ended responses. FINDINGS: Of 560 respondents, 51.4% expressed interest in WWP participation. Numerous adverse health and economic characteristics were associated with WWP interest, for example, interest was expressed by 63.3% of workers reporting fair/poor health status versus 47.1% reporting good/excellent; 56.9% of workers reporting moderate/severe pain versus 41.4% reporting mild/no pain; 64.7% of workers without health insurance versus 50.1% with health insurance; 69.0% of workers reporting depression versus 47.2% without depression; 70.4% of workers reporting obesity versus 48.0% without obesity; and 63.2% of workers often worried about expenses versus 46.9% reporting sometimes/never worried. Specific participation barriers were described by 34.2% of the 272 workers who were not interested. CONCLUSIONS/APPLICATIONS TO PRACTICE: A majority of workers with work-related permanent impairments-particularly those with adverse health and economic characteristics-were interested in WWPs. Many workers who reported no interest cited participation barriers. Further research is needed to determine whether addressing such barriers would enhance equitable access. Those undertaking WWP planning, implementation, and outreach should ensure that WWPs are inclusive and serve workers with disabilities.