Functional swallowing outcomes related to radiation exposure to dysphagia and aspiration-related structures in patients with head and neck cancer undergoing definitive and postoperative intensity-modulated radiotherapy.

BACKGROUND: The relationship between swallowing outcomes and radiotherapy dose to dysphagia and aspiration-related structures (DARS) may be different following definitive versus postoperative radiotherapy (PORT) for mucosal head and neck cancer (HNC) and has not been well-studied. METHOD: Patient- and clinician-reported swallowing measures were prospectively collected at six time points from baseline to 24 months postradiotherapy HNC. Radiotherapy plans were retrospectively analyzed to assess dose delivered to DARS. The association between swallowing outcomes and participant demographics, tumor characteristics, and radiotherapy dose in definitive and postoperative treatment cohorts was assessed. RESULTS: Ninety-three participants who received radiotherapy for HNC were included in the analysis (n = 49 definitive radiotherapy for laryngeal/pharyngeal primary tumors and n = 44 postoperative PORT for predominantly oral cavity/salivary gland tumors). Participants undergoing PORT had lower doses to DARS than those undergoing definitive RT. High dose to the pharyngeal constrictors and base of tongue for definitive RT and the esophageal inlet, supraglottic larynx and cervical esophagus for the PORT group were associated with worse swallowing function. CONCLUSION: Radiation dose to DARS is associated with post-treatment swallowing outcomes. These dose/outcome relationships may vary between the definitive and postoperative settings.

Association between vitamin D deficiency and exercise capacity in patients with CKD, a cross-sectional analysis.

BACKGROUND: Evidence is growing for a role of vitamin D in regulating skeletal muscle mass, strength and functional capacity. Given the role the kidneys play in activating total vitamin D, and the high prevalence of vitamin D deficiency in Chronic Kidney Disease (CKD), it is possible that deficiency contributes to the low levels of physical function and muscle mass in these patients. METHODS: This is a secondary cross-sectional analysis of previously published interventional study, with in vitro follow up work. 34 CKD patients at stages G3b-5 (eGFR 25.5 ± 8.3 mL/min/1.73m2; age 61 ± 12 years) were recruited, with a sub-group (n = 20) also donating a muscle biopsy. Vitamin D and associated metabolites were analysed in plasma by liquid chromatography tandem-mass spectroscopy and correlated to a range of physiological tests of muscle size, function, exercise capacity and body composition. The effects of 1α,25(OH)2D3 supplementation on myogenesis and myotube size was investigated in primary skeletal muscle cells from vitamin D deficient donors. RESULTS: In vivo, there was no association between total or active vitamin D and muscle size or strength, but a significant correlation with V̇O2Peak was seen with total vitamin D (25OHD). in vitro, 1α,25(OH)2D3 supplementation reduced IL-6 mRNA expression, but had no effect upon proliferation, differentiation or myotube diameter. CONCLUSIONS: Vitamin D deficiency is not a prominent factor driving the loss of muscle mass in CKD, but may play a role in reduced exercise capacity.

Fibrotic interstitial lung disease - palliative care needs: a World-Café qualitative study.

OBJECTIVES: The importance of palliative care in those with advanced fibrotic interstitial lung diseases (F-ILD) is recognised, but the palliative care requirements of patients and caregivers affected by F-ILD regardless of disease course are not established. We set out to explore this and identify optimal solutions in meeting the needs of a F-ILD population in Ireland. METHODS: Implementing a World-Café qualitative research approach, we captured insights evolving, iteratively in interactive small group discussions in response to six predefined topics on palliative care and planning for the future. Thirty-nine stakeholders participated in the World-Café including 12 patients, 13 caregivers, 9 healthcare professionals, 4 industry representatives and 1 representative of the clergy. RESULTS: Palliative care emerged as fundamental to the care and treatment of F-ILDs, regardless of disease progression. Unmet palliative care needs were identified as psychological and social support, disease education, inclusion of caregivers and practical/legal advice for disease progression and end-of-life planning. Participants identified diagnosis as a particularly distressing time for patients and families. They called for the introduction of palliative care discussions at this early-stage alongside improvements in integrated care, specifically increasing the involvement of primary care practitioners in referrals to palliative services. CONCLUSION: Patients and caregivers need discussions on palliative care associated with F-ILD to be included at the point of diagnosis. This approach may address persisting inadequacies in service provision previously identified over the course of the last decade in the UK, Ireland and European F-ILD patient charters.

Expanding your gay and lesbian patient base: what savvy medical practices know.

Many medical practices are looking at options to reach out to the gay, lesbian, bisexual, and transgender community as a means of expanding business and improving quality of care. This article sets out steps that any practice can take to market to this community and improve its cultural competence.

Satellite cell function, intramuscular inflammation and exercise in chronic kidney disease.

Skeletal muscle wasting is a common feature of chronic kidney disease (CKD) and is clinically relevant due to associations with quality of life, physical functioning, mortality and a number of comorbidities. Satellite cells (SCs) are a population of skeletal muscle progenitor cells responsible for accrual and maintenance of muscle mass by providing new nuclei to myofibres. Recent evidence from animal models and human studies indicates CKD may negatively affect SC abundance and function in response to stimuli such as exercise and damage. The aim of this review is to collate recent literature on the effect of CKD on SCs, with a particular focus on the myogenic response to exercise in this population. Exercise is widely recognized as important for the maintenance of healthy skeletal muscle mass and is increasingly advocated in the care of a number of chronic conditions. Therefore a greater understanding of the impact of uraemia upon SCs and the possible altered myogenic response in CKD is required to inform strategies to prevent uraemic cachexia.

The utility of linked cancer registry and health administration data for describing system-wide outcomes and research: a BreastScreen example.

RATIONALE, AIMS AND OBJECTIVES: Stratification of women with screen-detected ductal carcinoma in situ (DCIS) by risk of subsequent invasive breast cancer (IBC) could assist treatment planning and selection of surveillance protocols that accord with risk. We assessed the utility of routinely collected administrative data for stratifying by IBC risk following DCIS detection in a population-based screening programme to inform ongoing surveillance protocols. METHODS: A retrospective cohort design was used, employing linked data from the South Australian breast screening programme and cancer registry. Women entered the study at screening commencement and were followed until IBC diagnosis, death or end of the study period (1 December 2010), whichever came first. Routinely collected administrative data were analyzed to identify predictors of invasive breast cancer. RESULTS: Proportional hazards regression confirmed that the DCIS cohort had an elevated risk of IBC after adjustment for relevant confounders (HR = 4.0 (95% CL 3.4, 4.8)), which accorded with previous study results. Within the DCIS cohort, conservative breast surgery and earlier year of screening commencement were both predictive of an elevated invasive breast cancer risk. CONCLUSIONS: These linked cancer registry and administrative data gave plausible estimates of IBC risk following DCIS diagnosis, but were limited in coverage of key items for further risk stratification. It is important that the research utility of administrative datasets is maximized in their design phase in collaboration with researchers.

Changes in peripheral blood B cell subsets at diagnosis and after treatment with disease-modifying anti-rheumatic drugs in patients with rheumatoid arthritis: correlation with clinical and laboratory parameters.

OBJECTIVE: To assess variation in peripheral blood B lymphocyte subsets in rheumatoid arthritis (RA). METHODS: B lymphocyte subsets in disease-modifying anti-rheumatic drug (DMARD)-naïve patients with RA (n = 30), patients with RA treated with DMARDs (n = 73) and healthy controls (n = 46) were analyzed by flow cytometry. Total B cells, total memory B cells, immunoglobulin M (IgM) memory B cells, switched memory B cells, non-switched memory B cells, CD21lo B cells, transitional B cells and plasmablasts were measured. Correlation with clinical and laboratory parameters was performed. RESULTS: Total memory B cells, IgM memory B cells and non-switched memory B cells were reduced in RA patients at diagnosis compared to controls (P < 0.05). In patients with treated RA, there was a further reduction of total B cells, CD21lo cells, transitional B cells and plasmablasts, compared to controls (P < 0.05). The reduction in absolute numbers of total B cells, switched memory B cells, CD21lo cells, transitional B cells and plasmablasts in treated RA patients was significant (P < 0.05) even when compared to the DMARD-naïve patients. Only treatment responders (Disease Activity Score < 3.2) had reduced total B cells and absolute numbers of switched and IgM memory B cells (P < 0.05). In patients requiring leflunomide, total memory B cells, IgM memory B cells, non-switched memory B cells and absolute numbers of switched memory B cells were reduced compared with the remainder of the patient group (P < 0.05). CONCLUSION: There is reduction of various B cell subsets in RA patients at diagnosis. Treatment with DMARDs leads to further reduction in additional B cell subsets without correction of the abnormalities. Reduction in individual subsets may predict RA patients requiring more intensive therapy.

Risk profile of breast cancer following atypical hyperplasia detected through organized screening.

BACKGROUND: Few population-based data are available indicating the breast cancer risk following detection of atypia within a breast screening program. METHODS: Prospectively collected data from the South Australian screening program were linked with the state cancer registry. Absolute and relative breast cancer risk estimates were calculated for ADH and ALH separately, and by age at diagnosis and time since diagnosis. Post-hoc analysis was undertaken of the effect of family history on breast cancer risk. RESULTS: Women with ADH and ALH had an increase in relative risk for malignancy (ADH HR 2.81 [95% CI 1.72, 4.59] and (ALH HR 4.14 [95% CI 1.97, 8.69], respectively. Differences in risk profile according to time since diagnosis and age at diagnosis were not statistically significant. CONCLUSION: Estimates of the relative risk of breast cancer are necessary to inform decisions regarding clinical management and/or treatment of women with ADH and ALH.

Mortality risk after head injury increases at 30 years.

BACKGROUND: Age has long been recognized as a critical factor in predicting outcomes after head injury, with individuals older than 60 years predicted to have a worse outcome than those younger than 60. The object of this study was to determine the effect of age by decade of life beginning at birth in patients with head injuries of all levels of severity. STUDY DESIGN: The New York State Trauma Registry was searched for head injuries from January 1, 1994 to December 31, 1995; the 13,908 cases found were placed into age groups by decade. Data were sought for each patient on demographics, Glasgow Coma Score, ICD-9 injury code, New Injury Severity Score (NISS), and mechanism of injury. These data were analyzed with chi-square and one-way ANOVA tests, with significance set at p < 0.05. RESULTS: The risk of dying was significantly increased in patients beginning at 30 years of age compared with those in the younger age groups, with the greatest increases occurring after age 60 (p < 0.001). For the population with available Glasgow Coma Score data (n = 12,844), the mortality rate for patients ages 0 to 30 was 10.9%, and for patients ages 31 to 50 was 12.4%. The mean Glasgow Coma Score for nonsurvivors ages 0 to 20 (3.9) and for nonsurvivors ages 31 to 50 (5.1) were significantly different, with a risk ratio of 1.3 (p < 0.001). CONCLUSIONS: The risk of dying for patients suffering head injuries increases as early as 30 years of age, making it necessary for health-care providers to consider increased monitoring and treatment for patients in this younger age group.

Highly interactive multi-session programs impact physician behavior on hypertension management: outcomes of a new CME model.

There has been much discussion and study about the role of continuing medical education (CME) in improving patient care. The authors describe the processes used to develop and implement a series of live, half-day, highly interactive CME events that addressed knowledge, competency, and performance gaps in hypertension diagnosis and management in the primary care community and successfully changed physician behavior toward improved patient outcomes. Participation in an intensive, highly interactive, case-based didactic program was significantly associated with an increase in clinician knowledge and competency in diagnosing and managing patients with hypertension. Participation was also associated with a high likelihood for practice change and making guideline-driven and evidence-based decisions to positively impact patient care. A greater portion of participants were able to identify the appropriate blood pressure goal and select the most appropriate pharmacotherapy regimen for specific patients. Quality of education index indicated that participants were 52% more likely to practice guideline-driven and evidence-based medicine than those who did not participate in the CME activity.

Determination of national pediatric injury prevention priorities using the Injury Prevention Priority Score.

PURPOSE: Previous studies have found that the Injury Prevention Priority Score (IPPS) provides a reliable and valid method to gauge the relative importance of different injury causal mechanisms at individual trauma centers. This study examines its applicability to prioritizing injury mechanisms on a national level and within defined pediatric age groups. METHODS: A total of 47,158 patients (age <17) in the National Pediatric Trauma Registry were grouped into common injury mechanisms based on ICD-9 E-Codes. Patients also were stratified by age group. IPPS was calculated for each mechanism and within each age group. RESULTS: Falls of all types account for the greatest number of injuries (n = 15,042; 32%), whereas child abuse results in the most severe injuries (mean Injury Severity Score, 13.3) However, the most significant mechanisms of injury, according to IPPS, were motor vehicle crashes followed by pedestrian struck by motor vehicles. Certain age groups had specific injury problems including child abuse in infants and assault and gun injuries in adolescents. CONCLUSIONS: IPPS provides an objective, quantitative method for determining injury prevention priorities based on both frequency and severity at the national level. It also is sensitive to age-related changes in different mechanisms of injury.