Aug 15th, 2014
Two APK faculty members are being recognized for performing with distinction. Read more here […]
Aug 15th, 2014
Dr. Ashley Smuder, a NIH post-doctoral fellow in the Department of Applied Physiology and Kinesiology, has been promoted to Research Assistant Professor. She will continue her work in Dr. Scott […]
Nov 3rd, 2014
We are excited to announce that Dr. Beth Barton, currently in the Department of Anatomy and Cell Biology at the University of Pennsylvania, has been hired by APK as part […]
June 16, 2017
Women with breast cancer have long faced complicated choices about the best course of treatment. One particular concern has been the daily radiation therapy many women with breast cancer receive for six weeks after surgery. This form of therapy, also known as conventionally fractionated external beam radiation, has generally been recommended for most women undergoing breast conservation therapy. The goal has been to rid the body of any remaining cancerous cells that the surgeon’s tools could not remove. Radiation, however, can be time-consuming and expensive for the patient and society. It also carries a small risk for late complications, such as heart disease. New therapies have been tested that would shorten the length of radiotherapy from six weeks to three weeks, or deliver a single dose at the time of the lumpectomy procedure in the operating room. A shorter course of radiation means more convenience, perhaps, fewer side effects and fewer out-of-pocket expenses. And a single dose of radiation is much cheaper than whole breast radiation therapy delivered over multiple weeks, but is associated with a slightly higher risk of local recurrence. So which option should patients and physicians choose? In our recently published paper in the Journal of the National Cancer Institute, we came up with what we think is an answer. We showed through computer modeling that there is a better way for women – and one that can save our health care system nearly US$100 million every year. Problem and possible solutions For decades, breast cancer was considered such a formidable foe that doctors who treated it and women who had it wanted to use everything in their arsenal to fight it. That included the radical Halsted mastectomy, which often took out chest muscles along with the breast and left women disfigured. A woman’s chest a year after a double mastectomy. Flaxphotos/From www.shutterstock.com It also included lengthy radiation treatments, sometimes for as long as seven weeks (known as conventionally fractionated radiation), given every day Monday through Friday after surgery. This form of radiation comes at great cost to women and causes hardships for those who live far away from radiation clinics. In recent years, doctors studied new therapies for breast cancer. Halsted radical mastectomy has been replaced with a lumpectomy procedure that is usually performed on an outpatient basis. The radiation course has been shortened and is now delivered using sophisticated equipment, sparing unnecessary dose to the heart and lungs. The better equipment also began to allow researchers to look at ways to shorten treatment. Hypofractionated radiation, in which a portion of the breast is treated for a shorter time, was one result. Alternative therapies to conventional and hypofractionated radiation have also been recently introduced to deliver a single dose of radiation just to the tumor bed at the time of surgery. This is known is intraoperative radiotherapy, or IORT, meaning performed during the course of a surgical operation. Given the availability of choices with overlapping costs and outcomes, clinicians always face a dilemma: Which treatment is best for my patient? Likewise, patients can ask their clinicians, “What’s best for me?” And, if both treatments are equally effective, is there a difference in price that might guide decisions? Multiple randomized trials have shown that a 3- to 4-week course of whole breast radiation therapy is equivalent to a 6- to 8-week course. In fact, the National Comprehensive Cancer Network (NCCN) guidelines endorse the short hypofractionated course as the preferred approach. Despite all this, American doctors have not widely adopted the new strategy. The reasons for this are varied, including dissemination of new findings to private practitioners and financial incentives of treating with a longer course. Our current fee-for-service reimbursement structure pays more for the longer treatment, which may be a factor in the surprisingly slow adoption of the convenient hypofractionated whole breast radiotherapy approach. What might be adding more to this dilemma? Clinical trials have compared these treatment choices with one another. Several large randomized trials have compared a 6-week course to a 3- to 4-week course of whole breast treatment and found that the two treatment approaches are equivalent in terms of cancer control. In fact, one trial found that the shorter course of treatment yielded lower rates of acute toxic effects compared to the longer course. Several randomized trials have compared conventionally fractionated radiation therapy to a single fraction intraoperative treatment just to the tumor bed at the time of surgery. Although extremely convenient, IORT was slightly worse at controlling cancer recurrence. Yet, no single clinical trial has compared all three available options head-to-head. Another dilemma is that clinical trials usually follow patients for a period of five to 10 years, not a lifetime. That left an important question unanswered: How do we know which treatment is most beneficial over patient lifetime, and at what cost? Our study To solve this conundrum, we used computer modeling along with a cost-effectiveness analysis. In our study, our interdisciplinary team tried to identify the most optimal radiation therapy – that is, one that provides maximum value for money – for women diagnosed with early stage breast cancer. We simulated (created in computer) a hypothetical population of women diagnosed with early stage breast cancer. As per standard of care guidelines, women first get surgical treatment (lumpectomy). Now comes the uncertainty! These hypothetical women can get either conventional whole breast radiation, hypofractionated radiation or one-time intraoperative radiation. We obtained data from several clinical trials and databases to define treatment effectiveness and side effects, improvement or deterioration in quality of life, inconvenience (measures in term of travel time, lost wages, travel cost) and future consequences, including a possibility of cancer coming back or spreading to other organs. In our simulation, we then followed these hypothetical women over their lifetime to identify which treatment strategy is most valuable, or cost-effective. After extensive validation, we found that hypofractionated radiation is the most valuable treatment almost under all scenarios. It not only improves quality of life without compromising survival (adds four additional months of life with improved quality of health) but it also saves nearly $3,500 per patient. We also learned that IORT, or radiation treatment at the time of operation, may be appropriate for older women who live far from radiation facilities and would have to endure hardship when traveling for daily whole breast radiation for three to four weeks. Win-win for all! Our society saves health care dollars, and patients benefit most from treatment. Key takeaways Our analysis showed that conventionally fractionated radiation, in which women receive the radiation over six weeks, is not cost-effective under any scenario and should not be considered as a choice by physicians or patients. Our study is the first to evaluate this using the latest available data. A single dose of intraoperative radiation therapy, despite being much more convenient and less expensive, is associated with higher cancer recurrence rates. This difference in the risk of recurrence ends up costing the patient and society more than the hypofractionated treatment over a patient’s lifetime. Intraoperative radiation might be an option for older women who live in regions with poor access to health services. The shorter hypofractionated course is less expensive and improves quality of life substantially! With growing health care costs and an aging population, we are starting to focus more and more on identifying treatments that are less expensive and equally effective. We found that the use of the optimal strategy in this situation has the potential to improve health outcomes and save at least $100 million every year. This article was originally published on The Conversation. Read the original article.
June 16, 2017
Tourette syndrome is a mysterious medical curiosity that has puzzled doctors for more than a century. People who have it suffer from tics and other behavioral problems, such as obsessive compulsive traits and attention deficit disorder. In addition, they are cursed by a stereotype that they swear loudly and inappropriately. In reality, 10 percent actually experience these verbal outbursts, but many are stigmatized and isolated nonetheless. I have studied Tourette syndrome for years, and recently published a book about treatments and the common spectrum of behavioral disorders associated with it. Swearing isn’t even one of the more frequent ones. The fact is that over the last several years, many exciting and life-altering treatments have become available to Tourette patients and their families. We have reached a crossroads in this disease where it will become increasingly critical to reeducate the public and to make new therapies widely available. Twitches and tics French scientist Jean-Martin Charcot, the founder of modern clinical neurology, coined the eponym “Tourette syndrome” after his student, Georges Albert Gilles de la Tourette, who in 1885 described nine patients suffering from the tic “malady.” Jean-Martin Charcot, considered the founder of neurology. From wikimedia.com Researchers soon noticed that Tourette occurred among multiple family members across multiple generations. Over the generations, however, new knowledge came slowly. Critical gaps in our understanding of the syndrome remain, and half of all cases remain undiagnosed. Even the precise number of people affected has been hard to know. For example, the Centers for Disease Control and Prevention (CDC) estimates that one in 362 children, or 0.3 percent, has Tourette. The Tourette Association of America, on the other hand, estimates the disease is twice as common, with one in 166 kids (0.6 percent) affected. Some Tourette syndrome cases are mild, with symptoms such as nonbothersome eye blinking, or mild body twitching. In many cases, the motor tics will resolve in late adolescence or early adulthood. Many patients will even lead relatively normal lives. Lessons from the brain yield advances Knowledge of the syndrome has increased as scientists have learned more in general about the brain. The normal functions of the human brain seem to be dictated by rhythmic oscillations that continuously repeat over and over, much like a popular song on the radio. These oscillations change and modulate, and they act to control various human behaviors. If an oscillation “goes bad,” it can result in a disabling tic or other behavioral symptoms of Tourette syndrome. An important secret to the development of new therapies for Tourette is that we can alter these oscillations with rehabilitative therapies, cognitive behavioral intervention therapy (CBIT), medications such as tetrabenazine or even deep brain stimulation, which involves a small straw-like probe being inserted into the brain. Electricity can be delivered through this probe to disrupt the abnormal oscillations responsible for tics. Continued study also helping The genetics of Tourette remain opaque. Despite the fact that the disease tends to run in families, no one has discovered a single DNA abnormality linking all, or even most, cases. In the meantime, however, technology is offering new means of detection and treatment. Scientists have recorded tic signals from the human brain and even deployed the first smart devices to detect and suppress tics. Some investigators are studying newer generations of medicines that decrease the complications that can occur with old-fashioned drugs, such as Haloperidol, that have traditionally been used to treat Tourette. Scientists are also looking for way to suppress or modulate inappropriate brain signals, spurring development of new drugs with novel brain targets, such as cannabinoid receptors. Using marijuana to treat the symptoms of Tourette syndrome makes some scientific sense. Cannabinoids occur naturally in the body, and cannabinoid receptors are found throughout many brain regions. In fact, CB1 cannabinoid receptors are located in high concentrations in regions of the brain thought to be involved in Tourette syndrome. Living with Tourette syndrome While it may appear to the casual observer that someone with Tourette syndrome outgrows it in adolescence or early adulthood, in fact most do not. While the motor and vocal tics wane in most cases, the obsessive-compulsive and behavioral features may persist and even escalate. These behavioral features in Tourette syndrome, if left undiagnosed and untreated, will make it harder to live a normal life and will affect the person more than the noticeable motor and vocal tics. While new treatments may lie in the future, there are many things that patients and their families can do today. Many changes, often very simple, can be incorporated into patients’ lives. Comprehensive care teams from different disciplines play a key role. For example, a social worker can help to set up an individualized school education plan and connect families to resources that can transform difficult school situations into success stories. A rehabilitative therapist can now in many cases successfully address tics without the use of a single medication. Children and teens celebrate at the end of a week of camp at Twitch and Shout in Winder, Georgia in 2014. Building relationships with others who have Tourette syndrome is believed to be beneficial for young people. David Goldman/AP Our care team has taken care of close to 10,000 movement disorder patients at the University of Florida and tens of thousands more with our colleagues in the Southeast Regional Tourette Association of America Center of Excellence, which also includes neurologists, psychiatrists, rehabilitative specialists, social workers and scientists at the University of South Florida, Emory University, University of Alabama and the University of South Carolina. There are good reasons to try different treatments, even if none seems to work. Patients need to learn how to recognize when a plan or therapy isn’t working and how to speak with their doctors and care team about trying something else. The point is that left unchecked, brain vibrations can, in some Tourette cases, lead to neck-snapping tics which can cause injuries, even paralysis. Today even the most severe cases have a chance for treatment with deep brain stimulation. Though Tourette syndrome remains mysterious in the public eye, it is important that we teach families about the broad palette of options that provide tangible benefits for quality of life. That is definitely something worth shouting about. This article was originally published on The Conversation. Read the original article.
June 14, 2017
People who first became intoxicated as young teens have a greater risk of dying prematurely than those who first became drunk later in adolescence or not at all, according to a study led by University of Florida researchers. The findings appear online ahead of print in the journal Drug and Alcohol Dependence. “Although the causes remain uncertain and future studies are warranted, findings from this study suggest that early drunkenness is a strong predictor for premature mortality and can be used to identify high-risk populations for interventions,” said Hui Hu, Ph.D., the study’s lead author and a research assistant scientist in the department of epidemiology at the UF College of Public Health and Health Professions and the UF College of Medicine, both part of UF Health. Chronic alcohol misuse is associated with several health issues, including injuries, cardiovascular disease and cancer, as well as higher mortality rates. For the new study, researchers wanted to examine if becoming drunk at an early age might be associated with a higher risk of premature death later in life. Researchers used data collected from the National Institute of Mental Health Epidemiologic Catchment Area Survey, a large multisite study conducted in the early 1980s to understand the prevalence of adult mental health disorders. UF researchers linked those study participants to National Death Index records through 2007. Of the nearly 15,000 participants who answered questions about drinking in the original study, nearly 7,000 had died by the end of 2007. Eight percent of study participants reported first becoming intoxicated before the age of 15. Researchers found they were 23 percent more likely to die prematurely than those who reported first getting drunk at or after the age of 15, and 47 percent more likely to die prematurely than people who said they had never been drunk. While more research is needed to understand why people who get drunk for the first time in early adolescence may be at risk for dying prematurely, there are several possible contributing factors, Hu said. “People with early onset of drunkenness are more likely to develop alcohol use disorder, more likely to engage in other alcohol-related health behaviors such as smoking, fighting, unplanned and unprotected sex, and more likely to have low academic performance,” he said. The researchers were surprised to find early drunkenness was associated with premature mortality regardless of whether participants had alcohol use disorder at the time of the survey, suggesting there may be many factors at play. The UF researchers plan to explore the possible factors in future studies with the goal of informing interventions designed to decrease alcohol use among adolescents, Hu said. The Epidemiologic Catchment Area Survey is a unique study that is still providing researchers with valuable information 37 years after it was first conducted, said Linda B. Cottler, Ph.D., M.P.H., FACE, chair of the UF department of epidemiology, the senior author of the new study and coordinator of one of the five sites of the Epidemiologic Catchment Area Survey team in the 1980s. As new longitudinal studies are developed, it is important that researchers be thoughtful in the design of the questions, she said. “In epidemiology we design studies for life and questions that will stand the test of time,” said Cottler, PHHP’s associate dean for research and planning. In addition to Hu and Cottler, the study team included William W. Eaton, Ph.D., of The Johns Hopkins University, and James C. Anthony, Ph.D., of Michigan State University, who have both been involved in the Epidemiologic Catchment Area Survey since the beginning of the study, and Li-Tzy Wu, D.Sc., of Duke University Medical Center. The study was supported by funding from the National Institute on Drug Abuse.