Clinical effects of rectal retractor application in prostate cancer radiotherapy.

Background: Radiation-induced rectal toxicities remain as a major risk during prostate radiotherapy. One approach to the reduction of rectal radiation dose is to physically increase the distance between the rectal wall and prostate. Therefore, the aim of this study was to evaluate whether the application of the rectal retractor (RR) can reduce rectal dose and toxicity in prostate cancer 3-dimensional conformal radiotherapy (3D-CRT). Methods: Overall, 36 patients with localized prostate cancer were randomized into the 2 groups, 18 patients with RR in-place and 18 without RR. All patients underwent planning computed tomography (CT). Patients were treated with 70 Gy in 35 fractions of 3D-CRT. In the RR group, RR was used during cone-down 20 treatment fractions. Acute and late gastrointestinal (GI) toxicities were assessed using EORTC/RTOG scoring system weekly during radiotherapy, 3, and 12 months after treatment. Device-related events were recorded according to CTCAE version 4.0. Patient characteristics, cancer differences, and dosimetric data for the RR and non-RR groups were compared using a Man-Whitney U test for continuous variables, and Fisher exact test for categorical data. The EORTC/RTOG scores for the 2 groups were compared using Fisher exact test. A P value <0.05 was considered statistically significant. Results: A RR significantly reduced mean dose (Dmean) to the rectum as well as rectal volume receiving 50% to 95% (V50-95%) of prescribed dose. The absolute reduction of rectal Dmean was 10.3 Gy. There was no statistically significant difference in acute GI toxicity between groups during treatment or at 3 months. At 12 months, 2 patients in the RR group and 9 in the control group experienced late grade ≥ 1 GI toxicity (p=0.027). No patients in the RR group reported late grade ≥ 2 GI toxicity, whereas 3 patients in the control group experienced late grade 2 GI toxicity. In the RR group, 6 patients reported grade 1 rectal discomfort and pain according to CTCAE version 4.0. Conclusion: The application of the RR showed a significant rectum sparing effect, resulting in substantially reducing late GI toxicity.

Prevalence and associated comorbidities of restless legs syndrome (RLS): Data from a large population-based door-to-door survey on 19176 adults in Tehran, Iran.

BACKGROUND: Discrepancies have been reported in the prevalence rate of restless legs syndrome (RLS) among different ethnic groups and geographic populations. Furthermore, there are disagreements on determinant factors and associated comorbidities of RLS. We aimed to estimate prevalence of RLS and investigate its associated comorbid conditions and risk factors in a large population-based door-to-door survey. METHODS: Following a multistage random sampling from the households lived in 22 urban districts of Tehran, Iran, 19176 participants with ≥30 years of age were recruited. Trained surveyors filled study checklist consisting of baseline characteristics, risk factors and comorbidity profile and the International RLS Study Group (IRLSSG) diagnostic criteria through face-to-face interviews. RESULTS: In total, 1580 individuals were positively screened for RLS resulting in a standardized prevalence rate of 60.0/1000. There was a gradual increase in RLS prevalence by advancing age, however, sex difference disappeared after adjustment. Parkinsonism [adjusted odds' ratio (adj-OR) = 7.4 (95% CI: 5.3-10.4)], peripheral neuropathy [adj-OR = 3.7 (95% CI: 3.3-4.1)], subjective cognitive impairment (SCI) [adj-OR = 3.1 (95% CI: 2.7-3.4)], acting out dreams [adj-OR = 2.8 (95% CI: 2.5-3.2)], hyposmia [adj-OR = 2.5 (95% CI: 2.2-2.9)], active smoking [adj-OR = 1.5 (95% CI: 1.3-1.9)] and additional number of cardiometabolic diseases associated with higher risk of RLS [adj-OR = 1.6 (95% CI: 1.2-2.3)]. CONCLUSION: Our findings showed that neuro-cognitive co-morbidities such as parkinsonism, peripheral neuropathy, SCI, acting out dreams and hyposmia as well as cardio-metabolic risk factors and diseases were independent determinants of RLS. It is recommended to screen individuals with either these comorbid conditions for RLS or the ones with RLS for the accompanying diseases.

Mortality in Iranian Patients with Parkinson's Disease: Cumulative Impact of Cardiovascular Comorbidities as One Major Risk Factor.

Mortality rate, life expectancy, survival, and the impact of comorbidities on them in people with Parkinson's disease (PD) need to be assessed in settings with different sociodemographic backgrounds. We investigated mortality features in Iranian PD patients focusing on the role of cardiovascular multimorbidity on their survival. Data on mortality and comorbidity profile was gathered in a cohort of 190 individuals with idiopathic PD referred to a Movement Disorders Clinic. Standardized mortality ratio (SMR) compared to the Tehran general population was 3.44 and the life expectancy at birth was 67.4 (95% CI: 59.1-75.8) yr. Patients with at least one cardiovascular comorbidity had a shorter survival time after PD onset (14.0 versus 29.2 yr, p = 0.012). The hazard ratio for death increased 2.8 times (95% CI: 1.5-5.2, p = 0.002) with one additional cardiovascular comorbidity. Among all comorbid conditions, stroke showed the strongest independent effect on mortality in PD patients [HR = 13.1 (95% CI: 2.4-71.7), p = 0.003]. Conclusively, life expectancy was slightly lower in Iranian PD patients compared to the general population, while the SMR was high. Cardiometabolic multimorbidity substantially decreased survival in people with PD. Our study highlights the need for assessment, prevention, and treatment of cardiovascular morbidities in parkinsonian patients, given their effect on survival.

Heterogeneous Determinants of Quality of Life in Different Phenotypes of Parkinson's Disease.

OBJECTIVES: Health-related quality of life (HRQoL) is considered a very important outcome indicator in patients with Parkinson's disease (PD). A broad list of motor and non-motor features have been shown to affect HRQoL in PD, however, there is a dearth of information about the complexity of interrelationships between determinants of HRQoL in different PD phenotypes. We aimed to find independent determinates and the best structural model for HRQoL, also to investigate the heterogeneity in HRQoL between PD patients with different phenotypes regarding onset-age, progression rate and dominant symptom. METHODS: A broad spectrum of demographic, motor and non-motor characteristics were collected in 157 idiopathic PD patients, namely comorbidity profile, nutritional status, UPDRS (total items), psychiatric symptoms (depression, anxiety), fatigue and psychosocial functioning through physical examination, validated questionnaires and scales. Structural equation model (SEM) and multivariate regressions were applied to find determinants of Parkinson's disease summary index (PDSI) and different domains of HRQoL (PDQ-39). RESULTS: Female sex, anxiety, depression and UPDRS-part II scores were the significant independent determinants of PDSI. A structural model consisting of global motor, global non-motor and co-morbidity indicator as three main components was able to predict 89% of the variance in HRQoL. In older-onset and slow-progression phenotypes, the motor domain showed smaller contribution on HRQoL and the majority of its effects were mediated through non-motor features. Comorbidity component was a significant determinant of HRQoL only among older-onset and non-tremor-dominant PD patients. Fatigue was not a significant indicator of non-motor component to affect HRQoL in rapid-progression PD. CONCLUSIONS: Our findings showed outstanding heterogeneities in the pattern and determinants of HRQoL among PD phenotypes. These factors should be considered during the assessments and developing personalized interventions to improve HRQOL in PD patients with different phenotypes or prominent feature.

Medium-to-high prevalence of screening-detected parkinsonism in the urban area of Tehran, Iran: data from a community-based door-to-door study.

INTRODUCTION: Parkinsonism occurs in all ethnic groups worldwide; however, there are wide variations in the prevalence rates reported from different countries, even for neighboring regions. The huge socioeconomic burden of parkinsonism necessitates the need for prevalence studies in each country. So far, there is neither data registry nor prevalence information on parkinsonism in the Iranian population. The aim of our study was to estimate the prevalence rate of probable parkinsonism in a huge urban area in Iran, Tehran using a community-based door-to-door survey. MATERIALS AND METHODS: We used a random multistage sampling of the households within the network of health centers consisting of 374 subunits in all 22 districts throughout the entire urban area of Tehran. Overall, 20,621 individuals answered the baseline checklist and screening questionnaire and data from 19,500 persons aged ≥30 years were entered in the final analysis. Health care professionals used a new six-item screening questionnaire for parkinsonism, which has been previously shown to have a high validity and diagnostic value in the same population. RESULTS: A total of 157 cases were screened for parkinsonism using the validated six-item questionnaire. After age and sex adjustment based on the Tehran population, the prevalence of parkinsonism was calculated as 222.9 per 100,000. Using the World Health Organization's World Standard Population, the standardized prevalence rate of parkinsonism was 285 per 100,000 (95% confidence interval 240-329). The male:female ratio of probable parkinsonism was calculated as 1.62, and there was a significant increase in the screening rate by advancing age. CONCLUSION: The calculated rates for the prevalence of parkinsonism in our study are closer to reports from some European and Middle Eastern countries, higher than reports from Eastern Asian and African populations, and lower than Australia. The prevalence rate of >200 in 100,000 for parkinsonism in Tehran, Iran could be considered a medium-to-high rate.

A novel 6-item screening questionnaire for Parkinsonism: validation and comparison between different instruments.

BACKGROUND: Several instruments have been developed to screen Parkinson's disease (PD); yet, there is no consensus on the items, number of questions, and diagnostic accuracy. We aimed to develop a new questionnaire combining the best items with highest validity to screen parkinsonism and to compare its diagnostic value with that of the previous instruments using the same database. METHODS: 157 patients with parkinsonism and 110 healthy controls completed a comprehensive screening questionnaire consisting of 25 items on different PD symptoms used in previous studies. To select the optimal items, clinical utility index (CUI) was calculated and those who met at least good negative utility (CUI ≥0.64) were selected. Receiver operating characteristics (ROC) curves analysis was used to compare the area under the curve (AUC) of different screening instruments. RESULTS: Six items on 'stiffness & rigidity', 'tremor & shaking', 'troublesome buttoning', 'troublesome arm swing', 'feet stuck to floor' and 'slower daily activity' demonstrated good CUI. The new screening instrument had the largest AUC (0.977) compared to other instruments. CONCLUSIONS: We selected a new set of six items to screen parkinsonism, which showed higher diagnostic values compared to the previously developed questionnaires. This screening instrument could be used in population-based PD surveys in poor-resource settings.

Motor, psychiatric and fatigue features associated with nutritional status and its effects on quality of life in Parkinson's disease patients.

OBJECTIVES: Parkinson's disease (PD) patients are more likely to develop impaired nutritional status because of the symptoms, medications and complications of the disease. However, little is known about the determinants and consequences of malnutrition in PD. This study aimed to investigate the association of motor, psychiatric and fatigue features with nutritional status as well as the effects of malnutrition on different aspects of quality of life (QoL) in PD patients. METHODS: One hundred and fifty patients with idiopathic PD (IPD) were recruited in this study. A demographic checklist, the Unified Parkinson's Disease Rating Scale (UPDRS), the Hospital Anxiety and Depression Scale (HADS) and the Fatigue Severity Scale (FSS) were completed through face-to-face interviews and clinical examinations. The health-related QoL (HRQoL) was also evaluated by means of the Parkinson's Disease Questionnaire (PDQ-39). For evaluation of nutritional status, the Mini Nutritional Assessment (MNA) questionnaire was applied together with anthropometric measurements. RESULTS: Thirty seven (25.3%) patients were at risk of malnutrition and another 3 (2.1%) were malnourished. The total score of the UPDRS scale (r =  -0.613, P<0.001) and PD duration (r =  -0.284, P = 0.002) had a significant inverse correlation with the total MNA score. The median score of the Hoehn and Yahr stage was significantly higher in PD patients with abnormal nutritional status [2.5 vs. 2.0; P<0.001]. More severe anxiety [8.8 vs. 5.9; P = 0.002], depression [9.0 vs. 3.6; P<0.001] and fatigue [5.4 vs. 4.2; P<0.001] were observed in PD patients with abnormal nutritional status. Except for stigma, all other domains of the PDQ-39 were significantly correlated with the total score of the MNA. CONCLUSION: Our study demonstrates that disease duration, severity of motor and psychiatric symptoms (depression, anxiety) and fatigue are associated with nutritional status in PD. Different aspects of the HRQoL were affected by patients' nutritional status especially the emotional well-being and mobility domains.