Patient Navigation in Cancer Treatment: A Systematic Review

PURPOSE OF REVIEW

Patient navigation promotes access to timely treatment of chronic diseases by eliminating barriers to care. Patient navigation programs have been well-established in improving screening rates and diagnostic resolution. This systematic review aimed to characterize the multifaceted role of patient navigators within the realm of cancer treatment.

RECENT FINDINGS

A comprehensive electronic literature review of PubMed and Embase databases was conducted to identify relevant studies investigating the role of patient navigators in cancer treatment from August 1, 2009 to March 27, 2023. Fifty-nine articles were included in this review. Amongst studies focused on cancer treatment initiation, 70% found a significant improvement in treatment initiation amongst patients who were enrolled in patient navigation programs, 71% of studies focused on treatment adherence demonstrated significant improvements in treatment adherence, 87% of studies investigating patient satisfaction showed significant benefits, and 81% of studies reported a positive impact of patient navigators on quality care indicators. Three palliative care studies found beneficial effects of patient navigation. Thirty-seven studies investigated disadvantaged populations, with 76% of them concluded that patient navigators made a positive impact during treatment. This systematic review provides compelling evidence supporting the value of patient navigation programs in cancer treatment. The findings suggest that patient navigation plays a crucial role in improving access to care and optimizing treatment outcomes, especially for disadvantaged cancer patients. Incorporating patient navigation into standard oncology practice can reduce disparities and improve the overall quality of cancer care.

Navigating Financial Barriers to Papanicolaou Tests and Mammograms for Young Adult Women Residing in Rural and Border Areas of Texas

Purpose: Costs of Papanicolaou (Pap) tests and mammograms are a primary barrier for women aged 18-39 seeking screening and diagnostic services. Race/ethnicity and rural/border resident status compound their risks for delayed diagnosis, possibly resulting in higher mortality. Methods: We analyzed cross-sectional data from young adult (YA) women (aged 18-39) from a cancer education and patient navigation (PN) program in rural and border Texas from 2012 to 2016. Descriptive statistics, Chi-square tests, and logistic regressions summarized sociodemographic variables and receipt of PN, Pap tests, and mammograms. Results: The sample consisted of 1181 women aged 31.8 years (standard deviation 5.5) on average. A total of 795 (67.3%) received PN, 494 (41.8%) received a Pap test, and 121 (10.3%) received a mammogram. The YA women attending the program due to cost (odds ratio [OR]: 7.24; confidence interval [CI]: 4.74-11.05) and reporting 1 (OR: 3.84; CI: 2.40-6.14) or 2+ barriers (OR: 6.00; CI: 3.61-9.99) had higher odds of being navigated than those not concerned about cost and not identifying a barrier. The YA women attending due to cost (OR: 2.22, CI: 1.61-3.05) and receiving navigation (OR: 1.92; CI: 1.29-2.84) had higher odds of receiving a Pap test than their counterparts. The majority receiving a mammogram were worried about cost (85.1%); 40.5% had a family history of breast cancer, and a doctor or nurse recommended a mammogram for 15.7%. Conclusion: Detection of cervical and breast cancer in YA women residing in rural and border Texas may be improved with PN to assist with financial barriers to care and service coordination.

A comparison of survey incentive methods to recruit rural cancer survivors into cancer care delivery research studies

Unconditional (upfront) incentives are proposed to improve acceptance of cancer research among underrepresented, racial/ethnic minority populations, but few studies have tested incentive strategies among rural cancer survivors. Descriptive statistics summarized demographic characteristics of survey respondents, and response rates by arm were compared using Chi-square tests. We compared upfront ($2) and response-based ($10 conditional) incentives in a mailed survey of adult post-treatment rural survivors. Individuals meeting eligibility criteria from the electronic medical record (n = 2,830) were randomized into two incentive arms (n = 1,414 for the upfront arm and n = 1,416 for the contingent arm). Of the total delivered, presumed eligible participants (n = 1,304 upfront arm; n = 1,317 contingent arm), 67.8% were aged 65y+, 49.8% were female, and 95.1% were non-Hispanic white. The response rate for all participants was 18.5%. We received eligible surveys from 281 rural survivors in the first arm (response rate: 21.5%); and 205 surveys in the second arm (response rate: 15.6%). Participants who received the upfront incentive had a higher response rate than those receiving a response-based incentive, X2 (1, 2,621) = 15.53, p < 0.0001. Incentivizing survey completion with an upfront $2 bill encouraged a higher survey response rate; other supplemental strategies are needed to achieve a higher response rate for this population.

An Evaluation of Breast and Cervical Cancer Screening Outcomes in an Education and Patient Navigation Program in Rural and Border Texas

This study examines breast and cervical cancer screening uptake in a cancer education and patient navigation (PN) program for residents of rural and border counties in Texas by level of participation (education only, PN only, or education and PN). Data collected from March 1, 2012, to November 5, 2016, included 6663 follow-up surveys from participants aged 21-74. Logistic regression models assessed program participation on the odds of completing breast or cervical cancer screening. For women aged 40-74 years (N = 4942; mean age = 52 years), 58.4% reported a mammogram within 6 months on average from initial contact. In the breast cancer screening model, women who only received PN (OR: 6.06, CI: 4.87-7.53) or who participated in both the education plus PN program (OR: 3.33, CI: 2.77-4.02) had higher odds of mammogram screening compared to women who only received education. For women aged 21-64 years (N = 6169; mean age = 46 years), 37.7% received a Papanicolaou (Pap) test within 6 months on average from initial contact. In the Pap screening model, both education and PN (OR: 3.23, CI: 2.66-3.91) and PN only (OR: 2.35, CI: 1.88-2.93) groups had higher odds of screening for cervical cancer compared to those only receiving education. Graphed predicted probabilities examined significant interactions between race/ethnicity/language and program participation (P < 0.0001) for both screenings. PN, solely or in combination with education, is an effective strategy to increase screening for breast and cervical cancer, beyond educational outreach efforts alone, among un-/underserved, racially/ethnically diverse women in rural and border Texas counties.

County-Level Poverty and Barriers to Breast and Cervical Cancer Screening in a Health Education and Patient Navigation Program for Rural and Border Texas Residents

The study examined the impact of (1) county-level poverty rates and (2) patient navigation on breast and cervical cancer screening outcomes for women in rural and border counties in Texas reporting barriers to screening.Univariate analyses described the distribution and screening prevalence rates in the sample, while a series of random intercept logistic regression models analyzed mammogram (N = 2326 women aged 40+) and Papanicolaou (Pap; N = 2959 women aged 21-64) screening separately.Mammogram and Pap screening prevalence rates were highest among women who were aged 40-64, Spanish-speaking Latinas, lower educated, attending cancer education events because of the cost of the screenings, patient navigation recipients, living in the south region of Texas, and in counties with high poverty. Although models indicated significant variability in screening rates by county, county-level poverty was only significantly associated with odds of getting Pap screening in adjusted models. Not receiving patient navigation vs. receiving it was associated with lower odds for both mammogram (OR: 0.51, CI: 0.38-0.70) and Pap (OR: 0.69, CI: 0.50-0.94) screenings.County-level variation in screening rates exists for both mammogram and Pap tests and should be considered in the development and implementation of screening interventions in rural and border areas. However, other factors beyond poverty levels may explain the variation.

Assessing Health-Related Quality of Life Among Survivors of Testicular Cancer: A Systematic Review

This study aimed to determine if the current health-related quality of life (HRQoL) tools created for survivors of testicular cancer are collecting the highest quality of data via a two-step methodological critique of both the seminal studies that produced a survivor of testicular cancer HRQoL tool (Phase 1) and the actual tool itself (Phase 2). It is the goal of this current article to present and discuss Phase 1.

A systematic review aimed to assess the methodological quality of studies conducted to create instruments used to measure survivors of testicular cancer HRQoL. Five reviewers independently assessed each study with the 20-item Appraisal Tool for Cross-Sectional Studies (AXIS). Inter-rater agreement and Fleiss’ kappa was also assessed to ensure consistency in reported scores. Assessments for the EORTC QLQ-TC 26 and CAYA-T studies were low (AXIS 52.5%; IRA 95%; κ = 0.779) and fair (AXIS 65%; IRA 80%; κ = 0.599), respectively. Critical appraisal of the scales included issues within the three core AXIS domains. Primary concerns related to sampling methodology and the lack of a qualitative component of their core conceptual development phase.

Both reviewed seminal studies have significant methodological concerns that question the tools’ quality. Next steps include extensive appraisal of the psychometric properties of the EORTC QLQ TC-26 and the CAYA-T to complete the comprehensive review. Accurate and reliable data are necessary to understand survivor of testicular cancer HRQoL and assist in building the bridge of communication between health care professionals and survivors to help to improve patient outcomes.

Abstract PO-022: Exploring knowledge and perceptions of cancer care and clinical trials in the local Black community to develop culturally-tailored interventions

Introduction: In Forsyth County, North Carolina, 52% of Black residents live in three zip codes—27101, 27105, and 27107—that comprise East/South East Winston- Salem. Cancer incidence and mortality are significantly higher in Forsyth County when compared with the US average (11.2% and 30.7%, respectively). Given the harmful history of systemic anti-Black racism in the region, including forced segregation and eugenics, we sought to hear directly from stakeholders to better understand the knowledge, attitudes, beliefs, and experiences around cancer care and clinical trials (CTs) amongst Black residents in our catchment area. Methods: We collaborated with a Black-owned research group to implement a qualitative study using racially-concordant facilitators. Key informant interviews (n=14) were held with stakeholders, including health care providers (n=4), patients (n=24), caregivers (n=8), and patient advocates (n=13) in the local Black community; results informed the development of a focus group protocol. Four focus groups were conducted with black residents in Forsyth County including groups of cancer survivors and family members (n=46 participants total). Transcripts were coded using NVivo12 Plus and a code-based report was thematically generated and analyzed by community and academic stakeholders. Results: While many participants endorsed past participation in a CT, little knowledge about the structure and purpose of CTs was evident. None of the participants, including providers, could express that cancer patients enrolled in CTs would never only receive a placebo; cancer patients would always at least be given the standard of care (SOC), or when patients progress through SOC, would possibly be provided with a new therapeutic drug. Participants described cancer CTs as “riskier” because of the seriousness of the disease being treated. They also did not associate non-interventional trials focused on changing health behaviors or patient- reported outcomes with CTs. Barriers to CT participation included mistrust and fear of experimentation; facilitators of participation included personal benefit or benefit to others, monetary incentives, and personalized communication and treatment strategies. Conclusion: Limited patient, caregiver, and stakeholder knowledge about CTs suggested the need for an intervention to address this gap. A population health navigator (PHN) program was created to provide culturally concordant navigation to traditionally underserved patients (Hispanic, Black, rural). The role of the PHN includes educating patients on the importance of CTs and standardizes CT education to help normalize the role of research in cancer care. Based on results of this qualitative study, the PHN program is being adapted to provide culturally tailored education to increase overall CT awareness, knowledge, participation, and adherence among Black patients.

Citation Format: Kelsey Shore, Carla Strom, Kathryn Weaver, Derek Falk, Karen Winkfield. Exploring knowledge and perceptions of cancer care and clinical trials in the local Black community to develop culturally-tailored interventions [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-022.

Managing the cancer-work interface: the effect of cancer survivorship on unemployment

Objective

This study assessed differences in employment outcomes among cancer survivors using data from a nationally representative sample.

Methods

The 2011 Medical Expenditure Panel Survey (MEPS) data and the 2011 MEPS Experiences with Cancer Survivorship Supplement representing 3,360,465 people in the US population were analyzed to evaluate factors associated with unemployment among cancer survivors during the 5 years following diagnosis and treatment. The sample included adults 1) diagnosed with cancer within 5 years prior to survey completion and 2) engaged in paid employment since diagnosis. Individuals diagnosed with nonmelanoma skin cancer (n=33) were excluded from analyses.

Results

Data of 221 cancer survivors were used to identify factors associated with employment status at the time respondents were employed (n=155) vs unemployed (n=66). Results of bivariate analyses indicated that unemployed survivors were older, more likely to be women, more likely to be uninsured at the time of cancer diagnosis, and to report lower incomes than cancer survivors who continue to be employed. Unemployed survivors were more likely than employed survivors to have had anxiety about being forced to retire or quit early when they were employed because of cancer and to report cancer-related interference with physical and mental aspects of their job tasks; unemployed survivors also took less paid time off and were less likely to change to a flexible job schedule when they were employed. In multiple logistic regression analyses, worry about being forced to retire (protective), worry that cancer recurrence will interfere with home or work responsibilities (risk), and change to a flexible work schedule (risk) following cancer diagnosis were associated with unemployment after controlling for demographic differences between employed and unemployed cancer survivors.

Conclusion

Findings of this study highlight the extent to which the challenges of managing the cancer-work interface create challenges to employment among cancer survivors and may lead to long-term unemployment among cancer survivors. Future studies should evaluate the strategies that the survivors could use to manage the cancer-work interface during cancer treatment to attain medical, psychological, social, and employment outcomes.

Increasing Breast and Cervical Cancer Screening in Rural and Border Texas with Friend to Friend Plus Patient Navigation

The Friend to Friend plus Patient Navigation Program (FTF+PN) aims to build an effective, sustainable infrastructure to increase breast and cervical screening rates for underserved women in rural Texas. The objective of this paper is to identify factors that (1) distinguish participants who chose patient navigation (PN) services from those who did not (non-PN) and (2) were associated with receiving a mammogram or Papanicolaou (Pap) test. This prospective study analyzed data collected from 2689 FTF+PN participants aged 18-99 years from March 1, 2012 to February 28, 2015 who self-identified as African American (AA), Latina, and non-Hispanic white (NHW). Women who were younger, AA or Latina, had less than some college education, attended a FTF+PN event because of the cost of screening or were told they needed a screening, and who reported a barrier to screening had higher odds of being a PN participant. Women who were PN participants and had more contacts with program staff had greater odds of receiving a mammogram and a Pap compared with their reference groups. Latina English-speaking women had lower odds of receiving a mammogram and a Pap compared with NHW women and Latina Spanish-speaking women had higher odds of receiving a Pap test compared with NHW women. Women with greater need chose PN services, and PN participants had higher odds of getting a screening compared with women who did not choose PN services. These results demonstrate the success of PN in screening women in rural Texas but also that racial/ethnic disparities in screening remain.

Life-threatening DBS withdrawal syndrome in Parkinson's disease can be treated with early reimplantation

INTRODUCTION

The deep brain stimulation (DBS) withdrawal syndrome (DBS-WDS) is a rare, life-threatening complication in Parkinson's disease (PD) patients with long disease duration and stimulation when stimulation is terminated for extended periods mostly due to infection of the DBS-hardware.

METHODS, RESULTS

In five patients explantation became necessary because of infection after a mean of 11.4 years (range 4-15 years) of DBS and a mean disease duration of 24.6 years (range 3-22 years). Mean UPDRS motor-score pre-explantation was 38 points (range 24-55 points) which increased to a mean of 78.4 points (range 58-90 points) after explantation, despite optimal Levodopa dosing. Reimplantation of the hardware after 23 days (range 3-45 days) under antibiotic treatment led to an improvement to a mean of 40 points (range 25-73 points) and a complication free survival.

CONCLUSION

Early reimplantation of the DBS-hardware is a treatment option of the DBS-WDS when the life-threatening urgency overrides surgical standards. Observation of the syndrome indicates pharmacological unresponsiveness of the dopaminergic system in advanced PD and long-term DBS.

A Mixed Methods Review of Education and Patient Navigation Interventions to Increase Breast and Cervical Cancer Screening for Rural Women

Reviews have assessed studies of breast and cervical cancer screening access and utilization for rural women, but none analyze interventions to increase screening rates. A mixed methods literature search identified studies of breast and/or cervical cancer prevention education and patient navigation interventions for rural women. Rural areas need greater implementation and evaluation of screening interventions as these services address the challenges of delivering patient-centered cancer care to un-/underserved communities. The lack of intervention studies on breast and cervical cancer education and patient navigation programs compared to urban studies highlights the need for validation of these programs among diverse, rural populations.

German registry of paediatric deep brain stimulation in patients with childhood-onset dystonia (GEPESTIM)

BACKGROUND

Data on paediatric deep brain stimulation (DBS) is limited, especially for long-term outcomes, because of small numbers in single center series and lack of systematic multi-center trials.

OBJECTIVES

We seek to systematically evaluate the clinical outcome of paediatric patients undergoing DBS.

METHODS

A German registry on paediatric DBS (GEPESTIM) was created to collect data of patients with dystonia undergoing DBS up to the age of 18 years. Patients were divided into three groups according to etiology (group 1 inherited, group 2 acquired, and group 3 idiopathic dystonia).

RESULTS

Data of 44 patients with a mean age of 12.8 years at time of operation provided by 6 German centers could be documented in the registry so far (group 1 n = 18, group 2 n = 16, group 3 n = 10). Average absolute improvement after implantation was 15.5 ± 18.0 for 27 patients with pre- and postoperative Burke-Fahn-Marsden Dystonia Rating scale movement scores available (p < 0.001) (group 1: 19.6 ± 19.7, n = 12; group 2: 7.0 ± 8.9, n = 8; group 3: 19.2 ± 20.7, n = 7). Infection was the main reason for hardware removal (n = 6). 20 IPG replacements due to battery expiry were necessary in 15 patients at 3.7 ± 1.8 years after last implantation.

DISCUSSION

Pre- and postoperative data on paediatric DBS are very heterogeneous and incomplete but corroborate the positive effects of DBS on inherited and acquired dystonia. Adverse events including relatively frequent IPG replacements due to battery expiry seem to be a prominent feature of children with dystonia undergoing DBS. The registry enables collaborative research on DBS treatment in the paediatric population and to create standardized management algorithms in the future.

Effect of high-frequency subthalamic neurostimulation on gait and freezing of gait in Parkinson's disease: a systematic review and meta-analysis

The aim of this meta-analysis was to summarize the short- and long-term effects of bilateral deep brain stimulation of the subthalamic nucleus (STN-DBS) on gait and freezing of gait (FOG) in Parkinson's disease and to detect predictors of post-stimulation outcome. A comprehensive review of the literature was conducted up to October 2015 using Medline Ovid databases for studies analyzing the effect of bilateral STN-DBS on FOG and/or gait. Sixteen studies with available data for the gait item (no. 29) of the Unified Parkinson's Disease Rating Scale (UPDRS) and six studies with the FOG item (no. 14) were included. Data were summarized for the following follow-up periods: 6-15, 24-48 and >48 months. For the medication (Med)-Off/stimulation(Stim)-On condition compared with baseline Med-Off, STN-DBS significantly improved gait on average from 2.43 to 0.96, 2.53 to 1.31 and 2.56 to 1.40 points at 6-15, 24-48 and >48 months, respectively (P < 0.05). Pre-operative levodopa responsiveness of UPDRS-III and Med-Off severity of gait were the predictors of this beneficial effect. STN-DBS significantly improved FOG for the Med-Off/Stim-On condition compared with baseline on average from 2.26 to 0.82, 2.43 to 1.13 and 2.48 to 1.38 points at 6-15, 24-48 and >48 months, respectively (P < 0.05). There was no significant effect in the Med-On/Stim-On condition. This meta-analysis showed a robust improvement of gait and FOG by STN-DBS for more than 4 years in the Med-Off/Stim-On condition. No beneficial effect was found for the On state of medication. Pre-operative levodopa responsiveness of global motor performance (UPDRS-III) is the strongest predictor of the effect of deep brain stimulation on gait.

Posttraumatic stress among youths in juvenile detention

An estimated 1.8 million juveniles were arrested in the United States for delinquency in 2009. Previous studies indicate high rates of exposure to traumatic events and posttraumatic stress (PTS) symptoms for these youths. This study examined PTS in a sample of 170 youths in juvenile detention. The results of this study reveal higher rates of PTS symptoms (21%) compared to national rates (6%). The data also suggest youths suffering from more PTS symptoms also report higher depression, anxiety, anger, family relationship worries, thought problems, and attention problems. These factors provide a direction for continued practice targeting these youths.

Neurostimulation for Parkinson's disease with early motor complications

BACKGROUND

Subthalamic stimulation reduces motor disability and improves quality of life in patients with advanced Parkinson's disease who have severe levodopa-induced motor complications. We hypothesized that neurostimulation would be beneficial at an earlier stage of Parkinson's disease.

METHODS

In this 2-year trial, we randomly assigned 251 patients with Parkinson's disease and early motor complications (mean age, 52 years; mean duration of disease, 7.5 years) to undergo neurostimulation plus medical therapy or medical therapy alone. The primary end point was quality of life, as assessed with the use of the Parkinson's Disease Questionnaire (PDQ-39) summary index (with scores ranging from 0 to 100 and higher scores indicating worse function). Major secondary outcomes included parkinsonian motor disability, activities of daily living, levodopa-induced motor complications (as assessed with the use of the Unified Parkinson's Disease Rating Scale, parts III, II, and IV, respectively), and time with good mobility and no dyskinesia.

RESULTS

For the primary outcome of quality of life, the mean score for the neurostimulation group improved by 7.8 points, and that for the medical-therapy group worsened by 0.2 points (between-group difference in mean change from baseline to 2 years, 8.0 points; P=0.002). Neurostimulation was superior to medical therapy with respect to motor disability (P<0.001), activities of daily living (P<0.001), levodopa-induced motor complications (P<0.001), and time with good mobility and no dyskinesia (P=0.01). Serious adverse events occurred in 54.8% of the patients in the neurostimulation group and in 44.1% of those in the medical-therapy group. Serious adverse events related to surgical implantation or the neurostimulation device occurred in 17.7% of patients. An expert panel confirmed that medical therapy was consistent with practice guidelines for 96.8% of the patients in the neurostimulation group and for 94.5% of those in the medical-therapy group.

CONCLUSIONS

Subthalamic stimulation was superior to medical therapy in patients with Parkinson's disease and early motor complications. (Funded by the German Ministry of Research and others; EARLYSTIM ClinicalTrials.gov number, NCT00354133.).

Deep brain stimulation of the posterior hypothalamic area in intractable short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT)

Background: SUNCT (short-lasting unilateral neuralgiform headache with conjunctival injection and tearing) is a rare syndrome characterized by the sudden onset of excruciating unilateral periorbital pain that is accompanied by conjunctival injection and lacrimation or further autonomic signs. Similar to patients with chronic cluster headache, Leone and Lyons showed a beneficial effect of deep brain stimulation of the posterior hypothalamic region in two patients with a chronic SUNCT.

Case: Here, we present the case of a man with a chronic SUNCT responding to deep brain stimulation of the posterior hypothalamic area.

Conclusion: This case supports the idea of a central origin of SUNCT and shows that deep brain stimulation of the hypothalamic region can be effective in the treatment of the chronic form of this rare disorder.

Deep brain stimulation of the internal globus pallidus in dystonia: target localisation under general anaesthesia

Deep brain stimulation (DBS) of the internal globus pallidus (Gpi) is an effective therapy for various types of dystonia. The authors describe their technical approach for securing appropriate placement of the stimulating electrodes within the Gpi under general anaesthesia, including MRI based individualised anatomical targeting combined with electrophysiological mapping of the Gpi using micro-recording (MER) as well as macrostimulation and report the subsequent clinical outcome and complications using this method.

METHOD

We studied 42 patients (male-female ratio 25:17; mean age 43.6 years, range 9 to 74 years) consecutively operated at the Department of Neurosurgery, University Hospital Schleswig-Holstein, Campus Kiel, between 2001 - 2006. One patient underwent unilateral implantation after a right-sided pallidotomy 30 years before and strictly unilateral symptoms; all other implantations were bilateral. Two patients had repeat surgery after temporary removal of uni- or bilateral implants secondary to infection. Overall, 86 DBS electrodes were implanted. In 97% of the implantations, at least three microelectrodes were inserted simultaneously for MER and test stimulation. Initial anatomical targeting was based on stereotactic atlas coordinates and individual adaptation by direct visualisation of the Gpi on the stereotactic T2 or inversion-recovery MR images. The permanent electrode was placed according to the results of MER and test stimulations for adverse effects.

FINDINGS

The average improvement from baseline in clinical ratings using either the Burke-Fahn-Marsden-Dystonia (BFMDRS) or Toronto-Western-Spasmodic-Torticollis (TWSTR) rating scale at the last post-operative follow-up (mean 16.4 ; range 3-48 months) was 64.72% (range 20.39 to 98.52%). The post-operative MRI showed asymptomatic infarctions of the corpus caudatus in three patients and asymptomatic small haemorrhages in the lateral basal ganglia in two patients. One patient died due to a recurrent haemorrhage which occurred three months after the operation. The electrodes were implanted as follows: central trajectory in 64%, medial trajectory in 20%, anterior in 9% and lateral dorsal trajectories in 3.5% each. The reduction in BFMDRS or TWSTR motor score did not differ between the group implanted in the anatomically defined (central) trajectory bilateral (-64.15%, SD 23.8) and the physiologically adopted target (uni- or bilateral) (-63.39%, SD 23.1) indicating that in both groups equally effective positions were chosen within Gpi for chronic stimulation (t-test, p > 0.4).

CONCLUSIONS

The described technique using stereotactic MRI for planning of the trajectory and direct visualisation of the target, intra-operative MER for delineating the boundaries of the target and macrostimulation for probing the distance to the internal capsule by identifying the threshold for stimulation induced tetanic contractions is effective in DBS electrode implantation in patients with dystonia operated under general anaesthesia. The central trajectory was chosen in only 64%, despite individual adaptation of the target due to direct visualisation of the Gpi in inversion recovery MRI in 43% of the patients, demonstrating the necessity of combining anatomical with neurophysiological information.

Electrode implantation for deep brain stimulation in dystonia: a fast spin-echo inversion-recovery sequence technique for direct stereotactic targeting of the GPI

OBJECTIVE

Deep brain stimulation (DBS) of the globus pallidus internus (GPi) is an effective treatment for medically refractory primary dystonia. We present our technique for direct preoperative visualization of the target using a fast spin-echo inversion-recovery (FSE-IR) sequence.

METHODS

Twenty-three consecutive patients (mean age 41 years, range 9-68 years, male to female ratio 11:12) with severe dystonia were operated using a combination of FSE-IR imaging for direct visualization of the globus pallidus internus with stereotactic, gadolinium-enhanced T1-MPRage images. The complete procedure, including stereotactic MRI, was performed under general anesthesia with propofol and remifentanyl. We used multichannel microdrive systems (Medtronic; Alpha-Omega) to introduce up to five parallel microelectrodes for microelectrode recordings (MER) and test stimulation with the central trajectory directed at the anatomically predefined target. The initial standard coordinates in relation to the mid-commissural point (mid-AC-PC) were as follows: lateral 21 mm, anterior 3 mm, and inferior 2 mm, which were then adapted to the individual case based on direct visualization of the target area and further refined by the intraoperative neurophysiology.

RESULTS

In ten patients (43%) atlas-based standard coordinates were modified based on the direct visualization of the GPi in the FSE-IR images (bilaterally in seven patients, unilaterally in three). The modified targets ranged from 18.5 to 23.5 mm (mean 20.76 mm) laterally, 1-7 mm (mean 2.75 mm) anteriorly and 1-2 mm (mean 1.95 mm) inferiorly to the mid-AC-PC. We implanted the permanent electrode based on the results of MER and intraoperative stimulation performed to determine the threshold for pyramidal tract responses on the central trajectory in 67%, medially in 16%, anteriorly in 11%, laterally in 4%, dorsally in 2%. The procedure resulted in excellent clinical benefits (average reduction of the Burke-Fahn-Marsden Dystonia Rating Score (BFMDRS) or the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) were respectively 65.9%, range 20.9-91.4%) within the first year after surgery. Safety was demonstrated by the absence of intracranial bleeding or other surgical complications causing neurological morbidity.

CONCLUSION

Inversion recovery sequences are an excellent tool for direct visualization of the GPi. These images can be fused to stereotactic MRI or CCT and may help to improve anatomical targeting of the GPi for the implantation of DBS electrodes.

Failure of deep brain stimulation of the posterior inferior hypothalamus in chronic cluster headache - report of two cases and review of the literature

OBJECTIVE

Deep brain stimulation (DBS) has become a standard procedure for movement disorders such as Parkinson's disease, essential tremor or dystonia. Recently, deep brain stimulation of the posterior hypothalamus has been shown to be effective in the treatment of drug-resistant chronic cluster headache.

METHODS

DBS of the posterior inferior hypothalamus was performed on two patients with chronic cluster headaches, one 55-year-old man with medically intractable chronic cluster headache since 1996, and one 31-year-old woman with a chronic form since 2002. Both patients showed continuous worsening headaches in the last years despite high dose medical treatment. The patients fulfilled the published criteria for DBS in chronic cluster headaches. Electrodes were implanted stereotactically in the ipsilateral posterior hypothalamus according to the published coordinates (2 mm lateral, 3 mm posterior, 5 mm inferior) referenced to the mid-AC-PC line.

RESULTS

The intra- and postoperative course was uneventful and postoperative MRI control documented regular position of the DBS electrodes. The current stimulation parameters were at 12 months postoperatively 0 neg., G pos.; 5.5 V; 60 micros; 180 Hz (Case 1) and 0 neg., G pos.; 3.0 V; 60 micros; 185 Hz, at 3 months postoperatively (Case 2). Surgery- or stimulation-related side effects were not observed. Both patients showed initial pain reduction in the first days whereas 12 respectively 3 month follow-up did not show a significant reduction in attack frequency or intensity.

CONCLUSION

Deep brain stimulation of the posterior inferior hypothalamus is an experimental procedure and should be restricted to selected therapy-refractory patients and should be performed in centers experienced in patient selection and performance of DBS as well as postoperative pain treatment. A prospective multi-centre study is necessary to evaluate its effectiveness.

Residual feed intake of purebred Angus steers: Effects on meat quality and palatability

Relationships between residual feed intake (RFI) and other performance variables were determined using 54 purebred Angus steers. Individual feed intake and BW gain were recorded during a 70-d post-weaning period to calculate RFI. After the 70-d post-weaning test, steers were fed a finishing ration to a similar fat thickness (FT), transported to a commercial facility, and slaughtered. A subsample of carcasses (n = 32) was selected to examine the relationships among RFI, meat quality, and palatability. Steers were categorized into high (> 0.5 SD above the mean; n = 16), medium (mid; +/- 0.5 SD from the mean; n = 21), and low (< 0.5 SD below the mean; n = 17) RFI groups. No differences were detected in ADG, initial BW, and d 71 BW among the high, mid, and low RFI steers. Steers from the high RFI group had a greater DMI (P = 0.004) and feed conversion ratio (FCR; DMI:ADG; P = 0.002) compared with the low RFI steers. Residual feed intake was positively correlated with DMI (r = 0.54; P = 0.003) and FCR (r = 0.42; P = 0.002), but not with initial BW, d 71 BW, d 71 ultrasound FT, initial ultrasound LM area, d 71 ultrasound LM area, or ADG. The FCR was positively correlated with initial BW (r = 0.46; P = 0.0005), d 71 BW (r = 0.34; P = 0.01), and DMI (r = 0.40; P = 0.003) and was negatively correlated with ADG (r = -0.65; P = 0.001). There were no differences among RFI groups for HCW, LM area, FT, KPH, USDA yield grade, marbling score, or quality grade. Reflectance color b* scores of steaks from high RFI steers were greater (P = 0.02) than those from low RFI steers. There was no difference between high and low RFI groups for LM calpastatin activity. Warner-Bratzler shear force and sensory panel tenderness and flavor scores of steaks were similar across RFI groups. Steaks from high RFI steers had lower (P = 0.04) off-flavor scores than those from low RFI steers. Cook loss percentages were greater (P = 0.005) for steaks from low RFI steers than for those from mid RFI steers. These data support current views that RFI is independent of ADG, but is correlated with DMI and FCR. Importantly, the data also support the hypothesis that there is no relationship between RFI and beef quality in purebred Angus steers.

DairyBeef: Maximizing Quality and Profits—A Consistent Food Safety Message

To respond to meat safety and quality issues in dairy market cattle, a collaborative project team for 7 western states was established to develop educational resources providing a consistent meat safety and quality message to dairy producers, farm advisors, and veterinarians. The team produced an educational website and CD-ROM course that included videos, narrated slide sets, and on-farm tools. The objectives of this course were: 1) to help producers and their advisors understand market cattle food safety and quality issues, 2) help maintain markets for these cows, and 3) help producers identify ways to improve the quality of dairy cattle going to slaughter. DairyBeef. Maximizing Quality & Profits consists of 6 sections, including 4 core segments. Successful completion of quizzes following each core segment is required for participants to receive a certificate of completion. A formative evaluation of the program revealed the necessity for minor content and technological changes with the web-based course. All evaluators considered the materials relevant to dairy producers. After editing, course availability was enabled in February, 2003. Between February and May, 2003, 21 individuals received certificates of completion.

The effects of supplementation with 19-nor-4-androstene-3,17-dione and 19-nor-4-androstene-3,17-diol on body composition and athletic performance in previously weight-trained male athletes

The purpose of this study was to determine the effects of 8 weeks of norsteroid supplementation on body composition and athletic performance in previously weight-trained males. Subjects were weight and percent body fat matched and randomly assigned to receive either 100 mg of 19-nor-4-androstene-3,17-dione (N-dione) and 56 mg of 19-nor-4-androstene-3,17-diol (N-diol; 156 mg total norsteroid per day), or a placebo (a multivitamin). Each subject participated in resistance training 4 days/week for the duration of the study. Body composition was assessed via dual-energy X-ray absorptiometry. Circumference measures were taken of a relaxed and flexed arm (maximum circumference of the arm), waist (level of umbilicus), and thigh (15 cm proximal to the patella). Strength was determined with a one-repetition maximum bench press, while force and power were determined with a dumbbell bench press (60% body weight) on a Stratec Galileo force platform. Profile of mood states scores were evaluated for vigor and fatigue. There were no significant changes in any of the parameters measured. In conclusion, low-dose supplementation with N-dione and N-diol does not appear to alter body composition, exercise performance, or mood states.

Early hominid brain evolution: a new look at old endocasts

Early hominid brain morphology is reassessed from endocasts of Australopithecus africanus and three species of Paranthropus, and new endocast reconstructions and cranial capacities are reported for four key specimens from the Paranthropus clade. The brain morphology of Australopithecus africanus appears more human like than that of Paranthropus in terms of overall frontal and temporal lobe shape. These new data do not support the proposal that increased encephalization is a shared feature between Paranthropus and early Homo. Our findings are consistent with the hypothesis that Australopithecus africanus could have been ancestral to Homo, and have implications for assessing the tempo and mode of early hominid neurological and cognitive evolution.

Endocranial capacity in Sts 71 (Australopithecus africanus) by three-dimensional computed tomography

In a recent report on early hominid endocranial capacity, it was predicted that future studies would show that: (1) "several key early hominid endocranial estimates may be inflated"; (2) "current views on the tempo and mode of early hominid brain evolution may need reevaluation"; and (3) endocranial capacity in one of these, Sts 71, was "probably closer to 370 cm(3), very near the mean value for female chimpanzees, and not the currently accepted 428 cm(3)" (Conroy et al., Science, 1998; 280: 1730-1731; Falk, Science 1998; 20:1714). Subsequent studies tend to support the first two predictions, but not the third (Culotta, Science, 1999; 284: 1109; Falk, Am. J. Phys. Anthropol. Suppl., 1999; 28: 126; Falk et al., J. Hum. Evol. [in press]). Here we detail the reasons for thinking the currently accepted endocranial value for Sts 71 is probably correct by providing the first quantitative details of endocranial reconstruction in Sts 71 using three-dimensional computed tomography. Relative brain expansion in the hominid lineage started some half-million years before the earliest appearance of the genus Homo, possibly coincident with enhanced tool-making skills and carnivory.

A quantitative and qualitative reanalysis of the endocast from the juvenile Paranthropus specimen l338y-6 from Omo, Ethiopia

Based on an analysis of its endocast, Holloway (1981 Am J Phys Anthropol 53:109-118) attributed the juvenile Omo L338y-6 specimen to Australopithecus africanus (i.e., gracile australopithecines) rather than to Paranthropus (Australopithecus) boisei (robust australopithecines) favored by other workers (Rak and Howell [1978] Am J Phys Anthropol 48:345-366). Holloway's attribution was based on the specimen's (1) low cranial capacity, (2) gracile-like meningeal vessels, (3) gracile-like cerebellar hemispheres, and (4) absence of an enlarged occipital/marginal (O/M) sinus system. Recent work, however, has shown that criteria 1 and 2 are not useful for sorting gracile from robust australopithecines (Culotta [1999] Science 284:1109-1111; Falk [1993] Am J Phys Anthropol 92:81-98). In this paper, we test criterion 3 by quantifying the endocranial cerebellar and occipital morphology reproduced on the Omo L338y-6 endocast, and comparing it to seven endocasts from South and East African early hominids. Our preliminary results show that metric analysis of this specimen cannot be used to sort it preferentially with either robust or gracile australopithecines. Finally, we demonstrate that, contrary to previous reports, the Omo L338y-6 endocast reproduces an enlarged left occipital sinus (criterion 4). This observation is consistent with the original attribution of the Omo specimen to robust australopithecines (Rak and Howell [1978] Am J Phys Anthropol 48:345-366). Furthermore, if Omo L338y-6 was a robust australopithecine, this discovery extends the occurrence of an enlarged O/M sinus system to one of the earliest known paranthropines. Am J Phys Anthropol 110:399-406, 1999.

Characterization of staphylococcal bovine mastitis isolates using the polymerase chain reaction

A polymerase chain reaction (PCR) assay was adapted to detect toxin genes of staphylococcal isolates from cases of bovine mastitis. Samples were obtained from three geographical areas: Korea and Idaho and Washington in the northwest United States. Samples from Korea and Washington were randomly chosen. Idaho samples were from a prospective study of mastitis etiology. Forty-one milk samples from 25 commercial farms in south-central Idaho were collected from cows with symptoms of mastitis. Although Staphylococcus aureus constituted 37.5% of mastitis isolates, these isolates lacked genes for staphylococcal enterotoxins (SEs), toxic shock syndrome toxin, and exfoliative toxins. In contrast, 4 of 13 isolates from Washington and 6 of 20 isolates from South Korea expressed SEs. These results suggest that PCR may be an effective means of screening bovine isolates for toxins. They also emphasize the potential for significant geographic differences in mastitis etiology.

A comparative study of stereolithographically modelled skulls of Petralona and Broken Hill: implications for future studies of middle Pleistocene hominid evolution

Computer generated three-dimensional stereolithographic models of middle Pleistocene skulls from Petralona and Broken Hill are described and compared. The anterior cranial fossae of these models are also compared with that of another middle Pleistocene skull, Arago 21. Stereolithographic modelling reproduces not only the outer surfaces of skulls, but also features within the substance of the bones, and details of the internal braincase. The skulls of Petralona and, to a somewhat lesser degree, Broken Hill are extremely pneumatized. Previously undescribed features associated with pneumatization are detailed, along with their possible functional significance, polarity, and potential for understanding hominid cranial variation. Petralona and Broken Hill also exhibit a dramatic suite of cerebral features that is probably related to extensive pneumatization of the skull, namely frontal lobes that are tilted and located behind rather than over the orbits, laterally flared temporal lobes, marked occipital projection, and basal location of the cerebellum. Comparison of the anterior cranial fossae of Petralona, Broken Hill, and Arago 21 suggests that external resemblance of skulls may not always correlate with endocranial similarity. We believe that stereolithographic reconstructions have the potential for helping to resolve difficult questions about the origins of Neanderthal and anatomically modern people.

Relationship of squamosal suture to asterion on external skull surfaces versus endocasts of pongids: implications for Hadar early hominid AL 162-28

The relationship between the squamosal suture and asterion was quantified in 15 hemispheres of eight chimpanzee endocasts that were aligned in the conventional lateral view (i.e., with frontal pole [FP]-occipital pole [OP] horizontal). Using a three-dimensional digitizer, x, y, and z coordinates were collected for the highest and lowest points of the squamosal suture, and the most rostral point of the suture approximate to the coronal suture. Our results were compared to a similar study of the squamosal suture on the external surfaces of chimpanzee skulls that were oriented in the Frankfurt horizontal (Holloway and Shapiro, 1992). The relationship between the squamosal suture and asterion differs markedly between the outsides of skulls and endocasts. Whereas the squamosal suture is very rarely below asterion on the external skull, we found that most of the squamosal suture is located inferior to asterion on endocasts. We also found that the squamosal suture courses approximately 2.0 mm lower on the right side than the left. (An asymmetry of the same magnitude was reported for the external skull but, curiously, in the opposite direction.) It may be that a lowered right squamosal endosuture on chimpanzee endocasts is associated with earlier closure on that side. The discrepancy in results for the external skull versus endocast is partially attributable to orienting chimpanzee skulls in the Frankfurt horizontal, which usually results in the endocasts being tilted so that FP is above OP, i.e., FP-OP is not parallel with the Frankfurt horizontal. Falk's (1985) orientation of the early hominid endocast from Hadar (AL 162-28) is consistent with data determined from endocasts of chimpanzees.

Meningeal arterial patterns in great apes: implications for hominid vascular evolution

Arterial meningeal patterns were observed for 100 hemispheres from great ape endocasts (Pan paniscus, Pan troglodytes, Gorilla gorilla, and Pongo pygmaeus). Eight patterns emerged based on the relative contributions to the walls and dura mater of the middle part of the braincase of meningeal arteries that stem from two sources. These arteries enter the braincase through either the orbit (delivering blood from the internal carotid artery) or through the base of the middle cranial fossa (via the middle meningeal artery whose blood comes from the external carotid artery). The three genera of apes manifest different frequencies of the eight patterns, with orangutans highly dependent on orbital meningeal arteries at one extreme, and chimpanzees showing the greatest reliance on the middle meningeal artery at the other. As was the case in an earlier study of rhesus monkeys, there is a trend across the two genera of African apes for increased mean cranial capacity to be associated with increased reliance on the internal carotid artery for supplying the middle portion of the braincase. However, unlike the case for macaques, this trend does not reach statistical significance in African apes. Because it is rare for humans to manifest significant arterial contributions from the orbit to the middle cranial fossa, the comparative data on monkeys, apes, and humans suggest that, during the course of vascular evolution in Homo, the middle meningeal artery eventually took over supply of the entire middle cranial fossa. This hypothesis should be tested in the hominid fossil record. Earlier work on meningeal arterial patterns in apes has traditionally relied on Adachi's system that was determined from humans and focuses on the origin of the middle branch of the middle meningeal artery. As a result, the extensive orbital contributions to the middle portion of the braincase that characterize apes were not recognized and the eight patterns described in this paper were often erroneously assigned to the three patterns that adequately describe only humans. Adachi's system should therefore be abandoned for nonhuman primates and early hominids. A correct understanding of meningeal arterial evolution cannot be achieved until the orbital contributions to the meningeal arteries are recognized and incorporated into an evolutionary study that spans from apes to fossil hominids to living people.

Meningeal arteries in rhesus macaques (Macaca mulatta): implications for vascular evolution in anthropoids

The branching patterns of meningeal arteries are reported for 200 endocast hemispheres representing rhesus monkeys (Macaca mulatta) of known cranial capacity. We detect five basic patterns for the branching of the anterior division of the middle meningeal artery and its relationship with the anterior meningeal artery. These results confirm and elaborate trends published for much smaller samples that were based on direct dissections of rhesus monkey arterial patterns. The most common pattern is that in which the anterior meningeal artery dominates the blood supply above the rostral part of the middle cranial fossa. Analysis of cranial capacities reveals that presence of this pattern on both sides of endocasts is associated with increased cranial capacity. When studied in light of published reports of anatomical dissections of cranial arteries in apes and human embryological data, the anterior meningeal artery in rhesus monkeys appears to be a possible homologue of the lacrimal meningeal artery in apes and the anterior branch of the middle meningeal artery in humans. This finding provides a step towards understanding cranial vasculature homologies that may be useful for accurately scoring the branching patterns of the meningeal arteries in monkeys, apes, and humans.

Human cortical asymmetries determined with 3D MR technology

A method is described for obtaining clear 3D magnetic resonance (MR) images of the cortical surface of the brain in living human subjects. By combining volume composite and depth encoded images, we have obtained surface coordinate data that resulted in highly repeatable measurements of sulcal lengths and cortical surface areas in eight normal adult volunteers. Sulcal lengths were determined for specific parts of the Sylvian fissure, central sulcus and frontal operculum. Additionally, angles were computed between the anterior and posterior limbs of the pars triangularis and the ascending and horizontal limbs of the posterior Sylvian fissure. The cortical surface areas enclosed by these limbs were also computed. Finally, thirteen non-metric cortical features (e.g., petalias) were scored from the 3D MR images. All measurements were compared in right and left hemispheres. In addition to corroborating cortical asymmetries reported in the literature, we observed previously unrecognized directional asymmetries in the length of the anterior limb of the pars triangularis, length of the ascending limb of the posterior Sylvian fissure, and position of the lateral end of the central sulcus. We attribute the finding of three new directional asymmetries for the human cortex, as well as the high repeatability of our measurements, to the sensitivity and accuracy of the 3D MR imaging technology that has recently become available.