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Joaquim A, Vieira C, Ribeiro L, Barros A, Leão I, Alvim C, Pinheiro S, Nogueira M, Morais C. Head and neck cancer patient journey's health literacy: a multidisciplinary team perspective. VOICE study. Support Care Cancer 2024; 32:133. [PMID: 38280025 PMCID: PMC10821956 DOI: 10.1007/s00520-023-08256-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 12/12/2023] [Indexed: 01/29/2024]
Abstract
PURPOSE Health literacy is a current Public Health priority in Portugal. The participation of well-informed patients in their care and shared decision making are essential, especially in chronic aggressive and debilitating pathologies such as recurrent or metastatic (R/M) Head and Neck Squamous Cell Carcinoma (HNSCC). AIMS This study aimed to characterize R/M HNSCC patients' and caregivers' information needs identified by healthcare professionals (HCPs). METHODS Two online Focus Groups, one with only medical doctors and the other with other HCPs involved in the treatment of R/M HNSCC patients, were conducted, using a modified Metaplan, Lean or adapted PDCA methodology. The discussions were audio recorded in full and content analysis was performed using ATLAS.ti qualitative data analysis software. RESULTS Topics addressed were diagnosis, treatment, quality of life, and global evaluation. In general, all experts agreed that only essential information should be cautiously given, according to patients' and caregivers' wishes. It was consensual that patients are given the necessary information to adhere to treatment. Two main barriers were identified: one barrier was associated with verbal communication due to the lack of health literacy of these patients, and the other barrier regarded healthcare access. It was also considered important to remind patients of the daily and social activities that they could and should maintain, as well as providing sufficient social resources and problem-solving training to caregivers. CONCLUSIONS This qualitative study highlights the complexity of R/M HNSCC patients' care. Immediate availability of psychologists and psychiatrists should be implemented in all centers that treat HNSCC patients. The differences found between the physicians' Focus Group and other HCPs' Focus Group in some of the addressed topics emphasize the importance of a multidisciplinary and holistic approach, in a biomedical model integrated with a biopsychosocial model.
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Affiliation(s)
- Ana Joaquim
- Centro Hospitalar Vila Nova de Gaia E Espinho, Vila Nova de Gaia, Portugal
| | | | - Leonor Ribeiro
- Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Anabela Barros
- Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Inês Leão
- Centro Hospitalar Vila Nova de Gaia E Espinho, Vila Nova de Gaia, Portugal
| | - Cecília Alvim
- Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Sara Pinheiro
- Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Mafalda Nogueira
- MSD Portugal, R. da Qt. da Fonte 19, 2770-192, Paço de Arcos, Portugal
| | - Catarina Morais
- MSD Portugal, R. da Qt. da Fonte 19, 2770-192, Paço de Arcos, Portugal.
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Checklin M, O'Halloran R, Foster AM, Hutchison A, Wilson T, Bowen A, Vat L, Lawson N, Lenne P, Packer RL. The health care experiences of people with head and neck cancer: A scoping review. Head Neck 2024; 46:74-85. [PMID: 37882242 DOI: 10.1002/hed.27558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 09/12/2023] [Accepted: 10/16/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Understanding health care experience in head and neck cancer (HNC) is becoming increasingly important due to changes in the disease profile, survivorship, and a greater appreciation of patient health care experience as an important outcome measure. People with HNC encounter many different types of health care professionals and health care touchpoints. METHOD Through systematic database searching, this scoping review of qualitative English-language studies describes the self-reported care experiences of those with HNC across the health care continuum, and describes the current state of the literature. RESULTS Overall, the 95 studies identified were heterogeneous and investigated a broad range of topics. Trends across studies showed research centered on hospital-based care, conducted in developed countries, with more studies on feeding than other aspects of care. Generic qualitative research frameworks, with individual interviews, were the preferred method of data collection. CONCLUSION Despite identifying many studies, there are significant gaps in our understanding of the HNC patient experience.
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Affiliation(s)
- Martin Checklin
- Epworth Healthcare, Richmond, Victoria, Australia
- Discipline of Speech Pathology, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Robyn O'Halloran
- Discipline of Speech Pathology, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Abby M Foster
- Discipline of Speech Pathology, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
- Monash Health, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
- Centre for Research Excellence in Aphasia Recovery & Rehabilitation, Melbourne, Victoria, Australia
| | - Alana Hutchison
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | | | - Alanna Bowen
- Alanna Bowen Speech Pathology, Melbourne, Victoria, Australia
| | - Laura Vat
- Epworth Healthcare, Richmond, Victoria, Australia
| | | | | | - Rebecca L Packer
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
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3
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Baumgartner E, Giger R, Spichiger E. [Advanced nursing practice model for head and neck cancer: A practice development project]. Pflege 2023; 36:48-55. [PMID: 36255740 DOI: 10.1024/1012-5302/a000914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Advanced nursing practice model for head and neck cancer: A practice development project Abstract. Background: Head and neck cancer confronts patients and their families with big challenges due to complex treatments as well as changes in vital functions and appearance. They require multifaceted support and benefit from coordinated, interprofessional collaboration and advanced nursing practice. Problem/aim: In a tertiary head and neck cancer center, a coordinating contact person was missing for patients, families and the care team. Therefore, a project was launched to develop an advanced nursing practice program. Methods: Methods included an advanced nursing practice concept, approaches for practice development, and action research. The project consisted of four phases: Stakeholder analysis and literature review were followed by the definition of the advanced nursing practice program, which was then tested during a pilot phase, and evaluated using structural/process data and stakeholder interviews. Results: Evidence-based, continuous, person-centered care was improved across the care continuum for patients/families. The nurses' expertise was supported and the collaboration with internal/external clinicians was facilitated. Patients/families valued the continuity offered by the advanced practice nurse. Discussion: The methodological approaches supported a goal-oriented approach; especially participatory practice development helped to address employees' concerns. Limitations/transfer: To date, a sustainable program cannot yet be warranted. For similar projects, an approach with stakeholder analysis, multidisciplinary focus, and early evaluation planning is recommended.
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Affiliation(s)
- Eva Baumgartner
- Universitätsklinik für Hals-, Nasen- und Ohrenkrankheiten, Kopf- und Halschirurgie, Inselspital, Universitätsspital Bern, Schweiz.,Universitätsklinik für Schädel-, Kiefer-, und Gesichtschirurgie, Inselspital, Universitätsspital Bern, Schweiz
| | - Roland Giger
- Universitätsklinik für Hals-, Nasen- und Ohrenkrankheiten, Kopf- und Halschirurgie, Inselspital, Universitätsspital Bern, Schweiz
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4
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Millet N, Moss EL, Munir F, Rogers E, McDermott HJ. A qualitative exploration of physical and psychosocial well-being in the short and long term after treatments for cervical cancer. Eur J Cancer Care (Engl) 2022; 31:e13560. [PMID: 35166375 DOI: 10.1111/ecc.13560] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/29/2021] [Accepted: 01/26/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Cervical cancer is predominantly a cancer of younger women, and improvements in oncological outcomes have led to an increase in cervical cancer survivors living with the long-term effects of treatment. Understanding the recovery process after treatment is essential to increase awareness of the short- and long-term needs of survivors. The aim of this study was to qualitatively explore the recovery process and return to daily activity of cervical cancers survivors from a biopsychosocial perspective. METHODS Participants were 21 women treated for cervical cancer between the ages of 18 and 60 years, living in the United Kingdom. Interviews were undertaken face to face and via the telephone using a semi-structured interview schedule. RESULTS Data analysis revealed themes which represented participants' experience and perceptions of treatment as a paradox; emotional needs after treatment; and a journey of adversarial growth. A key finding from this analysis was the nuanced experiences between treatment modalities, with physical changes perceived to be more disruptive following radical treatments, whilst psychological repercussions were significant regardless of treatment type. CONCLUSION This study provides novel insight into the varied recovery experiences of those treated with surgery and/or chemoradiotherapy for cervical cancer, which can be used to improve the survivorship experience.
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Affiliation(s)
- Nessa Millet
- School of Sport, Exercise and Health Sciences, National Centre for Sport and Exercise Medicine, Loughborough University, Loughborough, UK
| | - Esther L Moss
- Leicester Cancer Research Centre, University of Leicester, Leicester, UK.,Department of Gynaecological Oncology, University Hospitals of Leicester, Leicester, UK
| | - Fehmidah Munir
- School of Sport, Exercise and Health Sciences, National Centre for Sport and Exercise Medicine, Loughborough University, Loughborough, UK
| | - Eva Rogers
- School of Sport, Exercise and Health Sciences, National Centre for Sport and Exercise Medicine, Loughborough University, Loughborough, UK
| | - Hilary J McDermott
- School of Sport, Exercise and Health Sciences, National Centre for Sport and Exercise Medicine, Loughborough University, Loughborough, UK
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Karampela M, Porat T, Mylonopoulou V, Isomursu M. Rehabilitation Needs of Head and Neck Cancer Patients and Stakeholders: Case Study. Front Oncol 2021; 11:670790. [PMID: 34631516 PMCID: PMC8499693 DOI: 10.3389/fonc.2021.670790] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 08/25/2021] [Indexed: 11/13/2022] Open
Abstract
Background The incidents of Head and Neck Cancer (HNC) are rising worldwide, suggesting that this type of cancer is becoming more common. The foreseen growth of incidents signifies that future rehabilitation services will have to meet the needs of a wider population. Objective The aim of this paper is to explore the needs of patients, caregivers and healthcare professionals during HNC rehabilitation. Methods This paper reports the empirical findings from a case study that was conducted in a cancer rehabilitation center in Copenhagen to elicit the needs of HNC cancer patients, informal caregivers and healthcare professionals. Results Four areas of needs during the rehabilitation process were identified: service delivery, emotional, social and physical needs. Service delivery needs and emotional needs have been identified as the most prevalent. Conclusions Stakeholders' needs during the rehabilitation process were found to be interrelated. All stakeholders faced service delivery challenges in the form of provision and distribution of information, including responsibilities allocation between municipalities, hospitals and rehabilitation services. Emotional and social needs have been reported by HNC patients and informal caregivers, underlining the importance of inclusion of all actors in the design of future healthcare interventions. Connected Health (CH) solutions could be valuable in provision and distribution of information.
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Affiliation(s)
- Maria Karampela
- Faculty of Information Technology and Electrical Engineering, University of Oulu, Oulu, Finland
| | - Talya Porat
- Faculty of Engineering, Dyson School of Design Engineering, Imperial College London, London, United Kingdom
| | - Vasiliki Mylonopoulou
- Department Of Applied Information Technology, Division of Human Computer Interaction, University of Gothenburg, Gothenburg, Sweden
| | - Minna Isomursu
- Faculty of Information Technology and Electrical Engineering, University of Oulu, Oulu, Finland
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MacDonald C, Theurer JA, Fung K, Yoo J, Doyle PC. Resilience: an essential element in head and neck cancer survivorship and quality of life. Support Care Cancer 2021; 29:3725-3733. [PMID: 33201311 DOI: 10.1007/s00520-020-05873-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 11/02/2020] [Indexed: 01/22/2023]
Abstract
PURPOSE Individuals with head and neck cancer (HNCa) face myriad biopsychosocial challenges. Even after treatment completion, these challenges may cause continued disablement and diminished quality of life (QoL). Resilience may serve to minimize the disabling impact of HNCa and, in turn, maximize QoL. The purpose of this study was to formally assess resilience in HNCa survivors and explore its relationship with QoL. METHODS A cross-sectional descriptive study was conducted. Forty HNCa survivors completed three validated, self-report questionnaires pertaining to the collection of resilience and QoL data. Descriptive and correlational analyses were performed. RESULTS Resilience was identified in HNCa survivors and a positive correlation was found between resilience and QoL. CONCLUSIONS Data suggest that resilience may buffer the influence of HNCa on QoL. Thus, screening for reduced levels of resilience may proactively facilitate identification of those who are most vulnerable to the psychosocial impact of HNCa. Interventions that foster resilience may ameliorate the challenges of HNCa and maximize QoL.
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Affiliation(s)
- Chelsea MacDonald
- Laboratory for Well-Being and Quality of Life in Oncology, Rehabilitation Sciences, Western University, Elborn College, Room 2200, 1201 Western Rd., London, N6G 1H1, Canada.
| | - Julie A Theurer
- School of Communication Sciences and Disorders, Western University, London, ON, Canada
- Department of Otolaryngology - Head and Neck Surgery, London Health Sciences Centre, Schulich School of Medicine & Dentistry, London, Canada
| | - Kevin Fung
- Department of Otolaryngology - Head and Neck Surgery, London Health Sciences Centre, Schulich School of Medicine & Dentistry, London, Canada
| | - John Yoo
- Department of Otolaryngology - Head and Neck Surgery, London Health Sciences Centre, Schulich School of Medicine & Dentistry, London, Canada
| | - Philip C Doyle
- Laboratory for Well-Being and Quality of Life in Oncology, Rehabilitation Sciences, Western University, Elborn College, Room 2200, 1201 Western Rd., London, N6G 1H1, Canada
- Department of Otolaryngology - Head and Neck Surgery, London Health Sciences Centre, Schulich School of Medicine & Dentistry, London, Canada
- Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
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Gild ML, Tsang VHM, Clifton-Bligh RJ, Robinson BG. Multikinase inhibitors in thyroid cancer: timing of targeted therapy. Nat Rev Endocrinol 2021; 17:225-234. [PMID: 33603220 DOI: 10.1038/s41574-020-00465-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2020] [Indexed: 02/06/2023]
Abstract
In the 9 years since the publication of our 2011 review of targeted treatment of thyroid cancer with multikinase inhibitors, much has changed in the landscape of this heterogeneous disease. New multikinase and selective inhibitor treatments for medullary thyroid cancer, radioiodine-refractory thyroid cancer and anaplastic thyroid cancer have completed trials and improved progression-free survival. Many physicians are concerned by dose-limiting adverse effects of these drugs and are wary to begin treatment in patients who are systemically well but have marked disease burden, which makes the timing of treatment initiation challenging. Published mechanistic data on tyrosine kinase inhibitors (TKIs) have helped guide our understanding of how to dose effectively with these drugs. A major goal in TKI therapy is to optimize inhibition of oncogenic kinase drivers while maintaining patient quality of life. Real-world data have now been published on how TKIs have fared outside the clinical trial environment. In this Review, we provide a summary of published data on the efficacy of TKIs in clinical practice, to provide clinicians with a more realistic view of how their patients will manage and respond to TKI therapy. Furthermore, we review the data on mechanisms of inhibition, outcomes and adverse effects of TKIs and provide an update on targeted treatment of thyroid cancer, focusing on optimizing the timing of treatment initiation.
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Affiliation(s)
- Matti L Gild
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, NSW, Australia.
- Cancer Genetics, Kolling Institute of Medical Research, Sydney, NSW, Australia.
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.
| | - Venessa H M Tsang
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, NSW, Australia
- Cancer Genetics, Kolling Institute of Medical Research, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Roderick J Clifton-Bligh
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, NSW, Australia
- Cancer Genetics, Kolling Institute of Medical Research, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Bruce G Robinson
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, NSW, Australia
- Cancer Genetics, Kolling Institute of Medical Research, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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8
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Steinau P, Walter S, Hübner J, Büntzel J. [Subjective significance of olfactory dysfunction after laryngectomy : Let's ask our patients]. HNO 2020; 69:878-885. [PMID: 33052423 DOI: 10.1007/s00106-020-00956-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Laryngectomy is usually associated with olfactory dysfunction. How do laryngectomees personally experience and feel about this change? MATERIALS AND METHODS In cooperation with the Bundesverband der Kehlkopfoperierten (German Association of Throat Cancer Patients) and together with laryngectomized patients, a new questionnaire was created and distributed via the regional offices according to the population sizes of the federal states (n = 293) for the first time in spring 2018. The questionnaire covers patient characteristics and daily life without a larynx, as well as the specific areas of smell and taste, albeit without differentiation between ortho- and retronasal olfaction. The items were designed to be answered using patient-friendly visual rating scales, multiple-choice answers, and free text. RESULTS Return rate was 198/293 (67.6%). Median age of all participants was 69 years (48-88). Overall life situation was rated by 99/198 (50%) participants as "good" or "very good." The primary subjective impairment for the patients was loss of voice (137/198, 69.1%) and loss of olfaction (113/198, 59.1%). Adaption to life without a larynx has been completed within a maximum of 3 years for 161/198 (81.3%) patients. Principally, 127/198 (64.1%) affirmed being able to smell and 176 of 198 (88.9%) being able to taste; however, only 29/198 (14.6%) rated their sense of smell and 109/198 (55.1%) their sense of taste as "good" or "very good." Most frequently detected smell sensations were perfume (141), smoke (126), and feces (99). Univariate analysis showed a significant (p < 0.05) correlation between adaptation time <1 year and current subjective smell and taste. CONCLUSION Subjective loss of smell and taste after laryngectomy is a daily problem for patients in Germany, which should be focused on promptly and included in early rehabilitation strategies.
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Affiliation(s)
- P Steinau
- Klinik für Innere Medizin II, Universitätsklinikum Jena, Jena, Deutschland
| | - S Walter
- Bundesverband der Kehlkopfoperierten e. V., Bonn, Deutschland
| | - J Hübner
- Klinik für Innere Medizin II, Universitätsklinikum Jena, Jena, Deutschland
| | - J Büntzel
- Klinik für HNO-Erkrankungen, Kopf-Hals-Chirurgie, Südharz-Klinikum Nordhausen, Dr.-Robert-Koch-Str. 39, 99734, Nordhausen, Deutschland.
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Patients' Perspectives on What Makes a Better Care Experience While Undergoing Treatment for Oropharyngeal Dysphagia Secondary to Head and Neck Cancer. Dysphagia 2019; 35:702-716. [PMID: 31748827 DOI: 10.1007/s00455-019-10077-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 11/07/2019] [Indexed: 10/25/2022]
Abstract
Patients' perceptions on what makes a better care experience for head and neck cancer (HNca) have not been widely sought. Patients' perceptions can play a crucial role in shaping quality care and client involvement. To investigate patients' perspectives on what makes a better care experience while undergoing rehabilitation for oropharyngeal dysphagia secondary to HNca. Qualitative data were collected in the form of semi-structured interviews from eight patients after they had undergone rehabilitation for HNca. The data were thematically analysed by two researchers independently. Six themes, plus subthemes, were identified. These themes were Supportive network is essential; Reassurance from staff professionalism; Access to service; Using own motivation and resilience; Receiving the right information and Ongoing shock and adjustment. Results are discussed in context of the literature and clinical implications and future research are recommended. Collation of patients' perspectives is valuable to increase insight into what makes a better rehabilitative journey for patients with HNca. Rehabilitation that is holistic, specialised and patient-specific is highly valued by patients with HNca.
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Rossa C, D'Silva NJ. Immune-relevant aspects of murine models of head and neck cancer. Oncogene 2019; 38:3973-3988. [PMID: 30696955 PMCID: PMC6533118 DOI: 10.1038/s41388-019-0686-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 11/26/2018] [Accepted: 12/05/2018] [Indexed: 12/19/2022]
Abstract
Head and neck cancers (HNCs) cause significant mortality and morbidity. There have been few advances in therapeutic management of HNC in the past 4 to 5 decades, which support the need for studies focusing on HNC biology. In recent years, increased recognition of the relevance of the host response in cancer progression has led to novel therapeutic strategies and putative biomarkers of tumor aggressiveness. However, tumor-immune interactions are highly complex and vary with cancer type. Pre-clinical, in vivo models represent an important and necessary step in understanding biological processes involved in development, progression and treatment of HNC. Rodents (mice, rats, hamsters) are the most frequently used animal models in HNC research. The relevance and utility of information generated by studies in murine models is unquestionable, but it is also limited in application to tumor-immune interactions. In this review, we present information regarding the immune-specific characteristics of the murine models most commonly used in HNC research, including immunocompromised and immunocompetent animals. The particular characteristics of xenograft, chemically induced, syngeneic, transgenic, and humanized models are discussed in order to provide context and insight for researchers interested in the in vivo study of tumor-immune interactions in HNC.
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Affiliation(s)
- Carlos Rossa
- Department of Diagnosis and Surgery, UNESP-State University of Sao Paulo, School of Dentistry at Araraquara, Araraquara - SP, Brazil. .,Department of Periodontics and Oral Medicine, School of Dentistry, Ann Arbor, MI, 48109, USA.
| | - Nisha J D'Silva
- Department of Periodontics and Oral Medicine, School of Dentistry, Ann Arbor, MI, 48109, USA. .,Department of Pathology, Medical School, University of Michigan, Ann Arbor, MI, 48109, USA.
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