Management and survival of patients with leptomeningeal disease from breast cancer: a case series

Leptomeningeal disease (LMD) in breast cancer is a rare complication and often portends a poor prognosis. There is a lack of randomized data guiding treatment decisions and no accepted standard of care in the management of LMD. We retrospectively analyzed the treatment and outcomes of six patients diagnosed with LMD at our institution. All patients were treated with intrathecal methotrexate, resulting in a median overall survival after LMD diagnosis of 18.5 weeks, with two patients surviving over 30 weeks. An Ommaya reservoir was used to deliver chemotherapy and this was well tolerated with minimal toxicity. The use of intrathecal methotrexate is a safe option, however, further studies are required to define its role in the management of LMD and identify populations that may derive a benefit.

An evaluation of whether discharge plans meet patients' requirements: A survey

Background:

The provision of discharge plans that meet the requirements of individual patients' needs is an essential component of rehabilitation. The purpose of this quality improvement activity was to survey patients to: investigate whether discharge plans met their requirements; identify factors that might predict the success of discharge planning; and investigate whether the perceptions of patients and a family member/carer regarding the success of discharge planning were in agreement.

Methods:

Forty patients discharged home from units within two rehabilitation hospitals were recruited. Patient surveys, undertaken via interviews, were conducted to determine participants' satisfaction with their discharge planning: one pre-discharge and the other 1–2 months' post-discharge.

Findings:

Overall, discharge plans were successfully developed and implemented. Most items that were listed on participants' discharge plans were provided, required, and met participants' requirements. The success of discharge planning did not appear to be influenced by factors including age, gender, length of stay, primary diagnosis, functional scores, or home address. Participants and a family member/carer had a high level of agreement regarding the success of discharge planning.

Conclusions:

The discharge plans of participants involved in this quality improvement activity accurately identified patients' needs, and the plans identified were provided and met the requirements of participants.

Utilization of mechanical diagnosis and therapy (MDT) for the treatment of lumbar pain in the presence of known lumbar transverse process fractures: a case study

BACKGROUND

Spinal fractures are typically considered a contraindication to mechanical diagnosis and therapy (MDT).

OBJECTIVE AND IMPORTANCE

The purpose of this case study is to illustrate how MDT was used safely and effectively to treat lumbar pain in a patient with multiple lumbar transverse process fractures.

CLINICAL PRESENTATION

The subject was a 24-year-old female with left L2-5 transverse process fractures, sustained 10 weeks prior in a pedestrian versus motor vehicle accident.

INTERVENTION AND TECHNIQUE

After collaboration with her physiatrist, an MDT examination revealed a presentation consistent with the lumbar derangement syndrome.

CONCLUSION

After three visits, utilizing patient generated forces with the extension principle of treatment, her pain, Oswestry disability index (ODI) score, and function all improved.

Management of aromatase inhibitor-associated musculoskeletal symptoms: A systematic review

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Background: Aromatase inhibitor-associated musculoskeletal symptoms (AIMSS) are experienced by a significant number of women on adjuvant aromatase inhibitors for breast cancer. These symptoms can result in therapy noncompliance and there is no accepted standardised treatment. We believe that this is the first systematic review to consider the evidence for all pharmacological and non-pharmacological interventions in the treatment of AIMSS. Methods: We conducted a systematic search in PubMed, EMBASE, CINAHL and CENTRAL. Clinical trials and observational studies for all potential pharmacological and non-pharmacological interventions were included. Two reviewers screened the results and extracted the relevant data. Risk of bias for the full papers were assessed using JADAD or a modified Newcastle Ottawa score, with conference abstracts and letters to the editor excluded from this process. Results: Of 1260 records being identified, 887 unique citations were screened with 93 full text papers retrieved for assessment, and 37 selected for inclusion. We identified 9 pharmacological interventions (RCT = 3, pre-post = 4, cohort = 2) and 28 non-pharmacological interventions (RCT/CCT = 16, pre-post = 8, cohort = 3). The largest number of studies were for various exercise interventions (n = 7) with the largest trial showing a 29% decrease in worst joint pain scores compared to the control (2%, p < 0.001). The highest number of RCTs was for acupuncture (n = 5), the majority of which showed a significant benefit with both real and sham acupuncture. Other single RCTs showing benefit include the use of testosterone, calcitonin and etoricoxib. No study adequately controlled for contamination bias from extraneous variables of both pharmacological and non-pharmacological interventions. Conclusions: Given that pharmacological treatment is often recommended for AIMSS, it is surprising that there is limited published evidence for its use. Although the interventions being used appear tolerable with minimal adverse effects, the current level of evidence is low, and additional large RCTs with more rigorous controlling for contamination from other interventions are required to confirm some of the reported promising results.

Evaluation of Toric Intraocular Lenses in Patients With Low Degrees of Astigmatism

PURPOSE

This study aimed to describe the efficacy of toric intraocular lenses (IOLs) in patients with low degrees of corneal astigmatism.

DESIGN

Retrospective case series was undertaken.

METHODS

Patients with low amounts of corneal astigmatism who were treated with either a toric monofocal lens (SN6AT2 Toric, n = 76) or a toric multifocal lens (SND1T2 +3.00, n = 44) were reviewed. Eyes were evaluated preoperatively and 3 months postoperatively. Refraction and visual outcomes were monitored.

RESULTS

Patients (69.7%) in the monofocal toric group obtained refractive cylinder less than 0.25 diopters (D) compared with 70.5% of the multifocal toric group. Both toric groups showed a statistically significant reduction in refractive cylinder after surgery (P = 0.001). Monofocal (66.7%) and multifocal (68.2%) toric patients achieved uncorrected distance visual acuity of 20/20 or better.

CONCLUSIONS

This represents the first article to investigate the use of low-power toric IOLs in patients with less than 1.25 D of corneal cylinder. Before the development of low-power toric IOLs, patients with low to moderate amounts of astigmatism required concurrent intraoperative adjustments or additional forms of treatment to benefit from cataract and IOL surgery. Evidence suggests that the toric T2 IOL now removes this barrier, providing consistent, accurate refractive and astigmatic results, and enables these patients to achieve excellent outcomes with a single treatment across IOL platforms. Larger studies will help to consolidate our results.

Framework of outcome measures recommended for use in the evaluation of childhood obesity treatment interventions: the CoOR framework

INTRODUCTION

Consensus is lacking in determining appropriate outcome measures for assessment of childhood obesity treatments. Inconsistency in the use and reporting of such measures impedes comparisons between treatments and limits consideration of effectiveness. This study aimed to produce a framework of recommended outcome measures: the Childhood obesity treatment evaluation Outcomes Review (CoOR) framework.

METHODS

A systematic review including two searches was conducted to identify (1) existing trial outcome measures and (2) manuscripts describing development/evaluation of outcome measures. Outcomes included anthropometry, diet, eating behaviours, physical activity, sedentary time/behaviour, fitness, physiology, environment, psychological well-being and health-related quality of life. Eligible measures were appraised by the internal team using a system developed from international guidelines, followed by appraisal from national external expert collaborators.

RESULTS

A total of 25,486 papers were identified through both searches. Eligible search 1 trial papers cited 417 additional papers linked to outcome measures, of which 56 were eligible. A further 297 outcome development/evaluation papers met eligibility criteria from search 2. Combined, these described 191 outcome measures. After internal and external appraisal, 52 measures across 10 outcomes were recommended for inclusion in the CoOR framework.

CONCLUSION

Application of the CoOR framework will ensure greater consistency in choosing robust outcome measures that are appropriate to population characteristics.

Demonstration of an 8-dimensional modulation format with reduced inter-channel nonlinearities in a polarization multiplexed coherent system

We demonstrate a polarization-managed 8-dimensional modulation format that is time domain coded to reduce inter-channel nonlinearity. Simulation results show a 2.3 dB improvement in maximum net system margin (NSM) relative to polarization multiplexed (PM)-BPSK, and a 1.0 dB improvement relative to time interleaved return-to-zero (RZ)-PM-BPSK, for five WDM channels propagating over 1600 km ELEAF with 90% inline optical dispersion compensation. In contrast to the other modulations considered, the new 8-dimensional format has negligible sensitivity to the polarization states of the neighboring WDM channels. High-density WDM (HD-WDM) measurements on a 5000 km dispersion-managed link show a 1.0 dB improvement in net system margin relative to PM-BPSK.

How do parents look after children's teeth? A qualitative study of attitudes to oral health in the early years

This study aimed to examine how parents and carers of pre-school children care for their children's teeth. Twelve in-depth interviews were conducted with mothers of pre-school children at a children's centre in Bristol. The interviewees were aged between 29 and 37 years, and the number of children in the families ranged from one to four, with their age range spanning four weeks to 11 years. Using a grounded theory approach, transcribed interviews were coded and analysed until several themes emerged from the data. The study identified an overarching theme of parents' belief that oral health care for their children was common sense, which was a key factor influencing advice seeking from professionals. Sub-themes were the difficulties in establishing home oral healthcare routines and a lack of knowledge of when to register their child with a dentist. Advice was often given inconsistently and parents experienced difficulties accessing services, with many not seeking advice and information pro-actively. The study concluded that some parents are missing out on important early information, advice and care around oral health for their young children.

Assessment of midperipheral anterior chamber depth in patient with posterior chamber phakic intraocular lens

We describe a patient who required surgical explantation of a phakic intraocular lens (pIOL) as a result of mechanical angle closure despite the absence of standard preoperative risk factors. An assessment of the patient's records suggested peripheral anterior chamber depth (ACD) values considerably shallower than the central ACD measurement. Subsequently, the midperipheral values of all patients having pIOL implantation at our practice were reviewed to provide potential baseline measurements for comparison against the values of the explanted pIOL eyes. Assessment of midperipheral anterior chamber anatomy may be advantageous in the evaluation of patients for pIOL surgery.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Impacts and perceptions of a computer-based length of stay benchmarking program

Aims

Length of stay (LOS) benchmark figures can be used to guide clinical practice in a rehabilitation setting. This prospective study trialled a computer-based program that provided real-time LOS benchmark figures and alerted staff of patients approaching or exceeding LOS benchmark figures, and assessed its ability to identify patients with LOS beyond benchmark figures, reasons for these delays and effect on LOS, and staff perceptions of its usefulness.

Methods

One-hundred-and-eight inpatients in a stroke rehabilitation unit (SRU) and 94 inpatients in a brain injury rehabilitation unit (BIRU) were included in the patient component of the study; 13 staff completed a post-trial survey.

Findings

LOS in excess of benchmark figures was found for 48 (44%) SRU and 44 (47%) BIRU participants, resulting in a total discharge delay of 6311 days. Reasons for discharge delay were diverse. Using the computer-based program did not consistently decrease LOS compared to data from the previous year. Staff perceptions regarding the usefulness of the computer-based program were mixed.

Conclusions

The use of a computer-based program that provided real-time LOS benchmark figures was able to identify patients with LOS beyond benchmark figures but did not consistently decrease LOS and, on the whole, was not favourably received by clinical staff.