Prospective phase II trial of preoperative hypofractionated proton therapy for extremity and truncal soft tissue sarcoma: the PRONTO study rationale and design.

BACKGROUND: Oncologic surgical resection is the standard of care for extremity and truncal soft tissue sarcoma (STS), often accompanied by the addition of pre- or postoperative radiation therapy (RT). Preoperative RT may decrease the risk of joint stiffness and fibrosis at the cost of higher rates of wound complications. Hypofractionated, preoperative RT has been shown to provide acceptable outcomes in prospective trials. Proton beam therapy (PBT) provides the means to decrease dose to surrounding organs at risk, such as the skin, bone, soft tissues, and adjacent joint(s), and has not yet been studied in patients with extremity and truncal sarcoma. METHODS: Our study titled "PROspective phase II trial of preoperative hypofractionated protoN therapy for extremity and Truncal soft tissue sarcOma (PRONTO)" is a non-randomized, prospective phase II trial evaluating the safety and efficacy of preoperative, hypofractionated PBT for patients with STS of the extremity and trunk planned for surgical resection. Adult patients with Eastern Cooperative Group Performance Status ≤ 2 with resectable extremity and truncal STS will be included, with the aim to accrue 40 patients. Treatment will consist of 30 Gy radiobiological equivalent of PBT in 5 fractions delivered every other day, followed by surgical resection 2-12 weeks later. The primary outcome is rate of major wound complications as defined according to the National Cancer Institute of Canada Sarcoma2 (NCIC-SR2) Multicenter Trial. Secondary objectives include rate of late grade ≥ 2 toxicity, local recurrence-free survival and distant metastasis-free survival at 1- and 2-years, functional outcomes, quality of life, and pathologic response. DISCUSSION: PRONTO represents the first trial evaluating the use of hypofractionated PBT for STS. We aim to prove the safety and efficacy of this approach and to compare our results to historical outcomes established by previous trials. Given the low number of proton centers and limited availability, the short course of PBT may provide the opportunity to treat patients who would otherwise be limited when treating with daily RT over several weeks. We hope that this trial will lead to increased referral patterns, offer benefits towards patient convenience and clinic workflow efficiency, and provide evidence supporting the use of PBT in this setting. TRIAL REGISTRATION: NCT05917301 (registered 23/6/2023).

Pragmatic Approaches to Scalable Prehabilitation.

Patients with cancer should ideally undergo proactive screening for muscle wasting, dietary deficiencies, functional changes, and/or psychological needs. Alternatively, a cross-referral strategy may be useful. A multimodal prehabilitation approach can address impairments and optimize function before treatment. Urological prehabilitation has led to improvements in lean body mass, bone density, erectile function, and urinary continence.

Fractured Knowledge: Making Sense of Exercise in Patients With Bone Metastases.

PURPOSE: Traditional dogma suggests that individuals with cancer-related bone metastases should restrict their physical activity, potentially engaging cautiously in isometric exercises. However, occurrences of adverse skeletal events during supervised exercise in patients with known metastatic bone lesions are exceedingly rare, contrasting with the substantial risks of inactivity. Recent studies advocate for well-designed exercise regimens for individuals with bone metastases, highlighting the potential benefits of enhanced mental well-being, fatigue mitigation, enhanced physical function, and an overall improved quality of life. As cancer rehabilitation physicians, it falls within our scope of practice to diagnose, assess, and manage risk while emphasizing the role of exercise and rehabilitation therapies, accompanied by necessary precautions, for individuals with metastatic cancer. This review aims to explore the safety and feasibility of exercise interventions for individuals affected by metastatic bone disease.

Palliative Care Education in US Physical Medicine and Rehabilitation Residency Programs: Current Practices, Perceived Needs, and Barriers.

Background: Physical medicine and rehabilitation (PM&R) clinicians commonly care for patients with serious illness/injury and would benefit from primary palliative care (PC) training. Objective: To assess current practices, attitudes, and barriers toward PC education among U.S. PM&R residencies. Design: This is a cross-sectional study utilizing an electronic 23-question survey. Setting/Subjects: Subjects were program leaders from U.S. PM&R residency programs. Results: Twenty-one programs responded (23% response). Only 14 (67%) offered PC education through lectures, elective rotations, or self-directed reading. Pain management, communication, and nonpain symptom management were identified as the most important PC domains for residents. Nineteen respondents (91%) felt residents would benefit from more PC education, but only five (24%) reported undergoing curricular change. Lack of faculty availability/expertise and teaching time were the most endorsed barriers. Conclusion: PC education is heterogeneous across PM&R programs despite its perceived value. PC and PM&R educators can collaborate to build faculty expertise and integrate PC principles into existing curricula.

Frequency and reasons for unplanned transfer to the primary acute care service of inpatient rehabilitation glioblastoma multiforme patients.

PURPOSE: To determine the percentage of and factors associated with unplanned transfer to the acute care service of glioblastoma multiforme acute rehabilitation inpatients. METHODS: Retrospective review of glioblastoma multiforme acute rehabilitation inpatients admitted 4/1/2016-3/31/2020 at a National Cancer Institute Comprehensive Cancer Center. RESULTS: One hundred thirty-nine consecutive admissions of unique glioblastoma multiforme acute rehabilitation inpatients were analyzed. Fifteen patients (10.7%, 95% confidence interval 6.5-17.1%) were transferred to the acute care service for unplanned reasons. The most common reasons for transfer back were neurosurgical complication 6/15(40%), neurologic decline due to mass effect 4/15(26.7%), and pulmonary embolism 2/15(13.3%). Older age (p = 0.010), infection prior to acute inpatient rehabilitation transfer (p = 0.020), and lower activity measure of post-acute care 6-click basic mobility scores (p = 0.048) were significantly associated with transfer to the acute care service. Patients who transferred to the acute care service had significantly lower overall survival than patients who did not transfer off (log-rank test p = 0.001). CONCLUSION: Acute inpatient physiatrists should closely monitor patients for neurosurgical and neurologic complications. The variables significantly associated with transfer to the acute care service may help identify patients at increased risk for medical complications who may require closer observation.

Navigating barriers to antiracist supervision within the veterans affairs health care system: Reflections on 2020 and a call to action.

In 2020, the COVID-19 pandemic, the murder of George Floyd as well as other Black Americans, waves of violence against Asian American communities, and the 2020 presidential election created a national climate in the United States that almost defies description with regard to historical significance, collective emotional pain, and the urgency of the resulting calls for justice-focused action. This article explores the experience of three White psychologists/psychologists-in-training within this national context, and specifically, the impact on psychology training and supervision in the wake of the Executive Order on Combatting Race and Sex Stereotyping released in September 2020. Consistent with the extant literature in our field, we understand supervision to be an essential space for in-depth attention to trainee development around cultural humility and critical consciousness wherein we as supervisors also grow and deepen our own practice (Falender et al., 2013; Hook et al., 2016). As we navigated 2020, we found several key supervision processes particularly salient, including antiracism in supervision as mindful practice, facilitating learning while doing our own learning, supervisor consultation, and recognizing the impact of privilege on these processes. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Rehabilitation of Individuals With Cancer.

The survival rate of cancer is increasing as treatment improves. As patients with cancer now live longer, impairments may arise that impact quality of life (QOL) and function. Therefore, a focus on QOL is often as important as survival. An interdisciplinary team can achieve goal-oriented and patient-centered rehabilitation, which can optimize function and QOL, and minimize impairments, restrictions, and activity limitations. In most cases, cancer patients must be active participants in therapy and exhibit carryover. Patients with cancer often have impairments that include fatigue, pain, brain fog, impaired cognition, paresis, mood disorders, difficulty with activities of daily living (ADL), bowel/bladder/sexual dysfunction, and bone and soft tissue involvement. Adaptive equipment, exercise, and ADL training can mitigate restrictions on activity. The trajectory and phase of the disease along the continuum of cancer care may influence the goals of rehabilitation in that time window. QOL is often influenced by participation in vocational, recreational, and home-based activities. A holistic perspective should include an analysis of distress, socioeconomic barriers, and transportation limitations when addressing issues.

Translating 2019 ACSM Cancer Exercise Recommendations for a Physiatric Practice: Derived Recommendations from an International Expert Panel.

In 2018, the American College of Sports Medicine (ACSM) reconvened an international, multi-disciplinary group of professionals to review pertinent published literature on exercise for people with cancer. The 2018 roundtable resulted in the publication of three articles in 2019. The three articles serve as an important update to the original ACSM Roundtable on Cancer, which convened in 2010. Although the focus of the three 2019 articles is on exercise, which is only one part of comprehensive cancer rehabilitation, the evidence presented in the 2019 ACSM articles has direct implications for physiatrists and other rehabilitation professionals who care for people with cancer. As such, the narrative review presented here has two primary objectives. First, we summarize the evidence within the three ACSM articles and interpret it within a familiar rehabilitation framework, namely the Dietz model of Cancer Rehabilitation, in order to facilitate implementation broadly within rehabilitation practice. Second, via expert consensus, we have tabulated relevant exercise recommendations for specific cancer populations at different points in the cancer care continuum and translated them into text, tables, and figures for ease of reference. Notably, the authors of this article are members of the Cancer Rehabilitation Physician Consortium (CRPC), a group of physicians who subspecialize in cancer rehabilitation medicine (CRM).

Motives for Smoking in Those With PTSD, Depression, and No Psychiatric Disorder.

Objective: Approaches for effectively treating smoking in those with posttraumatic stress disorder (PTSD) and with major depressive disorder (MDD) could be improved by identifying motivational processes underlying their tobacco dependence. The goal of this study was to identify the motivational processes influencing smoking dependence among smokers with PTSD and with MDD relative to non-diagnosed controls. Methods: Participants were United States (US) veterans who smoked daily (N = 162) and met DSM-IV criteria for either PTSD (n = 52), MDD (n = 52), or no current psychiatric disorder (controls; n = 58). Smoking dependence motives were assessed via the Brief Wisconsin Inventory for Smoking Dependence Motives (Brief WISDM). The 11 Brief WISDM subscales are categorized into two major factors: Primary Dependence Motives and Secondary Dependence Motives. Results: Smokers with PTSD scored higher than non-diagnosed controls on the following Primary Dependence Motives subscales: Automaticity, Craving, and Tolerance (all p-values <.05). Smokers with PTSD, relative to controls, also scored higher on the overall Secondary Dependence Motives subscale, and on five of the seven Secondary Dependence Motives subscales: Cue Exposure/Associative Processes, Affective Enhancement, Affiliative Attachment, Cognitive Enhancement, and Weight Control (all p-values < .05). Smokers with MDD scored significantly higher than controls on one Primary Dependence Motives subscale: Craving and on four of seven Secondary Dependence Motives subscales: Affective Enhancement, Affiliative Attachment, Cognitive Enhancement, and Weight Control (all p-values <.05). Finally, exploratory analyses directly contrasting the PTSD group with the MDD group showed that smokers with PTSD were higher than those with MDD in the overall Secondary Dependence Motives subscale and one of the seven Secondary Dependence Motives subscales: Cue Exposure/Associative Processes (all p-values < .05). Conclusions: Results suggest that both Primary Dependence Motives and Secondary Dependence Motives play a meaningful role in motivation to use tobacco in smokers with PTSD; smoking dependence in those with MDD may be primarily influenced by Secondary Dependence Motives.

Effects of motivation phase intervention components on quit attempts in smokers unwilling to quit: A factorial experiment.

BACKGROUND: Smoking reduction treatment is a promising approach to increase abstinence amongst smokers initially unwilling to quit. However, little is known about which reduction treatment elements increase quit attempts and the uptake of cessation treatment amongst such smokers. METHODS: This study is a secondary analysis of a 4-factor randomized factorial experiment conducted amongst primary care patients (N = 517) presenting for regular healthcare visits in Southern Wisconsin who were unwilling to quit smoking but willing to cut down. We evaluated the main and interactive effects of Motivation-phase intervention components on whether participants: 1) made a quit attempt (intentional abstinence ≥24 h) by 6- and 26-weeks post-study enrollment and, 2) used cessation treatment. We also evaluated the relations of quit attempts with abstinence. The four intervention components evaluated were: 1) Nicotine Patch vs. None; 2) Nicotine Gum vs. None; 3) Motivational Interviewing (MI) vs. None; and 4) Behavioral Reduction Counseling (BR) vs. None. Intervention components were administered over 6 weeks, with an option to repeat treatment; participants could request cessation treatment at any point. RESULTS: Nicotine gum significantly increased the likelihood of making a quit attempt by 6 weeks (23% vs. 15% without gum; p < .05). Conversely, nicotine patch reduced quit attempts when used with BR. Patch also discouraged use of cessation treatment (15.8% vs. 23% without patch; p < .05). Aided vs. unaided quit attempts produced abstinence in 42% vs. 10% of participants, respectively. CONCLUSION: Nicotine gum is a promising Motivation-phase intervention that may spur quit attempts amongst smokers initially unwilling to quit.

Attachment Anxiety as a Risk Factor for Subsequent Intimate Partner Violence Victimization: A 6-Month Prospective Study Among College Women.

Recent research suggests that individuals with attachment difficulties are at increased risk for experiencing intimate partner violence (IPV) victimization. However, most studies conducted on this topic have been cross-sectional, leaving it unclear whether attachment difficulties actually precede this type of violence. The current 6-month prospective study examined the relation between adult attachment and subsequent IPV victimization in a sample of 133 college women. At Time 1, participants completed the Experiences in Close Relationships (ECR) questionnaire to assess the two underlying orthogonal dimensions of adult attachment (anxiety and avoidance) and the Traumatic Life Events Questionnaire (TLEQ) to assess prior exposure to interpersonal traumatic events. At follow-up, participants completed a modified version of the Revised Conflict Tactics Scale (CTS-2) to assess IPV victimization. Results indicated that attachment anxiety was associated with an increased risk for experiencing physical assault during the 6-month follow-up period, even after statistically adjusting for prior interpersonal trauma. In contrast, attachment avoidance was unrelated to subsequent IPV victimization.

Distribution and Pathogenic Characterization of Pyrenophora tritici-repentis and Stagonospora nodorum in Ohio.

ABSTRACT To determine the distribution of Stagonospora nodorum and Pyrenophora tritici-repentis on wheat in Ohio, flag leaves with lesions were collected from wheat-producing counties in 2002 and 2003. Counties were arbitrarily grouped into seven regions. Log-linear analysis of pathogen presence within regions indicated that the presence of S. nodorum was independent of the presence of P. tritici-repentis. A logistic analysis revealed that the occurrence of both pathogens varied by region in one or both years. The aggressiveness of S. nodorum isolates was determined by inoculating two susceptible genotypes with a subsample of isolates from each region from both years. S. nodorum isolates obtained from northeast Ohio, with fewer wheat fields, were less aggressive than those from other regions. Isolates obtained from west-central Ohio, surrounded by regions with high wheat production annually, were significantly more aggressive than those obtained in the remaining five regions. Isolates from the five other regions did not differ significantly (P > 0.05) in aggressiveness. Races 1 and 2, and a few race 3 isolates, of P. tritici-repentis were detected in Ohio. The distribution of P. tritici-repentis races 1 and 2 was not associated with any region, although the prevalence of race 1 was three times greater than race 2. The rarer race 3 was associated with three dispersed regions. Results indicate that S. nodorum was the major wheat leaf-blotching pathogen. There were no positive or negative associations of S. nodorum and P. tritici-repentis or individual races of P. tritici-repentis in any of the tested regions, which indicates that neither pathogen can be used to predict the presence of the other. The isolated northeastern corner of Ohio appeared to contain isolates of S. nodorum with unique characteristics and potentially only one race of P. tritici-repentis, indicating that this area may be genetically isolated from the remaining tested areas of the state.

Reaction of Commercial Soft Red Winter Wheat Cultivars to Stagonospora nodorum in the Greenhouse and Field.

Thirteen cultivars were evaluated in the greenhouse and field for reaction to Stagonospora nodorum leaf and glume blotch. Coker 9663 exhibited consistent resistance across both greenhouse and field tests. In field plots, all cultivars tested had relatively high percentages of S. nodorum in harvested seed. Strong correlations between reactions from greenhouse and inoculated plots indicated that resistant and susceptible genotypes could be identified using either procedure. The amount of S. nodorum resistance expressed depended on the host organ assessed, but Coker 9663, and OH708 in inoculated field plots, had both leaf and glume blotch resistance. Cultivars reacted similarly in inoculated and naturally infested plots based on mean leaf or glume blotch severity, whereas severity was inconsistent between the greenhouse and naturally infested plots. Results indicated that leaf and glume blotch resistance could be identified in naturally infested plots in epidemic years, but that cultivar reactions should be confirmed in inoculated plots or greenhouse tests due to possible interference from other leaf blotch pathogens.

Effects of Choline, Betaine, and Wheat Floral Extracts on Growth of Fusarium graminearum.

Fusarium head blight has been more severe when infection occurs during anthesis, indicating that floral organs may be important infection courts. Choline acetate and glycinebetaine have been extracted from wheat and reported to be growth stimulants of Fusarium graminearum. They are hypothesized to enhance infection and tissue colonization. Growth of F. graminearum was examined on media amended with extracts from floral parts of nine wheat genotypes with various Fusarium head blight resistance levels. Results indicated no significant effect of anther, palea, or lemma extracts on radial growth when compared with unamended controls. Effects on spore germination and hyphal growth of F. graminearum by choline, betaine, and an equimolar mixture at concentrations ranging from 0.01 to 1,000 µM also were examined. Spore germination was not significantly (P ≤ 0.05) affected by choline, betaine, or a combination of the compounds compared with unamended controls. Radial hyphal growth also was not consistently affected (P ≤ 0.05) by choline or betaine when compared with controls. Equimolar mixtures of the two compounds showed significant slight reduction in growth rate at higher concentrations when compared with controls. The reduction in growth rate was due to higher concentrations of betaine. Results of this study indicate that endogenous compounds in floral parts may not be associated with wheat resistance to F. graminearum.

Evaluation of Inoculation Methods to Determine Resistance Reactions of Wheat to Fusarium graminearum.

Reliable greenhouse assays are needed to differentiate types of resistance in wheat to Fusarium graminearum. Genotypes with known field reactions were evaluated for resistance type using four greenhouse inoculation techniques. Percentage of spikelets with symptoms per spike (severity) and percentage of inoculated spikelets per spike developing symptoms were assessed 7, 10, and 14 days after inoculation (DAI). Genotypes were evaluated using disease assessments 14 DAI and area under the disease progress curve (AUDPC). Significant genotype-inoculation technique interactions for disease assessments indicated that genotypes responded differently to greenhouse inoculation techniques. The central floret injection technique used to assess resistance to spread within the spike (type II resistance) did not indicate a resistant response in genotypes with low field disease severity (putative type II). Atomizing macroconidia onto spikes, used to assess resistance to primary infection (type I resistance), indicated a resistant response in one of five genotypes with low field disease incidence (percentage of spikes with symptomatic spikelets) (putative type I). The inoculation techniques in the greenhouse were unable to differentiate between different types of partial resistance. Results indicated disparity in the ability of greenhouse inoculation methods to identify genotypes with partial resistance as observed in the field. It was concluded that atomizing conidia onto the spikes and assessing disease severity did not differentiate between resistance types. Additionally, a one-time assessment 14 DAI was determined to be as informative as multiple assessments and calculating the AUDPC.