Mitigating Radiotoxicity in the Central Nervous System: Role of Proton Therapy

OPINION STATEMENT

Central nervous system (CNS) radiotoxicity remains a challenge in neuro-oncology. Dose distribution advantages of protons over photons have prompted increased use of brain-directed proton therapy. While well-recognized among pediatric populations, the benefit of proton therapy among adults with CNS malignancies remains controversial. We herein discuss the role of protons in mitigating late CNS radiotoxicities in adult patients. Despite limited clinical trials, evidence suggests toxicity profile advantages of protons over conventional radiotherapy, including retention of neurocognitive function and brain volume. Modelling studies predict superior dose conformality of protons versus state-of-the-art photon techniques reduces late radiogenic vasculopathies, endocrinopathies, and malignancies. Conversely, potentially higher brain tissue necrosis rates following proton therapy highlight a need to resolve uncertainties surrounding the impact of variable biological effectiveness of protons on dose distribution. Clinical trials comparing best photon and particle-based therapy are underway to establish whether protons substantially improve long-term treatment-related outcomes in adults with CNS malignancies.

Mobile Intervention to Improve Sleep and Functional Health of Veterans With Insomnia: Randomized Controlled Trial

Background

Insomnia is a prevalent and debilitating disorder among veterans. Cognitive behavioral therapy for insomnia (CBTI) can be effective for treating insomnia, although many cannot access this care. Technology-based solutions and lifestyle changes, such as physical activity (PA), offer affordable and accessible self-management alternatives to in-person CBTI.

Objective

This study aims to extend and replicate prior pilot work to examine whether the use of a mobile app for CBTI (cognitive behavioral therapy for insomnia coach app [CBT-i Coach]) improves subjective and objective sleep outcomes. This study also aims to investigate whether the use of the CBT-i Coach app with adjunctive PA improves sleep outcomes more than CBT-i Coach alone.

Methods

A total of 33 veterans (mean age 37.61 years, SD 9.35 years) reporting chronic insomnia were randomized to use either the CBT-i Coach app alone or the CBT-i Coach app with a PA intervention over 6 weeks, with outcome measures of objective and subjective sleep at pre- and posttreatment.

Results

Although the PA manipulation was unsuccessful, both groups of veterans using the CBT-i Coach app showed significant improvement from baseline to postintervention on insomnia (P<.001), sleep quality (P<.001), and functional sleep outcomes (P=.002). Improvements in subjective sleep outcomes were similar in those with and without posttraumatic stress disorder and mild-to-moderate sleep apnea. We also observed a significant but modest increase in objective sleep efficiency (P=.02).

Conclusions

These findings suggest that the use of a mobile app–delivered CBTI is feasible and beneficial for improving sleep outcomes in veterans with insomnia, including those with comorbid conditions such as posttraumatic stress disorder or mild-to-moderate sleep apnea.

Trial Registration

ClinicalTrials.gov NCT03305354; https://clinicaltrials.gov/ct2/show/NCT03305354

The development and implementation of teleneuropsychology in an academic lifespan neuropsychology center: Lessons learned from the COVID-19 pandemic

INTRODUCTION

Teleneuropsychology (TNP) became a critical means for providing care during the COVID-19 pandemic and may continue as an option for delivery of neuropsychological services. To understand how patient characteristics impact clinician decisions and service models, this study examines practice patterns within a lifespan outpatient neuropsychology center before, during and post-pandemic.

METHODS

Patient volume, demographics, and characteristics were compared across four, 3-month time intervals in 2019-2020. Two baseline intervals when the center was physically open (PO) were compared to one interval when the center was physically closed (PC) (all evaluations were conducted via direct-to-home TNP) and a fourth interval when the center was physically reopened (RO) and evaluations were conducted in one of the three modalities: in-person, virtual only or hybrid (both virtual/in-person).

RESULTS

A total of 1,459 total neuropsychological evaluations were conducted with a 64.6% reduction during PC. At RO, the number of evaluations returned to pre-COVID baseline during which in-person (72.4%) evaluations were conducted at a higher rate than hybrid (7.1%) or virtual only (20.4%). Across the lifespan, mean number of appointments to complete evaluations was significantly greater during PC (p< .001) than at other time intervals, and during RO, hybrid evaluations required significantly more appointments (p < .001) than in-person and virtual. The majority of evaluations were conducted with adult patients (71.4%). For adult patients, neurodegenerative/memory disorders received TNP evaluations at a higher rate during PC and RO. Pediatric patients were significantly older during PC (p < .001); neurodevelopmental referrals received more hybrid and virtual evaluations.

CONCLUSIONS

Results indicate that patient characteristics, especially age and referral categories, impact the feasibility of TNP. Data from the RO period suggest that in-person evaluations not surprisingly remain the mainstay; however, for adult patients, and especially older adults with neurodegenerative/memory disorders, TNP may provide an important option for delivery of neuropsychological evaluations.

Cancer, cognition, and COVID: delivering direct-to-home teleneuropsychology services to neuro-oncology patients

BACKGROUND

The COVID-19 pandemic induced rapid adoption of telemedicine services for neuro-oncology patients at an increased risk of infection. Neuropsychological assessment is important to neuro-oncology care yet challenging to complete outside of a structured testing environment. Teleneuropsychology (TNP) has been explored in limited populations and proven feasible and reliable. Conducting TNP visits directly to patients' home (DTH) had minimal prior study.

METHODS

We used two voluntary surveys to examine acceptance (patients) and feasibility (providers) of DTH-TNP at two regionally diverse medical institutions providing neuropsychological services to neuro-oncology patients from April to September 2020.

RESULTS

A total of 119 patients were scheduled during the study period, 79 of whom completed neuropsychological testing via DTH-TNP. Neuropsychology providers completed surveys on 68 of these encounters (86%). In 98% of cases, neuropsychologists were able to achieve or partially achieve the individually defined goals of their assessment. Common problems reported included patient dysregulation (16%) and slow/unreliable internet (15%). Of the 52 patients who responded, 98% were satisfied with the DTH-TNP experience, and 92% would recommend the virtual visit to others. All respondents felt understood by the examiner (100%) and the majority denied technical difficulties (90%), communication challenges (94%), or privacy concerns (98%). Patients reported reduced risk of infection and saved travel time as favorable aspects of DTH-TNP.

CONCLUSIONS

These preliminary results suggest neuro-oncology patients find DTH-TNP acceptable and neuropsychologists find it a feasible practice, while also recognizing its limitations. Results suggest that further study of DTH-TNP (eg, reliability, validity) for neuro-oncology patients is warranted.

Economic evaluation of a community based exercise programme to prevent falls

OBJECTIVE

To assess the incremental costs and cost effectiveness of implementing a home based muscle strengthening and balance retraining programme that reduced falls and injuries in older women.

DESIGN

An economic evaluation carried out within a randomised controlled trial with two years of follow up. Participants were individually prescribed an exercise programme (exercise group, n=116) or received usual care and social visits (control group, n=117).

SETTING

17 general practices in Dunedin, New Zealand.

PARTICIPANTS

Women aged 80 years and older living in the community and invited by their general practitioner to take part.

MAIN OUTCOME MEASURES

Number of falls and injuries related to falls, costs of implementing the intervention, healthcare service costs resulting from falls and total healthcare service costs during the trial. Cost effectiveness was measured as the incremental cost of implementing the exercise programme per fall event prevented.

MAIN RESULTS

27% of total hospital costs during the trial were related to falls. However, there were no significant differences in health service costs between the two groups. Implementing the exercise programme for one and two years respectively cost $314 and $265 (1995 New Zealand dollars) per fall prevented, and $457 and $426 per fall resulting in a moderate or serious injury prevented.

CONCLUSIONS

The costs resulting from falls make up a substantial proportion of the hospital costs for older people. Despite a reduction in falls as a result of this home exercise programme there was no significant reduction in healthcare costs. However, the results reported will provide information on the cost effectiveness of the programme for those making decisions on falls prevention strategies.

Transgenic MUC1 interacts with epidermal growth factor receptor and correlates with mitogen-activated protein kinase activation in the mouse mammary gland

MUC1 is a large (>400 kDa), heavily glycosylated transmembrane protein that is aberrantly expressed on greater than 90% of human breast carcinomas and subsequent metastases. The precise function of MUC1 overexpression in tumorigenesis is unknown, although various domains of MUC1 have been implicated in cell adhesion, cell signaling, and immunoregulation. Stimulation of the MDA-MB-468 breast cancer line as well as mouse mammary glands with epidermal growth factor results in the co-immunoprecipitation of MUC1 with a tyrosine-phosphorylated protein of approximately 180 kDa. We have generated transgenic lines overexpressing full-length (MMF), cytoplasmic tail deleted (DeltaCT), or tandem repeat deleted (DeltaTR)-human MUC1 under the control of the mouse mammary tumor virus promoter to further examine the role of MUC1 in signaling and tumorigenesis. Immunoprecipitation experiments revealed that full-length transgenic MUC1 physically associates with all four erbB receptors, and co-localizes with erbB1 in the lactating gland. Furthermore, we detected a sharp increase in ERK1/2 activation in MUC1 transgenic mammary glands compared with Muc1 null and wild-type animals. These results point to a novel function of increased MUC1 expression, potentiation of erbB signaling through the activation of mitogenic MAP kinase pathways.

Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 2: Controlled trial in multiple centres

OBJECTIVES

To assess the effectiveness of trained nurses based in general practices individually prescribing a home exercise programme to reduce falls and injuries in elderly people and to estimate the cost effectiveness of the programme.

DESIGN

Controlled trial with one year's follow up.

SETTING

32 general practices in seven southern New Zealand centres.

PARTICIPANTS

450 women and men aged 80 years and older.

INTERVENTION

330 participants received the exercise programme (exercise centres) and 120 received usual care (control centres); 87% (371 of 426) completed the trial.

MAIN OUTCOME MEASURES

Number of falls, number of injuries resulting from falls, costs of implementing the programme, and hospital costs as a result of falls.

RESULTS

Falls were reduced by 30% in the exercise centres (incidence rate ratio 0.70, 95% confidence interval 0.59 to 0.84). The programme was equally effective in men and women. The programme cost $NZ418 (121 pound sterling) (at 1998 prices) per person to deliver for one year or $NZ1519 (441 pound sterling) per fall prevented. Fewer participants had falls resulting in injuries, but there was no difference in the number who had serious injuries and no difference in hospital costs resulting from falls in exercise centres compared with control centres.

CONCLUSIONS

An individually tailored exercise programme, delivered by trained nurses from within general practices, was effective in reducing falls in three different centres. This strategy should be combined with other successful interventions to form part of home programmes to prevent falls in elderly people.

Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 1: Randomised controlled trial

OBJECTIVES

To assess the effectiveness of a trained district nurse individually prescribing a home based exercise programme to reduce falls and injuries in elderly people and to estimate the cost effectiveness of the programme.

DESIGN

Randomised controlled trial with one year's follow up.

SETTING

Community health service at a New Zealand hospital.

PARTICIPANTS

240 women and men aged 75 years and older.

INTERVENTION

121 participants received the exercise programme (exercise group) and 119 received usual care (control group); 90% (211 of 233) completed the trial.

MAIN OUTCOME MEASURES

Number of falls, number of injuries resulting from falls, costs of implementing the programme, and hospital costs as a result of falls.

RESULTS

Falls were reduced by 46% (incidence rate ratio 0.54, 95% confidence interval 0.32 to 0.90). Five hospital admissions were due to injuries caused by falls in the control group and none in the exercise group. The programme cost $NZ1803 (523 pound sterling) (at 1998 prices) per fall prevented for delivering the programme and $NZ155 per fall prevented when hospital costs averted were considered.

CONCLUSION

A home exercise programme, previously shown to be successful when delivered by a physiotherapist, was also effective in reducing falls when delivered by a trained nurse from within a home health service. Serious injuries and hospital admissions due to falls were also reduced. The programme was cost effective in participants aged 80 years and older compared with younger participants.

Practical implementation of an exercise-based falls prevention programme

Muscle weakness and impaired balance are risk factors underlying many falls and fall injuries experienced by older people. Fall prevention strategies have included exercise programmes that lower the risk of falling by improving strength and balance. We have developed an individually tailored, home-based, strength and balance retraining programme, which has proven successful in reducing falls and moderate fall injuries in people aged 80 years and older. Here we describe a simple assessment of strength and balance and the content and delivery of a falls prevention exercise programme.

Exercise in preventing falls and fall related injuries in older people: a review of randomised controlled trials

OBJECTIVE

To assess the effectiveness of exercise programmes in preventing falls (and/or lowering the risk of falls and fall related injuries) in older people.

DESIGN

A review of controlled clinical trials designed with the aim of lowering the risk of falling and/or fall injuries through an exercise only intervention or an intervention that included an exercise component.

MAIN OUTCOME MEASURES

Falls, fall related injuries, time between falls, costs, cost effectiveness.

SUBJECTS

A total of 4933 men and women aged 60 years and older.

RESULTS

Eleven trials meeting the criteria for inclusion were reviewed. Eight of these trials had separate exercise interventions, and three used interventions with an exercise programme component. Five trials showed a significant reduction in the rate of falls or the risk of falling in the intervention group.

CONCLUSIONS

Exercise is effective in lowering falls risk in selected groups and should form part of falls prevention programmes. Lowering fall related injuries will reduce health care costs but there is little available information on the costs associated with programme replication or the cost effectiveness of exercise programmes aimed at preventing falls in older people.

Adolescents with sickle cell disease: determinants of support group attendance and satisfaction

Support groups have the potential to mitigate some of the developmental and condition-specific psychological and social issues common to sickle cell disease (SCD), yet little is known about how adolescents with SCD view and use these groups. As part of a larger study, 79 adolescents with SCD completed questionnaires assessing reasons for attending or not attending support groups, level and type of help received from group participation, group satisfaction, and attendance. This article reports on findings descriptively. Professionals can enhance their effectiveness as providers of social and mental health services by understanding the role that support groups play in the overall well-being of adolescents with SCD.

Falls prevention over 2 years: a randomized controlled trial in women 80 years and older

BACKGROUND

after 1 year, a home-based programme of strength and balance retraining exercises was effective in reducing falls and injuries in women aged 80 years and older. The exercise programme had been individually prescribed by a physiotherapist during the first 2 months of a randomized controlled trial.

OBJECTIVE

we aimed to assess the effectiveness of the programme over 2 years.

SUBJECTS

women from both the control group and the exercise group completing a 1-year trial (213 out of the original 233) were invited to continue for a further year.

METHODS

falls and compliance to the exercise programme were monitored for 2 years.

RESULTS

81 (74%) in the control group and 71 (69%) in the exercise group agreed to continue in the study. After 2 years, the rate of falls remained significantly lower in the exercise group than in the control group. The relative hazard for all falls for the exercise group was 0.69 (95% confidence interval 0.49-0.97). The relative hazard for a fall resulting in a moderate or severe injury was 0.63 (95% confidence interval 0.42-0.95). Those complying with the exercise programme at 2 years had a higher level of physical activity at baseline, were more likely to have reported falling in the year before the study and had remained more confident in the first year about not falling compared with the rest of the exercise group.

CONCLUSIONS

falls and injuries can be reduced by an individually tailored exercise programme in the home. For those who keep exercising, the benefit continues over a 2-year period.

Psychotropic medication withdrawal and a home-based exercise program to prevent falls: a randomized, controlled trial

OBJECTIVE

To assess the effectiveness of psychotropic medication withdrawal and a home-based exercise program in reducing falls in older people.

DESIGN

A randomized controlled trial with a two by two factorial design.

SETTING

Seventeen general practices in Dunedin, New Zealand.

PARTICIPANTS

Women and men aged 65 years registered with a general practitioner and currently taking psychotropic medication (n = 93).

INTERVENTIONS

Two interventions: (1) gradual withdrawal of psychotropic medication versus continuing to take psychotropic medication (double blind) and (2) a home-based exercise program versus no exercise program (single blind).

MEASUREMENTS

Number of falls and falls risk during 44 weeks of follow-up. Analysis was on an intent to treat basis.

RESULTS

After 44 weeks, the relative hazard for falls in the medication withdrawal group compared with the group taking their original medication was .34 (95% CI, .16-.74). The risk of falling for the exercise program group compared with those not receiving the exercise program was not significantly reduced.

CONCLUSIONS

Withdrawal of psychotropic medication significantly reduced the risk of falling, but permanent withdrawal is very difficult to achieve.

Randomised controlled trial of a general practice programme of home based exercise to prevent falls in elderly women

OBJECTIVE

To assess the effectiveness of a home exercise programme of strength and balance retraining exercises in reducing falls and injuries in elderly women.

DESIGN

Randomised controlled trial of an individually tailored programme of physical therapy in the home (exercise group, n = 116) compared with the usual care and an equal number of social visits (control group, n = 117).

SETTING

17 general practices in Dunedin, New Zealand.

SUBJECTS

Women aged 80 years and older living in the community and registered with a general practice in Dunedin.

MAIN OUTCOME MEASURES

Number of falls and injuries related to falls and time between falls during one year of follow up; changes in muscle strength and balance measures after six months.

RESULTS

After one year there were 152 falls in the control group and 88 falls in the exercise group. The mean (SD) rate of falls was lower in the exercise than the control group (0.87 (1.29) v 1.34 (1.93) falls per year respectively; difference 0.47; 95% confidence interval 0.04 to 0.90). The relative hazard for the first four falls in the exercise group compared with the control group was 0.68 (0.52 to 0.90). The relative hazard for a first fall with injury in the exercise group compared with the control group was 0.61 (0.39 to 0.97). After six months, balance had improved in the exercise group (difference between groups in change in balance score 0.43 (0.21 to 0.65).

CONCLUSIONS

An individual programme of strength and balance retraining exercises improved physical function and was effective in reducing falls and injuries in women 80 years and older.

Elderly people who fall: identifying and managing the causes

Falls are not a mundane and inevitable consequence of ageing, but are a serious threat to the health and the independence of many older people. There is now very good evidence that the risk of falls can be significantly lowered by careful clinical evaluation and institution of a physical retraining programme.

Circumcision and informed consent. Is more information always better?

This study observes that physicians routinely inform parents about a small minority of the medical complications and risks associated with elective circumcisions. When selecting which medical complications to mention to parents, physicians appeared to use a policy based on their subjective assessment of the frequency and seriousness of the complications' occurrence. Subsequent analyses revealed that the physicians' probability estimates were biased and their seriousness assessments were consistently less than those expressed by mothers of newborn sons. Replacing the physicians' policy of partial disclosure with a comprehensive disclosure of "unbiased" information of possible risks and complications had no effect on the mothers' decisions to have their sons circumcised but did generate numerous influences on the mothers' attitudes. Among the effects observed in mothers were a reduction in their confidence in the appropriateness of their decision and a dissatisfaction with their physician's behavior. The implications of these findings to informed consent are discussed, and a greater flexibility in providing informed consent is advocated.

Control of arg gene expression in Salmonella typhimurium by the arginine repressor from Escherichia coli K-12

The regulation of synthesis of arg enzymes in Salmonella typhimurium by the arginine repressor of Escherichia coli K-12 has been reevaluated using a strain of S. typhimurium in which the argR gene was rendered nonfunctional by inserting the translocatable tetracycline-resistance element Tn10 into the argR gene. In contrast to previous studies, the introduction of the argR+ allelle of E. coli on an F-prime factor to the argR::Tn10 S. typhimurium strain reduced the synthesis of arg enzymes to essentially wild-type levels. The elevated levels of arg enzymes observed in other hybrid merodiploids may have been the consequence of the formation of hybrid repressor molecules. The readily scoreable phenotype of tetracycline resistance facilitated establishing linkage of cod and argR (0.6% cotransduction) by P22 phage-mediated transduction.

Abductor pollicis longus transfer for replacement of first dorsal interosseous

One of the tendinous slips of the abductor pollicis longus has been used to replace the first dorsal interosseous. One of the slips which does not insert on the first metacarpal is prolonged by a tendon graft through a subcutaneous tunnel to the insertion of the first dorsal interosseous. This technique has been used in 18 patients who have been followed from 2 to 12 years. All patients had improved stability in pinch, were able to abduct and to flex the index finger independently, and were satisfied with the results. No significant complications were encountered.

Localization of rabbit gamma globulins in the mouse visceral yolk sac placenta

The yolk sac placenta has been implicated previously in transmission of passive immunity to the fetus. This work uses an immunohistochemical technique devised by Sternberger et al. ('69) to study this problem. Rabbit serum containing gamma globulins was injected into the uterine lumen of the White Swiss mouse during the last third of pregnancy. Two or four hours later yolk sacs were removed and fixed in 2% paraformaldehyde or freeze-dried and fixed with paraformaldehyde vapors. Finely chopped tissue was treated with (1) sheep antiserum to rabbit serum gamma globulin, (2) an antigen-antibody complex consisting of horseradish peroxidase and rabbit anti-horseradish peroxidase and (3) hydrogen peroxide and 3,3'-diaminobenzidine. Reaction product was heavily concentrated in visceral yolk sac endodermal cells, frequently deposited in endothelial cells of vitelline vessels, and rarely in the serosal basement membrane and mesothelial cells which border the exocoelomic cavity. This supports evidence of other workers that the yolk sac membrane rapidly absorbs substances with which it comes in contact, transport into vitelline vasculature is a route of transfer from mother to fetus, and possible transfer into the exocoelomic cavity and thence to the amniotic cavity may occur in mice.