Factors associated with imaging in patients with early breast cancer after initial treatment.

Background: Overuse of surveillance imaging in patients after curative treatment for early breast cancer (ebc) was recently identified as one of the Choosing Wisely Canada initiatives to improve the quality of cancer care. We undertook a population-level examination of imaging practices in Ontario as they existed before the launch of that initiative. Methods: Patients diagnosed with ebc between 2006 and 2010 in Ontario were identified from the Ontario Cancer Registry. Records were linked deterministically to provincial health care databases to obtain comprehensive follow-up. We identified all advanced imaging exams [aies: computed tomography (ct), bone scan, positron-emission tomography] and basic imaging exams (bies: ultrasonography, chest radiography) occurring within the first 2 years after curative treatment. Poisson regression was used to assess associations between patient or provider characteristics and the rate of aies. Results: Of 30,006 women with ebc, 58.6% received at least 1 bie, and 30.6% received at least 1 aie in year 1 after treatment. In year 2, 52.7% received at least 1 bie, and 25.7% received at least 1 aie. The most common aies were chest cts and bone scans. The rate of aies increased with older age, higher disease stage, comorbidity, chemotherapy exposure, and prior staging investigations (p < 0.001). Imaging was ordered mainly by medical oncologists (38%), followed by primary care physicians (23%), surgeons (13%), and emergency room physicians (7%). Conclusions: Despite recommendations against its use, imaging is common in ebc survivors. Understanding the factors associated with aie use helps to identify areas for further research and is required to lower imaging rates and to improve survivorship care.

Effects of the community-based Wellspring Cancer Exercise Program on functional and psychosocial outcomes in cancer survivors.

PURPOSE: In this study, we examined the effects of a 30-week community-based exercise program on cancer-related fatigue, quality of life, and other health-related outcomes in a sample of adults with mixed cancer diagnoses. METHODS: This prospective cohort study looked at outcomes for participants involved in the Wellspring Cancer Exercise Program in southern Ontario. The program consisted of an initial phase of two supervised sessions weekly for 10 weeks and a transition phase of one supervised session weekly for the subsequent 20 weeks. Outcomes were measured at baseline and every 10 weeks throughout the intervention, as well as at 16 weeks after program completion. RESULTS: During a period of 13 months, 229 of the 355 cancer survivors who enrolled in the exercise program consented to participate in the study. Participants attended 71% of the supervised exercise sessions in the initial phase and 49% in the transition phase. From baseline to the end of the initial phase, significant improvements in cancer-related fatigue, 6-minute walk test, social well-being, systolic blood pressure, balance, and physical activity volume were observed. During the transition phase, health-related quality of life and emotional well-being improved significantly. CONCLUSIONS: The Wellspring Cancer Exercise Program is associated with clinically meaningful improvements in cancer-related fatigue and functional aerobic capacity. Several other aspects of well-being in cancer survivors also improved for participants in the program. Community-based cancer exercise programs such as the Wellspring Cancer Exercise Program can improve well-being for cancer survivors and can provide an effective option that enhances sustainability and accessibility to exercise services for this population.

Enterostomy tube placement in children with spinal muscular atrophy type 1.

OBJECTIVE: To determine the major complication rate in the first 30 days after enterostomy tube insertion in infants with spinal muscular atrophy (SMA) type 1. STUDY DESIGN: A retrospective case review of all children with SMA type 1 who had a gastrostomy or gastrojejunostomy tube placed by the image-guided technique at the Hospital for Sick Children from 1994-2004. Major complications were classified as peritonitis, aspiration pneumonia, respiratory failure, nonelective admission to the pediatric intensive care unit, and death. RESULTS: Twelve children were identified as having SMA type 1 with an enterostomy tube insertion. The median age at tube insertion was 6.1 months (range 2.2 to 15.8 months). Major complications in the first 30 days after the procedure included aspiration pneumonia (5/12 patients [41.6%]), respiratory failure requiring admission to the pediatric intensive care unit (4/12 [33%]), and death (2/12 [16.7%]). Children with development of aspiration pneumonia were significantly older at time of tube insertion (P < .05) than those with no aspiration. CONCLUSIONS: Major complications including death are seen in children with SMA type 1 in the first 30 days after enterostomy tube insertion.

Properties of the estimated variance component for subject-by-formulation interaction in studies of individual bioequivalence.

Characteristics of the variance component for the subject-by-formulation interaction (sigma(2)(D)), estimated in simulated studies of individual bioequivalence and in three- and four-period cross-over trials reported by the FDA, were compared. sigma(2)(D) was estimated by (i) restricted maximum likelihood (REML) and (ii) the method of moments (MM). Variation of the variance component, estimated by both procedures (s(2)(D)) and for both the simulated and FDA data, increased with rising intra-individual variation. Consequently, a constant level of s(2)(D) (such as 0.0225 suggested by the FDA) may not be regarded as a basis for demonstrating substantial interactions. Features of the FDA and simulated parameters were similar. The results suggested that the FDA data were compatible with assuming sigma(D)=0.05 or perhaps 0.00. Therefore, there is no foundation for concerns about public health. Both simulations and calculations demonstrated that s(2)(D) estimated by MM was unbiased and its variance was proportional to sigma(4)(WF) when sigma(2)(D)=0.

Risk factors for pain and nausea following retinal and vitreous surgery under conscious sedation.

BACKGROUND: There have been no studies examining risk factors for pain and nausea during the first day after posterior segment surgery. We performed a study to identify significant risk factors for the development of pain and nausea during the first 24 hours after outpatient vitrectomy or scleral buckle surgery. METHODS: A total of 257 consecutive patients who underwent vitrectomy (192 patients), scleral buckling (57 patients) or combined vitrectomy-scleral buckling (8 patients) between July 1 and Dec. 31, 1995, were enrolled in this prospective study. The patients' age, sex and ethnicity, the duration of the procedure and the intraoperative use of minor tranquillizers, hypnotic agents, narcotic analgesics or major tranquillizers were recorded. Each patient rated his or her postoperative pain and nausea on two separate 100-mm lines. The left end of the line represented no pain (or nausea) whatsoever, and the right end of the line represented severe pain (or nausea). The distance of the recorded point from the origin of the line was used as the outcome measure for pain and nausea. All the data were analysed statistically by means of logistic regression analysis and descriptive statistics. RESULTS: The median pain scores were 1.0 for the patients who underwent vitrectomy, 47.0 for those who underwent scleral buckling and 35.0 for those who underwent combined vitrectomy-scleral buckling. The median nausea scores were 14.5, 45.0 and 55.5 respectively. The only variable that was identified as a predictor of postoperative pain or nausea was the intraoperative use of narcotic analgesics: in the vitrectomy group, postoperative nausea occurred almost three times as often among patients who received these agents as among those who did not (odds ratio 2.6, p = 0.00). INTERPRETATION: The identification of the intraoperative use of narcotic analgesics as a risk factor for nausea in the first 24 hours after outpatient vitrectomy suggests that, when possible, these agents should be avoided during surgery.

Adolescent substance use disorders: findings from a 14-year follow-up of speech/language-impaired and control children.

Intervening on the development of adolescent addiction requires an understanding of the role of precursors. In a community sample of youth with and without early childhood speech/language (S/L) impairments, 12.7% of participants had a substance use disorder (SUD). Among these participants, 42.0% met criteria for more than 1 SUD. Interestingly, rates of SUDs did not differ by S/L status. However, S/L-impaired participants did show greater psychiatric comorbidity and poorer functioning. A total of 80% of S/L participants with SUDs had a concurrent diagnosis of antisocial personality disorder, compared with 43.8% of SUDs controls. In a logistic regression analysis, we found age 5 mother-rated problem behavior scores and an interaction between S/L status and teacher-rated conduct problem scores were predictive of SUDs. High conduct scores were predictive of SUDs development among control participants but not among S/L-impaired participants. First substance use and initial SUDs symptoms suggest that a window of opportunity exists to reach these troubled young people before they spiral into addiction.

Fourteen-year follow-up of children with and without speech/language impairments: speech/language stability and outcomes.

This report concerns the speech and language outcomes of young adults (N = 242) who participated in a 14-year, prospective, longitudinal study of a community sample of children with (n = 114) and without (n = 128) speech and/or language impairments. Participants were initially identified at age 5 and subsequently followed at ages 12 and 19. Direct assessments were conducted in multiple domains (communicative, cognitive, academic, behavioral, and psychiatric) at all three time periods. Major findings included (a) high rates of continued communication difficulties in those with a history of impairment; (b) considerable stability in language performance over time; (c) better long-term outcomes for those with initial speech impairments than for those with language impairments; and (d) more favorable prognoses for those with specific language impairments than for those with impairments secondary to sensory, structural, neurological, or cognitive deficits. These general conclusions held when either a liberal or a more stringent criterion for language impairment was employed. Some of these findings are consistent with those from earlier follow-up studies, which used less optimal methods. Thus, the present replication and extension of these findings with a sound methodology enables greater confidence in their use for prognostic, planning, and research purposes.

Local norming of the test of adolescent/adult language-3 in the Ottawa Speech and Language Study.

The young adult norms for the Test of Adolescent/Adult Language-3 (TOAL-3; D. Hammill et al., 1994) are based only on individuals who pursued postsecondary education, a restriction that renders the norms inappropriate for many clinical and research purposes. This research note details the rationale, methods, and results of a local norming of the TOAL-3 spoken language subtests, based on participants from the Ottawa Speech and Language Study (C. J. Johnson et al., 1999). The resulting Ottawa norms represent the full range of young adult language abilities and, therefore, can be used with caution for some clinical and research purposes.

Ultrasound biomicroscopic quantitative analysis of light-dark changes associated with pupillary block.

PURPOSE: To quantitatively analyze the changes in anterior chamber angle and iris configuration induced by varying illumination in patients with narrow angles and pupillary block. METHODS: Twenty-four eyes of 24 patients with pupillary block (mean age, 52.5 years) had ultrasound biomicroscopic images of the angle and iris structures obtained superiorly, nasally, inferiorly, and temporally. Images were performed in the light and the dark. We measured the angle opening distance, iris thickness, iris chord length, iris-lens touch, and iris curvature. RESULTS: Changes in iris and angle configuration occurred within a few seconds of a change in lighting. The mean dark measurements were statistically significantly less than the mean light measurements for angle opening distance (96 +/- 18 vs 185 +/- 26 microm, P = .0001), iris chord length (2,505 +/- 61 vs 3,001 +/- 69 microm, P = .0001), and iris-lens touch (350 +/- 20 vs 693 +/- 35 microm, P = .0001). The mean dark measurements were statistically significantly greater than the mean light measurements for iris thickness at 500 microm from the scleral spur (367 +/- 10 vs 307 +/- 25 microm, P = .0001), and 1,500 microm from the scleral spur (404 +/- 14 vs 347 +/- 12 microm, P = .0001). Iris curvature in all four quadrants was statistically significantly greater in the dark than the light. CONCLUSIONS: This study quantitatively confirms that angle narrowing in the dark in eyes with pupillary block is associated with iris shortening, increased iris thickness, and increased iris convexity. Iris-lens touch is relatively small in pupillary block and decreases with dilation. Angle narrowing with dilation is not related to increased iris-lens touch and occurs promptly without requiring time for aqueous pressure buildup behind the iris.