Surveillance of long-term complications after treatment of adult brain tumor survivors-review and evidence-based recommendations.

As a result of treatment and diagnosis, adults with primary or metastatic brain tumors experience comorbidities that impacts their health and well-being. The Children's Oncology Group has guideline recommendations for childhood survivors of brain tumors; however, guidelines for monitoring long-term sequela among adult brain tumor survivors are lacking. The purpose of this review is to present the screening recommendations for the long-term complications after brain tumor treatment from a multidisciplinary panel of healthcare professionals. Chronic complications identified include cognitive dysfunction, vasculopathy, endocrinopathy, ophthalmic, ototoxicity, physical disability, sleep disturbance, mood disorder, unemployment, financial toxicity, and secondary malignancy. We invited specialists across disciplines to perform a literature search and provide expert recommendations for surveillance for long-term complications for adult brain tumor survivors. The Brain Tumor Center Survivorship Committee recommends routine screening using laboratory testing, subjective assessment of symptoms, and objective evaluations to appropriately monitor the complications of brain tumor treatments. Effective monitoring and treatment should involve collaboration with primary care providers and may require referral to other specialties and support services to provide patient-centered care during neuro-oncology survivorship. Further research is necessary to document the incidence and prevalence of medical complications as well as evaluate the efficacy of screening and neuro-oncology survivorship programs.

Behavioral dysregulation exacerbated by intrathecal baclofen in an adolescent with severe traumatic brain injury.

This is a case of a 19-year-old male with a history of remote severe traumatic brain injury (TBI) with an intrathecal baclofen (ITB) pump for dystonia management. Given concern for lack of efficacy despite increasing doses of ITB, his catheter was evaluated and found to be epidural rather than intrathecal. The baclofen dose was down-titrated and he underwent catheter revision. Post-op, his baclofen dose was up-titrated and complicated by significant behavioral changes including aggressive physical and verbal behaviors resulting in hospitalization. Work-up was negative for infection, new neurologic pathology, and epileptic activity. Psychiatric medications were adjusted but the behaviors persisted. Due to concern that the increased baclofen dose was causing his mood instability, his pump was down-titrated. As the dosage decreased, the frequency of outbursts also decreased. Throughout these dose adjustments, his dystonia remained stable and overall functional status improved. This is one of the first cases demonstrating that ITB may exacerbate mood instability in patients with TBI.

Prehabilitation Exercise Before Urologic Cancer Surgery: A Systematic and Interdisciplinary Review.

CONTEXT: The Consensus on Therapeutic Exercise Training (CONTENT) scale assesses the therapeutic validity of exercise programs. To date, prehabilitation exercise programs for heath optimization before urologic cancer surgeries have not been assessed for therapeutic validity or efficacy. OBJECTIVE: To systematically assess prehabilitation exercise programs before urologic cancer surgery for therapeutic validity and efficacy, informing discussion of best practices for future intervention. EVIDENCE ACQUISITION: A systematic review was performed using Ovid, Embase, Web of Science, and Cumulative Index of Nursing and Allied Health Literature (CINAHL) databases through June 2020. The review included prospective (randomized controlled and uncontrolled) trials where patients were enrolled in prehabilitation exercise programs before urologic cancer surgery. The primary outcomes of interest included therapeutic validity and efficacy (measures of cardiorespiratory fitness and postsurgical outcomes). Studies were evaluated for the risk of bias. A narrative synthesis was carried out given heterogeneity in populations, interventions, and outcomes across studies. EVIDENCE SYNTHESIS: Ten unique studies and two associated post hoc analyses met the inclusion criteria. Seven studies demonstrated therapeutic validity. Eight demonstrated a high risk of bias. All demonstrated significant improvement in cardiorespiratory fitness. Four of five studies evaluating quality of life observed significant improvements. To date, zero trials have demonstrated reduction in postsurgical complications, mortality, length of stay, or readmission rates following prehabilitation exercise interventions. CONCLUSIONS: While prehabilitation exercise may result in improved cardiorespiratory fitness and quality of life, current studies have yet to demonstrate impact on surgical outcomes. When designing prehabilitation exercise programs for use before urologic cancer surgery, the therapeutic validity of the intervention should be considered. Future prehabilitation studies should employ standardized content rubrics to ensure therapeutic validity. Consensus is needed regarding the appropriate outcomes to adjudicate prehabilitation efficacy. PATIENT SUMMARY: In this report, we looked at the effectiveness and quality of prehabilitation exercise programs before urologic cancer surgery. We found that these programs effectively improve presurgical fitness, but may benefit from the use of structured methodology and outcome assessment to understand their potential to improve surgical outcomes.

Jaw Pain and Oromandibular Dysfunction After a Complex Hospital Course: A Clinical Vignette.

ABSTRACT: A 38-yr-old man presented to the emergency department with severe chest pain and was found to have a type A aortic dissection. Forty-eight hours after an emergency mechanical Bentall and ascending hemiarch replacement, the patient developed agitation prompting administration of high-dose haloperidol. He was found to have evidence of multiple acute infarcts on head computed tomography/computed tomography angiography and brain magnetic resonance imaging. Four days later, he began to complain of jaw pain and difficulty opening his mouth. After admission to inpatient rehabilitation, he was found to have strong activity in the masseters bilaterally at rest on electromyography, indicating a diagnosis of oromandibular dystonia. Starting in the intensive care unit, the patient reported jaw pain and dysfunction for 40 days before having a diagnosis of oromandibular dystonia. At this point, treatment with onabotulinumtoxinA injections and baclofen did not provide relief. Because of an extended delay in diagnosis, it is believed that the patient has developed joint contractures. Oromandibular dystonia is an important diagnosis to consider in patients who experience jaw pain or difficulty with mouth opening. Treatment of this condition can decrease pain and trauma to oral structures as well as improve ability to perform oral hygiene, eat, and communicate.

The Value of Rehabilitation Medicine for Patients Receiving Palliative Care.

BACKGROUND: Rehabilitation medicine is a multidisciplinary field aimed at improving patients' quality of life by improving function. Patients receiving palliative care frequently share common symptoms including fatigue, decreased functional independence, mood disorders, pain, and breathlessness. Many rehabilitation interventions can improve these symptoms. OBJECTIVE: To evaluate the scope and effectiveness of rehabilitation interventions and exercise programs in improving quality of life and distressing symptoms in patients receiving palliative care. METHODS: We conducted a literature review of cancer rehabilitation topics and techniques specifically applied to patients with life-limiting conditions. Exercise and other rehabilitation interventions were analyzed for their effects on common symptoms and disabilities experienced by this patient population. CONCLUSION: Current available literature supports the use of exercise programs and rehabilitation interventions to improve fatigue, mood, functional independence, breathlessness, and pain. Rehabilitation and palliative care practitioners share many goals in their approach to patient care and augment one another well. Palliative care providers should consider referral to physiatry (physical medicine and rehabilitation) to help optimize patients' quality of life.