Views of Specialist Clinicians and People With Multiple Sclerosis on Upper Limb Impairment and the Potential Role of Virtual Reality in the Rehabilitation of the Upper Limb in Multiple Sclerosis: Focus Group Study

BACKGROUND

Finding enjoyable and effective long-term approaches to rehabilitation for improving the upper limb (UL) function of people with multiple sclerosis (MS) is challenging. Using virtual reality (VR) could be a solution to this challenge; however, there is a lack of reporting on the views of people with MS and clinicians on VR-based approaches and recommendations for games for rehabilitation.

OBJECTIVE

This study aims to identify common UL problems and their related current therapeutic approaches for people with MS, and to explore the opinions of people with MS and specialist clinicians on VR and obtain suggestions for the development and design of VR games.

METHODS

Separate focus groups were conducted with people with MS, recruited through the MS Society UK's research network, and clinicians, recruited through the MS Trust Therapists in MS network. A total of 10 people with MS (2 focus groups) and 8 clinicians (5 physiotherapists, 2 occupational therapists, and 1 MS nurse in 2 focus groups) were involved. The focus groups were recorded and transcriptions were analyzed using theme-based content analysis.

RESULTS

People with MS commonly reported that their UL problems interfered with activities of daily living and resulted in the loss of meaningful hobbies such as writing. Many people with MS neglected UL exercise and found strategies for adapting to the UL impairments. Similarly, clinicians stated UL rehabilitation was neglected within their service and that it was challenging to find interesting treatment strategies. VR was suggested by both participant groups as a solution, as it was convenient for people with MS to access and it could provide a more engaging and disguised approach to exercise. There were shared concerns with cybersickness and disengagement with using VR approaches. Both groups agreed games should be meaningful and adaptable for users but suggested different VR activities, with clinicians suggesting games directly reflecting activities of daily living and people with MS suggesting more abstract activities.

CONCLUSIONS

VR was well received by both people with MS and clinicians for UL rehabilitation. Recommendations were made for the development of VR rehabilitation games which are personalized and customizable for the varying abilities of people with MS.

Intensity-modulated radiotherapy and chemotherapy for canine right atrial tumors: A retrospective study of seven dogs

Most primary cardiac tumors in dogs are located in the right atrium/atrial appendage, with hemangiosarcoma being the most common. The aims of this retrospective, case series were to describe outcomes for seven dogs with right atrial tumors treated with hypofractionated intensity-modulated radiotherapy and concurrent vinblastine and propranolol. One dog had a complete response, four dogs had partial responses and two dogs had stable disease after treatment. Effusions resolved in all dogs. Median progression-free survival was 290 days. Five dogs died from metastatic disease, one dog from unrelated neoplasia, and one dog is alive. Median overall survival was 326 days. Three dogs with confirmed hemangiosarcoma survived 244, 326, and 445 days. Two dogs developed clinically significant, but nonfatal, cardiac arrhythmias. One dog that received three courses of radiation had subclinical myocardial and arterial fibrosis at necropsy. Hypofractionated chemoradiotherapy was well tolerated and may provide clinical benefit in dogs with right atrial tumors.

Development and evaluation of a novel educational program for providers on the use of polygenic risk scores

PURPOSE

This study aimed to develop an online educational program for using PRS for breast and ovarian cancer risk-assessments and evaluate the impact on genetic healthcare providers' (GHP) attitudes, confidence, knowledge, and preparedness.

METHODS

The educational program comprised of an online module covering theoretical aspects of PRS, and a facilitated virtual workshop with pre-recorded roleplays and case discussions. Data were collected in pre-and post-education surveys. Eligible participants were GHPs working in Australian familial cancer clinics registered to recruit patients for a breast and ovarian cancer PRS clinical trial (n=12).

RESULTS

124 GHPs completed the PRS education, of whom 80 (64%) and 67 (41%) completed the pre-and post-education surveys, respectively. Pre-education, GHPs reported limited experience, confidence and preparedness using PRS, but recognized its potential benefits. Post-education GHPs indicated improved attitudes (p=<0.001), confidence (p=<0.001), knowledge (p=<0.001), and preparedness (p=<0.001) to use PRS. Most GHPs felt the program entirely met their learning needs (73%) and was completely relevant to their clinical practice (88%). GHPs identified PRS implementation barriers, including limited funding models, diversity issues, and need for clinical guidelines.

CONCLUSIONS

Our education program improved GHP attitudes, confidence, knowledge, and preparedness for using PRS/personalized risk and provides a framework for development of future programs.

Tomotherapy Applied Total Lymphoid Irradiation and Allogeneic Hematopoietic Cell Transplantation Generates Mixed Chimerism in the Rhesus Macaque Model

Development of a new methodology to induce immunological chimerism after allogeneic hematopoietic cell (HC) transplantation in a rhesus macaque model is described. The chimeric state was achieved using a non-myeloablative, helical tomotherapy-based total lymphoid irradiation (TomoTLI) conditioning regimen followed by donor HC infusions between 1-haplotype matched donor/recipient pairs. The technique was tested as a feasibility study in an experimental group of seven rhesus macaques that received the novel TomoTLI tolerance protocol and HC allo-transplants. Two tomotherapy protocols were compared: TomoTLI (n = 5) and TomoTLI/total-body irradiation (TBI) (n = 2). Five of seven animals developed mixed chimerism. Three of five animals given the TomoTLI protocol generated transient mixed chimerism with no graft-versus-host disease (GVHD) with survival of 33, 152 and >180 days. However, the inclusion of belatacept in addition to a single fraction of TBI resulted in total chimerism and fatal GVHD in both animals, indicating an unacceptable conditioning regimen.

Definitive-intent intensity modulated radiotherapy for modified-Adams' stage 4 canine sinonasal cancer: A retrospective study of 29 cases (2011-2017)

Dogs with sinonasal tumors with cribriform plate lysis (modified Adams' stage 4) treated with non-conformal definitive radiotherapy (RT) have short median survivals of 6-7 months. Intensity-modulated radiotherapy with its greater conformality and tumor dose homogeneity may result in more favorable outcomes. Dogs with epithelial or mesenchymal sinonasal tumors and CT evidence of cribriform lysis that received 10 daily fractions of 4.2 Gray using IMRT by helical tomotherapy were included in this single-institution retrospective case series study. Dogs with distant metastasis, previous treatment, or concurrent chemotherapy were excluded. Based on CT, tumors were divided into two groups: cribriform plate lysis only (stage 4a) or intracranial extension (stage 4b). Twenty-nine dogs were included, 23 with carcinoma and six with sarcoma. Eight dogs had stage 4b tumors; two presented with neurologic signs. Two dogs had lymph node metastasis at diagnosis, one confirmed and one suspected. Radiation dose distributions were standardized and patient positioning for RT was verified daily using on-board megavoltage CT. All evaluable dogs had improvement of clinical signs. Median progression free survival was 177 days (95% CI, 128-294 days). Median overall survival was 319 days (95% CI, 188-499 days). Radiotherapy was well tolerated. The most common side effect was grade 1 or 2 oral mucositis. Two dogs that received additional treatment at progression (stereotactic RT [1]; surgery [1]) developed significant late effects. Image-guided definitive-intent IMRT may improve survival in dogs with modified Adams' stage 4 sinonasal tumors and is associated with low morbidity. Intracranial tumor extension was not prognostic in this cohort of uniformly treated dogs.

Volumetric tumor response assessment is inefficient without overt clinical benefit compared to conventional, manual veterinary response assessment in canine nasal tumors

Accurate assessment of tumor response to therapy is critical in guiding management of veterinary oncology patients and is most commonly performed using response evaluation criteria in solid tumors criteria. This process can be time consuming and have high intra- and interobserver variability. The primary aim of this serial measurements, secondary analysis study was to compare manual linear tumor response assessment to semi-automated, contoured response assessment in canine nasal tumors. The secondary objective was to determine if tumor measurements or clinical characteristics, such as stage, would correlate to progression-free interval. Three investigators evaluated paired CT scans of skulls of 22 dogs with nasal tumors obtained prior to and following radiation therapy. The automatically generated tumor volumes were not useful for canine nasal tumors in this study, characterized by poor intraobserver agreement between automatically generated contours and hand-adjusted contours. The radiologist's manual linear method of determining response evaluation criteria in solid tumors categorization and tumor volume is significantly faster (P < .0001) but significantly underestimates nasal tumor volume (P < .05) when compared to a contour-based method. Interobserver agreement was greater for volume determination using the contour-based method when compared to response evaluation criteria in solid tumors categorization utilizing the same method. However, response evaluation criteria in solid tumors categorization and percentage volume change were strongly correlated, providing validity to response evaluation criteria in solid tumors as a rapid method of tumor response assessment for canine nasal tumors. No clinical characteristics or tumor measurements were significantly associated with progression-free interval.

Clinical Implementation of Adaptive Helical Tomotherapy: A Unique Approach to Image-Guided Intensity Modulated Radiotherapy

Image-guided IMRT is a revolutionary concept whose clinical implementation is rapidly evolving. Methods of executing beam intensity modulation have included individually designed compensators, static multi-leaf collimators (MLC), dynamic MLC, and sequential (serial) tomotherapy. We have developed helical tomotherapy as an innovative solution to overcome some of the limitations of other IMRT systems. The unique physical design of helical tomotherapy allows the realization of the concepts of adaptive radiotherapy and conformal avoidance. In principle, these advances should improve normal tissue sparing and permit dose reconstruction and verification, thereby allowing significant biologically effective dose escalation.

Recent radiobiological findings can be translated into altered fractionation schemes that aim to improve the local control and long-term survival. This strategy is being tested at the University of Wisconsin using helical tomotherapy with its highly precise delivery and verification system along with meticulous and practical forms of immobilization. Innovative techniques such optical guidance, respiratory gating, and ultrasound assessments are being designed and tailored for helical tomotherapy use. The intrinsic capability of helical tomotherapy for megavoltage CT (MVCT) imaging for IMRT image-guidance is being optimized.

The unique features of helical tomotherapy might allow implementation of image-guided IMRT that was previously impossible or impractical. Here we review the technological, physical, and radiobiological rationale for the ongoing and upcoming clinical trials that will use image-guided IMRT in the form of helical tomotherapy; and we describe our plans for testing our hypotheses in a rigorous prospective fashion.

Image-guided stereotactic radiotherapy in 4 dogs with intracranial neoplasia

The purpose of this study was to describe the use, and side effects, of a novel stereotactic radiotherapy protocol using TomoTherapy(®) in 4 dogs with confirmed or suspected primary extra-axial intracranial neoplasia. Three fractions of 8 Gy were prescribed. Acute side effects were noted in 1 dog; no late effects were noted.

Predicting location of recurrence using FDG, FLT, and Cu-ATSM PET in canine sinonasal tumors treated with radiotherapy

Dose painting relies on the ability of functional imaging to identify resistant tumor subvolumes to be targeted for additional boosting. This work assessed the ability of FDG, FLT, and Cu-ATSM PET imaging to predict the locations of residual FDG PET in canine tumors following radiotherapy. Nineteen canines with spontaneous sinonasal tumors underwent PET/CT imaging with radiotracers FDG, FLT, and Cu-ATSM prior to hypofractionated radiotherapy. Therapy consisted of 10 fractions of 4.2 Gy to the sinonasal cavity with or without an integrated boost of 0.8 Gy to the GTV. Patients had an additional FLT PET/CT scan after fraction 2, a Cu-ATSM PET/CT scan after fraction 3, and follow-up FDG PET/CT scans after radiotherapy. Following image registration, simple and multiple linear and logistic voxel regressions were performed to assess how well pre- and mid-treatment PET imaging predicted post-treatment FDG uptake. R(2) and pseudo R(2) were used to assess the goodness of fits. For simple linear regression models, regression coefficients for all pre- and mid-treatment PET images were significantly positive across the population (P < 0.05). However, there was large variability among patients in goodness of fits: R(2) ranged from 0.00 to 0.85, with a median of 0.12. Results for logistic regression models were similar. Multiple linear regression models resulted in better fits (median R(2) = 0.31), but there was still large variability between patients in R(2). The R(2) from regression models for different predictor variables were highly correlated across patients (R ≈ 0.8), indicating tumors that were poorly predicted with one tracer were also poorly predicted by other tracers. In conclusion, the high inter-patient variability in goodness of fits indicates that PET was able to predict locations of residual tumor in some patients, but not others. This suggests not all patients would be good candidates for dose painting based on a single biological target.

Dementia knowledge transfer project in a rural area

INTRODUCTION

Rural Scotland has an ageing population. There has been an increase in the number of people with dementia and as the proportion of people aged over 75 years continues to rise, this will increase still further. The Scottish Government has produced a dementia strategy and implementing this will be a challenge for rural Scotland.

METHODS

Transferring academic knowledge into practice is challenging. A Knowledge Transfer Partnership was formed between NHS Highland and the University of Stirling. A literature review was undertaken of the rural dementia literature; local services were surveyed and described; and interviews were undertaken with people with dementia and carers. Work was conducted on training, diagnostic service provision and local policy. Throughout the project, a collaborative approach was used, which aimed at the joint production of knowledge.

RESULTS

Involving University staff in local service development had a substantial impact. Reviewing existing research knowledge and setting it in the context of local services, and of experience of service use, allowed the relevant priorities to be identified. As well as identifying training needs and providing training, the work influenced local decisions on diagnostic service design and standards, and on policy.

CONCLUSION

This embedded engagement model appeared to produce more rapid change than traditional models of use of academic knowledge.

Ecstasy-induced thyrotoxic periodic paralysis

A 21-year-old Caucasian man had recurrent hospital admissions for thyrotoxic periodic paralysis (TPP). He was poorly compliant with carbimazole treatment and admitted to recreational ecstasy use the night prior to each admission. This is the first time that ecstasy has been identified as a precipitant of TPP.

Four-fraction radiation therapy for macroscopic soft tissue sarcomas in 16 dogs

A retrospective study of 16 dogs with macroscopic soft tissue sarcomas was performed to evaluate response to a four-fraction radiotherapy protocol (prescribed dose of 32 Gy). Radiation was well tolerated with minimal side effects. The overall response rate was 50%, with seven partial responses and one complete response. The median time to progression was 155 days, and the median survival time was 309 days. Coarsely fractionated radiation therapy may be a reasonable palliative option for dogs with unresectable soft tissue sarcomas, although the response is relatively short-lived.

Prediction in breast cancer of the extent of axillary node involvement from the size and lymphovascular invasion status of the primary tumour: Medico-legal considerations

AIM

To ascertain for medico-legal purposes in the United Kingdom, the extent to which in breast cancer primary tumour size and lympho-vascular invasion (LVI) status determine axillary node staging.

METHODS

Four hundred and fifty symptomatic patients had their tumour sizes stratified into 1cm ranges and the percentage incidence/probability of the axillary stage being 1, 2 or 3 was calculated separately for those tumours that showed no evidence of LVI and those that did.

RESULTS

The presence of LVI has a marked effect on the likelihood and extent of axillary node involvement for all primary tumour sizes.

CONCLUSIONS

This needs to be recognized and quantified when prediction of this extent is made for medico-legal purposes. Within the constraints of the 'balance of probabilities' argument in UK law, it is rarely possible to differentiate between the likelihood of the axillary stage being 2 or 3.

Image guidance for precise conformal radiotherapy

PURPOSE

To review the state of the art in image-guided precision conformal radiotherapy and to describe how helical tomotherapy compares with the image-guided practices being developed for conventional radiotherapy.

MATERIALS AND METHODS

Image guidance is beginning to be the fundamental basis for radiotherapy planning, delivery, and verification. Radiotherapy planning requires more precision in the extension and localization of disease. When greater precision is not possible, conformal avoidance methodology may be indicated whereby the margin of disease extension is generous, except where sensitive normal tissues exist. Radiotherapy delivery requires better precision in the definition of treatment volume, on a daily basis if necessary. Helical tomotherapy has been designed to use CT imaging technology to plan, deliver, and verify that the delivery has been carried out as planned. The image-guided processes of helical tomotherapy that enable this goal are described.

RESULTS

Examples of the results of helical tomotherapy processes for image-guided intensity-modulated radiotherapy are presented. These processes include megavoltage CT acquisition, automated segmentation of CT images, dose reconstruction using the CT image set, deformable registration of CT images, and reoptimization.

CONCLUSIONS

Image-guided precision conformal radiotherapy can be used as a tool to treat the tumor yet spare critical structures. Helical tomotherapy has been designed from the ground up as an integrated image-guided intensity-modulated radiotherapy system and allows new verification processes based on megavoltage CT images to be implemented.

Arteriovenous fistula of the lateral superior and inferior geniculate arteries. A unique cause of a "recurrent prepatellar bursa

We report a previously undocumented case of an arteriovenous fistula of the superior and inferior lateral geniculate arteries presenting with what was thought to be a recurrent prepatellar bursa requiring repeated drainage and excision. The diagnosis was made by arteriography. Surgical exploration and ligation of the feeding and draining vessels, via a posterior approach, alleviated the symptoms. Vascular injury should be suspected in patients presenting with recurrent postoperative hematomas or hemarthroses following surgery on the knee.

Eyelid lymphatics II: a search for drainage patterns in the monkey and correlations with human lymphatics

PURPOSE

To study the lymphatic drainage of the cynomolgus monkey through the use of lymphoscintigraphy.

METHODS

Lymphoscintigraphy with 500 microCi of 99mTechnetium sulfur colloid injected at specific sites around the eyelids was performed with five cynomolgus monkeys in lateral and ventral positions.

RESULTS

Lymphoscintigraphy of the monkey eyelid and periocular tissue revealed lymphatic drainage to the parotid lymph nodes from the entire upper eyelid, medial canthus, and lateral lower eyelid and drainage to the submandibular lymph nodes from the medial and central lower eyelid. In addition to draining to the parotid lymph nodes, the central upper eyelid was also seen to drain to the submandibular lymph nodes.

CONCLUSIONS

Lymphoscintigraphy of the cynomolgus monkey eyelids reveals discrete lymphatic drainage pathways for the upper and lower eyelids and a dual pathway for the central upper eyelid. Future studies will help to clarify the lymphatic drainage pathways of human eyelids.

Eyelid lymphatics I: histochemical comparisons between the monkey and human

PURPOSE

To study the lymphatic drainage of the cynomolgus monkey and human eyelid and periocular tissue by means of histochemistry.

METHODS

Eyelid and periocular tissue from three cynomolgus monkeys undergoing sacrifice for glaucoma and retina research purposes and discarded tissue from a wedge resection of one human eyelid were used for histochemical analysis. Lymphatic capillaries were distinguished histochemically in monkey and human eyelids by light microscopy with a 5'-nucleotidase (5'-Nase) staining method. Identification of lymphatic vessels was based on strict morphologic criteria combined with specific 5'-Nase staining.

RESULTS

Histochemical analysis with 5'-nucleotidase revealed a subcutaneous and pretarsal lymphatic plexus in both the human and monkey.

CONCLUSIONS

Histochemical results demonstrate similar lymphatic plexi in the monkey and human. Future studies will help to clarify the lymphatic drainage pathways of monkey and human eyelids.

Impulsiveness and compulsiveness in alcoholics and nonalcoholics

Impulsiveness and compulsiveness questionnaires were completed by recovering alcoholics (n = 54) and by a community sample (n = 351). No relationship was found, indicating these traits are independent, distinct constructs. Alcoholics scored significantly higher on impulsiveness than nonalcoholics, and impulsiveness was negatively associated with age for both groups. Interestingly, the significant difference between the two groups on impulsiveness was maintained across age groups. Alcoholic and nonalcoholic compulsiveness scores showed no difference; however, compulsiveness was negatively related to age in nonalcoholics, but not alcoholics.

Characterization of the renal portal system of the common green iguana (Iguana iguana) by digital subtraction imaging

Digital subtraction angiography was used to map the venous blood flow from the pelvic limb and the tail in the common green iguana (Iguana iguana). The majority of blood returning from the pelvic limb bypassed the kidney and entered the general circulation, whereas venous blood flow from the tail entered the renal portal circulation. No evidence was found of a renal portal valve.

Compulsiveness and impulsiveness: unidimensional or bidimensional constructs?

The correlation of scores on the Obsessive-Compulsive Scale and the Barrett Impulsiveness Scale for 148 men and 255 women (18-84 years) was -.07, and both scores decreased across age groups, but age accounted for only 3% and 1.8% of the variance.