Frontal sinus stenting in endoscopic sinus surgery: the 10-year Oxford experience

BACKGROUND

Frontal sinus stents have been introduced to reduce frontal sinus re-stenosis after surgery and to improve outcomes.

METHOD

This study was a retrospective analysis of 19 patients who had endoscopic sinus surgery with approach to the frontal sinus and insertion of a soft sinus stent.

RESULTS

The frontal recess was patent in 78.9 per cent and stenosed in 21.1 per cent of patients; no completely closed recesses were observed. Mean follow up was 20.7 months, and time period of stenting was 9.8 months on average; complications were observed in 47.4 per cent of the patients, with post-operative sinonasal infection being the most common.

CONCLUSION

In the authors' experience, indications for frontal sinus stenting include recalcitrant chronic rhinosinusitis after multiple functional endoscopic sinus surgeries (especially in chronic rhinosinusitis with nasal polyps), patients with history of important craniofacial surgery or trauma, and recurrent mucoceles. The stent was overall well tolerated as only minor complications were observed. Close clinical follow up is mandatory.

Hearing Outcomes in Cisplatin or Cetuximab Combined with Radiation for Patients with HPV-Associated Oropharyngeal Cancer in NRG/RTOG 1016

PURPOSE/OBJECTIVE(S)

NRG/RTOG 1016 was a noninferiority phase 3 trial comparing the efficacy of radiation with either cisplatin (RT+Cisp) or cetuximab (RT+Cetux) for patients with HPV+ oropharyngeal cancer (OPC). Perceived hearing handicap was included as a patient-reported outcome (PRO) secondary endpoint. The primary hypothesis was that perceived hearing handicap would be greater for patients receiving RT+Cisp compared to RT+Cetux.

MATERIALS/METHODS

Perceived hearing handicap was measured at baseline, end of treatment, 3, 6, and 12-months post-treatment using the Hearing Handicap Inventory for Adults Screening Version (HHIA-S), a 10-item self-assessment questionnaire designed to measure patients' reactions to their hearing loss. Total HHIA-S scores range from 0 to 40; higher total score indicates more severe perceived hearing handicap. Hearing handicap categories (none, mild/moderate, and severe) were also analyzed. Mixed ordinal logistic models were used to analyze the raw HHIA-S scores and handicap categories (2-sided alpha 0.05).

RESULTS

Participation in the PRO assessments was optional, with 368 patients participating in the hearing PRO. No significant differences in patient/tumor characteristics were found between PRO participants/non-participants. Pre-treatment (mean [SD]) HHIA-S scores were not different for RT+Cisp (3.23 [6.28]) and RT+Cetux (4.77 [8.14]) groups. Post-treatment HHIA-S scores increased for RT+Cisp, and remained stable at the later follow-up time points. RT+Cetux scores remained stable from baseline. Change score from pre- to post-treatment was higher for RT+Cisp (4.32, 95% CI = [2.57, 6.07]) than RT+Cetux (0.08, 95% CI = [-1.15, 1.31]; p < 0.001). For hearing handicap category, post-treatment RT+Cisp had a significantly higher percentage of mild/moderate and severe cases (32%) compared to RT+Cetux (20%). From pre- to post-treatment, worsening of hearing handicap category from normal to mild/moderate or severe was greater for RT+Cisp (24%) than for RT+Cetux (9%). The conditional odds of being in a higher self-perceived hearing handicap category in the RT+Cisp arm were 3.57 (95% CI [2.04, 6.25]) times that in the RT+Cetux arm. Averaging over patients, the marginal odds ratio was 2.46 (95% CI [1.65, 3.66]).

CONCLUSION

Patients receiving concurrent RT+Cisp for HPV-associated OPC have significantly higher odds of worsening self-perceived hearing handicap after treatment than with RT+Cetux. This was consistent across time through one-year post-treatment. These findings inform hearing-related outcomes for patients with HPV-associated OPC.

Diagnostic challenges and prognostic implications of extranodal extension in head and neck cancer: a state of the art review and gap analysis

Extranodal extension (ENE) is a pattern of cancer growth from within the lymph node (LN) outward into perinodal tissues, critically defined by disruption and penetration of the tumor through the entire thickness of the LN capsule. The presence of ENE is often associated with an aggressive cancer phenotype in various malignancies including head and neck squamous cell carcinoma (HNSCC). In HNSCC, ENE is associated with increased risk of distant metastasis and lower rates of locoregional control. ENE detected on histopathology (pathologic ENE; pENE) is now incorporated as a risk-stratification factor in human papillomavirus (HPV)-negative HNSCC in the eighth edition of the American Joint Committee on Cancer (AJCC) and the Union for International Cancer Control (UICC) TNM classification. Although ENE was first described almost a century ago, several issues remain unresolved, including lack of consensus on definitions, terminology, and widely accepted assessment criteria and grading systems for both pENE and ENE detected on radiological imaging (imaging-detected ENE; iENE). Moreover, there is conflicting data on the prognostic significance of iENE and pENE, particularly in the context of HPV-associated HNSCC. Herein, we review the existing literature on ENE in HNSCC, highlighting areas of controversy and identifying critical gaps requiring concerted research efforts.

Prospective 5-Year Analysis of the United States Radiation Oncology Job Market Using the ASTRO Career Center Website

PURPOSE

We provide 5-year results of prospectively collected radiation oncology (RO) job opportunities and a longitudinal assessment of RO graduate numbers within the United States.

METHODS AND MATERIALS

Full-time domestic RO job opportunities were collected and categorized using the American Society for Radiation Oncology (ASTRO) Career Center from July 1, 2016 to June 30, 2021. A chi-square test was used to compare regional job availability by city size and position type. The corresponding number of graduating United States (US) RO residents (2017-2021) was collected. US census and Medicare database resources were used as comparators for population and workforce estimates. Pearson's correlation coefficients were used to examine changes in data over time and a 2-tailed t test was used to assess for statistical significance.

RESULTS

Over the 5-year study period, 819 unique job offers were posted, compared with 935 RO graduates (0.88 total jobs-to-graduates ratio). Most jobs were nonacademic (57.6%), located in populated areas >1 million (57.1%; median: 1.57M), with the largest proportion of jobs seen in the South region (32.4%). One-third of academic jobs were located at satellites. Regional differences were seen between academic versus nonacademic job availability (P < .01), with the highest proportion of academic jobs seen in the Northeast (60.3%) and the lowest in the Midwest (34.5%). Differences between regions were also observed for jobs in areas >1 million versus ≤1 million (P < .01), with the most jobs in areas >1 million seen in the West (64.6%) and the least in the South (51.3%). Regional job availability over time did not differ by position type (academic vs nonacademic) or population area size (P = .11 and P = .27, respectively). Annual graduate numbers increased with time (P = .02), with the highest percentage of graduates trained in the South (30.8%). Regional distribution of jobs versus graduates significantly differed (P < .01) with the lowest jobs-to-graduates ratio observed in the Northeast (0.67) and highest ratio in the West (1.07). Regional RO workforce estimates based on the 4336 radiation oncologists who were Medicare providers in 2020 were compared with total jobs and graduates by region with no difference observed between the distributions of the workforce and jobs (P = .39), but comparisons between the workforce and graduates were proportionally different (P < .01). The number of total jobs (vs graduates) per 10 million population in the Northeast, South, Midwest, and West were 30.2 (45.1), 21.0 (22.7), 30.6 (33.4), and 22.6 (21.2), respectively.

CONCLUSIONS

This multiyear quantitative assessment of the RO job market and graduates identified fewer job opportunities than graduates overall in most regions, most notably in the Northeast. Regional differences were seen between available job type (academic vs nonacademic) and population size (>1 million vs ≤1 million). The findings are worrisome for trainee oversupply and geographic maldistribution. The number and distribution of RO trainees and residency programs across the US should be evaluated to minimize job market imbalance for future graduates, promote workforce stability, and continue to meet the future societal needs of patients with cancer.

Evaluation of a training programme for critical incident debrief facilitators

BACKGROUND

Critical incident debriefs are a commonly used occupational health tool for supporting staff after traumatic work incidents. However, there is a dearth of literature evaluating training programmes for debrief facilitators.

AIMS

To evaluate a 5-day training programme to equip healthcare, social care and voluntary, community and social enterprise sector staff to act as post-incident peer supporters and debrief facilitators.

METHODS

A mixed-methods, single-arm, before-and-after study. Data were collected at baseline and post-training. The quantitative outcome measure was 'Confidence'; the sum of two items measuring confidence in (i) supporting peers after critical incidents and (ii) facilitating post-incident structured team discussions. At post-training, quantitative and qualitative feedback regarding experiences and perceptions of the training was also gathered.

RESULTS

We recruited 45 participants between October 2021 and January 2022. Confidence in supporting peers following incidents and facilitating post-incident structured team discussions increased significantly following the training, t(35) = -6.77, P < 0.001. A majority of participants reported they would do things differently because of the training and that they found the training relevant, useful and engaging. Summative content analysis of qualitative feedback indicated that participants (i) believed the role plays were an important learning tool and (ii) thought it was important that the trainer was engaging. Some participants would have preferred in-person delivery.

CONCLUSIONS

Participants valued training in post-incident peer support and debriefing skills. Organizations implementing post-incident support pathways could usefully include this training and ensure optimal uptake and engagement by (i) providing in-person and online delivery options and (ii) including role play as a learning technique.

The Falkland Islands marine ecosystem: A review of the seasonal dynamics and trophic interactions across the food web

The Falkland Islands marine environment host a mix of temperate and subantarctic species. This review synthesizes baseline information regarding ontogenetic migration patterns and trophic interactions in relation to oceanographic dynamics of the Falkland Shelf, which is useful to inform ecosystem modelling. Many species are strongly influenced by regional oceanographic dynamics that bring together different water masses, resulting in high primary production which supports high biomass in the rest of the food web. Further, many species, including those of commercial interest, show complex ontogenetic migrations that separate spawning, nursing, and feeding grounds spatially and temporally, producing food web connections across space and time. The oceanographic and biological dynamics may make the ecosystem vulnerable to climatic changes in temperature and shifts in the surrounding area. The Falkland marine ecosystem has been understudied and various functional groups, deep-sea habitats and inshore-offshore connections are poorly understood and should be priorities for further research.

An integrated approach to cardioprotection in lymphomas

In potentially curable cancers, long-term survival depends not only on the successful treatment of the malignancy but also on the risks associated with treatment-related toxicity, especially cardiotoxicity. Malignant lymphomas affect patients at any age, with acute and late toxicity risks that could have a severe effect on morbidity, mortality, and quality of life. Although our understanding of chemotherapy-associated and radiotherapy-associated cardiovascular disease has advanced considerably, new drugs with potential cardiotoxicity have been introduced for the treatment of lymphomas. In this Review, we summarise the mechanisms of treatment-related cardiac injury, available clinical data, and protocols for optimising cardioprotection in lymphomas. We discuss ongoing research strategies to advance our knowledge of the molecular basis of drug-induced and radiation-induced toxicity. Additionally, we emphasise the potential for personalised follow-up and early detection, including the role of biomarkers and novel diagnostic tests, highlighting the role of the cardio-oncology team.

Outcomes of Patients with a pH<7.0 Presenting to the Emergency Department (OPpHED Study)

Objectives The aim of this study was to assess the mortality and predictive factors in patients presenting with a pH<7.0 to the emergency department (ED). Methods A retrospective study of patients presenting to the ED of University Hospital Galway with a pH<7.0 from January 2014 to December 2017 was performed. A pH<7.0 on arrival to the ED from either an arterial or venous sample as measured by the blood gas analyser machine were assessed for inclusion. Results A total of 130 patients presented to ED over a 4-year period, with a mean age of 58 ±20 years. Eighty-one (63%) patients of the total cohort were male. In terms of aetiology of presentation, 66 (51%) cases were from cardiac arrest (CA), while the remaining 64 (49%) cases were non-cardiac arrest (NCA) related. Twenty-eight-day mortality was 69.5% overall, with significant mortality in the CA group (89%) compared to the NCA group (48%) (p<0.00). A modified early warning score (MEWS) (odds ratio [OR] 1.37, 95% CI: 1.18-1.59) and PCO2 ([OR] 1.35, 95% CI: 1.08-1.68.) were predictive of mortality. Conclusion In patients presenting to the ED with a pH of <7.0 the overall mortality was 69.5%, with survival more likely in NCA aetiologies. Mortality was associated with higher pCO2 and MEWS.

Human Papillomavirus-Negative Oropharyngeal Cancer Survival Outcomes Based on Primary Treatment: National Cancer Database Analysis

OBJECTIVE

To compare survival outcomes between primary surgery and primary radiation therapy (RT) in patients with human papillomavirus (HPV)-negative oropharyngeal squamous cell carcinoma (OPSCC).

STUDY DESIGN

A retrospective observational cohort study.

SETTING

National Cancer Database.

METHODS

A National Cancer Database review was conducted of 2635 patients with HPV-negative OPSCC who underwent surgery or RT ± chemotherapy between 2010 and 2014. Univariate analysis was performed on all variables and entered into a multivariate model. The main outcome was overall survival (OS).

RESULTS

A total of 2635 patients with HPV-negative OPSCC were organized into 4 groups based on cancer staging. In group 1 (T1-2 N0-1; n = 774), up-front surgery had significantly better 5-year OS (76.2%) than RT (56.8%; adjusted hazard ratio [aHR], 1.76; P = .009; 95% CI, 1.15-2.69) and chemoradiation therapy (CRT; 69.5%; aHR, 1.56; P = .019; 95% CI, 1.08-2.26). In group 2 (T3-4 N0-1; n = 327), no significant difference existed between surgery and CRT (5-year OS, 51.3% vs 52.4%; aHR, 0.96; P = .88; 95% CI, 0.54-1.69). In group 3a (T1-2 N2-3; n = 807), surgery with adjuvant treatment showed significantly better 5-year OS than CRT (78.6% vs 68.8%; aHR, 1.51; P = .027; 95% CI, 1.05-2.18). In group 3b (T3-4 N2-3; n = 737), surgery with adjuvant treatment was not statistically associated with better 5-year OS as compared with CRT (61.0% vs 43.7%; aHR, 1.53; P = .06; 95% CI, 0.98-2.39).

CONCLUSION

Primary surgery may provide improved survival outcomes in many cases of HPV-negative OPSCCs. These data should be used in weighing treatment options and may serve as a basis to better delineate treatment algorithms for HPV-negative disease.

Spontaneous cervical haematoma caused by extracapsular haemorrhage from a parathyroid carcinoma presenting with acute onset neck swelling and dysphonia

We present the case of a 69-year-old male patient who presented with progressive neck swelling causing symptoms of dysphonia and dysphagia. Flexible nasendoscopy revealed bruising of the right hemilarynx, hypopharynx and parapharyngeal mucosal consistent with a spontaneous cervical haematoma. After conservative management, the haematoma self-resolved and the source of the haematoma was thought to be a parathyroid adenoma. Surgical excision was completed, and histopathological assessment revealed a parathyroid carcinoma. Spontaneous cervical haematoma can progress to airway obstruction and the initial focus is to observe for any signs of progression and establish a secure airway if required. The subsequent challenge is to establish the origin of the haematoma and as in this case this can be a diagnostic challenge. This case highlights the diagnostic difficulties of spontaneous cervical haematoma, the importance of comprehensive investigation and the possibility of malignancy preoperatively, especially important when complete excision gives the best opportunity for cure.

RONC-22. SECOND TUMORS IN PEDIATRIC PATIENTS TREATED WITH PROTON THERAPY TO THE CENTRAL NERVOUS SYSTEM

BACKGROUND

Previous institutional data suggests the 10-year cumulative incidence of second tumors is 3% in children treated with photon radiation for central nervous system (CNS) malignancy, with 90% of these tumors occurring in areas receiving ≤36 Gy. Comparative figures for children treated with proton therapy (PT) does not exist.

METHODS

1056 consecutive pediatric patients with a median follow-up of 5.0 years were treated between 2006–2019 with double-scattered PT to a site within the craniospinal axis. 230 patients were ≤3 years old and 14 had neurofibromatosis. A second tumor was defined as any solid neoplasm with histologic features different from the original tumor that had arisen within the irradiated volume.

RESULTS

Five patients developed second tumors resulting in a 5- and 10-year cumulative incidence of 0.2% (95% CI: 0–1.2%) and 1.6% (95% CI: 0.6%-3.9%), respectively. Of those who developed second tumors, median age at radiation was 4.3 years old (range, 2.1 to 5.1 years old) and diagnoses consisted of medulloblastoma (n=2), ependymoma (n=2), and craniopharyngioma (n=1). The second tumors included high grade gliomas (n=3) and high grade sarcoma (n=1) that occurred in regions receiving at least 54 Gy. One patient with neurofibromatosis developed both a low-grade glioma and choroidal melanoma in craniospinal irradiation regions receiving 36 Gy. Four of five patients with second tumors are alive.

CONCLUSION

The reduction in moderate-to-low dose radiation exposure from proton therapy may be associated with a decreased incidence of second tumors in children treated for CNS neoplasms. More follow-up is needed to confirm these findings.

Otological surgery in paediatric photosensitive patients

There are a wide range of genetic and auto-immune conditions where UV light exposure poses a threat of UV irradiation to the external auditory canal, tympanic membrane and surrounding skin. Preoperative Ultraviolet Light (UV) measurements were taken in the operating theatre with standard operating microscope and an approved UV light meter prior to surgery on a patient with xeroderma pigmentosa. UV light meter readings of UV index 75 were taken at an operating distance of 290mm. Proceeding with otological surgery with a high UV index would result in a significant UV radiation burn. Utilising a Dermagard and a specific UV filter applied to the microscope resulted in acceptable UV light readings. We highlight the potential morbidity of otological surgery in paediatric photosensitive conditions. We also recommend a management plan to avoid damage by UV radiation in photosensitive patients.

Variation in water disappearance, daily dose, and synovial fluid concentrations of tylvalosin and 3-O-acetyltylosin in commerical pigs during five day water medication with tylvalosin under field conditions

Tylvalosin (TVN) is a water soluble macrolide used in swine production to treat enteric, respiratory, and arthritic pathogens. There is limited data on its distribution to synovial fluid beyond gavage studies, which do not represent field conditions. This study measured water disappearance, TVN concentration in the medicated water, daily dose, and concentrations of TVN and 3-O-acetyltylosin (3AT) in the synovial fluid and plasma of treated pigs over the administration period. The study emphasized understanding variation in tissue TVN concentrations within the context of a field setting. Sixty finisher pigs were housed individually with individual waterers. Six pigs were randomly allocated to the following time points for sample collection: 0, 48, 60, 72, 84, 96, 102, 108, 114, and 120 hr on medication. TVN was administered daily in the water for 5 days. Water disappearance and medicated water concentration were measured daily. At each time point, six pigs were euthanized and plasma and synovial fluid were collected for analysis. Median TVN synovial fluid concentrations ranged between <1 ng/ml (hour 0) to 3.6 ng/ml (hour 84). There was substantial variation between individual pigs for water disappearance (mean 4.36L and range 0-7.84). Median TVN water concentration was 59 ppm (range 38-75 ppm).

Pulling together and pulling apart: influences of convergence and divergence on distributed healthcare teams

Effective healthcare requires both competent individuals and competent teams. With this recognition, health professions education is grappling with how to factor team competence into training and assessment strategies. These efforts are impeded, however, by the absence of a sophisticated understanding of the the relationship between competent individuals and competent teams . Using data from a constructivist grounded theory study of team-based healthcare for patients with advanced heart failure, this paper explores the relationship between individual team members' perceived goals, understandings, values and routines and the collective competence of the team. Individual interviews with index patients and their healthcare team members formed Team Sampling Units (TSUs). Thirty-seven TSUs consisting of 183 interviews were iteratively analysed for patterns of convergence and divergence in an inductive process informed by complex adaptive systems theory. Convergence and divergence were identifiable on all teams, regularly co-occurred on the same team, and involved recurring themes. Convergence and divergence had nonlinear relationships to the team's collective functioning. Convergence could foster either shared action or collective paralysis; divergence could foster problematic incoherence or productive disruption. These findings advance our understanding of the complex relationship between the individual and the collective on a healthcare team, and they challenge conventional narratives of healthcare teamwork which derive largely from acute care settings and emphasize the importance of common goals and shared mental models. Complex adaptive systems theory helps us to understand the implications of these insights for healthcare teams' delivery of care for the complex, chronically ill.

'Multi-cropping', Intercropping and Adaptation to Variable Environments in Indus South Asia

Past human populations are known to have managed crops in a range of ways. Various methods can be used, singly or in conjunction, to reconstruct these strategies, a process which lends itself to the exploration of socio-economic and political themes. This paper endeavours to unpack the concept of 'multi-cropping' by considering diversity and variation in the cropping practices of the populations of South Asia's Indus Civilisation. It argues that nuanced interpretations of the evidence provided by the combinations of crop seeds and weeds present in specific contexts and phases of occupation can reveal much about Indus cropping strategies, which in turn enables consideration of issues related to adaptation, intensification and resilience in the face of changing social, political, economic and environmental climates.

The Edinburgh Malawi Cancer Partnership: helping to establish multidisciplinary cancer care in Blantyre, Malawi

In response to the growing incidence of cancer in Malawi, a new oncology unit was established at the Queen Elizabeth Central Hospital, Blantyre. The unit opened in 2010, the first in the country, and is led by a single consultant oncologist. In 2012, a healthcare partnership was formed between the oncology and palliative care unit at Queen Elizabeth Central Hospital and the Edinburgh Cancer Centre, UK. The principal objective of the partnership is to help develop high quality multidisciplinary cancer care in Malawi. Methods A needs assessment identified three priority areas for further improvement of cancer services: nurse-led treatment delivery; management of clinical data; and multidisciplinary working. The partnership received grant funding from the Scottish Government Malawi Development Programme in 2013 and a three year project plan was implemented. This has been conducted through a series of reciprocal training visits. Results Key achievements have been completion of a programme of oncology nursing education attended by 32 oncology nurses and other healthcare professionals, which has resulted in increased experience in cancer practice and standardisation of chemotherapy delivery procedures; development of a clinical database that enables prospective collection of data of all new patients with cancer and which links to the Malawi Cancer Registry; development of weekly multidisciplinary meetings involving oncology, gynaecology and surgery that has enabled a cross-specialty approach to patient care. Conclusion The Edinburgh Malawi Cancer Partnership is supporting nursing education, data use and cross-specialty collaboration that we are confident will improve cancer care in Malawi. Future work will focus on the further development of multidisciplinary breast cancer care and the development of a radiotherapy service for patients in Malawi.

Approaching rice domestication in South Asia: New evidence from Indus settlements in northern India

The nature and timing of rice domestication and the development of rice cultivation in South Asia is much debated. In northern South Asia there is presently a significant gap (c.4200 years) between earliest evidence for the exploitation of wild rice (Lahuradewa c.6000 BCE) and earliest dated evidence for the utilisation of fully domesticated rice (Mahagara c.1800 BCE). The Indus Civilisation (c.3000-1500 BCE) developed and declined during the intervening period, and there has been debate about whether rice was adopted and exploited by Indus populations during this 'gap'. This paper presents new analysis of spikelet bases and weeds collected from three Indus Civilisation settlements in north-west India, which provide insight into the way that rice was exploited. This analysis suggests that starting in the period before the Indus urban phase (Early Harappan) and continuing through the urban (Mature Harappan/Harappan), post-urban (Late Harappan) and on into the post-Indus Painted Grey Ware (PGW) period, there was a progressive increase in the proportion of domesticated-type spikelet bases and a decrease in wild-types. This pattern fits with a model of the slow development of rice exploitation from wild foraging to agriculture involving full cultivation. Importantly, the accompanying weeds show no increased proportions of wetland species during this period. Instead a mix of wetland and dryland species was identified, and although these data are preliminary, they suggest that the development of an independent rice tradition may have been intertwined with the practices of the eastern most Indus peoples. These data also suggest that when fully domesticated Oryza sativa ssp. japonica was introduced around 2000 BCE, it arrived in an area that was already familiar with domesticated rice cultivation and a range of cultivation techniques.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Concentrations of tylvalosin and 3-O-acetyltylosin attained in the synovial fluid of swine after administration by oral gavage at 50 and 5 mg/kg

The objectives of this study were to determine the concentration of tylvalosin (TVN) and its metabolite, 3-O-acetyltylosin (3AT) in the synovial fluid of growing pigs when administered as a single bolus by oral gavage at target doses of 50 mg/kg (Trial 1) and 5 mg/kg (Trial 2). TVN is a water soluble macrolide antimicrobial used in swine production. The stability of the drug in synovial fluid samples stored at -70 °C up to 28 days was also evaluated in Trial 2. In Trial 1, eight pigs were randomly assigned to one of eight time points for euthanasia and synovial fluid collection: 0, 1, 2, 3, 4, 6, 9, 12 h postgavage. For Trial 2, 24 pigs were randomly allocated to one terminal collection time point at 0, 2, 4, 6, 8 or 10 h postgavage. Synovial fluid was analyzed to determine TVN and 3AT concentrations. TVN and 3AT were detected in Trial 1 at all time points, except 0 h. At 2 h postgavage for trial 2, the mean concentrations peaked at 31.17 ng/mL (95% CI: 18.62-52.16) for TVN and at 58.82 ng/mL (95% CI: 35.14-98.46) for 3AT. Storage duration did not impact TVN or 3AT concentrations (P-value 0.9732).

Markers to differentiate between Kaposi's sarcoma and tuberculous pleural effusions in HIV-positive patients

BACKGROUND

Kaposi's sarcoma (KS) and tuberculosis (TB) commonly cause pleural effusions in high human immunodeficiency virus (HIV) burden resource-limited countries. Differentiating between them is challenging, as pleural biopsy and TB culture are rarely available.

OBJECTIVES

To identify markers to differentiate between TB effusions and KS effusions in HIV-positive patients, and to compare liquid culture and Xpert MTB/RIF in pleural fluid.

METHODS

Fifty HIV-positive patients with pleural effusions recruited in Malawi underwent pleural ultrasound and aspiration. Fluid visual inspection, cell count, bacterial culture, glucose/protein, solid and liquid TB culture and Xpert were performed.

RESULTS

The mean age of the patients was 32 years; 30/50 (60%) were male and 29 (58%) had cutaneous/oral KS. Thirteen (26%) pleural fluid samples were liquid culture-positive for TB, while 9/13 (69%) were Xpert-positive. Three (10.3%) KS patients had culture-positive TB effusions; 17 (58.6%) had KS effusions. The relative risk of TB in KS patients increased with limited KS, loculated fluid and low glucose. Eleven (52.3%) non-KS patients had culture-positive TB effusions associated with male sex, straw-coloured fluid and fibrin stranding on ultrasound.

CONCLUSIONS

KS patients were most likely to have KS effusion, but TB should be considered. Most non-KS patients had TB, supporting the use of World Health Organization guidelines. Xpert identified two thirds of liquid culture-positive results.

Multiplicity in public health supply systems: a learning agenda

Supply chain integration—merging products for health programs into a single supply chain—tends to be the dominant model in health sector reform. However, multiplicity in a supply system may be justified as a risk management strategy that can better ensure product availability, advance specific health program objectives, and increase efficiency.

First result from the Alpha Magnetic Spectrometer on the International Space Station: precision measurement of the positron fraction in primary cosmic rays of 0.5-350 GeV

A precision measurement by the Alpha Magnetic Spectrometer on the International Space Station of the positron fraction in primary cosmic rays in the energy range from 0.5 to 350 GeV based on 6.8 × 10(6) positron and electron events is presented. The very accurate data show that the positron fraction is steadily increasing from 10 to ∼ 250  GeV, but, from 20 to 250 GeV, the slope decreases by an order of magnitude. The positron fraction spectrum shows no fine structure, and the positron to electron ratio shows no observable anisotropy. Together, these features show the existence of new physical phenomena.

Physician-assessment and physician-enhancement programs in Canada

In the mid-1980s, the licensing authorities in Quebec, Ontario and Manitoba have introduced programs to conduct in-depth assessments of the clinical skills and abilities of physicians with suspected deficiencies. These assessments are intended to supplement the provincial licensing authorities' existing peer review or patient-complaint mechanisms by confirming the physicians' overall level of competence and identifying specific clinical strengths and weaknesses. An "educational prescription", based on the results of the assessment, focuses on aspects of clinical practice in which the physicians need or wish to enhance their skills. In some situations, licensure decisions are based on the assessment information. This article describes the programs in Quebec, Ontario and Manitoba. Each program comprises a different process of personal assessment and individualized continuing medical education to help physicians improve their clinical competence, and each is built on sound principles of clinical competence assessment and educational planning.

The incidence and consequences of early wound infection after internal fixation for trauma in HIV-positive patients

We report a prospective single-blind controlled study of the incidence of early wound infection after internal fixation for trauma in 609 patients, of whom 132 were HIV-positive. Wounds were assessed for healing using the ASEPSIS score. There was no significant difference in the rate of infection between HIV-positive and HIV-negative patients undergoing clean surgery (4.2% vs 6%, respectively; p = 0.65). HIV-positive patients did not receive additional antibiotic prophylaxis or antiretroviral therapy as part of their management. The difference in the rate of infection between HIV-positive and HIV-negative patients with an open fracture or other contamination was not significant (33% vs 15%, respectively; p = 0.064). There was no relationship between CD4 count and infection rate. HIV status did not significantly influence the number of secondary surgical procedures (p = 0.183) or the likelihood of developing chronic osteomyelitis (p = 0.131). Although previous contamination from the time of injury was a risk factor for infection in mal- and nonunions, it was not significantly increased in HIV-positive patients (p = 0.144). We conclude that clean implant surgery in HIV-positive patients is safe, with no need for additional prophylaxis.

Personality predicts individual responsiveness to the risks of starvation and predation

Theory suggests that individual personality is tightly linked to individual life histories and to environmental variation. The reactive-proactive axis, for example, is thought to reflect whether individuals prioritize productivity or survival, mutually exclusive options that can be caused by conflicts between foraging and anti-predation behaviour. Evidence for this trade-off hypothesis, however, is limited. Here, we tested experimentally whether exploration behaviour (EB), an assay of proactivity, could explain how great tits (Parus major) respond to changes in starvation and predation risk. Individuals were presented with two feeders, holding good or poor quality food, which interchanged between safe and dangerous positions 10 m apart, across two 24 h treatments. Starvation risk was assumed to be highest in the morning and lowest in the afternoon. The proportion of time spent feeding on good quality food (PTG) rather than poor quality food was repeatable within treatments, but individuals varied in how PTG changed with respect to predation- and starvation-risk across treatments. This individual plasticity variation in foraging behaviour was linked to EB, as predicted by the reactive-proactive axis, but only among individuals in dominant social classes. Our results support the trade-off hypothesis at the level of individuals in a wild population, and suggest that fine-scale temporal and spatial variation may play important roles in the evolution of personality.

Improving palliative treatment of patients with non-operable cancer of the oesophagus: training doctors and nurses in the use of self-expanding metal stents (SEMS) in Malawi

Cancer of the oesophagus is the 6th most common cancer in Malawi. Nationwide only three hospitals are able to perform oesophagectomies, and there is no radiotherapy or chemotherapy available. Owing to late presentation of the patients (sometimes in combination with co-morbidities such as HIV/AIDS or tuberculosis) the vast majority of patients are not suitable for surgery. Self-expanding metal stents (SEMS) of the oesophagus provide a suitable palliative option to improve the quality of life for patients. This project took a nationwide approach, raising funds for both technical equipment and training of endoscopists and nursing staff throughout Malawi.

Identifying putative candidate genes and pathways involved in immune responses to porcine reproductive and respiratory syndrome virus (PRRSV) infection

Differences in gene expression were compared between RNAs from lungs of high (HR) and low (LR) porcine reproductive and respiratory syndrome virus (PRRSV) burden pigs using the swine protein-annotated long oligonucleotide microarray, the Pigoligoarray. Pathway analyses were carried out to determine biological processes, pathways and networks that differ between the LR and HR responses. Differences existed between HR and LR pigs for 16 signalling pathways [P < 0.01/-log (P-value) >1.96]. Top canonical pathways included acute phase response signalling, crosstalk between dendritic cells and natural killer cells and tight junction signalling, with numerous immune response genes that were upregulated (SOCS1, SOD2, RBP4, HLA-B, HLA-G, PPP2R1A and TAP1) or downregulated (IL18, TF, C4BPA, C1QA, C1QB and TYROBP). One mechanism, regulation of complement activation, may have been blocked in HR (PRRSV-susceptible) pigs and could account for the poor clearance of PRRSV by infected macrophages. Multiple inhibiting signals may have prevented effective immune responses in susceptible HR pigs, although some protective genes were upregulated in these pigs. It is likely that in HR pigs, expression of genes associated with protection was delayed, so that the immune response was not stimulated early; thus, PRRSV infection prevented protective immune responses.

Activation of the bumetanide-sensitive Na+,K+,2Cl- cotransporter (NKCC2) is facilitated by Tamm-Horsfall protein in a chloride-sensitive manner

Active transport of NaCl across thick ascending limb (TAL) epithelium is accomplished by Na(+),K(+),2Cl(-) cotransporter (NKCC2). The activity of NKCC2 is determined by vasopressin (AVP) or intracellular chloride concentration and includes its amino-terminal phosphorylation. Co-expressed Tamm-Horsfall protein (THP) has been proposed to interact with NKCC2. We hypothesized that THP modulates NKCC2 activity in TAL. THP-deficient mice (THP(-/-)) showed an increased abundance of intracellular NKCC2 located in subapical vesicles (+47% compared with wild type (WT) mice), whereas base-line phosphorylation of NKCC2 was significantly decreased (-49% compared with WT mice), suggesting reduced activity of the transporter in the absence of THP. Cultured TAL cells with low endogenous THP levels and low base-line phosphorylation of NKCC2 displayed sharp increases in NKCC2 phosphorylation (+38%) along with a significant change of intracellular chloride concentration upon transfection with THP. In NKCC2-expressing frog oocytes, co-injection with THP cRNA significantly enhanced the activation of NKCC2 under low chloride hypotonic stress (+112% versus +235%). Short term (30 min) stimulation of the vasopressin V2 receptor pathway by V2 receptor agonist (deamino-cis-D-Arg vasopressin) resulted in enhanced NKCC2 phosphorylation in WT mice and cultured TAL cells transfected with THP, whereas in the absence of THP, NKCC2 phosphorylation upon deamino-cis-D-Arg vasopressin was blunted in both systems. Attenuated effects of furosemide along with functional and structural adaptation of the distal convoluted tubule in THP(-/-) mice supported the notion that NaCl reabsorption was impaired in TAL lacking THP. In summary, these results are compatible with a permissive role for THP in the modulation of NKCC2-dependent TAL salt reabsorptive function.

Corrosion Mechanisms of Spent Fuel Under Oxidizing Conditions

The release of99Tc can be used as a reliable marker for the extent of spent oxide fuel reaction under unsaturated high-drip-rate conditions at 90°C. Evidence from leachate data and from scanning and transmission electron microscopy (SEM and TEM) examination of reacted fuel samples is presented for radionuclide release, potential reaction pathways, and the formation of alteration products. In the ATM-103 fuel, 0.03 of the total inventory of99Tc is released in 3.7 years under unsaturated and oxidizing conditions. Two reaction pathways that have been identified from SEM are 1) through-grain dissolution with subsequent formation of uranyl alteration products, and 2) grain-boundary dissolution. The major alteration product identified by X-ray diffraction (XRD) and SEM, is Na-boltwoodite, Na[(UO2)(SiO3OH)]H20, which is formed from sodium and silicon in the water leachant.

A prospective randomized, controlled trial of intravenous versus oral iron for moderate iron deficiency anaemia of pregnancy

BACKGROUND

Iron deficiency anaemia is the most common deficiency disorder in the world, affecting more than one billion people, with pregnant women at particular risk.

OBJECTIVES AND DESIGN

We conducted a single site, prospective, nonblinded randomized-controlled trial to compare the efficacy, safety, tolerability and compliance of standard oral daily iron versus intravenous iron.

SUBJECTS

We prospectively screened 2654 pregnant women between March 2007 and January 2009 with a full blood count and iron studies, of which 461 (18%) had moderate IDA. Two hundred women matched for haemoglobin concentration and serum ferritin level were recruited.

INTERVENTIONS

Patients were randomized to daily oral ferrous sulphate 250 mg (elemental iron 80 mg) with or without a single intravenous iron polymaltose infusion.

RESULTS

Prior to delivery, the intravenous plus oral iron arm was superior to the oral iron only arm as measured by the increase in haemoglobin level (mean of 19.5 g/L vs. 12 g/L; P < 0.001); the increase in mean serum ferritin level (222 microg/L vs. 18 ug/L; P < 0.001); and the percentage of mothers with ferritin levels below 30 microg/L (4.5% vs. 79%; P < 0.001). A single dose of intravenous iron polymaltose was well tolerated without significant side effects.

CONCLUSIONS

Our data indicate that intravenous iron polymaltose is safe and leads to improved efficacy and iron stores compared to oral iron alone in pregnancy-related IDA.