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BACKGROUND: Pseudoneglect is a normal left sided spatial bias observed with attempted bisections of horizontal lines and a normal upward bias observed with attempted bisections of vertical lines. Horizontal pseudoneglect has been attributed to right hemispheric dominance for the allocation of attention. The goal of this study was to test the hypothesis that the upward bias in vertical line bisection may also relate to right hemispheric dominance for the allocation of attention and/or action-intention. METHODS: Twenty right handed healthy adults were asked to bisect vertical lines presented in the midsagittal plane (center space) and in sagittal planes to the left and right of the midsagittal plane (left and right hemispace) when using a pen held in either the right or left hand. RESULTS: Vertical line bisections were biased upward in all three sagittal planes and higher in left than right hemispace. However, bisections made with the left hand were lower than those made with the right hand. DISCUSSION: Whereas these results suggest a left hemispace-right hemispheric visuospatial attentional upward bias and a relative left hemispheric-right hand upward action-intentional bias, further studies are needed to document this intentional versus attentional bias and to understand the brain mechanisms that produce these biases. [ABSTRACT FROM AUTHOR]

Background: Posttreatment surveillance affects millions of cancer survivors, but empiric data to guide clinical practice are lacking. This study assessed whether the intensity of surveillance testing after radical prostatectomy or radiation therapy for localized prostate cancer is associated with overall survival., Methods: Men diagnosed with localized prostate cancer between 2005 and 2010 who underwent radical prostatectomy or radiation therapy at a Commission on Cancer-accredited facility were randomly sampled. Primary data collected from 10 147 patients sampled across 1007 facilities were linked with existing data from the National Cancer Database. Analysis examined whether intensity of surveillance measured as the number of prostate-specific antigen (PSA) tests in the first year after primary treatment (categorized as 0-1 [low intensity], 2 [medium], or ≥3 [high intensity] PSA tests) was associated with overall survival. Secondary outcomes included recurrence-free survival (RFS) and subsequent use of imaging tests, biopsy procedures, and salvage treatment., Results: Median follow-up exceeded 8 years from prostate cancer diagnosis. Overall survival was not statistically significantly different across surveillance intensity groups among radiation therapy (P = .59) or radical prostatectomy (P = .29) patients. RFS was not statistically significantly different across surveillance intensity groups for radiation therapy (P = .13) patients but was for radical prostatectomy (P = .01) patients with high intensity associated with the worst RFS. In both treatments, higher surveillance intensity was associated with more procedures and salvage treatments., Conclusions: In patients with localized prostate cancer, more frequent PSA surveillance testing after radical prostatectomy or radiation therapy was associated with increased procedures and salvage treatments but not overall survival., (© The Author(s) 2024. Published by Oxford University Press.)

Purpose: Dose escalation improves localized prostate cancer disease control, and moderately hypofractionated external beam radiation is noninferior to conventional fractionation. The evolving treatment approach of ultrahypofractionation with stereotactic body radiation therapy (SBRT) allows possible further biological dose escalation (biologically equivalent dose [BED]) and shortened treatment time., Methods and Materials: The American Association of Physicists in Medicine Working Group on Biological Effects of Hypofractionated Radiation Therapy/SBRT included a subgroup to study the prostate tumor control probability (TCP) with SBRT. We performed a systematic review of the available literature and created a dose-response TCP model for the endpoint of freedom from biochemical relapse. Results were stratified by prostate cancer risk group., Results: Twenty-five published cohorts were identified for inclusion, with a total of 4821 patients (2235 with low-risk, 1894 with intermediate-risk, and 446 with high-risk disease, when reported) treated with a variety of dose/fractionation schemes, permitting dose-response modeling. Five studies had a median follow-up of more than 5 years. Dosing regimens ranged from 32 to 50 Gy in 4 to 5 fractions, with total BED (α/β = 1.5 Gy) between 183.1 and 383.3 Gy. At 5 years, we found that in patients with low-intermediate risk disease, an equivalent doses of 2 Gy per fraction (EQD2) of 71 Gy (31.7 Gy in 5 fractions) achieved a TCP of 90% and an EQD2 of 90 Gy (36.1 Gy in 5 fractions) achieved a TCP of 95%. In patients with high-risk disease, an EQD2 of 97 Gy (37.6 Gy in 5 fractions) can achieve a TCP of 90% and an EQD2 of 102 Gy (38.7 Gy in 5 fractions) can achieve a TCP of 95%., Conclusions: We found significant variation in the published literature on target delineation, margins used, dose/fractionation, and treatment schedule. Despite this variation, TCP was excellent. Most prescription doses range from 35 to 40 Gy, delivered in 4 to 5 fractions. The literature did not provide detailed dose-volume data, and our dosimetric analysis was constrained to prescription doses. There are many areas in need of continued research as SBRT continues to evolve as a treatment modality for prostate cancer, including the durability of local control with longer follow-up across risk groups, the efficacy and safety of SBRT as a boost to intensity modulated radiation therapy (IMRT), and the impact of incorporating novel imaging techniques into treatment planning., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: Ultrahypofractionationed radiation therapy for prostate cancer is increasingly studied and adopted. The American Association of Physicists in Medicine Working Group on Biological Effects of Hypofractionated Radiotherapy therefore aimed to review studies examining toxicity and quality of life after stereotactic body radiation therapy (SBRT) for prostate cancer and model its effect., Methods and Materials: We performed a systematic PubMed search of prostate SBRT studies published between 2001 and 2018. Those that analyzed factors associated with late urinary, bowel, or sexual toxicity and/or quality of life were included and reviewed. Normal tissue complication probability modelling was performed on studies that contained detailed dose/volume and outcome data., Results: We found 13 studies that examined urinary effects, 6 that examined bowel effects, and 4 that examined sexual effects. Most studies included patients with low-intermediate risk prostate cancer treated to 35-40 Gy. Most patients were treated with 5 fractions, with several centers using 4 fractions. Endpoints were heterogeneous and included both physician-scored toxicity and patient-reported quality of life. Most toxicities were mild-moderate (eg, grade 1-2) with a very low overall incidence of severe toxicity (eg, grade 3 or higher, usually <3%). Side effects were associated with both dosimetric and non-dosimetric factors., Conclusions: Prostate SBRT appears to be overall well tolerated, with determinants of toxicity that include dosimetric factors and patient factors. Suggested dose constraints include bladder V(Rx Dose)Gy <5-10 cc, urethra Dmax <38-42 Gy, and rectum Dmax <35-38 Gy, though current data do not offer firm guidance on tolerance doses. Several areas for future research are suggested., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Cabozantinib Versus Sunitinib as Initial Targeted Therapy for Patients With Metastatic Renal Cell Carcinoma of Poor or Intermediate Risk: The Alliance A031203 CABOSUN Trial (CABOSUN) was a randomized, open-label, phase 2 trial evaluating first-line cabozantinib versus sunitinib in patients with advanced renal cell carcinoma (aRCC). This post hoc analysis evaluated quality-adjusted survival using Quality-adjusted Time Without Symptoms of disease or Toxicity of treatment (Q-TWiST)., Methods: Survival plots for cabozantinib and sunitinib (650-day follow-up) were partitioned into 3 health states: time spent before disease progression without toxicity (TWiST; toxicity based on National Cancer Institute Common Terminology Criteria for Adverse Events [version 4.0] grade 3/4 adverse events), time spent before disease progression with toxicity (TOX; durations of adverse events based on published literature), and time after disease recurrence (relapse) or progression to death (REL). Q-TWiST was the sum of the mean time spent in each state, with each state weighted to reflect patient preferences (from 0 [worst] to 1 [best]) using utility scores. TWiST was always weighted as 1. Overall survival and time to disease progression were based on all randomized patients (157 patients); TOX was based on all randomized and treated patients (150 patients)., Results: Across all utility combinations tested, Q-TWiST was found to be longer with cabozantinib versus sunitinib (range of differences, +24 days to +137 days). Q-TWiST differences that were found to be statistically significant (+92 days [95% confidence interval, 5-178 days] to +137 days [95% confidence interval, 60-214 days]) were of a clinically meaningful effect size (≥80 days), and were based on utility values that included those considered relevant for patients with aRCC (REL utility weight of 0.355, TOX utility weight of 0-1, and TWiST utility weight of 1)., Conclusions: In patients with aRCC, first-line cabozantinib was found to provide longer quality-adjusted survival compared with sunitinib. These findings may help to inform clinical decision making., Lay Summary: Cabozantinib and sunitinib are drugs that are used to treat patients with advanced kidney cancer. Clinical trials have shown that cabozantinib offers benefits over sunitinib, giving patients more time before their cancer progresses. It is important that this additional time before disease progression does not come at the expense of patients' quality of life, which can be affected by treatment side effects and/or ongoing cancer symptoms. Both quantity and quality of life are central to optimal treatment. In the current analysis of patients with advanced kidney cancer who were initiating treatment for the first time, cabozantinib provided more quality time before cancer progression compared with sunitinib., (© 2020 The Authors. Cancer published by Wiley Periodicals LLC on behalf of American Cancer Society.)

Purpose: Axicabtagene ciloleucel (axi-cel) is a CD19-directed chimeric antigen receptor (CAR) T-cell therapy for relapsed or refractory diffuse large B-cell lymphoma. Bridging therapy may be required for lymphoma control during the manufacturing interval between collection of autologous T cells and final CAR T product administration. The optimal bridging therapy is not known and patients are often chemorefractory. We present a case series of patients receiving radiation as a bridge to axi-cel., Methods and Materials: Between December 2017 and October 2018, 12 patients were intended to receive bridging radiation before axi-cel. The group was characterized by highly aggressive disease including 6 of 12 with "double hit" lymphoma and 6 of 12 with disease ≥10 cm in diameter. All patients received 2 to 4 Gy/fraction to a median dose of 20 Gy (range, 6-36.5 Gy). Half of patients received either 30 Gy in 10 fractions or 20 Gy in 5 fractions. Seven patients received concurrent chemotherapy. Eleven patients underwent axi-cel infusion and one did not. Median follow-up was 3.3 months (range, 1.1-12.0 months)., Results: No significant toxicities were identified during bridging radiation, and no patient experienced in-field progression of disease before axi-cel infusion. One patient experienced abdominal pain, which resolved after dose reduction. Two patients had out-of-field progression of disease during the bridging period. After axi-cel infusion, 3 of 11 patients (27%) experienced severe cytokine release syndrome or neurotoxicity. At 30 days, the objective response rate was 81.8% (11 of 12 evaluable; 1 stable disease, 1 out-of-field progression), with complete response in 27% (3 of 11). At last follow-up, the best objective response rate was 81.8%, with a complete response attained in 45% (5 of 11). Lymphocyte counts decreased slightly in 10 of 12 patients during radiation (median, 0.25 k/uL)., Conclusions: Radiation (with or without concurrent chemotherapy) can be safely administered as a bridge to axi-cel in high-risk lymphoma. Caution should be taken if irradiation is started before apheresis, and lymphocyte counts should be monitored closely throughout. Future investigation is warranted to optimize the use of bridging radiation before CAR T therapy., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background and Objective: Salience of emotional autobiographical memories may have temporal patterns associated with valence. Recall of negative emotional memories is often important in survival and well-being. Based on the possible survival value of negative memories, we posited that when given an open-ended request to recall either a sad or a happy memory, people are more likely to recall an older sad memory than a happy one., Methods: We asked 20 healthy participants, aged 18-63 years, to freely recall happy and sad emotional memories and estimate the length of time that had passed since the recalled event had occurred. We analyzed the age of each memory based on valence., Results: Sixteen of 20 participants volunteered a more remote sad than happy memory (P<0.05). Older participants' sad memories were more remote (P<0.05), but the ratio of happy to sad memories was not affected by age., Conclusions: Self-selected free retrieval of autobiographical happy and sad emotional memories reveals a time bias. Although the reason for this temporal dichotomy is unknown, it may be that engaging systems involved in defense and survival alters the encoding and/or retrieval characteristics of the memory that modify salience.

Importance: Localized prostate cancer diagnosis and treatment among elderly men who are not likely to benefit represents a potential source of low-value health care services., Objective: To quantify the costs to the Medicare program associated with detection and treatment of prostate cancer among elderly men in the United States., Design, Setting, and Participants: This nationwide, population-based, retrospective cohort study uses the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database to identify men 70 years or older diagnosed with localized prostate cancer between 2004 and 2007 and to ascertain Medicare costs associated with diagnosis and workup, treatment, follow-up, and morbidity management of the disease. National Medicare costs were estimated using per-person costs, stage-adjusted prostate cancer incidence rates by age from SEER 2007 through 2011, and 2010 Census population estimates by age., Main Outcomes and Measures: Estimated costs to the Medicare program overall, and in each (mutually exclusive) category related to diagnosis and workup, treatment, follow-up, and morbidity management., Results: This nationwide, population-based, retrospective cohort study included 49 692 men with nonmetastatic prostate cancer from the SEER-Medicare database (all participants were 70 years or older; 25 981 [52.3%] were 76 years or older). The median per-patient cost within 3 years after prostate cancer diagnosis was $14 453 (interquartile range [IQR], $4887-$27 899). The majority of this cost was attributable to treatment costs (median, $10 558; IQR, $1990-$23 718). Patients with a Gleason score of 6 or lower who pursued initial conservative management (no treatment within 12 months of diagnosis) had a 3-year median total cost of $1914 per patient. The estimated total 3-year cost to the Medicare program associated with the annual detection of prostate cancer in men 70 years or older is approximately $1.2 billion. Increasing active surveillance use in those with Gleason score of 6 or lower could reduce this cost by $320 million., Conclusions and Relevance: There is substantial cost to the Medicare program associated with the diagnosis and treatment of localized prostate cancer among elderly men in the United States, despite the fact that these men are unlikely to die of prostate cancer. The majority of costs are related to treatment. Reducing provision of low-value health care services among this patient population could result in significant health care savings.

Background: Stereotactic body radiation therapy is an emerging treatment for prostate cancer (PC), with potential biological and oncologic advantages. A well-established radiation dosing schedule (38Gy in 4 fractions) has shown excellent long-term efficacy in high-dose-rate (HDR) brachytherapy., Objective: To report 5-yr efficacy, toxicity, and quality-of-life (QOL) outcomes of a novel 4-d SBRT regimen., Design, Setting, and Participants: This was a single-arm prospective phase 2 trial involving 259 patients with low- or intermediate-risk PC treated at 18 US centers from December 2007 to February 2012. The median follow-up was 5yr (interquartile range 37-85mo)., Intervention: SBRT with 38Gy in four fractions; radiation plans mimicked HDR brachytherapy dosimetry., Outcome Measurements and Statistical Analysis: We measured freedom from biochemical recurrence (BCR) and assessed toxicities using the Common Terminology Criteria for Adverse Events v3.0 and QOL using the Expanded Prostate Cancer Index Composite., Results and Limitations: The 5-yr BCR-free rates were 100% and 88.5% for patients with low- and intermediate-risk PC, respectively. The cumulative 5-yr grade 2, 3, and 4 toxicity rates were 12.4%, 1.9%, and 0.4% for urinary, and 3.4%, 0%, and 0% for gastrointestinal toxicities, respectively. The median baseline prostate-specific antigen (PSA) level of 5.12ng/ml decreased to 0.1ng/ml by ≥42mo. QOL scores decreased at 1mo but returned to baseline by 6mo, with a later decline (≥24mo) in the urinary continence domain (pad use was 2% at baseline and 10% at 5yr), and lower sexual potency over time. Comparative outcomes versus other types of radiotherapy are difficult because the trial was not randomized., Conclusions: This regimen yields a high rate of BCR-free survival, with a very low median PSA nadir suggesting prostate ablation. For properly selected patients with low- or intermediate-risk PC who choose SBRT, this treatment regimen is effective., Patient Summary: This potent four-treatment stereotactic body radiotherapy regimen appears to be effective for patients with early prostate cancer., (Copyright © 2018 The Authors. Published by Elsevier B.V. All rights reserved.)

Background-objectives: When vertical lines are positioned above or below the center of the page, line bisection deviates toward the center of the page, suggesting that the edges of the page distract the allocation of attention to the line. A letter-character line (LCL) bisection requires both global and focal attention, to identify the target letter closest to the line's center. If more focal and less global attention is allocated to a LCL, more global attentional resources may be available and inadvertently allocated to the page. Alternatively, if the allocation of focal attention to a LCL inhibits global attentional processing, there may be less distraction by the page., Method: Twenty-four healthy adults (12 older) bisected vertical solid and character lines centered, or positioned closer to the top or bottom of the page., Results: There was no difference between bisection of solid and character lines centered on the page. Page-related deviations were greater with character lines than solid line bisections, and greater for lines positioned toward the top than the bottom of the page. With lines positioned toward the top, the older participants' attempted bisections were higher than those of the younger participants., Conclusions: These results suggest that the allocation of focal attention increases global attentional distractibility and that global-background attentional distraction is greater when the vertical lines are placed in the upper part of the page. Older participants appeared to be less distracted when lines were placed toward the top of the page, but the reason for this age difference requires further research.

Background/objectives: Compound horizontal lines are composed of 2 segments of unequal length and width. Line bisection requires that the participants attend to the entire line (global attention). The longer segment often distracts participants, suggesting that attention directed to this segment (focal attention) disrupts the allocation of global attention. This study attempted to learn whether the allocation of focal attention to a line segment is distracted by global attention allocated to the entire line and whether there are right-left distraction asymmetries when allocating focal or global attention., Method: Twenty-four healthy adults (12 > 65 years old) attempted to bisect horizontal lines composed of 2 segments of unequal length, with the larger segment placed to the right or left. They were also asked to bisect the longer segment of these lines., Results: When allocating focal attention to the larger segment, healthy participants were more distracted when the smaller segment was on the left than on the right. In contrast, when attempting to allocate global attention to the entire line, participants were more distracted when the larger segment was on the right side. There were no significant differences between older and younger participants., Conclusions: The asymmetrical global distraction during segment bisection might be related to the right hemisphere's dominance in mediating global attention and allocating attention leftward. In contrast, the asymmetrical focal distraction during full-line bisection might be related to the left hemisphere's dominance in mediating focal attention and allocating attention toward the right. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Background: Action-intentional programs control "when" we initiate, inhibit, continue, and stop motor actions. The purpose of this study was to learn if there are changes in the action-intentional system with healthy aging, and if these changes are asymmetrical (right versus left upper limb) or related to impaired interhemispheric communication., Methods: We administered tests of action-intention to 41 middle-aged and older adults (61.9 ± 12.3 years)., Results: Regression analyses revealed that older age predicted a decrement in performance for tests of crossed motor response inhibition as well as slower motor initiation with the left hand., Conclusion: Changes in action-intention with aging appear to be related to alterations of interhemispheric communication and/or age-related right hemisphere dysfunction; however, further research is needed to identify the mechanisms for age-related changes in the brain networks that mediate action-intention.

Background: Aggressive medical care at the end of life can be harmful to patients and families, but its prevalence in use among younger cancer patients is unknown. The goal of the study was to report on the use of aggressive care and hospice services for patients younger than age 65 years., Methods: Using the HealthCore Integrated Research Database, we analyzed patients who died between 2007 and 2014 with metastatic lung (n = 12 764), colorectal (n = 5207), breast (n = 5855), pancreatic (n = 3397), or prostate (n = 1508) cancer. Based on published quality measures, we assessed uses of chemotherapy, intensive care, emergency room visits, and hospice care at the end of life. We examined additional items including radiotherapy, invasive procedures, hospitalization, and in-hospital deaths. Multivariable modified Poisson regression models were used to adjust for age, sex, geographic region, rural/urban location, year of death, and regional education and income measures., Results: Across the five cancers, 10.1% to 14.1% of patients received chemotherapy within the last 14 days of life, 15.9% to 20.6% received intensive care in last 30 days, and 1.5% to 2.5% went to the emergency room two or more times in last 30 days. Hospice enrollment at least three days before death was 54.4% to 59.6%. However, 55.3% to 59.3% of patients had a hospital admission in the last 30 days, and one-third died (30.3%-35.4%) in the hospital., Conclusions: There was low use of cancer-directed treatment at the end of life for younger cancer patients, and hospice use was higher than 50%. However, there was a relatively high utilization of hospital-based care. These results demonstrate an opportunity for continued improvements in the provision of high-value, patient-centered care at the end of life., (© The Author 2017. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.)

In 1984, Watson and Heilman reported a patient with a partial callosal disconnection following an infarction of the anterior portion of her corpus callosum. This woman's performance on line-bisection tasks revealed "callosal disconnection neglect." The objective of this research is to reexamine this woman 34 years after her callosal disconnection to gain information about her recovery. The patient completed visual line-bisection tasks in which horizontal lines were placed in the right, left, and center hemispaces and she performed these bisections using her right or left hand. Unlike her performance 34 years ago in which each hand deviated to its ipsilateral hemispace, with greater deviation when lines were placed in the contralateral rather than ipsilateral hemispace, currently, there were no significant main effects for hand or spatial position. Thus, there were notable differences between this woman's most recent performance on the line bisection and her previous performance 34 years ago. Unlike her prior testing 34 years back, this woman's most recent performance resembled the performance of a previous tested healthy control group for whom differences in hand and hemispace were not found. It remains unclear whether her callosal disconnection neglect improved because each hemisphere learned to allocate ipsilateral spatial attention or because she learned a compensatory strategy in which she turned her body so that the lines placed in her right or left hemispace were now toward her midline.

Introduction: Computed tomography (CT), combined positron emitted tomography and CT (PET/CT), and magnetic resonance imaging (MRI) are commonly used in head and neck radiation planning. Hybrid PET/MRI has garnered attention for potential added value in cancer staging and treatment planning. Herein, we compare PET/MRI vs. planning CT for head and neck cancer gross tumor volume (GTV) delineation., Material and Methods: We prospectively enrolled patients with head and neck cancer treated with definitive chemoradiation to 60-70 Gy using IMRT. We performed pretreatment contrast-enhanced planning CT and gadolinium-enhanced PET/MRI. Primary and nodal volumes were delineated on planning CT (GTV-CT) prospectively before treatment and PET/MRI (GTV-PET/MRI) retrospectively after treatment. GTV-PET/MRI was compared to GTV-CT using separate rigid registrations for each tumor volume. The Dice similarity coefficient (DSC) metric evaluating spatial overlap and modified Hausdorff distance (mHD) evaluating mean orthogonal distance difference were calculated. Minimum dose to 95% of GTVs (D95) was compared., Results: Eleven patients were evaluable (10 oropharynx, 1 larynx). Nine patients had evaluable primary tumor GTVs and seven patients had evaluable nodal GTVs. Mean primary GTV-CT and GTV-PET/MRI size were 13.2 and 14.3 cc, with mean intersection 8.7 cc, DSC 0.63, and mHD 1.6 mm. D95 was 65.3 Gy for primary GTV-CT vs. 65.2 Gy for primary GTV-PET/MRI. Mean nodal GTV-CT and GTV-PET/MRI size were 19.0 and 23.0 cc, with mean intersection 14.4 cc, DSC 0.69, and mHD 2.3 mm. D95 was 62.3 Gy for both nodal GTV-CT and GTV-PET/MRI., Conclusion: In this series of patients with head and neck (primarily oropharynx) cancer, PET/MRI and CT-GTVs had similar volumes (though there were individual cases with larger differences) with overall small discrepancies in spatial overlap, small mean orthogonal distance differences, and similar radiation doses.

Objective: To assess the relationship between (1) task demands and workload, (2) task demands and performance, and (3) workload and performance, all during physician-computer interactions in a simulated environment., Methods: Two experiments were performed in 2 different electronic medical record (EMR) environments: WebCIS (n = 12) and Epic (n = 17). Each participant was instructed to complete a set of prespecified tasks on 3 routine clinical EMR-based scenarios: urinary tract infection (UTI), pneumonia (PN), and heart failure (HF). Task demands were quantified using behavioral responses (click and time analysis). At the end of each scenario, subjective workload was measured using the NASA-Task-Load Index (NASA-TLX). Physiological workload was measured using pupillary dilation and electroencephalography (EEG) data collected throughout the scenarios. Performance was quantified based on the maximum severity of omission errors., Results: Data analysis indicated that the PN and HF scenarios were significantly more demanding than the UTI scenario for participants using WebCIS (P < .01), and that the PN scenario was significantly more demanding than the UTI and HF scenarios for participants using Epic (P < .01). In both experiments, the regression analysis indicated a significant relationship only between task demands and performance (P < .01)., Discussion: Results suggest that task demands as experienced by participants are related to participants' performance. Future work may support the notion that task demands could be used as a quality metric that is likely representative of performance, and perhaps patient outcomes., Conclusion: The present study is a reasonable next step in a systematic assessment of how task demands and workload are related to performance in EMR-evolving environments., (© The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background/objectives: With aging, people commonly develop motor slowing (bradykinesia). Although this slowness with aging may be entirely related to degradation of the cerebral networks important in motor programing, it is possible that, at least in part, it may be a learned procedure for enhancing the accuracy and/or precision of movements. The goal of this study is to test these contradictory hypotheses., Methods: Twenty-four healthy adults, 12 younger than age 26 and 12 older than age 65 were asked to make alternative marks with a pen between a card centered in front of them and a series of circles distributed across a page. Performance was timed, and participants were instructed to complete the task as quickly as possible while not sacrificing accuracy for speed. The circle sizes and hand used varied by trial., Results: The older adults performed the task more slowly for all target circle diameters. As the circles decreased in size, the younger adults performed the task more rapidly than did the older participants, but the younger participants also had a greater decline in accuracy., Conclusions: During this aiming task, healthy older adults were less likely than younger adults to sacrifice accuracy for speed. Thus, at least in part, their slowing may be a learned adaptive strategy., (Copyright © 2016. Published by Elsevier Inc.)

Background: Randomized trials have shown that androgen-deprivation therapy (ADT) improves survival for men with intermediate-risk prostate cancer treated with radiotherapy (RT). The benefit of ADT to patients with favorable intermediate-risk prostate cancer treated with modern dose-escalated RT is unknown. This study evaluated the effectiveness of ADT on survival of men with favorable intermediate-risk prostate cancer treated with dose-escalated RT., Methods: This study was a retrospective cohort analysis of men with favorable intermediate-risk prostate cancer from 2004 to 2007 in the National Cancer Data Base. Favorable intermediate-risk disease was defined as 1 adverse risk factor (prostate-specific antigen level of 10-20 ng/mL or Gleason score of 7) and clinical T1/T2 prostate cancer. All patients were treated with primary dose-escalated RT (≥75.6 Gy or RT with a brachytherapy boost). Overall survival was analyzed with propensity score adjustment and Cox multivariate modeling., Results: The study included 18,598 patients. The use of ADT decreased from 43.5% in 2004 to 39.5% in 2007. The propensity score-adjusted survival analysis demonstrated similar 8-year overall survival for men treated with dose-escalated RT and ADT and men treated with RT alone (77.7% vs 78.4%). ADT was not associated with improved survival in any age or comorbidity subgroup. In a sensitivity analysis using Cox multivariate modeling, the receipt of ADT was not associated with overall survival (hazard ratio, 0.99; 95% confidence interval, 0.91-1.07; P = .768)., Conclusions: Adding ADT to modern dose-escalated RT was not associated with improved survival for patients with favorable intermediate-risk prostate cancer. The applicability of the survival benefit seen in older trials to modern patients is unclear. Because of the morbidity associated with ADT, dose-escalated RT alone for patients with favorable intermediate-risk prostate cancer may be a reasonable option. Cancer 2016;122:2341-2349. © 2016 American Cancer Society., (© 2016 American Cancer Society.)

Loss of ability of the left upper limb (LUL) to correctly produce spatial and temporal components of skilled purposeful movements was reported 34 years ago in a woman with a callosal infarction. To learn about recovery, we recently reexamined this woman. This woman was tested for ideomotor apraxia by asking her to pantomime to command and to seeing pictures of tools. Whereas she performed normally with her right upper limb, her LUL remained severely apraxic, making many spatial (postural and movement) errors. Initially, she did not reveal loss of finger-hand deftness (limb-kinetic apraxia), and when tested again with the coin rotation task, her left hand performance was normal. Without vision, she could name objects placed in her left hand but not name numbers written in this hand. Since this woman had a callosal lesion, failure to recover cannot be accounted for by left hemisphere inhibition of her right hemisphere. Although failure for her LUL to improve may have been related to not using her LUL for skilled actions, her right hemisphere was able to observe transitive actions, and this failure of her LUL to produce skilled purposeful movements suggests her right hemisphere may have not had the capacity to learn these movement representations. Without vision, her ability to recognize objects with her left hand, but not numbers written on her left palm, suggests graphesthesia may require that her left hand did not have access to movement representations important for programming these numbers when writing.

Importance: Agreement between patient- and practitioner-reported toxic effects during chemoradiotherapy for head and neck cancer is unknown., Objective: To compare patient-reported symptom severity and practitioner-reported toxic effects among patients receiving chemoradiotherapy for head and neck cancer., Design, Setting, and Participants: Forty-four patients participating in a phase 2 trial of deintensified chemoradiotherapy for oropharyngeal carcinoma were included in the present study (conducted from February 8, 2012, to March 2, 2015). Most treatment (radiotherapy, 60 Gy, with concurrent weekly administration of cisplatin, 30 mg/m2) was administered at academic medical centers. Included patients had no prior head and neck cancers, were 18 years or older, and had a smoking history of 10 pack-years or less or more than 10 pack-years but 30 pack-years or less and abstinent for the past 5 years. Cancer status was untreated human papillomavirus or p16-positive squamous cell carcinoma of the oropharynx or unknown head and neck primary site; and cancer staging was category T0 to T3, category N0 to N2c, M0, and Eastern Cooperative Oncology Group performance status 0 to 1. Baseline, weekly, and posttreatment toxic effects were assessed by physicians or nurse practitioners using National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE), version 4.0. Patient-reported symptom severity was measured using the Patient-Reported Outcomes version of the CTCAE (PRO-CTCAE). Descriptive statistics were used to characterize raw agreement between CTCAE grades and PRO-CTCAE severity ratings., Interventions: Baseline, weekly, and posttreatment toxic effects assessed using CTCAE, version 4.0, and PRO-CTCAE., Main Outcomes and Measures: Raw agreement indices between patient-reported toxic effects, including symptom frequency, severity, and interference with daily activities (score range, 0 [none] to 4 [very severe]), and practitioner-measured toxic effects, including swallowing, oral pain, and hoarseness (score range, 1 [mild] to 5 [death])., Results: Of the 44 patients included in the analysis (39 men, 5 women; mean [SD] age, 61 [8.4] years), there were 327 analyzable pairs of CTCAE and PRO-CTCAE symptom surveys and no treatment delays due to toxic effects. Patient-reported and practitioner-reported symptom severity agreement was high at baseline when most symptoms were absent but declined throughout treatment as toxic effects increased. Most disagreement was due to lower severity of toxic effects reported by practitioners (eg, from 45% agreement at baseline to 27% at the final week of treatment for pain). This was particularly noted for domains that are not easily evaluated by physical examination, such as anxiety and fatigue (eg, severity of fatigue decreased from 43% at baseline to 12% in the final week of treatment)., Conclusions and Relevance: Practitioner-reported toxic effects are lower than patient self-reports during head and neck chemoradiotherapy. The inclusion of patient-reported symptomatic toxic effects provides information that can potentially enhance clinical management and improve data quality in clinical trials.

Background: The purpose of this study was to evaluate salivary gland cancer incidence among patients with a previous cancer diagnosis and explore the potential relationship of salivary gland cancer among women with a previous diagnosis of breast cancer., Methods: We obtained information from the Surveillance, Epidemiology, and End Results (SEER) database for patients diagnosed between 1973 and 2011. Incidence, annual percent change (APC), and survival were examined., Results: Women were more likely than men to experience subsequent salivary gland cancer, female observed to expected (O/E) = 1.63 (95% confidence interval [CI], 1.49-1.78) versus male O/E = 1.34 (95% CI, 1.25-1.44). Index breast cancer does not confer greater risk of salivary gland cancer. Women demonstrate improved overall survival (OS) and cause-specific survival (CSS) compared with men for subsequent salivary gland cancer., Conclusion: Among patients with a previous cancer diagnosis, the risk of subsequent salivary gland cancer is greater among women than men. More research is needed to determine the relationship between index breast cancer and subsequent salivary gland cancer risk. © 2015 Wiley Periodicals, Inc. Head Neck 38: E446-E451, 2016., (© 2015 Wiley Periodicals, Inc.)

Objective: To evaluate outcomes for men with high Gleason score and low prostate-specific antigen (PSA) prostate cancer. Low PSA levels among men with Gleason 8-10 prostate cancer may be owing to cellular dedifferentiation rather than low disease burden. We hypothesized that men with Gleason 8-10 prostate cancer and low PSA levels have increased risk for advanced disease and worse survival., Materials and Methods: Men diagnosed from 2004 to 2007 with Gleason 8-10 prostate adenocarcinoma in the National Cancer Data Base were included. Patients were stratified by PSA levels at diagnosis: 0.1 to 3.9, 4.0 to 9.9, 10.0 to 19.9, and≥20.0ng/ml. Outcomes were clinical TNM category, pathologic stage (for prostatectomy patients), and overall survival (OS). Kaplan-Meier analysis and Cox proportional hazards models were used., Results: A total of 37,283 patients were included. Men with PSA levels of<4.0ng/ml were more likely than those with PSA levels of 4 to 9.9ng/ml to present with clinical T3-4 disease (15% vs. 10%, P<0.001), nodal (4% vs. 2%, P<0.001) and distant (5% vs. 3%, P<0.001) metastasis. However, among patients treated with prostatectomy, lower PSA levels were not associated with increased likelihood of pathologic T3-4 disease or nodal metastasis. Six-year OS was 89.1% (PSA: 0.1-3.9ng/ml) vs. 91.0% (PSA: 4.0-9.9ng/ml) for prostatectomy (log-rank P<0.001), and 75.8% vs. 81.0% for radiotherapy (P<0.001). Multivariable analyses showed OS of patients with PSA levels of 0.1 to 3.9ng/ml to be similar to those with PSA levels of 10 to 19.9ng/ml., Conclusions: Patients with Gleason 8-10 cancer and PSA levels of<4.0ng/ml have more aggressive disease than those with PSA levels of 4 to 9.9ng/ml; these low PSA cancers behave more like those with PSA levels of 10 to 19.9ng/ml. Further study is needed to evaluate potential biological differences in these patients with low PSA-producing cancers., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background and Objective: Healthy adults often deviate leftward on line bisection tasks (allocentric pseudoneglect) but rightward on body part bisection tasks (egocentric pseudoneglect). People visually estimate distance in peripersonal space by comparing the distance to the length of a body part such as an arm's length (an egocentric reference) or using standard units of distance such as inches (an allocentric reference). Our objective was to learn whether people have pseudoneglect when estimating distances in peripersonal space using egocentric versus allocentric reference frames., Methods: Twelve healthy participants standing either next to or 5 feet away from a wall were asked to move away from or toward the wall such that their shoulder would be what they judged to be an arm's length or a distance of 1, 2, or 3 feet from the wall., Results: The participants estimated their arm's length more accurately than the standard units of distance (possibly related to learning and practice). Participants were more precise when estimating the length of their left than their right arm. When estimating standard units of distance, participants underestimated the distances on their left side more than on their right., Conclusions: Our results support the postulate that left pseudoneglect is an allocentric phenomenon related to a hemispheric asymmetry in computing allocentric distances. The participants underestimated 2 and 3 feet, but overestimated 1 foot. This dichotomy may relate to using focused versus distributed attention. The brain mechanisms leading to these asymmetries remain to be determined.

Purpose: Accurate assessment of toxicity allows for timely delivery of supportive measures during radiation therapy for head and neck cancer. The current paradigm requires weekly evaluation of patients by a provider. The purpose of this study is to evaluate the feasibility of monitoring patient reported symptoms via mobile devices., Methods and Materials: We developed a mobile application for patients to report symptoms in 5 domains using validated questions. Patients were asked to report symptoms using a mobile device once daily during treatment or more often as needed. Clinicians reviewed patient-reported symptoms during weekly symptom management visits and patients completed surveys regarding perceptions of the utility of the mobile application. The primary outcome measure was patient compliance with mobile device reporting. Compliance is defined as number of days with a symptom report divided by number of days on study., Results: There were 921 symptom reports collected from 22 patients during treatment. Median reporting compliance was 71% (interquartile range, 45%-80%). Median number of reports submitted per patient was 34 (interquartile range, 21-53). Median number of reports submitted by patients per week was similar throughout radiation therapy and there was significant reporting during nonclinic hours. Patients reported high satisfaction with the use of mobile devices to report symptoms., Conclusions: A substantial percentage of patients used mobile devices to continuously report symptoms throughout a course of radiation therapy for head and neck cancer. Future studies should evaluate the impact of mobile device symptom reporting on improving patient outcomes.

Prostate cancer patients with adverse pathologic factors (i.e., positive surgical margin, pT3 disease) after radical prostatectomy are more likely not cured (>60%) than cured by surgery alone. Adjuvant radiotherapy compared with observation reduces recurrence by 49% to 57%, may improve overall survival, and improves long-term quality of life without increased long-term patient-reported urinary or gastrointestinal tract symptoms. Despite these results, adjuvant radiotherapy is uncommonly received by patients with these adverse factors.We discuss the rationale for adjuvant therapy as part of oncologic treatment and potential reasons why patients do not receive adjuvant radiotherapy in prostate cancer. We conclude that patients need a thorough discussion regarding the potential benefits and harms of both approaches (watch and wait vs. adjuvant radiotherapy) to make an informed decision.

Background: Clinical trials have helped refine management of early stage endometrial cancer (EC). For patients with intermediate risk features, adjuvant radiation is considered, primarily vaginal cuff brachytherapy. For higher risk patients, there may be a role for chemotherapy and radiation. The purpose of this study is to examine patterns of failure for early stage EC patients treated with postoperative high dose rate brachytherapy., Methods: In this single institution retrospective cohort study, 208 women with early stage endometrial cancer who received definitive therapy between January 1, 2000 and January 1, 2013 were identified., Results: Median follow-up was 46.4 (range, 6.2-137.3) months. Thirteen (6.3%) patients developed with locoregional recurrent disease and 15 (7.2%) patients developed distant metastasis. Freedom from recurrence at 5 years was 88.6% for white patients and 60.5% for black patients (p=0.0093). Five year recurrence free survival (RFS) for white vs. black patients was 82.9% vs. 48.9% (p=0.0007). Five year overall survival (OS) was 86.8% for white patients and 59.5% for black patients (p=0.0023). Black patients with unfavorable histology treated with chemotherapy and vaginal brachytherapy had a 15% locoregional recurrence rate, more than double the rate of local recurrence compared to AA patients with endometrioid histology and white patients with any histology (6% locoregional recurrence rate)., Conclusions: Black women with unfavorable histology early stage EC experience increased rates of recurrence and worse survival compared to white patients. Patterns of failure in this group also indicate a high locoregional failure rate for the black patients with unfavorable histology (type II)., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: Radiation oncologists rely on available clinical information (biopsy Gleason score and prostate-specific antigen [PSA]) to determine the optimal treatment regimen for each prostate cancer patient. Existing published nomograms correlating clinical to pathologic extent of disease were based on patients treated in the 1980s and 1990s at select academic institutions. We used the Surveillance, Epidemiology, and End Results (SEER) database to examine pathologic outcomes (Gleason score and cancer stage) in early prostate cancer patients based on biopsy Gleason score and PSA concentration., Methods and Materials: This analysis included 25,858 patients whose cancer was diagnosed between 2010 and 2011, with biopsy Gleason scores of 6 to 7 and clinical stage T1 to T2 disease, who underwent radical prostatectomy. In subgroups based on biopsy Gleason score and PSA level, we report the proportion of patients with pathologically advanced disease (positive surgical margin or pT3-T4 disease) or whose Gleason score was upgraded. Logistic regression was used to examine factors associated with pathologic outcomes., Results: For patients with biopsy Gleason score 6 cancers, 84% of those with PSA <10 ng/mL had surgical T2 disease with negative margins; this decreased to 61% in patients with PSA of 20 to 29.9 ng/mL. Gleason score upgrading was seen in 43% (PSA: <10 ng/mL) to 61% (PSA: 20-29.9 ng/mL) of biopsy Gleason 6 patients. Patients with biopsy Gleason 7 cancers had a one-third (Gleason 3 + 4; PSA: <10 ng/mL) to two-thirds (Gleason 4 + 3; PSA: 20-29.9 ng/mL) probability of having pathologically advanced disease. Gleason score upgrading was seen in 11% to 19% of patients with biopsy Gleason 4 + 3 cancers. Multivariable analysis showed that higher PSA and older age were associated with Gleason score upgrading and pathologically advanced disease., Conclusions: This is the first population-based study to examine pathologic extent of disease and pathologic Gleason score upgrading based on clinically available information in modern patients. These data inform the selection of radiation therapy strategies and an understanding of whether prostatectomy alone is likely to be curative for patients with early prostate cancers., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: Overuse of radiographic imaging in patients with prostate cancer (CaP) who are unlikely to have metastatic disease is costly and can lead to patient harm from unnecessary procedures. However, underuse of imaging can lead to undiagnosed metastatic disease, resulting in aggressive treatments in patients with incurable disease. The National Comprehensive Cancer Network (NCCN) recommends bone scans and computed tomography (CT) or magnetic resonance imaging (MRI) during initial work-up of select patients with intermediate- or high-risk CaP. We quantify the proportion of patients who received work-up discordant with NCCN guidelines., Methods: Patients in the SEER-Medicare database diagnosed from 2004 to 2007 were included. We report bone scan and CT/MRI from date of diagnosis to the earlier of first treatment or 6 months., Results: Sixty-five percent of patients for whom bone scan was recommended received it, and 49% received recommended CT/MRI. Further, 43% of patients for whom bone scan was not recommended received it, and 38% received CT/MRI when not recommended. Age and race were significantly associated with discordance on multivariable models. There was significant regional variation. Underuse of recommended bone and CT/MRI scans decreased in more recent years, but overuse of unnecessary CT/MRI increased., Conclusion: There is a high prevalence of both overuse and underuse of guideline-recommended imaging in CaP. Additional research is required to examine contributing factors to guideline nonadherence in the imaging work-up of CaP., (Copyright © 2015 by American Society of Clinical Oncology.)

Background/objective: Some of the behavioral disorders associated with Parkinson's disease (PD), such as the reduced magnitude of actions (hypometria) may be related to an impairment in cognitive disengagement. A reduced ability to disengage attention from previous sensory stimuli will alter perception with a reduced range of estimated stimulus magnitudes (contraction to the mean). To test this disengagement hypothesis, participants with PD were tested to learn whether they had abnormal sensory perception with overestimation of the relative magnitude of weaker tactile stimuli and underestimation of the relative magnitude of stronger tactile stimuli in relation to a reference stimulus., Design/method: The participants were 12 people with PD and 12 healthy adults. Test stimuli were applied to the palm using Semmes-Weinstein monofilaments (SWM) of 6 magnitudes, 3 greater and 3 less than a standard stimulus. In each trial, after being stimulated with the reference (standard) stimulus, a test monofilament was applied, and the participant was asked to provide a numerical estimate of the magnitude of the second stimulus relative to the standard., Results: Compared to the control group, participants with PD overestimated the magnitudes of the tactile stimuli below the standard stimulus and underestimated the magnitudes of stimuli above the standard stimulus., Conclusions: These results demonstrate that people with PD likely have a reduced ability to estimate the relative magnitudes of tactile sensory stimuli. Whereas deafferentation would alter perception in one direction, the impairment of these participants with PD may result from a disorder of disengagement, and disorders of disengagement are often due to frontal-executive dysfunction.

Global attention requires disengagement from focal elements of stimuli. Since people with Parkinson's disease (PD) may reveal impaired disengagement, this study attempted to learn if people with PD may be impaired at allocating global attention. Healthy adults and people with PD attempted to bisect lines of uniform thickness and lines composed of two segments of unequal thickness and length. When the longer line segment was to the right of the shorter segment, the group with PD demonstrated an increased deviation toward the longer segment, supporting the postulate that people with PD have an impaired ability to disengage focal attention and engage global spatial attention.

Background/objectives: In most right-handed people, the left hemisphere is dominant for programming the temporal and spatial "how" (praxis) aspects of purposeful skilled movements, and the right hemisphere is dominant for control of the intentional "when" aspects of actions that mediate initiation, persistence, termination, and inhibition. Since the interhemispheric axons of the corpus callosum are especially susceptible to shearing from torsional forces during traumatic brain injury (TBI), the goal of this study was to learn whether participants with a history of severe traumatic brain injury demonstrate three types of cognitive-motor impairments that may result from callosal injury: ideomotor apraxia of the left hand, limb kinetic apraxia of the left hand, and hypokinesia of the right hand in response to left hemispatial stimuli., Method: Nine participants with severe TBI and nine healthy control participants were studied for the presence of ideomotor apraxia, limb kinetic apraxia, and hypokinesia., Results: When compared to the control participants, the participants with TBI revealed ideomotor apraxia and limb kinetic apraxia of the left hand and hypokinesia in response to left-sided visual stimuli when tested with the right hand., Conclusions: TBI appears to cause unilateral disorders of cognitive-motor functions. Future research is needed to understand how these cognitive-motor disorders are related to interhemispheric disconnection most likely induced by injury to the corpus callosum.

Purpose: Large randomized trials have established the noninferiority of shorter courses of "hypofractionated" radiation therapy (RT) to the whole breast compared to conventional courses using smaller daily doses in the adjuvant treatment of selected breast cancer patients undergoing lumpectomy. Hypofractionation is more convenient and less costly. Therefore, we sought to determine uptake of hypofractionated breast RT over time., Methods and Materials: In the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database, we identified 16,096 women with node-negative breast cancer and 4269 with ductal carcinoma in situ (DCIS) who received lumpectomy followed by more than 12 fractions of RT between 2004 and 2010. Based on Medicare claims, we determined the number of RT treatments given and grouped patients into those receiving hypofractionation (13-24) or those receiving conventional fractionation (≥25). We also determined RT technique (intensity modulated RT or not) using Medicare claims. We evaluated patterns and correlates of hypofractionation receipt using bivariate and multivariable analyses., Results: Hypofractionation use was similar in patients with DCIS and those with invasive disease. Overall, the use of hypofractionation increased from 3.8% in 2006 to 5.4% in 2007, to 9.4% in 2008, and to 13.6% in 2009 and 2010. Multivariable analysis showed increased use of hypofractionation in recent years and in patients with older age, smaller tumors, increased comorbidity, higher regional education, and Western SEER regions. However, even in patients over the age of 80, the hypofractionation rate in 2009 to 2010 was only 25%. Use of intensity modulated RT (IMRT) also increased over time (from 9.4% in 2004 to 22.7% in 2009-2010) and did not vary significantly between patients receiving hypofractionation and those receiving traditional fractionation., Conclusions: Hypofractionation use increased among low-risk older US breast cancer patients with publication and maturation of evidence from randomized trials, but overall use of this cost-saving approach remained low. This contrasts with the more rapid rate of adoption of IMRT in the same time period, a costly innovation supported by less strong evidence of benefit., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Purpose: For patients with a high likelihood of having metastatic disease (high-risk prostate cancer), bone scan is the standard, guideline-recommended test to look for bony metastasis. We quantified the use of bone scans and downstream procedures, along with associated costs, in patients with high-risk prostate cancer, and their use in low- and intermediate-risk patients for whom these tests are not recommended., Methods and Materials: Patients in the Surveillance, Epidemiology, and End Results (SEER)-Medicare database diagnosed with prostate cancer from 2004 to 2007 were included. Prostate specific antigen (PSA), Gleason score, and clinical T stage were used to define D'Amico risk categories. We report use of bone scans from the date of diagnosis to the earlier of treatment or 6 months. In patients who underwent bone scans, we report use of bone-specific x-ray, computed tomography (CT), and magnetic resonance imaging (MRI) scans, and bone biopsy within 3 months after bone scan. Costs were estimated using 2012 Medicare reimbursement rates., Results: In all, 31% and 48% of patients with apparent low- and intermediate-risk prostate cancer underwent a bone scan; of these patients, 21% underwent subsequent x-rays, 7% CT, and 3% MRI scans. Bone biopsies were uncommon. Overall, <1% of low- and intermediate-risk patients were found to have metastatic disease. The annual estimated Medicare cost for bone scans and downstream procedures was $11,300,000 for low- and intermediate-risk patients. For patients with apparent high-risk disease, only 62% received a bone scan, of whom 14% were found to have metastasis., Conclusions: There is overuse of bone scans in patients with low- and intermediate-risk prostate cancers, which is unlikely to yield clinically actionable information and results in a potential Medicare waste. However, there is underuse of bone scans in high-risk patients for whom metastasis is likely., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Studies of patients with brain lesions have demonstrated that language and praxis are mediated by dissociable networks. However, language has the capacity to influence the selection of purposeful actions. The abilities to use language and to program purposeful movements are often mediated by networks that have anatomic proximity. With hemispheric injury, the diagnosis of apraxia is often confounded by the specific influence of language impairments on the ability to select and produce transitive gestures. We report a patient who illustrates this confound. This patient is a right-handed man who developed global aphasia and neglect after a right hemispheric stroke. His right hand remained deft, and when asked to produce specific transitive gestures (pantomimes), he often performed normally but did make some body part as object and perseverative errors. However, he did not demonstrate the temporal or spatial errors typical of ideomotor apraxia. He also had a perseverative agraphia. Our patient's left hemisphere praxis system appeared to be intact, and the error types demonstrated during production of transitive gestures cannot be attributed to a degradation of postural and movement (praxis) programs mediated by his left hemisphere. The praxis errors types are most consistent with a deficit in the ability to select the necessary praxis programs. Thus, our patient appeared to have dissociation between language and praxis programs that resulted in body part as object and perseverative errors.

Background. Arm spasticity is a challenge in the care of chronic stroke survivors with motor deficits. In order to advance spasticity treatments, a better understanding of the mechanism of spasticity-related neuroplasticity is needed. Objective. To investigate brain function correlates of spasticity in chronic stroke and to identify specific regional functional brain changes related to rehabilitation-induced mitigation of spasticity. Methods. 23 stroke survivors (>6 months) were treated with an arm motor learning and spasticity therapy (5 d/wk for 12 weeks). Outcome measures included Modified Ashworth scale, sensory tests, and functional magnetic resonance imaging (fMRI) for wrist and hand movement. Results. First, at baseline, greater spasticity correlated with poorer motor function (P = 0.001) and greater sensory deficits (P = 0.003). Second, rehabilitation produced improvement in upper limb spasticity and motor function (P < 0.0001). Third, at baseline, greater spasticity correlated with higher fMRI activation in the ipsilesional thalamus (rho = 0.49, P = 0.03). Fourth, following rehabilitation, greater mitigation of spasticity correlated with enhanced fMRI activation in the contralesional primary motor (r = -0.755, P = 0.003), premotor (r = -0.565, P = 0.04), primary sensory (r = -0.614, P = 0.03), and associative sensory (r = -0.597, P = 0.03) regions while controlling for changes in motor function. Conclusions. Contralesional motor regions may contribute to restoring control of muscle tone in chronic stroke.

Background: Normal adults demonstrate a slight upward bias (vertical pseudoneglect) when attempting vertical line bisection. The mechanism for this bias is unknown. Activation of the allocentric (object-centered) ventral visual system during attempted bisection may induce this bias. This object-centered ventral stream may also mediate focal attention. As compared to bisection, when normal participants perform a vertical line quadrisection task that requires more focal attention, they may have a greater upward bias., Methods: Sixteen participants bisected and quadrisected vertical lines., Results: The mean upward bias (deviation error) for the quadrisection tasks was significantly higher than the mean error for the line bisections., Conclusions: These results are consistent with the hypothesis that activation of the ventral stream by a task that requires focal allocentric attention can induce an upward vertical bias that is greater than the upward bias observed with allocentric line bisection, a task that requires more global attention., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective and Background: Persons with Parkinson disease (PD) show hypometric movements and make hypometric estimates of imagined actions. These deficits may be related to misestimates of the length of body parts. Our objective was to learn whether patients with PD are impaired in their estimations of their arm's length and standard units of distance., Methods: We tested 20 patients with PD, all on therapeutic doses of dopaminergic medications, and 13 healthy controls. In half of the trials, the participants stood so that either their right or left shoulder was adjacent to a wall; in the other half, their right or left shoulder was 5 feet from the wall. In the egocentric testing condition, they were asked to move their body toward or away from the wall to what they considered was an arm's length from the wall. In the allocentric testing condition, they were to move toward or away from the wall so that their proximal shoulder was a standard unit distance of 1, 2, or 3 feet from the wall., Results: The patients with PD made much greater hypometric (too close to the wall) errors. Since at 5 feet from the wall they had to move farther to underestimate distances, their errors cannot be explained by hypometric movements. The results did not differ significantly by egocentric or allocentric estimation, side of shoulder proximity, or side of PD onset., Conclusions: Our findings support the idea that the egocentric and allocentric hypometria associated with PD is a perceptual rather than motor disorder.

In this report, we outline the case of a patient who has Ehlers-Danlos Syndrome (EDS) who received two courses of CyberKnife stereotactic radiosurgery (SRS) for metastatic non-small cell lung cancer. Patients with EDS have increased blood vessel fragility, and therefore are subject to increased risk of bleeding. There are no published data regarding the risks of hemorrhage associated with SRS for intracranial metastases in this patient population. The patient described in this case report had two courses of SRS for two sites of brain metastases. She tolerated treatment well, with no acute toxicity and good local control to date. We have also included a discussion of published literature regarding toxicity of intracranial radiation in patients with EDS.

Background and Purpose: Understanding the mechanisms underlying stroke can aid the development of therapies and improve the final outcome. The purposes of this study were to establish whether there are characteristic mechanistic differences in the frequency, severity, functional outcome, and mortality between left- and right-hemisphere ischemic stroke and, given the velocity differences in the carotid circulation and direct branching of the left common carotid artery from the aorta, whether large-vessel ischemia (including cardioembolism) is more common in the territory of the left middle cerebral artery., Methods: Trial cohorts were combined into a data set of 476 samples. Using Trial of Org 10172 in Acute Stroke Treatment criteria, ischemic strokes in a total 317 patients were included in the analysis. Hemorrhagic stroke, stroke of undetermined etiology, cryptogenic stroke, and bilateral ischemic strokes were excluded. Laterality and vascular distribution were correlated with outcomes using a logistic regression model. The etiologies of the large-vessel strokes were atherosclerosis and cardioembolism., Results: The overall event frequency, mortality, National Institutes of Health Stroke Scale (NIHSS) score, Glasgow Coma Scale score, and rate of mechanical thrombectomy interventions differed significantly between the hemispheres. Left-hemispheric strokes (54%) were more common than right-hemispheric strokes (46%; p=0.0073), and had higher admission NIHSS scores (p=0.011), increased mortality (p=0.0339), and higher endovascular intervention rates (p≤0.0001). ischemic strokes were more frequent in the distribution of the left middle cerebral artery (122 vs. 97; p=0.0003) due to the higher incidence of large-vessel ischemic stroke in this area (p=0.0011)., Conclusions: Left-hemispheric ischemic strokes appear to be more frequent and often have a worse outcome than their right-hemispheric counterparts. The incidence of large-vessel ischemic strokes is higher in the left middle cerebral artery distribution, contributing to these hemispheric differences. The hemispheric differences exhibit a nonsignificant trend when strokes in the middle cerebral artery distribution are excluded from the analysis.

While Alois Alzheimer recognized the effects of the disease he described on speech and language in his original description of the disease in 1907, the effects of Alzheimer's disease (AD) on language in deaf signers has not previously been reported. We evaluated a 55-year-old right-handed congenitally deaf woman with a 2-year history of progressive memory loss and a deterioration of her ability to communicate in American Sign Language, which she learned at the age of eight. Examination revealed that she had impaired episodic memory as well as marked impairments in the production and comprehension of fingerspelling and grammatically complex sentences. She also had signs of anomia as well as an ideomotor apraxia and visual-spatial dysfunction. This report illustrates the challenges in evaluation of a patient for the presence of degenerative dementia when the person is deaf from birth, uses sign language, and has a late age of primary language acquisition. Although our patient could neither speak nor hear, in many respects her cognitive disorders mirror those of patients with AD who had normally learned to speak.

Background: Conceptual apraxia (CA), a feature of Alzheimer disease (AD), can be detected by asking participants to identify the correct tool to act on an object. Assessment can be based on either learned associations (a tool selection test) or the mechanical properties that the tool needs to alter the target object (an alternative tool selection test)., Objectives: We wanted to determine whether knowledge of semantic taxonomic relations (intrinsic properties shared by items) correlated with performance on tests for CA in people with AD or amnestic mild cognitive impairment (aMCI)., Methods: We tested 10 participants with AD, 12 with aMCI, and 18 healthy older adults for CA using an alternative tool selection test, a tool selection test, and a test of taxonomic relations., Results: The aMCI group did not differ from the control group on the CA tests. The patients with AD were impaired on all tests except tool selection; their performance on the alternative tool selection test correlated significantly with their performance on the taxonomic relations test., Conclusions: The correlation between performances on the alternative tool selection test and the taxonomic relations test in AD suggests a common pathophysiologic substrate, either impairment in accessing conceptual-semantic representations or a degradation of these representations.

Whereas the ventral visual processing stream mediates facial and object recognition, the dorsal stream mediates recognition of spatial relationships. In addition, ventral lesions have been reported to induce visual inattention to the upper visual field and dorsal lesions inattention to the lower field. The purpose of this study is to test the hypothesis that activation of the ventral stream will induce an upward attentional bias and activation of the dorsal stream, a downward bias, as assessed by vertical line bisection tests. Twelve healthy right-handed individuals performed vertical line bisections. During these trials, either pictures of famous faces or dots in different spatial locations were presented above and below the line. The participants were asked to recognize and remember the faces or locations of dots while they performed the bisections. In control trials, they were no faces or dots. An upward bias was observed in all conditions. This upward bias was significantly increased in the face recognition and recall condition, but not altered in the dot location condition. Although the face task appeared to activate the ventral stream and increase the upward vertical bias, the failure of the dot localization task to alter the bias may be related task selection. Dorsolateral lesions cause optic ataxia, a disorder of the egocentric "where" system, and the dot location task in this study was allocentric. Thus, further research will be needed to learn whether an egocentric spatial localization task, with a memory component, will alter the vertical attentional bias.

The objective of this study is to learn if participants with Parkinson disease (PD), when compared to normal controls, are impaired in making simultaneous but independent right and left hand movements. Participants were tested with Luria's Alternating Hand Postures (AHP) test and modified AHP tests. Twelve PD participants without dementia and twelve matched controls were assessed for their ability to perform the parallel AHP test (both hands remaining in the same coronal plane) and with modifications of this test into swimming (alternative arm extension with finger extension and arm flexion with finger flexion) and reverse swimming (alternative arm extension-finger flexion and arm flexion-finger extension) movements. The participants with PD were significantly impaired when performing the parallel and the reverse swimming movements AHP tests, but not impaired on the swimming movements AHP test. Swimming movements may be phylogenetically and ontogenetically more primitive and not as heavily dependent on frontal-basal ganglia networks; thus performance of swimming movements during the parallel AHP test may decrease this test's sensitivity.

Background: Reversible posterior leukoencephalopathy syndrome (RPLS) and hypertensive encephalopathy (HE) are terms generally used interchangeably to describe a syndrome characterized by encephalopathy, focal deficits, and vasogenic edema seen on magnetic resonance imaging, which are potentially reversible with treatment. The underlying pathologic changes are less well defined. Previously, the only pathologic data available came from a single autopsy series. Results from a recent biopsy report differ with the autopsy series leading to the suggestion that RPLS and HE may be distinct., Case Report: We report a markedly hypertensive patient with encephalopathy and hemiparesis and focal edema in the brainstem visualized on magnetic resonance imaging. A biopsy was performed that demonstrated pathologic changes associated with RPLS. With treatment of hypertension, the patient's symptoms resolved completely., Conclusions: We report an unusual brainstem variant of RPLS, adding to the neuropathologic features of this syndrome, and supporting the predominant view that RPLS and HE have a shared pathologic basis.