Did the pattern of practice in the prescription of palliative radiotherapy for the treatment of uncomplicated bone metastases change between 1999 and 2005 at the rapid response radiotherapy program?

AIMS

Since 1999, randomised clinical trials and meta-analyses have reported equal efficacy of pain relief from single- and multiple-fraction radiotherapy for bone metastases. A number of factors, including limited radiotherapy resources, waiting times, and patient convenience, suggest single fraction to be the treatment of choice for patients. However, international patterns of practice indicate that multiple fractions are still commonly used. This study examined whether dose-fractionation schemes used for the treatment of bone metastases at the Rapid Response Radiotherapy Program (RRRP) at the Odette Cancer Centre have changed since 1999.

MATERIALS AND METHODS

A retrospective review of the prospective RRRP database and hospital records were conducted for all patients treated with palliative radiotherapy for uncomplicated bone metastases at the RRRP in 1999 (or baseline), 2001, 2004 and from 1 January to 31 July 2005. Data were collected on patient demographics and clinical characteristics.

RESULTS

Of the 693 patients, 65 and 35% were prescribed single fraction (predominantly single 8 Gy) and multiple fractions (predominantly 20 Gy/five fractions), respectively. The administration of single treatments generally increased over time, from 51% in 1999 to 66% in 2005 (P=0.0001). On the basis of multiple logistic regression analyses, patients were more likely to be prescribed single-fraction radiotherapy if they had prostate cancer, had a poorer performance status, were treated to the limbs, hips, shoulders, pelvis, ribs, scapula, sternum, or clavicle (compared with the spine), were treated by a radiation oncologist who had been trained in earlier years, and who were treated after 1999.

CONCLUSIONS

Between 1999 and 2005, the use of single-fraction radiotherapy increased, corresponding to publications showing equal efficacy of pain relief between single and multiple fractions in the management of uncomplicated bone metastases. However, about a third of patients still received multiple fractions.

Quality of Life in Patients with Brain Metastases Treated with a Palliative Course of Whole-Brain Radiotherapy

BACKGROUND

The primary objective of this study was to assess whether there was an improvement in quality of life for patients with brain metastases as measured 1 and 2 months after a course of whole-brain radiotherapy. The secondary objective was to assess the level of agreement between patient and proxy quality of life scores.

METHODS AND MATERIALS

Sixty patients with brain metastases and their proxy completed the Functional Assessment of Cancer Therapy-Brain (FACT-BR) questionnaire independently. Proxies were given instructions to answer from the patient's perspective. Quality-of-life assessments were conducted at baseline, 1 month, and 2 months after completion of whole-brain radiotherapy. Paired t tests with Bonferroni adjustment for multiple comparisons were calculated to detect significant differences in global quality-of-life scores. Lin's concordance correlation coefficient measured agreement between patient and proxy quality-of-life ratings.

RESULTS

No significant difference was detected in overall quality of life after whole-brain radiotherapy. At 2 months after whole-brain radiotherapy, there was a trend toward worsening general and brain specific quality-of-life scores. There was poor concordance between patients and their proxies for all quality-of-life domains at baseline.

CONCLUSION

At 2 months after whole-brain radiotherapy, there was a trend toward worsening general and brain specific quality-of-life scores. Proxy rating of patients' quality of life showed poor concordance at baseline.

Transfusion requirements and outcomes in patients undergoing abdominal aortic surgery using intra-operative cell salvage

BACKGROUND

Intraoperative cell salvage (ICS) is the recovery, anticoagulation, filtration and reinfusion of blood lost during surgery. The aim of this study is to determine the safety and efficacy of ICS in emergency and elective abdominal aortic surgery.

METHODS

This study reviews volumes of blood loss, blood salvaged with ICS, allogenic blood requirements, and clinical outcomes in patients undergoing abdominal aortic surgery using ICS.

RESULTS

Seventy-nine patients undergoing abdominal aortic surgery are included. Supplemental allogenic blood was not required in 45/79 (57%) of all patients. Transfusion with allogenic blood was not necessary in 41/63 (66%) of elective abdominal aortic aneurysm repairs. ICS was associated with no major complications.

CONCLUSION

ICS is a safe procedure and substantially reduces the need for blood transfusion in patients undergoing abdominal aortic surgery. It may substantially alleviate shortages of allogenic blood and should be part of the armamentarium of vascular units.

Legibility of doctor's signatures: novel approaches to improving an age-old problem

In today's medico-legal environment, the importance of identification of the authors of notes in patient medical charts cannot be overemphasized. We evaluated three different techniques of signing patient notes, over a one month period, in order to determine which technique was the most effective in identifying the author of the note. Surgical NCHDs in our hospital were divided into three groups. Group 1 was asked to sign the notes as they normally would. Group 2 was asked to print their name in block capitals after their signature and Group 3 was given pens with a personal self inking stamp to be used in addition to signing the notes. The number of signatures in all the charts, compliance with the assigned technique and the legibility of signatures were calculated.

RESULTS

in Group 1, all NCHDs signed their name when writing notes (100% compliance), however the NCHD's signature was identified only 37% of the time. In Groups 2 (who signed in block capitals) and Group 3 (who used the pen with personalised stamp) the author was identifiable 100% of the time when the respective signing method was used. Using the pen with personalised self inking stamp was significantly more popular (77% compliance) compared to signing in block capitals (46% compliance). In conclusion the pen, with personalised self inking stamp, provides a fast and effective means to clarify signatures of NCHD's documentation, which is not only important in a day to day patient management, but is essential from a medico-legal stand point.

Low incidence of retained common bile duct stones using a selective policy of biliary imaging

AIM

Biliary imaging has decreased since the advent of laparoscopic cholecystectomy. This study aimed to examine the incidence of retained common bile duct (CBD) stones, using a selective policy of biliary imaging.

METHODS

A prospective computerised database was used to study patients who underwent laparoscopic cholecystectomy by one surgeon over 36 months. Two hundred and thirty-five patients (191 female, 44 male) were operated on. Ages ranged from 15 to 82 years (mean 47 years). Follow-up periods ranged from six to 39 months (mean 23.3 months). Selection for pre-operative endoscopic retrograde cholangiopacreatogram (ERCP), intraoperative cholangiography (IOC) or neither depended on liver function tests (LFTs) and CBD diameter on ultrasound prior to surgery. If LFTs were persistently raised and/or the CBD was dilated on ultrasound, patients underwent pre-operative ERCP. If LFTs were raised, and returned to normal promptly, IOC was performed.

RESULTS

Of 235 patients, 26 had pre-operative ERCP, 62 had IOC and 157 had neither. Ten patients had both ERCP and IOC. To date, one patient (0.43%) has radiologically-proven unsuspected retained CBD stones; these were successfully treated with ERCP.

CONCLUSION

Selective biliary imaging in patients undergoing laparoscopic cholecystectomy is safe. This process identifies the majority of patients with ductal calculi and minimises the need for unnecessary ERCP and peroperative cholangiography.

Antioxidant levels in the cord blood of term fetus

The aim of this study was to compare the differences in the total antioxidant levels in the cord blood after a normal vaginal delivery and after an elective caesarean section. This was a prospective study approved by the Wirral Hospital ethical research committee. The study was carried out in a district general hospital. We investigated 96 healthy pregnant women who had normal antenatal period with singleton pregnancies between 37 and 42 completed weeks of gestation. Sixty-five women had a spontaneous normal vaginal delivery and 31 underwent elective caesarean section. Umbilical cord blood was obtained immediately after delivery. Antioxidants such as glutathione peroxidase (GPX) and superoxide dismutase (SOD) were measured and compared between the normal vaginal delivery and elective ceasarean sections. The mean values for GPx in umbilical cord arterial blood (95; 86-103, n=74) was found to be significantly higher (P=0.0133) than that found in umbilical cord venous blood (84; 80-88, n=95). The arterial SOD values were found to be significantly higher (P=0.0337) in infants who had been delivered by caesarean section (1188; 1065-1311, n=22) than by vaginal delivery (1021;958-1083, n=39). The differences in the levels of GPX between the arterial and venous systems is not well documented but may be due to differences in the level of selenium, hydroperoxides or glutathione. In addition, why infants delivered by ceasarian section have a higher level of arterial SOD than those delivered by vaginal delivery remains unclear, but it may be a reflection of a relatively low level in infants subjected to the stress of labour.

Can the stem cell mobilization technique influence CD34+ cell collection efficiency of leukapheresis procedures in patients with hematologic malignancies?

A total of 415 leukaphereses in 201 patients stimulated with growth factor (GF; n = 119) or chemotherapy-GF (n = 296) were studied to determine CD34+ cell collection efficiency (CE). The pre-apheresis leukocyte count was 1-93 x 10(9)/l (median 20), and peripheral blood CD34 count (PBCD34) was 1-1104/microl (median 19). The total number of CD34+ cells collected was 4-6531 x 10(6) (median 151); corresponding to 0.1-111.4 x 10(6) (median 2.3) per kg. There was strong correlation between PBCD34 and the number of CD34+ cells collected (r = 0.9; P < 0.0001). CE was 7-145% (median 46). On multiple regression analysis, a higher leukocyte count (P < 0.0001) was the most important predictor of lower CE. CE with leukocytes < 20 was 7-145% (median 53%) compared to 10-132% (median 40%) with leukocyte > or = 20 (P < 0.0001). In all, 61% of the apheresis procedures performed after chemotherapy-GF occurred when leukocytes were < 20 compared to 21% of those performed after GF alone (P < 0.0001). We conclude that mobilizing patients with the combination of chemotherapy and GF rather than GF alone leads to leukapheresis being performed when the leukocyte count is low -- in a range that results in optimum CD34+ cell CE. Autologous stem cells should be mobilized with chemotherapy-GF rather than GF alone whenever possible.

Shigella flexneri 2a strain 2457T expresses three members of the H-NS-like protein family: characterization of the Sfh protein

Shigella flexneri 2a is known to express the H-NS nucleoid-structuring protein and the paralogous protein StpA. Using bioinformatic analysis we have now discovered a third member of the H-NS protein family, Sfh (Shigella flexneri H-NS-like protein), in strain 2457T. This protein is encoded by the sfh gene, which is located on a high-molecular-mass plasmid that is closely related to the self-transmissible plasmid R27. When expressed in Escherichia coli, the Sfh protein can complement an hns null mutation, restoring wild-type Bgl, porin protein, and mucoidy phenotypes, and wild-type expression of the fliC and proU genes. While a knockout mutation in the sfh gene alone had no effect on the expression of virulence genes in S. flexneri, an additive effect on virulence gene derepression was seen when the sfh lesion was combined with a mutation in hns. Over-expression of the sfh gene repressed expression of the VirB virulence regulatory protein and transcription of a VirB-dependent structural gene promoter. The purified Sfh protein bound specifically to DNA sequences containing the promoters of the virF and virB virulence regulatory genes. These findings show that Sfh has the ability to influence genetic events beyond the genetic element that encodes it, including the expression of the S. flexneri virulence genes. They raise the possibility of a triangular relationship among three closely related proteins with broad consequences for genetic events in the bacterium that harbours them.

All-terrain vehicles--unstable, unsafe and unregulated. A prospective study of ATV-related trauma in rural Ireland

All-terrain vehicles (ATVs) are fast, powerful machines that pose a significant threat to public safety. In the USA, ATVs are responsible for 273 deaths and over 68,000 injuries each year. As the incidence of ATV-related accidents in Britain and Ireland is unknown we carried out a prospective audit of all patients presenting to our Accident and Emergency Departments with ATV-related trauma over a 1-year period. Of 32 patients with ATV-associated injuries, 10 were under 16 years of age and 23 had no previous experience of operating an ATV. We documented 24 fractures (2 open) and 1 tension pneumothorax. Helmet usage was high and head injuries were few and not of a serious nature. Two-thirds of injuries occurred on commercial adventure sports courses. Since ATVs are off-road vehicles, they are exempt from safety regulations that apply to other forms of transport. As care-providers to trauma victims, we must make prevention of these injuries a priority and campaign for both voluntary and legislative controls to make ATV use a safer leisure pursuit.

Minimally displaced Colles' fractures: a prospective randomized trial of treatment with a wrist splint or a plaster cast

Sixty-six adult patients with minimally displaced distal radial fractures were randomly assigned to treatment with either a plaster cast or a lightweight removable wrist splint. Outcome assessment was by clinical and radiological evaluation and an independent physiotherapy assessment. There were significant differences between the treatments for cast satisfaction, cast problems and the functional assessment score at 6 weeks, with the removable splint scoring better in all cases.

Bacterial lipoprotein induces tolerance in human THP-1 monocytes with reduced tumour necrosis factor α production via a CD14-independent pathway

Background

Endotoxin (lipopolysaccharide; LPS) tolerance is characterized by diminished production of tumour necrosis factor (TNF) α during prolonged exposure to LPS, and therefore represents an essential control mechanism during sepsis. However, it is unknown whether bacterial lipoprotein (BLP), another major component of bacterial walls, can cause tolerance. This study sought to determine whether BLP pretreatment can induce tolerance in human THP-1 monocytes.

Methods

Human THP-1 monocytic cells were pretreated with culture medium alone and medium containing LPS 10 ng ml−1 or BLP 10 ng ml−1 for 24 h. Cells were further stimulated with high doses (0·1–1 mg ml−1) of LPS or BLP for 6 h. TNF-α levels were determined by enzyme-linked immunosorbent assay. CD14 receptor expression on THP-1 monocytes was assessed by flow cytometry.

Results

When THP-1 cells were incubated with culture medium, BLP stimulation resulted in much higher TNF-α levels than LPS stimulation (P &lt; 0·05). Following LPS pretreatment, LPS stimulation-induced TNF-α production was significantly attenuated, whereas BLP stimulation still produced a small amount of TNF-α. However, BLP pretreatment prevented both LPS and BLP stimulation-induced TNF-α production from THP-1 cells. FACScan analysis revealed that THP-1 monocytes do not express CD14 receptor.

Conclusion

These results demonstrate that BLP has a more potent effect than LPS on THP-1 monocyte TNF-α production. Furthermore, BLP pretreatment is capable of inducing both BLP as well as LPS tolerance via a CD14-independent pathway, indicating a unique ability to cause cross-tolerance.

Bacterial lipoprotein induces endotoxin-independent tolerance to the systemic inflammatory response syndrome in vivo and in vitro

Background

Sublethal doses of endotoxin (lipopolysaccharide; LPS) induce tolerance in vivo and in vitro, and protect against the lethal effects of a further LPS challenge. Tolerance is characterized by diminished production of tumour necrosis factor (TNF) α. Bacterial lipoprotein (BLP), another bacterial wall component, might induce tolerance against its own lethal effects as well as those of endotoxin.

Methods

Ninety male MF-1 mice (mean(s.d.) weight 18(2) g) were randomized into three groups (n = 30 per group). Mice in group 1 received a single BLP-tolerant dose (10 mg kg−1) by intraperitoneal injection, whereas mice in group 2 received a second BLP-tolerant dose (10 mg kg−1) after 24 h. Following induction of tolerance, all mice were challenged with high doses of LPS 45 mg kg−1, BLP 45 mg kg−1 or a combination of LPS 30 mg kg−1 plus BLP 30 mg kg−1. Mice in group 3 were treated with a high dose of the above agents only. Mortality was assessed at 24 and 48 h. Macrophages were isolated from mice and pretreated in vitro with culture medium alone or culture medium containing LPS 10 ng ml−1 or BLP 10 ng ml−1 for 24 h. The cells were then stimulated with high doses (100–1000 ng ml−1) of LPS, BLP or LPS plus BLP for 6 h. The cell culture supernatants were collected and TNF-α levels were determined using enzyme-linked immunosorbent assay.

Results

BLP-induced tolerance significantly improved survival compared with that of mice without tolerance (P &lt; 0·05). In vitro, pretreatment of murine macrophages with BLP significantly attenuated LPS, BLP and LPS plus BLP stimulation-induced TNF-α production.

Conclusion

BLP mimics LPS in the development of the systemic inflammatory response syndrome. Furthermore, BLP is capable of inducing tolerance, both in vivo and in vitro, which subsequently prevents BLP- and LPS plus BLP-induced death.

Violence risk assessment: combining actuarial and clinical information to structure clinical judgements for the formulation and management of risk

Throughout history most societies have assumed a link between mental disorder and violence to others. In recent times there has been increasing concern in the United Kingdom over law and order, specifically the risk of violence, and these issues are now high on the political and mental health agenda. Nurses and staff working in National Health Service Mental Health Service Trusts are the groups most at risk of violence. Many clinical decisions are based on risk. Mental health nurses play a pivotal role in the assessment and management of risk and it is argued that they need to adopt a clear structured approach to violence risk assessment and management, which is evidence-based. The advantages of clinical and actuarial approaches to risk assessment are briefly reviewed and a structured clinical judgement approach is proposed that combines these approaches. A method of linking the assessment process with the management plan via a risk formulation is discussed.