Volatile capture technology in sustainable anaesthetic practice: a narrative review

Anaesthetic practice contributes to climate change. Volatile capture technology, typically based on adsorption to a carbon- or silica-based substrate, has the potential to mitigate some of the harmful effects of using halogenated hydrocarbons. Anaesthetists have a professional responsibility to use anaesthetic agents which offer the greatest safety and clinical benefit with the lowest financial cost and environmental impacts. Inhalational anaesthetics should be used at an appropriate concentration with a minimal fresh gas flow via a circle system to minimise unnecessary waste. Once practice efficiencies have been maximised, only then should technical solutions such as volatile capture be employed. In this narrative review, we focus on the available literature relating to volatile capture technology, obtained via a targeted literature search and through contacting manufacturers and researchers. We found six studies focusing on the Blue-Zone Technologies Deltasorb®, SageTech Medical SID and Baxter/ZeoSys CONTRAfluran™ volatile capture systems. Though laboratory analyses of available systems suggest that > 95% in vitro mass transfer is possible for all three systems, the in vivo results for capture efficiency vary from 25% to 73%. Currently, there is no financial incentive for healthcare organisations to capture waste anaesthetic gases, and so the value of volatile capture technology requires quantification. System-level organisations, such as Greener NHS, are best positioned to commission such evaluations and make policy decisions to guide investment. Further research using volatile capture technology in real-world settings is necessary and we highlight some priority research questions to improve our understanding of the utility of this group of technologies.

Intrafraction Imaging Can Replace the Midtreatment Cone Beam Tomography for Lung Stereotactic Ablative Radiation Therapy Patients for Increased Treatment Efficiency

Purpose

To determine the feasibility of replacing the mid treatment cone beam computed tomography (MT CBCT) image with Intrafraction Imaging (IFI) acquired concurrently during dose delivery in lung Stereotactic Ablative Body Radiation therapy (SABR) patients, and thus improve treatment efficiency.

Methods and Materials

A review of departmental imaging data was performed on ten lung SABR patients treated with dual arc volumetric modulated arc therapy (VMAT) on an Elekta Versa HD linear accelerator with XVI imaging software.IFI data was extracted and a database of the translational (TX, TY, TZ) and the rotational (RX, RY, RZ) position errors was created for retrospective comparison, with the values of the MT CBCT for the same patients, treated between March 2021 and March 2022 at our center. The data was evaluated for correlation between the values in all 6° of freedom.

Results

The inter-class correlation (ICC) coefficient for Tx was 0.89 (95% CI, 0.80-0.94), Ty was 0.69 (95% CI, 0.49-0.82), Tz was 0.89 (95% CI, 0.82-0.95) in the translational planes, and Rx was 0.79 (95% CI, 0.65-0.88), Ry was 0.79 (95% CI, 0.65-0.88), and Rz was 0.91 (95% CI, 0.84-0.95) in rotational planes.The Bland-Altman (BA) statistics for Tx had a bias of -1.22 × 10-3, with an upper limit of agreement (UOA) of 0.07, and a lower limit of agreement (LOA) of -0.07, for Ty the bias was 0.01 (UOA: 0.18; LOA: -0.16), Tz bias was 2.6 × 10-3(UOA: 0.10; LOA: -0.09), Rx bias was 0.09 (UOA: 0.82; LOA: -0.64), Ry bias was -0.04 (UOA: 1.08; LOA: -1.16) and Rz was -0.03 (UOA: 0.44; LOA: -0.51).

Conclusions

The ICC was excellent for Tx, Tz, Rx, y, z, and good for Ty. The data demonstrated promising correlation between IFI and MT CBCT values, and therefore supports the use of IFI for clinical decision making and improving treatment efficiency.

A radiologist's guide to median sternotomy

Median sternotomy is widely recognised as the primary incision technique in cardiac surgery. This surgical procedure involves dividing the sternum to gain access to the heart and lungs, making it invaluable in correcting congenital heart defects. Furthermore, it is frequently employed in adult patients, particularly during coronary artery bypass graft (CABG) procedures. In this imaging review, we present a comprehensive overview of the pre-procedural assessment and various post-sternotomy complications encountered within our clinical experience at a tertiary cardiothoracic centre. The focus of this review is to outline the imaging features associated with mediastinal adhesions and establish the minimal safe distance between the sternum and common mediastinal structures when considering re-sternotomy. By providing visual examples, we aim to facilitate a better understanding of these key concepts. Moreover, we delve into a detailed discussion of a spectrum of postoperative complications that may arise following median sternotomy including those related to metalwork (sternal wire fracture), bone (sternal dehiscence, non-union and osteomyelitis), and soft tissue (abscess, haematoma).

Childhood cancer incidence & survival in Aotearoa, New Zealand 2010-2019

OBJECTIVE

To provide updated estimates of childhood cancer incidence and survival in Aotearoa, New Zealand.

METHOD

Registrations for children under the age of 15 years diagnosed with cancer between 2010 and 2019 were extracted from the New Zealand Children's Cancer Registry. Cases were stratified by age, sex, prioritised ethnicity (Māori, Pacific peoples, and non-Māori) and cancer type. Age-standardised incidence rates (ASRs) per million person years and observed survival rates were calculated.

RESULTS

During the study period, 1522 children were diagnosed with cancer providing an ASR of 169.1 per million per year (95 % Confidence Interval, CI: 157.0-181.2). For all childhood cancers combined, survival at 5-years was 85.6 % (95 % CI 83.7-87.3). There was a gap in 5-year survival between Māori (80.9 %, 95 % CI 76.5-84.6), Pacific peoples (82.6 %, 95 % CI 75.6-87,7) and Non-Māori (87.8 %, 95 % CI 85.6-89.7) In both adjusted and unadjusted models, this difference in survival was most marked (p < 0.05) among children who were 10-14 years of age at diagnosis.

CONCLUSION

Childhood cancer incidence and survival rates in Aotearoa, New Zealand remain comparable to other high-income countries. Further research is required to understand the survival difference between ethnic groups.

Efficacy of preoxygenation administration in volunteers, in extending the end-expiration breath-hold duration for application to abdominal radiotherapy

Background and purpose

End expiration breath hold (EEBH) is the preferred motion management method for abdominal Stereotactic Ablative Body Radiotherapy (SABR) treatments. However, multiple short EEBHs are required to complete a single treatment session. The study aimed to determine the efficacy of preoxygenation with hyperventilation in extending an EEBH duration.

Materials and methods

We randomised 10 healthy participants into two arms, each included breathing room air and oxygen at a rate of 10 L per minute (l/min) without hyperventilation for four minutes, and normally for four minutes and with hyperventilation for one minute at a rate of 20 breaths/minute for hyperventilation. The type of gas was blinded from the participants for each test. EEBH durations were then recorded, as well as systolic blood pressure, SpO₂ and heart rate. A discomfort rating was also recorded after each breath hold.

Results

A significant increase in duration of almost 50% was observed between normal breathing of room air and breathing oxygen normally followed by hyperventilation. Vital signs remained consistent between the 4 tests. The tests were well tolerated with 75% of participants recording none or minimal discomfort.

Conclusion

Preoxygenation with hyperventilation could be used to increase the EEBH duration for abdominal SABR patients which would assist in the accuracy of these treatments and possibly resulting in a reduction of overall treatment times.

Fluctuations of cell geometry and their nonequilibrium thermodynamics in living epithelial tissue

We measure different contributions to entropy production in a living functional epithelial tissue. We do this by extracting the functional dynamics of development while at the same time quantifying fluctuations. Using the translucent Drosophila melanogaster pupal epithelium as an ideal tissue for high-resolution live imaging, we measure the entropy associated with the stochastic geometry of cells in the epithelium. This is done using a detailed analysis of the dynamics of the shape and orientation of individual cells which enables separation of local and global aspects of the tissue behavior. Intriguingly, we find that we can observe irreversible dynamics in the cell geometries but without a change in the entropy associated with those degrees of freedom, showing that there is a flow of energy into those degrees of freedom. Hence, the living system is controlling how the entropy is being produced and partitioned into its different parts.

Imaging the acute abdomen in pregnancy: a radiological decision-making tool and the role of MRI

Acute abdominal pain in pregnancy poses a significant diagnostic challenge. The differential diagnosis is wide, clinical assessment is difficult, and the use of conventional imaging methods is restricted due to risks to the fetus. This can lead to delay in diagnosis, which increases the risk of maternal and fetal harm. Imaging techniques not involving ionising radiation are preferred. Sonography remains first line, but anatomical visualisation can be limited due to displacement of adjacent structures by the gravid uterus. MRI provides excellent cross-sectional soft-tissue assessment of the abdomen and pelvis, and no study to date has demonstrated significant deleterious effects to the fetus at any gestation; however, there remains a theoretical risk of tissue heating by radiofrequency pulses, and there must be consideration of benefit versus potential risk for any use of magnetic resonance imaging (MRI) in pregnancy. With a limited protocol of sequences, a broad spectrum of pathologies can be evaluated. Computed tomography carries the highest exposure of ionising radiation to the fetus, but may be necessary, particularly in cases of trauma. The patient must be kept informed and any potential risks to the patient and fetus should be clearly explained. We present a radiological decision-making tool to guide choice of imaging and best establish the underlying diagnosis in the acute pregnant abdomen. In addition, using illustrative examples from our practice at a large tertiary centre, we review the advantages and disadvantages of each imaging method, with particular focus on the utility of MRI.

Stepped-wedge randomized controlled trial of laparoscopic ventral mesh rectopexy in adults with chronic constipation

Background

The effectiveness of laparoscopic ventral mesh rectopexy (LVMR) in patients with defecatory disorders secondary to internal rectal prolapse is poorly evidenced. A UK-based multicenter randomized controlled trial was designed to determine the clinical efficacy of LVMR compared to controls at medium-term follow-up.

Methods

The randomized controlled trial was conducted from March 1, 2015 TO January 31, 2019. A stepped-wedge RCT design permitted observer-masked data comparisons between patients awaiting LVMR (controls) with those who had undergone surgery. Adult participants with radiologically confirmed IRP refractory to conservative treatment were randomized to three arms with different delays before surgery. Efficacy outcome data were collected at equally stepped time points (12, 24, 36, 48, 60, and 72 weeks). Clinical efficacy of LVMR compared to controls was defined as ≥ 1.0-point reduction in Patient Assessment of Constipation-Quality of Life and/or Symptoms (PAC-QOL and/or PAC-SYM) scores at 24 weeks. Secondary outcome measures included 14-day diary data, the Generalized Anxiety Disorder scale (GAD-7), the Patient Health Questionnaire-9 (PHQ-9), St Marks incontinence score, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), the chronic constipation Behavioral Response to Illness Questionnaire (CC-BRQ), and the Brief Illness Perception Questionnaire (BIPQ).

Results

Of a calculated sample size of 114, only 28 patients (100% female) were randomized from 6 institutions (due mainly to national pause on mesh-related surgery). Nine were assigned to the T0 arm, 10 to T12, and 9 to T24. There were no substantial differences in baseline characteristics between the three arms. Compared to baseline, significant reduction (improvement) in PAC-QOL and PAC-SYM scores were observed at 24 weeks post-surgery (– 1.09 [95% CI – 1.76, – 0.41], p = 0.0019, and – 0.92 [– 1.52, – 0.32], p = 0.0029, respectively) in the 19 patients available for analysis (9 were excluded for dropout [n = 2] or missing primary outcome [n = 7]). There was a clinically significant long-term reduction in PAC-QOL scores (− 1.38 [− 2.94, 0.19], p = 0.0840 at 72 weeks). Statistically significant improvements in PAC-SYM scores persisted to 72 weeks (− 1.51 [− 2.87, − 0.16], p = 0.0289). Compared to baseline, no differences were found in secondary outcomes, except for significant improvements at 24 and 48 weeks on CC-BRQ avoidance behavior (− 14.3 [95% CI − 23.3, − 5.4], and − 0.92 [− 1.52, − 0.32], respectively), CC-BRQ safety behavior (− 13.7 [95% CI − 20.5, − 7.0], and − 13.0 [− 19.8, − 6.1], respectively), and BIPQ negative perceptions (− 16.3 [95% CI − 23.5, − 9.0], and − 10.5 [− 17.9, − 3.2], respectively).

Conclusions

With the caveat of under-powering due to poor recruitment, the study presents the first randomized trial evidence of short-term benefit of LVMR for internal rectal prolapse.

Trial registration

ISRCTN Registry (ISRCTN11747152).

Supplementary Information

The online version contains supplementary material available at 10.1007/s10151-022-02633-w.

Radiation therapist-led telephone follow-up: identifying patients who require post-treatment care

INTRODUCTION

Radiation therapists implemented telephone follow-up (TFU) in 2015 as an additional point of care post-treatment. The purpose of this study was to determine whether TFU identified patients who required additional post-treatment care before the next scheduled review.

METHODS

Between January 2015 and July 2016, all patients who were prescribed curative intent treatment aged 18 years or over were called 10 days post-radiation therapy (RT). Eight questions were developed and included asking patients how they were coping, if their side effects were improving, if they needed to contact the hospital and if more dressings were required. Patients who could not be contacted after two attempts were excluded from the study. Microsoft Excel and Statistical Package for Social Sciences (SPSS) were used to analyse the responses.

RESULTS

Data were collected from 850 patients. A total of 28/846 (3%) of patients reported they were not coping after RT, with 26/830 (3%) reporting their side effects were getting worse. A total of 97/826 (12%) of patients felt they needed to contact the hospital because they were unwell. This study identified 104/677 (15%) of patients who responded required more dressings, with 67/104 (65.7%) and 10/104 (9.8%) of this cohort identified in the breast, and head and neck groups, respectively.

CONCLUSION

Radiation therapist-led TFU has shown to be beneficial in identifying a small cohort of breast and head and neck cancer patients who required additional care post-radiation treatment.

Stereotactic body radiotherapy in the management of hepatocellular carcinoma: An Australian multi-institutional patterns of practice review

INTRODUCTION

Stereotactic body radiotherapy (SBRT) is an emerging, therapeutic option in the management of hepatocellular carcinoma (HCC). A multicentre Liver Ablative Stereotactic Radiation (LASR) database was established to provide a collaborative platform for Australian institutions to define the practice of liver SBRT for HCC. This study explores the patterns of SBRT practice amongst Australian institutions.

METHODS

This was a multi-institutional retrospective study of patients treated with SBRT for HCC at 10 institutions between January 2013 and December 2019. Patients' demographics, disease characteristics and SBRT details were evaluated.

RESULTS

Three hundred and seventeen patients were evaluated with a median age of 67 years (range, 32-90). Liver cirrhosis was present in 88.6%, baseline Child-Pugh score was A5/6 in 85.1% and B7/8 in 13.2%. Median size of HCC treated was 30 mm (range, 10-280). 63.1% had early-stage disease (Barcelona clinic liver cancer (BCLC) stage 0/A) and 36% had intermediate/advanced-stage disease (BCLC B/C). In 2013/2014, six courses of SBRT were delivered, increasing to 108 in 2019. SBRT was prescribed in five fractions for 71.3% of the cohort. The most common dose fractionation schedule was 40 Gy in five fractions (24.3%). Median biologically effective dose (BED₁₀ ) delivered was 85.5 Gy for early-stage and 60 Gy for intermediate/advanced disease, respectively. The most common prescription range was 100-120 Gy BED₁₀ (32.8%).

CONCLUSION

SBRT utilisation for HCC is increasing in Australia. There was wide variation in size of tumours and disease stages treated, and prescription patterns. Uniform reporting of clinical and dosimetric details are important in refining the role of liver SBRT.

Bladder Care in Palliative Care Inpatients: A Prospective Dual Site Cohort Study

Background: Urinary catheterization is often undertaken to relieve distressing bladder symptoms in palliative care.

Objective: The primary aim of this study was to determine the incidence of, and clinical indications that predispose patients admitted to palliative care units to, urinary catheterization. The secondary aims were to determine causal factors, including the type of malignancy, antecedent medications, and duration of admission in these patients.

Methods: This was a prospective observational dual site cohort study in palliative care inpatients. Univariate categorical chi-square analysis was performed to compare patients with and without urinary catheterization, and to identify risk factors associated with urinary catheter use.

Results: The incidence of catheterization in this cohort was 41% (43/104) and urinary retention (63%) was the most common cause. Agitation (47%) and urinary incontinence (70%) were common symptoms in those catheterized. Medications that were significantly associated with the need for urinary catheterization were benzodiazepines (p < 0.01) and antipsychotics (p = 0.01). All measures that define poor functional status were found to be significant (p < 0.01). Patients with prolonged hospitalization of greater than three weeks were catheterized more frequently (p = 0.017). The majority of patients catheterized (79%) were admitted for terminal care.

Conclusions: The high incidence of urinary catheterization highlights the need for good bladder care for all patients in the palliative care setting. Patients with risk factors include the use of antipsychotics and benzodiazepines, declining functional status and prolonged hospital admission are more likely to be catheterized.

Vascular bowel and mesenteric injury in blunt abdominal trauma: a single centre experience

AIM

To establish common patterns of injury in vascular bowel and mesenteric injury (VBMI) and to identify any factors that may lead to delayed treatment.

METHODS AND MATERIALS

Forty-one patients with blunt VBMI presented to the level 1 trauma centre of the The Royal London Hospital over 5 years. Computed tomography (CT) images were reviewed to identify the specific location of injury and additional features such as seatbelt bruising and lumbar hernias. Surgical reports were reviewed to record any pertinent surgical findings at laparotomy.

RESULTS

The commonest mechanism of injury was a restrained car occupant involved in a road traffic collision (49%, n=20). The ileocaecal mesenteric vasculature was most frequently injured (41.5%, n=17), followed by the mid ileum (17.1%, n=7). Seatbelt bruising was identified in 80% of restrained car occupants and lumbar hernias in 22% of all patients with VBMI.

CONCLUSION

Restrained car occupants involved in road traffic collisions are at increased risk of VBMI with particular susceptibility of the ileocaecal mesentery. This has implications for the reporting radiologist and trauma surgeon in deciding which patients require careful monitoring for the development of delayed bowel ischaemia.

Introducing PEEP: The psychiatry early experience programme

At Guy's King's and St Thomas’ School of Medicine, a unique initiative is the Psychiatry Early Experience Programme (PEEP), which allows students to shadow psychiatry trainees at work several times a year. The students’ attitudes towards psychiatry and the scheme are regularly assessed and initial results are already available.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Simultaneous Determination of Multiple Tetracycline Residues in Milk by Metal Chelate Affinity Chromatography: Collaborative Study

To meet federal and state regulatory needs, a liquid chromatographic (LC) method with ultraviolet (UV) detection was developed for determination of 7 tetracyclines at 30 ng/mL in milk. Raw milk samples are defatted, acidified, and centrifuged to remove proteins, and tetracyclines are specifically absorbed from the milk by chelation with metal ions bound to small Chelating Sepharose Fast Flow columns. Tetracyclines are removed from these columns with EDTA-containing buffer, and extracts are further cleaned by ultrafiltration. Finally, extracts are concentrated and analyzed simultane ously by using on-line concentration. This method was validated in a collaborative study that involved 11 laboratories, including the authors’ laboratory. Each laboratory was asked to prepare and analyze known control and fortified milk samples, as well as 18 coded blind samples. Eight laboratories completed all analyses. Average interlaboratory recoveries for the known fortified samples ranged from 59% (methacycline at 15 ng/mL) to 78% (oxytetracy cline at 60 ng/mL). Average recovery for each of 7 residues at 30 ng/mL were between 60 and 110%, meeting single-residue guidelines for accuracy set by the U.S. Food and Drug Administration. Reproducibility relative standard deviation (RSDR) for the known fortified samples varied from 11 to 39%, with 6 of 7 residues at the 30 ng/mL level having RSDR values at or below 20%. Seven of 8 laboratories correctly identified blind control milk samples and all 28 residues present in blind samples. The metal chelate affinity—LC method for determination of multiple tetracycline residues in milk has been adopted first action by AOAC INTERNATIONAL.

Improving Population-Wide Collection of Stage at Diagnosis for Childhood Cancer: International Collaboration and Progress

Background: There are huge international disparities in childhood cancer survival. The International Agency for Research on Cancer's Global Initiative for Cancer Registry Development has improved cancer registry coverage of the world's population, particularly in low- and middle-income countries (LMICs). However, for virtually all registries around the world, the challenge remains of collecting comparable and population-wide information on stage at diagnosis. This information is essential to understand and address disparities in outcomes. In response to this, a UICC-endorsed set of consensus guidelines for assigning stage for 16 of the most common types of childhood cancer was recently developed (the Toronto Guidelines), for use by population registries in both high and LMICs. Aim: To trial the Toronto Guidelines on a population-basis, and develop a structured protocol, suitable for global implementation, for collecting the required data elements and assigning cancer stage at diagnosis for childhood cancer. Methods: Using an innovative approach, data items as defined in the Toronto Guidelines were gathered from the medical record and entered electronically. Stage at diagnosis was assigned automatically using computer algorithms, thus reducing errors and maximizing consistency. Data collection and assignment of stage were incorporated into an online platform that was then trialed in the national childhood cancer registries of Australia and New Zealand for cases diagnosed between 2006 and 2014. Results: Stage at diagnosis was successfully assigned for 94% of all eligible patients (n=1662) across both countries. In contrast, stage as recorded by the treating clinician was located in the medical record for only 39% of cases in Australia. Conclusion: Practical implementation of the Toronto Guidelines has been highly successful to date and further testing is planned in LMICs. This approach has the potential to improve global epidemiologic monitoring of childhood cancer and lead to better understanding of the reasons underlying disparities in outcome.

Long-term outcomes in 1121 Australian prostate cancer patients treated with definitive radiotherapy

INTRODUCTION

Optimal definitive treatment of prostate cancer is controversial, especially in high-risk patients. We report the largest prospective cohort of Australian patients treated with radiotherapy for localised prostate cancer.

METHODS

One thousand, one hundred and twenty-one patients with prostate cancer were prospectively registered and treated to a dose of 70-74 Gy. Patients were classified as low, intermediate or high risk based on PSA, clinical staging and Gleason score. Intermediate-risk patients were treated with 0-6 months of hormonal therapy (ADT) and high-risk patients were offered neoadjuvant and adjuvant ADT. Overall survival (OS) and biochemical relapse-free survival (bNED) were calculated using the Kaplan-Meier method.

RESULTS

Median follow-up was 92 months. Eight-year OS and bNED were 78.4% and 68.1% respectively in the entire cohort. OS for the low, intermediate and high-risk groups was 84.5%, 78.4% and 68% respectively. For these risk groups, bNED was 80.3%, 65.7% and 53.7% respectively. In the intermediate and high-risk group, OS and bNED decreased with increasing number of risk factors.

CONCLUSION

Definitive radiotherapy is an effective treatment for prostate cancer, including in high-risk cases.

Defining a Leader Role curriculum for radiation oncology: A global Delphi consensus study

BACKGROUND AND PURPOSE

The need for radiation oncologists and other radiation oncology (RO) professionals to lead quality improvement activities and contribute to shaping the future of our specialty is self-evident. Leadership knowledge, skills and behaviours, like other competencies, can be learned (Blumenthal et al., 2012). The objective of this study was to define a globally applicable competency set specific to radiation oncology for the CanMEDS Leader Role (Frank et al., 2015).

METHODS

A modified Delphi consensus process delivering two rounds of on-line surveys was used. Participants included trainees, radiation/clinical oncologists and other RO team members (radiation therapists, physicists, and nurses), professional educators and patients.

RESULTS

72 of 95 (76%) invitees from nine countries completed the Round 1 (R1) survey. Of the 72 respondents to RI, 70 completed Round 2 (R2) (97%). In R1, 35 items were deemed for 'inclusion' and 21 for 'exclusion', leaving 41 'undetermined'. After review of items, informed by participant comments, 14 competencies from the 'inclusion' group went into the final curriculum; 12 from the 'undetermined' group went to R2. In R2, 6 items reached consensus for inclusion.

CONCLUSION

This process resulted in 20 RO Leader Role competencies with apparent global applicability. This is the first step towards developing learning, teaching and assessment tools for this important area of training.

Comparing the educational impact of simulation training to role play and didactic teaching for integrating mental and physical healthcare

Introduction

Addressing the interaction between mental and physical health to provide more integrated healthcare has been highlighted as an international priority for health and education systems. Educational interventions focusing on multi-disciplinary, interprofessional approaches to integrated mental and physical healthcare are an essential part of transforming health systems. Simulation training is one tool by which such training can be delivered, in contrast to traditional teaching methods. However, simulation training can be high-cost and clarity over the impact is required.

Aim

To compare simulation training for integrating mental and physical health to role-play and didactic teaching, on their effect on confidence, knowledge, and attitudes of participants.

Methods

Participants in simulation training (n = 24) and role play plus didactic teaching (n = 87) both completed self-report measures of confidence and knowledge in working with mental and physical health needs, as well as the Readiness for interprofessional learning scale (RIPLS) collecting attitudes towards interprofessional collaboration. All participants also completed post-course qualitative feedback form with open questions.

Results

T-tests found statistically significant increases in confidence and knowledge following both educational interventions. T-tests showed statistically significant increases in attitudes to interprofessional collaboration (RIPLS) following simulation training, while there were no statistically significant changes after role-play and didactic teaching. Thematic analyses of post-course open questions demonstrated differing learning outcomes.

Conclusions

Simulation training appears to have a different and beneficial impact to role play and didactic teaching alone, when training participants on integrating mental and physical health.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Who Learns More in Interprofessional Mental Health Simulation Training? A Study Comparing Learning Outcomes of Different Professionals who Work in Mental and Physical Health Care Settings

Introduction

Simulation training has the potential to develop communication and teamwork skills, as well as technical knowledge and competency. Mental health simulation training aims to promote awareness of mental health conditions and to enhance human factors (or non-technical) skills that will enable professionals that work in mental and physical healthcare settings to improve their collaborative and patient-centered clinical practice. This study explored the differences in learning outcomes after a mental health simulation course between different professionals–nursing staff, medical staff, and allied health professionals.

Aims and objectives This project examined the different learning outcomes of human factors, confidence and knowledge, for nursing, medical and allied health professionals following mental health simulation training.

Methods

Course-specific measures of confidence and knowledge were administered pre- and post-training to all participants, in addition to The Human Factors Skills for Healthcare Instrument (HFSHI). A post-course evaluation for with free-text responses to open questions regarding the impact of the training was utilised to collect qualitative data.

Results

With data collection ongoing, preliminary results indicate differences in learning outcome depending on professional background, both in terms of quantitative measures and qualitative findings.

Conclusions

Learning outcomes may differ for different professionals despite receiving the same simulation training focusing on mental and physical health, evidencing the importance of sharing individual learning experiences in simulation using a debrief model.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Long Term Patient Reported Urinary Function Following External Beam Radiotherapy for Prostate Cancer

INTRODUCTION

This study reports long-term patient reported urinary function and urinary-related quality of life (uQoL) after external beam radiotherapy (EBRT) for localized prostate cancer.

METHODS

574 men underwent definitive prostate EBRT to 70-78 Gy±androgen deprivation therapy between 2000 and 2009. The median follow-up from EBRT was 44 months. Patients were evaluated at baseline (pre-EBRT) and at intervals post-treatment using the International Prostate Symptom Score (IPSS) instrument.

RESULTS

Patients with mild IPSS at baseline (total 0-7) reported median total scores of 3, 4 and 3 at baseline, 6 and 48 months respectively post-EBRT. For patients with moderate IPSS at baseline (total 8-19), median total IPSS was 12 at baseline and 9 at both 6 and 48 months. For the severe IPSS group at baseline (total 20-35), the median total IPSS was 24, 12 and 14 at baseline, 6 and 48 months post-EBRT. The cumulative risk of persistent IPSS increase (greater than 5 points above baseline) at 48 months was 16%, 10% and 6% for patients with mild, moderate and severe baseline IPSS respectively. 94%, 54% and 11% of patients with mild, moderate and severe baseline IPSS reported good uQoL at baseline respectively, with these proportions increasing to 95%, 83% and 69% at 48 months.

CONCLUSION

Urinary symptoms and uQoL as measured by the IPSS instrument remained stable or improved for the majority of men after definitive EBRT with or without ADT for prostate cancer. This was especially notable for the group of men with worse baseline symptoms or uQoL, with risk of persistent worsening of urinary symptoms decreasing with higher baseline IPSS category. Understanding the expected pattern of urinary symptoms and related uQoL in the months and years following EBRT taking into account baseline urinary function is highly valuable for counselling men as part of the therapeutic decision-making process.

Radiological assessment of paediatric cervical spine injury in blunt trauma: the potential impact of new NICE guidelines on the use of CT

AIM

To determine the potential effect of changes to the National Institute for Health and Care Excellence (NICE) guidelines to the use of computed tomography (CT) in the assessment of suspected paediatric cervical spine (c-spine) injury.

MATERIAL AND METHODS

A 5 year retrospective study was conducted of c-spine imaging in paediatric (<10 years) patients presenting following blunt trauma at a Level 1 trauma centre in London. All patients under the age of 10 years who underwent any imaging of the c-spine following blunt trauma were included. Clinical data relating to the presenting signs and symptoms were obtained from the retrospective review of electronic records and paper notes. This was then applied to the previous NICE guideline (CG56) and to the new NICE guideline (CG176). Patients with incomplete data were excluded.

RESULTS

Two hundred and seventy-eight patients <10 years underwent imaging of the c-spine following blunt trauma. Two hundred and seventy (97.12%) examinations had complete data and were included in further analysis. One hundred and forty-nine (55.19%) met the criteria for a CT of the c-spine under NICE CG56, whereas 252 (93.33%) met the updated NICE CG176 criteria for c-spine CT. Five (1.85%) patients had a c-spine injury and met the criteria under both CG56 and CG176 NICE guidelines.

CONCLUSION

Recent changes to NICE Head Injury Guidelines relating to radiological assessment of paediatric c-spine following blunt trauma are likely to result in an increased usage of CT as the initial radiological investigation over plain radiographs, without an apparent increase in specificity in the present series.

A MultiCenter Pilot Randomized Controlled Trial of Remote Ischemic Preconditioning in Major Vascular Surgery

A pilot randomized controlled trial that evaluated the effect of remote ischemic preconditioning (RIPC) on clinical outcomes following major vascular surgery was performed. Eligible patients were those scheduled to undergo open abdominal aortic aneurysm repair, endovascular aortic aneurysm repair, carotid endarterectomy, and lower limb revascularization procedures. Patients were randomized to RIPC or to control groups. The primary outcome was a composite clinical end point comprising any of cardiovascular death, myocardial infarction, new-onset arrhythmia, cardiac arrest, congestive cardiac failure, cerebrovascular accident, renal failure requiring renal replacement therapy, mesenteric ischemia, and urgent cardiac revascularization. Secondary outcomes were components of the primary outcome and myocardial injury as assessed by serum troponin values. The primary outcome occurred in 19 (19.2%) of 99 controls and 14 (14.1%) of 99 RIPC group patients ( P = .446). There were no significant differences in secondary outcomes. Our trial generated data that will guide future trials. Further trials are urgently needed.

Religion, assessment and the problem of 'normative uncertainty' for mental health student nurses: a critical incident-informed qualitative interview study

There is limited research around how mental health (MH) student nurses interpret and differentiate between people's religious and cultural beliefs and the existence of psychopathological symptomatology and experiences. Here we focus on one cultural issue that arose from research exploring how MH student nurses approach and interpret religion and culture in their practice - that is, the difficulties in determining the clinical significance of the religious beliefs and experiences expressed by the people they care for. While problems with establishing the cultural boundaries of normality in clinical assessments are an important area of debate in cultural psychiatry, it remains a peripheral issue in MH nurse education. An anthropologically informed qualitative research design underpinned 'critical incident' (CI)-focused ethnographic interviews with 36 second and third-year MH nursing field students and seven undergraduate MH branch lecturers. Follow up focus groups were also carried out. Interview transcripts were subject to thematic analysis. Four subthemes were identified under the broad theme of the clinical significance of religious-type expression and experience: (1) identifying the difference between delusions and religious belief; (2) identifying whether an experience was hallucination or religious experience; (3) the clinical implications of such challenges; and (4) applying religion-specific knowledge. There are clinical implications that may result from the difficulties with assessing the clinical significance of religious beliefs and experiences, identified in both our research and within international cultural psychiatry literature and research. Misinterpretation and therefore wrongly assessing someone's experience as pathological is a significant concern. It is suggested that CI analysis could be adapted to help nurses, nursing students and nurse educators recognize the religious dimensions of mental distress, particularly those that then potentially impact upon the accuracy and person centeredness of clinical assessment. Further research is proposed to investigate the clinical assessment and training needs of nurses in the area of religion and mental distress.

Using routine clinical and administrative data to produce a dataset of attendances at Emergency Departments following self-harm

Background

Self-harm is a significant public health concern in the UK. This is reflected in the recent addition to the English Public Health Outcomes Framework of rates of attendance at Emergency Departments (EDs) following self-harm. However there is currently no source of data to measure this outcome. Routinely available data for inpatient admissions following self-harm miss the majority of cases presenting to services.

We aimed to investigate (i) if a dataset of ED presentations could be produced using a combination of routinely collected clinical and administrative data and (ii) to validate this dataset against another one produced using methods similar to those used in previous studies.

Methods

Using the Clinical Record Interactive Search system, the electronic health records (EHRs) used in four EDs were linked to Hospital Episode Statistics to create a dataset of attendances following self-harm. This dataset was compared with an audit dataset of ED attendances created by manual searching of ED records. The proportion of total cases detected by each dataset was compared.

Results

There were 1932 attendances detected by the EHR dataset and 1906 by the audit. The EHR and audit datasets detected 77 % and 76 % of all attendances respectively and both detected 82 % of individual patients. There were no differences in terms of age, sex, ethnicity or marital status between those detected and those missed using the EHR method. Both datasets revealed more than double the number of self-harm incidents than could be identified from inpatient admission records.

Conclusions

It was possible to use routinely collected EHR data to create a dataset of attendances at EDs following self-harm. The dataset detected the same proportion of attendances and individuals as the audit dataset, proved more comprehensive than the use of inpatient admission records, and did not show a systematic bias in those cases it missed.

Improving the identification of high risk precursor B acute lymphoblastic leukemia patients with earlier quantification of minimal residual disease

The stratification of patients with acute lymphoblastic leukemia (ALL) into treatment risk groups based on quantification of minimal residual disease (MRD) after induction therapy is now well accepted but the relapse rate of about 20% in intermediate risk patients remains a challenge. The purpose of this study was to further improve stratification by MRD measurement at an earlier stage. MRD was measured in stored day 15 bone marrow samples for pediatric patients enrolled on ANZCHOG ALL8 using Real-time Quantitative PCR to detect immunoglobulin and T-cell receptor gene rearrangements with the same assays used at day 33 and day 79 in the original MRD stratification. MRD levels in bone marrow at day 15 and 33 were highly predictive of outcome in 223 precursor B-ALL patients (log rank Mantel-Cox tests both P<0.001) and identified patients with poor, intermediate and very good outcomes. The combined use of MRD at day 15 (≥1×10⁻²) and day 33 (≥5×1⁻⁵) identified a subgroup of medium risk precursor B-ALL patients as poor MRD responders with 5 year relapse-free survival of 55% compared to 84% for other medium risk patients (log rank Mantel-Cox test, P = 0.0005). Risk stratification of precursor B-ALL but not T-ALL could be improved by using MRD measurement at day 15 and day 33 instead of day 33 and day 79 in similar BFM-based protocols for children with this disease.

High-risk childhood acute lymphoblastic leukemia in first remission treated with novel intensive chemotherapy and allogeneic transplantation

Children with acute lymphoblastic leukemia (ALL) and high minimal residual disease (MRD) levels after initial chemotherapy have a poor clinical outcome. In this prospective, single arm, Phase 2 trial, 111 Dutch and Australian children aged 1-18 years with newly diagnosed, t(9;22)-negative ALL, were identified among 1041 consecutively enrolled patients as high risk (HR) based on clinical features or high MRD. The HR cohort received the AIEOP-BFM (Associazione Italiana di Ematologia ed Oncologia Pediatrica (Italy)-Berlin-Frankfurt-Münster ALL Study Group) 2000 ALL Protocol I, then three novel HR chemotherapy blocks, followed by allogeneic transplant or chemotherapy. Of the 111 HR patients, 91 began HR treatment blocks, while 79 completed the protocol. There were 3 remission failures, 12 relapses, 7 toxic deaths in remission and 10 patients who changed protocol due to toxicity or clinician/parent preference. For the 111 HR patients, 5-year event-free survival (EFS) was 66.8% (±5.5) and overall survival (OS) was 75.6% (±4.3). The 30 patients treated as HR solely on the basis of high MRD levels had a 5-year EFS of 63% (±9.4%). All patients experienced grade 3 or 4 toxicities during HR block therapy. Although cure rates were improved compared with previous studies, high treatment toxicity suggested that novel agents are needed to achieve further improvement.

Retroviral vector integration in post-transplant hematopoiesis in mice conditioned with either submyeloablative or ablative irradiation

X-linked chronic granulomatous disease (X-CGD) is an inherited immunodeficiency with absent phagocyte NADPH oxidase activity caused by defects in the gene encoding gp91^phox. Here we evaluated strategies for less intensive conditioning for gene therapy of genetic blood disorders without selective advantage for gene correction, such as might be used in a human X-CGD protocol. We compared submyeloablative with ablative irradiation as conditioning in murine X-CGD, examining engraftment, oxidase activity and vector integration in mice transplanted with marrow transduced with a gamma-retroviral vector for gp91^phox expression. The frequency of oxidase-positive neutrophils in the donor population was unexpectedly higher in many 300 cGy-conditioned mice compared to lethally irradiated recipients, as was the fraction of vector-marked donor secondary CFU-S12. Vector integration sites in marrow, spleen, and secondary CFU-S12 DNA from primary recipients were enriched for cancer-associated genes, including Evi1, and integrations in or near cancer-associated genes were more frequent in marrow and secondary CFU-S12 from 300 cGy-conditioned mice compared to fully ablated mice. These findings support the concept that vector integration can confer a selection bias, and suggest that intensity of the conditioning regimen may further influence the effects of vector integration on clonal selection in post-transplant engraftment and hematopoiesis.

Activation and clinical significance of the unfolded protein response in breast cancer

INTRODUCTION

The tumour microenvironment is hypoglycaemic, hypoxic and acidotic. This activates a stress signalling pathway: the unfolded protein response (UPR). The UPR is cytoprotective if the stressor is mild, but may initiate apoptosis if severe.Activation of the UPR in breast carcinoma is induced by microenvironmental stress such as glucose and oxygen deprivation, but may also be linked to oestrogen stimulation. It may be clinically significant as it may alter chemosensitivity to doxorubicin.

METHODS

395 human breast adenocarcinomas were immunohistochemically stained for UPR activation markers (glucose-regulated protein (GRP-78 and XBP-1). A model of UPR activation in vitro by glucose deprivation of T47D breast cancer cells was developed to determine how the UPR affects cellular sensitivity to doxorubicin and 5-fluorouracil. Cytotoxicity was assessed using a colorimetric cytotoxicity assay (MTT). The effect of oestrogen stimulation and tamoxifen exposure on UPR activation by T47D cells was determined by western blotting measurement of the key UPR protein, GRP-78.

RESULTS

Expression of GRP78 and XBP-1 was demonstrated in 76% and 90% of the breast cancers, respectively, and correlated with oestrogen receptor positivity (P=0.045 and 0.017, respectively). In vitro UPR activation induced resistance to both doxorubicin and 5-flurouracil, (P<0.05). Oestrogen stimulation induced GRP78 and XBP1 over-expression on western blotting. Tamoxifen did not block this response and may induce UPR activation in its own right.

CONCLUSIONS

The UPR is activated in the majority of breast cancers and confers resistance to chemotherapy. In vitro oestrogen stimulates UPR induction. UPR activation may contribute to breast cancer chemoresistance and interact with oestrogen response elements.

Automated analysis of viral integration sites in gene therapy research using the SeqMap web resource

Research in gene therapy involving genome-integrating vectors now often includes analysis of vector integration sites across the genome using methods such as ligation-mediated PCR (LM-PCR) or linear amplification-mediated PCR (LAM-PCR). To help researchers analyze these sites and the functions of nearby genes, we have developed SeqMap (http://seqmap.compbio.iupui.edu/) a secure, web-based comprehensive vector integration site management tool that automatically analyzes and annotates large numbers of vector integration sites derived from LM-PCR experiments in human and model organisms upon a common genome database. We believe the use of this resource will enable better reproducibility and understanding of this important data.

Treatment of urinary incontinence after stroke in adults

BACKGROUND

Urinary incontinence can affect 40-60% of people admitted to hospital after a stroke, with 25% still having problems on hospital discharge and 15% remaining incontinent at one year.

OBJECTIVES

To determine the optimal methods for treatment of urinary incontinence after stroke in adults.

SEARCH STRATEGY

We searched the Cochrane Incontinence and Stroke Groups specialised registers (searched 15 March 2007 and 5 March 2007 respectively), CINAHL (January 1982 to January 2007), national and international trial databases for unpublished data, and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials evaluating the effects of interventions designed to promote continence in people after stroke.

DATA COLLECTION AND ANALYSIS

Data extraction and quality assessment were undertaken by two reviewers working independently. Disagreements were resolved by a third reviewer.

MAIN RESULTS

Twelve trials with a total of 724 participants were included in the review. Participants were from a mixture of settings, age groups and phases of stroke recovery. BEHAVIOURAL INTERVENTIONS: Three trials assessed behavioural interventions, such as timed voiding and pelvic floor muscle training. All had small sample sizes and confidence intervals were wide. SPECIALISED PROFESSIONAL INPUT INTERVENTIONS: Two trials assessed variants of professional input interventions. Results tended to favour the intervention groups: in a small trial in early rehabilitation, fewer people had incontinence at discharge from hospital after structured assessment and management than in a control group (1/21 vs. 10/13; RR 0.06, 95% CI 0.01 to 0.43); in the second trial, assessment and management by Continence Nurse Advisors was associated with fewer participants having urinary symptoms (48/89 vs. 38/54; RR 0.77, 95% CI 0.59 to 0.99) and statistically significantly more being satisfied with care. COMPLEMENTARY THERAPY INTERVENTIONS: Three small trials all reported fewer participants with incontinence after acupuncture therapy (overall RR 0.44; 95% 0.23 to 0.86), but there were particular concerns about study quality. PHARMACOTHERAPY AND HORMONAL INTERVENTIONS: There were three small trials that included groups allocated meclofenoxate, oxybutinin or oestrogen. There were no apparent differences other than in the trial of meclofenoxate where fewer participants had urinary symptoms in the active group than in the control group (9/40 vs. 27/40; RR 0.33, 95% CI 0.18 to 0.62).

AUTHORS' CONCLUSIONS

Data from the available trials are insufficient to guide continence care of adults after stroke. However, there was suggestive evidence that professional input through structured assessment and management of care and specialist continence nursing may reduce urinary incontinence and related symptoms after stroke. Better quality evidence is required of the range of interventions that have been suggested for continence care after stroke.