Mock Pages Are a Valid Construct for Assessment of Clinical Decision Making and Interprofessional Communication.

IMPORTANCE: Answering pages from nurses about patients in need of immediate attention is one of the most difficult challenges a resident faces during their first days as a physician. A Mock Page program has been developed and adopted into a national surgical resident preparatory curriculum to prepare senior medical students for this important skill. OBJECTIVE: The purpose of this study is to assess standardized mock page cases as a valid construct to assess clinical decision making and interprofessional communication skills. DESIGN, SETTING, PARTICIPANTS: Mock page cases (n = 16) were administered to 213 senior medical students from 12 medical schools participating in a national surgical resident preparatory curriculum in 2013 and 2014. MAIN OUTCOME MEASURES: Clinical decision making and interprofessional communication were measured by case-specific assessments evaluating these skills which have undergone rigorous standard-setting to determine pass/fail cut points. RESULTS: Students' performance improved in general for both communication and clinical decision making over the 4-week course. Cases have been identified that seem to be best suited for differentiating high- from low-performing students. Chest pain, pulmonary embolus, and mental status change cases posed the greatest difficulty for student learners. CONCLUSIONS AND RELEVANCE: Simulated mock pages demonstrate an innovative technique for training students in both effective interprofessional communication and management of common postoperative conditions they will encounter as new surgical interns.

Impact of Age, Gender and Anesthesia Modality on Post-Operative Pain in Total Knee Arthroplasty Patients.

BACKGROUND: Optimizing pain control following total knee arthroplasty is of utmost importance to the immediate post-operative course. Various anesthesia modalities are available, but studies comparing multiple anesthesia modalities, patient age, and sex are limited. QUESTIONS/PURPOSE: The purpose of our study was to examine the impact of patient age, gender, and perioperative anesthesia modality on postoperative pain following primary total knee arthroplasty. METHODS: 443 patients who underwent primary total knee arthroplasty by 14 surgeons with some combination of general anesthesia, spinal anesthesia, femoral nerve block, and intrathecal morphine were identified. Anesthesia route and type, length of surgery, post-operative patient-reported pain measures using the Visual Analog Scale, opioid consumption, and length of hospital stay were recorded for each patient and used to compare differences among study groups. RESULTS: No significant differences were noted between anesthesia groups with regards to postoperative pain or length of hospital stay. Patients receiving spinal anesthesia and femoral nerve block without intrathecal morphine were significantly older than other groups. Patients receiving general anesthesia required significantly more daily intravenous morphine equivalents than patients receiving spinal anesthesia. Patients receiving spinal anesthesia with femoral nerve block and intrathecal morphine consumed the least amount of morphine equivalents. When comparing males and females among all groups, females had significantly higher pain ratings between 24-36 and 24-48 hours postoperatively. CONCLUSION: Although no significant differences were noted on pain scores, patients who received spinal anesthesia with intrathecal morphine and femoral nerve block used less narcotic pain medication than any other group. Females reported significantly higher pain between 24-48 hours post-op compared with males but not significantly greater anesthetic usage. LEVEL OF EVIDENCE: Level III, Therapeutic Study, (Retrospective Comparative study).

Mitral Valve Surgery in The Elderly: Should We Treat Atrial Fibrillation Too?

BACKGROUND: The study aim was to examine whether concomitant atrial fibrillation (AF) surgery at the time of mitral valve surgery in the elderly results in increased operative mortality (OM). METHODS: Medicare beneficiaries aged ≥65 years undergoing primary mitral valve repair or replacement between 2004 and 2006 were included. The cohort was divided into three groups: Group 1, AF- (n = 2,705); group 2, AF+AF surgery- (n = 2,119), and group 3, AF+AF surgery+ (n = 1,832). The primary outcomes were OM and long-term survival. A secondary outcome was the association between hospital annual mitral procedure volume and OM. RESULTS: The unadjusted OM was 6.4% for group 1 (AF-), 10.3% for group 2 (AF+AF surgery-), and 7.1% for group 3 (AF+AF surgery+) (p = 0.0001). Adjusted OM for AF+AF surgery+ patients was not significantly different from that of AF- patients (OR 1.16, 95% CI 0.90-1.48), or from AF+AF surgery patients (OR 0.83, 95% CI 0.66-1.06). When comparisons were adjusted for differences in baseline characteristics, AF+AF surgery- patients were more likely to experience long-term mortality than AF- patients (HR 1.30, 95% CI 1.17-1.45), as well as AF+AF surgery+ patients (HR 1.17, 95% CI 1.05-1.31). An annual average mitral procedure volume ≤40 was independently predictive of OM (OR 1.42, 95% CI 1.13-1.78). The effect of institutional volume on mortality was strongest in those who received AF surgery (AF+AF surgery+) (HR 1.75, 95% CI 1.15-2.65), compared to those who did not undergo surgery (AF+AF surgery-) (OR 1.20, 95% CI 0.86-1.67). CONCLUSIONS: Elderly patients undergoing mitral valve surgery do not appear to have an increased mortality when clinical judgment favored the performance of concomitant AF surgery.

Additional procedures performed during elective colon surgery and their adverse impact on postoperative outcomes.

BACKGROUND: The need for additional procedures during a segmental elective colectomy is considered to lead to increased postoperative morbidity, but there have been few data that have validated and quantified this risk. PURPOSE: We hypothesized that patients having additional procedures performed during a segmental colectomy have worse outcomes compared to patients undergoing a colectomy alone. PATIENTS AND METHODS: All patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who underwent an elective open or laparoscopic segmental colectomy during 2005-2009 and met the inclusion criteria were analyzed. Using current procedural terminology (CPT) codes, patients were stratified into three groups. Group 1 only had CPT codes for a colectomy. Group 2 had additional CPT codes for procedures that were considered related to the colectomy, such as splenic flexure mobilization and endoscopy or a relatively minor procedure such as an appendectomy. Group 3 included patients that had additional procedures performed along with a segmental colectomy. Serious morbidity, overall morbidity, return to the operating room, and death were calculated and compared for each group. RESULTS: There were 25,996 patients in the open and 20,396 patients in the laparoscopic colectomy group. Thirty-six percent of patients in the open colectomy group vs. 18 % in the laparoscopic colectomy group had additional procedures performed. After adjustment for available differences in the groups, patients undergoing open and laparoscopic segmental colectomy along with an additional procedure had worse postoperative outcomes compared to patients undergoing a colectomy alone. LIMITATIONS: The study is limited by the possibility of coding errors in the ACS NSQIP database leading to a case ascertainment bias and a selection bias given the observational nature of the study. It also could not differentiate between additional procedures that were planned or incidental at the time of surgery. CONCLUSIONS: A proportion of patients undergoing elective open and laparoscopic segmental colon resections undergo additional procedures that adversely impact postoperative outcomes. This is mainly related to the type of additional procedures performed and therefore should be accounted for when counseling patients about the risks of surgery and in comparisons of outcomes.

The measured effect of delay in completing operative performance ratings on clarity and detail of ratings assigned.

PURPOSE: Operative performance ratings (OPRs) need adequate clarity and detail to support self-directed learning and valid progress decisions. This study was designed to determine (1) the elapsed time between observing operative performances and completing performance ratings under field conditions and (2) the effect of increased elapsed time on rating clarity and detail. METHODS: Overall, 895 OPRs by 19 faculty members for 37 general surgery residents were the focus of this study. The elapsed time between observing the performance and completing the evaluation was recorded. No-delay comparison data included 45 additional ratings of 8 performances collected under controlled conditions immediately following the performance by 17 surgeons whose sole responsibility was to observe and rate the performances. Item-to-item OPR variation and the presence and nature of comments were indicators of evaluation clarity, detail, and quality. RESULTS: Elapsed time between observing and evaluating performances under field conditions were as follows: 1 day or less, 116 performances (13%); 2 to 3 days, 178 performances (20%); 4 to 14 days, 377 performances (42%); and more than 14 days, 224 performances (25%). Overall, 87% of performances rated more than 14 days after observation had no item-to-item ratings variation compared with 62% rated with a delay of 4 to 14 days, 41% rated with a delay of 2 to 3 days, 42% rated within 1 day, and 2% rated immediately. In addition, 70% of ratings completed more than 14 days after observation had no written comments, compared with 49% for those completed with a delay of 4 to 14 days, 45% for those completed in 2 to 3 days, and 46% for those completed within 1 day. Moreover, 47% of comments submitted after more than 14 days were exclusively global comments (less instructionally useful) compared with 7% for those completed with a delay of 4 to 14 days and 5% for those completed in 1 to 3 days. CONCLUSIONS: The elapsed time between observation and rating of operative performances should be recorded. Immediate ratings should be encouraged. Ratings completed more than 3 days after observation should be discouraged and discounted, as they lack clarity and detail about the performance.

Variations in senior medical student diagnostic justification ability.

PURPOSE: To determine the diagnostic justification proficiency of senior medical students across a broad spectrum of cases with common chief complaints and diagnoses. METHOD: The authors gathered diagnostic justification exercise data from the Senior Clinical Comprehensive Examination taken by Southern Illinois University School of Medicine's students from the classes of 2011 (n = 67), 2012 (n = 66), and 2013 (n = 79). After interviewing and examining standardized patients, students listed their key findings and diagnostic possibilities considered, and provided a written explanation of how they used key findings to move from their initial differential diagnoses to their final diagnosis. Two physician judges blindly rated responses. RESULTS: Student diagnostic justification performance was highly variable from case to case and often rated below expectations. Of the students in the classes of 2011, 2012, and 2013, 57% (38/67), 23% (15/66), and 33% (26/79) were judged borderline or poor on diagnostic justification performance for more than 50% of the cases on the examination. CONCLUSIONS: Student diagnostic justification performance was inconsistent across the range of cases, common chief complaints, and underlying diagnoses used in this study. More than 20% of students exhibited borderline or poor diagnostic justification performance on more than 50% of the cases. If these results are confirmed in other medical schools, attention needs to be directed to investigating new curricular methods that ensure deliberate practice of these competencies across the spectrum of common chief complaints and diagnoses and do not depend on the available mix of patients.

Patient demographics and risk factors in pediatric distal humeral supracondylar fractures.

The literature on distal humeral supracondylar fractures does not systematically define relationships between patient characteristics and the severity or complications of these injuries. This study evaluated age, sex, height, and body mass index (BMI) in relation to fracture severity and posttreatment complications in a pediatric population. The medical records of 382 pediatric patients treated for distal humeral supracondylar fractures over a 5-year period at 1 institution were included. Variables included age, sex, height, weight, injury mechanism, fracture severity (Gartland Classification), treatment, follow-up duration, and treatment complications. Body mass index and BMI-for-age percentile were calculated. Descriptive statistics with univariate analyses and logistic regression analysis with odds ratios and 95% confidence intervals were used. Children sustaining Gartland type 3 fractures were significantly older and taller than those sustaining Gartland type 1 and 2 fractures. No significant difference existed in fracture occurrence between boys and girls. Fracture severity did not differ significantly due to sex, BMI, or BMI-for-age percentile. Severe fractures were associated with increased posttreatment complications. Complication rates did not vary significantly by age, sex, height, BMI, or BMI-for-age. Taller children aged 5 to 6 years were at the greatest risk for Gartland type 3 distal humeral supracondylar fractures. Severe fractures are associated with an increased complication risk. Sex, BMI, and BMI-for-age percentile had no effect on fracture severity or complication rates.

Active comparator-controlled, rater-blinded study of corticotropin-based immunotherapies for opsoclonus-myoclonus syndrome.

To test the efficacy and safety of corticotropin-based immunotherapies in pediatric opsoclonus-myoclonus syndrome, 74 children received corticotropin alone or with intravenous immunoglobulin (groups 1 and 2, active controls); or both with rituximab (group 3) or cyclophosphamide (group 4); or with rituximab plus chemotherapy (group 5) or steroid sparers (group 6). There was 65% improvement in motor severity score across groups (P < .0001), but treatment combinations were more effective than corticotropin alone (P = .0009). Groups 3, 4, and 5 responded better than group 1; groups 3 and 5 responded better than group 2. The response frequency to corticotropin was higher than to prior corticosteroids (P < .0001). Fifty-five percent had adverse events (corticosteroid excess), more so with multiagents (P = .03); and 10% had serious adverse events. This study demonstrates greater efficacy of corticotropin-based multimodal therapy compared with conventional therapy, greater response to corticotropin than corticosteroid-based therapy, and overall tolerability.

Influence of systemic lupus erythematosus on procedure selection and outcomes of patients undergoing isolated mitral valve surgery.

BACKGROUND: Cardiovascular disease is the main cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE). SLE as a risk factor for adverse outcomes during mitral surgery has not been studied. The purpose of this investigation was to compare procedure selection and outcomes of patients with and without SLE. METHODS: The 2005-2008 Nationwide Inpatient Sample database was searched to identify patients ≥18 years of age undergoing isolated mitral repair or replacement. Patients with and without SLE were compared on baseline characteristics and hospital outcomes. Within patients with SLE, those undergoing repair and replacement were compared. RESULTS: SLE patients comprised 0.9% (620/70,969) of the isolated mitral valve surgery population. Patients with SLE were significantly younger, more likely to be female, less likely to be white, had higher Charlson comorbidity index, and less often presented electively. Patients with SLE had a higher incidence of prolonged hospitalization (LOS > 10 days; 44.4% vs. 34.7%, p = 0.0392). Mortality was similar for patients with and without SLE undergoing isolated mitral valve surgery (OR = 0.76, 95% CI 0.28-2.05, p = 0.5821). Patients with SLE were less likely to have mitral valve repair (27.1% vs. 45.6%, p = 0.0002). Baseline characteristics were similar between SLE repair and replacement subsets. Median LOS was higher for replacement (10 days vs. 7 days, p = 0.0014). Hospital mortality was 0% for SLE mitral repair patients and <4.0% for SLE replacement patients. CONCLUSIONS: Patients with SLE present for isolated mitral valve surgery at a much younger age and with worse preoperative profiles. Although mitral repair rates were lower in patients with SLE, hospital outcomes were excellent, and comparable to those of patients without SLE.

Sternotomy or bilateral thoracoscopy: pain and postoperative complications after lung-volume reduction surgery.

OBJECTIVES: Video-assisted thoracoscopic surgery (VATS) and median sternotomy (MS) are two approaches in lung-volume reduction surgery (LVRS). This study focused on the two surgical approaches with regard to postoperative pain. METHODS: In this prospective, non-randomized study, pain was measured preoperatively and postoperatively using the visual analog scale (VAS) and the brief pain inventory (BPI). Incentive spirometry (IS) assessed restriction of the thoracic cage due to pain. Factors associated with treatment complications, medication usage, hospital stay, operating times, and chest-tube duration differences were examined between groups. RESULTS: Of 85 patients undergoing LVRS, 23 patients underwent reduction via MS and 62 patients via bilateral VATS. VAS scores revealed no difference in postoperative pain except for VAS scores on days 6 (PM) and 7 (PM). BPI scores yielded higher scores in the VATS group on postoperative day (POD) 1 in the reactive dimension, but no other overall differences. MS patients receiving tramadol consumed a higher mean amount than VATS patients on POD 5 and POD 6. IS change from baseline to postoperative were similar between groups, and increased pain correlated with decreased IS scores on POD 1. Chest-tube duration, complications, and pain medication were similar between groups. CONCLUSIONS: Bilateral VATS and MS offer similar outcomes with regard to postoperative pain and complications. These results suggest that the choice of LVRS operative approach should be dependent on disease presentation, surgeon expertise, and patient preference, not based upon differences in perceived postoperative pain between MS and bilateral VATS.

Is chronic obstructive pulmonary disease an independent risk factor for transfusion in coronary artery bypass graft surgery?

OBJECTIVE: The literature is inconsistent regarding the role of chronic obstructive pulmonary disease (COPD) as a risk factor for blood product transfusion during coronary artery bypass graft (CABG). One reason may be lack of objective criteria to define COPD in previously published reports. We examined the role of COPD as a risk factor for transfusion using a strict definition based on objective pulmonary function test (PFT) data. METHODS: We identified 180 patients, who underwent primary isolated non-emergent CABG and had PFTs performed preoperatively. COPD was defined as forced expiratory volume in 1s/forced vital capacity (FEV1/FVC) <70% and further stratified into mild/moderate/severe/very severe based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Patients with and without COPD were compared with respect to preoperative and postoperative characteristics and transfusion requirements. RESULTS: The overall transfusion rate was 59.4% (107/180). COPD patients (31.1%, 56/180) were older (66.6 ± 11.4 vs 62.3 ± 10.3 years, p = 0.01), had lower body mass index (BMI) (28.5 ± 5.8 vs 31.7 ± 6.0 kg/m(2), p=0.001), and were more often smokers (51.8% vs 36.3%, p = 0.05). COPD patients had shorter cardiopulmonary bypass (CPB) times (99.4 ± 27.9 vs 110.9 ± 32.4 min, p = 0.02), but left internal mammary artery (LIMA) use, number of bypass grafts, mortality, and postoperative complications were similar (p > 0.05). Transfusion rates were similar for patients with and without COPD. Further stratification into mild/moderate/severe/very severe COPD failed to identify COPD as a predictor of blood transfusion. CONCLUSIONS: Using objective PFT data, our study clarifies the disagreement in the literature with respect to the role of COPD as a risk factor for transfusion in CABG. Decreased pulmonary function does not appear to increase risk of transfusion during CABG, even for patients with severe COPD.

Transitioning between clerkship directors.

OBJECTIVE: The authors report on succession-planning for mid-level academic positions. METHOD: The authors describe the process of succession-planning between clerkship directors and the smooth transition resulting in one case. RESULTS: Gradually transitioning allowed a new faculty person to assume the clerkship-director position with minimal disruption of the clerkship. The respectful treatment of the exiting clerkship director encouraged other faculty to discuss future plans with the Chair, facilitating strategic planning. CONCLUSION: The authors stress the need to study quantitatively the effect of transitions on training.

Use of simulated pages to prepare medical students for internship and improve patient safety.

PURPOSE: During the transition from medical school to internship, trainees experience high levels of stress related to pages on the inpatient wards. The steep learning curve during this period may also affect patient safety. The authors piloted the use of simulated pages to improve medical student preparedness, decrease stress related to pages, and familiarize medical students with common patient problems. METHOD: A multidisciplinary team at Southern Illinois University School of Medicine developed simulated pages that were tested among senior medical students. Sixteen medical students were presented with 11 common patient scenarios. Data on assessment, management, and global performance were collected. Mean confidence levels were evaluated pre- and postintervention. Students were also surveyed on how the simulated pages program influenced their perceived comfort in managing patient care needs and the usefulness of the exercise in preparing them to handle inpatient pages. RESULTS: Mean scores on the assessment and management portions of the scenarios varied widely depending on the scenario (range -15.6 ± 41.6 to 95.7 ± 9.5). Pass rates based on global performance ranged from 12% to 93%. Interrater agreement was high (mean kappa = 0.88). Students' confidence ratings on a six-point scale increased from 1.87 preintervention to 3.53 postintervention (P < .0001). CONCLUSIONS: Simulated pages engage medical students and may foster medical student preparedness for internship. Students valued the opportunity to simulate "on call" responsibilities, and exposure to simulated pages significantly increased their confidence levels. Further studies are needed to determine effects on patient safety outcomes.

Physical activity type and intensity among rural breast cancer survivors: patterns and associations with fatigue and depressive symptoms.

INTRODUCTION: Our study aims were to describe physical activity patterns and associations with fatigue and depressive symptoms among rural breast cancer survivors. METHODS: Population-based, mailed survey of 483 rural breast cancer survivors including the International Physical Activity Questionnaire (IPAQ). RESULTS: With regard to type and intensity, domestic/gardening and moderate intensity accounted for the largest percentage of total energy expenditure (i.e., 60% and 69%, respectively). MET-mins/week variables were categorized as 0, > 0 to < 500, and ≥ 500 to reflect sedentary, insufficient, and meets current public health recommendations. After adjustment, fatigue was significantly associated with domestic/gardening (mean fatigue for sedentary, insufficient, and meets recommendations were 18.9, 16.4, and 13.4, respectively; p = .0019), leisure activity (means were 16.0, 14.5, and 11.8, respectively; p = .047), moderate intensity (means were 18.4, 16.7, and 13.7, respectively; p = .011), and daily minutes sitting (means for ≤ 120 min, > 120 to ≤ 360 min, and > 360 min of sitting were 12.5, 14.2, and 17.2, respectively; p = .0029). Fatigue was not associated with occupational, transportation, walking, or vigorous activity. After adjustment, only leisure activity was associated with depressive symptoms (means for sedentary, insufficient, and meets recommendations were 7.8, 7.7, and 6.2, respectively; p = .039). CONCLUSIONS: Physical activity measurement tools that do not include domestic/gardening activities may underestimate physical activity in rural breast cancer populations. Physical activity associations with fatigue and depressive symptoms differed based on physical activity type and intensity suggesting hypotheses related to exercise effects on fatigue and depressive symptoms.

Statins for prevention of contrast-induced nephropathy in patients undergoing non-emergent percutaneous coronary intervention.

AIM: Oxidative stress and ischaemia are suggested as possible mechanisms of contrast-induced nephropathy (CIN). Statins may offer renoprotection in both acute and chronic kidney diseases because of their antioxidant and anti-inflammatory properties. We investigated whether use of statins before non-emergent percutaneous coronary intervention (PCI) reduces the incidence of CIN. METHODS: We retrospectively evaluated 540 consecutive adult patients who underwent non-emergent PCI over a 3 year period at a tertiary care centre. CIN was defined as 25% or 44 mmol/L increase from baseline creatinine at 48-72 h. In addition, we classified patients based on Mehran score for risk of development of CIN and analysed the effect of statins. RESULTS: Three-hundred and fifty-three patients met inclusion criteria. Two-hundred and thirty-nine patients were taking statins before PCI and 114 were not. Baseline characteristics were similar for both groups. CIN occurred in 75 patients (21.2%). There was a higher incidence of CIN in patients on statins as compared with patients not on statins (24.7% vs 14%; 95% CI: 1.09-3.67; P = 0.02). However, propensity-based adjustment for receipt of statins revealed no significant differences in CIN between both groups (OR: 1.6; 95% CI: 0.87-3.22; P = 0.12). Multivariate logistic regression revealed Mehran score to be independently predictive of CIN. None of the patients who developed CIN required dialysis. CONCLUSIONS: Statin use before non-emergent PCI is not associated with reduction in CIN. Further randomized controlled trials based on proper risk adjustment for development of CIN are needed.

Long-term outcomes of drug-eluting stents versus bare-metal stents in saphenous vein graft disease: results from the Prairie "Real World" Stent Registry.

OBJECTIVES: This study was designed to compare long-term clinical outcomes of drug-eluting stents (DES) versus bare metal stents (BMS) in patients with saphenous vein graft (SVG) disease in the "real world." BACKGROUND: The safety and efficacy of DES versus BMS in SVG remains uncertain due to contradictory reports of either lower revascularization rates with DES; or clinical equivalence to BMS; or even an excess of clinical events associated with DES use. METHODS: We identified consecutive patients who underwent stent placement within a de novo SVG lesion between May 1, 2003 and July 31, 2007. Follow-up was obtained at regular intervals. The Kaplan-Meier method was used to produce actuarial survival estimates. Cox regression analysis was used to predict the risk associated with stent type, and propensity scores were generated to risk-adjust the results. RESULTS: The study group included 379 stent recipients (284 DES; 95 BMS) with 410 stented lesions. BMS were placed more frequently in current smokers, acute myocardial infarctions, larger vessels, and longer lesions. In-hospital mortality was higher in BMS recipients than in their DES counterparts (3.2% vs. 0, respectively; P = 0.015). At 3 years, there was no significant difference in clinical adverse event rates between DES and BMS recipients, even after risk adjustment. CONCLUSIONS: Three-year adverse event rates are similar among patients treated with DES or BMS in SVG lesions. Therefore, while DES are safe, they do not appear to offer an advantage in terms of long-term graft patency.

AnchorSeed for the reduction of source movement in prostate brachytherapy with the Mick applicator implant technique.

PURPOSE: The purpose of this study was to evaluate the influence of potential contributing factors to the incidence of seed slippage and quality of prostate brachytherapy dosimetry comparing "coated" vs. "bare" seeds with a Mick applicator. METHODS AND MATERIALS: Two consecutive groups of 89 patients were treated with (125)I prostate brachytherapy at a high treatment volume single institution. All the patients were evaluated with Day 0 plain films of the pelvis and CT-based dosimetry analysis. The incidence of seed slippage was quantified. The seed slippage outcome was evaluated with respect to source type (bare vs. coated). The Day 0 prostate V(100), V(150), D90%, rectal V(100), and urethra D(30) outcomes were evaluated with respect to source type. RESULTS: A total of 13,512 seeds were placed in 178 patients. An average of 76 seeds and 16 needles were used for each patient. The bare seed group was significantly higher on fluoroscopy minutes (2.34 vs. 1.58 min), seed slippage (5 vs. 1.5 mm), volume of rectum receiving 100% of dose (0.05 vs. 0.0 cc), dose percentage received by 30% of urethra (119% vs. 113.64%), and volume of prostate receiving 100% of prescription dose (95.21% vs. 92.8%). No significant differences in volume of prostate receiving 150% of prescription dose, dose percentage received by 90% of prostate, vascular seed migration, or operating room procedure time were seen. No seed drift greater than 10mm outside the "packet" of other seeds was seen in the AnchorSeed (BrachySciences, a division of Biocompatibles, Inc. Oxford, CT) cohort. CONCLUSION: The report is the first to show the unique "fixity" of AnchorSeed to remain in position after deployment from the Mick applicator. Minimizing seed drag can reduce dose to the penile bulb, and maximize radiation coverage to the apex of the gland.

Exercise preference patterns, resources, and environment among rural breast cancer survivors.

CONTEXT: Rural breast cancer survivors may be at increased risk for inadequate exercise participation. PURPOSE: To determine for rural breast cancer survivors: (1) exercise preference "patterns," (2) exercise resources and associated factors, and (3) exercise environment. METHODS: A mail survey was sent to rural breast cancer survivors identified through a state cancer registry, and 483 (30%) responded. FINDINGS: The majority (96%) were white, with mean education of 13 (+/-2.5) years and mean 39.0 (+/-21.5) months since diagnosis. Most participants (67%) preferred face-to-face counseling from an exercise specialist (27%) or other individual (40%). A third (31%) preferred home-based exercise with non face-to-face counseling from someone other than an exercise specialist. Participants preferring face-to-face counseling were more apt to prefer supervised exercise (38% vs 9%, P < 0.001) at a health club (32% vs 8%, P < 0.001). Home exercise equipment was reported by 63%, with 97% reporting home telephone and 67% reporting Internet access. Age, education, self-efficacy, treatment status, and exercise behavior were associated with exercise resources. The physical environment was often not conducive to exercise but a low crime rate and high trust in neighbors was reported. CONCLUSIONS: Rural health education programs encouraging exercise should offer multiple programming options while considering the physical environment and capitalizing on available resources and beneficial social environmental characteristics.

Exercise preferences among patients with head and neck cancer: prevalence and associations with quality of life, symptom severity, depression, and rural residence.

BACKGROUND: Our aim was to determine exercise preferences among patients with head and neck cancer and their associations with quality of life, symptom severity, depression, and rural residence. METHODS: This study involved a cross-sectional chart review and self-administered survey, with 90 outpatients with head and neck cancer (response rate = 83%). RESULTS: The majority were <65 years old (65%), male (78%), and white (96%) with stage > or = III (81%). Lack of preference was the most frequent option for counseling source (66%), counseling delivery (47%), and exercise variability (52%). Popular specific preferences included outdoors (49%), morning (47%), and alone (50%). Significant adjusted associations occurred for patients' interest with lower functional well-being, alone with higher functional well-being, and morning with higher total quality of life and emotional, social, and functional well-being. No significant associations occurred with symptoms, depression, or rural residence. CONCLUSION: Patients with head and neck cancer may be open to a variety of exercise options. Quality of life may influence interest and preference for exercising alone or in the morning.

Factors associated with quality of life in outpatients with head and neck cancer 6 months after diagnosis.

BACKGROUND: Identifying patients with head and neck cancer at greatest risk of poor health-related quality of life (HRQOL) will facilitate screening for such patients and targeted interventions. METHODS: This was a cross-sectional, self-administered survey with medical record review among 65 out-patients with head and neck cancer >6 months from diagnosis and off treatment. RESULTS: Most were men (80%) and white (95%), with a mean age of 60 +/- 13 years. The most prevalent cancer type was squamous cell (88%), site was pharyngeal (40%), and stage was III or IV (80%). Lower total HRQOL was independently associated with gastrostomy (p < .001) and history of radiation therapy (p < .05)(R(2) = 0.27). Certain HRQOL subscales were also independently associated with depression, body mass index, age, and education. CONCLUSIONS: Several factors can be used to identify patients with head and neck cancer at risk for persistent reductions in HRQOL requiring intervention.