Radiation oncologists have long understood the potential benefit of radiation therapy (RT) in palliating the distressing symptoms of advanced abdominal and pelvic cancers. Often, the role of external beam radiation therapy (EBRT) or brachytherapy in controlling bleeding or obstructive symptoms finds only a passing reference and most palliative medicine texts are silent on this important topic. Palliative RT achieves hemostasis in patients with unresectable gastric carcinoma not fit for systemic chemotherapy and is associated with a statistically significant rise in their hemoglobin levels. RT has been used for symptom relief in gynecological malignancies for many years. For abdominal malignancies, bony landmarks are less reliable for treatment planning, as compared to pelvic malignancies. This chapter discusses some case scenarios which illustrate the role of palliative radiation therapy in the treatment of bladder cancer, vaginal bleeding, rectal cancer, vulvar cancer, and liver metastasis.

This chapter provides a conceptual framework for understanding access to medical care and discusses many of the barriers faced by residents of rural communities. The sociodemographic characteristics of rural residents differ from those of urban populations in ways that may affect their need for medical care. A substantial body of research indicates that individuals without health insurance coverage are at substantially greater risk for poor medical care access and health outcomes. One of the more intractable access problems facing rural Americans is the relatively lower supply of medical care professionals practicing in rural versus urban settings. To address the shortage of health care professionals, the more limited financial resources of rural residents, and the geographic dispersion of rural populations, the federal government has implemented a number of programs aimed at improving access to rural medical care.

The past century and a half has witnessed remarkable achievements in child health in the United States. Disparities exist for many health conditions because societal and environmental influences determine how children’s bodies form and grow, and experience determines how they think and feel. This chapter outlines the contours of the problem of health inequity for children by delineating some statistics drawn from U.S. sources. It illustrates the situation by giving an example of the path through which societal inequity leads to poor health and developmental outcomes in a child with asthma. Despite what can look like a very distressing picture, all is not bleak. There are tried and true interventions that are working all over the United States. The chapter shares some of these ideas and provides bibliographic references for the reader to analyze deeper into learning about the causes of and interventions for addressing disparities in child health.

While differences in health outcomes between men and women emerged in the last century, the differences in health outcomes between groups distinguished by race, ethnicity, and other socially related factors have persisted for more than a century; as long as we have had data in the United States and across the globe. Improvements in population health and achieving health equity require an accelerated development of an area of specialization that can explicate how and why inequities among men exist, and present evidence that informs efforts to improve the health of men and reduce inequities among them. This chapter describes the phenomenon of "diseases of despair" and how it relates to men’s health disparities. It discusses how it differs from other disparity populations. It explains why discussions of men’s health disparities should inherently take an intersectionality lens and describes health disparities faced by African American men in particular.

Bone marrow failure (BMF) refers to the inability of hematopoiesis to meet the physiologic demands for the production of functional blood cells. BMF can be classified into three categories based on the presumed etiology: idiopathic, secondary, and inherited. This chapter discusses idiopathic and secondary BMF, which is usually called acquired aplastic anemia (AA). It also reviews the most common inherited bone marrow failure syndromes (IBMFSs). The clear differences in clinical management and outcomes in patients with IBMFSs compared to those with acquired AA highlight the need to have a clear understanding of these disorders and how to recognize them.

CD4⁺ T cells control both cell-mediated and humoral immune responses to protein antigens, and are, therefore, justifiably called the “conductors of the immunological orchestra”. Elucidating the biology of these cells is a key to understanding protective immunity and immunological diseases and developing therapies for autoimmune diseases and cancer. This chapter reviews the activation of CD4⁺ T cells. All immune responses, including the responses of T cells, are initiated and develop in the secondary lymphoid organs, the lymph nodes, spleen, and mucosa, and the skin-associated lymphoid tissues. The major cytokine involved in early T cell responses is interleukin-2. The end result of T cell activation is the differentiation of naive cells into antigen-specific effector and memory cells. One of the most informative discoveries in immunology was the identification of subpopulations of CD4⁺ T cells that make different cytokines and serve distinct functions.

Activity keys provide detailed suggestions for how one might craft the answer for a given activity. Part IV of the text provides the “how-to” practice chapters for the act phase to help you learn each of the steps in this phase. All of the work in the act phase builds on the work in define and study phases. This chapter provides the answer for each of the following activity keys namely, create integrated set of recommendations; develop key implementation milestones; revisit stakeholder analysis; create communication plan; implement communication plan and validate approval/consensus of recommendations; develop detailed implementation plan; and monitor results against key performance indicators.

In acupuncture, needles are inserted at specific points along the meridians to regulate the flow of this energy and to produce a therapeutic effect. Clinical research shows that acupuncture can reduce many physical and emotional symptoms commonly experienced by cancer patients and thereby improve their quality of life. Some of the symptoms benefited by acupuncture include pain, chemotherapy-induced nausea and vomiting, chemotherapy-induced neuropathy, hot flashes, and xerostomia. Acupuncture studies on the general population have shown that it decreases constipation, insomnia, anxiety, tinnitus, and nocturia. These symptoms are common complaints of the geriatric patient, and acupuncture may provide a safe option to pharmaceuticals for relief in these areas. Acupuncture is generally safe when it is performed by qualified practitioners. Patients should be advised to receive acupuncture treatment from practitioners who are professionally trained, properly credentialed, and experienced in treating cancer patients.

“Acute graft-versus-host disease (GVHD) is a frequent and sometimes life-threatening complication following allogeneic hematopoietic cell transplantation (HCT). It can best be described as an inflammatory syndrome with associated immune dysregulation that can lead to end-organ damage, and typically occurs within the first 3 to 4 months after HCT. Precipitated by tissue damage caused by the transplant preparative regimen, acute GVHD is mediated by immune-competent T cells contained in the donor graft that recognize certain tissues of the recipient (host) as “foreign,” thereby triggering an immune response. The skin, gastrointestinal (GI) tract, and liver are the principal target organs in patients with acute GVHD. Despite pharmacologic prophylaxis with immunosuppressive agents, clinically significant acute GVHD requiring treatment occurs in approximately 50% of patients who receive allogeneic HCT from HLA-identical sibling donors. Acute GVHD may be even more common and severe following HCT from HLA-matched unrelated donors, with further increasing incidence and severity if donor and recipient are HLA-mismatched.”