Oral Health Advice for Looked-After-Children: A pilot care pathway in Buckinghamshire, UK

INTRODUCTION

Looked-After-Children (LAC) frequently are more likely to have untreated dental caries, periodontal diseases or dental trauma (McMahon et al., 2018). The COVID-19 pandemic reduced the availability of dental appointments, including for LAC. This initiative piloted the inclusion of a dental pathway into the existing LAC care pathway in Buckinghamshire. The key principle was providing oral health messaging around maintaining good oral health and preventing disease in these children by training those involved with their care.

METHODS

A working group was convened, which included dental public health, clinical and training expertise. A care pathway was developed with resources drawn from existing programmes including mini Mouth Care Matters (mMCM). The care pathways were designed to identify children who needed care urgently due to pain or discomfort, signpost them to the relevant/most appropriate providers and provide oral health improvement advice for everyone. Local partners were engaged to ensure that the processes and training were appropriate. A pilot training session was then carried out for a range of staff engaged in the care of LAC within Buckinghamshire.

RESULTS

The pilot dental pathway, launched in March 2022, initiative was welcomed by all stakeholders, including dental commissioners. The pilot training session received positive feedback from participants, with requests for more sessions. Training sessions were subsequently translated into video sessions, accessible when needed, for new staff or as refresher sessions.

CONCLUSION

There are opportunities to reduce future inequalities for these children by inculcating positive behaviours early in their care journey. This will reduce their need for care. Identifying and implementing the most appropriate initiatives requires collaboration and commitment from all stakeholders.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Reactivation of mutant p53 by a dietary-related compound phenethyl isothiocyanate inhibits tumor growth

Mutations in the p53 tumor-suppressor gene are prevalent in human cancers. The majority of p53 mutations are missense, which can be classified into contact mutations (that directly disrupts the DNA-binding activity of p53) and structural mutations (that disrupts the conformation of p53). Both of the mutations can disable the normal wild-type (WT) p53 activities. Nevertheless, it has been amply documented that small molecules can rescue activity from mutant p53 by restoring WT tumor-suppressive functions. These compounds hold promise for cancer therapy and have now entered clinical trials. In this study, we show that cruciferous-vegetable-derived phenethyl isothiocyanate (PEITC) can reactivate p53 mutant under in vitro and in vivo conditions, revealing a new mechanism of action for a dietary-related compound. PEITC exhibits growth-inhibitory activity in cells expressing p53 mutants with preferential activity toward p53^R175, one of the most frequent ‘hotspot' mutations within the p53 sequence. Mechanistic studies revealed that PEITC induces apoptosis in a p53^R175 mutant-dependent manner by restoring p53 WT conformation and transactivation functions. Accordingly, in PEITC-treated cells the reactivated p53^R175 mutant induces apoptosis by activating canonical WT p53 targets, inducing a delay in S and G2/M phase, and by phosphorylating ATM/CHK2. Interestingly, the growth-inhibitory effects of PEITC depend on the redox state of the cell. Further, PEITC treatments render the p53^R175 mutant sensitive to degradation by the proteasome and autophagy in a concentration-dependent manner. PEITC-induced reactivation of p53^R175 and its subsequent sensitivity to the degradation pathways likely contribute to its anticancer activities. We further show that dietary supplementation of PEITC is able to reactivate WT activity in vivo as well, inhibiting tumor growth in xenograft mouse model. These findings provide the first example of mutant p53 reactivation by a dietary compound and have important implications for cancer prevention and therapy.

Quality of life measurement in cancer patients receiving palliative radiotherapy for symptomatic lung cancer: a literature review

Approximately 27% of North American cancer deaths are attributable to cancer of the lung. Many lung cancers are found at an advanced stage, rendering the tumours inoperable and the patients palliative. Common symptoms associated with palliative lung cancer include cough, hemoptysis, and dyspnea, all of which can significantly debilitate and diminish quality of life (QOL). In studies of the effects of cancer therapies, the frequent evaluative endpoints are survival and local control; however, it is imperative that clinical trials with palliative patients also have a QOL focus when a cure is unattainable. We conducted a literature review to investigate the use of QOL instrument tools in trials studying QOL or symptom palliation of primary lung cancer or lung metastases through the use of radiotherapy. We identified forty-three studies: nineteen used a QOL tool, and twenty-four examined symptom palliation without the use of a QOL instrument. The European Organization for Research and Treatment of Cancer (eortc) QLQ-C30 survey was the most commonly used QOL questionnaire (in thirteen of twenty trials). Of those thirteen studies, eight also incorporated the lung-specific QOL survey eortc QLQ-LC13 (or the eortc QLQ-LC17). A second lung-specific survey, the Functional Assessment of Cancer Therapy-Lung (fact-L) was used in only two of the twenty trials. In total, only ten of forty-three trials (23%) used a lung-specific QOL tool, suggesting that QOL was of low priority as an endpoint and that measures created for lung cancer patients are underused. We encourage investigators in future trials to include specific QOL instruments such as the eortc QLQ-LC13 or the fact-L for studies in palliative thoracic radiotherapy because those instruments provide a measure of QOL specific to patients with lung cancer or lung metastases.

Radiotherapy for oncologic emergencies on weekends: examining reasons for treatment and patterns of practice at a Canadian cancer centre

Purpose

Radiotherapy for oncologic emergencies is an important aspect of the management of cancer patients. These emergencies—which include malignant spinal cord compression, brain metastases, superior vena cava obstruction, and uncontrolled tumour hemorrhage —may require treatment outside of hospital hours, particularly on weekends and hospital holidays. To date, there remains no consensus among radiation oncologists regarding the indications and appropriateness of radiotherapy treatment on weekends, and treatment decisions remain largely subjective. The main aim of the present study was to document the incidence and indications for patients receiving emergency treatment on weekends or scheduled hospital holidays at a single institution. The secondary aim was to investigate the compliance of such treatment with the institution’s quality assurance policies, both local and provincial.

Methods

From September 1, 2002, to September 30, 2004, patients being treated over weekends (defined as commencing at 6 pm on a Friday and concluding at 8 am of the next scheduled workday) and hospital holidays were retrospectively identified using the Oncology Patient Information System scheduling module. Relevant patient data—including patient age, sex, primary cancer site, specific radiation field, rationale for treatment, referring hospital, total treatment dose, radiation dose fractionation, inpatient or outpatient status, and duration of treatment—were collected and subsequently analyzed. Comparison to local policy was performed subjectively.

Results

Over the 2-year period, 161 patients were prescribed urgent radiotherapy over a weekend or on a hospital holiday. Of this cohort, 68% were treated on both Saturday and Sunday, 22% on Saturday alone, and 10% on Sunday alone. Most patients presented with lung (31%), prostate (18%), and breast cancer (17%). The top reasons for referral for emergency weekend treatment included spinal cord compression (56%), brain metastases (15%), and superior vena cava obstruction (6%). Most of the indications for treatment generally followed the quality assurance policies implemented both locally and provincially.

Conclusions

Patients treated over a weekend or on a hospital holiday were generally found to be treated with appropriate intent. Most treatment indications within this study both complied with provincial policy and showed a pattern of care similar to that seen in other studies in the literature. Local policy appears to be robust; however, policy improvements may allow for more cohesiveness across radiation oncologists in patterns of care in this important group of patients. Comparisons with practice at other institutions would be valuable and also a key step in developing sound guidelines for all members of the radiotherapy community to follow.

Demographic profile and utilization statistics of a Canadian inpatient palliative care unit within a tertiary care setting

Background

Canadian data describing inpatient palliative care unit (pcu) utilization are scarce. In the present study, we performed a quality assessment of a 24-bed short-term pcu with a 3-months-or-less life expectancy policy in a tertiary care setting.

Methods

Using a retrospective chart review, we explored wait time (wt) for admission (May 2005 to April 2006), length of stay [los (February 2005 to January 2006)], and patient demographics.

Results

The wt data showed 508 referrals, with 242 resulting in admissions (92% malignant diagnoses) and 266 not (82% malignant). The most common malignancies in both groups were gastrointestinal, lung, and genitourinary. Median wt for admitted patients was 6 days, varying with referral source, such as the same hospital, home, or another hospital (6, 4, and 8.5 days respectively). Most admissions (93%) occurred in 21 or fewer days. Patient death (52%), admission to another pcu (25%), and declined offer (10%) were common reasons for no admission. Median los for 219 admitted patients was 19 days (range: 0–249 days). Most patients (94%) died in the pcu; a minority were discharged.

Conclusions

Many patients requiring pcu services are admitted within a few days of referral, especially patients with the least available support: those at home. However, half of the non-admitted patients die while waiting—a potential area for improvement. The los for admitted patients complied with the 3-month “expected lifespan” pcu policy. Results are significant, because ensuring quality of life for palliative care patients includes timely pcu access and sufficient los to address end-of-life needs.

Percutaneous cementoplasty of lytic metastasis in left acetabulum

Minimally invasive procedures such as percutaneous cementoplasty can provide immediate pain relief and can restore mechanical stability for patients with bone metastases who are not candidates for surgery or who show resistance to radiotherapy or analgesic treatment. Here, we examine a case of percutaneous cementoplasty to treat a lytic lesion of the acetabulum from breast cancer. Good filling was observed, and no complications occurred. A research assistant recorded the patient’s scores on the Karnofsky Performance Scale, Townsend Functional Assessment Scale, and Brief Pain Inventory before surgery and at days 1, 2, and 4 and weeks 1, 2, and 4 post-procedure. Improvement in pain and walking ability was demonstrated within the first 48 hours of treatment, and that improvement remained constant throughout follow-up. These findings echo the literature, in that percutaneous cementoplasty provides immediate and long-term pain relief with few complications. We recommend that percutaneous cementoplasty be used as an additional tool for palliative treatment of patients with bone metastases.

New multidisciplinary prostate bone metastases clinic: first of its kind in Canada

Prostate cancer is the most common non-skin malignancy in men. Almost all men who die from prostate cancer have hormone-refractory prostate cancer with metastasis to bone. Emerging supportive treatments—including chemotherapy, bisphosphonates, and surgery—require integration that is optimized in a multidisciplinary setting. A multidisciplinary clinic for bone metastases has been in place at Toronto–Sunnybrook Regional Cancer Centre since 1999, combining orthopedic surgery, radiation oncology, interventional radiology, and palliative medicine for all patients with bone metastases. The addition of a prostate-focused multidisciplinary clinic integrates these services for patients with advanced prostate cancer.

Radiation recall dermatitis: case report and review of the literature

"Radiation recall"-also called "radiation recall dermatitis"-has been defined as the "recalling" by skin of previous radiation exposure in response to the administration of certain response-inducing drugs. Although the phenomenon is relatively well known in the medical world, an exact cause has not been documented. Here, we report a rare occurrence of the radiation recall phenomenon in a breast cancer patient after palliative radiotherapy for bone, brain, and orbital metastases.

Change in urinary markers of osteoclast activity following palliative radiotherapy for bone metastases

AIMS

To examine the effect of radiotherapy for bone metastases on urinary markers of osteoclast activity.

MATERIALS AND METHODS

Patients with radiological evidence of bone metastases planned for palliative radiotherapy were eligible for the study. A urine specimen was collected before and 1 month after radiotherapy to assess levels of calcium, creatinine, magnesium, phosphate, N-telopeptide and pyridinoline. The Brief Pain Inventory was completed in person at baseline and by telephone follow-up at 1 month after radiotherapy. Patients were classified as responders (complete or partial pain response) or non-responders (stable or progressive pain) to radiotherapy based on the International Bone Metastases Consensus Criteria for end point measurements. Absolute values of urine markers were compared between responders and non-responders, or between responders and patients with progression.

RESULTS

Our study population consisted of 74 men and 51 women. A single 8 Gy or 20 Gy in five daily fractions were commonly employed. At the 1 month follow-up, all Brief Pain Inventory functional interference scores showed a highly significant decrease from baseline (P<0.01). From our study population, 58 (64%) were classified as responders and 57 (46%) as non-responders to radiotherapy. We compared the urinary markers between the responders and the non-responders. There were no statistically significant differences between the two groups either in terms of baseline markers or in terms of month 1 follow-up markers. There was no significant change from baseline to the 1 month follow-up in responders or in non-responders to radiotherapy.

CONCLUSION

Baseline levels of urinary markers could not predict which patient would benefit from palliative radiotherapy.

Brain Metastasis from an Unknown Primary, or Primary Brain Tumour? A Diagnostic Dilemma

Brain metastasis is increasingly common, affecting 20%–40% of cancer patients. After diagnosis, survival is usually limited to months in these patients. Treatment for brain metastasis includes whole-brain radiation therapy, surgical resection, or both. These treatments aim to slow progression of disease and to improve or maintain neurologic function and quality of life. Although less common, primary brain tumours produce symptoms that are similar to those of brain metastasis. Glioblastoma, the most common malignant tumour of the brain, has a median survival of less than 12 months. Patients are often treated with surgical resection followed by radical radiation therapy and chemotherapy. Here, we present 2 separate cases of lesions in the brain radiologically compatible with brain metastasis. In both cases, no primary cancer site had been established, and neurosurgical intervention was sought to obtain a pathologic diagnosis. Both cases were pathologically confirmed as glioblastoma. These cases demonstrate the importance of differentiation between brain metastases and primary brain tumours to ensure that the appropriate management strategy is implemented.

After radiotherapy, do bone metastases from gastrointestinal cancers show response rates similar to those of bone metastases from other primary cancers?

PURPOSE

Reports investigating whether the response rates to palliative radiation therapy (RT) for painful bone metastases from gastrointestinal (GI) cancers are similar to rates for bone metastases from other primary cancer sites have been limited. The present study evaluated response rates for symptomatic bone metastases from gi cancers after palliative outpatient rt in the Rapid Response Radiotherapy Program (RRRP).

PATIENTS AND METHODS

We identified 69 patients with bone metastases from gi primaries who received palliative rt in the RRRP clinic during 1999-2006. We extracted records for 31 of these patients during 1999-2003 from an RRRP database that used the Edmonton Symptom Assessment Scale (ESAS). Record for the remaining 38 patients during 2003-2006 were extracted from an RRRP database that used the Brief Pain Inventory (BPI). Eligibility criteria for encryption in the two RRRP databases and for collection of patient demographic information (age, sex, primary cancer site, and Karnofsky performance status) were identical. Response rates for this cohort of metastatic gi patients were then compared to rates for 479 patients receiving palliative RT for bone metastases from other primary cancer sites. Pain scores from the ESAS and BPI and data on analgesic consumption were collected at baseline and by telephone follow-up at 4, 8, and 12 weeks after RT for all patients. Complete (CR), partial (PR), and overall (CR+PR) responses were evaluated according to International Consensus Endpoints.

RESULTS

Assessment of the 69 patients with metastatic GI cancers revealed CR, PR, and CR+PR rates of 18%, 42%, and 61% at 4 weeks; 22%, 35%, and 57% at 8 weeks; and 50%, 21%, and 71% at 12 weeks for evaluable patients. The 479 evaluable patients with metastatic cancer from other primary cancer sites had CR, PR, and CR+PR rates of 25%, 27%, and 51% at 4 weeks; 26%, 22%, and 48% at 8 weeks; and 22%, 29%, and 51% at 12 weeks. No statistically significant differences were observed in RT response rates for bone metastases from GI cancers than from other primary cancer sites.

CONCLUSIONS

After palliative RT, bone metastases from gi cancers demonstrate response rates that are similar to rates for metastases from other primary cancer sites. Patients with symptomatic bone metastases from GI malignancies should be referred for palliative RT as readily as patients with osseous metastases from other primary cancer sites.

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

AIMS

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Improving community knowledge of obstetric fistula prevention and treatment

In recent years, information has emerged in the scientific literature regarding the experience of physicians and clinical staff who try to prevent and treat obstetric fistulas at health facilities in developing countries. However, little is known about attempts to match the services they provide with policy and programmatic interventions in the communities they serve. To determine what is known about community involvement in the prevention and treatment of obstetric fistulas, the authors inquired into experiments carried out by EngenderHealth and partners in 15 African and Asian countries. From raw data, gray literature, and personal communications with those working in the field, they learned that engaging the community may be the keystone in the eradication of fistulas in low-resource settings, and they learned how to engage the community.

Solitary bone metastasis beneath the shoulder shield: coincidence or cause?

Post-mastectomy radiotherapy has been demonstrated to improve locoregional control in breast cancer patients. We report a case involving a 44-year-old breast cancer patient who presented with a solitary bone metastasis in the area beneath the shoulder shield, likely from a coincidental recurrence.

Solitary Bone Metastasis beneath the Shoulder Shield: Coincidence or Cause?

Post-mastectomy radiotherapy has been demonstrated to improve locoregional control in breast cancer patients. We report a case involving a 44-year-old breast cancer patient who presented with a solitary bone metastasis in the area beneath the shoulder shield, likely from a coincidental recurrence.

The do-not-resuscitate order: incidence of documentation in the medical records of cancer patients referred for palliative radiotherapy

Patients with symptomatic metastases referred for outpatient palliative radiotherapy for symptom control at the Rapid Response Radiotherapy Program (RRRP) and the Bone Metastases Clinic (BMC) at the Toronto-Sunnybrook Regional Cancer Centre have a limited life expectancy. Relevant medical information is missing from the files of many referred patients when they arrive at the clinics, potentially causing delayed treatment and ambiguity in the best management of their needs in situations of worsening condition. Clear documentation of the do-not-resuscitate (DNR) order is imperative to avoid panic and the taking of unnecessarily aggressive measures in situations in which cardiopulmonary resuscitation (CPR) has no benefit or is not desired. Here, we report the current practices of CPR code status documentation for patients referred to the RRRP and the BMC for out-patient palliative radiotherapy.We reviewed referral notes and accompanying medical records for 209 consecutive patients seen in the RRRP and the bmc during May-August 2004 for documentation of CPR-related advance directives. Patient demographics and cancer history were also recorded.Only 13 (6.2%) of the 209 patients had any documented reference to CPR code status. Of these 13 patients, 8 were DNR-coded, and 5 were full code. As compared with patients having no documented cpr code status, patients with documented status were significantly older (median age: 77 years; p = 0.0347), had poorer performance status (median Karnofsky performance status score: 40; p = 0.0001), and were more likely to be referred hospital inpatients (69%, p = 0.0004).Only a small proportion of symptomatic advanced cancer patients had any documentation of CPR code status upon referral for outpatient palliative radiotherapy. In future, our clinics plan to request information about CPR code status on our referral form.

An innovative rapid response radiotherapy program to reduce waiting time for palliative radiotherapy

BACKGROUND

Waiting for radiation therapy (RT) in Ontario has been a major problem for the past decade. In 1996, the Toronto-Sunnybrook Regional Cancer Centre (TSRCC) initiated a Rapid Response Radiotherapy Program (RRRP) to provide timely palliative RT for symptom relief of patients with terminal cancer.

PURPOSE

This study reviews the clinical activity of the RRRP over the past 8 years to evaluate if we are meeting the objectives of the program.

MATERIALS AND METHODS

From the TSRCC oncology patient information system (OPIS) database, we retrieved the number of patients referred to the RRRP, their demographics, diagnosis and treatment for the calendar years 1996 to 2003 inclusive. We calculated the time interval between referral to consultation, consultation to simulation and the percentage of cases who started RT on their initial consultation for all new cases referred to the RRRP.

RESULTS

From 1996 to 2003, the number of cases seen in consultation increased from just over 200 cases annually in the first 2 years to about 500 cases per year in the last 4 years, for a total of 3,290. There were 1,792 (54%) men and 1,498 (46%) women; median age was 69 years (range, 21-95 years). Breast, lung, genitourinary and gastrointestinal primaries accounted for over 80% of all referrals. The majority was referred for palliative treatment of symptomatic bone (70%) or brain (14%) metastases. The dose fractionation for bone metastases was a single 8-Gy fraction in 45%, 20 Gy in five fractions in 42%, 30 Gy in ten fractions in 4% and other dose fractionations in 9%. Nearly 90% were seen within 2 weeks of referral (38% within 1 week). Eighty-five percent were simulated on the day of their initial consultation. Sixty percent started their RT treatment on the day of their consultation visit. The overall median interval from referral to treatment was 8 days.

CONCLUSION

Over the past 8 years, the annual number of new cases referred to the RRRP has doubled. The overall median interval from referral to consultation was 8 days. Sixty percent were simulated, planned and started treatment on the day of their initial consultation. We therefore are meeting our goal of providing rapid access to palliative RT for symptomatic cancer patients.

Use of overlapping peptide mixtures as antigens for cytokine flow cytometry

Intracellular cytokine staining and flow cytometry can be used to measure T-cell responses to defined antigens. Although CD8+ T-cell responses to soluble proteins are inefficiently detected by this approach, peptides can be used as antigens. Using overlapping peptides spanning an entire protein sequence, CD8+ T-cell responses can be detected to multiple epitopes, regardless of HLA type. In this study, overlapping peptide mixes of various lengths were compared and 15 amino acid peptides with 11 amino acid overlaps were found to stimulate both CD4+ and CD8+ T-cell responses. Such peptide mixes stimulated CD4+ T-cell responses equivalent to those observed with whole recombinant protein, while simultaneously stimulating CD8+ T-cell responses much higher than those observed with whole protein. Although 8-12 amino acid peptides produced the highest level of CD8+ T-cell responses, 15 amino acid peptides were still very effective. Peptides that were 20 amino acids in length, however, did not stimulate strong CD8+ T-cell responses at the same peptide dose. The cytokine responses to individual epitopes added up approximately to the response to the entire mix, demonstrating that large mixes can detect responses in a quantitative fashion. Unlike whole protein antigens, peptide mixes were effective at stimulating responses in both cryopreserved PBMC and blood stored for 24 h at room temperature. Thus, overlapping 15 amino acid peptide mixes may facilitate the analysis of antigen-specific CD4+ and CD8+ T-cell responses by cytokine flow cytometry, using clinical specimens that include shipped blood or cryopreserved PBMC.

Training programs in school consultation

The need to train psychiatrists in school consultation is important to approach mental health and psychosocial concerns from the broad perspective of addressing barriers to learning and promoting healthy development. There is a major national impetus to improve academic achievement and literacy, which can be amplified by addressing the social, emotional, and mental health needs of children and youth. Training in school consultation allows the psychiatrist to better understand a critical institution in each child's life and also provides technical assistance and training to school personnel, which facilitates networking between programs and individuals involved in or interested in school mental health. Each of the described programs approaches consultation from a specific focus that varies in time commitment, placement options, and frequency and order of didactic presentations. There is no conclusive available evidence as to which program is most effective, since such evaluation depends on the overall goals of the consultation program itself.

The nef gene products of both simian and human immunodeficiency viruses enhance virus infectivity and are functionally interchangeable

Adult rhesus macaques infected with nef-defective simian immunodeficiency virus (SIV) exhibit extremely low levels of steady-state virus replication, do not succumb to immunodeficiency disease, and are protected from experimental challenge with pathogenic isolates of SIV. Similarly, rare humans found to be infected with nef-defective human immunodeficiency virus type 1 (HIV-1) variants display exceptionally low viral burdens and do not show evidence of disease progression after many years of infection. HIV-1 Nef induces the rapid endocytosis and lysosomal degradation of cell surface CD4 and enhances virus infectivity in primary human T cells and macrophages. Although expression of SIV Nef also leads to down-modulation of cell surface CD4 levels, no evidence for SIV Nef-induced enhancement of virus infectivity was observed in earlier studies. Thus, it remains unclear whether fundamental differences exist between the activities of HIV-1 and SIV Nef. To establish more clearly whether the SIV and HIV-1 nef gene products are functionally analogous, we compared the replication kinetics and infectivity of variants of SIVmac239 that either do (SIVnef+) or do not (SIV delta nef) encode intact nef gene products. SIVnef+ replicates more rapidly than nef-defective viruses in both human and rhesus peripheral blood mononuclear cells (PBMCs). As previously described for HIV-1 Nef, SIV Nef also enhances virus infectivity within each cycle of virus replication. As a strategy for evaluating the in vivo contribution of HIV-1 nef alleles and long terminal repeat regulatory sequences to the pathogenesis of immunodeficiency disease, we constructed SIV-HIV chimeras in which the nef coding and U3 regulatory regions of SIVmac239 were replaced by the corresponding regions from HIV-1/R73 (SIVR7nef+). SIVR7nef+ displays enhanced infectivity and accelerated replication kinetics in primary human and rhesus PBMC infections compared to its nef-defective counterpart. Converse chimeras, containing SIV Nef in an HIV-1 background (R7SIVnef+) also exhibit greater infectivity than matched nef-defective viruses (R7SIV delta nef). These data indicate that SIV Nef, like that of HIV-1, does enhance virus replication in primary cells in tissue culture and that HIV-1 and SIV Nef are functionally interchangeable in the context of both HIV-1 and SIV.

Immunohistochemical changes and PCR detection of HIV provirus DNA in brains of asymptomatic HIV-positive patients

The stage of HIV infection at which the virus enters the nervous system remains poorly understood. Examination of brains of HIV-positive non-AIDS patients often shows lymphocytic meningitis, myelin pallor and gliosis, but no immunohistochemical (IHC) evidence of the virus. In this study we have examined a number of brains from HIV-positive patients with (23) and without (8) AIDS as well as brains from 5 HIV-negative controls by morphological, morphometric, IHC and polymerase chain reaction (PCR) methods in an attempt to establish at what stage of the infection HIV can be detected in the brain and to correlate its presence with the pathological changes in the cortex. HIV-1 proviral DNA was found by PCR in the cortex of the majority of AIDS and in 2 out of 8 non-AIDS cases. Astroglial reaction was observed in the cortex of the majority of AIDS brains but not in most of the non-AIDS brains which showed, in addition, a dramatic reduction of glial fibrillary acidic protein staining around blood vessels; moreover, in this group the density of microglial cells was higher than in the AIDS group. These results show that: 1) HIV proviral DNA can be found in the brains of HIV-positive non-AIDS patients; 2) in the same group there is an increase in density of microglial cells which 3) appears to be transient, since AIDS brains without neuropathology show a lower density of these cells. They also suggest that the status of 'immune reaction' existing in AIDS may predate this period.(ABSTRACT TRUNCATED AT 250 WORDS)

Visualisation of arterial structure in vivo with intravascular ultrasound

BACKGROUND

Contrast angiography provides a silhouette of the arterial lumen, but does not give information about arterial wall structure. Catheter-tip ultrasound transducers can now provide a cross-sectional image of the arterial wall. This study examined the pathological correlation of intravascular ultrasound images and the accuracy of ultrasound measurements of vascular geometry.

METHODS

Intravascular ultrasound images were obtained with a mechanically rotated catheter-tip transducer and recorded on videotape. Initial validation studies were performed in fresh, post-mortem arterial specimens, which were filled with saline at physiological pressures. Ultrasound images at specific sites were compared with the pathological findings at that site and measurements of luminal diameter were compared with corresponding angiographic measurements. Subsequently, intravascular ultrasound was employed to examine the aorta, ilio-femoral and coronary arteries in patients undergoing balloon angioplasty.

RESULTS

The pathological correlations showed that intravascular ultrasound can detect early initial thickening and mild atherosclerotic lesions that do not result in luminal deformation. Ultrasound images provided definition of calcified, fibrotic and lipid-filled lesions. Ultrasound measurements of luminal diameter correlated well with pathology measurements (r = 0.93), as did ultrasound measurements of plaque area (r = 0.89). The in vivo studies demonstrated that intravascular ultrasound can define atheroma lesions not evident on contrast angiography and permits detailed evaluation of the results of interventions such as balloon angioplasty.

CONCLUSIONS

Intravascular ultrasound provides a unique window upon arterial structure and pathology in humans. Ultrasound images allow accurate measurements of vascular geometry and define early atheromatous lesions that are not evident with angiography.

Impaired joint mobility in Guillain-Barré syndrome: a primary or a secondary phenomenon?

Three patients with Guillain-Barré syndrome had significant residual impairment of joint mobility. Pain in the limbs and axial skeleton was a prominent early feature, as were autonomic disturbances and bulbar involvement resulting in prolonged mechanical ventilation. All three patients developed marked joint stiffness and contractures despite having physiotherapy from the outset. The skeletal problems and complications became major components of disability despite improving neurological status.

Varicella-zoster virus encephalitis in acquired immunodeficiency syndrome: report of four cases

Four patients with acquired immunodeficiency syndrome, a 27-year-old female intravenous drug abuser and three males (two drug addicts aged 27 and 33 years and a 40-year-old homosexual) presented with a rapidly progressive encephalopathy. Two had generalized varicella-zoster virus skin infection, one had had a regressive thoracic zoster rash 7 months previously and one had no history of cutaneous eruption. Neuropathological examination revealed, in each case, multifocal necrotic changes with numerous, intranuclear Cowdry type A inclusion bodies in glial cells, endothelial cells, macrophages and neurons, within and around the lesions. These inclusion bodies were stained positively for varicella-zoster virus by immunocytochemistry and contained herpes virus nucleocapsids by electron microscopy. Molecular biology using the polymerase-chain-reaction method demonstrated viral genome. In one case, zoster-induced non-inflammatory vasculopathy involved medium sized leptomeningeal vessels and was associated with circumscribed areas of cortico-subcortical infarction. In another case, varicella-zoster virus encephalitis was associated with human immunodeficiency virus encephalitis and a secondary cerebral lymphoma. Multinucleated giant cells expressing human immunodeficiency virus proteins in their cytoplasm, were found in the lymphomatous deposits and in the varicella-zoster virus necrotic lesions. In these latter lesions, Cowdry type A inclusion bodies could be seen in the nuclei of some multinucleated giant cells confirming previous observations of MGCs co-infected by HIV and CMV, and supporting the hypothesis that DNA viruses interact with HIV, thus increasing its effect.

Detection of HIV proviral DNA in cortex and white matter of AIDS brains by non-isotopic polymerase chain reaction: correlation with diffuse poliodystrophy

OBJECTIVE

(1) To determine whether detection of HIV proviral DNA sequences in the cerebral cortex correlates with the presence of pathological changes in this region, believed to contribute to the HIV-associated cognitive/motor complex. (2) To compare the frequency with which HIV infects cortical and subcortical regions of the brain.

DESIGN

In vitro studies on HIV neurotoxicity suggest that HIV may be involved in the pathogenesis of cortical damage, recently defined as diffuse poliodystrophy (DPD) in AIDS. Previous detection of HIV antigen has localized HIV more frequently to subcortical than to cortical regions. It is not known whether HIV preferentially infects subcortical tissues or if viral expression varies in these two regions.

METHODS

HIV antigen and proviral DNA sequences were detected in anterior frontal lobe tissues using immunohistochemistry (IHC) and the polymerase chain reaction (PCR), respectively. DPD was assessed by staining with antibodies against astrocytes (GFAP) and microglia/macrophages (HAM 56).

RESULTS

HIV proviral DNA was detected in nine out of 15 cortical samples and in 10 out of 15 white matter samples, whilst HIV p24 antigen was localized to the cortex in three out of 15 and to the white matter in seven out of 15 cases. DPD was found in 10 cases, although in five a different aetiology may have been involved. However, DPD was present in eight out of the nine cases in which HIV proviral DNA was detected in the cortex.

CONCLUSIONS

Using a non-isotopic PCR method, HIV was detected in the brains of more cases than would be expected on the basis of IHC detection, and was present in the cortex as frequently as in the white matter. HIV, together with other factors, may contribute to the pathogenesis of DPD.

The pathology of the posterior root ganglia in AIDS and its relationship to the pallor of the gracile tract

The spinal cord and the thoracic and lumbar posterior root ganglia (PRGs) of 14 HIV-positive men and 7 age- and sex-matched controls were studied by routine histology, morphometric analysis of the number of nodules of Nageotte (nN) and the diameters of sensory ganglion cells, immunohistochemistry and in situ hybridization. In 7 patients (2 of whom had evidence of cytomegalovirus ganglionitis) there were increased numbers of nN and diffuse, mild infiltration with CD45R+ T lymphocytes; no B lymphocytes were observed. Macrophages were increased in number in all cases. Whenever more than one ganglion was examined from the same patient, the appearances were similar in all. There was no alteration in the distribution of ganglion cell diameters. Changes in the spinal cord included vacuolar myelopathy (5 cases), HIV myelitis (1 case), microglial nodules (3 cases) and pallor of the gracile tracts (GTP) in 7 cases, in 6 of whom it co-existed with increased numbers of nN. Seven cases had no abnormalities, except the increase in number of macrophages in PRGs. In spite of a correlation between sensory nerve cell loss and GTP our findings suggest that other mechanisms, such as 'dying back' may contribute to the pathogenesis of GTP. Moreover, sensory disturbances were found most commonly in association with nerve cell loss; however, loss of sensory ganglion cells was not necessarily associated with evidence of sensory impairment.

Special education placements of language-disordered children in a psychiatric population

Children evaluated by an interdisciplinary team that provided data on psychiatric disturbance, language handicaps, and psychoeducational assessment were placed in special education classes following the complete evaluation. Discriminant analysis as a special case of multiple regression analysis determined that mean reading achievement score, pre-evaluation classroom placement, and to a lesser degree, Performance IQ predicted classroom placement. Overall, correct classroom predictions approached 90 percent. These findings highlight the value of interdisciplinary evaluation to educators and mental health professionals.

HIV encephalopathy presenting as hypomania

Images

Macrophages in human sensory ganglia: an immunohistochemical and ultrastructural study

The paper describes the immunohistochemical and ultrastructural features of normal posterior root ganglia in a group of humans aged 1 day to 80 years and compares the findings with those seen in the ganglia of normal rats of various ages, some of which underwent permanent traumatic lesions of the sciatic nerve. In humans, cells with the immunohistochemical reactions of macrophages are present in small number at birth, most of them having an endoneurial position. Subsequently, their number increases and more of them are seen around neurons, where their processes intermingle with those of satellite cells. Ultrastructural studies confirm that, in addition to interstitial cells, a small number of cells in satellite position have features of mesenchymal cells. In this respect, human sensory ganglia differ from those of rodents and this difference may explain why no nodules of Nageotte can be found either in ageing animals or after a permanent damage to the nerve has produced considerable cell loss. Other features observed in human ganglia, but absent in rats, are multiple layers of satellite cells surrounding each neuron and desmosome-like structures between satellite cell processes. Previous studies describing maturation of the satellite-nerve cell complex in animals are confirmed. In addition, the present investigation shows that, in human ganglia, satellite cells acquire a more elaborate structure than in rodents. It is also suggested that mesenchymal cells may play a role in the trophism of nerve cells and their removal after irreversible damage.