ABSTRACT
BACKGROUND: Necrotising otitis externa is a severe ear infection for which there are no established diagnostic or treatment guidelines. METHOD: This study described clinical characteristics, management and outcomes for patients managed as necrotising otitis externa cases at a UK tertiary referral centre. RESULTS: A total of 58 (63 per cent) patients were classified as definite necrotising otitis externa cases, 31 (34 per cent) as probable cases and 3 (3 per cent) as possible cases. Median duration of intravenous and oral antimicrobial therapy was 6.0 weeks (0.49-44.9 weeks). Six per cent of patients relapsed a median of 16.4 weeks (interquartile range, 23-121) after stopping antimicrobials. Twenty-eight per cent of cases had complex disease. These patients were older (p = 0.042), had a longer duration of symptoms prior to imaging (p < 0.0001) and higher C-reactive protein at diagnosis (p = 0.005). Despite longer courses of intravenous antimicrobials (23 vs 14 days; p = 0.032), complex cases were more likely to relapse (p = 0.016). CONCLUSION: A standardised case-definition of necrotising otitis externa is needed to optimise diagnosis, management and research.
Subject(s)
Otitis Externa , Anti-Bacterial Agents/therapeutic use , Humans , Otitis Externa/diagnosis , Otitis Externa/drug therapy , Retrospective StudiesABSTRACT
Cranial cavity extraction is often the first step in quantitative neuroimaging analyses. However, few automated, validated extraction tools have been developed for non-contrast enhanced CT scans (NECT). The purpose of this study was to compare and contrast freely available tools in an unseen dataset of real-world clinical NECT head scans in order to assess the performance and generalisability of these tools. This study included data from a demographically representative sample of 428 patients who had completed NECT scans following hospitalisation for stroke. In a subset of the scans (n = 20), the intracranial spaces were segmented using automated tools and compared to the gold standard of manual delineation to calculate accuracy, precision, recall, and dice similarity coefficient (DSC) values. Further, three readers independently performed regional visual comparisons of the quality of the results in a larger dataset (n = 428). Three tools were found; one of these had unreliable performance so subsequent evaluation was discontinued. The remaining tools included one that was adapted from the FMRIB software library (fBET) and a convolutional neural network- based tool (rBET). Quantitative comparison showed comparable accuracy, precision, recall and DSC values (fBET: 0.984 ± 0.002; rBET: 0.984 ± 0.003; p = 0.99) between the tools; however, intracranial volume was overestimated. Visual comparisons identified characteristic regional differences in the resulting cranial cavity segmentations. Overall fBET had highest visual quality ratings and was preferred by the readers in the majority of subject results (84%). However, both tools produced high quality extractions of the intracranial space and our findings should improve confidence in these automated CT tools. Pre- and post-processing techniques may further improve these results.
Subject(s)
Image Processing, Computer-Assisted , Stroke , Humans , Image Processing, Computer-Assisted/methods , Neural Networks, Computer , Software , Stroke/diagnostic imaging , Tomography, X-Ray Computed/methodsABSTRACT
Background. Water, sanitation and hygiene are critically important in reducing morbidity and mortality from childhood diarrhoeal disease and malnutrition in low-income settings.Objectives. To assess the association of diarrhoeal disease with factors relating to domestic hygiene, the environment, sociodemographic status and anthropometry in children <2 years of age.Methods. This was a case-control study conducted in a periurban community 35 km from the centre of Cape Town, South Africa. The study included 100 children with diarrhoeal disease and 100 age-matched controls without diarrhoea, who were recruited at primary healthcare clinics. Sociodemographic status, environmental factors and domestic hygiene were assessed using a structured questionnaire; anthropometry was assessed using the World Health Organization's child growth standards. Univariate and multivariate logistic regression analyses were performed to identify the factors associated with diarrhoea. Results. The results of the univariate logistic regression showed significant susceptibility to diarrhoea in study cases compared with controls when the caregiver was ≥25 years old (odds ratio (OR) 1.82; 95% confidence interval (CI) 1.02 - 3.23; p=0.042); when children were in day care or cared for by a family member or a relative than when cared for by their mother (OR 1.97; 95% CI 1.06 - 3.65; p=0.032); and when the mothers were employed rather than at home (OR 2.23; 95% CI 1.21 - 4.12; p=0.01). Multivariate logistic regression analysis was used to identify predictors of diarrhoea, which entailed relaxing the inclusion criteria for the univariate analysis variables (p<0.25). The predictors significantly associated with diarrhoea were household problems relating to rat infestation (OR 2.44; 95% CI 1.13 - 5.28; p=0.027); maternal employment (OR 2.47; 95% CI 1.28 - 4.76; p=0.007); and children in day care or cared for by a relative (OR 2.34; 95% CI 1.21 - 4.54; p=0.01). Significantly more of the mothers who were employed than those who were unemployed had children in day care or cared for by a relative. Conclusion. Practices relating to employment, childcare and the domestic environment were significant predictors of diarrhoea. Effective policy implementation on water, sanitation and domestic hygiene could prevent diarrhoeal disease and reduce its impact on children's growth, especially during the annual diarrhoeal surge season in this and similar periurban communities.
Subject(s)
Humans , Female , Infant , Child, Preschool , Housing Sanitation , Diarrhea, Infantile , Environment , Sociodemographic FactorsABSTRACT
OBJECTIVE: To ensure clinicians can rely on point-of-care testing results, we assessed agreement between point-of-care tests for creatinine, urea, sodium, potassium, calcium, Hb, INR, CRP and subsequent corresponding laboratory tests. PARTICIPANTS: Community-dwelling adults referred to a community-based acute ambulatory care unit. INTERVENTIONS: The Abbott i-STATTM (Hb, clinical chemistry, INR) and the AfinionTM Analyser (CRP) and corresponding laboratory analyses. OUTCOMES: Agreement (Bland-Altman) and bias (Passing-Bablok regression). RESULTS: Among 462 adults we found an absolute mean difference between point-of-care and central laboratory analyses of 6.4g/L (95%LOA -7.9 to +20.6) for haemoglobin, -0.5mmol/L (95%LOA -4.5 to +3.5) for sodium, 0.2mmol/L (95%LOA -0.6 to +0.9) for potassium, 0.0mmol/L (95%LOA -0.3 to +0.3) for calcium, 9.0 µmol/L (95%LOA -18.5 to +36.4) for creatinine, 0.0mmol/L (95%LOA -2.7 to +2.6) for urea, -0.2 (95%LOA -2.4 to +2.0) for INR, -5.0 mg/L (95%LOA -24.4 to +14.4) for CRP. CONCLUSIONS: There was acceptable agreement and bias for these analytes, except for haemoglobin and creatinine.
Subject(s)
Ambulatory Care , Blood Chemical Analysis/methods , Point-of-Care Testing , Adult , Humans , Reproducibility of ResultsABSTRACT
OBJECTIVES: We aimed to determine age-specific rates of delirium and associated factors in acute medicine, and the impact of delirium on mortality and re-admission on long-term follow-up. DESIGN: Observational study. Consecutive patients over two 8-week periods (2010, 2012) were screened for delirium on admission, using the confusion assessment method (CAM), and reviewed daily thereafter. Delirium diagnosis was made using the Diagnostic and Statistical Manual Fourth Edition (DSM IV) criteria. For patients aged ≥65â years, potentially important covariables identified in previous studies were collected with follow-up for death and re-admission until January 2014. PARTICIPANTS: 503 consecutive patients (age median=72, range 16-99â years, 236 (48%) male). SETTING: Acute general medicine. RESULTS: Delirium occurred in 101/503 (20%) (71 on admission, 30 during admission, 17 both), with risk increasing from 3% (6/195) at <65â years to 14% (10/74) for 65-74â years and 36% (85/234) at ≥75â years (p<0.0001). Among 308 patients aged >65â years, after adjustment for age, delirium was associated with previous falls (OR=2.47, 95% CI 1.45 to 4.22, p=0.001), prior dementia (2.08, 1.10 to 3.93, p=0.024), dependency (2.58, 1.48 to 4.48, p=0.001), low cognitive score (5.00, 2.50 to 9.99, p<0.0001), dehydration (3.53, 1.91 to 6.53, p<0.0001), severe illness (1.98, 1.17 to 3.38, p=0.011), pressure sore risk (5.56, 2.60 to 11.88, p<0.0001) and infection (4.88, 2.85 to 8.36, p<0.0001). Patients with delirium were more likely to fall (OR=4.55, 1.47 to 14.05, p=0.008), be incontinent of urine (3.76, 2.15 to 6.58, p<0.0001) or faeces (3.49, 1.81-6.73, p=0.0002) and be catheterised (5.08, 2.44 to 10.54, p<0.0001); and delirium was associated with stay >7â days (2.82, 1.68 to 4.75, p<0.0001), death (4.56, 1.71 to 12.17, p=0.003) and an increase in dependency among survivors (2.56, 1.37 to 4.76, p=0.003) with excess mortality still evident at 2-year follow-up. Patients with delirium had fewer re-admissions within 30-days (OR=0.32, 95% CI 0.09 to 1.1, p=0.07) and in total (median, IQR total re-admissions=0, 0-1 vs 1, 0-2, p=0.01). CONCLUSIONS: Delirium affected a fifth of acute medical admissions and a third of those aged ≥75â years, and was associated with increased mortality, institutionalisation and dependency, but not with increased risk of re-admission on follow-up.
Subject(s)
Delirium/epidemiology , Hospitalization/statistics & numerical data , Mortality , Patient Readmission/statistics & numerical data , Adolescent , Adult , Age Distribution , Aged , Aged, 80 and over , Cognition Disorders/epidemiology , Comorbidity , Female , Humans , Independent Living , Length of Stay , Longitudinal Studies , Male , Middle Aged , Young AdultABSTRACT
INTRODUCTION: Routine cognitive screening for in-patients aged ≥75 years is recommended, but there is uncertainty around how this should be operationalised. We therefore determined the feasibility and reliability of the Abbreviated mental test score (AMTS/10) and its relationship to subjective memory complaint, Montreal Cognitive Assessment (MoCA/30) and informant report in unselected older admissions. METHODS: Consecutive acute general medicine patients aged ≥75 years admitted over 10 weeks (March-May 2013) had AMTS and a question regarding subjective memory complaint (if no known dementia/delirium). At ≥72 h, the 30-point Montreal Cognitive Assessment (MoCA) and Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) were done. Cognitive impairment was defined as AMTS < 9 or MoCA < 26 (mild impairment) and MoCA < 20 (moderate/severe impairment) or IQCODE ≥ 3.6. RESULTS: Among 264 patients (mean age/SD = 84.3/5.6 years, 117 (44%) male), 228 (86%) were testable with AMTS. 49/50 (98%) testable patients with dementia/delirium had low AMTS compared with 79/199 (44%) of those without (P < 0.001). Subjective memory complaint agreed poorly with objective cognitive deficit (39% denying a memory problem had AMTS < 9 (kappa = 0.134, P = 0.086)) as did informant report (kappa = 0.18, P = 0.15). In contrast, correlation between AMTS and MoCA was strong (R2 = 0.59, P < 0.001) with good agreement between AMTS < 9 and MoCA < 20 (kappa = 0.50, P < 0.01), although 85% of patients with normal AMTS had MoCA < 26. CONCLUSIONS: The AMTS was feasible and valid in older acute medicine patients agreeing well with the MoCA albeit with a ceiling effect. Objective cognitive deficits were prevalent in patients without known dementia or delirium but were not reliably identified by subjective cognitive complaint or informant report.
Subject(s)
Cognition Disorders/diagnosis , Memory Disorders/diagnosis , Patient Admission/statistics & numerical data , Aged , Aged, 80 and over , Delirium/diagnosis , Dementia/diagnosis , Female , Humans , Male , Mass Screening/methods , Neuropsychological Tests , Reproducibility of Results , Surveys and QuestionnairesABSTRACT
AIMS: The effects of radiotherapy on health-related quality of life (HRQOL) may influence decisions about adjuvant radiotherapy after breast-conserving surgery. We sought women's ratings of HRQOL during and after radiotherapy. MATERIALS AND METHODS: Women completed HRQOL measures before, during and after adjuvant radiotherapy for node-negative, hormone receptor-positive breast cancers that were less than 2 cm in size. Acute and late toxicities were rated by clinicians. RESULTS: There were 161 participants with a median age of 58 years (range 34-82). Mean scores for most aspects of HRQOL worsened only slightly during radiotherapy and improved to baseline levels or better within a few months. The symptoms rated as most distressing were: difficulty sleeping (29%), fatigue (23%), breast discolouration (21%), uncertainty about the future (18%), feeling sad or depressed (18%), feeling anxious or worried (19%). Most rated their experience as better (39%) or much better (28%) than expected. Grade 3 toxicities were rare (5% acute, 1% late) with no grade 4 toxicities. CONCLUSIONS: Radiotherapy was associated with transient and generally mild impairments in a few aspects of HRQOL. Concerns about adverse effects on HRQOL should not weigh heavily on decisions about adjuvant breast radiotherapy.
Subject(s)
Breast Neoplasms/radiotherapy , Patient Satisfaction , Adult , Aged , Aged, 80 and over , Breast Neoplasms/pathology , Breast Neoplasms/psychology , Breast Neoplasms/surgery , Decision Making , Female , Humans , Mastectomy, Segmental , Middle Aged , Neoplasm Staging , Quality of Life , Radiotherapy, Adjuvant , Randomized Controlled Trials as Topic , Surveys and QuestionnairesABSTRACT
BACKGROUND: The Montreal Cognitive Assessment (MoCA) appears more sensitive to mild cognitive impairment (MCI) than the Mini-Mental State Examination (MMSE): over 50% of TIA and stroke patients with an MMSE score of ≥27 ('normal' cognitive function) at ≥6 months after index event, score <26 on the MoCA, a cutoff which has good sensitivity and specificity for MCI in this population. We hypothesized that sensitivity of the MoCA to MCI might in part be due to detection of different patterns of cognitive domain impairment. We therefore compared performance on the MMSE and MoCA in subjects without major cognitive impairment (MMSE score of ≥24) with differing clinical characteristics: a TIA and stroke cohort in which frontal/executive deficits were expected to be prevalent and a memory research cohort. METHODS: The MMSE and MoCA were done on consecutive patients with TIA or stroke in a population-based study (Oxford Vascular Study) 6 months or more after the index event and on consecutive subjects enrolled in a memory research cohort (the Oxford Project to Investigate Memory and Ageing). Patients with moderate-to-severe cognitive impairment (MMSE score of <24), dysphasia or inability to use the dominant arm were excluded. RESULTS: Of 207 stroke patients (mean age ± SD: 72 ± 11.5 years, 54% male), 156 TIA patients (mean age 71 ± 12.1 years, 53% male) and 107 memory research subjects (mean age 76 ± 6.6 years, 46% male), stroke patients had the lowest mean ± SD cognitive scores (MMSE score of 27.7 ± 1.84 and MoCA score of 22.9 ± 3.6), whereas TIA (MMSE score of 28.4 ± 1.7 and MoCA score of 24.9 ± 3.3) and memory subject scores (MMSE score of 28.5 ± 1.7 and MoCA score of 25.5 ± 3.0) were more similar. Rates of MoCA score of <26 in subjects with normal MMSE ( ≥27) were lowest in memory subjects, intermediate in TIA and highest after stroke (34 vs. 48 vs. 67%, p < 0.001). The cerebrovascular patients scored lower than the memory subjects on all MoCA frontal/executive subtests with differences being most marked in visuoexecutive function, verbal fluency and sustained attention (all p < 0.0001) and in stroke versus TIA (after adjustment for age and education). Stroke patients performed worse than TIA patients only on MMSE orientation in contrast to 6/10 subtests of the MoCA. Results were similar after restricting analyses to those with an MMSE score of ≥27. CONCLUSIONS: The MoCA demonstrated more differences in cognitive profile between TIA, stroke and memory research subjects without major cognitive impairment than the MMSE. The MoCA showed between-group differences even in those with normal MMSE and would thus appear to be a useful brief tool to assess cognition in those with MCI, particularly where the ceiling effect of the MMSE is problematic.
Subject(s)
Cognition/physiology , Cognitive Dysfunction/physiopathology , Ischemic Attack, Transient/physiopathology , Memory/physiology , Stroke/physiopathology , Aged , Aged, 80 and over , Cognition Disorders/psychology , Humans , Mental Status Schedule , Middle Aged , Neuropsychological TestsABSTRACT
GOALS OF WORK: Radiotherapy is routinely used in the treatment of early breast cancer, particularly in women who have undergone lumpectomy. Its impact on the quality of life of patients is important and is taken into consideration when making informed choices about treatment from both a patient's and health professional's point of view. This study reports on the quality of life of women at baseline, the completion of radiotherapy and 7 months after the completion of radiotherapy. MATERIALS AND METHODS: European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C-30 and BR-23 questionnaires were used to evaluate quality of life of 61 women treated with radiotherapy for breast cancer. Additionally, demographic and treatment variables were analysed in relation to quality of life outcomes to determine if there were any significant predictors of quality of life. MAIN RESULTS: There was no difference in quality of life of women at baseline, completion and 7 months after completion of radiotherapy. Fatigue and breast symptoms increased during radiotherapy but returned to baseline levels at 7 months. Fatigue was the strongest predictor of poor quality of life in women after radiotherapy. CONCLUSION: Women retain a high quality of life and return to baseline function by 7 months after radiotherapy. Treatment may best be targeted to alleviate fatigue and breast symptoms during radiotherapy.
Subject(s)
Breast Neoplasms/radiotherapy , Quality of Life , Radiotherapy, Adjuvant/adverse effects , Adult , Aged , Breast Neoplasms/physiopathology , Combined Modality Therapy , Fatigue/etiology , Female , Follow-Up Studies , Humans , Mastectomy, Segmental/psychology , Middle Aged , Surveys and Questionnaires , Survivors , Treatment OutcomeABSTRACT
Surgery and radiotherapy commonly cause adverse musculoskeletal problems, particularly loss of strength and range of motion, in the upper quadrant of breast cancer patients. Few well-designed studies have investigated whether these impairments can be prevented. Stretching is an effective technique for increasing range of motion, hence the aim of this study was to investigate whether a stretching program reduced acute musculoskeletal impairments in patients undergoing radiotherapy for breast cancer. Sixty-four women were recruited prior to commencement of radiotherapy following breast cancer surgery. Participants were randomised to either a control or stretch group. Participants in both groups were reviewed by the physical therapist on a weekly basis for approximately 6 weeks, and were given general information about skin care and lymphedema. The control group received no advice about exercise. The stretch group received instruction on low-load, prolonged pectoral stretches, which were to be performed daily and were checked at weekly visits. Shoulder range of motion, strength, arm circumference, and quality of life measurements were taken prior to, and at completion of radiotherapy, and at 7 months after radiotherapy. There was no difference in any outcome between groups. Breast symptoms increased for both groups during radiotherapy, without loss of strength or range of movement. The incidence of lymphedema during the study was low for both groups and did not differ between groups. The pectoral stretching program did not influence the outcomes measured because the symptoms reported by patients were not a consequence of contracture.
Subject(s)
Breast Neoplasms/rehabilitation , Breast Neoplasms/radiotherapy , Muscle Stretching Exercises , Muscular Diseases/prevention & control , Pectoralis Muscles/physiology , Female , Humans , Lymphedema/etiology , Lymphedema/prevention & control , Middle Aged , Muscular Diseases/etiology , Pectoralis Muscles/pathology , Quality of Life , Range of Motion, Articular , Single-Blind Method , Treatment OutcomeABSTRACT
BACKGROUND: Many cancer survivors experience ongoing morbidity over the survivorship continuum and their supportive care needs have yet to be comprehensively assessed. METHODS: This study aimed to develop and empirically evaluate a self-report measure of cancer survivors' supportive care needs. In Phase I, questionnaire items were generated based upon previous qualitative research that identified both unique and shared needs in survivors and their partners; items were constructed into the Cancer Survivors' Unmet Needs measure (CaSUN). In Phase 2, the CaSUN was completed by 353 cancer survivors who had been diagnosed with cancer between 1 and 15 years earlier and were currently disease-free. RESULTS: After modification, the CaSUN included 35 unmet need items, 6 positive change items and an open-ended question. Good acceptability, internal consistency and validity were demonstrated, although test-retest reliability was low. Maximum likelihood factor analysis identified five discrete factors: Existential Survivorship, Comprehensive Care, Information, Quality of Life and Relationships. CONCLUSIONS: Preliminary data indicates that the CaSUN meets the majority of psychometric criteria for assessment measures, although its low test-retest reliability awaits further investigation. The CaSUN will facilitate the evaluation of supportive care services and generation of service delivery recommendations for cancer survivors.
Subject(s)
Health Services Needs and Demand , Neoplasms/epidemiology , Neoplasms/psychology , Social Support , Survivors , Adult , Demography , Disease-Free Survival , Factor Analysis, Statistical , Female , Humans , Male , Middle Aged , Psychometrics , Quality of Life , Surveys and QuestionnairesABSTRACT
PURPOSE: The use of chemotherapy and endocrine therapies in the treatment of premenopausal women carries with it reproductive and gynecologic implications that young women may find distressing and discordant with plans for childbearing. This multicenter study aimed to investigate fertility- and menopause-related information needs among young women with a diagnosis of early-stage breast cancer. PATIENTS AND METHODS: Two hundred twenty-eight women with a diagnosis of early-stage breast cancer who were aged 40 years or younger at diagnosis and who were 6 to 60 months after diagnosis were entered onto the trial. Participants completed a mailed self-report questionnaire that included a purposely designed fertility- and menopause-related information needs survey and standardized measures of distress, anxiety, quality of life, menopausal symptoms, and information-seeking style. RESULTS: Seventy-one percent of participants discussed fertility-related issues with a health professional as part of their breast cancer treatment, and 86% discussed menopause-related issues. Consultation with a fertility or menopause specialist was the most preferred method of obtaining this information. Receiving fertility-related information was rated as being significantly more important than receiving menopause-related information at time of diagnosis (P < .001) and at treatment decision making (P = .058). Receiving menopause-related information was rated as being significantly more important than receiving fertility-related information during adjuvant treatment (P < .05), at completion of adjuvant treatment (P < .001), and during follow-up (P < .001). Common questions, sources of information, and correlates of perceived importance were identified. CONCLUSION: The results of this study suggest that younger women have unmet needs for fertility- and menopause-related information and provide preliminary empirical data to guide the development of better fertility- and menopause-related patient education materials for younger women with a diagnosis of early breast cancer.
Subject(s)
Breast Neoplasms/complications , Breast Neoplasms/therapy , Fertility , Menopause , Needs Assessment , Adult , Age of Onset , Breast Neoplasms/psychology , Female , Health Care Surveys , Humans , Neoplasm Staging , Patient Education as Topic , Quality of Life , Stress, PsychologicalSubject(s)
Adenosine Triphosphatases/genetics , Amino Acid Substitution , Basal Ganglia/pathology , Brain Ischemia/etiology , Cation Transport Proteins/genetics , Dysarthria/etiology , Gait Disorders, Neurologic/etiology , Hepatolenticular Degeneration/genetics , Mesencephalon/pathology , Mutation, Missense , Point Mutation , Brain Ischemia/diagnostic imaging , Codon/genetics , Copper-Transporting ATPases , Hepatolenticular Degeneration/complications , Hepatolenticular Degeneration/diagnosis , Hepatolenticular Degeneration/pathology , Homozygote , Humans , Tomography, X-Ray ComputedABSTRACT
Due to improvements in medical treatment and survival following breast cancer, researchers have turned their attention to investigating the needs of breast cancer survivors. There is disagreement about the extent to which survivors continue to experience psychological morbidity after treatment ends. Whilst the majority of women adjust well to breast cancer, some may have continued psychosocial needs. Available research suggests that younger pre-menopausal women are at increased risk of psychological morbidity following breast cancer. The present study aimed to gather preliminary qualitative data on the psychosocial needs of breast cancer survivors and to identify the shared and unique needs of younger versus older survivors. A qualitative methodology was chosen as this was a relatively unexplored area of enquiry. Patients treated for early-stage breast cancer who had completed their hospital-based treatment 6-24 months prior to participation were recruited. Sampling was discontinued when informational redundancy was achieved. Eighteen telephone interviews were conducted. A wide variety of on-going psychosocial and information needs were reported by breast cancer survivors including support needs, psychological needs, practical needs, physical needs and information needs. Younger women reported more needs than their older counterparts. Several needs reported by younger women were directly related to being of younger age or pre-menopausal at the time of diagnosis. Clinical implications are discussed.
Subject(s)
Breast Neoplasms/psychology , Needs Assessment , Social Support , Survivors/psychology , Adaptation, Psychological , Adult , Age Factors , Aged , Breast Neoplasms/pathology , Breast Neoplasms/therapy , Cross-Sectional Studies , Female , Humans , Male , Middle Aged , Neoplasm StagingABSTRACT
BACKGROUND AND PURPOSE: Blood oxygenation level-dependent (BOLD) functional MRI (fMRI) is a promising method for defining brain recovery after stroke quantitatively. Applications thus far have assumed that the BOLD hemodynamic response in patients after stroke is identical to that in healthy controls. However, because of local vascular compromise or more diffuse vascular disease predisposing to infarction, this assumption may not be justified after stroke. We sought to test whether patients who have suffered a lacunar stroke show BOLD fMRI response characteristics identical to those of healthy controls. METHODS: We measured the BOLD fMRI signal time course in the sensorimotor cortex contralateral to the affected hand with finger- or hand-tapping tasks for minimally or mildly impaired right-handed patients (n=12) after lacunar strokes causing limb weakness and for healthy controls (n=20). RESULTS: With a right-handed sequential finger-tapping task, the rate of rise and maximum increase of the BOLD signal in the contralateral sensorimotor cortex were > 30% lower (P< or =0.01) in the stroke patients. Similar relative decreases were found for the same task performed with the left hand. These changes were found in patients both in the hemisphere affected by stroke and in the unaffected hemisphere, suggesting that the BOLD fMRI time course differences observed arise from a diffuse functional pathology. The difference between patients and controls is not a result of age alone, since differences were not found between the younger (n=10; aged 22 to 38 years) and the older (n=10; aged 56 to 83 years) healthy controls. The effect also does not seem to be dependent on the specific hand movement task used. CONCLUSIONS: The magnitude of the BOLD fMRI response can be reduced in stroke patients even if infarcts do not involve the cortex. This may be a consequence of the stroke, but the observation that the BOLD signal time course is similar in the affected and unaffected hemispheres suggests that it also could result from preexisting pathophysiological changes in the cerebral microvasculature.
Subject(s)
Echo-Planar Imaging/methods , Stroke/diagnosis , Stroke/physiopathology , Adult , Age Factors , Aged , Brain Ischemia/physiopathology , Female , Fingers , Hemodynamics , Humans , Kinetics , Male , Middle Aged , Motor Cortex/blood supply , Motor Cortex/physiopathology , Motor Skills , Oxygen/blood , Sensitivity and SpecificityABSTRACT
BACKGROUND AND PURPOSE: Further recovery from stroke can occur late, long after the end of the apparent evolution of pathological changes. This observation and evidence obtained from functional imaging for altered patterns of activation after brain injury suggest that cortical reorganization may contribute to recovery. Here, we have tested for potentially adaptive reorganization in the primary sensorimotor cortex. METHODS: We used functional MRI to study brain activation with dominant hand movement in right-handed healthy control subjects (n=20) and in patients after subcortical ischemic infarcts causing mild to moderate right hemiparesis (n=8). The numbers of pixels activated above threshold and the geometric centers of activation clusters were determined. RESULTS: Although random-effects analysis identified some differences in activation maxima, similar regions of the brain were activated with sequential finger tapping in the patient and control groups. However, consistent with the heterogeneity in the locations, sizes, and times after the infarcts, patterns and magnitudes of activation showed some heterogeneity between patients. Nonetheless, for the group as a whole, there was a decreased motor cortex lateralization index (-0.1+/-0.7 in patients and 0.7+/-0.3 in control subjects, P=0.05). The geometric center of activation of the primary sensorimotor cortex activation cluster contralateral to the affected hand in patients was also shifted posteriorly (mean 12 mm, P<0.04) relative to that of the control subjects. To confirm the latter observation, the activation response with a simple hand-tapping task was examined in some of the subjects. With this task, there was also a trend (mean 10 mm, P=0.07) toward a more posterior activation in patients. CONCLUSIONS: These results confirm altered patterns of activation in the contralateral and ipsilateral primary sensorimotor cortices after recovery from strokes causing hemiparesis. These (and other changes) suggest that modulation of widely distributed parts of the cortical network for motor control may contribute to adaptations leading to functional recovery after stroke.
Subject(s)
Magnetic Resonance Imaging , Somatosensory Cortex/physiopathology , Stroke/physiopathology , Acute Disease , Adaptation, Physiological , Adult , Aged , Aged, 80 and over , Chronic Disease , Female , Fingers/physiopathology , Functional Laterality , Hand , Humans , Male , Middle Aged , Movement , Paresis/etiology , Paresis/physiopathology , Recovery of Function , Somatosensory Cortex/blood supply , Somatosensory Cortex/pathology , Stroke/complications , Stroke RehabilitationABSTRACT
PURPOSE: Extracorporeal irradiation (ECI) has been used selectively in the management of primary malignant bone tumors since 1996. We report our techniques for ECI and the short-term oncologic and orthopedic outcomes. METHODS AND MATERIALS: Sixteen patients with primary malignant bone tumors were treated with ECI from 1996 to 2000. The median age was 14 years. The histologic diagnoses were Ewing's sarcoma (11), osteosarcoma (4) and chondrosarcoma (1). The treated sites were femur (7), tibia (4), humerus (2), ilium (2), and sacrum (1). Following induction chemotherapy in Ewing's sarcomas and osteosarcoma, en bloc resection of the tumor and tumor-bearing bone was performed. A single dose of 50 Gy was delivered to the bone extracorporeally using either a linear accelerator (9 cases) or a blood product irradiator (7 cases). The orthopedic outcome was recorded using a standard functional scale. RESULTS: At a median follow-up of 19.5 months, there were no cases of local recurrence or graft failure. One patient required amputation due to chronic osteomyelitis. For the 10 patients with follow-up greater than 18 months, the functional outcomes were graded good to excellent. CONCLUSION: The short-term oncologic and orthopedic results are encouraging and suggest that ECI provides a good alternative for reconstruction in limb conservative surgery in selected patients. This technique should only be used in a multidisciplinary setting, where careful follow-up is available to assess the long-term outcomes.
Subject(s)
Bone Neoplasms/radiotherapy , Chondrosarcoma/radiotherapy , Osteosarcoma/radiotherapy , Sarcoma, Ewing/radiotherapy , Adolescent , Adult , Bone Neoplasms/drug therapy , Bone Neoplasms/surgery , Child , Child, Preschool , Chondrosarcoma/drug therapy , Chondrosarcoma/surgery , Female , Humans , Male , Neoadjuvant Therapy , Osteosarcoma/drug therapy , Osteosarcoma/surgery , Sarcoma, Ewing/drug therapy , Sarcoma, Ewing/surgery , Treatment OutcomeABSTRACT
An evaluation of extra nodal spread (ENS) in predicting overall survival and locoregional relapse rates in 311 node positive breast cancer patients was undertaken: the study group comprised 71 patients with ENS and the control group comprised 240 patients with no ENS. A review of pathology reports that described ENS was performed and a scoring system to categorize focal involvement, extensive axillary fat involvement, and positive axillary surgical margins was devised. Median follow up time was 3.1 years. Overall survival, disease specific survival and disease-free survival rates were significantly worse in the study group in comparison with the control group. Poorer survival with more extensive pathological invasion of ENS was demonstrated. Multivariate analysis of disease specific survival in those patient with 1-3 involved lymph nodes demonstrated that ENS positivity was prognostically significant (P=0.013). Although locoregional relapse was increased in the presence of ENS, axillary relapses were uncommon and do not warrant axillary radiation.
ABSTRACT
BACKGROUND AND PURPOSE: One aspect of good radiotherapeutic practice is to achieve dose homogeneity. Dose inhomogeneities occur with breast tangent irradiation, particularly in women with large breasts. MATERIALS AND METHODS: Ten Australian radiation oncology centres agreed to participate in this multicentre phantom dosimetry study. An Alderson radiation therapy anthropomorphic phantom with attachable breasts of two different cup sizes (B and DD) was used. The entire phantom was capable of having thermoluminescent dosimeters (TLD) material inserted at various locations. Nine TLD positions were distributed throughout the left breast phantom including the superior and inferior planes. The ten centres were asked to simulate, plan and treat (with a prescription of 100 cGy) the breast phantoms according to their standard practice. Point doses from resultant computer plans were calculated for each TLD position. Measured and calculated (planning computer) doses were compared. RESULTS: The dose planning predictability between departments did not appear to be significantly different for both the small and large breast phantoms. The median dose deviation (calculated dose minus measured dose) for all centres ranged from 2. 3 to 5.3 cGy on the central axis and from 2.1 to 7.5 cGy for the off-axis planes. The highest absolute dose was measured in the inferior plane of the large breast (128.7 cGy). The greatest dose inhomogeneity occurred in the small breast phantom volume (median range 93.2-105 cGy) compared with the large breast phantom volume (median range, 100.1-107.7 cGy). There was considerable variation in the use (or not) of wedges to obtain optimized dosimetry. No department used 3D compensators. CONCLUSION: The results highlight areas of potential improvement in the delivery of breast tangent radiotherapy. Despite reasonable dose predictability, the greatest dose deviation and highest measured doses occurred in the inferior aspects of both the small and large breast phantoms.
Subject(s)
Breast Neoplasms/radiotherapy , Dose-Response Relationship, Radiation , Female , Humans , Phantoms, Imaging , Radiation Injuries/prevention & control , Radiotherapy Dosage , Radiotherapy Planning, Computer-Assisted , Reproducibility of Results , Sensitivity and SpecificityABSTRACT
BACKGROUND AND PURPOSE: Several hundred studies have been published over the last few years on imaging and measurement of carotid stenosis. Despite all this research, there is still no consensus about how best to image and measure stenosis. One possible explanation for this is that many of the studies have not been large enough or methodologically sound enough to allow useful conclusions to be drawn. We aimed to assess the design and methods of a random sample of published studies of imaging and measurement of carotid stenosis using 9 simple criteria. METHODS: A formal literature search was performed for studies of imaging and measurement of carotid stenosis. Two subsets were randomly selected for detailed assessment: 20 studies published before 1991 and 20 published between 1993 and 1997 (some years after the initial publication of the ECST and NASCET trials). The criteria used to assess the selected studies were as follows: prospective rather than retrospective study design; patient selection based on a consecutive series or a random sample; adequate detail of study population; adequate detail of imaging techniques; inclusion of all investigations, ie, patients with poor-quality imaging were not excluded; blinded assessment of images; adequate detail of derivation of measurement of stenosis from images or data; adequate data on the reproducibility of measurements of stenosis; and study powered according to a sample-size calculation. RESULTS: There were many basic methodological deficiencies in both subsets of studies, with relatively little evidence of improvement with time. For example, only 33% of studies were prospective, only 45% studied a consecutive or random selection of patients, and only 38% reported any data on the reproducibility of measurements. More than half of the studies satisfied < or =4 of the 9 quality criteria. However, there was considerable variation between studies, with 7 studies satisfying > or = 7 criteria and 10 studies satisfying < or =2. No study was based on a sample-size calculation. The number of patients studied was often small, particularly in the more recent studies: median sample size was 100 in the 1970-1990 studies and 58 in the 1993-1997 studies (P<0.0001). CONCLUSIONS: The design and reporting of published studies of imaging and measurement of carotid stenosis are poor and have not improved much in recent years. The majority of published studies are not of a sufficient standard to enable the results to be used to inform clinical practice. The utility of future studies could be improved considerably by better adherence to 9 simple methodological guidelines.