Mary M. Vargo

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 womens 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.

Brain tumor rehabilitation.

Brain and other central nervous system tumors have a very high likelihood of producing long-term disabling effects owing to the tumor itself and the effects of treatment, including surgical complications, neurotoxic effects of radiation, and debility caused by chemotherapy. Even benign or low-grade brain tumors can cause significant disability. Brain tumors occur over the life span, showing progressively higher incidence with advancing age. The common types of primary brain tumor differ between pediatric and adult age groups. Evidence for effectiveness of rehabilitation is favorable. Brain tumor patients treated in acute rehabilitation settings improve comparably with individuals with stroke or traumatic brain injury. Although patients with primary brain tumors have been better studied than those with metastatic disease, significant gains with inpatient rehabilitation have been reported in the latter group also. Outpatient programs to address cognitive deficits in brain tumor survivors, including cognitive therapy and pharmacologic strategies, have found benefit. While the patient is receiving rehabilitation care, physiatrists, in interdisciplinary collaboration with the pertinent oncology-related services, assist with managing symptoms including fatigue, headache, and sleep disturbance and medical complications including depression, seizures, and thromboembolic disease. Better methods are needed to identify patients for rehabilitation services when appropriate over the course of the disease process.

Inpatient Cancer Rehabilitation: A Retrospective Comparison of Transfer Back to Acute Care Between Patients With Neoplasm and Other Rehabilitation Patients

OBJECTIVE To determine whether patients with diagnoses of neoplasm undergoing acute rehabilitation differ from other patients in frequency of acute care transfer and type of medical complications. DESIGN Retrospective cohort analysis. SETTING Acute rehabilitation hospital located within an academic medical center. PARTICIPANTS Patients with diagnosis of neoplasm (n=40) and patients without neoplasm (n=253) requiring transfer were identified from a database of 2801 rehabilitation discharges over nearly a 4-year period. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Frequency of unplanned transfer and reasons for the transfer. RESULTS Significant difference occurred in overall rate of transfer between patients with neoplasm (21%) and controls (9.7%; P<.001). When evaluated separately for type of neoplasm (with patients receiving corresponding type of rehabilitation as controls), a significantly higher rate of transfer to acute care was found for brain tumor (25% vs 12%; P=.004) and spinal cord neoplasms (23% vs 10%; P=.009), but statistical significance was not reached for other tumor types (12.5% vs 7.4%; P=.19). Patients with stroke with neoplasm as a comorbidity, analyzed separately, with the other patients with stroke as controls, had significantly higher risk of transfer (22% vs 10%; P=.012). Logistic regression analysis found an odds ratio (OR) of 2.5 for unplanned transfer among patients with diagnosis of neoplasm (OR=2.5 for malignancy; OR=2.4 for benign neoplasm). Patients with neoplasm had infection as the most common reason for transfer (28% of the neoplasm transfers vs 18% of other transfers; P=.01), whereas in the nonneoplasm group, cardiopulmonary factors predominated (12% of patients with tumor vs 31% of patients without tumor transfers; P<.001). CONCLUSIONS In the present sample, patients with neoplasm were more likely to require transfer than patients without neoplasm, although this pattern did not reach statistical significance for noncentral nervous system cases. Overall, patients with neoplasm appear more likely than those without neoplasm to have an infectious cause for unplanned transfer. Increased awareness of this difference may lead to improved medical management on rehabilitation units.

A prospective study of peripheral nerve lesions occurring in traumatic brain-injured patients.

The purpose of this study was to determine the frequency and severity of peripheral nerve lesions occurring in patients with traumatic brain injury. A prospective study of 132 patients was conducted. Patients fulfilling research criteria (flaccidity, areflexia, abnormal motor patterns) underwent neurodiagnostic examination. Fifteen electromyograph/NCV studies were performed, yielding positive findings in 13 patients (10%); 3 patients were found to have preventable lesions. Many patients had permanent impairment or attendant complications from the peripheral nerve injury that adversely affected eventual recovery.

CONTRALATERAL V IPSILATERAL CANE USE: Effects on Muscles Crossing the Knee Joint

Although using a cane contralaterally has been shown to reduce muscular activity across the hip joint, little is known about effects on the knee. We measured muscular activity around the knee in 10 able-bodied subjects. We simultaneously recorded integrated rectified surface electromyographic activity from the right quadriceps, medial and lateral hamstrings, gastrocnemius and hip abductors during various standing maneuvers: two-legged stance, unsupported one-legged stance and one-legged stance putting maximal, moderate (20% body weight) or minimal (10% body weight) force through an ipsilateral or contralateral cane. Electromyographic activity was expressed as the percentage of that recorded during unsupported one-legged stance in each muscle. Hip abductor activity was lowest when maximal weight was placed through a contralateral cane (66%) and highest with maximal weight ipsilaterally (424%). Medial hamstrings activity increased by 404% and 200%, respectively, when maximal and moderate force was applied to a contralateral cane, although there was no change with ipsilateral cane. Lateral hamstrings were also most active during contralateral cane use. Quadriceps activity decreased using a cane in either hand with moderate or minimal force (range 57 to 84%). Gastrocnemius activity decreased during contralateral (60 to 66%) and ipsilateral (75 to 96%) cane use. This data suggests that forces generated by muscular activity around the knee are not uniformly diminished by holding a cane in the contralateral hand and may even be increased.

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

To assess the frequency and spectrum of referrals to rehabilitation disciplines in a concussion clinic population and factors associated with need for referral.

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

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.

Simplifying the 360-Degree Peer Evaluation in a Physical Medicine and Rehabilitation Residency Program:

ObjectiveA 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. DesignTo 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). ResultsThere 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 &agr; = 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 &agr; = 0.96). ConclusionsThe 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.

Does a 3-Sip Test Detect Dysphagia in Acute Stroke Rehabilitation Patients?

(1) Evaluate sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a 3‐sip test within 24 hours of acute stroke as a screening for clinically relevant dysphagia during acute rehabilitation. (2) For those patients who pass the 3‐sip test, identify factors predictive of later detection of clinically relevant dysphagia.

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.