• A Beta Test of a Computer-Assisted Instruction Module in Improving Dermatologic Physical Exam Skills in Third Year Medical Students

      Baldor, Robert; Domino, Frank; Deligiannidis, Konstantinos (2004-06-01)
      Introduction: Third year medical students at UMass. Medical School have only a brief exposure to dermatology during their first two years, resulting in limited skills in dermatology physical diagnosis. While other skills of the physical exam – e.g. the cardiac exam, the abdominal exam – are taught in the first 2 years and are applied and refined with repetition and instruction during students’ clinical rotations, dermatology remains limited in its exposure and instruction during the third year. This may prevent students from gaining the needed physical diagnosis skills in this important clinical area. Given this scenario, a computer-assisted instruction module was created and beta-tested to improve students’ physical diagnosis skills in dermatology. Method:A computer-based dermatology physical diagnosis presentation was created using Microsoft PowerPoint to instruct third year medical students in dermatology physical exam skills. Each slide presented students with a dermatology physical exam finding, a brief description, and a picture. In order to test the students’ knowledge of dermatology physical exam findings, a 23-item multiple-choice exam was created using XCom Exam Composer. 9 questions dealt with knowledge of verbal descriptions of lesions, while 14 questions dealt with the identification of lesions. The test was administered both before and after the presentation to 15 students taking a required 6-week Family Medicine clerkship at UMass. Medical School. Results:13 out of the 15 sampled students completed the curriculum. The average pre-test score was 18.4/23 questions correct (80%); the average post-test score was 20.5/23 questions correct (89.1%) - with an average improvement of 2.1 points (9.1%). These results (i.e., the increase in scores post-test) were statistically significant using both a parametric paired t-test (t = 2.720; p=.019) as well as a non-parametric Wilcoxon Signed Ranks Test to take the small sample size into account (z = 2.508; p=.012). Discussion: This computer-assisted instruction in dermatology significantly improved students’ physical exam skills, as measured by this multiple-choice exam. Informal comments were positive: students enjoyed the module, and appreciated the increased exposure to dermatology. Future studies are needed to evaluate student experience during this module, as well as their competence and confidence in diagnosing dermatologic lesions. Also, the Family Medicine Clerkship faculty intends to evaluate this module with a larger population of students, including those at different stages of their third year medical training, in order to examine the module’s effects. Furthermore, studies using a larger population are needed to evaluate the benefit and cost-effectiveness of this computer-assisted instruction program versus traditional book-based instruction.
    • A comparison of exercise-induced hematocrit (Hct) changes between non-invasive infrared sensors (NIRS) and venous blood draws

      Soller, Babs; Johnson, Kenneth E. (2006-06-01)
      Background:Near Infrared spectroscopy (NIRS) uses the principle of light absorbance by hemoglobin, coupled with complex mathematical algorithms, to obtain a relative value of the blood’s hematocrit (Hct), a reflection of its oxygen carrying capacity. Because of the rapid, non-invasive nature of NIRS, it could be very useful in a variety of clinical settings for determining patients’ homological status and immediate response to treatment (e.g. during shock and trauma). Objectives:To compare the Hct values calculated using the NIRS sensor with those obtained from venous blood samples, the ultimate goal being to develop an NIRS system that accurately and continuously determines a patient’s hematocrit. Methods:Healthy volunteer subjects (n=5) were challenged with a one-handed grip exercise test, with the NIRS sensor secured to the subjects’ forearm. Subjects underwent four separate exercise sessions, each of five minutes duration and separated by thirty minute intervals. NIRS readings were taken immediately before each session (baseline values). They were then taken every minute during the exercise period, and subsequently averaged (exercise values). Venous blood samples were also taken from the same arm at each of these time points. Each blood sample was drawn into three microcapillary tubes, centrifuged, and measured on a capillary tube reader scaled for hematocrit. Results: For the NIRS data, the Hct values consistently decreased with exercise amongst all five patients. On average, the NIRS values decreased by 0.004 points of the readout (P Conclusion:Based on this set of values, there was a lack of consistency between Hct values obtained by NIRS and those taken from venous blood samples, as they trended in opposite directions. Though this was a small sample size, these differences were statistically significant and were seen consistently amongst all subjects. Further subject trials must be conducted, as well as continued work on the mathematical algorithms, to determine if a direct correlation in Hct values determined by these two techniques can be consistently recorded.
    • A Lymphocyte Surface Protein Produces the Signaling Molecule Poly (ADP-ribose) from NAD

      Rossini, Aldo; Morrison, Alan R. (2005-06-01)
      Elucidation of signaling pathways that prevent immune cells from damaging self-tissue could help target diseases like lupus and juvenile diabetes. Through one such pathway, NAD and its metabolites appear to inhibit T cells of the immune system. NAD is a substrate for two enzyme families that covalently transfer ADP-ribose from NAD to acceptor proteins -- mono-ADP-ribosyl transferases (mARTs) and poly(ADP-ribose) polymerases (PARPs). PARPs distinguish themselves by polymerizing ADP-ribose on the acceptor proteins. Despite differences in amino acid sequences, mARTs and PARPs have similar structural elements in their catalytic cores. Here we report that in the presence of NAD, ART2, a mART and T cell surface protein, forms ADP-ribose polymers on an arginine in a crucial loop of its catalytic core. ART2 appears to be the first hybrid between the mARTs and PARPs, and structural data suggest a mechanism for polymerization activity. The data suggest that signaling with NAD metabolites like ADP-ribose may be a more versatile process than previously recognized, and that molecules like ART2 may have the potential to participate in novel immune cell signaling pathways.
    • A National Survey of Oral Health Curriculum in All U.S. Allopathic and Osteopathic Medical Schools

      Silk, Hugh; Savageau, Judith A.; Ferullo, Ashley; Silk, Hugh; Savageau, Judith A. (2010-05-01)
      Background:Oral Health (OH) is an important topic and area of medicine that all physicians should understand and that has become a more pressing issue in the last decade. OH is clearly tied to overall health and a number of systemic diseases, such as diabetes, immune disorders and infectious diseases, are known to have oral manifestations. Likewise, a number of oral diseases have systemic manifestations. (Migliorati, 2007). Oral disease and oral health issues affect all ages from infancy through adulthood. Childhood caries affect up to 25% of children in the U.S. and can lead to a lifetime of other oral health issues (Vargas, 2006). Given these known issues, the Association of American Medical Colleges (AAMC) published Report IX: Contemporary Issues in Medicine: Oral Health Education for Medical and Dental Students in 2008, which challenged medical schools to revise their curricula to include oral health education. The report outlined the necessary changes to a school’s curriculum to provide students with adequate OH training. This report was in response to the 2000 Surgeon General’s Oral Health in America Report and the 2003 A National Call to Action to Promote Oral Health which helped to make the medical and dental communities aware of the fact that they should be trained to provide adequate oral health care. In addition, the USMLE Step 2CK and Step 3 exams include oral health topics, also making it evident that medical students should be learning oral health subjects during their training. There are some existing oral health curricula, such as the Academy of Pediatrics (AAP) modules on pediatric oral health and care and the Society of Teachers in Family Medicine’s (STFM) Smiles for Life comprehensive oral health curriculum, of which some schools are taking advantage. However, it is unclear to what extent medical schools have actually integrated oral health topics into their curricula to adequate train their students. Objective:The objective of our survey was to determine the extent to which U.S. allopathic and osteopathic schools are including oral health in their curricula. We specifically were interested in finding out how much time is dedicated to oral health and which topics are being covered, as well as finding out if schools who have not implemented OH are aware of the current guidelines. We also wanted to determine what the level of interest for developing stronger OH curricula is at the schools with no or little OH curriculum. Methods:Via web search and phone contacts, the ‘Dean of Education’ at all U.S. allopathic and osteopathic schools was identified. A 22-question survey was constructed to elicit demographic information about the school and information about its oral health curriculum (e.g., hours of oral health education, topics covered, and student evaluations about oral health). Other questions included: awareness of USMLE topics in oral health, the existence of the AAMC’s report encouraging OH curriculum development, awareness of existing oral health curriculum, current use of existing curriculum and plans to develop or expand curriculum at their institution. The survey was put into SurveyMonkey format to be sent to schools via e-mail. The survey was pilot tested with 10 New England schools to gauge implementation issues, response rates and ease of completing the 15-minute survey. Once revisions were made for clarity, the survey was emailed to the remaining 154 Deans of Education (at 126 allopathic and 28 osteopathic schools) with an email explaining the purpose of the study. One week prior to the distribution of the survey link, an email announcing the upcoming survey was sent to all schools. We sent a reminder email to non-respondents (with the survey link) every 2 weeks for a total of 3 reminders. A final phone call was made to each non-responding school to encourage participation. Descriptive univariate analyses were done using SPSS statistical software. This data was then assessed using chi-square tests and t-tests to examine relationships with school size, school location and the presence of an established affiliation with either a dental school or dental residency using an alpha of .05 to denote statistical significance. Results:A total of 88 schools replied to the survey out of the 154 schools contacted (response rate: 57.1%). Of the 88 schools, 72 Allopathic schools and 13 Osteopathic schools replied; the remaining 3 were unknown. All regions of the country were represented with slightly higher responses from the Midwest region (29.6%) and lower responses from the Western region (12.5%). Response rates increased with increasing class size; the majority (55.7%) of respondents being from schools with more than 150 students. Most of the responding schools did not have an affiliated dental school (70.5%) nor a dental residency (62.5%). Finally, most schools offered either 1-2 hours (28.4%) or 3-4 hours (30.7%) of oral health curriculum over a student’s four years; one in 10 schools (10.2%) offered no oral health curriculum hours. An analysis of the relationship between demographic information and the number of current hours of oral health curriculum (less than 5 hours or greater than 5 hours) found that hours of curriculum was statistically significantly related to matriculating class size (p=.022). Schools with greater than 150 students were more likely to offer 5 or more hours of oral health curriculum than small or mid-size schools. School location and having a dental residency and/or school were not found to be statistically significantly related to number of hours of oral health curriculum (p=.728 and p=.271, respectively). Awareness of oral health questions on the USMLE board exams and/or the AAMC Report on Oral Health Education was also not associated with curriculum volume. In schools with an OH curriculum, topics being covered ranged from 10.0% teaching hands-on skills training to 81.7% covering oral cancers. Only 29.9% reported evaluating students around OH topics. Conclusions:Few medical and osteopathic schools are currently providing more than 4 hours of oral health curriculum. Only large school size seems to have a positive association with more oral health curriculum. Fewer still are conducting rigorous evaluations of such education. Being aware of the AAMC Report on oral health education or that the USMLE has test questions on oral health, or being affiliated with a dental school or residency did not have a positive effect on the quantity of oral health curriculum. Future educational efforts should utilize these results to create a strategy aimed at promoting an awareness of oral health education requirements, training materials and potential oral health educational champions. Presented as part of the Senior Scholars Program at the University of Massachusetts Medical School, May 3, 2010.
    • A predictive model of cochlear implant performance in postlingually deafened adults

      Sarah Poissant; Roditi, Rachel E.; Poissant, Sarah F.; Bero, Eva M.; Lee, Daniel J. (Lippincott Williams & Wilkins, 2009-06-01)
      OBJECTIVE: To develop a predictive model of cochlear implant (CI) performance in postlingually deafened adults that includes contemporary speech perception testing and the hearing history of both ears. STUDY DESIGN: Retrospective clinical study. Multivariate predictors of speech perception after CI surgery included duration of any degree of hearing loss (HL), duration of severe-to-profound HL, age at implantation, and preoperative Hearing in Noise Test (HINT) sentences in quiet and HINT sentences in noise scores. Consonant-nucleus-consonant (CNC) scores served as the dependent variable. To develop the model, we performed a stepwise multiple regression analysis. SETTING: Tertiary referral center. PATIENTS: Adult patients with postlingual severe-to-profound HL who received a multichannel CI. Mean follow-up was 28 months. Fifty-five patients were included in the initial bivariate analysis. INTERVENTION(S): Multichannel cochlear implantation. MAIN OUTCOME MEASURES(S): Predicted and measured postoperative CNC scores. RESULTS: The regression analysis resulted in a model that accounted for 60% of the variance in postoperative CNC scores. The formula is (pred)CNC score = 76.05 + (-0.08 x DurHL(CI ear)) + (0.38 x pre-HINT sentences in quiet) + (0.04 x long sev-prof HL(either ear)). Duration of HL was in months. The mean difference between predicted and measured postoperative CNC scores was 1.7 percentage points (SD, 16.3). CONCLUSION: The University of Massachusetts CI formula uses HINT sentence scores and the hearing history of both ears to predict the variance in postoperative monosyllabic word scores. This model compares favorably with previous studies that relied on Central Institute for the Deaf sentence scores and uses patient data collected by most centers in the United States.
    • A Qualitative Study of the Collaboration between Health Care Providers and Lawyers within the Family Advocates of Central Massachusetts Program

      Keller, David; Hargreaves, Allison M. (2006-06-01)
      Background:Family Advocates of Central Massachusetts (FACM) is a medical-legal collaborative between pediatric health care providers and lawyers at Legal Assistance Corporation of Central Massachusetts. The program is designed to assist disadvantaged families, and more specifically, to improve the health of children which is often impacted by legal issues. A needs assessment conducted by medical students in four pediatrics practices in the summer of 2003 determined that 50% of the approximately 80 families interviewed required referrals for legal services (Dhruvakumar et al. 2003). Reasons for referral fall under the broad categories of housing, financial stability (including benefits, employment, nutrition), dignity and safety (including domestic violence and immigration issues), and access to health care and educational services. In the two and one-half years since the inception of FACM, which now involves five pediatrics practices in central Massachusetts, fewer referrals than projected have been generated by health care providers (Keller et al. 2005). A recent study used the Massachusetts Advocacy Screening Questionnaire (MASQ), a self-administered survey, to assess the need for a legal referral among families waiting to see a health care provider. Following the clinical encounter, the provider was then asked whether the patient’s family required a referral for legal services. While the MASQ identified more patients potentially in need (sensitivity 0.81 for the MASQ and 0.65 for providers), health care provider assessment was similar to the MASQ in identifying patients who ultimately agreed to a referral (specificity 0.75 for the MASQ and 0.95 for providers), indicating that under-identification is only part of the problem. Other factors must be contributing to the lower-than-predicted referral rate. Ascertaining these factors may lead to improvements in the FACM medical-legal collaborative. Objectives:The goal of this qualitative study is to find out how FACM can enhance the collaboration between health care providers and lawyers advocating for low-income families with legal issues. The study utilizes focus groups of health care providers to uncover what is working, what is not working, and what improvements can be made to FACM. The information obtained can then be directly applied to FACM, providing the changes needed to create a more successful collaboration. Methods:The project proposal, recruitment letter, consent form, focus group script, and post-focus group demographics questionnaire were drafted and submitted to the IRB for approval, which was granted. Each of the five pediatrics practices within FACM received a letter and follow-up e-mail inviting health care providers and interested staff to participate in a research study. Targeted subjects included attending physicians, residents, nurse practitioners, nurses, medical assistants, social workers, care coordinators, and any other interested staff. Each volunteer was asked to sign a consent form in order to participate in a 60-minute focus group. The groups were asked a series of questions from a script, which generated discussion among the participants. Subjects offered their opinions of FACM as well as suggestions for improvement in answer to questions and prompts provided by the moderator. Each participant was then asked to complete a questionnaire for demographics purposes. All focus groups were recorded on two separate audio tapes and were transcribed by the co-investigator. Each of the transcripts was then analyzed by the primary investigator, co-investigator, and one of FACM’s legal partners using content analysis, in which the data was organized into categories and themes related to the key questions of the study. Results:Three focus groups and one extended in-depth interview were conducted. Focus groups took place at South County Pediatrics in Webster, Community Health Center in Fitchburg, and Family Health Center in Worcester with 5, 9, and 6 participants respectively. And extended in-depth interview with 2 participants was conducted at Pediatric Primary Care in Worcester. Community Pediatrics in Milford did not respond to the invitation to participate in the study. There were 22 participants in total: 5 attending physicians, 2 residents, 2 nurse practitioners, 5 nurses, 3 social workers, 2 care coordinators, 2 advocates, and 1 medical assistant. 18 participants were female and 4 were male. 12 had previously attended a FACM training session, 8 recalled receiving a FACM code card, and 4 had actually used the code card. As of March 2006, Webster has submitted 53 referrals, Fitchburg 14 referrals, FHC Worcester 46 referrals, Worcester Pediatrics 60 referrals, and Milford 9 referrals. The focus group data was broken down into five major categories: identification of patients in need, referral process of patients in need, feedback from FACM, practice changes as a result of FACM, and changes in children’s health as a result of FACM. Each category was then further divided into subcategories. Under the category of identification of patients, there were facilitators, barriers, and recommendations. Facilitators primarily revolved around the patients volunteering information—either bringing up a potential legal issue at a medical encounter, inquiring about legal services based on FACM signs seen posted in the waiting room, or asking the provider a non-medical question about his or her well-being that the provider was unable to answer. Some providers found that asking screening questions facilitated identification. Barriers were related to providers’ inability to probe for legal issues due to time constraints and true medical concerns being the priority. Recommendations surrounded outreach—targeting the patient population more to promote self-referral to providers and involving more non-physician personnel in training and education since it is often those staff members to whom patients will reveal their need for assistance. Regarding the referral process, there were also facilitators, barriers, and recommendations. Participants liked the fact that making a referral involves completing a simple one-page form and faxing it. They also liked knowing to whom they were referring. However, at times patients are reluctant to be referred due to fear (e.g. undocumented patients) or pride. Providers admitted not knowing the extent of the services that FACM provides and therefore not knowing which issues are appropriate for referral. Recommendations centered on making FACM a more prominent presence in the practices—publishing brochures, posting signs, and having face-to-face meetings with providers and staff. When asked about feedback from FACM, some responses fell under the category of sufficient with providers commenting that phone calls and e-mails are promptly returned and patients report positive interactions and outcomes. However, most responses reflected insufficient feedback with providers not knowing the outcome of their patients’ legal conflicts and often not knowing whether contact was even made between the lawyers and the patient. Recommendations were all ways in which FACM can provide feedback to the practices. Providers would like to be notified by e-mail or phone when a lawyer has made contact with a referred patient. Feedback concerning the final outcome of a legal conflict would also be appreciated. Participants were also interested in receiving feedback about what kind of issues their respective practices are referring the most and least often and also updates on changes in the law that may affect their patient populations, especially immigration law. The final two categories, practice changes and changes in the health of children, were subdivided into changes that have occurred and proposed future changes. In terms of practice changes, providers feel much more confident and supported now that they have FACM backing them up—they are happy to be able to have their questions answered, provide comprehensive care to their patients, address the increasing social and financial issues they are seeing, and safely refer their undocumented patient population. Proposed practice changes echoed the sentiments above—add a question about legal issues to already existing routine patient questionnaires, invite the lawyers to be more of a presence in the practice both through office hours and training/educational sessions, and involve more non-physician personnel in FACM-related matters. Changes in children’s health are difficult to report, primarily related to the aforementioned lack of feedback. However, many participants revealed anecdotes about patients who reported very positive outcomes after being referred to FACM. Overall, providers seem to agree that FACM allows families to be educated and empowered, and that the program undoubtedly has the potential to positively impact the future health of children in Worcester County. Conclusions:Several conclusions can be drawn from general observation of the groups. Milford has conveyed a concerning lack of interest in FACM both in failing to respond to the invitation to participate in this study, and in their paucity of referrals. This raises the question of whether Community Pediatrics in Milford is an appropriate site for identifying and referring patients in need. Fitchburg had the highest number of participants but the least amount of knowledge about FACM, asking a number of questions about the program. The interest is there, but more training and education has to be provided to this site. As of right now, it is an untapped source of patients in need, as the issues are there, but FACM is underutilized. Both Webster and FHC Worcester have a great deal of knowledge about FACM and generate a large number of referrals. Of interest, both sites have care coordinators, social workers, and advocates actively involved in referral of patients, which is a consideration in terms of what groups FACM should be targeting in current and future practices involved in the collaborative. Worcester Pediatrics was a difficult focus group to arrange due to scheduling difficulties, and certainly not a lack of interest. In this busy practice, utilizing a survey instrument or non-physician personnel may increase the already impressive number of referrals. Looking at the data generated by the focus groups, there are a number of things that FACM is doing well. The aspect of the identification and referral process that can be improved seems to be outreach, both to patients and families as well as to all types of providers and staff in the practices. Feedback is a major concern and should be addressed by FACM. Notifying providers that a patient has been contacted will certainly put providers’ minds at ease, enhance their collaboration with the lawyers, and encourage them to make future referrals. Individual providers have certainly altered the way they practice somewhat, knowing that FACM is a resource that is available to them. Broader changes are subject to the standards of each individual practice. Finally, anecdotal evidence reveals small improvements in the health and well-being of children whose families have been involved with FACM. Future directions should include a more formal assessment of practice changes and improvements in children’s health as a result of FACM.
    • A Retrospective Analysis of Opioid Consumption Among Different Orthopedic Surgeons for Total Joint Replacement

      Arnel J. Almeda, Russell M. Flatto, Anthony L. Schwagerl; Gioules, Costas J.; Rockson, Hayden B.; Flatto, Russell M.; Almeda, Arnel J.; Schwagerl, Anthony L. (2013-05-01)
      Background: Throughout the world, baby boomers reaching their sixth, seventh, and eighth decade of life are requiring a significant number of joint replacements—hips and knees. Due to the increasing number of joint replacements, it is important to find a multi-modal approach (MMA) to control pain, reduce the amount of opioid consumption, and improve patient satisfaction. Purpose: The purpose of this study was to evaluate the intraoperative, postoperative, and total opioid consumption of patients undergoing total hip and knee replacements in an effort to develop a multi-modal approach to decrease opioid consumption, minimize adverse effects secondary to narcotic administration, and to achieve better pain control. This MMA was achieved by administering oxycodone, gabapentin, celecoxib, and acetaminophen starting before surgical incision. Methods: The study sample consisted of 192 patients undergoing total hip and knee replacements over a 10-month period between June 2012 and March 2013 at UMASS Memorial performed by five orthopedic surgeons. The main objective was to record intraoperative, postoperative, total opioid consumption, and patient satisfaction amongst these patients. Furthermore, the patients were subdivided based on the type of procedure (hip vs knee), type of anesthetic (general vs spinal), and the presence or absence of an indwelling catheter to deliver anesthetic (catheter vs no catheter). Results: The data showed a large variability among the surgeons in regards to the amount of opioid used intraoperatively, postoperatively and total opioid consumption. In terms of type of anesthetic, the patients undergoing spinal anesthesia used statistically significantly less opioids intraoperatively but not postoperatively, compared to general anesthesia. As for catheter use with general and spinal anesthesia, surprisingly, there was no significant difference in opioid consumption compared to the non-catheter counterpart. Furthermore, there seems to be no correlation between body mass index (BMI) and intraoperative or postoperative opioid use. Patient satisfaction was another variable that showed no correlation with opioid use intraoperatively or postoperatively. In terms of age, the data suggests that older patients use less opioids postoperatively in both hip and knee replacements. Conclusions: Our results quantitatively show spinal anesthesia to be far superior than general anesthesia in both joint replacements. Spinal anesthesia provides better pain control intraoperatively which allows one to use less opioids, thereby minimizing the adverse side effects of narcotic administration which include respiratory depression, urinary retention, nausea and post-operative ileus to name just a few. One surgeon’s patients required significantly less opioids intraoperatively compared to the rest of the surgeons. Further studies might warrant examining this surgeon’s technique or the demographics of his patient population to determine how better pain control and less opioid consumption could be achieved across all joints with all participating surgeons.
    • A systematic review and meta-analysis of adjuvant and neoadjuvant chemotherapy for upper tract urothelial carcinoma

      Joaquim Bellmunt (Dana Farber); Leow, Jeffrey J.; Martin-Doyle, William; Fay, Andre P.; Choueiri, Toni K.; Chang, Steven L.; Bellmunt, Joaquim (2014-09-01)
      CONTEXT: The role of adjuvant chemotherapy (AC) or neoadjuvant chemotherapy (NC) remains poorly defined for the management of upper tract urothelial carcinoma (UTUC), although some studies suggest a benefit. OBJECTIVE: To update the current evidence on the role of NC and AC for UTUC patients. EVIDENCE ACQUISITION: We searched for all studies investigating NC or AC for UTUC in Medline, Embase, the Cochrane Central Register of Controlled Trials, and abstracts from the American Society of Clinical Oncology meetings prior to February 2014. A systematic review and meta-analysis were performed. EVIDENCE SYNTHESIS: No randomized trials investigated the role of AC for UTUC. There was one prospective study (n=36) investigating adjuvant carboplatin-paclitaxel and nine retrospective studies, with a total of 482 patients receiving cisplatin-based or non-cisplatin-based AC after nephroureterectomy (NU) and 1300 patients receiving NU alone. Across three cisplatin-based studies, the pooled hazard ratio (HR) for overall survival (OS) was 0.43 (95% confidence interval [CI], 0.21-0.89; p=0.023) compared with those who received surgery alone. For disease-free survival (DFS), the pooled HR across two studies was 0.49 (95% CI, 0.24-0.99; p=0.048). Benefit was not seen for non-cisplatin-based regimens. For NC, two phase 2 trials demonstrated favorable pathologic downstaging rates, with 3-yr OS and disease-specific survival (DSS) < /= 93%. Across two retrospective studies investigating NC, there was a DSS benefit, with a pooled HR of 0.41 (95% CI, 0.22-0.76; p=0.005). CONCLUSIONS: There appears to be an OS and DFS benefit for cisplatin-based AC in UTUC. This evidence is limited by the retrospective nature of studies and their relatively small sample size. NC appears to be promising, but more trials are needed to confirm its utility. PATIENT SUMMARY: After a comprehensive search of studies examining the role of chemotherapy for upper tract urothelial cancer, the pooled evidence shows that cisplatin-based adjuvant chemotherapy was beneficial for prolonging survival.
    • Adipose Tissue Therapeutics for Scar Rehabilitation after Thermal Injury

      Janice Lalikos; Michael Chin; Perry, Dylan; Lujan-Hernandez, Jorge R.; Chappell, Ava; Min, So Yun; Appasani, Raghu; Rojas-Rodriguez, Raziel; Chin, Michael S.; Corvera, Silvia; Lalikos, Janice F. (2015-04-29)
      Background: Burn injuries are common and in the long term can lead to hypertrophic or keloid scars, pain and pruritus, limited mobility across joints, and disfigurement. Numerous reports suggest adipose derived tissues, including adipose derived stem cells (ADSCs) and processed lipoaspirate, can improve acutely healing wounds from a variety of etiologies including excisional, thermal, and radiation injuries by both secretion of growth factors and direct differentiation. There are many options for scar treatment, including laser therapy, silicone sheets, steroid injection, and even skin grafting however these techniques either lack optimal efficacy or involve significant cost and morbidity. Clinical case series suggest a beneficial effect of adipose tissues in improving scarred tissues, however this phenomenon has not been extensively studied in animal models especially in a thermal scar model. Objectives: (1) Determine if adipose tissue can accelerate and improve scar remodeling subacutely after acute wound healing has occurred. (2) Determine if the effect is related to adipose derived stem cells or other components of lipoaspirate. Methods: 50 CD1 nu/nu athymic mice received a standardized 70°C 10 second burn with a brass rod to the dorsal skin. Digital photographs and hyperspectral images were taken immediately following injury and serially over the study’s entirety. Burned skin reliably progressed through normal stages of wound healing to a scarred and granulating state. At six weeks post-burn animals received subcutaneous injection immediately beneath the scar with fresh human lipoaspirate (n=10), high dose hADSCs in matrigel (n=10), low dose hADSCs in matrigel (n=10), matrigel control (n=10), or were not injected (n=10). At 4 weeks post-injection (10 weeks post-burn) animals were sacrificed and tissue samples were harvested for histological molecular analysis. Results: Oxygenation and perfusion profiles from hyperspectral imaging and scar wound area correlated between groups suggesting methodological consistency of burns prior to any intervention. Oxygenated hemoglobin at 10 weeks in scars treated with lipoaspirate increased significantly more compared to 6-week pre-treatment baseline than all other groups (1.57x vs. 0.85x, p Conclusion: A consistent model of burn injury and scar maturation is described. Preliminary HSI and scar area data suggest scar improvement in lipoaspirate treated scars compared to ADSCs and controls.
    • Adjuvant chemotherapy for invasive bladder cancer: a 2013 updated systematic review and meta-analysis of randomized trials

      Joaquim Bellmunt (Dana Farber); Leow, Jeffrey J.; Martin-Doyle, William; Rajagopal, Padma S.; Patel, Chirayu G.; Anderson, Erin M.; Rothman, Andrew T.; Cote, Richard J.; Urun, Yuksel; Chang, Steven L.; et al. (2014-07-01)
      CONTEXT: The role of adjuvant chemotherapy remains poorly defined for the management of muscle-invasive bladder cancer (MIBC). The last meta-analysis evaluating adjuvant chemotherapy, conducted in 2005, had limited power to fully support its use. OBJECTIVE: To update the current evidence of the benefit of postoperative adjuvant cisplatin-based chemotherapy compared with control (ie, surgery alone) in patients with MIBC. EVIDENCE ACQUISITION: A comprehensive literature review was performed to identify all randomized controlled trials (RCTs) comparing adjuvant cisplatin-based chemotherapy with control for patients with MIBC. The search included the Medline, Embase, Cochrane Central Register of Controlled Trials databases, and abstracts from the American Society of Clinical Oncology meetings up to May 2013. An updated systematic review and meta-analysis was performed. EVIDENCE SYNTHESIS: A total of 945 patients included in nine RCTs (five previously analyzed, one updated, and three new) were examined. For overall survival, the pooled hazard ratio (HR) across all nine trials was 0.77 (95% confidence interval [CI], 0.59-0.99; p=0.049). For disease-free survival, the pooled HR across seven trials reporting this outcome was 0.66 (95% CI, 0.45-0.91; p=0.014). This disease-free survival benefit was more apparent among those with positive nodal involvement (p=0.010). CONCLUSIONS: This updated and improved meta-analysis of randomized trials provides further evidence of an overall survival and disease-free survival benefit in patients with MIBC receiving adjuvant cisplatin-based chemotherapy after radical cystectomy.
    • Admission Hyperglycemia in Setting of Acute Heart Failure is Associated with Increased In-hospital Mortality Among Patients without Diabetes

      Jane S. Saczynski; Maselli, Nicholas J.; Darling, Chad E.; McManus, David D.; Lessard, Darleen M.; Goldberg, Robert J.; Saczynski, Jane S. (2012-05-02)
      Background: Heart Failure (HF) in the setting of comorbid diabetes mellitus (DM) has been extensively examined and is associated with increased mortality. More recently, hyperglycemia independent of DM status during critical illness admissions has become recognized as an indicator of poor outcomes. Despite evolving understanding of DM in the setting of acute HF, hyperglycemia at time of admission for acute HF has not been examined with regard to in-hospital treatment and patient outcomes. Objective: The goal of this study is to examine differences in in-hospital treatment and outcomes of patients hospitalized for acute HF according to glycemic status. Methods: The sample consisted of 9,748 residents of the Worcester (MA) metropolitan area hospitalized at all 11 greater Worcester medical centers for acute decompensated HF during the years 1995 - 2004 with data available on diabetic status and admission glucose measurements. Patients were stratified into three groups based on history of DM and admission hyperglycemia defined by glucose ≥200 mg/dL: 1) nondiabetic, normoglycemic (NDNG); 2) non-diabetic, hyperglycemic (NDHG); and 3) diabetic (DM). Results: Non-diabetic, normoglycemic patients were similar to NDHG patients with respect to age and medical history and were significantly older and less likely to have a history of various comorbid conditions such as hypertension, stroke and renal disease when compared to diabetics (p-values Conclusions: The results of our population-based investigation suggest that non-diabetic patients hospitalized for acute HF who are hyperglycemic at the time of admission represent a vulnerable group of patients at risk for increased mortality during hospitalization. Hyperglycemia ≥200 mg/dL during acute HF hospitalization should be taken into account when providing in-hospital management for HF with additional consideration given to ascertainment of diabetic status and glycemic control.
    • Admission volume determines outcome for patients with acute pancreatitis

      Singla, Anand; Simons, Jessica P.; Li, Youfu; Csikesz, Nicholas G.; Ng, Sing Chau; Tseng, Jennifer F.; Shah, Shimul A. (2009-09-08)
      BACKGROUND and AIMS: There is controversy over the optimal management strategy for patients with acute pancreatitis (AP). Studies have shown a hospital volume benefit for in-hospital mortality after surgery, and we examined whether a similar mortality benefit exists for patients admitted with AP. METHODS: Using the Nationwide Inpatient Sample, discharge records for all adult admissions with a primary diagnosis of AP (n = 416,489) from 1998 to 2006 were examined. Hospitals were categorized based on number of patients with AP; the highest third were defined as high volume (HV, >or=118 cases/year) and the lower two thirds as low volume (LV, <118 cases>/year). A matched cohort based on propensity scores (n = 43,108 in each group) eliminated all demographic differences to create a case-controlled analysis. Adjusted mortality was the primary outcome measure. RESULTS: In-hospital mortality for patients with AP was 1.6%. Hospital admissions for AP increased over the study period (P < .0001). HV hospitals tended to be large (82%), urban (99%), academic centers (59%) that cared for patients with greater comorbidities (P < .001). Adjusted length of stay was lower at HV compared with LV hospitals (odds ratio, 0.86; 95% confidence interval, 0.82-0.90). After adjusting for patient and hospital factors, the mortality rate was significantly lower for patients treated at HV hospitals (hazard ratio, 0.74; 95% confidence interval, 0.67-0.83). CONCLUSIONS: The rates of admissions for AP in the United States are increasing. At hospitals that admit the most patients with AP, patients had a shorter length of stay, lower hospital charges, and lower mortality rates than controls in this matched analysis.
    • Advances in interventional neuroradiology

      Gounis, Matthew J.; DeLeo, Michael J. III; Wakhloo, Ajay K. (2010-02-01)
    • Advances in interventional neuroradiology

      Wakhloo, Ajay K.; DeLeo, Michael J. III; Brown, Martin M. (2009-05-01)
      In 2008 we witnessed a rapid advancement in stent technology, which is reflected in the high number of case reports, publications of case series, and randomized trials. Stents not only served for a combined intrasaccular and extrasaccular treatment of challenging aneurysms but also assisted the revascularization in acute and chronic ischemic conditions of the neurovascular system. Although a self-expanding nitinol semiopen cell stent is currently used for intracranial occlusive disease, a new retrievable closed-cell designed stent is widely used for aneurysms because of its easy delivery through a microcatheter in frequently tortuous head and neck as well as cerebrovascular circulation (Figure 1). However, despite numerous publications in the field, the widespread acceptance of the use of stents to routinely treat carotid stenosis awaits the results of the multicenter randomized clinical trials that should be available in 2009. The role of interventional neuroradiology in the treatment of acute ischemic stroke continues to expand and excite interest.
    • Altered Serum Zinc Concentration in Patients with Visceral Leishmaniasis (L. donovani) and Healthy Regional Controls from Bihar, India: A Correlation with Susceptibility to Disease

      Singh, Sarman; Godkin, Michael; Carpenter, Stephen (2007-06-01)
      Background: Visceral leishmaniasis (VL) is a multiorgan disease of the reticuloendothelial system caused by obligate intracellular protozoan parasites of the Leishmania genus, spread through the bite of the phlebotomine sand fly, and leads to death in nearly all untreated cases. In India, VL is almost entirely caused by the species L. donovani, and is epidemic in the rural Eastern states of that country, most notably the Indian State of Bihar. Mounting a successful CD4-TH1 (CD4+ T-helper lymphocyte type 1) immune response has been shown necessary to combat intracellular pathogens, such as L. donovani, and prevent the development of full-blown VL. Zinc is a micronutrient necessary for T-cell development and preferential activation of a TH1 immune response over the TH2 pathway by modulating cytokine release favoring IFN-γ and IL-2 release. We show that specific zinc deficiency is present in control subjects and VL patients from Bihar, but not urban controls from Delhi, independent of nutritional status, suggesting that zinc deficiency may specifically predispose to VL if patients are infected with the intracellular parasite L. donovani. Objectives:1. To optimize a protocol for reliably measuring serum zinc concentration using a standard colorimetric spectrophotometer. 2. To understand the relationship of serum zinc concentrations in VL patients from Bihar, regional controls (from Bihar), and urban controls (from Delhi). 3. To determine whether observed differences in serum zinc between groups were related to nutritional deficiency by measuring serum albumin and total protein. 4. To estimate whether immune function was altered in favor of a TH2 response in any of these groups by measuring serum globulin concentration. Methods: Serum samples were collected from 18 VL patients from Bihar, 47 healthy urban controls (from New Delhi), and 22 healthy regional controls from Bihar between September 2004 and November 2006. All samples were tested for the presence of anti-L. donovaniantibodies using the rKE-16 (recombinant kinesin 16) ELISA. Serum zinc estimation was performed by chelating zinc present in serum samples, and measuring the absorbance of zinc-chelator complex with a colorimetric spectrophotometer, comparing it with the absorbance of chelated zinc in a standard solution to determine concentration. Serum total protein and albumin were measured using a biochemical analyzer with standardized reagents in a colorimetric assay, and serum globulin was estimated using these results. One-way ANOVA and Tukey post-hoc tests were used to compare the means of each group for each category, and a Pearson correlation was used to evaluate correlation between dependent variables, all using SPSS Statistics Package 10. Results: A decrease in serum zinc (mean ± SD) was observed in VL patients from Bihar as compared to urban controls (from Delhi) (8.96 ± 2.81 µmol / L vs. 11.15 ± 3.39 µmol / L, p=0.064), but not between VL and regional controls (from Bihar) (8.46 ± 3.70 µmol / L, p=0.894). Delhi and Bihar control groups showed significantly different serum zinc levels (11.15 ± 3.39 µmol / L vs. 8.46 ± 3.70 µmol / L, p=0.011). Zinc deficiency (serum zinc < 9.95 µmol / L) was seen in both the VL patients (12 of 17 patients) as well as the controls from Bihar (13 of 20 controls), but not in the Delhi controls (20 of 46 patients). Used as a marker for nutritional status, serum albumin was similar in regional controls (from Bihar) and urban controls (from Delhi) (6.16 ± 0.34 mg/dL and 6.20 ± 0.73 mg/dL, p=0.999), but was significantly lower in VL patients compared with both groups (3.76 ± 1.31 mg/dL, p0.273). As a marker for immune status, serum globulin was significantly increased in patients with VL (9.36 ± 3.01 mg/dL) as compared to urban (Delhi) controls (7.83 ±1.77 mg/dL, pConclusions: The decreased serum zinc observed in both VL patients, as well as controls from the Indian State where VL is epidemic (Bihar), indicates that citizens from this region of India may, in general, have a low baseline serum zinc that predisposes them to visceral leishmaniasis (VL) when infected with L. donovani. The majority of these controls from Bihar displayed overt zinc deficiency, while a much smaller proportion of urban controls were clinically deficient in zinc. Serum albumin levels in the regional controls (from Bihar) were within normal limits and comparable to urban controls (from Delhi), indicating that these patients were specifically zinc-deficient at baseline and this deficiency was not due to general malnutrition. The significantly increased serum globulin in VL patients, but not in other groups, is consistent with an increased Th2 response with immunoglobulin production and supports the hypothesis that patients who progress to VL were not able to produce an adequate Th1 response. The role of zinc in T-cell immune function makes oral zinc supplementation a good candidate for treatment and prevention of VL in the Bihar, India, and other regions with a profile of low socioeconomic status and high Leishmaniaspecies prevalence.
    • Alternatively Activated M2 Macrophages Improve Autologous Fat Graft Survival in a Mouse Model through Induction of Angiogenesis

      Janice Lalikos, MD/Plastic Surgery; Chappell, Ava; Lujan-Hernandez, Jorge; Perry, Dylan; Corvera, Silvia; Lalikos, Janice F. (2015-08-01)
      Comment on: Alternatively activated M2 macrophages improve autologous Fat Graft survival in a mouse model through induction of angiogenesis. [Plast Reconstr Surg. 2015]
    • An Analysis of Implicit Bias in Medical Education

      Sonia Nagy Chimienti, MD; Wells, Racquel J.; Motzkus, Christine; Cashman, Suzanne B.; Allison, Jeroan J.; Buckner, Michael; Chimienti, Sonia; Plummer, Deborah L. (2016-04-27)
      Background: The Implicit Association Test (IAT) is a well-researched method of identifying an individual's implicit bias. Occurring outside of conscious awareness, implicit bias manifests itself in the form of nonverbal thoughts, behaviors and actions that influence an individual and that are suggestive of unequal treatment. In the undergraduate medical education curriculum, the IAT is commonly used to assess the medical students' personal bias. Studies from the American Association of Medical Colleges (AAMC) have shown that bias is ranked highly as one of the least addressed educational goals in medical education and training. The medical literature suggests that implicit bias affects how clinical faculty make patient care decisions, and that this in turn affects medical student education. Data collected from our medical school's first year curriculum suggest that there are missed opportunities to explore the effects of bias on health outcomes. Objective: The purpose of this study was to analyze comments in reflection papers submitted by students enrolled in the required Determinants of Health (DoH) course during the Fall 2014- Spring 2015 curriculum at the University of Massachusetts Medical School (UMMS). The DoH course assignment asked students to select a reading, experience in taking the IAT or class discussion, and comment on how the material led to new insight about the potential effect of biases or stereotyping on future clinical decisions. The themes from this analysis provided context for relevant areas for further exploration of the impact of implicit bias in medical education. Method: 125 first-year medical students (48% female, 52% male; mean age 25 years; 95% from Massachusetts, 9% identified as under-represented ethnic/racial minorities) in the entering class of 2014 submitted written reflections following attendance and discussion-based learning in the DoH course. Grounded theory methodology was used for the qualitative analysis of the comments. Papers were de-identified, read, and codes were constructed according to emerging themes (descriptive, diagnostic, and prescriptive) found. The codebook development focused on "bias," "systemic/institutional bias," "individual bias," "awareness" and "health disparities". Student commentary was coded for themes and tallied for total amount of discussion for each theme. Inter-rater reliability was calculated for 20% of the sample using Cohen's kappa. Results: The following themes emerged: 1) an understanding of the IAT and the results of the IAT; 2) a definition of bias; 3) a suggestion of source of bias; 4) factors informing bias; and 5) action items to combat the effects of implicit bias on future physicians. Ninety-five of 125 students' comments (76%) mapped to descriptive themes associated with bias; 27% (n=26/95) of comments suggested all individuals have bias; 57% (n=55) of comments suggested potential sources of bias, ranging from cultural and community upbringings to societal media; 83% (n=79) of comments focused on the negative effect implicit bias can have on decision-making in patient care; and nearly 96% (n=91) of comments felt that acknowledging their own implicit bias would benefit their interactions with patients in their future medical careers. Additionally, 58% (n=73/125) of students' comments noted that making a conscious effort to self-reflect and address bias would improve decision-making, and 32% (n=40) of comments noted it was a physician's responsibility to dismantle the bias found in the healthcare system (15 comments suggested this happen through avenues such as advocacy and legislation). Seventy students' comments (56%) mapped to comments discussing the lAT. Forty-three percent (n=30) comments noted students surprised by their results and 29% (n=20) of comments suggested that the student was not surprised. While 75 students (60%) did not comment on their reaction, the IAT sparked self-reflection of implicit bias and its origin in 68 of these students, and 16% (n=20) of comments found the IAT to be a valuable tool in identifying implicit bias. With regard to the current climate ofhealthcare, 40 responding students (32%) identified racism or racial bias existing within the medical field, noting potential sources of racism including lack of trust in physicians from historical events such as the Tuskegee Syphilis Experiment and societal inequalities as a whole. Additionally, 29 students' comments (23%) mentioned systemic/institutional bias as potentially having an impact on individual bias and vice versa. Conclusions: The use of the IAT in the medical education curriculum is informative and the medical student response to it is impactful. Medical students gain insight into the importance of understanding personal implicit bias and the effect it may have on clinical decision-making through courses such as Determinants of Health. Students have the ability and the desire to identify and self-reflect on the development of behaviors and skills that will facilitate improved decision-making in the care of patients, and improved patient interactions. This analysis also points to the significance of further exploration of faculty involvement in these topics to further engage medical students throughout their undergraduate medical training. As over 93% of the first-year medical school courses did not utilize race identifiers and non-medical factors in clinical vignettes, this is another opportunity to apply real-life scenarios to the educational curriculum.
    • An Old Idea Revisited: Reflections on the Role of Aesthetic Surgery in Behavioral and Social Change

      Janice Lalikos, MD; Chappell, Ava G.; Lalikos, Janice F. (2016-09-01)
      Although the notion that an individual’s morality can be changed from bad to good solely with a procedure that improves physical appearance is controversial, the relationship between appearance and behavior is complex and pertinent to an individual’s psychology and quality of life. Where plastic surgery comes into play, as either treatment or adjuvant therapy, remains to be determined.
    • Analysis of Acute Perihematomal Edema in Warfarin-Related Intracerebral Hemorrhage

      Rosand, Jonathan; Finkelstein, David (2005-06-01)
      Background: Little is known about the mechanisms of acute edema formation around a hematoma in intracerebral hemorrhage (ICH). Gebel et al, Stroke (2000) showed that there is significantly decreased hyperacute perihematomal edema in thrombolysis / anticoagulant -- related ICH compared to spontaneous ICH. Multiple animal models have suggested that successful clot formation is required for the development of acute perihematomal edema. These observations led to the hypothesis that acute perihematomal edema is osmotic in nature and reflects clot integrity. That is, as a hematoma forms, proteins in the serum exude out from the hematoma and act as osmotic agents, drawing fluid toward them and causing perihematomal edema. If this hypothesis is true, it would suggest that the edema is a reflection of how well-formed the clot is. It may therefore, seemingly paradoxically, be a predictor of better outcome. Gebel et al, Stroke(2002) showed that hyperacute perihematomal relative edema was a strong, independent predictor of 3-month functional outcome (increased relative edema, decreased odds of poor outcome). Objectives:We sought to test this hypothesis by determining whether there was a relationship between INR and acute edema volume and whether edema predicted mortality. We also wanted to explore whether any other factors correlated positively or negatively with edema volume. Our main hypothesis: INR is negatively correlated with edema volume. Methods:We performed a retrospective observational study of 49 consecutive warfarin-related ICH cases that presented to the Massachusetts General Hospital Emergency Department between 10/98 and 4/04 to determine the predictors and outcomes related to acute perihematomal edema. Initial CT Scans of patients taking warfarin with supratentorial ICH were analyzed using Alice software. ICH volumes and volumes of perihematomal edema were measured. Patient information was obtained from the Clinical Trials Unit database, and the following predictors of ICH and edema volumes were examined: age, PT, aPTT, INR, platelet count, SBP, DBP, serum glucose, gender, hx CAD, hx ischemic CVA, DM, antiplatelet use, location of ICH, and APOE ε genotype. All statistical analyses performed were nonparametric, because the outcomes of interest were not normally distributed. Results: 49 consecutive cases of warfarin-related supratentorial ICH that presented to Massachusetts General Hospital were examined. Population characteristics were as follows, with mean and (standard deviation): age 76.8 years (8.4), INR 3.8 (2.3), admission SBP 173.4 mm Hg (36.5), admission DBP 91.5 mm Hg (19.6), blood glucose 151.4 mg/dl (45.5), symptom onset to scan time 6.5 hours (7.9), ICH volume 55.5 cc (55.9), and edema volume 22.1 cc (25.1). Other characteristics of the population include 59.2 % female, 36.2 % with a history of CAD, 18.8 % with diabetes mellitus, 45.2 % with a history of ischemic stroke, 40.8 % with antiplatelet use, 60.7 % homozygous for the APOE ε3 allele, and 46.9 % with a lobar location of bleeding (versus deep). In terms of ICH volume, a few significant relationships were found: A positive correlation between blood glucose and ICH volume (r = 0.408, p = 0.005). A positive relationship between lobar location and ICH volume (lobar: mean volume 76.9 cc ± 12.6, deep: mean volume 36.6 cc ± 8.7, p=0.012). A positive relationship between antiplatelet use and ICH volume (antiplatelet use: mean volume 77.9 ± 13.2, no antiplatelet use: mean volume 40.1 ± 9.1, p=0.007). In terms of edema, absolute edema is defined as the total amount of edema around the hematoma. Relative edema is defined as the volume of edema divided by the volume of the hematoma. Significant relationships found for absolute edema were: A positive correlation between absolute edema and ICH volume (r = 0.924, p Discussion / Conclusion: These analyses yield some interesting data in relation to hematoma and edema volumes in warfarin-related ICH. First, our initial hypothesis was not supported. The relative amount of edema was not significantly correlated to INR. A negative trend existed, but the p value was 0.106. Thus, this does not support the original hypothesis of perihematomal edema being osmotic and reflecting clot integrity, since increasing INR should make the blood less likely to clot. At the start of this project, we did not know what the relationship between ICH volume and absolute edema volume would be like. It could be hypothesized that edema formation is based on surface area of the hematoma, and thus larger ICH volumes, which have a smaller ratio of surface area to volume, might have less relative edema. However, our data strongly suggest otherwise. We show a strong positive correlation between absolute edema volume and ICH volume. When this data is plotted, a linear relationship is observed. Thus, the relative amount of edema does not appear to differ in small vs. large hemorrhages. Absolute edema does appear to correlate strongly with hematoma volume. Another interesting finding is in relation to blood glucose. Song et al, Stroke(2003) developed a rat model of ICH. They found that hyperglycemic animals had significantly increased brain water content compared to controls. High blood glucose would be expected to correlate with increased edema, since glucose is an osmotic particle. Our findings showed a strong positive correlation between glucose and ICH volume in univariate analysis, a positive non-significant correlation between glucose and absolute edema volume in univariate analysis, and a negative correlation between glucose and relative edema volume in univariate analysis. In multivariate analysis, blood glucose was a negative, independent predictor of both absolute and relative edema. Since glucose is strongly correlated with ICH, and absolute edema is strongly correlated with ICH, the relationship between glucose and absolute edema in univariate analysis is likely caused by these relationships. In the multivariate regression models, however, it appears that glucose independently and negatively predicts edema formation. The biologic cause of this is unknown. It is important to note that this is a correlation, not a cause and effect. The correlation between antiplatelet use and increased ICH volume in people taking warfarin is also of note. However, this was not found with larger sample sizes in previous studies by our group. This will have to be looked into further. Finally, we have found ICH volume to be the only independent predictor of in-hospital and one month mortality. One possible limitation of this study relates to the feasibility of measuring edema on CT scan. Perihematomal edema was considered as the hypodense area around the hematoma. This is often difficult to see visually, so hounsfield unit measurements were used to confirm visual tracings. Yet other factors, such as periventricular white matter disease, produce hounsfield units of a similar range. A potential biasing factor was the fact that no exclusions based on time from symptom onset to CT scan were used. The average time was 6.5 hours, but in several instances the time of symptom onset wasn?t known, and these times were probably a lot longer. Since hyperacute vs. acute vs. subacute edema volumes may differ, this could be an important bias. Future directions could include measuring edema volumes on non-warfarin patients and doing comparisons between the two groups. Also, more standardized time constraints could be looked at in the future. Finally, we could perform edema volume measurements on MRI.
    • Analysis of axillary coverage during tangential radiation therapy to the breast

      Thomas J. Fitzgerald; Reznik, Julia; Cicchetti, Maria Giulia; Degaspe, Barbara; Fitzgerald, Thomas J. (2005-01-01)
      PURPOSE: To evaluate the percent of the prescribed radiation dose to the breast delivered to the axillary tissue and to evaluate the volume of the axilla receiving 95% of the prescribed dose with normal and with high tangential fields. METHODS AND MATERIALS: Computed tomographic scan images with 5-mm sections were retrospectively analyzed for 35 patients who had undergone three-dimensional (3D) planning for whole-breast radiation. The axillary nodal region was identified and divided into Levels I to III and Rotter's nodes (RN). Digitally reconstructed radiographs were created, and two plans were developed: (a) the standard clinical opposed tangential irradiation fields and (b) the high-tangential irradiation fields. Axillary coverage was examined by use of dose-volume histograms (DVH), and the average coverage for the four nodal groups was obtained. RESULTS: The data show that with the standard tangential irradiation fields, the average dose delivered to Levels I, II, III, and RN is 66% (standard deviation, or SD = 13%), 44% (SD = 18%), 31% (SD = 20%), and 70% (SD = 19%) of the prescribed dose, respectively. The coverage increases to 86% (SD = 9%), 71% (SD = 19%), 73% (SD = 17%), and 94% (SD = 8%) of the prescribed dose, respectively, for Levels I, II, III, and RN when the high tangential irradiation fields are used. 51% of Level I, 26% of Level II, and 15% of Level III receive 95% of the prescribed dose with normal tangents. The volume increases to 79%, 51%, and 49% of Levels I, II, and III, respectively, with high tangents. CONCLUSION: The tangential fields designed to treat only the breast do not adequately cover the axillary region and, therefore, cannot be relied upon for prophylactic therapy of the axilla. The high tangential irradiation fields increase the dosages received by the axillary region, but the average dosages received by the lower axillary regions are still less than 90% of the prescribed dose.