The Role of Outpatient Physical Medicine and Rehabilitation in a Multidisciplinary Prehabilitation Program for Older Adults before Allogeneic Hematopoietic Stem Cell Transplant.

INTRODUCTION: Physical rehabilitation is increasingly incorporated throughout the allogeneic hematopoietic stem cell transplant (allo-HSCT) journey for older adults. OBJECTIVE: This study aimed to describe physical medicine and rehabilitation (PM&R)-related diagnoses, exercise barriers, and management recommendations for older adults before allo-HSCT. DESIGN: Fifty PM&R consults as part of the Enhanced Recovery-Stem Cell Transplant (ER-SCT) multidisciplinary prehabilitation program at a comprehensive cancer center were retrospectively reviewed. RESULTS: Many PM&R-related diagnoses (173), exercise barriers (55), and management recommendations (112) were found. Common diagnoses were musculoskeletal dysfunction (more commonly back, shoulder, then knee) (n = 39, 23%) and fatigue (n = 36, 21%). Common exercise barriers were also musculoskeletal dysfunction (more commonly back, knee, then shoulder) (total n = 20, 36%) and fatigue (n = 20, 36%). Most patients (n = 32, 64%) had 1 or more exercise barriers. Common PM&R management recommendations were personalized exercise counseling (n = 37, 33%), personalized nutrition management (n = 19, 17%), body composition recommendations (n = 17, 15%), medications (n = 15, 13%), and orthotics and durable medical equipment (n = 8, 7%). CONCLUSION: Routine PM&R referral of older allo-HSCT patients for prehabilitation resulted in the identification of many rehabilitative needs and substantial additional management recommendations. Increased early, collaborative prehabilitation efforts between PM&R and allo-HSCT teams to optimize care for these patients is recommended.

The molecular mechanism of obesity: The science behind natural exercise yoga and healthy diets in the treatment of obesity.

The review centers on the scientific evidence underlying obesity, providing a detailed examination of the role of perilipin in this condition. It explores potential causes of obesity and delves into therapeutic approaches involving exercise, yoga, and herbal treatments. The paper discusses natural sources that can contribute to combating obesity and underscores the importance of exercise in a scientific context for overcoming obesity. Additionally, it includes information on herbal ingredients that aid in reducing obesity. The review also examines the impact of exercise type and intensity at various time intervals on muscle development. It elucidates triglyceride hydrolysis through different enzymes and the deposition of fatty acids in adipose tissue. The mechanisms by which alpha/beta hydrolase domain-containing protein 5 (ABHD5) and hormone-sensitive lipase (HSL) target and activate their functions are detailed. The inflammatory response in obesity is explored, encompassing inflammatory markers, lipid storage diseases, and their classification with molecular mechanisms. Furthermore, the hormonal regulation of lipolysis is elaborated upon in the review.

Knowledge, attitudes, and beliefs of oncology trainees on function and cancer rehabilitation medicine.

BACKGROUND: Improved function is associated with reduced morbidity and mortality in patients with cancer. Cancer rehabilitation medicine (CRM) is a subspecialty of physical medicine and rehabilitation (PM&R) that focuses on improving function in patients with cancer. One of the barriers to patients accessing CRM services is the lack of referrals from oncology providers. Understanding the knowledge, attitudes and beliefs of oncology trainees regarding the importance of function and the role of CRM is essential to reducing educational gaps and improving patients' access to essential rehabilitation services. OBJECTIVE: To determine oncology trainees' knowledge, attitude and beliefs about the importance of function and the role of CRM in the care of patients with cancer. SETTING: The study was conducted at a comprehensive cancer center in the United States. INTERVENTION: Descriptive survey study was administered to postgraduate oncology trainees who spent at least 1 day a week providing patient care. MAIN OUTCOME: Participants' report of their knowledge, attitudes, and beliefs on the importance of function and CRM in the care of patients with cancer. RESULTS: The survey was sent to 197 oncology trainees with a response rate of 67% (n = 132) and 126 were ultimately included. All participants believed that function is important in the care of patients with cancer. The majority believed that better function improves treatment tolerance (94%) and survival (84%). Most reported that having CRM physicians (80%) and an inpatient rehabilitation unit (88%) in the oncological setting is important; however, most participants reported that they refer fewer than 25% of their patients to CRM services. Participants with prior exposure to PM&R were significantly more likely to consult PM&R compared to those without exposure (p = .005). Most oncology trainees (81%) believed that education in CRM should be part of their oncology training. CONCLUSION: This study demonstrates that oncology trainees believe that function is important. They also believe that access to CRM would improve treatment tolerance and survival, but most report that they rarely refer patients to CRM services. Most trainees desire increased exposure to CRM during oncology training.

Effect of Vitamin D Supplementation on CD4 Count in HIV-Infected Children and Adolescents in North India: A Non-Randomized Comparative Study.

BACKGROUND: HIV infection is still a serious public health issue globally. Suboptimal vitamin D status is highly prevalent in HIV-infected children and adolescents throughout the world. OBJECTIVES: To evaluate the outcome of vitamin D supplementation on CD4 count in HIV-infected children and adolescents with suboptimal vitamin D status. METHODS: Vitamin D level of HIV-infected children and adolescents were measured at enrolment. Suboptimal vitamin D level was defined as 25(OH)D < 30 ng/ml. Vitamin D insufficiency and deficiency were defined as 21-29 and <20 ng/ml, respectively. Children with suboptimal vitamin D levels were supplemented with vitamin D. RESULTS: This was a single-centre, non-randomized comparative study enrolling 50 eligible participants. There were 20 patients who were vitamin D sufficient, 7 were vitamin D insufficient and 23 were found to be vitamin D deficient at enrolment. However, after supplementation, the status of sufficient remained same and 7 insufficient become sufficient, whereas in 23 deficient, 18 (78.3%) become sufficient and 5 (21.7%) become insufficient and this change was found statistically significant among the groups (χ2 = 6.52, p = 0.038). There was a significant improvement of CD4 count from baseline to 4 months in deficient group on vitamin D supplementation (p value < 0.001; 1.2-fold rise). No significant change was seen in vitamin D insufficient (p value = 0.791) and sufficient groups (p value = 0.168). CONCLUSION: Vitamin D should be supplemented in HIV-infected children on ART with low CD4 counts.

A Qualitative Exploration to Understand the Sexual Behavior and Needs of Young Adults: A Study Among College Students of Pune, India.

OBJECTIVE: Youth and adolescents are the priority population to target the interventions as risky behaviors persist and they contribute to almost half of the new Human immunodeficiency virus (HIV) infections. The youth in India have a unique and diverse need of sex health education. The present study was conducted with the objective to understand their sexual behavior and requirements of sexual health. METHODS: Focus group discussions were conducted among 74 college students, separately for boys and girls. The participant students were from different streams of education. The domains of enquiry were related to the relationships, risk behaviors, sources of information and use of technology for sex health education. The qualitative data was analyzed based on the themes and subthemes derived from these discussions. RESULTS: A majority of the youth favoured active involvement of parents, school teachers in sex health education. They suggested that better-informed parents lead to better-informed adolescents. Open discussion with experts was also desired by the students. The use of mobile/web based application for sex health education and awareness about HIV and sexually transmitted infections (STIs) was preferred, however, they suggested that based on personal requirements, individual need based counseling and guidance is important. CONCLUSIONS: Active parental involvement and open discussions on sexuality were the preferred options by the student to seek the knowledge and guidance. Innovative mobile application for sex health education will be useful for the young adults for information and communication. The study highlighted a need to develop a holistic approach to generate a culturally-sensitive sex health education and life skills model.

Barriers in the access, diagnosis and treatment completion for tuberculosis patients in central and western Nepal: A qualitative study among patients, community members and health care workers.

BACKGROUND: Nepal has achieved a significant reduction of TB incidence over the past decades. Nevertheless, TB patients continue to experience barriers in access, diagnosis and completion of the treatment. The main objective of this study was to explore the factors affecting the access to the health services, diagnosis and the treatment completion for TB patients in central and western Nepal. METHODS: Data were collected using in-depth interviews (IDI) with the TB patients (n = 4); Focus Group Discussions (FGDs) with TB suspected patients (n = 16); Semi Strucutred Interviews (SSIs) with health workers (n = 24) and traditional healers (n = 2); and FGDs with community members (n = 8). All data were audio recorded, transcribed and translated to English. All transcriptions underwent thematic analysis using qualitative data analysis software: Atlas.ti. RESULTS: Barriers to access to the health centre were the long distance, poor road conditions, and costs associated with travelling. In addition, lack of awareness of TB and its consequences, and the belief, prompted many respondents to visit traditional healers. Early diagnosis of TB was hindered by lack of trained health personnel to use the equipment, lack of equipment and irregular presence of health workers. Additional barriers that impeded the adherence and treatment completion were the need to visit health centre daily for DOTS treatment and associated constraints, complex treatment regimen, and the stigma. CONCLUSIONS: Barriers embedded in health services and care seekers' characteristics can be dealt by strengthening the peripheral health services. A continuous availability of (trained) human resources and equipment for diagnosis is critical. As well as increasing the awareness and collaborating with the traditional healers, health services utilization can be enhanced by compensating the costs associated with it, including the modification in current DOTS strategy by providing medicine for a longer term under the supervision of a family member, peer or a community volunteer.

Mobility Functional Outcomes of Neurofibromatosis Patients: A Preliminary Report.

OBJECTIVE: The aim of the study was to describe the mobility outcomes of neurofibromatosis (NF) patients who received acute inpatient rehabilitation. DESIGN: This is a retrospective study of 62 consecutive neurofibromatosis patients of any age who received physical medicine and rehabilitation consultations at a comprehensive cancer center. Postoperative, inpatient rehabilitation admission and discharge functional independence measures (FIM scores) of transfers and gait and length of hospital stay were obtained from 37 patients who were transferred to inpatient rehabilitation (acute rehabilitation) and 25 who had an alternative disposition (consultation only). RESULTS: Mean age was 34 yrs. Both groups had similar postoperative FIM transfer and gait scores; however, at approximately postoperative day 10, the consultation only group was discharged with median FIM of 5 (supervision level) as compared with the acute rehabilitation group FIM of 4 (P = 0.000). The acute rehabilitation group had improved mobility FIM scores from postoperative to rehabilitation admission and again from rehabilitation admission to discharge (P < 0.0001). At discharge, the acute rehabilitation group ambulated a significantly longer distance (500 f. vs. 300 ft) (P = 0.04). The median length of hospital stay for the acute rehabilitation and consultation only groups was 20 and 10 days, respectively (P = 0.004). CONCLUSIONS: Acute inpatient rehabilitation leads to improvement in mobility-associated FIM scores for neurofibromatosis patients minimizing caregiver needs at home.

Evaluating Disability Insurance Assistance as a Specific Intervention by Physiatrists at a Cancer Center.

Because of their expertise, physiatrists provide disability insurance assistance for cancer survivors. In this brief report, we perform a descriptive retrospective analysis of all new (354) outpatient physiatry consultations from January 1, 2009, to December 31, 2013, at a National Cancer Institute Comprehensive Cancer Center. Disability and/or work accommodations were brought up at some point with the physiatrist during the duration of their care for 131 (37%) of 354 patients. More than 90% of the discussions took place during the first visit. Of those patients who had a documented disability/employment discussion, 58 (44.3%) of 131 patients were originally referred for disability assistance specifically, and 58 (44.3%) of 131 also had disability insurance paperwork completed by the physiatrist. Outcomes of initial physiatry disability insurance assistance were 45 (77.6%) of 58 approved/renewed, 5 (8.6%) of 58 denied, and 8 (13.8%) of 58 unknown/died during the disability application process. The median form size was 33 (SD, 25.95) items. This study is the first of its kind and provides an initial look at work-related discussions and support with disability insurance paperwork as a specific intervention provided by physiatrists at a cancer center. The results are compelling and demonstrate that physiatrists frequently provide these interventions. These interventions take considerable time and effort but are generally successful.

Patient-Reported Usefulness of Acute Cancer Rehabilitation.

BACKGROUND: Cancer survivors often have unmet needs, and cancer rehabilitation is becoming an integral part of the continuum of care. Understanding the needs and satisfaction of patients undergoing cancer rehabilitation is important for the development of effective programs. OBJECTIVE: To determine the overall perception of acute inpatient cancer rehabilitation usefulness. DESIGN: Prospective study. SETTING: Acute inpatient cancer rehabilitation unit at a National Cancer Institute (NCI) Comprehensive Cancer Center. PARTICIPANTS: Patients admitted to the acute inpatient cancer rehabilitation unit from September 2014 to July 2015 were approached, and 200 patients enrolled with completed surveys. METHODS: Patients meeting study criteria were asked to complete a survey about their perception of the rehabilitation received; their attitudes and beliefs on their condition, treatment, functional independence; and their attitudes and beliefs on obtaining health information and psychosocial issues. MAIN OUTCOME MEASURES: Functional Independence Measure (FIM) scores, FIM efficiency, and results from an anonymous survey with a 22-item Likert-type scale at the end of patients' rehabilitation stay were analyzed. RESULTS: Of 327 patients admitted, 239 patients (73%) were approached, and 200 patients (84%) were enrolled with completed surveys. Patients agreed or strongly agreed that rehabilitation helped with improving physical function (n = 193, 97%), regaining physical independence (n = 181, 91%), and preparing to deal with self-care tasks (n = 183, 94%). Patients agreed that rehabilitation improved hope (n = 187, 94%), mood (n = 176, 84%), anxiety (n = 180, 90%), and spirituality (n = 182, 94%). FIM score improvements (from admission to discharge) and FIM efficiency (change in FIM score / length of stay) were significant in all functional domains. Overall, respondents believed that their rehabilitation stay was extremely good (n = 128, 64%) or very good (n = 60, 30%). CONCLUSIONS: Patients perceived their rehabilitation stay as beneficial in multiple respects. Significant improvements in FIM measurements were also found. LEVEL OF EVIDENCE: IV.

Efficacy of Natural Compounds in Neurodegenerative Disorders.

Neurodegenerative disorders represent clusters of serious diseases that results in progressive deterioration of normal structure and physiology of central nervous system. Pathophysiology of Alzheimer's, Parkinson's or other neurodegenerative disorders involves multifaceted permutation of genetic and environmental factors. Combinations of lifestyle modification linked with environmental factor jointly or alone represent the largest share of cases of these disorders. Etiology of such neuronal degeneration involves manifestation of toxic reaction in the form of functional anomalies leading to dysfunction of the ubiquitin-proteasome system, activated inflammatory cascade, compromised neuronal survival pathway, mitochondrial dysfunction and finally neuronal apoptosis/necrosis and cell death. Furthermore, evidences from various studies exhibited role of oxidative stress and compromised anti-oxidant defense system as one of the prime factors associated with activation of various signal transduction pathways that would ultimately lead to the formation of amyloid beta or alpha synuclein in the brain. Keeping in view of complex etiology and pathophysiology along with a miniscule of available treatment options associated with these neurodegenerative disorders, the role of natural agents and herbal extracts as therapeutic alternatives alone or in combination with synthetic drugs could not be ruled out. In the same context the present chapter has been aimed to investigate the role of selected natural plants like Withania somnifera, Bacopa monnieri, Curcuma longa, Centella asiatica, Ocimum sanctum, Nardostachys jatamansi and Emblica officinalis in various neurodegenerative disorders and explore their targets to ameliorate neurotoxicity in various experimental models. The rationale for selection of these plants was based on their strong anti-inflammatory and anti-oxidant potential and large body of evidence that suggest their efficacy in preclinical as well as in clinical studies. Active constituents if these herbals might play an important role in preserving the integrity of various neurotransmitters and their receptor in the brain influencing its functions at the molecular level.

Poly(ethylene glycol) versus dendrimer prodrug conjugates: influence of prodrug architecture in cellular uptake and transferrin mediated targeting.

Many polymer based drug delivery nanosystems are currently being explored for delivering cytotoxic agents to the tumors. However, very few strategies delineate the comparative carrier ability of nanosystems, in similar experimental settings. As a result, it remains unclear how to optimally design polymer based multicomponent prodrug systems for delivery applications. The present study is aimed to design polymeric prodrug conjugate carriers for the comparative cellular delivery ability of anticancer drug doxorubicin hydrochloride (DOX) using linear poly(ethylene glycol) (PEG), hyperbranched poly(amido amine) (PAMAM) G4 dendrimer, and PAMAM G4 dendrimer-PEG conjugate using MCF-7 cells. Furthermore, the cellular targetability and in vitro anticancer activity of DOX conjugates is evaluated using transferrin (Tf) as a targeting ligand. Interestingly, conjugation of DOX to PAMAM G4-OH dendrimer significantly influences the cytotoxicity of DOX leading to -4 fold decrease in the IC50 dose when compared to pegylated DOX. This study establishes the rational and comparative structural activity relationship of polymeric prodrug carriers for delivery of anticancer drugs. The schematic representation of design of prodrug conjugates with varied polymeric architecures is as shown below (Fig. 1).

Neuroprotective efficacy of curcumin in arsenic induced cholinergic dysfunctions in rats.

Our recent studies have shown that curcumin protects arsenic induced neurotoxicity by modulating oxidative stress, neurotransmitter levels and dopaminergic system in rats. As chronic exposure to arsenic has been associated with cognitive deficits in humans, the present study has been carried out to implore the neuroprotective potential of curcumin in arsenic induced cholinergic dysfunctions in rats. Rats treated with arsenic (sodium arsenite, 20mg/kg body weight, p.o., 28 days) exhibited a significant decrease in the learning activity, assessed by passive avoidance response associated with decreased binding of (3)H-QNB, known to label muscarinic-cholinergic receptors in hippocampus (54%) and frontal cortex (27%) as compared to controls. Decrease in the activity of acetylcholinesterase in hippocampus (46%) and frontal cortex (33%), staining of Nissl body, immunoreactivity of choline acetyltransferase (ChAT) and expression of ChAT protein in hippocampal region was also observed in arsenic treated rats as compared to controls. Simultaneous treatment with arsenic and curcumin (100mg/kg body weight, p.o., 28 days) increased learning and memory performance associated with increased binding of (3)H-QNB in hippocampus (54%), frontal cortex (25%) and activity of acetylcholinesterase in hippocampus (41%) and frontal cortex (29%) as compared to arsenic treated rats. Increase in the expression of ChAT protein, immunoreactivity of ChAT and staining of Nissl body in hippocampal region was also observed in rats simultaneously treated with arsenic and curcumin as compared to those treated with arsenic alone. The results of the present study suggest that curcumin significantly modulates arsenic induced cholinergic dysfunctions in brain and also exhibits neuroprotective efficacy of curcumin.

Inpatient cancer rehabilitation: the experience of a national comprehensive cancer center.

OBJECTIVE: Cancer rehabilitation is an important but often underutilized treatment in the comprehensive care of the cancer patient. Cancer patients have varying levels of access to rehabilitation services. Acute inpatient, inpatient consultation-based, and outpatient-based cancer rehabilitation services have been described in the literature. We will discuss acute inpatient cancer rehabilitation and some of its outcomes at the University of Texas MD Anderson Cancer Center in Houston, TX, which is the only national comprehensive cancer center to have its own acute inpatient rehabilitation unit dedicated solely to cancer patients. DESIGN: We retrospectively reviewed the inpatient medical records of consecutive inpatients admitted to the acute inpatient cancer rehabilitation unit from September 2008 to August 2009 for the following information: patient age, sex, primary tumor type, rehabilitation diagnoses, length of stay, discharge destination, and payer source. RESULTS: From September 2008 to August 2009, the physical medicine and rehabilitation service at MD Anderson Cancer Center had 1098 inpatient consultations, of which 427 patients were admitted to the inpatient rehabilitation unit with a mean length of stay of 11 days. Of the 427 patients, 73 (17%) were patients with primary neurologic-based tumor, 71 (16%) were patients with hematologic-based tumors, 48 (11%) were sarcoma patients, 35 (8%) were gastrointestinal tumor patients, 27 (6%) were head and neck tumor patients, 25 (6%) were prostate and bladder cancer patients, 24 (6%) were lung cancer patients, 22 (5%) were melanoma patients, 20 (5%) were breast cancer patients, 15 (4%) were renal cancer patients, 14 (3%) were gynecologic cancer patients, and 53 (12%) were patients with other types of cancer. Of the 427 patients admitted to acute inpatient rehabilitation at MD Anderson Cancer Center, 324 (76%) were discharged home, 72 (17%) went back to acute care service, 15 (4%) were sent to a skilled nursing facility, 9 (2%) were discharged to palliative care, and 5 (1%) were discharged to a long-term acute care facility. CONCLUSIONS: An active inpatient rehabilitation unit within a national comprehensive cancer center receives referrals from patients with a wide variety of tumor types and is able to successfully discharge home 76% of its patients.

The effects of a brief relaxation program on symptom distress and heart rate variability in cancer patients.

OBJECTIVES: To determine whether a 15-minute, one-time guided relaxation program for cancer patients could improve symptom distress as measured by the Edmonton Symptom Assessment System (ESAS). In addition, we were interested in characterizing the changes of the autonomic nervous system, as demonstrated by heart rate variability (HRV) high-frequency (HF) spectral analysis, before and after this relaxation program. DESIGN: Nonrandomized pilot study. SETTING: Comprehensive cancer center. METHODS: Twenty cancer patients underwent a 15-minute relaxation program. The ESAS and a 5-minute HRV recording were completed before and after the relaxation program. MAIN OUTCOME MEASURES: The differences between the pre- and post-summed ESAS score and HRV values were compared by a paired t-test. RESULTS: The summed ESAS scores were significantly lower after the relaxation program (P<.01), with an average 31% decrease in total score. However, no differences were found in HRV HF power. There was no correlation between the change in HRV HF and change in symptom distress, as measured by ESAS. CONCLUSIONS: A brief guided relaxation program can significantly improve symptoms as measured by ESAS. More research is required to understand the effects of relaxation on HF HRV power.

Neuroprotective effect of curcumin in arsenic-induced neurotoxicity in rats.

Our recent studies have shown that arsenic-induced neurobehavioral toxicity is protected by curcumin by modulating oxidative stress and dopaminergic functions in rats. In addition, the neuroprotective effect of curcumin has been investigated on arsenic-induced alterations in biogenic amines, their metabolites and nitric oxide (NO), which play an important role in neurotransmission process. Decrease in the levels of dopamine (DA, 28%), norepinephrine (NE, 54%), epinephrine (EPN, 46%), serotonin (5-HT, 44%), 3,4-dihydroxyphenylacetic acid (DOPAC, 20%) and homovanillic acid (HVA, 31%) in corpus striatum; DA (51%), NE (22%), EPN (47%), 5-HT (25%), DOPAC (34%) and HVA (41%) in frontal cortex and DA (35%), NE (35%), EPN (29%), 5-HT (54%), DOPAC (37%) and HVA (46%) in hippocampus, observed in arsenic (sodium arsenite, 20 mg/kg body weight, p.o., 28 days) treated rats exhibited a trend of recovery in rats simultaneously treated with arsenic and curcumin (100 mg/kg body weight, p.o., 28 days). Increased levels of NO in corpus striatum (2.4-fold), frontal cortex (6.1-fold) and hippocampus (6.2-fold) in arsenic-treated rats were found decreased in rats simultaneously treated with arsenic and curcumin. It is evident that curcumin modulates levels of brain biogenic amines and NO in arsenic-exposed rats and these results further strengthen its neuroprotective efficacy.

Effect of Saponins of Albizia lebbeck (L.) Benth bark on the reproductive system of male albino rats.

Oral administration of saponins isolated from Albizia lebbeck bark at the dose level of 50 mg/kg/b.w. per day for 60 days to male rats brought about a significant decrease in the weights of testes, epididymides, seminal vesicle and ventral prostate. The production of round spermatid was reduced by 73.04% in Albizia lebbeck treated rats. The population of preleptotene spermatocytes and spermatogonia were reduced by 65.07% and 47.48% and secondary spermatocytes by 73.41%, respectively. Cross sectional surface area of Sertoli cells as well as the cell counts were found to be depleted significantly. Leydig cell nuclear area and number of mature Leydig cells were decreased by 57.47% and 54.42%, respectively. Sperm motility as well as sperm density were reduced significantly. Albizia lebbeck reduced the fertility of male rats by 100%. There were no significant changes in RBC and WBC count, haemoglobin, haematocrit and glucose in the blood and cholesterol, protein, triglyceride and phospholipid in the serum. The protein, glycogen and cholesterol contents of the testes, fructose in the seminal vesicle and protein in epididymides were significantly decreased. Histoarchitecture of the testes showed vacuolization at primary spermatocytes stage. Highly reduced seminiferous tubular diameter and increased intertubular space were also observed when compared to controls.