Roadmap for Connecting Cancer Rehabilitation With Survivorship to Improve Patient Outcomes and Clinical Efficiency.

ABSTRACT: An evolved model of comprehensive cancer care is needed that begins at cancer diagnosis to proactively manage cancer treatment toxicities and optimize patient health, function, and well-being. Building new care models requires connecting oncology, primary care, and specialized clinicians from many disciplines including cancer rehabilitation. Having a vision for an evolved standard of comprehensive cancer care is a requirement, but it is not enough to bring an innovative clinical program to life and sustain it over the long term. To inform the development of new clinical programs, two example programs are presented that successfully integrate cancer rehabilitation services along with details of a three-step process these programs used to facilitate their success and build robust business models that ensure their sustainability. Following the roadmap for growth presented here, gaining input from stakeholders and ensuring their buy-in, leveraging existing programmatic priorities, as well as developing a strategic growth plan can help clinical innovators ensure that new programs anticipate and continually meet the needs of oncology, primary care, subspecialty care, and programs, while addressing the business needs of administrators and improving the experience for patients.

Efficient triaging of advice and guidance referrals using teledermatology via the UK National Health Service e-Referral service platform: reporting positive outcomes from the COVID era.

BACKGROUND: Substantial increases in the implementation and use of dermatology advice and guidance (A&G) services has been a legacy of the COVID pandemic. OBJECTIVES: To evaluate the impact that a 45-month period of A&G use had on the health service outcomes in a university teaching hospital dermatology department. METHODS: A&G data for June in 2019, 2020, 2021 and 2022 were retrospectively analysed. Areas analysed included: total number of A&G requests; number of requests converted to referrals; percentage of discharges at first attendance; and referral-to-treatment (RTT) performance (defined as percentage of referrals seen by 18 weeks). RESULTS: A&G requests increased over the study period, from 45 requests in June 2019 to 1384 in June 2021. Increased request numbers were because of the COVID-19 pandemic, and then a subsequent change to the referral pathway. In January 2021, A&G became the obligatory referral route for all routine referrals to our department. The percentage of A&G requests converted to referral were 22.4%, 46.4%, 43.4% and 52.2% in June 2019, 2020, 2021 and 2022, respectively. Between 2019 and 2022 our discharges at first attendance decreased from 36.7% to 29.0%. RTT performance remained consistently above the national average; local RTT performances were 95.2% (2543/2671), 59.8% (782/1308), 90.1% (1697/1884) and 87.9% (1660/1888), in June 2019, 2020, 2021 and 2022, respectively, which compared favourably against RTT figures for England (90.2%, 56.5%, 78.2% and 65.1%). CONCLUSIONS: We highlight to other NHS dermatology departments the positive impact A&G triaging can have on outcomes, as observed for our service, reducing our discharges at first attendance and maintaining an RTT performance above the national average.

A Brief Review of Inpatient Palliative Rehabilitation.

Cancer patients face many challenges that can have a significant impact on their quality of life (QOL). When patients experience multiple functional impairments due to disease or treatment, their QOL and the efficient use of healthcare resources can be compromised. This is particularly true for patients who are nearing the end of their lives, as the physical and emotional burden of cancer can have a profound effect on both the individual and their caregivers. One approach to improving QOL in these patients is through palliative rehabilitation. Despite being an underutilized and understudied resource, palliative rehabilitation has shown promise in helping patients with advanced cancer retain their dignity and sense of control. By maximizing functional independence and reducing symptom burdens, palliative rehabilitation can provide a vital source of support for patients and their caregivers during this challenging time. Inpatient rehabilitation is one way that palliative rehabilitation can be applied in a healthcare setting. While further research is needed to fully understand the benefits of this approach, it is clear that palliative rehabilitation has the potential to play a key role in helping patients and their caregivers navigate the challenges of cancer treatment and end-of-life care. This approach is specific to the USA context but can be applied in other settings where cancer patients require such care.

Chat GPT vs Clinician: challenging the diagnostic capabilities of A.I. in dermatology.

BACKGROUND: Chat Generative Pre-trained Transformer (Chat GPT) is an online language-based platform, designed to answer questions in a human-like way, using deep learning technology. OBJECTIVE: To examine the diagnostic capabilities of Chat GPT using real world, anonymised, medical dermatology cases. METHODS: Clinical information from 90 consecutive patients referred to a single dermatology emergency clinic between June to December 2022 were examined. Thirty-six patients were included. Anonymised clinical information was transcribed and input into Chat GPT 4.0 followed by the question "what is the most likely diagnosis?". The suggested diagnosis made by Chat GPT was then compared to the diagnosis made in dermatology. RESULTS: After inputting a clinical history and examination by a dermatologist, Chat GPT made a correct primary diagnosis 56% of the time (20/36). Using the clinical history and cutaneous signs from non-specialists, it was able to make a correct diagnosis 38% of the time (14/36). This was similar to the diagnostic rate of non-specialists 36% (13/36), although much lower than dermatologists (83%, 30/36). There was no differential offered by referring sources 27% of the time (10/36), unlike chat GPT which provided a differential diagnosis 100% of the time. Qualitative analysis showed Chat GPT offered responses with caution, often justifying reasoning. CONCLUSION: This study illustrates that whilst Chat GPT has a diagnostic capability, in its current form it does not significantly improve diagnostic yield in primary or secondary care.

Disease decreases variation in host community structure in an old-field grassland.

Disease may drive variation in host community structure by modifying the interplay of deterministic and stochastic processes that shape communities. For instance, deterministic processes like ecological selection can benefit species less impacted by disease. When communities have higher levels of disease and disease consistently selects for certain host species, this can reduce variation in host community composition. On the other hand, when host communities are less impacted by disease and selection is weaker, stochastic processes (e.g., drift, dispersal) may play a bigger role in host community structure, which can increase variation among communities. While effects of disease on host community structure have been quantified in field experiments, few have addressed the role of disease in modulating variation in structure among host communities. To address this, we conducted a field experiment spanning three years, using a tractable system: foliar fungal pathogens in an old-field grassland community dominated by the grass Lolium arundinaceum, tall fescue. We reduced foliar fungal disease burden in replicate host communities (experimental plots in intact vegetation) in three fungicide regimens that varied in the seasonal duration of fungicide treatment and included a fungicide-free control. We measured host diversity, biomass, and variation in community structure among replicate communities. Disease reduction generally decreased plant richness and increased aboveground biomass relative to communities experiencing ambient levels of disease. These changes in richness and aboveground biomass were consistent across years despite changes in structure of the plant communities over the experiment's three years. Importantly, disease reduction amplified host community variation, suggesting that disease diminished the degree to which host communities were structured by stochastic processes. These results of experimental disease reduction both highlight the potential importance of stochastic processes in plant communities and reveal the potential for disease to regulate variation in host community structure.

Cutaneous sarcoma: a review and practical approach to management.

Sarcomas arising in the skin are rare but potentially fatal. These tumours originate from mesenchymal cells and can be divided between those that arise in soft tissue and those arising from bone. General guidelines exist for the management of soft-tissue sarcomas; however, there are no specific guidelines for cutaneous sarcomas. Current literature was reviewed for management of seven cutaneous sarcomas including atypical fibroxanthoma, pleomorphic dermal sarcoma, dermal and subcutaneous leiomyosarcoma, dermatofibroma sarcoma protuberans, Kaposi sarcoma, cutaneous angiosarcoma and malignant peripheral nerve sheath tumour. All suspected sarcomas should be discussed in a sarcoma multidisciplinary team meeting. This article is not a clinical guideline but should serve as a practical summary of how these tumours present, how they are recognized histologically, and how best to manage and follow-up patients. The aim is to support clinicians and facilitate the best and most evidence-based standard of care available.

Historical contingency in parasite community assembly: Community divergence results from early host exposure to symbionts and ecological drift.

Host individuals are commonly coinfected with multiple parasite species that may interact to shape within-host parasite community structure. In addition to within-host species interactions, parasite communities may also be structured by other processes like dispersal and ecological drift. The timing of dispersal (in particular, the temporal sequence in which parasite species infect a host individual) can alter within-host species interactions, setting the stage for historical contingency by priority effects, but how persistently such effects drive the trajectory of parasite community assembly is unclear, particularly under continued dispersal and ecological drift. We tested the role of species interactions under continued dispersal and ecological drift by simultaneously inoculating individual plants of tall fescue with a factorial combination of three symbionts (two foliar fungal parasites and a mutualistic endophyte), then deploying the plants in the field and tracking parasite communities as they assembled within host individuals. In the field, hosts were exposed to continued dispersal from a common pool of parasites, which should promote convergence in the structure of within-host parasite communities. Yet, analysis of parasite community trajectories found no signal of convergence. Instead, parasite community trajectories generally diverged from each other, and the magnitude of divergence depended on the initial composition of symbionts within each host, indicating historical contingency. Early in assembly, parasite communities also showed evidence of drift, revealing another source of among-host divergence in parasite community structure. Overall, these results show that both historical contingency and ecological drift contributed to divergence in parasite community assembly within hosts.

Addressing Social Determinants of Health to Reduce Disparities Among Individuals with Cancer: Insights for Rehabilitation Professionals.

PURPOSE OF REVIEW: This report aims to provide a framework for cancer rehabilitation professionals to assess social determinants of health in individuals with cancer and discuss strategies that can be implemented in practice to overcome barriers to care. RECENT FINDINGS: There has been an increased focus in improving patient conditions that can affect access to cancer rehabilitation. Along with government and world health organization initiatives, healthcare professionals and institutions continue to work towards decreasing disparities. Several disparities exist in healthcare and education access and quality, patients' social and community context, neighborhood and built environments, and economic stability. The authors emphasized the challenges that patients who require cancer rehabilitation face that healthcare providers, institutions, and governments can mitigate with outlined strategies. Education and collaboration are essential to make true progress in decreasing disparities in the populations most in need.

Effects of joint loading on the development of capital femoral epiphysis morphology.

INTRODUCTION: The deleterious influence of increased mechanical forces on capital femoral epiphysis development is well established; however, the growth of the physis in the absence of such forces remains unclear. The hips of non-ambulatory cerebral palsy (CP) patients provide a weight-restricted (partial weightbearing) model which can elucidate the influence of decreased mechanical forces on the development of physis morphology, including features related to development of slipped capital femoral epiphysis (SCFE). Here we used 3D image analysis to compare the physis morphology of children with non-ambulatory CP, as a model for abnormal hip loading, with age-matched native hips. MATERIALS AND METHODS: CT images of 98 non-ambulatory CP hips (8-15 years) and 80 age-matched native control hips were used to measure height, width, and length of the tubercle, depth, width, and length of the metaphyseal fossa, and cupping height across different epiphyseal regions. The impact of age on morphology was assessed using Pearson correlations. Mixed linear model was used to compare the quantified morphological features between partial weightbearing hips and full weightbearing controls. RESULTS: In partial weightbearing hips, tubercle height and length along with fossa depth and length significantly decreased with age, while peripheral cupping height increased with age (r > 0.2, P < 0.04). Compared to normally loaded (full weightbearing) hips and across all age groups, partially weightbearing hips' epiphyseal tubercle height and length were smaller (P < .05), metaphyseal fossa depth was larger (P < .01), and posterior, inferior, and anterior peripheral cupping heights were smaller (P < .01). CONCLUSIONS: Smaller epiphyseal tubercle and peripheral cupping with greater metaphyseal fossa size in partial weightbearing hips suggests that the growing capital femoral epiphysis requires mechanical stimulus to adequately develop epiphyseal stabilizers. Deposit low prevalence and relevance of SCFE in CP, these findings highlight both the role of normal joint loading in proper physis development and how chronic abnormal loading may contribute to various pathomorphological changes of the proximal femur (i.e., capital femoral epiphysis).

Can a novel constructivist theory-informed feedback intervention reduce prescribing errors ? A pre-post study.

CONTEXT: Medical interns (interns) find prescribing challenging and many report lacking readiness when commencing work. Errors in prescribing puts patients' safety at risk. Yet error rates remain high, despite education, supervision and pharmacists' contributions. Feedback on prescribing may improve performance. Yet, work-based prescribing feedback practices focus on rectifying errors. We aimed to explore if prescribing can be improved using a theory-informed feedback intervention. METHODS: In this pre-post study, we designed and implemented a constructivist-theory informed prescribing feedback intervention, informed by Feedback-Mark 2 Theory. Interns commencing internal medicine terms in two Australian teaching hospitals were invited to engage in the feedback intervention. Their prescribing was evaluated by comparing errors per medication order of at least 30 orders per intern. Pre/baseline (weeks 1-3) were compared with post intervention (weeks 8-9). Interns' baseline prescribing audit findings were analysed and discussed at individualised feedback sessions. These sessions were with a clinical pharmacologist (Site 1) and a pharmacist educator (Site 2). RESULTS: Eighty eight intern's prescribing over five 10-week terms was analysed from two hospitals. The frequency of prescribing errors significantly reduced at both sites after the intervention, across all five terms (p < 0.001).There were initially 1598 errors in 2750 orders (median [IQR] 0.48 [0.35-0.67] errors per order) and after the intervention 1113 errors in 2694 orders (median [IQR] 0.30 [0.17-0.50] errors per order). CONCLUSION: Our findings suggest interns' prescribing practices may improve as a result of constructivist -theory learner centred, informed feedback with an agreed plan. This novel intervention, contributed, to a reduction in interns' prescribing errors. This study suggests new strategies for improving prescribing safety should include the design and implementation of theory-informed feedback interventions.

Smaller epiphyseal tubercle in hips with slipped capital femoral epiphysis compared to the uninvolved contralateral hip.

Recent investigations suggest that physeal morphologic features have a major role in the capital femoral epiphysis stability and slipped capital femoral epiphysis (SCFE) pathology, with a smaller epiphyseal tubercle and larger peripheral cupping of the femoral epiphysis being present in hips with progressive SCFE compared to healthy controls. Yet, little is known on the causal versus remodeling nature of these associations. This study aimed to use preoperative magnetic resonance imaging (MRI) of patients with unilateral SCFE to perform a comparison of the morphology of the epiphyseal tubercle, metaphyseal fossa, and peripheral cupping in hips with SCFE versus the contralateral uninvolved hips. Preoperative MRIs from 22 unilateral SCFE patients were used to quantify the morphological features of the epiphyseal tubercle (height, width, and length), metaphyseal fossa (depth, width, and length), and peripheral cupping height in three dimension. The quantified anatomical features were compared between hips with SCFE and the contralateral uninvolved side across the whole cohort and within SCFE severity subgroups using paired t-test. We found significantly smaller epiphyseal tubercle heights (p < 0.001) across all severities of SCFE when compared to their uninvolved contralateral side. There was a marginally smaller metaphyseal fossa length (p = 0.05) in SCFE hips compared to their contralateral uninvolved hips, with mild SCFE hips specifically having smaller fossa and epiphyseal lengths (p < 0.05) than their contralateral uninvolved side. There were no side-to-side differences in any other features of the epiphyseal tubercle, metaphyseal fossa and peripheral cupping across all severities (p > 0.05). These findings suggest a potential causal role of epiphyseal tubercle in SCFE pathogenesis.

Diagnosis of paediatric tuberculosis by optically detecting two virulence factors on extracellular vesicles in blood samples.

Sensitive and specific blood-based assays for the detection of pulmonary and extrapulmonary tuberculosis would reduce mortality associated with missed diagnoses, particularly in children. Here we report a nanoparticle-enhanced immunoassay read by dark-field microscopy that detects two Mycobacterium tuberculosis virulence factors (the glycolipid lipoarabinomannan and its carrier protein) on the surface of circulating extracellular vesicles. In a cohort study of 147 hospitalized and severely immunosuppressed children living with HIV, the assay detected 58 of the 78 (74%) cases of paediatric tuberculosis, 48 of the 66 (73%) cases that were missed by microbiological assays, and 8 out of 10 (80%) cases undiagnosed during the study. It also distinguished tuberculosis from latent-tuberculosis infections in non-human primates. We adapted the assay to make it portable and operable by a smartphone. With further development, the assay may facilitate the detection of tuberculosis at the point of care, particularly in resource-limited settings.

A qualitative assessment of patient satisfaction with remote dermatology consultations utilized during the UK's first wave of the COVID-19 pandemic in a single secondary care dermatology department.

During the first wave of the SARS-CoV-2 coronavirus (COVID-19) pandemic, many dermatology departments in the UK delivered remote consultations in order to minimize viral transmission. To assess patient perception of remote consultations delivered in a single dermatology department during this time, we retrospectively contacted patients via an electronic questionnaire and the responses are summarized. We anticipate that increased use of remote consultations will be a legacy of the pandemic, although healthcare professionals will have a responsibility for ensuring appropriate patient suitability.

Thermochemical Studies of Ni(II) and Zn(II) Ternary Complexes using Ion Mobility-Mass Spectrometry.

This article describes an experimental protocol using electrospray-ion mobility-mass spectrometry (ES-IM-MS) and energy-resolved threshold collision-induced dissociation (TCID) to measure the thermochemistry of the dissociation of negatively-charged [amb+M(II)+NTA]- ternary complexes into two product channels: [amb+M(II)] + NTA or [NTA+M(II)]- + amb, where M = Zn or Ni and NTA is nitrilotriacetic acid. The complexes contain one of the alternative metal binding (amb) heptapeptides with the primary structures acetyl-His1-Cys2-Gly3-Pro4-Tyr5-His6-Cys7 or acetyl-Asp1-Cys2-Gly3-Pro4-Tyr5-His6-Cys7, where the amino acids' Aa1,2,6,7 positions are the potential metal-binding sites. Geometry-optimized stationary states of the ternary complexes and their products were selected from quantum chemistry calculations (presently the PM6 semi-empirical Hamiltonian) by comparing their electronic energies and their collision cross-sections (CCS) to those measured by ES-IM-MS. From the PM6 frequency calculations, the molecular parameters of the ternary complex and its products model the energy-dependent intensities of the two product channels using a competitive TCID method to determine the threshold energies of the reactions that relate to the 0 K enthalpies of dissociation (ΔH0). Statistical mechanics thermal and entropy corrections using the PM6 rotational and vibrational frequencies provide the 298 K enthalpies of dissociation (ΔH298). These methods describe an EI-IM-MS routine that can determine thermochemistry and equilibrium constants for a range of ternary metal ion complexes.

A suspicious skin nodule with dilated chest veins: the importance of a full skin examination.

This letter outlines the case of a new-onset skin nodule, which led to the diagnosis of both a primary bronchial carcinoma and a cutaneous metastatic squamous cell carcinoma deposit. This case highlights the importance of a full skin examination to pick up important clinical signs as, although these can be subtle, they can have a significant effect on further management.

A Microbial Mutualist Within Host Individuals Increases Parasite Transmission Between Host Individuals: Evidence From a Field Mesocosm Experiment.

The interactions among host-associated microbes and parasites can have clear consequences for disease susceptibility and progression within host individuals. Yet, empirical evidence for how these interactions impact parasite transmission between host individuals remains scarce. We address this scarcity by using a field mesocosm experiment to investigate the interaction between a systemic fungal endophyte, Epichloë coenophiala, and a fungal parasite, Rhizoctonia solani, in leaves of a grass host, tall fescue (Lolium arundinaceum). Specifically, we investigated how this interaction impacted transmission of the parasite under field conditions in replicated experimental host populations. Epichloë-inoculated populations tended to have greater disease prevalence over time, though this difference had weak statistical support. More clearly, Epichloë-inoculated populations experienced higher peak parasite prevalences than Epichloë-free populations. Epichloë conferred a benefit in growth; Epichloë-inoculated populations had greater aboveground biomass than Epichloë-free populations. Using biomass as a proxy, host density was correlated with peak parasite prevalence, but Epichloë still increased peak parasite prevalence after controlling for the effect of biomass. Together, these results suggest that within-host microbial interactions can impact disease at the population level. Further, while Epichloë is clearly a mutualist of tall fescue, it may not be a defensive mutualist in relation to Rhizoctonia solani.

Adenocarcinoma of the Rete Testis: A Case Report.

Adenocarcinoma of the rete testis is an extremely rare and aggressive tumor that carries a poor prognosis. Successful long-term treatment for such tumors remains elusive as more cases are discovered worldwide. Treatment typically involves radical orchiectomy, retroperitoneal pelvic lymph node dissection, adjuvant chemotherapy, and/or continued surveillance. Here we describe the case of a 42-year-old male with a history of low testosterone who presented with a localized adenocarcinoma of the left rete testis. He was treated with radical orchiectomy and continued surveillance alone due to a lack of evidence of metastasis on follow-up imaging. History, prognosis, diagnostics, and treatment guidelines, as well as the most significant recent cases since the last rete testis adenocarcinoma literature meta-analysis, are discussed.

Clinical Implications of Hematologic and Hemostatic Abnormalities in Children With COVID-19.

Leukopenia, thrombocytopenia, elevated D-dimer, and prolonged prothrombin time are considered poor prognostic factors in adults with acute Coronavirus Disease 2019. The prognostic significance of these abnormalities among pediatric patients remains underreported in the literature. This retrospective cohort study evaluates the prognostic implications of hematologic and hemostatic derangements in patients younger than 22-years-of-age who were admitted to a tertiary-care referral institution for management of acute Coronavirus Disease 2019 infection. Leukopenia and thrombocytopenia were identified as independent prognostic factors of disease severity. Although the majority of children, with available results, had elevated D-dimer or prolonged prothrombin time upon initial presentation, these markers were not found to be associated with the development of severe clinical complications.

Indirect interactions among co-infecting parasites and a microbial mutualist impact disease progression.

Interactions among parasites and other microbes within hosts can impact disease progression, yet study of such interactions has been mostly limited to pairwise combinations of microbes. Given the diversity of microbes within hosts, indirect interactions among more than two microbial species may also impact disease. To test this hypothesis, we performed inoculation experiments that investigated interactions among two fungal parasites, Rhizoctonia solani and Colletotrichum cereale, and a systemic fungal endophyte, Epichloë coenophiala, within the grass, tall fescue (Lolium arundinaceum). Both direct and indirect interactions impacted disease progression. While the endophyte did not directly influence R. solani disease progression or C. cereale symptom development, the endophyte modified the interaction between the two parasites. The magnitude of the facilitative effect of C. cereale on the growth of R. solani tended to be greater when the endophyte was present. Moreover, this interaction modification strongly affected leaf mortality. For plants lacking the endophyte, parasite co-inoculation did not increase leaf mortality compared to single-parasite inoculations. By contrast, for endophyte-infected plants, parasite co-inoculation increased leaf mortality compared to inoculation with R. solani or C. cereale alone by 1.9 or 4.9 times, respectively. Together, these results show that disease progression can be strongly impacted by indirect interactions among microbial symbionts.

Evaluation of a serum-based antigen test for tuberculosis in HIV-exposed infants: a diagnostic accuracy study.

BACKGROUND: Non-sputum methods are urgently needed to improve tuberculosis diagnosis and treatment monitoring in children. This study evaluated the ability of a serum assay quantifying a species-specific peptide of the Mycobacterium tuberculosis CFP-10 virulence factor via nanotechnology and matrix-assisted laser desorption ionization time-of-flight mass spectrometry to diagnose tuberculosis in HIV-infected and HIV-uninfected infants. METHODS: Serum CFP-10 peptide signal was blinded evaluated in cryopreserved sera of 519 BCG-immunized, HIV-exposed infants (284 HIV-infected, 235 HIV-uninfected) from a multi-center randomized placebo-controlled isoniazid prophylaxis trial conducted in southern Africa between 2004 and 2008, who were followed up to 192 weeks for Mtb infection and TB. Children were classified as confirmed, unconfirmed, or unlikely tuberculosis cases using 2015 NIH diagnostic criteria for pediatric TB. RESULTS: In HIV-infected infants, CFP-10 signal had 100% sensitivity for confirmed TB (5/5, 95% CI, 47.8-100) and 83.7% sensitivity for unconfirmed TB (36/43, 95% CI 69.3-93.2), with 93.1% specificity (203/218, 95% CI 88.9-96.1). In HIV-uninfected infants, CFP-10 signal detected the single confirmed TB case and 75.0% of unconfirmed TB cases (15/20; 95% CI 50.9-91.3), with 96.2% specificity (177/184, 95% CI, 92.3-98.5). Serum CFP-10 achieved 77% diagnostic sensitivity for confirmed and unconfirmed TB (13/17, 95% CI, 50-93%) at ≤ 24 weeks pre-diagnosis, and both CFP-10-positivity and concentration declined following anti-TB therapy initiation. CONCLUSIONS: Serum CFP-10 signal exhibited high diagnostic sensitivity and specificity for tuberculosis in HIV-infected and HIV-uninfected infants and potential utility for early TB detection and monitoring of anti-TB treatment responses.