Neuropathic and nociceptive pain in head and neck cancer patients receiving radiation therapy

BACKGROUND: Pain is common in head and neck cancer (HNC) patients and may be attributed to the malignancy and/or cancer treatment. Pain mechanisms and patient report of pain in HNC are expected to include both nociceptive and neuropathic components. The purpose of this study was to assess the trajectory of orofacial and other pain during and following treatment, using patient reports of neuropathic pain and nociceptive pain and pain impact. METHODS: 124 consecutive HNC patients receiving radiation therapy (RT) (95 men, 29 women; mean age: 54.7 ± 12.3 years) participated in a patient-reported outcome (PRO) assessment. Patients completed the McGill Pain Questionnaire three times during therapy and 3 months following study entry. RESULTS: The majority of patients related their pain to the tumor and/or cancer treatment. Whereas 59% reported their pain to be less severe than they expected, 29% were not satisfied with their level of pain despite pain management during cancer therapy. Worst pain was 3.0 ± 1.3 on a 0- to 5-point verbal descriptor scale. Pain intensity was present at entry, highest at 2-week follow-up, declining towards the end of treatment and persisting at 3-month follow-up. The most common neuropathic pain descriptors chosen were aching (20%) and burning (27%); nociceptive words chosen were dull (22%), sore (32%), tender (35%), and throbbing (23%), and affective/evaluative descriptors were tiring (25%) and annoying (41%). 57% of patients reported continuous pain, and combined continuous and intermittent pain was reported by 79% of patients. DISCUSSION: This study provides evidence that patients with HNC experience nociceptive and neuropathic pain during RT despite ongoing pain management. The affective and evaluative descriptors chosen for head and neck pain indicate considerable impact on quality of life even with low to moderate levels of pain intensity. These findings suggest that clinicians should consider contemporary management for both nociceptive and neuropathic pain in head and neck cancer patients

Prognostic significance of Absolute Neutrophil Count in Patients with Heart Failure with Preserved Ejection Fraction

Background: The role of inflammation and neutrophil/lymphocyte ratio has been defined in systolic heart failure (HF) and coronary artery disease, but it is uncertain if such a relationship exists in HF with preserved ejection fraction (HFpEF) patients (pts). We sought to identify the prognostic impact of Absolute Neutrophil Count (ANC) in HFpEF in the absence of coronary artery disease history (CAD Hx).Methods: In this retrospective cohort, the institutional HF data base was queried to identify HFpEF pts diagnosed in 2006 (registry initiation date) based on symptoms, BNP, and Echocardiogram with no CAD Hx. Measured outcomes were cardiovascular disease (CVD) mortality and number of HF re-admissions (poor outcome if > 2 HF re-admissions). Results: We identified 125 eligible pts. Mean age was 70.8 ± 11.7 years. Women constituted 56.6%. Mean follow up was for 8.75 ± 0.17 years. The CVD mortality rate was 7.1%. Poor outcome was identified in 52.6%. Mean ANC was 6.3 ± 3.2, and in multivariate regression analysis, including baseline demographic, clinical, and biochemical covariates, ANC remained significantly associated with poor outcome and an independent predictor of mortality (OR 1.14, 95% CI 1.02-1.29, P=0.04 after adjustment for age, sex, hypertension, and other risk factors)(table).Conclusion: In HFpEF pts, ANC is a significant predictor of poor outcome as well as mortality in the absence of coronary artery disease. Accordingly, ANC can be utilized as one of the non-invasive prognostic markers in HFpEF patients

Bullying in the American Graduate Medical Education System: A National Cross-Sectional Survey.

OBJECTIVES:To deliver an estimate of bullying among residents and fellows in the United States graduate medical education system and to explore its prevalence within unique subgroups. DESIGN/SETTING/PARTICIPANTS:A national cross-sectional survey from a sample of residents and fellows who completed an online bullying survey conducted in June 2015. The survey was distributed using a chain sampling method that relied on electronic referrals from 4,055 training programs, with 1,791 residents and fellows completing the survey in its entirety. Survey respondents completed basic demographic and programmatic information plus four general bullying and 20 specific bullying behavior questions. Between-group differences were compared for demographic and programmatic stratifications. MAIN OUTCOMES/MEASURES:Self-reported subjected to workplace bullying from peers, attendings, nurses, ancillary staff, or patients in the past 12 months. RESULTS:Almost half of the respondents (48%) reported being subjected to bullying although both those subjected and not subjected reported experiencing ≥ 1 bullying behaviors (95% and 39% respectively). Attendings (29%) and nurses (27%) were the most frequently identified source of bullying, followed by patients, peers, consultants and staff. Attempts to belittle and undermine work and unjustified criticism and monitoring of work were the most frequently reported bullying behaviors (44% each), followed by destructive innuendo and sarcasm (37%) and attempts to humiliate (32%). Specific bullying behaviors were more frequently reported by female, non-white, shorter than < 5'8 and BMI ≥ 25 individuals. CONCLUSIONS/RELEVANCE:Many trainees report experiencing bullying in the United States graduate medical education programs. Including specific questions on bullying in the Accreditation Council for Graduate Medical Education annual resident/fellow survey, implementation of anti-bullying policies, and a multidisciplinary approach engaging all stakeholders may be of great value to eliminate these pervasive behaviors in the field of healthcare

Medical student preferences for the internal medicine residency interview day: A cross-sectional study

<div><p>Background</p><p>Applicant recruitment is an essential part of a residency program’s activities with valuable resources dedicated to ensuring its success. Most programs design interview days based on a mix of tradition, budget availability and perception of applicant preferences. There is a paucity of available data on preferences of applicants for interview days.</p><p>Objective</p><p>We sought to investigate Internal Medicine applicant preferences for a residency recruitment day in aggregate and stratified by medical school background: United States vs. International Medical School Graduate.</p><p>Methods</p><p>A survey was developed and used in a cross-sectional study of Internal Medicine categorical and preliminary medicine candidates. Applicants ranked different facets of the interview day using a Likert scale. Variables included interview type, start time, length of interview day, number of interviews, length of each interview, background of interviewers, types of questions, interaction time with residents, month of interview, and components of interview day.</p><p>Results</p><p>265 applicants received the surveys and 215 completed them correctly (81%). Overall, applicants tended to favor an 8–9 am start time (81.9%) and an optimal duration of four hours (82.8%). The interview was the most preferred component of the day (80.0%) with one-on-one (98.1%) and 15–30 min (95.3%) interviews preferred. Several statistically significant differences were found between the United States and International students as well as Categorical and Preliminary applicants.</p><p>Conclusion</p><p>Our findings offer insights into various factors of the interview day that may appeal to Internal Medicine candidates. This information will be useful to graduate medical education departments engaged in recruitment.</p></div

Oral examination findings, taste and smell testing during and following head and neck cancer therapy

PURPOSE: Diet and nutrition are critical in health and disease and are highly impacted by the presence and treatment for head and neck cancer (HNC). The purpose of this paper is to present oral examination findings and taste and smell test results in patients during and following HNC. METHODS: Patients with HNC were evaluated during and following radiation therapy with/without chemotherapy. Oral examination findings including mucositis, saliva, oral hygiene (plaque levels, gingivitis), and taste and smell testing was completed on all subjects. NCI Common Terminology Criteria for Adverse Events (CTCAE) 4.0, and the Scale of Subjective Total Taste Acuity (STTA) were used to provide patient report of symptoms. RESULTS: Mucositis and pain affected oral diet during therapy and improved in follow-up. Weight loss of 5% during and 12% following treatment was identified. Tobacco use was associated with increased severity of mucositis and increased weight loss. The subjects maintained excellent oral hygiene as reflected in plaque levels and gingivitis. Spicy/pungent perception was the most strongly disliked of testing stimuli. Umami and fat taste perception were reported of highest intensity during HNC treatment and rated as moderate in intensity after treatment. These results suggest improvement in these taste functions over time following treatment. Salt taste was of high intensity and associated with strong dislike in follow-up. CONCLUSIONS: In HNC patients, oral status and taste change occurs throughout the cancer trajectory and represent potential concerns in cancer survivorship. Taste change (as evaluated by taste testing) occurred in all HNC patients, whereas olfactory changes occurred in 30% of cases. Management of oral changes and symptoms should be considered in all HNC patients in addition to dietary and nutritional guidance in patient care to promote oral intake. Continuing study of taste changes may further define this problem and support dietary and nutritional guidance and product development

Inappropriate use of commercial Antinuclear Antibody Testing in a community-based US hospital: a retrospective study

Healthcare providers use antinuclear antibodies (ANAs) to screen and diagnose patients with autoimmune diseases. In the recent years, commercial multiplex ANA kits have emerged as a convenient and fast diagnostic method. Diagnostic testing should follow sequenced algorithms: initial screen followed by specific antibody analysis. Second-level testing as an initial screen for autoimmune disease is inappropriate. We reviewed 68 patients with ANA comprehensive panels over a 6-month period from May 2015 to October 2015. We assessed appropriateness and estimated incurred losses from inappropriate testing. We found 92.6% (63 out of 68) of the ANA comprehensive panel results to be negative. Incurred losses from inappropriate ANA comprehensive panel testing were $66,000. Physicians should become familiar with ANA-sequenced diagnostic algorithms to avoid unnecessary higher level testing

Percentages of Bullying Behaviors by Professional Characteristics.

<p>Percentages of Bullying Behaviors by Professional Characteristics.</p