Information in radiotherapy for men with localised prostate cancer: An integrative review.

INTRODUCTION: Men with prostate cancer may receive radiotherapy as part of their management. They encounter a range of information related to radiotherapy, and a crucial role for therapeutic radiographers and other healthcare practitioners is ensuring patients receive appropriate information related to their treatment. This integrative review aims to identify, synthesise and analyse literature reporting experiences of men with localised prostate cancer related to information in radiotherapy. METHODS: A systematic literature search encompassing database and hand searches was carried out between February and March 2017 with date limits of 2000-2017 applied. Initially, 4,954 articles were identified. Systematic screening and detailed examination identified that 33 met the inclusion criteria. Data were synthesised and analysed thematically. RESULTS: Few studies explicitly addressed the issue of information in radiotherapy for men with localised prostate cancer. Themes that emerged and were explored are information needs, information regarding adverse effects, information and time, information preferences, satisfaction with information related to radiotherapy and patient experience related to radiotherapy information. CONCLUSION: This review suggests that although several aspects related to information for men with localised prostate cancer have been documented, few were explored in detail with respect to radiotherapy indicating that further research in this area is warranted.

Photodynamic therapy: A targeted literature review focussing on outcomes and optimisation in solid organ transplant recipients.

Squamous cell carcinoma incidence is 65- to 250-fold in solid organ transplant recipients, BCC is 10-fold and in Australia, rates of skin cancer in solid organ transplant recipients reach 70-82% prevalence within the first 20 years; hence, effective, evidence-based treatment of early and precancerous lesions is an essential tool in dermatological patient care. Photodynamic therapy is used to treat a range of conditions including actinic keratoses, squamous cell carcinoma in situ, superficial basal cell carcinoma and nodular basal cell carcinoma. A literature review was undertaken to examine the outcomes of photodynamic therapy in solid organ transplant recipients and methods of optimising outcomes in solid organ transplant recipients. Study sizes were small and protocols varied widely, so meta-analysis was not possible; however, photodynamic therapy appears to be an acceptable treatment for approved indications in solid organ transplant recipients in whom ongoing surveillance is maintained to ensure clearance and detect recurrence. Methods for improving efficacy were also reviewed for this population. Improved outcomes may be achieved by combining photodynamic therapy with other local methods such as 5-fluorouracil or ablative fractional laser.

Effective Antimicrobial Stewardship Strategies for Cost-effective Utilization of Telavancin for the Treatment of Patients With Hospital-acquired Bacterial Pneumonia Caused by Staphylococcus aureus.

PURPOSE: Clinicians and stewardship programs are challenged with positioning of novel, higher priced antibiotic agents for the treatment of clinical infections. We developed a decision-analytic model to describe costs, including drug, total treatment costs, and health care outcomes, associated with telavancin (TLV) compared with vancomycin (VAN) for patients with Staphylococcus aureus (SA) hospital-acquired bacterial pneumonia (HABP). METHODS: This decision-analytic model assessed the treatment of SA-HABP with TLV versus VAN. Data were obtained from the ATTAIN (Assessment of Telavancin for Treatment of Hospital-Acquired Pneumonia) clinical trials on the following: the probability of clinical cure; probability of nephrotoxicity; and prevalence of polymicrobial infection (30%), methicillin-resistant Staphylococcus aureus (MRSA) (68%), and SA with VAN MIC ≥1 µg/mL (85%). Data on length of stay for cure (10 days), failure (10 additional days), and nephrotoxicity (3.5 days) were based on literature. Cost per treated patient and incremental cost-effectiveness ratio (ICER) per additional cure were calculated for SA-HABP and for monomicrobial SA-HABP. One-way sensitivity analyses were performed. FINDINGS: Patients with SA-HABP were sub-grouped by methicillin susceptibility (n = 140, 32%) or resistance (n = 293, 68%), and occurrence of polymicrobial (n = 128, 30%) vs monomicrobial (n = 305, 70%) infections. Under the base case, hospital cost for patients with HABP treated with TLV was $42,564 and with VAN, it was $42,296. Telavancin was associated with higher drug ($2082) and nephrotoxicity ($467) costs and lower intensive care unit (-$1738) and ventilator (-$114) costs. ICER was $4156 per additional cure. ICER was sensitive to probabilities of cure, length of treatment in cures, intensive care unit cost, TLV cost, and additional length of stay due to failure. For monomicrobial SA-HABP, TLV was associated with a net cost savings of $907 per patient and yielded economic dominance. IMPLICATIONS: Our decision-analytic model suggests that TLV for monomicrobial SA-HABP is associated with higher drug acquisition costs but a favorable ICER relative to VAN, provided that effective antimicrobial stewardship limits therapy to 7 days. Sensitivity analyses suggest a potential economic benefit of TLV treatment with appropriate patient selection. Antimicrobial stewardship programs may be able to reduce total costs through judicious use of novel antimicrobial agents. ClinicalTrials.gov identifiers: NCT00107952 and NCT00124020.

Primary Care Physicians' Decision Making Regarding Initial Oncology Referral for Adolescents and Young Adults With Cancer.

PURPOSE: The objectives of this study were to determine whether pediatricians are more likely than other primary care physicians (PCPs) to refer newly diagnosed adolescent and young adult patients with cancer to pediatric oncological specialists, and to assess the physician and patient characteristics that affect patterns of referral. METHODS: A cross-sectional vignette survey was mailed to PCPs to examine hypothetical referral decisions as a function of physician characteristics and patient characteristics, including diagnosis, age, gender, race/ethnicity, family support, transportation, insurance, and patient preference for site of care. Pediatrician PCPs and nonpediatrician PCPs (family medicine, internal medicine, and emergency medicine physicians) practicing in North Carolina and in Washington State participated in the study. RESULTS: A total of 406 surveys were completed (35.8% response rate). Sixty percent of pediatric PCPs referred their hypothetical patients with cancer to pediatric specialists (PSs), compared with only 37% of nonpediatric PCPs. Patient age also influenced referral patterns; 89% of 13-year-olds, 74% of 16-year-olds, 25% of 19-year-olds, and only 9% of 22-year-old patients were referred to a PS. Multivariate logistic regression demonstrated that diagnosis and physician practice setting also were associated with referral patterns. CONCLUSIONS: Both patient age and PCP specialty were significant predictors of referral patterns in hypothetical vignettes of newly diagnosed adolescent and young adult patients with cancer. Pediatricians were more likely than nonpediatrician PCPs to refer patients to a PS. Referrals to PSs decreased dramatically between ages 16 and 19. Because the site of oncological care can impact outcomes, these data have the potential to inform awareness and education initiatives directed at PCPs.

Pachyonychia Congenita: A Spectrum of KRT6a Mutations in Australian Patients.

BACKGROUND: Pachyonychia congenita (PC) is a rare inherited disorder of keratinization characterised by hypertrophic nail dystrophy, painful palmoplantar blisters, cysts, follicular hyperkeratosis and oral leukokeratosis. It is associated with mutations in five differentiation-specific keratin genes, KRT6A, KRT6B, KRT6C, KRT16, or KRT17. OBJECTIVES: Living with Pachyonychia Congenita can be isolating. The aim of this paper is to document a single patient's experience within a national context. METHOD: We report the case of a 2 year old female with an atypical presentation of PC due to a mutation in KRT6A with severely hypertrophic follicular keratoses, skin fragility, relative sparing of nail hypertrophy on one hand and failure to thrive in early infancy. In collaboration with the International Pachyonychia Congenita Research Registry (IPCRR), a database search was performed using Australian residency and KRT6A mutation as inclusion criteria. The IPCRR database was also searched for a matching KRT6A mutation. Six Australian patients were identified in addition to one patient with an identical mutation residing in the United States. The detailed standardized patient questionnaire data was manually collated and analysed. RESULTS: Fingernail hypertrophy and oral leukokeratosis were the most common features. There was no recording of asymmetric distribution in any other Australian patient. Trouble nursing as an infant and follicular hyperkeratosis also occurred in the American patient, however they did not have asymmetric distribution and the oral leukokeratosis appeared later in life. CONCLUSION: This case has unique features. Sharing information can assist patients navigating life with this condition.

Big Data Clinical Research: Validity, Ethics, and Regulation.

Electronic Health Records (EHR) promise improvement for patient care and also offer great value for biomedical research including clinical, public health, and health services research. Unfortunately, the full potential of EHR big data research has remained largely unrealized. The purpose of this study was to identify rate limiting factors, and develop recommendations to better balance unrestricted extramural EHR access with legitimate safeguarding of EHR data in retrospective research. By exploring primary, secondary, and tertiary sources, this review identifies external constraints and provides a comparative analysis of social influencers in retrospective EHR-based research. Results indicate that EHRs have the advantage of reflecting the reality of patient care but also show a frequency of between 4.3-86% of incomplete and inaccurate data in various fields. The rapid spread of alternative analytics for health data challenges traditional interpretations of confidentiality protections. A confusing multiplicity of controls creates barriers to big data EHR research. More research on the use of EHR big data is likely to improve accuracy and validity. Information governance and research approval processes should be simplified. Comprehensive regulatory policies that do not exclusively cover health care entities, are needed. Finally, new computing safeguards are needed to address public concerns, like research access only to aggregate data and not to individually identifiable information.

Dietary Advice and Collaborative Working: Do Pharmacists and Allied Health Professionals Other Than Dietitians Have a Role?

Long term health conditions either wholly or partly diet-related continue to increase. Although pharmacists and allied health professionals (AHPs) have a role in the management of patients with long term conditions, there is limited research exploring whether pharmacists and AHPs other than dietitians have a role in the delivery of dietary advice. This research aimed to explore their views regarding the provision of dietary advice to patients. The research involved a qualitative methodology utilising five uni-professional focus groups with a total of 23 participants. All groups considered the provision of dietary advice in the context of their own professional roles, discussed issues relating to referral to the dietitian for specialist advice and most discussed the need for written information. Interprofessional and collaborative working is needed to maximise the role in the delivery of dietary advice, access to evidence based nutritional information and utlisation of referral pathways across pharmacists and AHPs to ensure the timely provision of nutritional advice to patients. There is a potential role for dietitians to take the lead and further research should focus on this area.

Botulinum toxin A injection for chronic anal fissures and anal sphincter spasm improves quality of life in recessive dystrophic epidermolysis bullosa.

We report a 20-year-old female with generalized, severe, recessive dystrophic epidermolysis bullosa who developed secondary chronic anal fissures. This resulted in anal sphincter spasm and severe, disabling pain. She was treated with five botulinum toxin A injections into the internal anal sphincter over a period of 2 years and gained marked improvement in her symptoms. This case demonstrates the successful use of botulinum toxin A injections to relieve anal sphincter spasm and fissuring, with long-term improvement.

Human T-lymphotropic virus type 1 infective dermatitis in central Australia.

The Human T-Lymphotropic Virus type 1 (HTLV-1) is a single-stranded RNA retrovirus that preferentially infects CD4+ T cells. The spectrum of diseases that are associated with the most frequent genotype, the HTLV-1 cosmopolitan subtype A, has been well described. In contrast, very few cases of HTLV-1 related diseases have been reported for the HTLV-1 subtype C variant, which is endemic to Australia and the nearby islands of Melanesia. Here we describe the first case of infective dermatitis associated with the HTLV-1 Australo-Melanesian subtype C. This was complicated by repeated episodes of invasive infection with Staphylococcus aureus and illustrates the life-threatening nature of infective dermatitis among HTLV-1 carriers who live in conditions of social disadvantage.

Prospective study of patch testing in patients with vulval pruritus.

Forty-three patients with the primary complaint of vulval pruritus were recruited to take part in this prospective patch-testing study. A detailed questionnaire was administered to each and patch testing to an extended battery of allergens was undertaken. This included the European standard series, preservatives, corticosteroids and a battery of common over-the-counter topical vulval treatments. Analysis of demographic data and prior treatments used, and various other parameters, were studied in the context of patch-test results. This prospective study reports a very high rate of contact sensitivity in patients presenting with vulval pruritus, with 81.4% of those tested having at least one contact allergen detected. One or more clinically relevant allergens were found in 44% of the subjects patch tested. The variables found to predict a greater likelihood of a contact allergy were a biopsy diagnosis of vulval dermatitis, the use of multiple topical treatments, sexual inactivity and patients with severe pruritus on a self-reported scale. Most importantly, many clinically relevant allergens these patients reacted to were outside the European standard series. This highlights the need for an extended series in this patient population.

Tackling tough management issues: advice from the top.

Wondering how your peers across the country are managing the myriad challenges that confront HIM professionals? We assembled a panel of experts to address common problems and concerns.