The efficacy, challenges, and facilitators of telemedicine in post-treatment cancer survivorship care: an overview of systematic reviews

BACKGROUND

Telemedicine services have been increasingly used to facilitate post-treatment cancer survivorship care, including improving access; monitoring health status, health behaviors, and symptom management; enhancing information exchange; and mitigating the costs of care delivery, especially since the COVID-19 pandemic. To inform guidance for the use of telemedicine in the post-COVID era, the aim of this overview of systematic reviews (SRs) was to evaluate the efficacy of, and survivor engagement in, telemedicine interventions in the post-treatment survivorship phase, and to consider implementation barriers and facilitators.

METHODS

PubMed, Cochrane CENTRAL, CINAHL, Embase, and Web of Science databases were searched. SRs that examined the use of telemedicine in the post-treatment phase of cancer survivorship, published between January 2010 and April 2021, were included. Efficacy data were synthesized narratively. Implementation barriers and facilitators were synthesized using the Consolidated Framework for Implementation Research.

RESULTS

Twenty-nine SRs were included. A substantive body of evidence found telemedicine to benefit the management of psychosocial and physical effects, particularly for improving fatigue and cognitive function. There was a lack of evidence on the use of telemedicine in the prevention and surveillance for recurrences and new cancers as well as management of chronic medical conditions. This overview highlights a range of diverse barriers and facilitators at the patient, health service, and system levels.

CONCLUSIONS

This review highlights the benefits of telemedicine in addressing psychosocial and physical effects, but not in other areas of post-treatment cancer survivorship care. This large review provides practical guidance for use of telemedicine in post-treatment survivorship care.

Recruit fitness and police academy performance: a prospective validation study

BACKGROUND

Police academies need fit recruits to successfully engage in training activities. In a previous retrospective study, we documented that recruits with poor fitness at entry to the academy had significantly lower graduation rates, and we also suggested evidence-based entry-level fitness recommendations.

AIMS

To validate our findings in a prospective cohort of police recruits.

METHODS

Recruits entering Massachusetts municipal police academies during 2015-16 were followed prospectively until they dropped out, failed or successfully graduated their academy classes. Entry-level fitness was quantified at the start of each training class using: body composition, push-ups, sit-ups, sit-and-reach and 1.5-mile run time. The primary outcome of interest was the odds of failure (not successfully graduating from an academy). We used logistic regression to assess the probability of not graduating, based on entry-level fitness.

RESULTS

On average, successful graduates were leaner and possessed better overall entry-level fitness. After adjusting for age, gender and body mass index, several fitness measures were strongly associated with academy failure: fewer sit-ups completed (OR 9.6 (95% CI 3.5-26.3) (≤15 versus 41-60)); fewer push-ups completed (OR 6.7 (95% CI 2.5-17.5) (≤20 versus 41-60)); and slower run times (OR 18.4 (95% CI 6.8-50.2) (1.5 miles in > 15 min 20 s versus 10 min 37 s to 12 min 33 s)). The prospective study results supported previously suggested minimum entry-level fitness (95% graduation rate) and target (98% graduation rate) recommendations.

CONCLUSIONS

Push-ups completed and 1.5-mile run time at police academy entry were successfully validated as predictors of successful academy graduation, while sit-ups were also a strong independent predictor in the prospective study.

Ambient temperature modulates the effects of the Prader-Willi syndrome candidate gene Snord116 on energy homeostasis

Germline deletion of the Prader-Willi syndrome (PWS) candidate gene Snord116 in mice leads to some classical symptoms of human PWS, notably reductions in body weight, linear growth and bone mass. However, Snord116 deficient mice (Snord116^-/-) do not develop an obese phenotype despite their increased food intake and the underlying mechanism for that is unknown. We tested the phenotypes of germline Snord116^-/- as well as neuropeptide Y (NPY) neuron specific Snord116^lox/lox/NPY^cre/+ mice at 30°C, the thermoneutral temperature of mice, and compared these to previous reports studies conducted at normal room temperature. Snord116^-/- mice at 30°C still weighed less than wild type but had increased body weight gain. Importantly, food intake and energy expenditure were no longer different at 30°C, and the reduced bone mass and nasal-anal length observed in Snord116^-/- mice at room temperature were also normalized. Mechanistically, the thermoneutral condition led to the correction of the mRNA expression of NPY and pro-opiomelanocortin (POMC), which were both previously observed to be significantly up-regulated at room temperature. Importantly, almost identical phenotypes and NPY/POMC mRNA expression alterations were also observed in Snord116^lox/lox/NPY^cre/+ mice, which lack the Snord116 gene only in NPY neurons. These data illustrate that mild cold stress is a critical factor preventing the development of obesity in Snord116^-/- mice via the NPY system. Our study highlights that the function of Snord116 in the hypothalamus may be to enhance energy expenditure, likely via the NPY system, and also indicates that Snord116 function in mice is strongly dependent on environmental conditions such as cold exposure.

Combined heart-liver transplantation with extended cardiopulmonary bypass

We report a case of combined heart and liver transplantation for familial amyloid polyneuropathy. This is the first such combined transplant performed in Asia, and differs from previously described cases, in that cardiopulmonary bypass was continued at partial flow during liver transplantation in our case. This was done in order to provide haemodynamic support to the cardiac graft and to protect it from the impending reperfusion insult that frequently accompanies liver transplantation. The utility of this management course is discussed, along with its actual and potential complications. We also describe the impact of a lung-protective ventilation strategy employed during cardiac transplantation.

VITATOPS, the VITAmins TO prevent stroke trial: rationale and design of a randomised trial of B-vitamin therapy in patients with recent transient ischaemic attack or stroke (NCT00097669) (ISRCTN74743444)

BACKGROUND

Epidemiological studies suggest that raised plasma concentrations of total homocysteine (tHcy) may be a common, causal and treatable risk factor for atherothromboembolic ischaemic stroke, dementia and depression. Although tHcy can be lowered effectively with small doses of folic acid, vitamin B(12) and vitamin B(6), it is not known whether lowering tHcy, by means of B vitamin therapy, can prevent stroke and other major atherothromboembolic vascular events.

AIM

To determine whether the addition of B-vitamin supplements (folic acid 2 mg, B(6) 25 mg, B(12) 500 microg) to best medical and surgical management will reduce the combined incidence of stroke, myocardial infarction (MI) and vascular death in patients with recent stroke or transient ischaemic attack (TIA) of the brain or eye.

DESIGN

A prospective, international, multicentre, randomised, double blind, placebo-controlled clinical trial.

SETTING

One hundred and four medical centres in 20 countries on five continents.

SUBJECTS

Eight thousand (6600 recruited as of 5 January, 2006) patients with recent (<7 months) stroke (ischaemic or haemorrhagic) or TIA (brain or eye).

RANDOMISATION

Randomisation and data collection are performed by means of a central telephone service or secure internet site.

INTERVENTION

One tablet daily of either placebo or B vitamins (folic acid 2 mg, B(6) 25 mg, B(12) 500 mug).

PRIMARY OUTCOME

The composite of stroke, MI or death from any vascular cause, whichever occurs first. Outcome and serious adverse events are adjudicated blinded to treatment allocation.

SECONDARY OUTCOMES

TIA, unstable angina, revascularisation procedures, dementia, depression. STATISTICAL POWER: With 8000 patients followed up for a median of 2 years and an annual incidence of the primary outcome of 8% among patients assigned placebo, the study will have at least 80% power to detect a relative reduction of 15% in the incidence of the primary outcome among patients assigned B vitamins (to 6.8%/year), applying a two-tailed level of significance of 5%.

CONCLUSION

VITATOPS aims to recruit and follow-up 8000 patients between 1998 and 2008, and provide a reliable estimate of the safety and effectiveness of folic acid, vitamin B(12), and vitamin B(6) supplementation in reducing recurrent serious vascular events among a wide range of patients with TIA and stroke throughout the world.

Sustained Homocysteine-Lowering Effect over Time of Folic Acid-Based Multivitamin Therapy in Stroke Patients despite Increasing Folate Status in the Population

BACKGROUND AND AIMS

It is uncertain what impact increasing voluntary folate fortification may be having on the statistical power of randomized trials testing the homocysteine hypothesis of atherothrombosis. The objective of this study was to determine whether there has been a change in folate status between 1998 and 2002 in stroke patients randomized into the VITAmins TO Prevent Stroke (VITATOPS) Study at a single center in Perth, Australia, and what impact this may have had on the magnitude of the homocysteine-lowering effect achieved over time with folic acid-based multivitamin therapy.

METHODS

We conducted a randomized, double-blind, placebo-controlled study involving 285 patients with stroke or transient ischemic attack who were recruited between 1998 and 2002 and randomized to long-term folic acid 2.0 mg/day, pyridoxine 25 mg/day and cobalamin 0.5 mg/day (active VITATOPS medication) or placebo. Fasting plasma total homocysteine, red cell folate, serum cobalamin and serum pyridoxine levels were measured at baseline and 6 months, and the change in blood levels over 4 time quartiles and differences in levels between the two randomized treatments were examined.

RESULTS

Between 1998 and 2002, there was a significant rise in baseline mean red cell folate levels over 4 time quartiles among the entire stroke cohort (723.3, 780.1, 922.6 and 1,023.7 nmol/l in the first, second, third and fourth quartiles, respectively; p < 0.0001), but this was not associated with a spontaneous reduction in mean baseline total homocysteine levels during the same time period (12.7, 14.3, 12.1 and 12.8 micromol/l in the first, second, third and fourth quartiles, respectively; p = 0.55). The homocysteine-lowering effect of the active VITATOPS trial medication at 6 months after randomization also did not change significantly between 1998 and 2002 (difference between randomized groups: -4.1, -4.1, -3.1 and -3.6 micromol/l in the first, second, third and fourth quartiles, respectively; p = 0.56).

CONCLUSIONS

The homocysteine-lowering effect of the active VITATOPS trial medication has not attenuated significantly in the past 5 years despite increasing voluntary fortification of foods with folic acid as reflected by a progressive rise in baseline folate status. These data suggest that in the continuing absence of a program of mandatory folate fortification of food in populations served by centers participating in the VITATOPS trial, the study will remain adequately powered to test the homocysteine-lowering hypothesis for which it was designed.

Homocysteine-Lowering Treatment With Folic Acid, Cobalamin, and Pyridoxine Does Not Reduce Blood Markers of Inflammation, Endothelial Dysfunction, or Hypercoagulability in Patients With Previous Transient Ischemic Attack or Stroke

Background and Purpose— Epidemiological and laboratory studies suggest that increasing concentrations of plasma homocysteine (total homocysteine [tHcy]) accelerate cardiovascular disease by promoting vascular inflammation, endothelial dysfunction, and hypercoagulability.

Methods— We conducted a randomized controlled trial in 285 patients with recent transient ischemic attack or stroke to examine the effect of lowering tHcy with folic acid 2 mg, vitamin B 12 0.5 mg, and vitamin B 6 25 mg compared with placebo on laboratory markers of vascular inflammation, endothelial dysfunction, and hypercoagulability.

Results— At 6 months after randomization, there was no significant difference in blood concentrations of markers of vascular inflammation (high-sensitivity C-reactive protein [ P =0.32]; soluble CD40L [ P =0.33]; IL-6 [ P =0.77]), endothelial dysfunction (vascular cell adhesion molecule-1 [ P =0.27]; intercellular adhesion molecule-1 [ P =0.08]; von Willebrand factor [ P =0.92]), and hypercoagulability (P-selectin [ P =0.33]; prothrombin fragment 1 and 2 [ P =0.81]; D-dimer [ P =0.88]) among patients assigned vitamin therapy compared with placebo despite a 3.7-μmol/L (95% CI, 2.7 to 4.7) reduction in total homocysteine (tHcy).

Conclusions— Lowering tHcy by 3.7 μmol/L with folic acid-based multivitamin therapy does not significantly reduce blood concentrations of the biomarkers of inflammation, endothelial dysfunction, or hypercoagulability measured in our study. The possible explanations for our findings are: (1) these biomarkers are not sensitive to the effects of lowering tHcy (eg, multiple risk factor interventions may be required); (2) elevated tHcy causes cardiovascular disease by mechanisms other than the biomarkers measured; or (3) elevated tHcy is a noncausal marker of increased vascular risk.

Hypercalcemia in malignant paraganglioma due to parathyroid hormone-related protein

A 15-year-old boy had hypercalcemia in association with malignant retroperitoneal paraganglioma. He had suppressed circulating levels of intact parathyroid hormone, whereas parathyroid hormone-related protein (PTHrP) immunoreactivity was elevated in plasma. Both the serum 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D levels were normal. Preoperatively the patient required control of hypercalcemia with intravenous pamidronate therapy. His circulating calcium and PTHrP concentrations became normal after a successful surgical resection of the primary retroperitoneal tumor. To our knowledge, this is the first reported case of elevated PtHrP levels in a patient with paraganglioma which resolved postoperatively.

Professionalism, where are you?

The practice of medicine continues to evolve in ways that are not always compatible with good patient care, and physicians now control less and less of their practices. One of the casualties of the new health economics is the concept of professionalism, which becomes more difficult to adhere to in the face of restrictions placed by outside forces. Nevertheless, physicians can maintain a sense of professionalism despite all the difficulties. Indeed, we must do so in order to remain true to our ideals.

SSPE: but we thought measles was gone!

Subacute sclerosing panencephalitis (SSPE) is a progressive neurodegenerative disease caused by the measles (rubeola) virus and is most often seen in children. Many affected children have a history of measles infection in the first years of life or exposure to the live measles virus vaccine. Typically, there is a rapid onset of neurological symptoms degenerating into a stuporous state in the patient. Four children and their families are reviewed. Their individual courses, medical and nursing problems and interventions, and implications for immunizations with the measles-mumps-rubella (MMR) vaccine will be discussed.

High-dose methotrexate with leucovorin rescue plus vincristine in advanced sarcoma: a Southwest Oncology Group study

Twenty-six evaluable patients with advanced soft tissue and bony sarcomas refractory to chemotherapy were treated with vincristine plus high-dose methotrexate and leucovorin rescue. A 14% response rate was observed among 14 patients presenting with refractory soft tissue sarcomas. No responses were observed among 12 patients with bony sarcoma. Toxic reaction with nausea, vomiting, nephrotoxicity, and myelosuppression was manageable. While this study did demonstrate activity of this regimen in doxorubicin-refractory patients, the duration of the responses was relatively brief. Thus, the clinical utility of such a regimen is questionable.

[Efficacy and tolerance of trimethoprim sulfamoxole combination in childhood (author's transl)]

CN 3123 was tested in 4 hospitals on 257 children, 218 of whom were included in the evaluation of the success of therapy. It was administered for the treatment of urinary tract infections (n = 125), bronchial infections (n = 24), intestinal infections (n = 25) and ENT infections (n = 37). The results indicated that, with a failure rate of only 7%, the drug was successfully employed. Tolerance to the medicament was good. Vomiting occurred in 7 children (2.7%) and allergic skin reactions were observed in 6 children (2.3%). A comparative study of CN 3123 and Co-trimoxazole showed the same efficacy and tolerance for both medicaments.