This document summarizes factors that influence quality of life in adult patients with primary brain tumors. It discusses how quality of life domain scores may be different for high-grade, low-grade, and benign brain tumors. Several patient, treatment, and sociocultural factors can influence quality of life scores. Pretreatment baseline quality of life scores have also been shown to predict survival outcomes. The document reviews quality of life issues specifically for high-grade gliomas and low-grade gliomas.
Modeling the Dynamics of Glioblastoma Multiforme and Cancer Stem CellsStephen Steward
In this talk, we extend the work of Kronik, Kogan, Vainstein, and Agur (2008) by incorporating the cancer stem cell hypothesis into a treatment model for Glioblastoma Multiforme. Cancer Stem Cells (CSCs) are a specialized form of tumor cell with normal adult stem cell properties. CSCs are believed to be one of the primary reasons for cancer recurrence since they are more resilient to current treatment practices and are able to repopulate the tumor. We present a system of nonlinear ordinary differential equations that describes the interaction between cancer stem cells, tumor cells, and alloreactive cytotoxic-T-lymphocytes (CTLs). Under the assumption of constant treatment, we present conditions on the treatment amount that leads to a locally stable cure state. We also explore a more biologically accurate treatment schedule in which CTLs are injected periodically. In the case of periodic treatment, we numerically establish treatment schedules that lead to cancer persistence, cancer recurrence, and cancer eradication. We conclude with a sensitivity analysis of our parameters and a discussion of biological implications.
Brian Covello writes a paper on radiotherapy and the DNA damage response associated with radiation.
The information below is taken from http://www.nature.com/nrc/posters/dnadamage/index.html:
The DNA damage response in tumorigenesis and cancer treatment
Jiri Bartek and Jiri Lukas
The DNA damage response pathways can activate cell cycle checkpoints (which can involve p53) to arrest the cell either transiently or permanently (senescence) or they can activate specific DNA repair pathways in response to certain types of DNA damage. Some of the proteins in these pathways are mutated or non-functional in human tumours. This can cause cancer cells to be more reliant on an intact DNA repair pathway or survival, providing a therapeutic window. Inhibition of these intact pathways can selectively target tumour cells and the success of this strategy is illustrated by the progress of poly(ADP-ribose) polymerase (PARP) inhibitors in early phase clinical trials. This Poster highlights how the DNA damage response is thought to protect against tumour progression and the therapeutic rationale for specifically targeting members of the DNA damage response pathways. Some of the drugs that are under development or in clinical trials are also included.
Modeling the Dynamics of Glioblastoma Multiforme and Cancer Stem CellsStephen Steward
In this talk, we extend the work of Kronik, Kogan, Vainstein, and Agur (2008) by incorporating the cancer stem cell hypothesis into a treatment model for Glioblastoma Multiforme. Cancer Stem Cells (CSCs) are a specialized form of tumor cell with normal adult stem cell properties. CSCs are believed to be one of the primary reasons for cancer recurrence since they are more resilient to current treatment practices and are able to repopulate the tumor. We present a system of nonlinear ordinary differential equations that describes the interaction between cancer stem cells, tumor cells, and alloreactive cytotoxic-T-lymphocytes (CTLs). Under the assumption of constant treatment, we present conditions on the treatment amount that leads to a locally stable cure state. We also explore a more biologically accurate treatment schedule in which CTLs are injected periodically. In the case of periodic treatment, we numerically establish treatment schedules that lead to cancer persistence, cancer recurrence, and cancer eradication. We conclude with a sensitivity analysis of our parameters and a discussion of biological implications.
Brian Covello writes a paper on radiotherapy and the DNA damage response associated with radiation.
The information below is taken from http://www.nature.com/nrc/posters/dnadamage/index.html:
The DNA damage response in tumorigenesis and cancer treatment
Jiri Bartek and Jiri Lukas
The DNA damage response pathways can activate cell cycle checkpoints (which can involve p53) to arrest the cell either transiently or permanently (senescence) or they can activate specific DNA repair pathways in response to certain types of DNA damage. Some of the proteins in these pathways are mutated or non-functional in human tumours. This can cause cancer cells to be more reliant on an intact DNA repair pathway or survival, providing a therapeutic window. Inhibition of these intact pathways can selectively target tumour cells and the success of this strategy is illustrated by the progress of poly(ADP-ribose) polymerase (PARP) inhibitors in early phase clinical trials. This Poster highlights how the DNA damage response is thought to protect against tumour progression and the therapeutic rationale for specifically targeting members of the DNA damage response pathways. Some of the drugs that are under development or in clinical trials are also included.
GLIOBLASTOMA MULTIFORME
This seminar is presented as a part of weekly journal club and seminar regularly conducted at Apollo hospital,Kolkata Department of Radiation oncology.
This is a PDF of a presentation given to the Radiation Oncology department at the University of Minnesota in October 2015. This PDF focuses on evaluation, management, and state-of-the-art approach to gliomas from a medical neuro-oncology perspective.
Stereotactic Radiotherapy of Recurrent Malignant Gliomas Clinical White PaperBrainlab
Learn more: https://www.brainlab.com/intraoperative-mri
Tumors of the central nervous system (CNS) represent approximately 176,000 newly diagnosed cases worldwide per year, with an estimated annual mortality of 128,000. Malignant gliomas comprise 30% of all primary CNS tumors and remain one of the greatest challenges in oncology today, despite access to state-of-the-art surgery, imaging, radiotherapy and chemotherapy.
The dream of any physician and consequently every patient is to receive the right treatment in the right time with cost effectiveness. To achieve this goal, the 3 pillars: evidence based medicine, clinical research innovation & resources utilization should be integrated efficiently.
In this presentation, I'll try to comprehensively review the following:
1- How are we used to perform clinical trials in Oncology?
2- Does it fits in today’s needs?
3- Integration of biology knowledge in shaping drug development
4- New Clinical trial designs “Can they offer solution for accelerating drug development?”
5- The supporting infrastructure role in clinical trial execution
The 2016 World Health Organization classification of tumors of the central nervous system broadly employs genetic alterations for diagnostic criteria including isocitrate dehydrogenase-1 (IDH1) mutation or IDH2 mutation, and 1p/19q codeletion,[1] with the goal of creating more homogeneous disease categories with greater prognostic value.[2-5] Molecular diagnostics is becoming an increasingly important aspect of clinical oncologic neuropathology practice.
GLIOBLASTOMA MULTIFORME
This seminar is presented as a part of weekly journal club and seminar regularly conducted at Apollo hospital,Kolkata Department of Radiation oncology.
This is a PDF of a presentation given to the Radiation Oncology department at the University of Minnesota in October 2015. This PDF focuses on evaluation, management, and state-of-the-art approach to gliomas from a medical neuro-oncology perspective.
Stereotactic Radiotherapy of Recurrent Malignant Gliomas Clinical White PaperBrainlab
Learn more: https://www.brainlab.com/intraoperative-mri
Tumors of the central nervous system (CNS) represent approximately 176,000 newly diagnosed cases worldwide per year, with an estimated annual mortality of 128,000. Malignant gliomas comprise 30% of all primary CNS tumors and remain one of the greatest challenges in oncology today, despite access to state-of-the-art surgery, imaging, radiotherapy and chemotherapy.
The dream of any physician and consequently every patient is to receive the right treatment in the right time with cost effectiveness. To achieve this goal, the 3 pillars: evidence based medicine, clinical research innovation & resources utilization should be integrated efficiently.
In this presentation, I'll try to comprehensively review the following:
1- How are we used to perform clinical trials in Oncology?
2- Does it fits in today’s needs?
3- Integration of biology knowledge in shaping drug development
4- New Clinical trial designs “Can they offer solution for accelerating drug development?”
5- The supporting infrastructure role in clinical trial execution
The 2016 World Health Organization classification of tumors of the central nervous system broadly employs genetic alterations for diagnostic criteria including isocitrate dehydrogenase-1 (IDH1) mutation or IDH2 mutation, and 1p/19q codeletion,[1] with the goal of creating more homogeneous disease categories with greater prognostic value.[2-5] Molecular diagnostics is becoming an increasingly important aspect of clinical oncologic neuropathology practice.
PER AVER SUCCESSO NEL RECUPERO DELLA FERTILITA’ MASCHILE E’ NECESSARIO INTERVENIRE SUI FATTORI DI RISCHIO
PER TUTELARE LA FERTILITA’ DEL NASCITURO E’ NECESSARIO INTERVENIRE SULLO STILE DI VITA DEI GENITORI - L’INFERTILITA’ MASCHILE E’ TRASMISSIBILE DA GENITORE A FIGLIO E FRA CIO’ CHE VIENE TRASMESSO ANCHE L’INADEGUATO STILE DI VITA
IL MONDO NON LO DOBBIAMO CONSIDERARE UN BENE CHE CI E’ STATO OFFERTO MA UN DONO DA LASCIARE AI NOSTRI FIGLI! mf
DNA Methylation and Histone Modification in Low-Grade Gliomas: Current Unders...Ahmad Ozair
Ozair A, Bhat V, Alisch RS, Khosla AA, Kotecha RR, Odia Y, McDermott MW, Ahluwalia MS***. DNA Methylation and Histone Modification in Low-Grade Gliomas: Current Understanding and Potential Clinical Targets. Cancers (Basel). 2023;15(4): 1342. ([Review Article], IF = 6.6, Available from: https://www.mdpi.com/2072-6694/15/4/1342)
Letter: Is the Stupp Protocol an expensive and unsustainable standard of care...Ahmad Ozair
Glioblastoma multiforme (GBM) is the most common and aggressive primary adult brain neoplasm with an age-adjusted incidence rate of 3.22 per 100 000 individuals and a 5-yr survival rate of 6.8%.1 In 2005, Stupp and colleagues proposed maximal safe resection, concomitant temozolomide (TMZ) with radiotherapy, and adjuvant TMZ as the optimal treatment. Implementation of the Stupp protocol in high-income countries (HICs) has resulted in increased survival compared to previous regimens. With little-to-no literature on the management and outcomes of patients with GBM in low- and middle-income countries (LMICs), it is unclear whether the Stupp protocol is being adopted or whether it is, or ever can be, the optimal strategy in LMICs...
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This presentation will highlight the promising new therapeutic strategies in the treatment of gliomas, with a focus on trials or therapies that will soon be available for Canadian patients.
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Malignant Mixed Mullerian Tumor – Case Reports and Review ArticleApollo Hospitals
Malignant mixed mullerian tumors are very rare genital tumors. They are biphasic neoplasms composed of an admixture of malignant epithelial and mesenchymal elements. In descending order of frequency they originate in the uterus, ovaries, fallopian tubes, cervix and vagina. Also they arise denovo from peritoneum. They are highly aggressive and tend to occur in postmenopausal low parity women. Because of rarity, there is as such no treatment guidelines available. Multimodality treatment in the form of radical surgery followed by adjuvant chemotherapy or radiotherapy or combined chemoradiation gives a better prognosis & outcome. Two case reports of such tumors, one from ovary and other from penitoneum are presented along with the review of literature.
Intra-Fetal Laser Ablation of Umbilical Vessels in Acardiac Twin with Success...Apollo Hospitals
To interrupt blood supply to the acardiac twin in a case of TRAP sequence of monochorionic diamniotic multiple pregnancy to allow for continuation of the normal twin.
Breast Cancer in Young Women and its Impact on Reproductive FunctionApollo Hospitals
Breast cancer is the most common cancer in women in developed countries. Chemotherapy for breast cancer is likely to negatively impact on reproductive function. We review current treatment; effects on reproductive function; breastfeeding and management of menopausal symptoms following breast cancer.
Turner syndrome (gonadal dysgenesis) is one of the most common chromosomal abnormalities occuring 1 in 2500 to 1 in 3000 live-born girls. It is an important cause of short stature in girls and primary amenorrhea in young women that is usually caused by loss of part or all of an X chromosome. This review briefly summarises the current knowledge about the syndrome and the management strategies.
Due to pregnancy thyroid economy is affected with changes in iodine metabolism, TBG and development of maternal goiter. The incidence of hypothyroidism in pregnancy is quite common with autoimmune hypothyroidism being the most important cause. Overt as well as subclinical hypothyroidism has a varied impact on maternal and neonatal outcome. After multiple studies also, routine screening in pregnancy for hypothyroidism can still not be recommended. Management mainly comprises of dosage adjustments as soon as pregnancy is diagnosed based on results of thyroid function tests. The aim should be to keep FT4 at the upper end of normal range.
Growth Hormone Deficiency (GHD) can persist from childhood or be newly acquired. Confirmation through stimulation testing is usually required unless there is a proven genetic/structural lesion persistent from childhood. Growth harmone (GH) therapy offers benefits in body composition, exercise capacity, skeletal integrity, and quality of life measures and is most likely to benefit those patients who have more severe GHD. The risks of GH treatment are low. GH dosing regimens should be individualized. The final decision to treat adults with GHD requires thoughtful clinical judgment with a careful evaluation of the benefits and risks specific to the individual.
Advances in the management of thalassemia have led to marked improvements in the life span and quality of life of children and young adults. This poses new challenges for the treating physicians. There is now increasing recognition that thalassemics have impaired bone health which is multifactorial in etiology. This paper aims to highlight the factors that predispose these patients to osteoporosis and suggests measures to minimise the impact on bone health.
Laparoscopic Excision of Foregut Duplication Cyst of StomachApollo Hospitals
Retroperitoneal gastric duplication cysts lined by ciliated columnar epithelium are extremely rare lesions and its presentation during adulthood is a diagnostic challenge for treating clinicians. This entity often resembles cystic pancreatic neoplasm, retroperitoneal cystic lesions and sometimes as an adrenal cystic neoplasm. Correct diagnosis on the basis of radiological investigation is difficult and histopathologic analysis. We report a case of gastric duplication cyst in a 16year old girl that mimicked as a retroperitoneal /pancreatic /adrenal cystic lesion and was successfully managed by laparoscopy.
Occupational Blood Borne Infections: Prevention is Better than CureApollo Hospitals
Viral infections like HIV, hepatitis Band C virus pose a big risk to the contacts of individuals with high risk behaviour as well as to the attending health care workers. Blood, semen, vaginal and other potentially infectious materials can transmit the infection to the susceptible contacts. Universal precautions should be strictly implemented during clinical examination, laboratory work and surgical procedures to prevent transmission to the health care providers. Health care workers should receive vaccination for hepatitis B infection. An inadvertent exposure should be managed with proper first aid and infectivity of the source and severity of exposure should be assessed. Severity of exposure is based on the nature and area of exposed surface, mode of injury and volume of infective material. Post-exposure prophylaxis (PEP) should be started as soon as possible after a proper counseling about the effectiveness of post-exposure prophylaxis, side effects and risk of carrying the infection to his familial contacts and its prevention.
Evaluation of Red Cell Hemolysis in Packed Red Cells During Processing and St...Apollo Hospitals
Storage of red cells causes a progressive increase in hemolysis. Inspite of the use of additive solutions for storage and filters for leucoreduction some amount of hemolysis is still inevitable. The extent of hemolysis however should not exceed the permissible threshold for hemolysis even on the 42nd day of storage.
Efficacy and safety of dexamethasone cyclophosphamide pulse therapy in the tr...Apollo Hospitals
Various drugs used to treat pemphigus can cause remission, but none can provide permanent remission as relapses are common. With the introduction of DCP in pemphigus in 1984, patients started being in prolonged/permanent remission. This study was done to compare the efficacy of DCP to oral corticosteroids and cyclophosphamide in combination.
Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)Apollo Hospitals
Severe skin adverse drug reactions can result in death. Toxic epidermal necrolysis (TEN) has the highest mortality (30–35%); Stevens-Johnson syndrome and transitional forms correspond to the same syndrome, but with less extensive skin detachment and a lower mortality (5–15%). Hypersensitivity syndrome, sometimes called Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS), has a mortality rate evaluated at about 10%. It is characterised by fever, rash and internal organ involvement. Prompt diagnosis is vital, along with identification and early withdrawal of suspect medicines and avoidance of re-exposure to the responsible agent is essential. Cross-reactivity to structurally-related syndrome caused by Carbamazepine medicines is common, thus first-degree relatives may be predisposed to developing this syndrome. We report a case of DRESS secondary to use of Carbamazepine.
Difficult Laparoscopic Cholecystectomy-When and Where is the Need to Convert?Apollo Hospitals
Laparoscopic cholecystectomy has now become the treatment of choice for the gall bladder stone. With increasing experience, surgeon has started to take more difficult cases which were considered relative contra indications for laparoscopic removal of gall bladder few years back.
We conducted this study at our hospital and included all laparoscopic cholecystectomy done from May'08 to January'10. Total time taken in surgery, conversion rate and complication rate were analysed. Factors making laparoscopic cholecystectomy difficult were also analysed. We defined difficult laparoscopic cholecystectomy when we found -dense fibrotic adhesions in and around Callot's triangle, gangrenous gall bladder, empyma, large stone impacted at gall bladder neck, contracted gall bladder, Mirrizi's syndrome, h/o biliary pancreatitis, CBD stones, acute cholecystitis of <72 hrs duration.
Out of 206 cases done during above period, 56 cases were considered difficult. Only two cases were converted to open.
With growing experience and technical advancement surgery can be completed in most of the difficult cases. This is important because recently it is shown in literature that laparoscopic cholecystectomy is associated with less morbidity than open method irrespective of duration of the surgery.
Deep vein thrombosis prophylaxis in a tertiary care center: An observational ...Apollo Hospitals
Deep vein thrombosis (DVT) is a major health problem with substantial mortality and morbidity in medically ill patients. Prevention of DVT by risk factor stratification and subsequent antithrombotic prophylaxis in moderate- to severe-risk category patients is the most rational means of reducing morbidity and mortality.
The spread of dengue and dengue haemorrhagic fever is increasing, atypical manifestations are also on the rise, although they may be under reported because of lack of awareness. We report two such cases of dengue hemorrhagic fever with hepatitis, intraocular hemorrhage, ARDS and myocarditis.
A 71-year-old male presented in ENT department with dysphagia for last three weeks, more to solids than liquids. He had a hard bony bulge in the posterior pharyngeal wall on palpation and hence was referred for an Orthopaedic opinion. Lateral radiograph of the cervical spine revealed diffuse ossification of the anterior longitudinal ligament. This ossification was extending almost half the width of the cervical body from its anterior body at C1 and C2 vertebra level.
Pediatric Liver Transplant (LT) is now an established procedure for End Stage Liver Disease (ESLD) with biliary atresia being the commonest indication. Intensive pre-transplant evaluation, nutritional buildup and immunization are the fundamental pre-requisites of a successful LT. With improvement in surgical micro-anastomotic techniques and superior immunosuppressive regimens the success rate of pediatric LT is in excess of 90%. Most of the transplants in our country however are Living related, due to which a fairly large number of children expire awaiting a donor liver. There should be a concerted effort to evolve the cadaveric donation program, so that majority of the children are benefitted.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Thyroid Gland- Gross Anatomy by Dr. Rabia Inam Gandapore.pptx
Qol paper
1. Neuro-Oncology 14: iv8 –iv16, 2012.
doi:10.1093/neuonc/nos205 N E U RO - O N CO LO GY
Factors influencing quality of life in adult
patients with primary brain tumors
Rakesh Jalali and Debnarayan Dutta
NeuroOncology Group, Tata Memorial Hospital, Mumbai, India (R.J.); Apollo Specialty Hospital, Chennai,
India (D.D.)
Downloaded from http://neuro-oncology.oxfordjournals.org/ at Tata Memorial Hospital on October 24, 2012
We performed a literature review with respect to factors in- low, with diffuse low-grade glioma transforming to
fluencing health-related quality of life (QOL) in adults with high-grade in a median duration of 5 – 7 years.3,4
primary brain tumors. A comprehensive, peer-reviewed In benign tumors, neurological and neurocognitive
literature search was performed including studies exam- function preservation is the prime concern of
ining QOL in adults with high-grade gliomas and low- treatment. Therefore, preservation of normal daily activ-
grade gliomas and in routine neuro-oncology practice. ities and neurological function is being increasingly
The interpretation and implication of QOL domain taken into consideration in the present day neuro-
scores may be different in high-grade, low-grade, and oncology practice, and quality of life (QOL) is consid-
benign brain tumors. Several patient-related, treat- ered an important end point.5 Prospective studies
ment-related, and sociocultural factors influence QOL evaluating the impact of disease progression and treat-
scores. Pretreatment baseline QOL domain scores have ment on QOL domain parameters have shown disease
been shown to be a predictive parameter for survival progression to have detrimental impact on QOL
function. Implementation of QOL scores in routine clin- domain scores.6,7
ical practice is underused. QOL is an important outcome A meta-analysis of 30 prospective clinical trials
measure in the treatment of patients with brain tumors (n ¼ 10,108) from different primary tumor sites con-
and should be incorporated as a surrogate end point firmed that pretreatment (baseline) QOL parameter
along with traditional end points, such as disease-free scores, such as physical functioning, pain, appetite
and overall survival in most current trials. loss, and World Health Organization performance
status, have prognostic significance on survival function.
Keywords: adult, primary brain tumor, quality of life, Age, sex, socio-demographic parameters, and distant
routine clinical practice. metastasis have also been shown to influence QOL
score.8
Treatment with aggressive surgery, radiation therapy,
Background and chemotherapy schedules in advanced and metastatic
disease impair QOL domain scores.6 – 8 There is a need
for caution regarding some of the potentially aggressive
P
rimary brain tumors comprise 2% of all malignan-
cies in the adult patient population.1 Over the past treatments, which may improve the clinically meaningful
few years, improvements in treatment approaches survival function, but may significantly impair QOL func-
have included refinements in surgical resection, radiation tion. On the other hand, prospective clinical trials in other
therapy delivery methods, and newer systemic agents for cancer sites have proven that early supportive care and
these tumors. There have also been tremendous advanc- preservation of QOL eventually improves survival func-
es in the understanding of the molecular biology of these tion.9 Similarly, many other prospective studies suggest
tumors, aiding the exploration of several new potential that pretreatment baseline QOL domain scores are also
therapeutic avenues.2 Such advancements have im- predictive of survival function.10
proved survival function in both benign and malignant
brain tumors. Unfortunately, even with modern treat-
ment modalities, long-term outcomes in high-grade QOL Evaluation Tools
gliomas and other such tumors remain disappointingly
There are various QOL and neurocognitive function as-
Corresponding Author: Rakesh Jalali, MD, Professor of Radiation sessment tools being used in clinical trials and clinical
Oncology and NeuroOncology, 1129, Homi Bhabha Block, practice.5,11 – 19 Functional evaluations are broad, either
Tata Memorial Hospital, Parel, Mumbai, India 400 012 with objective assessment (eg, clinical examination by
(rjalali@tmc.gov.in). physician or nurse) or subjective assessment through
# The Author(s) 2012. Published by Oxford University Press on behalf of the Society for Neuro-Oncology. All rights
reserved. For permissions, please e-mail: journals.permissions@oup.com.
2. Jalali et al.: QOL in adults with primary brain tumors
questionnaire-based evaluation of well-being and QOL. injury due to aggressive surgical intervention may also
Commonly used objective evaluation tools are induce further neurological deficit and, thus, impair
Karnofsky performance score (KPS), neurological perfor- QOL and survival.32 In a non-randomized prospective
mance score (NPS), Barthel’s activity of daily living, and study, safe surgical resection improved neurological
others. Objective questionnaire-based QOL evaluation function and QOL domain scores.35 It seems that safe
tools are mainly European Organization for Research surgical resection with no additional neurological
and Treatment of Cancer (EORTC) Core Quality of deficit after surgery leads to optimal survival function
Life Questionnaire (QLQ-C30), brain-specific module improvement and preservation of QOL.
(BN-20), and Functional Assessment of Cancer Therapy In HGG, postoperative radiotherapy (RT) has been
(FACT) cancer-specific scales.12 – 19 Neurocognitive func- shown to improve survival.4,22 Median survival even
tion is assessed using a various battery of tests.16 The ex- after treatment is relatively short (12 –17 months), and
tensive MD Anderson Symptom Inventory-Brain Tumor therefore, preservation of neurological function and
Module (MDASI-BT) has 22 symptom items that mea- QOL is an important end point. RT may decrease
sures affective, cognitive, focal neurologic deficit, consti- QOL scores in patients with adverse effects, such as
tutional, generalized symptom, and gastrointestinal- hair loss, fatigue, somnolence, and cognitive problems.33
Downloaded from http://neuro-oncology.oxfordjournals.org/ at Tata Memorial Hospital on October 24, 2012
related factor. In the MDASI-BT, data collection tools Early QOL studies (n ¼ 525) in both newly diagnosed
included a patient-completed demographic data sheet, and recurrent HGG showed that patients with HGGs
an investigator-completed clinician checklist, and a core have impairment in QOL domains, particularly in
inventory with 18 neurological symptoms.15 In the fatigue, uncertainty about the future, motor difficulties,
RTOG 0525 phase-III randomized study (n ¼ 833), a drowsiness, communication difficulties, and headache.33
dose-dense temozolomide (TMZ) regimen after concom- Patients with controlled disease had better QOL domain
itant chemo-radiation therapy in gliobloastoma was eval- scores than did those with residual/recurrent disease.33
uated with survival function and QOL.20 Patients with recurrent disease had poorer QOL scores,
compared with patients with newly diagnosed
HGGs.21,33,34 There was no significant difference in
Factors Influencing QOL Score QOL domain scores in patients with anaplastic astrocy-
tomas and those with GBMs.33 Corticosteroid and anti-
QOL scores depend on various patient-, tumor-, and convulsant treatments have been shown to have a
treatment-related factors.11,12,20 – 32 There may be differ- detrimental effect in few of the QOL domain scores
ential importance of various factors influencing QOL (fatigue, somnolence) and may reduce neurocognitive
scores in high-grade gliomas (HGGs) and low-grade function.33
gliomas (LGGs). In both in HGGs and LGGs, the Prospective, multi-centric randomized studies estab-
tumor appears to be one of the major factors influencing lished the role of concomitant chemotherapy with
cognitive function and QOL domain scores.4,21,22,33,34 TMZ and RT in newly diagnosed GBMs.3 Patients
Patients with controlled disease have the most preserved with GBM (n ¼ 583) treated with TMZ+RT had statis-
QOL domain scores, whereas there are impairments on tically significant improvement in survival function
progression.4,22 Other tumor-related factors influencing (2 months overall survival benefit with RT + TMZ;
QOL scores are tumor site, laterality, size, hypothalamic P ¼ .001).3 Long-term follow-up in the same study con-
involvement, hormonal deficiencies, and epilepsy.23 – 29 firmed the superiority of TMZ+RT as the new standard
Anticonvulsants, corticosteroids, new neurological of care in newly diagnosed GBMs.36 Although there was
deficit, higher dose of radiation therapy, and chemother- evidence of improvement with TMZ + RT in GBMs, the
apy all have detrimental effects on QOL scores.29 – 32 main apprehension was with regard to QOL and toxicity
Complete surgical resection, radiation therapy in profile with TMZ when prescribed along with RT. TMZ
HGGs, or low dose per fraction radiation therapy in is known to have mainly hematological (thrombocytope-
LGGs with loco-regional control will improve or main- nia) and gastrointestinal (nausea) toxicities.37 Prospective
tain QOL domain scores.4,22,23,28 Different socioeco- QOL study in the same cohort of patients established that
nomic and cultural factors also play a role in QOL there was no significant detrimental effect of TMZ along
domain scores.11 with RT.21 The RT + TMZ arm had poorer nausea and
vomiting scores after RT completion, although there
was no statistically significant difference compared with
QOL Issues in HGGs the RT alone arm.21 There was improvement in global
QOL score after RT + TMZ that was maintained until
Patients with HGGs often present with convulsion disor- there was clinical or radiological progression. The
ders, headache, and neurological deficit.18 These symp- TMZ + RT arm had worse social functioning score
toms lead to definite impairment of functional abilities (P ¼ .0052).21
and QOL. Impairment of cognitive function domains Dose escalation study with conformal irradiation
in HGG depends on tumor size and location of the (dose levels, 66, 72, 78, and 84 Gy) were evaluated pro-
tumor.21,23 – 26,33,34 Surgical excision of the tumors spectively, and QOL was assessed with the Spitzer
reduces the mass effect, mainly improving motor func- Quality of Life Index (RTOG 93 – 03).38 Patients with
tion and related QOL domains. On the other hand, tumor control had shown preservation of QOL
NEURO-ONCOLOGY † SEPTEMBER 2012 iv9
3. Jalali et al.: QOL in adults with primary brain tumors
scores.38 Dose escalation was not shown to be a signifi- as strong predictors of overall survival. These included
cant detrimental factor for QOL.38 However, there is a baseline physical functioning (0.988; 95% confidence
need for a larger study to evaluate the impact of dose es- interval [CI], 0.977 –0.999; P ¼ .029), baseline delayed
calation on QOL. Dose escalation with brachytherapy in recognition (0.874; 95% CI, 0.771 – 0.991; P ¼ .036),
HGGs has been shown to have a detrimental impact on cognitive function decline (MDASI-BT; 1.82; 95% CI,
both survival function and QOL.32 1.14– 2.89; P ¼ .012), cognitive function decline
In HGGs, tumor is an important factor influencing (QLQ-BN20; 1.95; 95% CI, 1.23 –3.09; P ¼ .004),
neurocognitive function and QOL.21,34 Disease recur- deterioration of motor function (1.59; 95% CI, 1.02–
rence/progression is associated with impairment of 2.47; P ¼ .041), and deterioration of delayed recogni-
QOL domain scores.34 Treatment modalities in recur- tion (1.90; 95% CI; 1.14 – 3.15; P ¼ .013). The investi-
rent HGGs also influence QOL scores. Treatment with gators have demonstrated that changes in QOL can
TMZ had no significant negative effect on QOL in pa- act as useful markers of response and/or progression.
tients with recurrent GBM.39 Responders to TMZ had In addition, encouragingly, collecting detailed QOL
improvement in QOL domain scores (global, motor dys- data are feasible in a large clinical trial setting.20 This
function, emotional function, drowsiness, future uncer- may well act as a benchmark for future clinical trials.
Downloaded from http://neuro-oncology.oxfordjournals.org/ at Tata Memorial Hospital on October 24, 2012
tainty, and communication deficit) until clinical or
radiological disease progression.39
Although TMZ and RT in GBM have not been shown QOL Issues in LGGs
to have any significant detrimental effect on QOL
scores,21 combined procarbazine, CCNU (lomustine), LGGs include diffuse fibrillary astrocytoma, oligo-
and vincristine (PCV) chemotherapy after RT in patients dendroglioma, and mixed oligo-astrocytomas, and
with anaplastic oligodendroglioma (n ¼ 368; EORTC median PFS after diagnosis is 5–7 years; 5- and 10-year
26951) did show a negative impact on early QOL PFS rates are 50% and 12%, respectively.4 In LGG,
domain scores (nausea/vomiting, appetite loss, and tumor is the most important factor influencing the QOL
drowsiness).30,40 In longer follow-up, however, there and neurocognitive function score.4,22 LGGs are treated
was a significant difference between RT alone and with total or near-total surgical resection. Patients with
RT+PCV.40 In anaplastic oligodendrogliomas (RTOG LGG treated with gross surgical excision have been
94 – 02), there was no progression-free survival benefit shown to have improved QOL domain scores.4 In LGG,
with PCV and no impact on QOL.41 Dose escalation after safe surgical excision with no additional neurologi-
study in GBM with carmustine chemotherapy (RTOG cal deficit, peri-operative injuries do not impair QOL
98 – 03) showed progressive deterioration of QOL func- domain scores.4 Patients with biopsy only had poorer
tion.42 Few studies with small numbers of patients QOL scores.4,22 It appears that patients with deep
showed no QOL benefit with carmustine- seated/eloquent area LGGs are treated with biopsy
impregnated wafers in recurrent/progressive HGGs.43 only, and impaired QOL function may be mostly attribut-
Early studies with bevacizumab (a humanized monoclo- able to the location of tumor rather than surgery
nal antibody that binds and inhibits the activity of type.4,11,22 Prospective evaluation of LGGs (n ¼ 101)
VEGF) showed promising results in recurrent/refractory with pre- and postoperative QOL evaluation and long-
HGGs in terms of neurocognitive function preserva- term evaluation (.10 years) suggests that there is short-
tion.44 A randomized phase II study comparing bevaci- term impairment of cognitive and QOL domain functions
zumab alone or in combination with irinotecan after surgery.47 However, after safe surgical resection,
(n ¼ 167) in patients with recurrent/refractory GBM QOL is maintained in long-term follow up.47 Location
showed 75% reduction of corticosteroid dose at 6 of the tumor has shown to influence QOL score.24
months after treatment follow-up.45 It seems that the Patients with dominant hemisphere tumor had more dis-
steroid-sparing effect of bevacizumab improves neuro- ability in cognitive function scores.24 Patients treated with
logical symptoms and may have a positive impact on anti-epileptics had poor attention and execution func-
QOL in recurrent/refractory HGGs. Long-term survi- tion.26 Right hemisphere lesions cause poor perception
vors with HGGs show improvement in QOL domain and psychomotor speed function.24 Left hemisphere
scores and may match healthy individuals.45 A review lesions are associated with poor attention and execution
of 300 patients with GBM treated with re-irradiation function.24
yielded 6-month PFS of 28%– 39%; 1-year overall sur- Two important studies have evaluated the RT dose-
vival of 18% – 48% and clinical improvements (QOL response relationship in LGGs.23,48 There was a
score) were observed in 24% – 45%. Patients with KPS plateau in the dose-response curve after RT dose of
,70 had higher risk of early progression and lesser 45 Gy (in 1.8 –2 Gy/fraction). The EORTC 22845
benefit from re-irradiation.46 study addressed the role of RT (early vs late) in LGGs
The recently concluded RTOG-0525 study compared in multi-centric, prospective, randomized setting.23
dose-dense TMZ to standard adjuvant TMZ in a large The recent update with longer follow-up (follow-up
patient population (n ¼ 833) and extensively evaluated range, 2 –22 years; median, 9.3 years) of this random-
QOL endpoints in addition to survival. QOL was ized study with a large cohort of patients (n ¼ 311)
overall worse in patients receiving a dose-dense TMZ showed PFS benefit in the early RT arm and no diffe-
schedule. Of interest, several QOL domains emerged rence in overall survival.4 Thus, young patients with
iv10 NEURO-ONCOLOGY † SEPTEMBER 2012
4. Jalali et al.: QOL in adults with primary brain tumors
seizures and near complete surgical excision are consid- QOL Studies in Routine Clinical Practice
ered for late RT at progression. On the other hand, pa-
tients with higher probability of local recurrence The majority of data on QOL in brain tumors are from
(according to Pignatti’s criteria) were considered for western populations in which the socioeconomic and
early RT.49 Early RT in patients with LGG with high- cultural backgrounds are different from those in Asian
risk of recurrence delays disease progression and, thus, populations.11,21,22,33,34 Interpretation and implication
may also preserve cognitive function. Unfortunately, in of QOL domain scores may be different in clinical
this randomized study, QOL assessment was not includ- trials with well-informed patients and comprehensive
ed; thus, the impact of early or late RT on QOL param- consent forms than in routine clinical practices in
eters was not evaluated. which patients are less informed about the outcome of
A prospective study of 195 LGGs at Maastricht the treatment.11 Socio-cultural factors may interfere
University with long-term follow up (median follow-up, with dissemination of appropriate information regard-
12 years) assessed the QOL parameters with RT in ing the disease and prognosis.11 There are publications
LGGs.50,51 Patients with LGGs had poorer cognitive on QOL in routine clinical practice from neuro-
function scores, compared with healthy matched indi- oncology centers in Asian countries, such as China,
Downloaded from http://neuro-oncology.oxfordjournals.org/ at Tata Memorial Hospital on October 24, 2012
viduals and patients with Non-Hodgkin Lymphoma/ Taiwan, and India. There are QOL studies from both
Chronic lymphocytic leukemia.50 It suggests that clinical trials and routine clinical practice from devel-
tumor impairs cognitive function and QOL. First assess- oped countries.57 – 60
ment at 6 years after RT did not show any significant dif- A QOL study from Brazil (n ¼ 30) with FACT Br and
ference in cognitive function domains between the early SF36 questionnaires showed the feasibility of QOL
RT and the no (delayed) RT arms.50 However, at second studies in routine clinical practice.18 Tsay et al. from
assessment after 12 years, significant worsening of Taiwan evaluated the impact of pre-surgery distress
cognitive domains, such as executive functioning and anxiety in benign primary brain tumors (n ¼ 58)
(P ¼ .03), information processing speed (P ¼ .05), and in routine clinical practice and its impact on QOL.58
attention domain (P ¼ .003), were seen in the early RT There was impairment of QOL scores with severe dis-
arm.51 Higher dose per fraction (.2 Gy) may have tress and anxiety. A QOL evaluation from China using
accelerated detrimental impact on cognitive functions.51 the EORTC- QLQ C30 questionnaire showed emotional
This study showed that even conventional RT (1.8–2 Gy impairment in 84.8%, social and cognitive impairment
per fraction) can cause additional late delayed cognitive in 75%, physical impairment in 70.7% and role impair-
function impairment, especially in the attention domain. ment in 50% of patients with gliomas (n ¼ 92).57
Chemotherapy also has shown to impair cognitive func- Factors, such as age, KPS, WHO grade, and tumor recur-
tion (“chemobrain”).29 A prospective study of TMZ in rence, significantly affected QOL scores. Ruge et al.
LGGs showed preserved QOL scores in patients with con- (n ¼ 33) performed a short-term (median follow-up,
trolled/stable disease.31 18 months) QOL evaluation with SF-36 in LGGs
treated in routine clinical practice.61 Chaichana et al.
showed that, in HGGs (n ¼ 544), preoperative KPS
QOL Issues in Benign Tumors score ≥90, preoperative seizures, gross-total resection,
TMZ, new postoperative motor deficit, older age, and
Benign brain tumors/lesions (eg, craniopharyngiomas, tumor recurrence influences functional status and QOL
pituitary tumor) do not progress to higher grade and in routine clinical practice.62 A Canadian study
usually have long survival.52 – 56 Reduction of mass (n ¼ 130) suggested that older age has a detrimental
effect with surgical intervention, prevention of progres- effect on QOL scores.63 Computer-based QOL monitor-
sion, and preservation of neurological function are the ing (EORTC C30 and BN20) has also been shown to be
main goals of treatment. Unfortunately, there are only feasible in routine clinical practice.64 Patients with
few prospective cognitive function and QOL studies in GBM (n ¼ 50) in routine practice with poor distress
adult patients with these rare benign conditions. In cra- and anxiety scores had poorer QOL questionnaire com-
niopharyngiomas and pituitary tumors, hydrocephalus, pliance.60 Patients with HGG (n ¼ 648) with better
growth hormone (GH) deficiency, and hypothalamic in- seizure control had better preservation of QOL
volvement have been shown to impair cognitive func- scores.60 A retrospective series of 91 patients with me-
tion.52 – 56 The transsphenoidal approach has been ningioma treated in Germany confirmed the negative
shown to preserve QOL domains in pituitary tumors.55 impact of age on cognitive function.59
Patients with acromegaly with controlled disease have Our earlier published study showed that patients with
preserved QOL scores compared to patients with uncon- brain tumors treated in routine clinical practice in devel-
trolled disease.56 GH deficiency has a detrimental impact oping countries have a different patient demographic
on QOL.54 Patients with craniopharyngiomas have im- profile, compared with patients from developed coun-
paired cognitive function scores, compared with healthy tries.65 In developing countries, HGGs occur 1 decade
individuals.52 It seems that conventional postoperative earlier than in developed countries, and the proportion
RT has no detrimental effect on patients with pituitary of patients with benign tumors was relatively lower in
tumors or craniopharyngiomas.52,53 developing country data. It seems that these variations
NEURO-ONCOLOGY † SEPTEMBER 2012 iv11
5. Jalali et al.: QOL in adults with primary brain tumors
in patient demographic profile may be related to differ- dysfunction 5. In mini-mental state examination,
ential life expectancy in different countries. QOL in MCID ranges from 5 to 14.66
routine clinical practice (n ¼ 243) described the diffe- Subjective questionnaire-based QOL evaluation has
rence in baseline future uncertainty scores in patients few other concerns, such as questionnaire filling and
from developed countries with that in patients from de- missing data. Caregivers commonly fill out question-
veloping countries.11 Tumor type (HGG and LGG) and naires on behalf of patients with HGGs and severe neu-
neurological function status (KPS and NPS) influenced rological deficits.67 There are differences in concordance
baseline QOL domain scores. On the other hand, eco- between the patient and caregiver scores, and these
nomic and literacy status did not have a significant influ- factors dilute subjective assessment scales. Prospective
ence on QOL scores. In the same cohort of patients, study regarding concordance suggested that, in .50%
follow-up evaluation showed .20-point improvements of questions, there was some degree of disagreement
in scores in seizure control, motor dysfunction (34%), between the patients and their caregivers. The most
pain (30%), insomnia (28%), headaches (26%), and common disagreements were in the domains of emotions
communication deficit (22%). In LGGs, significant and household needs.68
(.20 point) improvement was seen in seizure (33%), Concerns regarding the effects of missing pattern of
Downloaded from http://neuro-oncology.oxfordjournals.org/ at Tata Memorial Hospital on October 24, 2012
social function (30%), and headache (30%) domains, patient in subsequent follow-up have been the topic of
whereas there was some deterioration was in appetite discussion for the past 2 decades.69 Initially, the missing
loss (39%) and fatigue (24%) domains. During post- pattern was thought to be a random phenomenon and,
treatment follow-up, patients from high economic thus, may not influence the QOL scores in subsequent
strata had more preserved global QOL function than follow-up. Of interest, patients who had missed baseline
did those form middle or low economic strata. Patients QOL evaluation because of some administrative error
with complete or near-total excision of tumor had pre- also had lower QOL scores. Quality of QOL data may
served QOL scores and patients who underwent only be improved by minimizing administrative error, collec-
biopsy had poor pretreatment QOL scores. This tion of consecutive patient data, and reducing dropout
suggests that site of the disease (surgically unapproach- rates in subsequent follow-up.69 Implications of QOL
able region or deep-seated tumor) and type of tumor ad- domain score may be different in patients from
versely influences the QOL score rather than surgical developed or developing countries with vast contrast
intervention itself. On the contrary, this may be a in social support system and cultural influence.
result of reduction of effect of tumor (mass effect/hydro- Questionnaire in regional language is critical for appro-
cephalus) after radical surgery. Although there were dif- priate QOL evaluation.
ferences in few QOL domains, in overall review, there In summary, QOL is an important end point in
was no significant difference between QOL data ob- modern day clinical practice. In neuro-oncology, there
tained from developing countries and those from devel- are several patient-related, treatment-related, and socio-
oped countries. cultural factors that influence the QOL scores and their
interpretation. There are no apparent differences in
QOL domain score interpretation in clinical trial or
routine clinical practice. There are differences in few
QOL Evaluation Concerns and Issues QOL domains in patients from developing and devel-
oped countries, particularly in future uncertainty
Evaluation, interpretation, and collection of QOL data
related domains. There is a need to incorporate QOL
are the most contentious issues and are now seriously
study in most clinical trials with modern aggressive
evaluated.66 – 68 A major problem of the questionnaire
treatment modalities.
method of QOL measurement is the internal consisten-
cy.66 There are debates regarding the change in QOL
domain scores, which may have a clinically meaningful Search Parameters
impact of follow-up evaluation. A small change in
QOL scores from baseline may have statistical signifi- Our PubMed search was done with (“brain tumour”[All
cance; however, if the change in score is small, there Fields] OR “brain neoplasms”[MeSH Terms] OR
may not be any clinically meaningful change in patient (“brain”[All Fields] AND “neoplasms”[All Fields]) OR
perception. It seems that clinically relevant QOL “brain neoplasms”[All Fields] OR (“brain”[All Fields]
domain score change depends on different domains AND “tumor”[All Fields]) OR “brain tumor”[All
and may also be influenced by socio-economic and cul- Fields]) AND (“quality of life”[MeSH Terms] OR
tural factors.66 Recent studies suggest that minimum (“quality”[All Fields] AND “life”[All Fields]) OR
clinically important difference (MCID) in BN 20 “quality of life”[All Fields]) AND (“adult”[MeSH
domain scores for improvement or deterioration in phys- Terms] OR “adult”[All Fields]).
ical domain is 9, role function 12, cognitive functioning
8, global health status 4, fatigue 9, and motor Conflict of interest statement. None declared.
iv12 NEURO-ONCOLOGY † SEPTEMBER 2012
6. Jalali et al.: QOL in adults with primary brain tumors
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