Calibration of a simple model for waste stabilisation pond performance in seasonal climates

The paper describes the calibration of a model for waste stabilisation pond (WSP) performance in seasonal climates, based on the use of readily available climate data sets. Calibration data were taken from a wide geographical area of Canada and the USA, including coastal and moderately seasonal sites. Good agreement with measured values was shown using a biochemical oxygen demand (BOD) decay constant of 0.3 day(-1) for facultative ponds and 0.07-0.1 day(-1) for storage/maturation ponds with a temperature-related Arrhenius constant of 1.05, and a fixed BOD decay constant of 0.007 day(-1) at water temperatures below 0 °C. The results suggested that such models could potentially be used as the basis for WSP design guidelines tailored to a wide range of climatic conditions.

Abstract P1-01-01: Learning Sentinel Node Biopsy in the UK: Results of the NEW START Training Program

Background: NEW START-a structured, validated multi-professional surgical training programme, was established to allow rapid transfer of appropriate knowledge and technical skills to ensure safe and competent practice of sentinel lymph node biopsy (SLNB) across the UK.

Methods: Multi-professional teams attended a theory/skills-lab course delivering a standardized educational package, following which they performed SLNB in 30 consecutive patients, either concurrently with their standard axillary staging procedure — mentorship training model-or as stand-alone SLNB — apprenticeship training model. An accredited NEW START trainer mentored the first 5 procedures in the participants’ hospital, or all 30 if stand-alone. Validation standards were a localization rate of ≥90% and in the mentorship program where a minimum of 10 cases were node positive, a false-negative rate of ≥10%. SLNB was performed according to a standardised protocol using the combined technique of isotope (0.05-0.1ml of 99mTc-albumin colloid — Nanocoll®) and blue dye (Patent blue V) injected into the tumour quadrant peri-areolar tissue. Isotope was injected intra-dermally and static scintigraphic images were obtained, blue dye was injected sub-dermally after anaesthetic induction.

Results: From October 2004 to December 2008, 210 SLNB naive surgeons, in 103 centres, performed 6,685 SLNB procedures of which 31% (2,098/6,685) were node positive. The mentorship training model was followed in 87% (5,849/6,685). Scintigraphy identified axillary lymph node drainage in 85% (5,564/6,511) with an overall SLN localization rate of 98.9% (6,610/6,685, 95% CI 98.6% to 99.1%). Node positivity was higher (P<0.001) for failed (58.7%, 44/75) than successful (31.1%, 2054/6610) localizations. The mentorship false negative rate (FNR) was 8.9% (163/1821, 95% CI 7.7% to 10.4%). The median SLN yield was 2.0 (range 1-11).

SLN localization and FNR improved with surgeon caseload so that after 20 procedures the FNR fell below 10% but no statistically significant learning curve was identified. The FNR patients who had one SLN harvested was 14.8%. The FNR rate declined to 9.4%, 6.3%, 4.5% and 4.0% for those patients with 2, 3, 4 and more than 4 SLNs removed.

Conclusion: NEW START demonstrates that a standardized injection protocol and structured multi-professional training can abolish learning curves so ensuring patient safety during national adoption of a new technique. Tumor quadrant injection using both isotope and dye has a high localization rate and low false-negative rate. Failed localization indicates higher probability of axillary nodal involvement. It is not necessary to remove more than 4 SLNs to achieve a FNR of less than 5%.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-01-01.

Subjective distress predicts treatment seeking for depression, bipolar, anxiety, panic, neurasthenia and insomnia severity spectra

OBJECTIVE

To examine correlates of mental health treatment seeking such as gender, diagnosis, impairment, distress and mastery.

METHOD

Longitudinal epidemiological data from the Zurich Study of common psychiatric syndromes, including unipolar and bipolar depression, panic, anxiety, neurasthenia and insomnia, were utilized. In longitudinal Generalized Estimating Equations, treatment seeking was regressed on measures of subjective distress and impairment, childhood family problems, mastery and number of comorbid diagnoses.

RESULTS

Approximately half of all treated participants across all six syndromes suffered from subthreshold disorders. Meeting full or subthreshold diagnostic criteria was associated with treatment seeking for insomnia. Being female was associated with treatment seeking for depression. The only variable highly and consistently associated with treatment seeking, across all syndromes, was subjective distress. Treated participants reported high levels of distress, work and social impairment in both diagnostic and subthreshold groups.

CONCLUSION

Subjective distress may be a better indicator of treatment seeking than symptom count.

Seat-belt trauma of the breast in a pregnant woman causing milk-duct injury: a case report and review of the literature

Injury to the milk-duct following a road traffic accident has not been reported in the literature. This case report describes a 25-year-old postpartum lady with massive swelling of the breast due to milk-duct injury and collection of milk within the breast. We describe the possible mechanism of milk-duct injury, its presentation and management, and also review the literature on seat-belt injury to the breast.

Intra-Operative Assessment of Sentinel Lymph Nodes with Touch Imprint Cytology – Experience on 232 Patients with Breast Cancer

IntroductionSentinel lymph nodes (SLNs) are generally evaluated by histology which takes about 3-5 days and axillary clearance is then carried out if SLN is positive for metastasis. This second operation to perform axillary clearance can be avoided, if a reliable intraoperative assessment is available. This will allow the surgeon to proceed to axillary clearance during the primary operation if intra-operative assessment of SLNs is positive. Touch imprint cytology (TIC), is a relatively new technique for intraoperative assessment. This study aimed to evaluate the accuracy and feasibility of TIC in our practice.MethodsThis was a prospective study of 232 patients with breast cancer. SLN biopsy was performed first and sent for TIC while surgeon proceeded with wide local excision or mastectomy. In pathology, nodes less than 5mm were bisected and others were sliced at 2mm intervals.Each cut surface was touched onto a slide allowing the weight of the node to release the cells onto the slide. The slides were assessed by dedicated breast pathologists and the results telephoned to theatre. If TIC was positive, axillary clearance was performed. Permanent histological sections were evaluated with hematoxylin and eosin stain and immuno-histochemical staining. The TIC results were compared with the final histology of the SLN. We calculated the accuracy, sensitivity, specificity, positive predictive and negative predictive value of TIC. The time required for intra-operative assessment was recorded prospectively in the last 30 patients. We also calculated the percentage of patients who were spared from having a second operation for axillary clearance based on the results of TIC.ResultsAccuracy of TIC was 90%. Sensitivity and specificity was 54% and 100% respectively. Positive and negative predictive value was 100% and 88% respectively. On final histology, 52 patients (22%) were node positive. TIC diagnosed metastasis in 28(54%) patients (95% Confidence Interval 0.39-0.67). Thus 28 patients (54%) avoided a second operation. Among patients with falsely negative TIC, micrometastasis was seen in 6/24(25%) patients and isolated tumour cells in 1/24(4%) patient. Average time from harvesting of the nodes to receiving of result of the TIC for each patient was 32 minutes (range 15-53). This was proportional to the number of nodes sent. Average time taken by cytopathologist was 15 minutes. Prolongation of operation time was seen in only 22% patients on an average by 7 minutes (range 2-15).ConclusionsTIC is a simple and feasible technique with prolongation of operation time seen in only 22% patients on an average by 7 minutes. It is a reliable technique with an accuracy of 90%. No patient was subjected to unnecessary axillary clearance. Patients should however be counseled preoperatively about chance of false negative results on TIC and need for a second operation. TIC avoided a second operation for axillary lymph node clearance in 54% patients and thus also avoided delay in the adjuvant treatment of these patients.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1030.

Transcutaneous oximetry in clinical practice: consensus statements from an expert panel based on evidence

Transcutaneous oximetry (PtcO2) is finding increasing application as a diagnostic tool to assess the peri-wound oxygen tension of wounds, ulcers, and skin flaps. It must be remembered that PtcO2 measures the oxygen partial pressure in adjacent areas of a wound and does not represent the actual partial pressure of oxygen within the wound, which is extremely difficult to perform. To provide clinical practice guidelines, an expert panel was convened with participants drawn from the transcutaneous oximetry workshop held on June 13, 2007, in Maui, Hawaii. Important consensus statements were (a) tissue hypoxia is defined as a PtcO2 <40 mm Hg; (b) in patients without vascular disease, PtcO2 values on the extremity increase to a value >100 mm Hg when breathing 100% oxygen under normobaric pressures; (c) patients with critical limb ischemia (ankle systolic pressure of < or =50 mm Hg or toe systolic pressure of < or =30 mm Hg) breathing air will usually have a PtcO2 <30 mm Hg; (d) low PtcO2 values obtained while breathing normobaric air can be caused by a diffusion barrier; (e) a PtcO2 <40 mm Hg obtained while breathing normobaric air is associated with a reduced likelihood of amputation healing; (f) if the baseline PtcO2 increases <10 mm Hg while breathing 100% normobaric oxygen, this is at least 68% accurate in predicting failure of healing post-amputation; (g) an increase in PtcO2 to >40 mm Hg during normobaric air breathing after revascularization is usually associated with subsequent healing, although the increase in PtcO2 may be delayed; (h) PtcO2 obtained while breathing normobaric air can assist in identifying which patients will not heal spontaneously.

Effective patient blinding during hyperbaric trials

Hyperbaric medicine is applied for several disease states. Laboratory evidence is compelling but clinical efficacy remains incompletely validated. The standard by which supportive research is measured is termed evidence-based medicine, with results of randomized, blinded trials being most desirable. Blinding patients during hyperbaric exposure poses unique challenges. Few such studies are reported and confirmation of its success lacking. A study of patients suffering radiation-induced proctitis was conducted. It involved blinding of sham controls via a minimal air compression technique. Prior to unblinding 72 patients were surveyed using a standardized questionnaire to determine if they had been aware of their treatment allocation. Twenty of the 33 in the treatment group answered that they were in the treatment group, one answered sham and 12 did not know. Twenty-three of 39 in the sham group thought they were in the treatment group, two said sham and 14 did not know. A Chi-square analysis detected no relationship between what treatment was provided and what patients thought they received (p = 0.9058). Eliminating those who did not know, a Kappa statistic was p = 0.0299, indicating that there was no agreement beyond chance. Minimal air compression is an effective blinding tool for patients enrolled in hyperbaric trials.

Pharmacological management of inappropriate sexual behaviours: a review of its evidence, rationale and scope in relation to men with intellectual disabilities

BACKGROUND

The management of inappropriate sexual behaviours (ISB) including sexual offending is difficult, especially when the person treated has intellectual disabilities (ID). Psychological therapies are the accepted first line of treatment. Pharmacological treatments have also been advocated, particularly for people who have committed serious sexual offences. There is limited information on available drugs and evidence of their efficacy in the treatment of ISBs, in particular for people with ID.

METHODS

A literature search of electronic databases was undertaken. Pharmaceutical companies were contacted for unpublished information. Trials that included people with ID were systematically reviewed for the benefits and outcome in that population.

RESULTS

Androgen depleting drugs (cyproterone acetate, medroxyprogesterone acetate and luteinising hormone releasing hormone agonists) and psychotropic drugs (serotonin specific reuptake inhibitors and antipsychotics) are the two major categories of medications used in the treatment of ISBs. The majority of studies identified were open trials and most relied on self-report measures. Trials that included people with ID were few in number. Most trials indicated beneficial effects including reduction in sexually deviant fantasies and behaviours.

CONCLUSION

The quality of evidence base for the use of pharmacological agents in the treatment of ISBs is inadequate to justify their use in routine clinical practice. If used, they should only be a part of a comprehensive treatment programme and closely monitored. In addition, there are several clinical, ethical and legal issues to be addressed before considering pharmacological treatment of ISBs in people with ID.

The phenomenology and diagnosis of psychiatric illness in people with Prader-Willi syndrome

BACKGROUND

Psychotic illness is strongly associated with the maternal uniparental disomy (mUPD) genetic subtype of Prader-Willi syndrome (PWS), but not the deletion subtype (delPWS). This study investigates the clinical features of psychiatric illness associated with PWS. We consider possible genetic and other mechanisms that may be responsible for the development of psychotic illness, predominantly in those with mUPD.

METHOD

The study sample comprised 119 individuals with genetically confirmed PWS, of whom 46 had a history of psychiatric illness. A detailed clinical and family psychiatric history was obtained from these 46 using the PAS-ADD, OPCRIT, Family History and Life Events Questionnaires.

RESULTS

Individuals with mUPD had a higher rate of psychiatric illness than those with delPWS (22/34 v. 24/85, p<0.001). The profile of psychiatric illness in both genetic subtypes resembled an atypical affective disorder with or without psychotic symptoms. Those with delPWS were more likely to have developed a non-psychotic depressive illness (p=0.005) and those with mUPD a bipolar disorder with psychotic symptoms (p=0.00005). Individuals with delPWS and psychotic illness had an increased family history of affective disorder. This was confined exclusively to their mothers.

CONCLUSIONS

Psychiatric illness in PWS is predominately affective with atypical features. The prevalence and possibly the severity of illness are greater in those with mUPD. We present a 'two-hit' hypothesis, involving imprinted genes on chromosome 15, for the development of affective psychosis in people with PWS, regardless of genetic subtype.

Equivalent-Forms Reliability of Printed and Spoken Versions of the NASA-TLX

Sixty-four participants provided subjective workload assessments after each of 15 trials of selected laparoscopic training tasks, including cannulation, ring transfer, and rope inspection. Half of the participants responded to the NASA-TLX using the traditional printed format with manual (written) responses. The remainder listened to auditory scale cues and made vocal responses. A comparison of the two formats revealed strong (r > .80) correlations and equivalent sensitivity to task and training effects, indicating that the vocal format may be a suitable substitute for traditional administration methods in the evaluation of surgical technology.

Dynamics of domain walls in magnetic nanostrips

We express the dynamics of domain walls in ferromagnetic nanowires in terms of collective coordinates, generalizing Thiele's steady-state results. For weak external perturbations the dynamics is dominated by a few soft modes. The general approach is illustrated on the example of a vortex wall relevant to recent experiments with flat nanowires. A two-mode approximation gives a quantitatively accurate description of both the steady viscous motion of the wall in weak magnetic fields and its oscillatory behavior in moderately high fields above the Walker breakdown.

A training syllabus for radiation protection in dental radiology

The EU Council Directive 97/43/EURATOM (MED) states that Member States shall ensure that adequate theoretical and practical training is provided for dental practitioners working with ionising radiation; this also includes the provision of continuing education and training programmes, post-qualification. The area of dental radiology is specifically mentioned in this legally binding document. The Department of Medical Physics and Bioengineering, St James's Hospital, Dublin, is particularly interested in the area of radiation protection training and routinely provides educational courses both at national and international levels. A recent review of their dental radiation protection course was undertaken in conjunction with a number of Principal Dental Surgeons within the Health Service Executive in Ireland. The revised course was delivered to over 200 dental staff members at two separate meetings during 2006. The response from attendees was very positive. It is proposed to extend this course to other dental professionals, working both in the Irish private and public health sectors in the future.

Factors associated with ownership and use of written asthma action plans in North-West Melbourne

PURPOSE

Written asthma action plans (WAAPs) have become a core component of asthma management in Australia. We investigated ownership, utilisation and factors associated with ownership of asthma action plans by caregivers.

METHODS

443/776 (57%) caregivers of children aged 2-14 years with asthma were identified from 32 GP clinics as part of a randomised controlled trial (RCT), and completed self-administered questionnaires.

RESULTS

Only 29% of participants owned a WAAP, while 13% possessed verbal instructions, and 56% had no plan. An asthma action plan for children, which was developed by a general practitioner (GP) was more likely to comprise verbal instructions (p = 0.001), while action plans developed by paediatricians were more likely to be written (p < 0.001). Just over one half of caregivers (59%) reported discussing their child's action plan the last time they visited their doctor for asthma. Factors associated with WAAP ownership included nights waking (p = 0.013), self reported severity (p = 0.001), and days lost from school (p = 0.037). Children who had seen a GP in the last 3 months for asthma, or who had been to the Emergency Department (ED) or hospital were more likely to possess a WAAP (p < 0.001). Caregivers who were less satisfied with their child's asthma control were more likely to own a WAAP (p = 0.037). Caregivers with any action plan found it useful and 82% reported using their action plan for management of an acute attack. However, caregivers with a WAAP were more likely to adhere to the plan for an acute attack compared to caregivers with verbal instructions (OR = 4.5, p < 0.05). Caregivers with a WAAP were more knowledgeable about asthma (p = 0.002), better able to recognise the difference between preventer and reliever medications (p = 0.01), and better able to recognise an asthma attack (p = 0.006).

CONCLUSIONS

Ownership of WAAPs in this group was still too low. Importantly, caregivers with written instructions were more knowledgeable about asthma and more likely to report following the action plan during an asthma attack.