Knowledge and competences in hematological malignancies amongst radiation oncology residents in Germany-results from a national survey

INTRODUCTION

Radiation oncology is a pivotal modality in the treatment of hematologic malignancies. To enable state-of-the-art patient care, structured education during residency is essential. However, given the lack of detailed data, the scope of educational opportunities available to trainees remains elusive. This prompted our group to perform a national survey amongst radiation oncology residents in Germany assessing the status quo of competences in the treatment of lymphoma and leukemia patients. Furthermore, areas of potential improvement were identified to further the goal of competence-based education for residents.

METHODS

A survey-based analysis was conducted to assess the knowledge and competence of radiation oncology residents in Germany regarding hematological malignancies. A decisive questionnaire covering demographics, self-assessment of competences, and areas for improvement was developed in adaption of a survey by the Association of Residents in Radiation Oncology and distributed amongst 1439 members of the German Society of Radiation Oncology. Responses were collected anonymously via an online survey tool and analyzed using descriptive statistics and chi-square tests.

RESULTS

A total of 59 complete and 22 partial responses were collected, yielding a 5.6% response rate. Participants' competence varied, with notable experience gaps in pediatric cases, proton therapy, and large-field techniques like total-skin irradiation or pediatric total body irradiation. While participants felt confident in treatment planning and patient counseling, they showed deficiencies in the definition of the planning target volume for modern involved site radiotherapy. Resources for education included national and international guidelines, scientific reviews, and textbooks. Board-certified radiation oncologists and physicians from specialized lymphoma centers demonstrated higher overall competence levels.

CONCLUSION

This survey highlights the diversity of resident education regarding hematological malignancies in German radiation oncology programs. Knowledge gaps exist in key areas, including pediatric cases and specialized techniques. Competence-based education, interactive teaching formats, and rotations to specialized centers are potential strategies to address these gaps. The study contributes to the understanding of the federal educational landscape, underscoring the need for standardized and comprehensive training to ensure optimal patient care in hematological malignancies within the context of radiation oncology. Further research and collaborations are warranted to enhance training and expertise in this critical domain.

Health Care Provider Perceptions of Using Social Media to Improve Sexual Health for Adolescent and Young Adult Cancer Survivors

This study explored (1) health care provider (HCP) perceived barriers and facilitators to social media communication about sexual health with adolescent and young adult survivors, and (2) strategies that can help HCPs navigate social media use for this purpose. Thematic analysis of 11 semistructured HCP interviews resulted in four themes and suggests that social media platforms offer a promising avenue to foster sexual health communication but that resources and training are needed to improve HCP capacity to use this approach ethically and effectively. Future studies are needed to determine specific communication strategies and whether these strategies would lead to improved outcomes.

Attitudes and Barriers to Planned Family Building among Professionals and Trainees in Radiation Oncology

PURPOSE/OBJECTIVE(S)

The timing of residency training often coincides with peak biological fertility. However, family building is frequently deferred and may lead to unanticipated infertility. The attitudes and barriers to family planning are not well described among medical professionals and trainees in radiation oncology (RO).

MATERIALS/METHODS

The Society for Women in Radiation Oncology (SWRO) conducted an electronic survey among practicing physicians, physicists, and residents between January and February 2023, using email and social media as recruitment tools. The survey questions queried demographics, family planning, fertility. Frequencies of responses were summarized using descriptive statistics.

RESULTS

On interim analysis, 147 responses were collected; 123 (89.8%) were SWRO members. Gender identities reported were female (136, 93.2%), male (7, 4.8%), nonbinary or gender diverse (2, 1.4%), and transgender female (1, 0.7%). 95 (64.6%) respondents were age 35 or younger. The majority were practicing physicians (72, 49.0%) followed by RO residents (45, 30.6%), medical physicists (17, 11.6%), medical students, (5, 3.4%), and medical physics residents (4, 2.7%). Most respondents agreed that their reproductive timeline had been impacted by medical training (106, 76.3%). Of those who deferred parenthood due to training or career, 40 (36.7%) were dissatisfied with their choice and 33 (30.2%) were satisfied. 129 (92.8%) reported not receiving any information about fertility preservation during training. Only 65 (47.4%) felt they had a mentor with whom they could approach to discuss family planning. Overall, 84 (60.4%) expressed concern about their fertility and 34 (24.5%) had previously undergone fertility testing. 16 (11.5%) completed at least one cycle of elective fertility preservation and 12 (8.6%) were planning to do so. 39 (28.1%) had considered elective fertility preservation but not pursued it, while 65 (46.8%) had not considered it. Among those two groups, the common reported barriers to accessing fertility services were financial burden (n = 28, 28.6%), lack of awareness of available options (n = 12, 12.2%), difficulty accessing fertility services (n = 6, 6.1%), and difficulty finding time during training (n = 4, 4.1%). Insurance coverage for elective fertility preservation was fully or partially covered by insurance for 12 (8.8%), not covered for 53 (38.7%), and 72 (52.6%) were uncertain of their coverage.

CONCLUSION

The study highlights the impact of training on family building plans of medical professionals in RO. Despite high levels of concern about fertility, few respondents received education about fertility options in training and a limited number had access to mentors to discuss this issue. Significant barriers exist to accessing fertility services, including knowledge gaps about insurance coverage, highlighting a need for further exploration of these barriers and advocacy for improved family planning support for those in RO who desire it.

The Society for Women in Radiation Oncology: Where are We Five Years Later?

PURPOSE/OBJECTIVE(S)

The Society for Women in Radiation Oncology (SWRO) was founded in 2017 with a mission to promote representation and gender equity in the field of radiation oncology (RO). SWRO members include faculty and trainee radiation oncologists and medical physicists. We aim to assess the current experiences of SWRO members using a comprehensive survey of gender-related workforce issues we developed. Data was used to establish a 5-year benchmark.

MATERIALS/METHODS

From January to February 2023, an anonymous survey was distributed to current SWRO members. Questions included demographics, family planning/fertility issues, perceptions of the field, and membership needs. Descriptive statistics were used to summarize frequencies of the multiple-choice items on the survey.

RESULTS

On interim analysis, 115 of 680 (17%) completed the survey from 11 countries, 81% of which reside in the US. 55% were faculty physicians, 26% resident physicians, 10% faculty physicists, and 3% physics residents. The majority were female (97%) and either married or in a domestic partnership (74%). 47% reported having at least one child, and 26% reported that they or their partner became pregnant during residency. Length of leave was impacted by residents' desire to complete residency training on schedule. 53% felt RO was perceived as family-friendly, but much fewer (17%) agreed that it is. After clinical responsibilities (70%), insufficient mentorship was cited as the second most common limitation to professional productivity (35%). 48% reported being somewhat or extremely satisfied with current mentorship availability at their institution, while 56% reported being similarly satisfied with the mentorship available within the field. 69% reported seeking or having sought female mentorship outside of their institution. Unwanted sexual comments, attention, or advances by superiors or colleagues was reported by 38% of respondents. Additionally, 72% either agreed or strongly agreed that SWRO membership and participation were a valuable use of their time, with the top three reasons for joining being networking opportunities, mentorship opportunities, and increasing the visibility of women and gender minorities in RO. Suggested improvements included increasing female physics representation and advocacy, and physics-related events, as well as providing opportunities for members to socialize and interact.

CONCLUSION

This study provides an update on the experiences of women and gender minorities in the field of RO since the creation of SWRO in 2017. The study highlights ongoing targets for improvement such as gender-based obstacles, opportunity for additional education and advocacy, support of family-friendly culture shifts, mentorship, and increased physics inclusion and advocacy. These findings support the need for organizations such as SWRO to continue to promote representation and gender equity in RO.

Radiation Oncology Virtual Education Rotation (ROVER) 2.0 for Residents: Implementation and Outcomes

The COVID-19 pandemic catalyzed the integration of a virtual education curriculum to support radiation oncologists in training. We report outcomes from Radiation Oncology Virtual Education Rotation (ROVER) 2.0, a supplementary virtual educational curriculum created for radiation oncology residents globally. A prospective cohort of residents completed surveys before and after the live virtual webinar sessions (pre- and post-surveys, respectively). Live sessions were structured as complex gray-zone cases across various core disease sites. Resident demographics and responses were summarized using means, standard deviations, and proportions. Nine ROVER sessions were held from October 2020 to June 2021. A total of 1487 registered residents completed the pre-survey, of which 786 attended the live case discussion and 223 completed post-surveys. A total of 479 unique radiation oncology residents (of which 95, n = 19.8%, were international attendees) from 147 institutions (national, n = 81, 55.1%; international, n = 66, 44.9%) participated in the sessions. There was similar participation across post-graduate year (PGY) 2 through 5 (range n = 86 to n = 105). Of the 122 unique resident post-surveys, nearly all reported learning through the virtual structure as "very easy" or "easy" (97.5%, n = 119). A majority rated the ROVER 2.0 educational sessions to be "valuable or "very valuable" (99.2%, n = 121), and the panelists-attendee interaction as "appropriate" (97.5%, n = 119). Virtual live didactics aimed at radiation oncology residents are feasible. These results suggest that the adoption of the ROVER 2.0 curricula may help improve radiation oncology resident education.

Assessment of Lymphoma and Other Hematologic Malignancies Training Needs Among Radiation Oncology Residents: a Brief Report

The role of radiation therapy (RT) varies across hematologic malignancies (HM). Radiation oncology (RO) resident comfort with specific aspects of HM patient management is unknown. The International Lymphoma RO Group (ILROG) assessed resident HM training opportunities and interest in an HM away elective. RO residents (PGY2-5) in the Association of Residents in RO (ARRO) database (n = 572) were emailed an anonymous, web-based survey in January 2019 including binary, Likert-type scale (1 = not at all, 5 = extremely, reported as median [interquartile range]), and multiple-choice questions. Of 134 resident respondents (23%), 86 (64%) were PGY4/5 residents and 36 (27%) were in larger programs (≥ 13 residents). Residents reported having specialized HM faculty (112, 84%) and a dedicated HM rotation (95, 71%). Residents reported "moderate" preparedness to advocate for RT in multidisciplinary conferences (3 [2-3]); make HM-related clinical decisions (3 [2-4]); and critique treatment planning (3 [2-4]). They reported feeling "moderately" to "quite" prepared to contour HM cases (3.5 [3-4]) and "quite" prepared to utilize the PET-CT five-point scale (4 [3-5]). Overall, residents reported feeling "moderately" prepared to treat HM patients (3 [2-3]); 24 residents (23%) felt "quite" or "extremely" prepared. Sixty-six residents (49%) were potentially interested in an HM away elective, commonly to increase comfort with treating HM patients (65%). Therefore, HM training is an important component of RO residency, yet a minority of surveyed trainees felt quite or extremely well prepared to treat HM patients. Programs should explore alternative and additional educational opportunities to increase resident comfort with treating HM patients.

WeWhoCurie: An Initiative to Advocate for Those Underrepresented in Radiation Oncology

Purpose

An initiative to advocate for those underrepresented in radiation oncology.

Methods and Materials

Inspired by the success of the #ILookLikeAnEngineer and #ILookLikeASurgeon campaigns, this initiative aimed to break down stereotypes in traditionally male-dominated fields. In honor of Marie Curie's birthday, on November 7, 2018, the Society for Women in Radiation Oncology launched a social media campaign called #WomenWhoCurie day. However, as the popularity of the social media campaign increased, it become evident that members of the wider radiation community, in particular women of color, nonbinary and transgender people did not feel supported by the #WomenWhoCurie movement. In November 2021, after consultation with diversity and inclusion leaders and members of other national radiation oncology organizations, Society for Women in Radiation Oncology launched #WeWhoCurie alongside the #WomenWhoCurie campaign for women and gender minorities in radiation oncology. Radiation oncologists, physicists, dosimetrist, therapists, nurses, and other professionals from around the world gathered and shared photos and social media posts throughout the day on multiple platforms including Facebook, Instagram, and Twitter.

Results

In the year #WeWhoCurie, #WomenWhoCurie, #_______ WhoCurie campaign launched, we saw an increase in participation across the globe from 9 countries: the United States, Canada, Mexico, Brazil, Italy, Spain, China, New Zealand, and Australia. There were over 720 tweets contributing to the campaign with over 2000 messages, representing 3,365,444 "potential impacts", or the number of times someone saw the hashtag.

Conclusions

Through this campaign we aim to celebrate the incredible women, gender minorities, and allies who are "Curie-ing" patients with cancer and conducting cutting edge research to improve cancer care across the globe. As an organization we believe adding our voices to the masses will foster a culture of inclusion for everyone. Afterall, what good is the practice of radiation oncology if all are not equally welcome?

Transitioning Roles from Residency to Attending Physician in Radiation Oncology

Moving from the role of resident into that of a young attending is one of the most anticipated transitions in a medical trainee's career path. Radiation oncology residency training is typically apprentice-style focused in the outpatient setting, which carries additional unique challenges. Twenty-seven junior attendings at academic institutions within their first 5 years of practice were sent an online open-ended questionnaire in 2018 regarding aspects of their practice using a snowball sampling method. Responses were collected, and a thematic analysis was conducted in which two independent reviewers coded the responses. Nineteen junior attendings (70%) from 18 institutions completed the questionnaire. General themes included the importance of cultivating relationships for peer support and to be professional and polite as confidence was gained to enable them to be seen as an attending. All respondents felt that bringing an open mind, balance, and adaptability was crucial in their transition. Respondents stayed up to date on literature and practices by subscribing to journals, courses, and participation in resident education. Forty-two percent of young attendings were matched with a mentor at their new institution through a formal mentor-mentee relationship. Respondents wished that they had more autonomy during residency to prepare for independent practice. Transitioning from residency to a junior attending provides unique stressors and challenges. Allowing for residents to have more autonomy during their training, such as a senior resident clinic, may help improve this transition by providing an opportunity for independent decision-making with guidance as appropriate.

Female erectile tissues and sexual dysfunction after pelvic radiotherapy: A scoping review

Sexual function is a vital aspect of human health and is recognized as a critical component of cancer survivorship. Understanding and evaluating the impacts of radiotherapy on female sexual function requires precise knowledge of the organs involved in sexual function and the relationship between radiotherapy exposure and sexual tissue function. Although substantial evidence exists describing the impact of radiotherapy on male erectile tissues and related clinical sexual outcomes, there is very little research in this area in females. The lack of biomedical data in female patients makes it difficult to design studies aimed at optimizing sexual function postradiotherapy for female pelvic malignancies. This scoping review identifies and categorizes current research on the impacts of radiotherapy on normal female erectile tissues, including damage to normal functioning, clinical outcomes of radiation-related female erectile tissue damage, and techniques to spare erectile tissues or therapies to treat such damage. An evaluation of the evidence was performed, and a summary of findings was generated according to Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Extension for Scoping Reviews guidelines. Articles were included in the review that involved normal female erectile tissues and radiotherapy side effects. The results show that little scientific investigation into the impacts of radiotherapy on female erectile tissues has been performed. Collaborative scientific investigations by clinical, basic, and behavioral scientists in oncology and radiotherapy are needed to generate radiobiologic and clinical evidence to advance prospective evaluation, prevention, and mitigation strategies that may improve sexual outcomes in female patients.

Short-term ADT and Dose-escalated IMRT in Patients With Intermediate-risk Prostate Cancer: Benefit or Caution?

OBJECTIVES

In the era of dose-escalated prostate radiation therapy (RT), the use of androgen deprivation therapy (ADT) is undefined for intermediate-risk (IR) prostate cancer. There is growing concern of the risk of ADT to be detrimental to quality of life. This single-institution retrospective analysis aimed to evaluate outcomes of IR patients treated with dose-escalated intensity modulated radiation therapy (IMRT) with or without concurrent/adjuvant short-term ADT.

MATERIALS AND METHODS

Data was collected from 260 consecutive patients treated with dose-escalated IMRT with daily image-guided RT for newly diagnosed IR prostate cancer. Biochemical recurrence-free survival (BCRFS), distant metastasis-free survival, prostate cancer-specific survival, and overall survival (OS) were calculated using Kaplan-Meier methodology.

RESULTS

Median follow-up was 93 months. A total of 181 patients had unfavorable IR disease, and 36.2% (N=94) received ADT, with median ADT duration of 6 months. Seven-year BCRFS was 94.1% vs. 86.2% (P=0.067), for ADT and no ADT, respectively, and no difference in distant metastasis-free survival or prostate cancer-specific survival was observed. ADT was associated with significantly worse 7-year OS (80.0% vs. 91.3%, P=0.010). Analysis of the unfavorable IR cohort alone, showed similar results; 7-year BCRFS and 7-year OS in patients who received ADT versus no ADT were 93.7% vs. 85.9% (P=0.093), and 79.0% vs. 90.6% (P=0.019), respectively.

CONCLUSIONS

In our 15-year experience treating IR prostate cancer with dose-escalated IMRT with daily image-guided RT, short-term concurrent ADT was associated with a statistically significant worse OS. Additional studies are needed to determine if ADT is beneficial or detrimental for patients with IR prostate cancer treated with dose-escalated radiation.

Education in gynecological brachytherapy

Brachytherapy is an essential component in the curative treatment of many gynecological malignancies. In the past decade, advances in magnetic resonance imaging and the ability to adapt and customize treatment with hybrid interstitial applicators have led to improved clinical outcomes with decreased toxicity. Unfortunately, there has been a shift in clinical practice away from the use of brachytherapy in the United States. The decline in brachytherapy is multifactorial, but includes both a lack of exposure to clinical cases and an absence of standardized brachytherapy training for residents. In other medical specialties, a clear relationship has been established between clinical case volumes and patient outcomes, especially for procedural-based medicine. In surgical residencies, simulation-based medical education (SBME) is a required component of the program to allow for some autonomy before operating on a patient. Within radiation oncology, there is limited but growing experience with SBME for training residents and faculty in gynecological brachytherapy. This review includes single institutional, multi-institutional and national initiatives using creative strategies to teach the components of gynecological brachytherapy. These efforts have measured success in various forms; the majority serve to improve the confidence of the learners, and many have also demonstrated improved competence from the training as well. The American Brachytherapy Society launched the 300 in 10 initiative in 2020 with a plan of training 30 competent brachytherapists per year over a 10 year period and has made great strides with a formal mentorship program as well as externships available to senior residents interested in starting brachytherapy programs. Moving forward, these curricula could be expanded to provide standardized brachytherapy training for all residents. SBME could also play a role in initial certification and maintenance of certification. Given the burden of disease, it would be valuable to develop similar training for providers in low and middle income countries.

Does obesity influence the preferred treatment approach for early-stage cervical cancer? A cost-effectiveness analysis

OBJECTIVE

Abdominal radical hysterectomy in early-stage cervical cancer has higher rates of disease-free and overall survival compared with minimally invasive radical hysterectomy. Abdominal radical hysterectomy may be technically challenging at higher body mass index levels resulting in poorer surgical outcomes. This study sought to examine the influence of body mass index on outcomes and cost effectiveness between different treatments for early-stage cervical cancer.

METHODS

A Markov decision-analytic model was designed using TreeAge Pro software to compare the outcomes and costs of primary chemoradiation versus surgery in women with early-stage cervical cancer. The study used a theoretical cohort of 6000 women who were treated with abdominal radical hysterectomy, minimally invasive radical hysterectomy, or primary chemoradiation therapy. We compared the results for three body mass index groups: less than 30 kg/m², 30-39.9 kg/m², and 40 kg/m² or higher. Model inputs were derived from the literature. Outcomes included complications, recurrence, death, costs, and quality-adjusted life years. An incremental cost-effectiveness ratio of less than $100 000 per quality-adjusted life year was used as our willingness-to-pay threshold. Sensitivity analyses were performed broadly to determine the robustness of the results.

RESULTS

Comparing abdominal radical hysterectomy with minimally invasive radical hysterectomy, abdominal radical hysterectomy was associated with 526 fewer recurrences and 382 fewer deaths compared with minimally invasive radical hysterectomy; however, abdominal radical hysterectomy resulted in more complications for each body mass index category. When the body mass index was 40 kg/m² or higher, abdominal radical hysterectomy became the dominant strategy because it led to better outcomes with lower costs than minimally invasive radical hysterectomy. Comparing abdominal radical hysterectomy with primary chemoradiation therapy, recurrence rates were similar, with more deaths associated with surgery across each body mass index category. Chemoradiation therapy became cost effective when the body mass index was 40 kg/m² or higher.

CONCLUSION

When the body mass index is 40 kg/m² or higher, abdominal radical hysterectomy is cost saving compared with minimally invasive radical hysterectomy and primary chemoradiation is cost effective compared with abdominal radical hysterectomy. Primary chemoradiation may be the optimal management strategy at higher body mass indexes.

Implications of Medical Board Certification Practices on Family Planning and Professional Trajectory for Early Career Female Radiation Oncologists

PURPOSE

Our purpose was to evaluate the effect of the current structure and schedule of the American Board of Radiology (ABR) radiation oncology initial certification (RO-IC) examinations, with a primary focus on implications for family planning and early professional barriers among female radiation oncologists.

METHODS AND MATERIALS

A survey was conducted of crowdsourced ABR candidates and diplomates for radiation oncology between June and July of 2020. The primary study cohort was early career female radiation oncologists of the 2016 through 2021 graduating classes.

RESULTS

The survey response rate of early career female radiation oncologists was 37% (126 of an estimated 337). Among this cohort, 58% (73 of 126) reported they delayed or are currently delaying/timing pregnancy or adoption to accommodate the annual schedule of the 4 qualifying and certifying examinations required to achieve board certification in radiation oncology. One in every 3 respondents who had attempted to become pregnant reported experiencing infertility (25 of 79, 32%). Women who reported intentionally delaying pregnancy to accommodate the ABR RO-IC examination schedule were significantly more likely to experience infertility (46% vs 18%, P = .008). Seven women (6%) reported at least a 1-year delay in sitting for a RO-IC examination due to an unavoidable scheduling conflict related to childbirth and/or the peripartum period. A majority reported that full board certification had a significant effect on achieving academic promotion or professional partnership (52%), annual compensation (54%), and nonclinical professional commitments (58%) - these rates mirror those of surveyed early career male counterparts (n = 101).

CONCLUSIONS

The current structure and scheduling of the ABR RO-IC examinations imposes noteworthy hurdles for many female radiation oncologists when entering the workforce. The recent transition to virtual examination platforms creates an important opportunity to increase flexibility in the structure and scheduling of the board examination process to improve equitable board certification practices.

Integrating Radiation Oncology Into Undergraduate Medical Education

Cancer is one of the most important public health problems. However, medical education has not advanced at the same rate when it comes to cancer education. Currently, the United States Medical Licensing Examination subject examinations do not cover radiation oncology, prevention, and survivorship planning in its assessment model. Incorporating medical oncology and radiation oncology training into the undergraduate medical education curriculum can have a significant benefit in training future physicians. In this paper, we review current literature and propose some ideas that can help incorporate oncology, and specifically radiation oncology, into undergraduate medical education.

Why an Increasing Number of Unmatched Residency Positions in Radiation Oncology? A Survey of Fourth-Year Medical Students

Purpose

The number of US fourth-year medical students applying to radiation oncology has decreased during the past few years. We conducted a survey of fourth-year medical students to examine factors that may be influencing the decision to pursue radiation oncology.

Methods and Materials

An anonymous online survey was sent to medical students at 9 participating US medical schools.

Results

A total of 232 medical students completed the survey. Of the 153 students who stated they were never interested in radiation oncology, 77 (50%) reported never having been exposed to the specialty as their reason for not pursuing radiation oncology. The job market was the most commonly cited factor among students who said they were once interested in but ultimately chose not to pursue radiation oncology. Conversely, the recent low pass rates for board examinations and a perception of a lack of diversity within radiation oncology had the least influence.

Conclusions

Despite discussion of potential measures to address this disquieting trend, there have been minimal formal attempts to characterize and address potential causes of a decreasing interest in radiation oncology. This study's data are consistent with previous research regarding the trend of decreased medical student interest in radiation oncology and may be used as part of ongoing introspective assessment to inform future change within radiation oncology.

Radiation Oncology Virtual Education Rotation (ROVER) for Medical Students

PURPOSE

We describe the implementation of a novel virtual educational program for medical students, Radiation Oncology Virtual Education Rotation (ROVER), and its effect on student interest and knowledge in radiation oncology.

METHODS AND MATERIALS

ROVER comprised a series of virtual educational panels with case-based discussions across disease sites tailored to medical students. The panels were moderated by radiation oncology residents and included faculty panelists from academic radiation oncology programs across the country. Student pre- and postsession surveys were collected. Paired t tests were used to compare the pre- and postsession assessment results.

RESULTS

Six ROVER sessions were held from June 4, 2020, to August 20, 2020, with a total of 427 medical students registering for at least 1 session. Of these, 231 students attended at least 1 session, with 140 completing at least 1 postsession survey (60.6% response rate). Fourth-year medical students were the largest group represented among attendees (32.0%). Most attendees had exposure to radiation oncology (78.8%) before the sessions. The majority of students signed up for these sessions for education (90.6%). Some students signed up for the sessions to help with specialty selection (30.9%) and to network (30.4%). Medical students' understanding of the role of radiation oncology in each disease site (breast, sarcoma, central nervous system, pediatrics, gastrointestinal, genitourinary, gynecologic, lymphoma, lung, and head and neck) was improved by attending each session (pre- vs postsession; P < .0001 for all disease sites). Over three-quarters of respondents stated they were considering applying or were likely to apply to radiation oncology both before and after the sessions.

CONCLUSIONS

ROVER improved medical student perceived knowledge of radiation oncology across all disease sites covered. ROVER fulfills a need for a national medical student education platform for radiation oncology. Future work is warranted to augment virtual and open educational platforms to improve access to radiation oncology education.

The Case for Brachytherapy: Why It Deserves a Renaissance

The recent global events related to the coronavirus disease of 2019 pandemic have significantly changed the medical landscape and led to a shift in oncologic treatment perspectives. There is a renewed focus on preserving treatment outcomes while maintaining medical accessibility and decreasing medical resource utilization. Brachytherapy, which is a vital part of the treatment course of many cancers (particularly prostate and gynecologic cancers), has the ability to deliver hypofractionated radiation and thus shorten treatment time. Studies in the early 2000s demonstrated a decline in brachytherapy usage despite data showing equivalent or even superior treatment outcomes for brachytherapy in disease sites, such as the prostate and cervix. However, newer data suggest that this trend may be reversing. The renewed call for shorter radiation courses based on data showing equivalent outcomes will likely establish hypofractionated radiation as the standard of care across multiple disease sites. With shifting reimbursement, brachytherapy represents the pinnacle in hypofractionated, conformal radiation therapy, and with extensive long-term data in support of the treatment modality brachytherapy is primed for a renaissance.

Current Social Media Use Among Radiation Oncology Trainees

Purpose

Resident physicians use social media (SM) for many reasons. We sought to characterize current SM use by radiation oncology (RO) trainees for education and professional development.

Methods and Materials

An anonymous 40-question survey was sent by e-mail to RO residents in the 2018 to 2019 academic year. SM platform use, time spent on SM, professional use, and opinions regarding SM use were assessed. Descriptive statistics and a univariate logistic regression analysis were performed to identify factors associated with perceptions of SM and spending >25% of SM time for academic or professional purposes.

Results

Of the 615 residents surveyed, 149 responded (24% response rate). Facebook (73%), theMednet (62%), Instagram (59%), Twitter (57%), and Doximity (50%) were the top SM platforms used. Most respondents (53%) reported <25% of overall SM time on professional/academic purposes, and 21% reported using SM >60 minutes per day over the past week. Residents with an RO mentor on SM (n = 35; 24%; odds ratio [OR]: 2.79; 95% confidence interval [CI], 1.29-6.08; P = .010), those participating in RO discussions on SM (n = 71; 48%; OR: 2.85; 95% CI, 1.42-5.72; P = .003), and those interacting with professional societies (n = 69; 46%; OR: 7.11; 95% CI, 3.32-15.24; P < .001) were more likely to spend >25% of their SM time on professional/academic purposes. The vast majority of respondents agreed that SM exposed them to novel educational content (82%) and was helpful for career development (65%). In addition, 69% agreed that SM can improve clinical skills and knowledge. A substantial minority agreed that SM distracts them from studying (38%) or they felt pressure to have a SM presence (29%).

Conclusions

Most RO residents reported that SM provides novel educational content and can help with career development. Potential disadvantages of SM for trainees may include distraction and pressure to maintain a SM presence. SM use by RO trainees merits further research to optimize its potential for education and professional development.

Increasing Medical Student Engagement Through Virtual Rotations in Radiation Oncology

Corona virus disease 2019 (COVID-19) affected medical student clerkships and education around the country. A virtual medical student clerkship was created to integrate didactic education with disease specific lectures for medical students, contouring, and hands on learning with telehealth. Twelve medical students in their 3rd and 4th year were enrolled in this 2 week elective from April 27, 2020 to June 5, 2020. There was significant improvement of overall knowledge about the field of radiation oncology from pre elective to post elective (P < .001). Feedback included enjoying direct exposure to contouring, telehealth, and time with residents. Overall this 2 week rotation was successful in integrating radiation oncology virtually for medical students. This is now being expanded to multiple institutions as an educational resource and future rotations for medical students.

#ThisIsBrachytherapy: Increasing awareness of brachytherapy

PURPOSE

The use of brachytherapy continues to be a vital application of radiation oncology for various cancers. Despite this, there has been a decrease in the utilization of brachytherapy in many cancers. Social media in medicine facilitates engagement and advocacy. We launched a social media campaign to bring awareness of brachytherapy throughout the world with #ThisIsBrachytherapy hashtag on July 17, 2019.

METHODS AND MATERIALS

#ThisIsBrachytherapy hashtag was registered with Symplur Healthcare Hashtag Project. We collected total tweet counts, retweet counts, impression counts, geolocation, top 10 influencers, associated hashtags, associated words, and word sentiment score.

RESULTS

The campaign launched on July 17, 2019, had a total of 145 tweets on that day with 213,416 impressions. Twenty-seven accounts (45%) were identified as physicians. Top countries which tweeted, among those with information available, included the United States, United Kingdom, and Australia. Since July 17, 2019, there has been an increase in tweets using #ThisIsBrachytherapy, with 1990 total tweets with 1,999,248 impressions. Fifty-four percent (1030) of the tweets contained photos and 319 contained links. This was from 462 unique users. Word sentiment was overwhelmingly positive. Associated hashtags with #ThisIsBrachytherapy included most commonly #radonc, #brachytherapy, #brachy, #prostatecancer, and #pcsm.

CONCLUSIONS

The #ThisIsBrachytherapy inaugural campaign was successful and has continued to grow throughout the months after the initiation. By continuing to advocate for brachytherapy through the social media campaign #ThisIsBrachytherapy, we can empower radiation oncologists, especially trainees, and patients to address underutilization.

COVID-19 impact on timing of brachytherapy treatment and strategies for risk mitigation

PURPOSE

The purpose of this study was to highlight the importance of timely brachytherapy treatment for patients with gynecologic, breast, and prostate malignancies, and provide a framework for brachytherapy clinical practice and management in response to the COVID-19 pandemic.

METHODS AND MATERIALS

We review amassing evidence to help guide the management and timing of brachytherapy for gynecologic, breast, and prostate cancers. Where concrete data could not be found, peer-reviewed expert opinion is provided.

RESULTS

There may be a significant negative impact on oncologic outcomes for patients with gynecologic malignancies who have a delay in the timely completion of therapy. Delay of prostate or breast cancer treatment may also impact oncologic outcomes. If a treatment delay is expected, endocrine therapy may be an appropriate temporizing measure before delivery of radiation therapy. The use of shorter brachytherapy fractionation schedules will help minimize patient exposure and conserve resources.

CONCLUSIONS

Brachytherapy remains a critical treatment for patients and may shorten treatment time and exposure for some. Reduced patient exposure and resource utilization is important during COVID-19. Every effort should be made to ensure timely brachytherapy delivery for patients with gynecologic malignancies, and endocrine therapy may help temporize treatment delays for breast and prostate cancer patients. Physicians should continue to follow developing institutional, state, and federal guidelines/recommendations as challenges in delivering care during COVID-19 will continue to evolve.

Interobserver reliability in describing radiographic lung changes after stereotactic body radiation therapy

PURPOSE

Radiographic lung changes after stereotactic body radiation therapy (SBRT) vary widely between patients. Standardized descriptions of acute (≤6 months after treatment) and late (>6 months after treatment) benign lung changes have been proposed but the reliable application of these classification systems has not been demonstrated. Herein, we examine the interobserver reliability of classifying acute and late lung changes after SBRT.

METHODS AND MATERIALS

A total of 280 follow-up computed tomography scans at 3, 6, and 12 months post-treatment were analyzed in 100 patients undergoing thoracic SBRT. Standardized descriptions of acute lung changes (3- and 6-month scans) include diffuse consolidation, patchy consolidation and ground glass opacity (GGO), diffuse GGO, patchy GGO, and no change. Late lung change classifications (12-month scans) include modified conventional pattern, mass-like pattern, scar-like pattern, and no change. Five physicians scored the images independently in a blinded fashion. Fleiss' kappa scores quantified the interobserver agreement.

RESULTS

The Kappa scores were 0.30 at 3 months, 0.20 at 6 months, and 0.25 at 12 months. The proportion of patients in each category at 3 and 6 months was as follows: Diffuse consolidation 11% and 21%; patchy consolidation and GGO 15% and 28%; diffuse GGO 10% and 11%; patchy GGO 15% and 15%; and no change 49% and 25%, respectively. The percentage of patients in each category at 12 months was as follows: Modified conventional 46%; mass-like 16%; scar-like 26%; and no change 12%. Uniform scoring between the observers occurred in 26, 8, and 14 cases at 3, 6, and 12 months, respectively.

CONCLUSIONS

Interobserver reliability scores indicate a fair agreement to classify radiographic lung changes after SBRT. Qualitative descriptions are insufficient to categorize these findings because most patient scans do not fit clearly into a single classification. Categorization at 6 months may be the most difficult because late and acute lung changes can arise at that time.

Hiding single photons with spread spectrum technology

We describe a proof-of-principal experiment demonstrating the use of spread spectrum technology at the single photon level. We show how single photons with a prescribed temporal shape, in the presence of interfering noise, may be hidden and recovered.

External and middle ear trauma resulting from ear impressions

When taking an impression of the external ear canal and ear, the audiologist is engaged in an invasive procedure whereby a foreign body is first placed into the ear canal and then removed. There is always an element of risk for significant medical problems when a clinician is performing an invasive procedure. Although some minor patient discomfort and, at times, some slight trauma to the ear canal occur when taking ear impressions, the incidence of significant trauma to the external or middle ear appears to be low. The purpose of this report is to provide some illustrative cases of significant external and middle ear trauma as a result of taking impressions of the external ear. Audiologists are advised to develop and implement an appropriate risk management program for taking ear impressions to reduce the potential risks associated with this procedure to their patients and to their practices.

Skull metastasis from renal cell carcinoma. Case report and literature review

Metastatic tumors to the head and neck are uncommon. We report a case of renal cell carcinoma that presented as an epidermal inclusion cyst on the forehead. The forehead is an exceedingly uncommon site for renal cell metastases. We review the biology of tumor metastases and explore the pathways by which infraclavicular tumors spread to the head and neck. We then discuss the clinical appearance and management of metastatic renal cell carcinoma.

rsc: a novel oncogene with structural and functional homology with the gene family of exchange factors for Ral

A novel oncogene, rsc (rabbit squamous cell carcinoma), has been identified from a DMBA-induced rabbit squamous cell carcinoma using gene transfer and the nude mouse tumorigenesis assay. A full-length cDNA has been isolated and sequenced. rsc has potent tumorigenic activity in nude mice (latency <4 weeks), but does not induce focus formation or anchorage independent growth. The oncogene resulted from the fusion of rHR 23A (a rabbit homologue of yeast Rad 23) with a member of the ral-GDS family which we named rgr (ral-GDS related). Deletion analysis demonstrated that the oncogenic potential resides in the Rgr portion of the gene. Rgr is 40% identical overall to Ral-GDS, with identity increasing to 72% over a 100 amino acid region of the catalytic domain. Biochemical experiments indicate that Rgr has GTP/GDP exchange activity for Ral, providing evidence that this pathway is associated with tumorigenesis. The linkage between the Ral pathway and tumorigenesis by a molecule in the Ral-GDS gene family (Ral-GDS being a known effector for Ras) will open the way for the characterization of this pathway and provide an important tool to understand its biological function.

Antigenicity and nutritional value of selected milk proteins and their hydrolysate in growing rats

Two liquid diets containing selected milk proteins (SMP) or its small peptide hydrolysate (SPH) were fed to growing rats for 2 wk and the effects on growth, nitrogen balance, and small intestine adaptation were determined. Residual antigenicity of the SPH diet as measured by immunodot was reduced by 98.8%. Nitrogen intakes were not different. Weight gain was significantly higher in rats fed the SMP diet. In contrast, the absolute nitrogen balance was similar, suggesting that protein storage was identical with the two diets. A better nitrogen digestion-absorption rate with the SPH diet was observed as evidenced by the significantly increased fecal excretion with the SMP diet. Small intestine adaptation showed no difference between the two diets for mucosal weight, protein content/10 cm as well as for sucrase, glucoamylase, and N-aminopeptidase total activity/10 cm or specific activity (mU/mg protein). The DNA content of the mucosa/10 cm was significantly higher suggesting a mucosal hyperplasia in the SPH diet. The data suggest that in rats the SPH diet leads to nitrogen retention and small intestine adaptation similar to that of the SMP diet, despite better body weight gain by the latter.

Mutagenic effects of tumorigenic neutron radiation

A fraction of thymic lymphomas induced by high LET neutron radiation contains activating mutations (single-base substitutions) in the ras genes. To determine whether such mutations are the result of the interaction of high LET radiation with cellular DNA, we have utilized an in vitro model system to screen and isolate neutron-radiation-induced mutants. With that aim, we irradiated the PL61 hamster cell line with 0.4 MeV neutrons. This cell line contains linked copies of the gpt and neo(r) genes, which permits selection for large or small alterations, depending on the selection imposed. Mutants selected for large alterations represented 98.2% of the total. When selection for small mutations was imposed, 9 clones grew. The molecular and biochemical analysis of these clones revealed that 5 of them had identifiable mutations in the gpt gene, consisting of small insertions and deletions, but no single-base substitutions were detected. This represents the first sequence characterization of neutron-induced mutants. The results obtained are consistent with the notion that the ras point mutations identified in the neutron-induced tumors are most likely detected due to the strong selective advantage that they confer to the host cell, but they probably arose during tumour evolution, since they represent a negligible proportion of the total number of alterations induced by neutron radiation.

In vitro lymphocyte proliferation with milk and a casein-whey protein hydrolyzed formula in children with cow's milk allergy

Discordant results have been reported about the role of lymphocyte proliferation assays in patients with cow's milk allergy. We studied the peripheral blood mononuclear cell response of 10 children with cow's milk allergy by means of a lymphocyte proliferation test to determine the diagnostic value of this assay, the clinical tolerance of a new therapeutic hydrolyzed formula, and the evolution of lymphocyte proliferation after 3 months of a cow's milk-free diet with the hydrolyzed formula. The lymphocyte proliferation at the time of diagnosis in the patients with cow's milk allergy was not statistically different from the results in the control group. The proliferation test performed after 3 months of diet with the hydrolyzed formula and restriction of cow's milk protein showed that the cellular proliferation remained globally the same compared with the proliferation at the time of diagnosis. The hydrolyzed formula proteins induced a lower cellular proliferation than milk proteins in patients with cow's milk allergy. Our results suggest that the lymphocyte proliferation test cannot be recommended for diagnostic purposes. However, in patients with cow's milk allergy the proliferation test affirmed the absence of immunogenicity of the hydrolyzed formula because it induced no significant T-cell activation.

Link design for nondirected wireless infrared communications

We optimize the design of a short-range communication system using nondirected line-of-sight IR radiation. We propose a receiver structure comprising a spherical thin-film optical filter and a truncated spherical lens that can significantly outperform an optimized planar-filter system. We can make the passband of the spherical filter arbitrarily narrow without constraining the field of view by using an arbitrarily large filter radius. We argue that a truncation angle of 90° maximizes the receiver field of view when a spherical filter is used. We jointly optimize the transmitter radiation pattern and receiver optical components. Numerical results show that 269 mW of transmitted signal power is sufficient to achieve 100 Mbit/s throughout a 4-m-radius cell with high background irradiance.

An overexpressed N-ras proto-oncogene cooperates with N-methylnitrosourea in mouse mammary carcinogenesis

The induction of tumors with chemicals and the production of transgenic animals are two experimental approaches to study oncogene involvement in carcinogenesis. The combination of both strategies offers an excellent model system to study tumor development. This study analyzes the potential cooperation of N-methylnitrosourea (MNU) treatment and N-ras proto-oncogene overexpression in tumorigenesis in transgenic mice. The overexpression of the N-ras proto-oncogene in these animals is associated with development of mammary tumors and lymphomas. After MNU treatment we analyzed tumor incidence and latency, levels of transgene expression, and pattern of ras mutations in codons 12, 13, and 61 of H-, K-, and N-ras genes in both tumor types. Transgenic mice treated with MNU had significantly (P < 0.001) shorter latency of appearance of mammary tumors [8.6 +/- 3.0 (SD) months] than phosphate-buffered saline-treated transgenics (12.8 +/- 2.3 months). All mammary tumors overexpressed the N-ras transgene and lacked ras mutations. Moreover, MNU-treated transgenics had an incidence and latency of lymphomas similar to that of MNU-treated nontransgenic mice. No significant differences in incidence of point mutations (K-ras codon 12 or 13 and N-ras codon 61) in lymphomas were seen between these two groups. All lymphomas overexpressed the N-ras transgene, except for those carrying a K-ras point mutation. Overexpression of the N-ras proto-oncogene cooperates with non-ras genes mutated by MNU in mouse mammary carcinogenesis. Conversely, N-ras proto-oncogene overexpression does not show cooperation with MNU in lymphomagenesis in our system. This study suggests that proto-oncogene overexpression may be a mechanism of activation of the ras pathway, alternative to point mutation. Similarly to actions for ras genes activated by point mutation, overexpression of the N-ras protooncogene predisposes to tumorigenesis and cooperates with a carcinogen in tumorigenesis. The possibility that ras overexpression plays a role in human breast tumorigenesis requires active investigation.

Dietary components of malt extract such as maltodextrins, proteins and inorganic salts have distinct effects on glucose uptake and glycogen concentrations in rats

As shown previously, glycogen deposition in liver and muscle is significantly greater in rats fed a diet containing barley malt extract than in those fed diets containing glucose or starch. We investigated whether particular components of malt extract (glucose oligomers, inorganic salts, protein) were responsible for this effect. Food-deprived rats were fed diets containing carbohydrates of different chain lengths [glucose, maltose, maltodextrins or malt carbohydrates (84-86 g/100 g)] in the presence and absence of inorganic salts (2 g/100 g) and maltodextrin diets (78 g/100 g) containing either no protein or 20 g casein/100 g. Dietary glucose oligomers caused higher blood glucose concentrations than consumption of glucose or maltose but had no significant influence on liver or muscle glycogen. Salt addition resulted in higher muscle glycogen concentrations but had no effect on blood glucose or liver glycogen. Hepatic glycogen concentrations were significantly greater in rats fed casein compared with those fed no protein. We propose that consumption of malt extract has the following advantages over consumption of diets containing glucose or maltose: 1) better glucose absorption related to the presence of glucose oligomers, 2) greater hepatic glycogen concentrations associated with the protein in malt extract, and 3) greater glycogen concentrations in muscle due to the presence of inorganic salts.

Effects of two protein hydrolysates on growth, nitrogen balance and small intestine adaptation in growing rats

The effects of feeding 2 protein hydrolysates, one prepared by controlled pepsin and pancreatic protease (including elastase II) hydrolysis of milk proteins (PPPH) and the other a di- and tripeptide bacterial protease hydrolysate of bovine albumin (DTPH), on the growth, nitrogen balance and small intestine adaptation of growing rats were analyzed. Two groups of 3-week-old rats (8 rats/group) were fed the liquid diets ad libitum for 2 weeks. The diets had the same caloric, nitrogen, carbohydrate and lipid contents. The amino acid compositions fulfilled the needs of growing rats. The diet differed in the original proteins, the hydrolysis technique used and the molecular weights of the peptides. Nitrogen intakes were similar. Although there was no difference in weight gain, nitrogen balance was significantly higher in the rats fed the PPPH diet (day 4-day 6:PPPH, 60 +/- 4%, DTPH, 25 +/- 5%; day 12-day 15: PPPH, 58 +/- 3%; DTPH, 30 +/- 5%). The stool nitrogens were identical, suggesting improved nitrogen storage in the rats fed the PPPH diet. Small intestine adaptation showed that the rats on the PPPH diet had significantly more protein (mg) and DNA (microgram) per 10 cm of the jejunum (PPPH, 25.6 +/- 2, 393 +/- 20; DTPH: 15.7 +/- 2, 258 +/- 23) and sucrase-specific activity and per microgram of DNA (PPPH, 133 +/- 5.7, 9.7 +/- 0.5; DTPH, 113 v 5, 7 +/- 1). The N-aminopeptidase-specific activity was the same in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Practical and clinical aspects of multifactorial therapy in obesity]

In the present study the effect of a combination of protein-restricted modified hypocaloric diet and a behavioural therapy in 125 obese patients was analyzed. Patients were divided in two groups: 96 patients were instructed and controlled by practitioners (group 1) and 29 patients were followed in our out-patient clinic (group 2). After 14 weeks on diet a mean weight reduction of 10.6 kg in group 1 and of 9.8 kg in group 2 was observed. Furthermore, a significant decrease in systolic and diastolic blood pressure and in mean cholesterol and triglyceride values was seen. Our results show the good effect of a modified protein-sparing fast in obese patients. However, it has to be emphasized that the most promising results have been those utilizing not only a nutritional but also a behavioral approach.

Refeeding of rats fasted 36 hours with five different carbohydrates and with malt extract: differential effects on glycogen deposition in liver and muscle, on plasma insulin and on plasma triglyceride levels

Rats fasted for 36 h were refed for 1, 2, 4 or 6 h with a diet containing 12 g/100 g casein, 2 g/100 g NaCl and 86 g/100 g glucose, fructose, maltose, sucrose, starch or malt extract. Blood glucose reached constant levels after 1 to 2 h of refeeding. The increase in plasma insulin paralleled food intake rather than the increase in blood glucose. Plasma triglycerides decreased upon refeeding starch, maltose and malt extract and increased with sucrose and fructose. Recovery of absorbed carbohydrates was highest in rats refed malt extract. Glycogen deposition in muscle was highest in rats fed malt extract and lowest in those fed fructose; sucrose yielded intermediate values. Glucose, maltose and starch resulted in muscle glycogen depositions slightly lower than those obtained with malt extract. In liver, sucrose and fructose were better precursors for glycogen than glucose and starch. With carbohydrates containing only glucose units, much more glycogen was found to be deposited in total muscle than in liver. This asymmetry was less notable or even was reversed with sucrose and fructose. Glycogen deposition in muscle and in liver is influenced by the carbohydrate used for refeeding, and muscle, rather than liver, is the main glycogen storing tissue.

Hilger facial nerve stimulator: a 25-year update

Percutaneous nerve excitability testing using the Hilger facial nerve stimulator was introduced about 25 years ago. The test is reliable, easy to use, and inexpensive; it continues to be the most frequently used method for predicting prognosis of facial nerve disorders. Between 1966 and 1974, we recorded 10,243 nerve excitability tests on 865 patients with a mean of 3.29 tests for each peripheral branch and 3.43 for the trunk. Using a multiple regression model, we determined the effect on nerve stimulation values of age, sex, race, diabetes, hypertension, partial or complete clinical paralysis, diagnosis of herpes zoster, year of testing, and eventual facial paralysis recovery profile. We discuss statistical reliability, provide a table of interpretive results, and offer "tips and traps" invaluable to the practitioner. A prospective study of 25 patients with residual facial paralysis was evaluated by two separate otolaryngologists to determine intertester reliability.

The influence of the initial state of hydration on endocrine responses to exercise in the heat

This study examines the effect of the initial state of hydration on hormone responses to prolonged exercise in the heat. Five subjects at two initial hydration levels (hypohydrated and hyperhydrated) were exposed to a 36 degrees C environment for 3 h of intermittent exercise. During exercise, the subjects were either fluid-deprived, or rehydrated with water or an isotonic electrolyte sucrose solution (ISO). Both the stress hormones, adrenocorticotropic hormone and cortisol, and the main fluid regulatory hormones, aldosterone, renin activity (PRA) and arginine vasopressin (AVP), were measured in blood samples taken every hour. Prior hyperhydration significantly reduced initial AVP, aldosterone and PRA levels. However, except for AVP, which responded to exercise significantly less in previously hyperhydrated subjects (p less than 0.05), the initial hydration state did not influence the subsequent vascular and hormonal responses when the subjects were fluid-deprived while exercising. Concurrent rehydration, either with water or with ISO, reduced or even abolished the hormonal responses. There were no significant differences according to the initial hydration state, except for PRA responses, which were significantly lower (p less than 0.01) in previously hyperhydrated subjects who also received water during exercise. These results indicate that prior hydration levels influence only slightly the hormonal responses to prolonged exercise in the heat. Progressive rehydration during exercise, especially when extra electrolytes are given, is more efficient in maintaining plasma volume and osmolarity and in reducing the hormonal responses.

[Differentiated enteral feeding in the post-aggression phase in polytrauma patients. Comparison of a high calorie nutritionally defined diet (whole protein high calorie diet) with a peptide diet]

Two groups of 10 patients with an identical mean injury score (25 + 5) were treated from day 3 after injury until day 10 with a whole protein high caloric (WPHC) diet (group A) or with a peptide diet (PD) (group B). Intake of calories, protein, water, Na+ and K+ was measured daily as well as excretion of urine, Na+ and K+. Gastric reflux, bowel movement and plasma levels of Na+ and K+ were registered and the nitrogen balance and Na+/K+ quotient in urine were calculated daily. Clinically both diets were well tolerated, with low gastric reflux and no diarrhea. The calculated caloric demand could be covered in group A on day 7 post-injury (or day 4 of enteral nutrition) and in group B on day 11 post-injury (or day 7 of enteral nutrition). The caloric intake in group A remained significantly higher on days 4-10. There was no difference in nitrogen balance. Total enteral Na+ and fluid intake were significantly lower in group A, but some additional parenteral Na+ had to be given to keep plasma Na+ levels in the normal range. There was no difference in urine output between the 2 groups; therefore, there was a significant fluid retention in group B. Interestingly, the Na+/K+ quotient in urine was significantly higher in group A. The low Na+ intake might influence the back flow of interstitial edema in the 'flow phase'. This diet seems to be adequate, especially for the nutrition of burn patients and of patients with cardiac disease, and can cover the high caloric needs of polytraumatised patients within a few days.