bluuebunny/crossref_metadata_2025 huggingface dataset:
Safety of Symptom-Based Modification of Physical Therapy Interventions in Pediatric Oncology Patients With and Without Low Blood Counts
Authors: Gilchrist Laura , Tanner Lynn R.
Published: July 2018

Background:

Pediatric patients being treated for cancer often have low blood counts, yet physical therapy (PT) intervention and activity during treatment are thought to be important. The current practice at one institution is to modify PT interventions based on symptoms rather than relying on complete blood cell (CBC) counts.

Purpose:

This study investigates the safety of a symptomatic, rather than count-based, approach to modification of PT interventions in a pediatric cancer population at least 2 months into treatment.

Methods:

A retrospective chart review was performed to investigate the number and type of adverse events that occurred within 48 hours of a PT session in pediatric oncology patients. Information related to CBC values and type of interventions was abstracted from medical records. Associations between adverse events and low hemoglobin, platelets, and white blood cell (WBC) counts were assessed, and risk ratios were calculated.

Results:

CBC values were often abnormal. Adverse events occurred during or after 37 of 406 PT sessions, with the most common event being tachycardia not requiring medical intervention. No serious adverse events occurred. While an increased number of events occurred in those with low hemoglobin levels, this was nonsignificant when tachycardia was removed. A higher rate of adverse events did occur when platelets were below 20 000/mm3 (χ2 = 11.08, P = .001; Risk Ratio = 4.91; 95% confidence interval, 1.76-13.67), although none were bleeding-related. Low WBC count was not associated with an increased risk of adverse events.

Conclusion:

PT interventions can be safely incorporated into patient care when symptoms, rather than CBC values, guide clinical decision making about treatment modification.
Opioid Campaigns' Impact on Advanced Cancer and Hospice and Palliative Care: An Invited Commentary
Authors: Wilson Christopher M.
Published: July 2018

Background:

Opioids effectively manage pain, but increasing misuse has resulted in significant abuse, addiction, and even death. This misuse has accelerated to the point that an “opioid epidemic” has been declared. Several government agencies and professional associations (including the APTA) are developing well-meaning programs to address opioid abuse.

Purpose:

Recent national opioid campaigns may have significant, unintentional, and adverse consequences on the medical management of patients with advanced cancers or those receiving hospice and palliative care (HPC). This commentary describes the role of the physical therapist (PT) in the palliative symptom management of terminally ill individuals during this paradigm shift in opioid-prescribing practices.

Discussion:

Opioids have long been a staple in the management of symptoms present in patients with advanced cancer or in HPC (ie, pain, dyspnea). New opioid management guidelines are likely to impose even tighter controls on opioids, further reducing accessibility to these drugs for these individuals. There is concern that these well-meaning public initiatives may have unintended consequences for end-of-life care if the HPC community is not vigilant in its advocacy. The expected reduction in opioid prescriptions prompts an increasingly critical role for PTs in palliative symptom management to optimize remaining quality of life.

Conclusion:

During refinement of policies, procedures, and legislation related to medical use of opioids, health care providers (including PTs) caring for individuals with a life-threatening illness must provide input to regulatory bodies in order to avoid overly restrictive regulations that may increase pain and suffering near the end of life.
Integrating Edema Management Into Entry-Level Doctor of Physical Therapy Curriculum: A Case Report
Authors: Sander Antoinette P. , Perdomo Marisa
Published: July 2018

Background and Purpose:

The Commission on Accreditation in Physical Therapy Education includes criteria for the management of edema. The purpose of this case report is to outline content and instructional guidelines for edema and lymphedema management in 2 entry-level Doctor of Physical Therapy curricula.

Case Description:

Teaching edema management includes both general and specific knowledge of the anatomy and physiology of the lymphatic system, an understanding of the pathophysiology of edema, and competency in traditional and innovative skills of edema management in the context of a patient management model and evidence-based practice. Northwestern University Department of Physical Therapy and Human Movement Science has a required dedicated course that combines clinical management of patients with lymphatic and integumentary dysfunction. The University of Southern California integrates edema management throughout the 3-year curriculum. Both of these programs are presented in detail.

Outcomes:

The Northwestern program has been presented continuously since 2003; the University of Southern California began integrative edema management in 2002 and evolved into the current model in 2005. Mean scores on the Federation of State Boards of Physical Therapy examination consistently indicate that graduates from both schools rank higher than other first-time test takers from US accredited programs in the area of cardiovascular/pulmonary and lymphatic systems.

Discussion and Conclusion:

This report provides objectives, methods, and references to guide an instructional course in edema management in an entry-level Doctor of Physical Therapy curriculum. Two cases of integrating edema content within a current curriculum are presented. An essential element for a successful program is the availability of academic or clinical faculty trained in lymphedema management.
Oncology Section EDGE Task Force on Cancer: A Systematic Review of Clinical Measures for Pain
Authors: Harrington Shana E. , Gilchrist Laura , Lee Jeannette , Westlake Frances L. , Baker Alicia
Published: July 2018

Background:

Pain is one of the most common complaints in individuals with cancer and can occur at any point during the course of cancer treatment.

Purpose:

To identify outcome measures for assessing pain and to evaluate their psychometric properties and relevance to adults with a diagnosis of cancer.

Methods:

Three electronic databases (CINAHL, MEDLINE, and PsycINFO) were reviewed using specific search terms to locate articles that identify outcome measures assessing pain in adults with a diagnosis of cancer. From the 1164 articles identified, 494 articles were reviewed and 22 outcome measures were selected for analysis. Each outcome measure was independently reviewed and rated by 2 reviewers using the updated Cancer EDGE Task Force Outcome Measure Rating Form. Any discrepancies between reviewers were discussed, and an overall recommendation for each measure was made using the 4-point Cancer EDGE Task Force Rating Scale.

Results:

On the basis of the psychometric properties, clinical utility, and relevance to adults with a diagnosis of cancer, the following 3 measures are highly recommended: McGill Pain Questionnaire–Short Form, Numeric Rating Scale, and Visual Analog Scale. Four measures are recommended: Brief Pain Inventory, Brief Pain Inventory–Short Form, McGill Pain Questionnaire, and Pain Disability Index. Eleven measures are recommended as reasonable to use, and 3 are not recommended.

Conclusions:

Seven of the 22 pain measures demonstrated satisfactory psychometric properties and clinical utility and are thereby recommended for clinical and research use in adults with a diagnosis of cancer.
Identifying Fall Risk of Patients Receiving Hematopoietic Cell Transplant
Authors: Rindflesch Aaron B. , Hake Melissa P. , Meyer Tanya , Murphy Ryan , Olson Morgan L. , Uphoff Kayla , Hollman John H.
Published: July 2018

Background and Purpose/Objective:

Few studies have examined the efficacy of fall risk assessment tools for patients undergoing hematopoietic cell transplant (HCT). The purpose of this study was to determine whether the Hendrich II Fall Risk Model (HFRM II) can distinguish patients who fell from those who did not fall in the inpatient HCT population.

Methods:

Observational study.

Design:

Retrospective chart review.

Setting:

Academic medical center.

Patients:

Patients undergoing HCT who fell during the first 100 days posttransplant.

Intervention:

None.

Measurements:

Independent-sample t tests were performed to determine differences in HFRM II score, age, pulse, systolic and diastolic blood pressure, platelet count, hemoglobin concentration, and hematocrit for fallers compared with nonfallers. Chi-square tests of independence determined differences regarding sex, assistive device used on the day of fall, transplant type, and physical therapy. Logistic regression analysis detected odds of falling dependent on transplant type, pulse rate, and HFRM II score.

Results:

Forty-seven patients who fell within 100 days after HCT were control matched by transplant date with 2 nonfallers each. Significant differences included HFRM II mean score (5.36 for fallers vs 3.41 for nonfallers; t = 4.510, P < .001) and mean pulse rates (100.09 vs 88.70 bpm; t = 3.398, P = .001). Patients with allogeneic HCT were 3.46 times more likely to have fallen than those with autologous HCT (P = .007).

Limitations:

Potential selection bias of retrospective review.

Conclusions:

HCT patients with higher HFRM II scores, greater pulse rate, or allogeneic transplant were more likely to fall.
Evaluating Hand Grip Strength Prior to Hematopoietic Stem Cell Transplantation as a Predictor of Patient Outcomes
Authors: Bailey Charlotte , Asher Arash , Kim Sungjin , Shinde Arvind , Lill Michael
Published: July 2018

Background and Purpose:

The primary purpose of this study was to determine the predictive capacity of hand grip strength on overall survival among patients undergoing hematopoietic stem cell transplantation (HCT).

Design:

Retrospective chart review.

Setting:

Hand grip strength was measured at the time of HCT in an inpatient setting in 2009.

Patients:

Forty-nine patients with various hematologic malignancies.

Intervention:

Hand grip strength was performed using the dominant hand. The Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) was administered during the same visit. Chart abstraction was performed 5 years postassessment to obtain mortality data, Karnofsky Performance Status (KPS) at HCT, graft type, gender, comorbidity index, and age at HCT.

Main Outcome Measure:

Survival

Results:

Median follow-up time was 5.62 years. In multivariable analyses, higher hand grip strength was associated with shorter length of stay, higher FACIT-F total score, and higher FACIT-F subscale score in female patients only. Higher hand grip strength was associated with an improved overall survival in all patients with and without adjustment for gender, graft type, and comorbidity index (unadjusted hazard ratio [HR]: 0.86; 95% confidence interval [CI]: 0.74-0.99;P= .034; adjusted HR: 0.82; 95% CI: 0.69-0.98;P= .033).

Limitations:

Retrospective design did not allow for assessment of posttransplant complications.

Conclusion:

Higher hand grip strength was associated with a shorter length of stay, higher quality of life, and lower fatigue for female patients, and better overall survival among men and women. Larger prospective studies are needed to confirm this finding.
Effects of Preoperative Exercise on Physical Fitness and Body Composition in Pancreatic Cancer Survivors Receiving Neoadjuvant Therapy: A Case Series
Authors: Marker Ryan J. , Peters John C. , Purcell W. Thomas , Jankowski Catherine A.
Published: July 2018

Background and Purpose:

Poor preoperative physical fitness and muscle mass are associated with increased morbidity and mortality in pancreatic cancer survivors. While neoadjuvant therapy improves viability for and effectiveness of a surgical resection in patients with borderline-resectable pancreatic adenocarcinoma, it also reduces preoperative fitness and muscle mass. The purpose of this investigation was to prevent fitness and muscle mass declines in this population with a supervised, preoperative exercise program.

Methods:

Patients recently diagnosed with borderline-resectable pancreatic adenocarcinoma and prescribed neoadjuvant therapy were recruited. Assessments of body composition, physical fitness, and health-related quality of life were assessed at baseline (<4 weeks from diagnosis), preoperatively, and 6 weeks after hospital discharge. Participants attended 2 to 3 supervised exercise sessions per week for the duration of neoadjuvant therapy. Sessions consisted of aerobic, resistance, and flexibility exercises tailored to the individual. Adherence to the exercise program was recorded to assess feasibility.

Results:

Only 3 participants were recruited in an 8-month window, primarily due to location limitations, and are presented as a case series. All participants increased lean muscle mass and physical fitness after the exercise program. Two participants met cancer cachexia diagnostic criteria at baseline but not after the exercise program. One participant developed metastatic disease and did not receive surgery. Neither of the participants who underwent surgery was readmitted to the hospital after discharge.

Conclusion:

This study provides preliminary evidence that a preoperative exercise program during neoadjuvant therapy may be effective at maintaining or improving muscle mass and physical fitness in pancreatic cancer survivors.
Exercise in African American and White Colorectal Cancer Survivors: A Mixed-Methods Approach
Authors: Ray Andrew D. , Masucci Twarozek Annamaria , Williams Brian T. , Erwin Deborah O. , Underwood Willie , Mahoney Martin C.
Published: July 2018

Background:

African American (AA) colorectal cancer (CRC) survivors tend to be more obese and less physically active than white survivors.

Purpose/Objective:

To test the feasibility of an aerobic exercise program as well as explore perceptions about supervised exercise among AA CRC survivors.

Methods:

A prospective supervised exercise intervention performed on a cycle ergometer 2 d/wk for 12 weeks. Peak (

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2peak) and submaximal exercise (Six-Minute Walk Test [6MWT]) along with questionnaires (36-Item Short Form Health Survey [SF-36], Memorial Sloan Kettering Cancer Center Bowel Function Instrument [BFI], Functional Assessment of Cancer Therapy–Colorectal (FACT-C) and Fatigue (FACIT-F), and Brief Symptom Inventory [BSI]). A second group of survivors participated in an interview evaluating perceptions regarding exercise.

Design:

Prospective case series and qualitative interview.

Setting:

Research university and academic medical center.

Patients:

AA and white CRC survivors.

Results:

Quantitative: A total of 237 letters were mailed to CRC survivors (112 whites, 126 AAs). From the letters, 25 whites and 15 AAs expressed interest; only 5 whites (4.5%) and 4 AAs (3.2%) enrolled. Two AA and 5 white survivors (7/9) finished the program. There was an improvement in peak exercise (P = .011) and quality of life (QOL) (SF-36 total, P = .035) posttraining. Qualitative: 30 CRC survivors (12 AAs and 18 whites) participated in qualitative interviews and selected comorbidity, motivation, and location as primary barriers to exercise.

Limitations:

Small sample size.

Conclusions:

Recruiting CRC survivors (regardless of race) into an exercise program is challenging; however, there are exercise and QOL benefits associated with participation. Barriers to exercise are similar between AA and white CRC survivors.
The Influence of Cognitive Function on Balance, Mobility, and Falls in Older Cancer Survivors
Authors: Blackwood Jennifer
Published: July 2018

Introduction:

Older cancer survivors fall more often, as disease-associated sequelae such as impaired cognitive function contribute to a higher falls risk. Cognitive dysfunction may contribute to falls and mobility; however, this relationship is not well described. The purpose of this study was to examine associations between cognitive function, gait speed, balance, and falls in older cancer survivors.

Methods:

A cross-sectional analysis of 573 older cancer survivors was conducted from the 2010 Health and Retirement Study wave. Groups were assigned on the basis of falls history: Falls (N = 222) or No Falls (N = 351). Groupwise comparisons on demographic, cognitive, and physical mobility variables were completed. Linear regression analyses were performed to examine associations between cognitive function (recall, orientation, executive function), gait speed, tandem balance, and falls in the sample and by group.

Results:

Significant between-group differences existed in demographic, cognitive function, falls, and mobility variables. Falls were inversely associated with executive function (β = −0.18, P < .05). Delayed recall was linearly associated with tandem stance in the whole sample (β = 0.11, P < .05). Falls history was able to detect differing relationships between gait speed and each of the cognitive processes (β = 0.11-0.17 for fallers; β = 0.11-0.22 for nonfallers), indicating the underlying influence of cognition on mobility in cancer survivors.

Discussion:

Different cognitive processes influence falls, balance, and mobility in the older cancer survivor, especially those with a history of falling. Assessments of balance and falls should include screening more than orientation to detect cognitive impairments that impact mobility and falls.
Computed Tomography–Derived Thoracic Muscle Size as an Indicator of Sarcopenia in People With Advanced Lung Disease
Authors: Mathur Sunita , Rodrigues Nicole , Mendes Polyana , Rozenberg Dmitry , Singer Lianne G.
Published: July 2018

Purpose:

Computed tomography (CT) of the chest is routinely performed in people with lung disease; however, the utility of measuring thoracic muscle size to assess the presence of sarcopenia (low muscle mass and function) has not been studied. The purpose of this study was to examine the reliability and validity of thoracic muscle size obtained from chest CT as a surrogate of sarcopenia.

Methods:

In this observational study, chest CT was obtained from routine clinical evaluation in 32 individuals with advanced lung disease awaiting lung transplantation. Thoracic muscle area from vertebral levels T4–T6 was manually segmented using Slice-O-Matic software, and average muscle cross-sectional area (CSA) and muscle volume were calculated. Measures of sarcopenia included quadriceps CSA and thickness from ultrasound, quadriceps, and biceps torque and short physical performance battery (SPPB).

Results:

Intrareliability and interrater reliability for muscle CSA were high (intraclass correlation coefficient = 0.96, 0.99; absolute difference = 0.61, 1.7 cm2, respectively). Thoracic muscle CSAs and volume correlated with quadriceps size and limb muscle strength (r = 0.56–0.71, P < .001) but not SPPB. Cross-sectional areas from single slices at T4–T6 were highly correlated with muscle volume (r = 0.89–0.91, P < .001).

Conclusions:

Thoracic muscle size seems to be a reliable and valid technique that can be applied in large studies evaluating the presence of sarcopenia in patients with advanced lung disease.
Reliability of Physical Therapists in Performing Ankle-Brachial Index Measurements
Authors: Clifft Judy K. , Meekins Myra M. , Coleman F. Ann , Bradford Jacque L. , Hatten Marie W.
Published: July 2018

Purpose:

Reliability of ankle-brachial index (ABI) testing has been assessed in some health care providers, but there is conflicting information on the reliability of physical therapists (PTs). The purpose of this study was to determine the reliability of practicing PTs in performing ABI measurements in an older adult population.

Methods:

Two practicing PTs measured systolic blood pressure in all 4 extremities of 23 subjects (mean age 61.9 yr) using Doppler ultrasound. The measurements were repeated in all subjects and an ABI was calculated for each extremity using the conventional and an alternate method.

Results:

Reliability was assessed with the intraclass correlation coefficient (ICC). The ICC for interrater reliability when using the conventional method for calculating ABI was 0.649 (95% CI [443, 789]). The ICC for intrarater reliability was 0.710 (95% CI [0.530, 0.828]) for rater 1 and 0.586 (95% CI [0.359, 0.748]) for rater 2. The ICCs were generally higher when the alternate method was used to calculate ABI.

Conclusions:

Interrater reliability of PTs was good, and intrarater reliability was fair to excellent when calculating ABI by the conventional and alternate methods. Physical therapists who follow recommended procedures can obtain reliable ABI measurements.
Clinical Predictors of Inspiratory Muscle Strength in Adults With Stable Cystic Fibrosis: A Pilot Study
Authors: Dekerlegand Robert L. , Hadjiliadis Denis , Swisher Anne K. , Parrott James Scott , Heuer Albert J. , Myslinski Mary Jane
Published: July 2018

Purpose:

Inspiratory muscle strength (IMS) ranges from below normal to supernormal levels in adults with cystic fibrosis (CF). An understanding of disease-related factors contributing to this variability may identify adults with CF at greater risk of respiratory pump dysfunction. The purpose of this study was to explore the ability of clinical measures to predict IMS in adults with CF.

Methods:

Maximal inspiratory pressure (MIP) was assessed in 58 adults with stable CF across a range of disease severity (forced expiratory volume in 1-second [FEV1] = 20% to 130% of the predicted) using a cross-sectional design. The ability of clinical factors to predict IMS was evaluated through multivariable regression analysis.

Results:

The linear combination of percent of predicted FEV1, percent of predicted residual volume (%RV), lean body mass index, and age explained 43% of the variance in MIP expressed in cm H2O. The linear combination of percent of predicted inspiratory capacity, %RV, and body mass index explained 52% of the variance in MIP expressed as percent of the predicted.

Conclusions:

A combination of pulmonary, nutritional, and demographic clinical factors explained approximately half of the variance in IMS in adults with CF. Nutritional status and hyperinflation seem to have the greatest influence on the inspiratory muscles.
The Functional Difficulties Questionnaire: A New Tool for Assessing Physical Function of the Thoracic Region in a Cardiac Surgery Population
Authors: Sturgess Tamica R. , Denehy Linda , Tully Elizabeth A. , McManus Margaret , Katijjahbe Mohd Ali , El-Ansary Doa
Published: July 2018

Purpose:

There is a paucity of functional outcome measures that specifically target the thoracic region and none that are specific for use in people following cardiac surgery. The aim of this study was to develop a functional questionnaire for this purpose and investigate its psychometric properties.

Methods:

Participants who underwent cardiac surgery were included in this single-site, observational study (part A, n = 38 and part B, n = 25). The investigators developed a 13-item Functional Difficulties Questionnaire (FDQ) informed by the literature, theory, and clinical practice. The questionnaire and measures of physical function, pain, and health-related quality of life (HRQOL) were completed at 4 time points by 38 participants to investigate internal consistency, convergent validity, and responsiveness to change of the FDQ (part A). A different group of 25 participants completed the questionnaire twice within a single day to investigate test–retest reliability, and minimal detectable change (MDC) was calculated (part B).

Results:

The questionnaire showed good internal consistency (Cronbach alpha coefficient = 0.971); moderate to good correlation with assessments for HRQOL 3 months postoperatively (rho = 0.54–0.65 for 5 36-Item Short Form Health Survey subscales) and total pain at all postoperative time points (rho = 0.55–0.69); a responsiveness to change with significant differences in scores across time (Χ2 [3, n = 38] = 41.37, P ≤ 0.0001); and excellent test–retest reliability (intraclass correlation 0.918). The MDC was 16.35 cm out 130 cm.

Conclusions:

The FDQ is an appropriate functional outcome measure specific to the thoracic region for people after cardiac surgery. It may also be suitable for use by clinicians and researchers assessing the thoracic region within other surgical or medical populations, and this warrants further investigation.
Effect of combined circuit exercise on arterial stiffness in hypertensive postmenopausal women: a local public health center-based pilot study
Authors: Jeon Kyoungkyu , Lee Sewon , Hwang Moon-Hyon
Published: July 2018

Objective:

Postmenopausal women have increased arterial stiffness compared with premenopausal women. Regular physical activity including aerobic and resistance exercises are recommended to lower cardiovascular disease risk and to enhance musculoskeletal health in these women. This study examined the effect of combined circuit exercise on arterial stiffness in hypertensive postmenopausal women. Furthermore, it ascertained whether performing this exercise program is feasible in local public health centers with better accessibility than research and commercial facilities.

Methods:

Among 24 hypertensive postmenopausal women, 16 finished this study in either the control (n = 8) or exercise (n = 8) group. Except for one participant who withdrew from the study due to the difficulty of the exercise program, seven participants withdrew due to reasons unrelated to the study. Circuit-type exercise (aerobic- and resistance-combined) program was applied to the exercise group, 60 min/d and 3 d/wk for 12 weeks under supervision. Brachial–ankle pulse wave velocity was measured to assess arterial stiffness.

Results:

In response to the combined exercise, brachial–ankle pulse wave velocity was significantly reduced in the hypertensive women (−0.7 m/s; P < 0.05). Weight, body mass index, and total cholesterol level were also significantly decreased after the exercise program (−2.1 kg, −0.8 kg/m2, and −16 mg/dL, respectively; P < 0.05). In addition, changes in arterial stiffness were related to body adiposity, blood pressure, and blood lipid alterations (r = 0.61-0.70; P < 0.01).

Conclusions:

Circuit combined exercise is an effective intervention to improve arterial stiffness in hypertensive postmenopausal women, and is feasible in local public health centers.
Apolipoprotein E4 genotype in combination with poor metabolic profile is associated with reduced cognitive performance in healthy postmenopausal women: implications for late onset Alzheimer's disease
Authors: Karim Roksana , Koc Melissa , Rettberg Jamaica R. , Hodis Howard N. , Henderson Victor W. , St. John Jan A. , Allayee Hooman , Brinton Roberta D. , Mack Wendy J.
Published: July 2018

Objective:

We hypothesized the association of metabolic profile on cognition in postmenopausal women will be greater among ApoE4 carriers compared with noncarriers.

Methods:

Metabolic biomarkers and measures of global cognition, executive functions, and verbal memory, collected among postmenopausal females, were used in this analysis. Clustering analyses of metabolic biomarkers revealed three phenotypes: healthy, predominantly hypertensive, and poor metabolic with (borderline normal laboratory values). General linear models tested whether an association of metabolic cluster with cognition differed by ApoE4 genotype.

Results:

In the total sample of 497 women, verbal memory was lower in the poor metabolic cluster (P = 0.04). Among ApoE4+ women, performance in all cognitive domains was lowest in the poor metabolic cluster. Differences in executive functions among metabolic clusters were detected only in ApoE4+ women (P value for interaction = 0.003).

Conclusions:

In a general population of postmenopausal women, association between poor metabolic profile with reduction in cognitive performance is more apparent in women who carry an ApoE4 allele. These data indicate a window of opportunity for interventions to reverse the trajectory of the preclinical phase of Alzheimer's disease.
Conceptualization, Assessment, and Treatment of Traumatic Stress in First Responders: A Review of Critical Issues
Authors: Lewis-Schroeder Nina F. , Kieran Kathryn , Murphy Beth L. , Wolff Jonathan D. , Robinson Matthew A. , Kaufman Milissa L.
Published: July 2018

First responders are regularly confronted with exposure to traumatic events, including potentially life-threatening situations as well as the grave injuries and deaths of colleagues and civilians. Evidence indicates that the prevalence of posttraumatic stress disorder (PTSD) is substantially higher among first responders than the general population. This article provides information about the outpatient trauma services at McLean Hospital’s LEADER (Law Enforcement, Active Duty, Emergency Responder) program to assist clinicians who encounter these first responders in their practices or who are specifically interested in working with this patient population. We begin by synthesizing the literature on the prevalence of PTSD in first responders following work-related exposure to traumatic stress, and by addressing the occupation-specific risk factors and the third-variable risk factors that may contribute to potentiated risk. We then discuss assessment strategies and treatment options used in our program, which is tailored for individuals who are dealing with mental health issues stemming from occupation-specific traumatic-stress exposure. We also address the unique challenges of treating traumatized first responders with more complex issues such as traumatic stress exposure across the lifespan and safety issues, including acute suicidality. We conclude by discussing notable gaps in the literature, including the need to investigate why and how women present with different PTSD symptoms than men and how these differences need to be taken into account in determining appropriate treatment for women.
Obesity and Overweight Problems Among Individuals 1 to 25 Years Following Acute Rehabilitation for Traumatic Brain Injury: A NIDILRR Traumatic Brain Injury Model Systems Study
Authors: Dreer Laura E. , Ketchum Jessica M. , Novack Thomas A. , Bogner Jennifer , Felix Elizabeth R. , Corrigan John D. , Johnson-Greene Doug , Hammond Flora M.
Published: July 2018

Objective:

Examine the prevalence of weight classifications and factors related to obesity/overweight among persons 1 to 25 years following traumatic brain injury (TBI) using the Traumatic Brain Injury Model Systems national database.

Design:

Multicenter, cross-sectional, observational design.

Setting:

Traumatic Brain Injury Model Systems inpatient rehabilitation facilities.

Participants:

Persons (N = 7287) 1, 2, 5, 10, 15, 20, or 25 years after TBI who required inpatient acute rehabilitation.

Main Outcome Measures:

Body mass index, demographic characteristics, functional, health, satisfaction with life, and global outcomes.

Results:

Overall postinjury weight prevalence rates were 23% obese, 36% overweight, 39% normal, and 3% underweight. Higher rates for obesity and overweight problems were associated with increasing time since injury. Younger (18-19 years) and older (80+ years) age, those in a vegetative state, and those reporting excellent health were less likely to be obese. Individuals with a history of hypertension, heart failure, or diabetes were more likely to be obese.

Conclusions:

Being obese or overweight presents a health risk in the years following rehabilitation for TBI. The findings support the need for longitudinal studies and highlight the advisability of monitoring weight and promoting healthy lifestyle behaviors over time in survivors of TBI.
Human Papillomavirus Correlates With Histologic Anal High-Grade Squamous Intraepithelial Lesions in Hispanics With HIV
Authors: Medina-Laabes Diana T. , Suarez-Perez Erick L. , Guiot Humberto M. , Muñoz Cristina , Colón-López Vivian , Tirado-Gómez Maribel , Ortiz Ana Patricia
Published: July 2018

Objective

To estimate the magnitude of association between anal infection with high-risk human papilloma virus (HR-HPV) types and severity of biopsy-confirmed histopathological anal squamous intraepithelial lesions (SILs) among a clinic-based sample of HIV-infected adults in Puerto Rico.

Methods

This cross-sectional study analyzed data from medical records of adult patients who visited a specialized anal neoplasia clinic from June 2015 to December 2017 (n = 239); sociodemographics, behavioral risk factors, medical history, clinical data, and pathology reports were collected. The magnitude of association between anal HR-HPV and severity of anal SIL, adjusted for potential confounders, was assessed using a multinomial logistic model.

Results

A 78.7% of patients had anal HR-HPV infection, 43.9% had histopathological low-grade SIL (LSIL), and 37.7% had histopathological high-grade SIL (HSIL). The prevalence of anal HR-HPV infection was 63.6% among patients with no anal SIL, 70.5% for those with LSIL and 95.6% for those with HSIL. After adjusting for different predictors, patients with anal HR-HPV infection were more likely to have HSIL (odds ratio, 11.0; 95% confidence interval, 3.2-37.2) than those without anal HR-HPV infection, whereas no significant excess was observed for LSIL (odds ratio, 1.4; 95% confidence interval, 0.6-3.1).

Conclusions

This study showed a strong association between anal HR-HPV infection and HSIL. Likewise, a high prevalence of anal HR-HPV infection and presence of anal SIL was observed among HIV-infected individuals. Our result highlights the importance of screening for anal HR-HPV infection and anal SIL and optimizing strategies for HPV vaccination in HIV-infected individuals.
Treatment of hepatitis C with direct-acting antivirals significantly reduces liver-related hospitalizations in patients with cirrhosis
Authors: Hill Lucas A. , Delmonte Ronnie J. , Andrews Barbara , Richards Lisa , Soto Robin , Collier Summer , Kuo Alexander , Cachay Edward
Published: July 2018

Background

The availability of direct-acting antivirals (DAA) for the treatment of hepatitis C (HCV) has resulted in the ability to safely and effectively treat patients with cirrhosis and end-stage liver disease. However, information is limited with regard to the impact of DAA treatment on inpatient health-related resource utilization in patients with advanced HCV-related cirrhosis. We aimed to ascertain the impact of DAA treatment on the frequency of liver-related hospitalizations and associated costs in patients with cirrhosis.

Patients and methods

Retrospective cohort analysis carried out at a single US reference center that compared patients with HCV cirrhosis according to treatment status: the untreated group (January 2011 to December 2013) and the DAA-treated group (January 2014 to March 2017). The primary outcome was the difference in the incidence rate of liver-related hospitalizations. Secondary outcomes included differences in the incidence of hepatocellular carcinoma, liver transplant, and all-cause mortality. We calculated the projected savings per-patient treated per-year on the basis of calculated hospitalization rate stratified by Child–Turquotte–Pugh (CTP) score.

Results

Baseline characteristics were similar between the untreated (n=182) and DAA-treated (n=196) cohorts. Mean follow-up time in the untreated and treated cohort was 20.4 and 17.7 months, respectively. The incidence rates of liver-related hospitalizations were 29.1/100 and 10.4/100 person-years of follow-up (P≤0.0001) in the untreated and treated cohorts, respectively. This was accounted for by a decreased incidence of hospitalizations in patients with CTP-A (75.8%) and CTP-B (64.5%), but not CTP-C.

Conclusion

Successful DAA treatment reduces hospitalization rate and resource utilization costs in patients with CTP-A and CTP-B, but not in those with CTP-C.
The Potential of Glycemic Control and Body Weight Change as Early Markers for Pancreatic Cancer in Patients With Long-standing Diabetes Mellitus
Authors: Mueller Alexandra M. , Meier Christoph R. , Jick Susan S. , Schneider Cornelia
Published: July 2018

Objectives

The aim of this study was to characterize the role of glycemic control and weight change as markers for pancreatic cancer (PaC) in patients with long-standing diabetes.

Methods

We conducted case-control analyses in patients with long-standing diabetes (>2 years) in the United Kingdom–based Clinical Practice Research Datalink. Cases were patients with PaC matched to control subjects on variables including age, sex, and diabetes duration. We compared glycated hemoglobin (HbA1c) levels, blood glucose levels, and weight change before cancer detection (matched date) between cases and control subjects to assess associations between the potential markers and PaC.

Results

Cases were more likely than control subjects to have high HbA1c levels. The adjusted odds ratio (aOR) was 4.94 (95% confidence interval [CI], 3.52–6.94) for HbA1c of 64.0 mmol/mol or greater compared with HbA1c of 47.5 mmol/mol or less within 6 months before cancer detection and within >1 to 2 years, 2.66 (95% CI, 2.00–3.54). Weight loss was also more common in cases, with an aOR of 15.40 (95% CI, 10.65–22.26) for loss of 15.0% body weight or greater compared with stable weight. The aOR for patients with both weight loss of 15.0% or greater and high HbA1c at 2 years or less before diagnosis was 60.97 (95% CI, 35.87–103.65), compared with patients with neither.

Conclusions

Poor glycemic control and weight loss, particularly in combination, may be useful early markers for PaC in patients with long-standing diabetes.
Systemic Depletion of Nerve Growth Factor Inhibits Disease Progression in a Genetically Engineered Model of Pancreatic Ductal Adenocarcinoma
Authors: Saloman Jami L. , Singhi Aatur D. , Hartman Douglas J. , Normolle Daniel P. , Albers Kathryn M. , Davis Brian M.
Published: July 2018

Objectives

In patients with pancreatic ductal adenocarcinoma (PDAC), increased expression of proinflammatory neurotrophic growth factors (eg, nerve growth factor [NGF]) correlates with a poorer prognosis, perineural invasion, and, with regard to NGF, pain severity. We hypothesized that NGF sequestration would reduce inflammation and disease in the KPC mouse model of PDAC.

Methods

Following biweekly injections of NGF antibody or control immunoglobulin G, beginning at 4 or 8 weeks of age, inflammation and disease stage were assessed using histological, protein expression, and quantitative polymerase chain reaction analyses.

Results

In the 8-week anti-NGF group, indicators of neurogenic inflammation in the dorsal root ganglia (substance P and calcitonin gene–related peptide) and spinal cord (glial fibrillary acidic protein) were significantly reduced. In the 4-week anti-NGF group, TRPA1 mRNA in dorsal root ganglia and spinal phosphorylated ERK protein were elevated, but glial fibrillary acidic protein expression was unaffected. In the 8-week anti-NGF group, there was a 40% reduction in the proportion of mice with microscopic perineural invasion, and no macrometastases were observed.

Conclusions

Anti-NGF treatment beginning at 4 weeks may increase inflammation and negatively impact disease. Treatment starting at 8 weeks (after disease onset), however, reduces neural inflammation, neural invasion, and metastasis. These data indicate that NGF impacts PDAC progression and metastasis in a temporally dependent manner.
Impact of the Controlling Nutritional Status Score on the Prognosis After Curative Resection of Pancreatic Ductal Adenocarcinoma
Authors: Kato Yoshiyasu , Yamada Suguru , Suenaga Masaya , Takami Hideki , Niwa Yukiko , Hayashi Masamichi , Iwata Naoki , Kanda Mitsuro , Tanaka Chie , Nakayama Goro , Koike Masahiko , Fujiwara Michitaka , Kodera Yasuhiro
Published: July 2018

Objectives

The controlling nutritional status (CONUT) score is a useful tool to evaluate immune-nutritional status. This study aimed to investigate the impact of the CONUT score on short- and long-term outcomes after curative resection of pancreatic ductal adenocarcinoma (PDAC).

Methods

Consecutive 344 PDAC patients receiving pancreatectomy without neoadjuvant therapy were examined retrospectively. After the best predictive value of the CONUT score for survival was identified, association between the CONUT score and long-term outcomes was evaluated using log-rank tests and a Cox regression model. Then correlations between the CONUT score and postoperative complications were analyzed.

Results

The optimal cutoff value of the CONUT score was 4. The high CONUT score group showed significantly lower overall survival than the low CONUT score group (P = 0.002). In contrast, no significant difference in recurrence-free survival was found (P = 0.43). A multivariate analysis demonstrated that high CONUT score had an independent association with overall survival (hazard ratio, 1.64; P = 0.003). The CONUT score showed no association with postoperative pancreatic fistula, Clavien-Dindo grade, or postoperative hospital stay.

Conclusion

The CONUT score had an independent association with survival in patients with PDAC after pancreatectomy and was not associated with recurrence or postoperative complications.
The Design of an Evidence-Based Competency Model
Authors: Winter Peggi Banahan
Published: July 2018

A nursing professional practice model is designed to provide a framework for how nursing practices, communicates, leads, collaborates, and provides the highest quality of care as individuals navigate the complex healthcare system. An infrastructure for learning, competency, and performance needs to be integrated into this model as a foundation for accelerating business and clinical initiatives, promoting standardization, and sharing successful practices. This article describes the process that a large healthcare system used to develop a 5-year strategy whose outcomes resulted in professional and foundational competency domains, assumptions about their use, and future work to align and embed these competencies into the current environment. It provides a road map for nursing professional development practitioners to identify evidenced-based competencies which reflect the professional practice model and then use it as a framework to impart the knowledge, skills, and judgment required for practicing professional nurses.
Learning Style Preferences of Practicing Nurses
Authors: Mangold Kara , Kunze Katie L. , Quinonez Michelle M. , Taylor Lorna M. , Tenison Ashley J.
Published: July 2018

Nursing professional development practitioners are encouraged to consider incorporating preferred learning styles into professional development programs. However, conclusive evidence about preferred learning styles does not exist. This study describes the preferred learning styles of nursing staff. Results showed that learning style preferences existed and were correlated with satisfaction, years of experience, and gender. The results can be used to plan and deliver professional development opportunities that are engaging and promote retention of learning.
The Dilemma of HER2 Double-equivocal Breast Carcinomas
Authors: Marchiò Caterina , Dell’Orto Patrizia , Annaratone Laura , Geyer Felipe C. , Venesio Tiziana , Berrino Enrico , Verdun di Cantogno Ludovica , Garofoli Andrea , Rangel Nelson , Casorzo Laura , dell’Aglio Carmine , Gugliotta Patrizia , Trisolini Elena , Beano Alessandra , Pietribiasi Francesca , Orlassino Renzo , Cassoni Paola , Pich Achille , Montemurro Filippo , Mottolese Marcella , Vincent-Salomon Anne , Penault-Llorca Frédérique , Medico Enzo , Ng Charlotte K.Y. , Viale Giuseppe , Sapino Anna
Published: July 2018

The American Society of Clinical Oncology/College of American Pathologists (ASCO/CAP) 2013 guidelines for HER2 assessment have increased the number of HER2 equivocal breast carcinomas following in situ hybridization reflex testing, that is, HER2 “double equivocal” (equivocal protein expression and equivocal gene copy number). Forty-five double-equivocal carcinomas were subjected to Prosigna analysis. Twenty-seven cases were investigated for the expression of genes found to be differentially expressed between estrogen receptor (ER)-positive/HER2-positive (N=22) and ER-positive/HER2-negative (N=22) control cases. Twenty-nine of the 45 cases were also analyzed by targeted sequencing using a panel of 14 genes. We then explored the pathologic complete response rates in an independent series of double-equivocal carcinoma patients treated with trastuzumab-containing chemotherapy. All cases were ER-positive, with a mean Ki67 of 28%. Double-equivocal carcinomas were predominantly luminal B (76%); 9 cases (20%) were luminal A, and 2 cases (4%) HER2-enriched. The majority (73%) showed a high risk of recurrence by Prosigna, even when the carcinomas were small (<2 cm), node-negative/micrometastatic, and/or grade 2. Double-equivocal carcinomas showed TP53 (6/29, 20%), PIK3CA (3/29, 10%), HER2 (1/29, 3%), and MAP2K4 (1/29, 3%) mutations. Compared with grade-matched ER-positive/HER2-negative breast carcinomas from METABRIC, double-equivocal carcinomas harbored more frequently TP53 mutations and less frequently PIK3CA mutations (P<0.05). No significant differences were observed with grade-matched ER-positive/HER2-positive carcinomas. Lower pathologic complete response rates were observed in double-equivocal compared with HER2-positive patients (10% vs. 60%, P=0.009). Double-equivocal carcinomas are preferentially luminal B and show a high risk of recurrence. A subset of these tumors can be labeled as HER2-enriched by transcriptomic analysis. HER2 mutations can be identified in HER2 double-equivocal cases.
Eosinophilic Solid and Cystic (ESC) Renal Cell Carcinomas Harbor TSC Mutations
Authors: Palsgrove Doreen N. , Li Yunjie , Pratilas Christine A. , Lin Ming-Tseh , Pallavajjalla Aparna , Gocke Christopher , De Marzo Angelo M. , Matoso Andres , Netto George J. , Epstein Jonathan I. , Argani Pedram
Published: July 2018

Eosinophilic solid and cystic (ESC) renal cell carcinoma (RCC) has recently been described as a potentially new subtype of RCC based upon morphologic and immunohistochemical features. These neoplasms typically demonstrate solid and cystic architecture, and the neoplastic cells contain voluminous eosinophilic cytoplasm with granular cytoplasmic stippling. There is frequently focal immunoreactivity for cytokeratin 20. Although the initial cases all occurred in adult females and had benign outcome, we recently expanded the proposed spectrum of this neoplasm to include pediatric cases, multifocal neoplasms, and a case with hematogenous metastasis. ESC has been postulated to be analogous to a subtype of RCC consistently identified in tuberous sclerosis complex patients, and while previous work has demonstrated loss of heterozygosity at the TSC1 locus and copy number gains at TSC2 in ESC RCC, these genes have not been sequenced in ESC RCC. Using capture-based and amplicon-based next-generation sequencing, we now demonstrate the consistent presence of either TSC1 or TSC2 gene mutations in pediatric ESC RCC (8/9 cases) and adult ESC RCC (6/6 cases). These included a metastatic ESC RCC which had a complete response to mTOR targeted therapy. We also found these mutations in some neoplasms with variant morphology and thus potentially expand the spectrum of ESC RCC. These include one of our adult cases which demonstrated dominant “type 2” papillary RCC morphology and 2 of 3 previously unclassified pediatric RCC with features of ESC RCC minus granular cytoplasmic stippling. We also demonstrate TSC mutations in a case of so-called “oncocytoid RCC after neuroblastoma” with identical morphology and immunoprofile, providing a molecular link between the latter and ESC RCC. In summary, ESC RCC consistently harbors actionable TSC1 or TSC2 mutations, which are infrequently seen in established subtypes of RCC. These findings support TSC1/2 mutation as a molecular marker of ESC RCC, and suggest expansion of the clinicopathologic spectrum to include neoplasms with papillary architecture, occasional cases lacking well-developed granular cytoplasmic stippling, and a subset of RCC with oncocytic features in patients who have survived neuroblastoma.