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.

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.

The Who, What, Why, When, Where, and How of Team-Based Interdisciplinary Cancer Rehabilitation.

OBJECTIVE: To review the key components necessary for successful application of rehabilitation principles to oncology survivors. DATA SOURCES: Validated databases, including PubMed, MEDLINE, and Scopus. CONCLUSION: Rehabilitation is an essential component of cancer care that addresses functional needs for oncology survivors and is best accomplished via an interdisciplinary team. Interdisciplinary care, provided by nursing, physiatry, rehabilitation therapy, and exercise physiology, are critical components for comprehensive intervention. Challenges exist in implementing services, but opportunity also exists within the post-acute care sector. IMPLICATIONS FOR NURSING PRACTICE: Nurses play an important role in the screening, assessment, and treatment of cancer-related functional impairments.

Magnetic Resonance Imaging of the Digital Nerves of the Hand: Anatomy and Spectrum of Pathology.

Digital nerves are intrinsic to the sensory and motor function of the hand. These nerves represent the terminal ramifications of the ulnar, median, and radial nerves and are located distal to the carpal tunnel and Guyon canal. With magnetic resonance imaging, traumatic and nontraumatic abnormalities of the digital nerves can be shown with high contrast as well as high spatial resolution. Digital nerve abnormalities are most commonly posttraumatic in nature; however, infection, inflammatory, vascular malformations, and neoplasms can rarely occur. Magnetic resonance imaging is playing an increasing role in the assessment of peripheral nerve injury throughout the body, and in the hand, which can accurately identify the extent and character of digital nerve abnormalities before operative intervention.

Flexor Tendon Ruptures After Distal Scaphoid Excision for Scaphotrapeziotrapezoid Osteoarthritis.

BACKGROUND: Distal scaphoid excision is one treatment option for osteoarthritis of the scaphotrapeziotrapezoid (STT) joint following failure of conservative measures. Potential complications of this procedure include injury to the carpal ligaments, cartilage, and radial artery. METHODS: A single case was identified by the senior author, and the medical record was reviewed for surgical notes, progress notes, and radiographs. RESULTS: A 68-year-old male sustained ruptures of the flexor digitorum superficialis (FDS) and flexor digitorum profundus to the index finger 3 years following a distal scaphoid excision for symptomatic STT osteoarthritis. He required a flexor tendon reconstruction using the remaining FDS tendon for graft incorporated with a Pulvertaft weave. His midcarpal pain continued after recovery of his index finger function, eventually requiring a 4-corner fusion of the wrist. CONCLUSIONS: Flexor tendon rupture is a previously unreported complication of distal scaphoid excision for STT arthritis.

Differentiating neuromyelitis optica from other causes of longitudinally extensive transverse myelitis on spinal magnetic resonance imaging.

BACKGROUND: Although spinal magnetic resonance imaging (MRI) findings of neuromyelitis optica (NMO) have been described, there is limited data available that help differentiate NMO from other causes of longitudinally extensive transverse myelitis (LETM). OBJECTIVE: To investigate the spinal MRI findings of LETM that help differentiate NMO at the acute stage from multiple sclerosis (MS) and other causes of LETM. METHODS: We enrolled 94 patients with LETM into our study. Bright spotty lesions (BSL), the lesion distribution and location were evaluated on axial T2-weighted images. Brainstem extension, cord expansion, T1 darkness and lesion enhancement were noted. We also reviewed the brain MRI of the patients during LETM. RESULTS: Patients with NMO had a greater amount of BSL and T1 dark lesions (p < 0.001 and 0.003, respectively). The lesions in NMO patients were more likely to involve greater than one-half of the spinal cord's cross-sectional area; to enhance and be centrally-located, or both centrally- and peripherally-located in the cord. Of the 62 available brain MRIs, 14 of the 27 whom were NMO patients had findings that may be specific to NMO. CONCLUSIONS: Certain spinal cord MRI features are more commonly seen in NMO patients and so obtaining brain MRI during LETM may support diagnosis.

Nuances of the unenhanced abdominal CT: careful inspection discloses critical findings.

Patients who have unenhanced abdominal CT scans are often critically ill. The unenhanced CT may reveal many unsuspected subtle abnormalities in the lower chest, abdomen, and pelvis and accordingly warrants careful attention. This article reviews unenhanced CT findings in the setting of pulmonary embolus, acute aortic syndromes, mesenteric and deep venous thrombosis, gastrointestinal hemorrhage, pancreatitis and its complications, as well as pyelonephritis.

MRI of sports-related peripheral nerve injuries.

OBJECTIVE: Sports-related peripheral nerve injuries are common among athletes and are often underrecognized because of symptom overlap with more usual sports-related bone, soft-tissue, and joint injuries. CONCLUSION: MRI plays an increasingly important role in the workup of peripheral nerve injuries and may reveal severe nerve abnormalities before they are diagnosed by electrodiagnostic testing or a clinical examination. Sport-specific peripheral nerve injuries and their MRI appearance will be discussed in this article.

Features suggestive of gallbladder malignancy: analysis of T1, T2, and T3 tumors on cross-sectional imaging.

OBJECTIVES: Gallbladder cancer carries an extremely high mortality rate, with a 5-year survival rate as low as 12%. Survival is dependent on the diagnosis of these tumors in their earliest stages. This study sought to describe the clinical and imaging features of stages T1, T2, and T3 gallbladder tumors and to illustrate features that may allow radiologists to make an early diagnosis. MATERIALS AND METHODS: After approval from the institutional review board, a search of the pathology department database yielded 18 patients with surgically proven T1, T2, and T3 gallbladder cancers with available preoperative computed tomography (CT) or magnetic resonance imaging. The imaging was reviewed for lesional morphology (focal polyploid mass, focal wall thickening, circumferential wall thickening), enhancement characteristics, liver invasion, locoregional lymphadenopathy, and distant metastatic disease. The electronic medical record was also searched for demographic information and clinical presentation. RESULTS: There were 10 women and 8 men with a mean age of 69 years. Virtually all patients were symptomatic, with most patients demonstrating symptoms suggestive of underlying malignancy (including jaundice, weight loss, and chronic abdominal pain). Tumors on CT and MRI included 6 polyploid masses, 9 tumors with focal wall thickening, and 3 with circumferential wall thickening. The mean attenuation of those tumors imaged with CT was 59.4 Hounsfield units (HUs) on the arterial phase and 86.5 HUs on the venous phase, with a mean increase in Hounsfield attenuation between the arterial and venous phases of 28.2 HUs. Twelve of the 18 patients were correctly diagnosed prospectively on CT. CONCLUSIONS: The imaging findings of gallbladder cancer can be subtle, regardless of whether the tumor presents as a discrete mass, focal wall thickening, or circumferential diffuse wall thickening, and radiologists should be aware of the wide range of different possible appearances. Moreover, the vast majority of these patients had clinical symptoms suggestive of an underlying malignancy, and this should precipitate a careful evaluation of the gallbladder in all such cases.

Medicare reform and primary care concerns for future physicians.

The widening income gap between specialists and primary care physicians (PCPs) has spurred many physician associations to reform the current Resource-Based Relative Value Scale fee schedule and sustainable growth rate expenditure target system. Hoping to better represent primary care, the American Association of Family Physicians formed a task force in 2011 to suggest supplements to the Relative Value Update Committee's procedural code recommendations to the Centers for Medicare and Medicaid Services. In addition, the predicted shortage of PCPs has caused many medical schools to increase class sizes; the scarcity of PCPs has also spurred the founding of new medical schools. Such measures, however, have not been met with more residency program sites or graduate medical education funding. The present article highlights major Medicare reform strategies and explores several issues affecting the field of primary care, including reimbursement, representation, and residency training.

Substituents on quinone methides strongly modulate formation and stability of their nucleophilic adducts.

Electronic perturbation of quinone methides (QM) greatly influences their stability and in turn alters the kinetics and product profile of QM reaction with deoxynucleosides. Consistent with the electron-deficient nature of this reactive intermediate, electron-donating substituents are stabilizing and electron-withdrawing substituents are destabilizing. For example, a dC N3-QM adduct is made stable over the course of observation (7 days) by the presence of an electron-withdrawing ester group that inhibits QM regeneration. Conversely, a related adduct with an electron-donating methyl group is very labile and regenerates its QM with a half-life of approximately 5 h. The generality of these effects is demonstrated with a series of alternative quinone methide precursors (QMP) containing a variety of substituents attached at different positions with respect to the exocyclic methylene. The rates of nucleophilic addition to substituted QMs measured by laser flash photolysis similarly span 5 orders of magnitude with electron-rich species reacting most slowly and electron-deficient species reacting most quickly. The reversibility of QM reaction can now be predictably adjusted for any desired application.