Telemedicine impact on patient disparities and physician practice patterns in cancer rehabilitation: A multicenter retrospective study.

OBJECTIVE: To examine the impact of telemedicine on demographic and practice patterns between outpatients receiving virtual versus in-person cancer rehabilitation physiatry care. DESIGN: Multicenter retrospective study. SETTING: Outpatient cancer rehabilitation physiatry clinics at four academic medical centers in the United States. PATIENTS: Patients with cancer diagnoses or history of cancer diagnosis. INTERVENTIONS: Cancer rehabilitation physiatry encounters. MAIN OUTCOME MEASURES: Visit mode (in-person, telemedicine); disparities variables (age, race, and gender) by visit mode, and practice interventions (imaging, medications, procedures, other orders, and orders of any type) by visit mode. RESULTS: Among a total of 7004 encounters, 2687 unique patients were found. In-person participants were significantly older than the average telemedicine participant (mean 62.9 vs. 60.7 years; p < .001). A race effect was seen (p = .037) with individuals reporting as Asian or other being more likely to have telemedicine encounters. No gender disparities were seen. Using a random visit analysis model to compare populations receiving in-person versus telemedicine care, a slight majority (53%) of follow-up visits were via telemedicine, versus 40% of new patient visits (p < .001). No significant differences were seen in medication prescribing frequency (38.9% telemedicine vs. 36.7% in-person, adjusted relative risk [RR]: 0.988, confidence interval [CI]: 0.73-1.34; p = .988) or imaging frequency (2.4% telemedicine vs. 7.6%; adjusted RR: 0.784, CI: 0.44-1.39; p = .408) between telemedicine versus in-person visit types. Other orders were significantly less likely to be placed during telemedicine than in-person visits (19.9% telemedicine vs. 28.6% in-person; adjusted RR: 0.623, CI: 0.45-0.86, p = .004). Order(s) of any type were placed in 54% of visits (52% telemedicine vs. 56% in-person; adjusted RR: 0.92 for telemedicine, CI: 0.83-1.01, p = .082). CONCLUSIONS: Telemedicine has been integrated into cancer rehabilitation physiatry practices and appears to be conducive for placing many types of orders, especially medications. Age was found to be the only major demographic difference between in-person and telehealth patients.

First Report of Xanthomonas campestris Causing Leaf Blight on Buttercup (Ranunculus asiaticus) in South Carolina, USA.

Buttercup (Ranunculus asiaticus L.) is a popular and high value ornamental species grown in landscapes and gardens and as cut flowers. It is mostly cultivated in Europe, the Mediterranean, and the Americas (Beruto and Debergh, 2004). In January 2022, leaf blight was observed on approximately 24 of forty 4-month-old R. asiaticus plants grown in a high tunnel at a cut flower farm located in Anderson County, South Carolina, USA. Symptoms included irregular, vein-limited, and necrotic leaf lesions and yellowing. Some lesions had a chlorotic halo. Two diseased plants were submitted to the Clemson University Plant and Pest Diagnostic Clinic. Symptomatic leaves were surface sterilized with 10% bleach for 1 min and rinsed in sterile water. Small leaf portions (1 × 1 cm2) were excised from the margin of lesions. They were macerated in 500 µl of sterile water and incubated at room temperature for 10 min. A loopful of suspension was streaked on nutrient agar (NA). Slightly convex, yellowish-mucoid colonies appeared after incubation at 28°C for 48 h. Two isolates, 23A and 23B, from two plants were obtained by transferring single colonies to new NA plates. Both isolates were identified as X. campestris (probability values > 0.8) using a Biolog Microbial Identification System (GEN III Microplate; Identification Database v.2.8.0.15G). PCR amplification of these two isolates were performed for housekeeping genes gyrB, rpoD, and dnaK (Young et al. 2008). The amplicon sequences (GenBank accession nos.: OR101193 and OR101194 [dnaK]; OR101195 and OR101196 [gyrB]; OR101197 and OR101198 [rpoD]) were identical between the two isolates based on sequence alignment in MEGA11 (Tamura et al. 2021). Nucleotide BLAST of these three genes showed 94.6 to 98.9% identity (dnaK: 912 of 922 bp; gyrB: 827 of 839 bp; rpoD: 803 of 849 bp) with 100% coverage with the Xanthomonas campestris pv. campestris type strain (AE008922). A neighbor joining phylogenetic tree with the concatenated sequences of these three genes showed that 23A and 23B had the closest match with X. campestris pv. campestris. However, these two isolates tested negative in the probe-based qPCR assay specific for X. campestris pv. campestris with only the positive control amplified (Köhl et al. 2011), suggesting that they may belong to a new pathovar of X. campestris. To confirm the pathogenicity of these isolates, three healthy R. asiaticus plants each were spray inoculated with suspensions of 23A and 23B in sterile tap water until runoff (OD600 = 0.1, approx. 108 CFU/ml). The non-inoculated control plants received a sterile tap water spray. The experiment was conducted twice. All plants were maintained in a growth chamber at 24°C with 10-h photoperiod. Seven to 15 days after inoculation, necrotic lesions with chlorotic halo and leaf yellowing, similar to those observed in the field, were observed on inoculated plants, while the non-inoculated control plants remained symptomless. Koch's postulates were fulfilled by reisolating the bacteria from the symptomatic plants and confirming the bacterial identity with the sequence analysis described above. The disease was first reported in California in 1996 (Azad et al. 1996) but to the best of our knowledge has not been reported again in the United States. This is the first report of X. campestris causing bacterial leaf blight in R. asiaticus in South Carolina. Since more than 50% of the flower producers/farmers grow Ranunculus in South Carolina, further work is necessary to determine how widespread the disease is and its economic impact.

Outcome Measures and Patient-Reported Metrics in Cancer Rehabilitation.

PURPOSE OF REVIEW: The current panorama of measurement tools for use in cancer rehabilitation is reviewed. For rehabilitation purposes, evaluating function is of the highest priority. RECENT FINDINGS: From a patient-reported outcome (PRO) standpoint, SF-36 and EORTC-QLQ-C30 are in most common use in cancer rehabilitation research; these are quality of life measures that contain functional subdomains. Newer tools which are based on item response theory and have options for both computer assisted or short form (SF) administration, including the Patient-Reported Outcomes Measurement Information System (PROMIS) and Activity Measure for Post-acute Care (AMPAC) instruments, show increasing use, especially PROMIS Physical Function SF, and, recently, PROMIS Cancer Function Brief 3D, which has been validated in the cancer population, with domains of physical function, fatigue, and social participation, to track clinical rehabilitation outcomes. Evaluating objective measures of function in cancer patients is also crucial. Utilization of clinically feasible tools for cancer rehabilitation, to employ for both screening purposes and for monitoring of rehabilitation treatment efficacy, is an evolving area, much needed to promote further research and improved, consistent clinical care for cancer patients and survivors.

Risk factors for reduced function in women with a history of breast cancer.

PURPOSE: People with a history of breast cancer are at risk of losing function during and after treatment. Unfortunately, little is known about the individual and additive effects of specific treatment, disease-related, and demographic factors that may contribute to functional decline. This manuscript reports the results of a multi-center study to evaluate the effects of these factors on function. METHODS: In this cross-sectional study, women with a history of breast cancer referred to physical medicine and rehabilitation cancer rehabilitation clinics were administered the PROMIS® Cancer Function Brief 3D Profile to evaluate function in the domains of physical function, fatigue, and social participation. Clinical and demographic information, including treatment history and disease status, was recorded by clinicians. Patients were analyzed in two groups: those with active disease on antineoplastic treatment, and those with no evidence of disease (NED). A multivariable model was constructed to detect associations between clinical and demographic factors. RESULTS: In patients with NED, the presence of chemotherapy-induced peripheral neuropathy (CIPN) was strongly associated with reduced function in all three domains. In those with active disease, having brain metastases was significantly associated with reduced function in all domains and CIPN with reduced physical function. Radiation was associated with improved function in both cohorts. CONCLUSIONS: Among women seeking rehabilitative care, CIPN and the presence of brain metastases were most strongly associated with a decline in function. The effects of radiation on function were unexpected and may be partially explained by the treatment's role in symptom management. Clinicians who treat breast cancer should consider a patient's functional status when providing supportive care.

Responsiveness and interpretation of the PROMIS Cancer Function Brief 3D Profile.

BACKGROUND: Measuring function with valid and responsive tools in patients with cancer is essential for driving clinical decision-making and for the end points of clinical trials. Current patient-reported outcome measurements of function fall short for many reasons. This study evaluates the responsiveness of the Patient-Reported Outcomes Measurement Information System (PROMIS) Cancer Function Brief 3D Profile, a novel measure of function across multiple domains. METHODS: Two hundred nine participants across five geographically distinct tertiary care centers completed the assessment and pain rating at two outpatient cancer rehabilitation clinic visits. Patients and providers completed a global rating of change measure at the second visit to indicate whether the patient was improving or worsening in function. Multiple response indices and linear models measured whether the measure was responsive to self-reported and clinician-rated changes over time. Correlations between changes in function and changes in anchors (pain rating and performance status) were also calculated. RESULTS: Function as measured by the PROMIS Cancer Function Brief 3D Profile changed appropriately as both patients and clinicians rated change. Small to moderate effect sizes supported the tool's responsiveness. Function was moderately correlated with pain and more strongly correlated with performance status, and changes in function corresponded with changes in anchor variables. No floor/ceiling effect was found. CONCLUSIONS: The PROMIS Cancer Function Brief 3D Profile is sensitive to changes over time in patients with cancer. The measure may be useful in clinical practice and as an end point in clinical trials. LAY SUMMARY: We gave patients a questionnaire by which they told their physicians how well they were functioning, including how fatigued they were. This study tested that questionnaire to see whether the scores would change if patients got better or worse.

Psychometric Characteristics and Validity of the PROMIS Cancer Function Brief 3D Profile.

OBJECTIVE: To develop an item response theory (IRT)-calibrated, patient-reported outcome measure (the PROMIS Cancer Function Brief 3D Profile) of physical function, including associations with fatigue and social participation, in cancer rehabilitation patients. DESIGN: Large-scale field testing, graded response model IRT analyses, and multivariate regression analysis. SETTING: Six cancer rehabilitation clinics associated with cancer centers across the United States. PARTICIPANTS: Adults (N=616) treated in outpatient cancer rehabilitation medicine clinics. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: The PROMIS(r) Cancer Function 3D Profile (including existing items from PROMIS(r) item banks). RESULTS: A total of 616 patients completed 21 items in the initial item pool. Nine items were removed because of comparatively lower information that they provide according to the IRT item calibrations, low item-total correlations, or bimodal distributions. The remaining items generated a 12-item short form. Regression analyses determined that the items were responsive to and representative of the patient population across trait ranges and multiple domains and subdomains of function. CONCLUSIONS: This psychometric investigation supports the use of the PROMIS Cancer Function Brief 3D Profile for evaluating function in outpatient cancer rehabilitation patients.

The Cancer Rehabilitation Medicine Metrics Consortium: A Path to Enhanced, Multi-Site Outcome Assessment to Enhance Care and Demonstrate Value.

PURPOSE: A primary objective stated at the Cancer Rehabilitation Symposium at the National Institutes of Health was to improve outcome measurement. The purpose of this project was for the Cancer Rehabilitation Medicine Metrics Consortium (CRMMC) to develop an assessment tool to evaluate function in cancer patients via a data-driven and methodologically sound process. There is no agreed-upon measure of physical and cognitive function for cancer patients, making it difficult to demonstrate the value of rehabilitation interventions. Cancer patients are a particularly challenging population, with many tumor- and treatment-related variables impacting function. METHODS: Investigators from nine different cancer rehabilitation programs participated in a modified-Delphi process to delineate necessary aspects of an ideal patient assessment tool, including instrument type, domains evaluated, applicability across a range of patient traits, clinical feasibility, and item response characteristics. This involved numerous meetings, data review, and analysis of items involved in patient assessment. RESULTS: The CRMMC developed a 21-item patient-reported outcome measure based on item response theory. The process by which the short form was developed was documented and provides a framework for other clinicians to follow. CONCLUSION: This document provides a framework for rehabilitation providers to follow when developing an assessment tool. This process is described in a stepwise fashion for reproducibility even in different, non-cancer populations.

Brain Tumors and Metastases.

Patients with brain tumor exhibit wide-ranging prognoses and functional implications of their disease and treatments. In general, the supportive care needs of patients with brain tumor, including disabling effects, have been recognized to be high. This review (1) briefly summarizes brain tumor types, treatments, and prognostic information for the rehabilitation clinician; (2) reviews evidence for rehabilitation, including acute inpatient rehabilitation and cognitive rehabilitation, and the approaches to selected common symptom and medical management issues; and (3) examines emerging data about survivorship, such as employment, community integration, and fitness.

Rehabilitation of patients with glioma.

Disabling sequelae occur in a majority of patients diagnosed with brain tumor, including glioma, such as cognitive deficits, weakness, and visual perceptual changes. Often, multiple impairments are present concurrently. Healthcare staff must be aware of the "biographic disruption" the patient with glioma has experienced. While prognostic considerations factor into rehabilitation goals and expectations, regardless of prognosis the treatment team must offer cohesive support, facilitating hope, function, and quality of life. Awareness of family and caregiver concerns plays an important role in the overall care. Inpatient rehabilitation, especially after surgical resection, has been shown to result in functional improvement and homegoing rates on a par with individuals with other neurologic conditions, such as stroke or traumatic brain injury. Community integration comprises a significant element of life satisfaction, as has been shown in childhood glioma survivors. Employment is often affected by the glioma diagnosis, but may be ameliorated, when appropriate, by addressing modifiable factors such as depression, fatigue, or sleep disturbance, or by workplace accommodations. Further research is needed into many facets of rehabilitation in the setting of glioma, including establishing better care models for consistently identifying and addressing functional limitations in this population, measuring outcomes of various levels of rehabilitation care, identifying optimal physical activity strategies, delineating the long-term effects of rehabilitation interventions, and exploring impact of rehabilitation interventions on caregiver burden. The effective elements of cognitive rehabilitation, including transition of cognitive strategies to everyday living, need to be better defined.

Interdisciplinary Rehabilitation Referrals in a Concussion Clinic Cohort: An Exploratory Analysis.

OBJECTIVE: To assess the frequency and spectrum of referrals to rehabilitation disciplines in a concussion clinic population and factors associated with need for referral. DESIGN: Retrospective study. SETTING: Concussion clinic within the Physical Medicine and Rehabilitation Department of an academic medical center. PARTICIPANTS: Patients receiving physiatric management for concussion care. MAIN OUTCOME MEASURES: Referral to physical therapy (PT), occupational therapy, speech therapy (ST), neuropsychology, or any referral (Any), and reasons for referral. INTERVENTIONS: Demographic and clinical variables were analyzed for possible association with referral to rehabilitation disciplines. These independent variables included mechanism of injury, referral source, age, gender, provider, days since injury, presenting Sports Concussion Assessment Tool 2 (SCAT2) symptom score, insurance type, clinical risk factors, whether the injury was work related and whether the patient had been hospitalized. RESULTS: Among 262 patients meeting inclusion criteria, the most commonly prescribed individual therapy was physical therapy (74 patients; 28%), followed by speech therapy (60 patients, 23%), neuropsychology (27 patients, 10.3%), and occupational therapy (19 patients, 7.2%). In all, 121 (46%) of patients were referred to one or more disciplines. The most common reasons for referral were cognitive strategies (54 patients, 21%), balance/vestibular therapy (50 patients,19%), and neck pain (32 patients, 12%). Per multivariate logistic regression analysis, covariates associated with PT: age, SCAT2 symptom score, gender, provider, and (inversely) cognitive/learning disorder; ST: time elapsed since injury, gender, and referral source of internal clinic; Any: SCAT2 symptom score. Referrals did not significantly vary by mechanism of injury (sports, fall, vehicular, etc), whether work-related, or whether the patient had been hospitalized. Insurance factors were significant for PT and Any on the univariate analysis but not logistic regression. CONCLUSIONS: Relatively little has been described about the typical rehabilitation requirements of individuals recovering from concussion. Although rest and guided return to usual activities have been emphasized as mainstays of management, a large number of patients in this concussion cohort were determined to require additional rehabilitation services to assist in recovery.

A Community-Based Exercise and Support Group Program Improves Quality of Life in African-American Breast Cancer Survivors: A Quantitative and Qualitative Analysis.

African-American (AA) breast cancer (BCa) survivors have higher mortality rates, more comorbidities and are less likely to meet national physical activity guidelines after diagnosis compared to Caucasian BCa survivors. We previously reported that a 20-week resistance exercise intervention coupled with a support group and home walking program, conducted using facilities and personnel at a community cancer support center, in Stage I-III AA BCa survivors improved strength, fitness and circulating C-peptide levels. Here, we report our findings on changes in quality of life (QoL) and other behavioral measures associated with this 20-week intervention and, discuss findings from a qualitative analysis of semi-structured patient interviews. We found a clinically relevant improvement in QoL using the Functional Assessment of Cancer Therapy for Breast Cancer (FACT-B) (Baseline, B: 101.1 ± 21.5; End-of-Intervention, EOI: 108.5 ± 21.6; p = 0.05) and, a significant decrease in depression using the Beck Depression Inventory-II (B: 11.9 ± 8.1; EOI: 9.0 ± 5.5; p = 0.03). Our analysis of the patient interviews support improvements in these behavioral measures in that participants stated that they "feel better", were "more motivated" and "uplifted" after the program. The patient interviews also provided insights to the primary motivators (e.g., social support, improvements in strength and function, weight loss) and barriers (e.g., family and health issues) in adhering to the program and provided suggestions for improving the program (e.g., incorporating nutritional and treatment related side-effect discussions). Our results suggest that community-based lifestyle interventions may improve QoL and depression in AA BCa survivors and lend insights for improving future programs.

National Institutes of Health Stroke Scale (NIHSS) as An Early Predictor of Poststroke Dysphagia.

BACKGROUND: Despite the availability of multiple comprehensive screening methods to detect dysphagia during acute stroke care, consensus is lacking as to the best practice. Our previous study demonstrated favorable sensitivity of the Functional Independence Measure (FIM) compared with a bedside 3-sip test. However, the FIM is challenging to administer during acute stroke care. The National Institutes of Health Stroke Scale (NIHSS) is administered routinely in the emergency department. OBJECTIVE: To evaluate the utility of the NIHSS as a predictor of clinically relevant poststroke dysphagia compared with FIM data in the same cohort. DESIGN: Retrospective analysis. SETTING: Academic medical center. PATIENTS: Individuals with acute stroke who were admitted for acute care and later transferred to acute rehabilitation within the same institution. METHODS: Clinically relevant dysphagia was defined as aspiration on modified barium swallow or laryngeal penetration on modified barium swallow requiring diet change, or aspiration pneumonia. NIHSS and FIM scores were compiled for all patients. MAIN OUTCOME MEASUREMENTS: Sensitivity, specificity, positive predictive value, and negative predictive value were calculated for NIHSS and FIM. Sensitivity and specificity of different values of NIHSS and FIM were analyzed via receiver operator characteristic curves. RESULTS: Of 290 patients admitted to acute stroke rehabilitation, 88 (30%) manifested clinically relevant dysphagia during their rehabilitation stay. Sensitivity analyses suggested cut-off values for the NIHSS and the FIM of >9 and <55, respectively. Sensitivity, specificity, positive predictive value, and negative predictive value for the NIHSS were 75%, 62%, 46%, and 85%, respectively. For the FIM, these parameters were 80%, 72%, 55%, and 92%, respectively. CONCLUSIONS: The NIHSS >9 and FIM <55 are moderately predictive of clinically relevant dysphagia. Although the NIHSS clinical test characteristics are not as favorable as the FIM, NIHSS appears to be more sensitive than some other reported methods such as a 3-sip water test. Further study into development of paradigms that incorporate NIHSS into initial assessment of dysphagia risk may be appropriate.

Supportive care after curative treatment for breast cancer (survivorship care): resource allocations in low- and middle-income countries. A Breast Health Global Initiative 2013 consensus statement.

Breast cancer survivors may experience long-term treatment complications, must live with the risk of cancer recurrence, and often experience psychosocial complications that require supportive care services. In low- and middle-income settings, supportive care services are frequently limited, and program development for survivorship care and long-term follow-up has not been well addressed. As part of the 5th Breast Health Global Initiative (BHGI) Global Summit, an expert panel identified nine key resources recommended for appropriate survivorship care, and developed resource-stratified recommendations to illustrate how health systems can provide supportive care services for breast cancer survivors after curative treatment, using available resources. Key recommendations include health professional education that focuses on the management of physical and psychosocial long-term treatment complications. Patient education can help survivors transition from a provider-intense cancer treatment program to a post-treatment provider partnership and self-management program, and should include: education on recognizing disease recurrence or metastases; management of treatment-related sequelae, and psychosocial complications; and the importance of maintaining a healthy lifestyle. Increasing community awareness of survivorship issues was also identified as an important part of supportive care programs. Other recommendations include screening and management of psychosocial distress; management of long-term treatment-related complications including lymphedema, fatigue, insomnia, pain, and women's health issues; and monitoring survivors for recurrences or development of second primary malignancies. Where possible, breast cancer survivors should implement healthy lifestyle modifications, including physical activity, and maintain a healthy weight. Health professionals should provide well-documented patient care records that can follow a patient as they transition from active treatment to follow-up care.

A Community-Based Exercise and Support Group Program in African-American Breast Cancer Survivors (ABCs).

African-American (AA) women have higher rates of breast cancer (BCa) mortality than Caucasian women, and a recent study using data from the Surveillance, Epidemiology and End Results (SEER) registry suggests that this disparity may be due, in part, to the poorer health status of AAs at diagnosis and not treatment related issues. Randomized controlled trials involving supervised aerobic and resistance exercise have shown improved body composition and improvement in cancer-related biomarkers in BCa patients and may lead to improved recurrence and survival rates; however, most trials have focused on Caucasians and many have been conducted in academic- and clinic-based settings. We evaluated the feasibility of conducting a 20-week, supervised, resistance training, group exercise intervention coupled with a support group and home walking program utilizing facilities and personnel at a community cancer support center (The Gathering Place, Beachwood, Ohio) in AA Stage I-III BCa survivors who were within 12 months of completing treatment (surgery, chemotherapy, and/or breast irradiation); and, evaluated the potential effects of this intervention on physical measures and cancer-related biomarkers. 27 patients provided informed consent and 19 participated in the program. On average, attendance rates were 70.0% ± 19.1% for the exercise sessions and 63.1% ± 13.8% for the support group. We observed a significant decrease in circulating C-peptide levels (B: 893.9 ± 399.1 pg/mL; EOI: 723.9 ± 319.0 pg/mL; p=0.01). Although we did not observe a significant decrease in weight in the entire sample, there was a significant decrease in waist circumference and percent total body fat among those who attended 70% or more of the exercise sessions. In summary, we demonstrated that conducting lifestyle interventions in AA BCa survivors in a community setting is feasible. Future interventions should invoke strategies to enhance adherence and include a structured dietary intervention to enable greater weight loss.

Simplifying the 360-degree peer evaluation in a physical medicine and rehabilitation residency program.

OBJECTIVE: A previous study determined that multiple questions on a 360-degree evaluation instrument were highly correlated, suggesting possible redundancy in what was being measured, and that some questions may be eliminated. The current study uses factor analysis and examines a larger data set to further explore this question. DESIGN: To evaluate the structure of the questionnaire, a factor analysis was performed on 3 yrs of data from a 19-item resident 360-degree evaluation. The number of factors was determined by examining the scree plot of eigenvalues for each item in the instrument, with a cutoff where the slope changes from rapid to slow decline. A reliability analysis was performed with the indicated number of factors, with deletion of each variable to evaluate its influence on overall reliability (Cronbach alpha). RESULTS: There were 299 evaluations with complete responses to all 19 questions. The scree plot supported a single factor model. The reliability of the full, single factor survey was excellent (Cronbach α = 0.99). The three items with the highest loading on the factor were retained, which related to humanistic, moral/ethical, and professional responsibility behaviors. The reliability for these final three items remained excellent (Cronbach α = 0.96). CONCLUSIONS: The factor analysis suggests that one overall opinion of the evaluated resident was informing the responses of the evaluator. Shortening the instrument to the three items responsible for the greatest influence on the survey does not result in a large decrease in reliability as measured by Cronbach alpha. It is possible that time limitations prevent residents from putting thought into the evaluation of their peers, which results in unidimensional responses. Shortening the instrument may improve evaluations and should be studied in the future.