Acute Gastrointestinal and Genitourinary Toxicity Results from a Prospective Randomized Phase II Trial Evaluating Adjuvant Pelvic Radiotherapy Using Either IMRT or 3-Dimensional Planning for Endometrial Cancer

PURPOSE/OBJECTIVE(S)

To compare the incidence of grade ≥2 gastrointestinal (GI) or genitourinary (GU) toxicity for patients undergoing 3DRT versus IMRT in the post-operative setting for endometrial cancer.

MATERIALS/METHODS

Patients were post-operatively enrolled in a prospective randomized phase II trial from 2010 to 2020. Those eligible were adults aged ≥18 scheduled to receive adjuvant pelvic radiotherapy (RT) for histologically confirmed endometrial carcinoma with the following AJCC 2009 grade/stage: Grade 2: stage IB (LVSI +/or >60 yrs); Grade 3: stage IA and IB; or Grade 1-3: Stage II and IIIA, IIIB and IIIC1; who had an ECOG-PS 0-2, and who had surgery consisting of total hysterectomy, +/- bilateral salpingo-oophorectomy, +/- lymph node sampling. Exclusion criteria included previous irradiation to the pelvic region, patients in whom concurrent chemotherapy was planned, a history of inflammatory bowel disease, and previous bowel surgery. Patients were randomly assigned to one of two parallel groups in 1:1 ratio, to have their RT delivered using either a 3DRT technique or using IMRT. Prescription dose was 45 Gy in 25 fractions over 5 weeks followed by 11 Gy in 2 fractions vaginal vault brachytherapy. Toxicity was graded according to CTCAE ver. 3.0. Acute toxicity was assessed weekly during RT. Fisher's exact tests were used to test for associations between toxicity and arm. Differences in dosimetric parameters for patients with or without toxicity were tested using Mann-Whitney U-tests.

RESULTS

Ninety-two patients with a median age of 63 were enrolled, with 8 patients not evaluable for primary outcome. The median follow-up was 52 months. 14 (35%) participants from the 3DRT arm and 15 (34%) from the IMRT arm experienced acute grade ≥2 GI toxicity. 20 (50%) participants from the 3DRT arm and 25 (57%) from the IMRT arm experienced acute grade ≥2 GI or GU toxicity (p = .662). Grade 3 GI toxicity was 5 (12%) and 4 (9%) for 3DRT and IMRT, respectively. 12 (30%) patients from the 3DRT arm and 17 (39%) from the IMRT arm experienced acute grade ≥2 GU toxicity (p = .493). Rates for grade 3 GU toxicity were 4 (10%) and 4 (9%) for 3DRT and IMRT, respectively. Those with acute grade ≥2 GU toxicity had a median PTV D99% of 43.2 Gy (35.5-44.6) compared with a median of 43.4 Gy (41.5-44.6; p = 0.042) for those who did not have a grade ≥2 GU toxicity.

CONCLUSION

No statistically significant differences in the incidence of acute GI or GU toxicity were found between patients treated with adjuvant IMRT versus 3DRT radiotherapy for endometrial cancer. Although IMRT can reduce dose to normal tissue, in this study no benefit in acute toxicity outcome was seen.

Prototyping Apps for the Management of Sleep, Fatigue, and Behavioral Health in Austere Far-Forward Environments: Development Study

BACKGROUND

Military service inherently includes frequent periods of high-stress training, operational tempo, and sustained deployments to austere far-forward environments. These occupational requirements can contribute to acute and chronic sleep disruption, fatigue, and behavioral health challenges related to acute and chronic stress and disruption of team dynamics. To date, there is no centralized mobile health platform that supports self- and supervised detection, monitoring, and management of sleep and behavioral health issues in garrison and during and after deployments.

OBJECTIVE

The objective of this study was to adapt a clinical decision support platform for use outside clinical settings, in garrison, and during field exercises by medics and soldiers to monitor and manage sleep and behavioral health in operational settings.

METHODS

To adapt an existing clinical decision support digital health platform, we first gathered system, content, and context-related requirements for a sleep and behavioral health management system from experts. Sleep and behavioral health assessments were then adapted for prospective digital data capture. Evidence-based and operationally relevant educational and interventional modules were formatted for digital delivery. These modules addressed the management and mitigation of sleep, circadian challenges, fatigue, stress responses, and team communication. Connectivity protocols were adapted to accommodate the absence of cellular or Wi-Fi access in deployed settings. The resulting apps were then tested in garrison and during 2 separate field exercises.

RESULTS

Based on identified requirements, 2 Android smartphone apps were adapted for self-monitoring and management for soldiers (Soldier app) and team supervision and intervention by medics (Medic app). A total of 246 soldiers, including 28 medics, received training on how to use the apps. Both apps function as expected under conditions of limited connectivity during field exercises. Areas for future technology enhancement were also identified.

CONCLUSIONS

We demonstrated the feasibility of adapting a clinical decision support platform into Android smartphone-based apps to collect, save, and synthesize sleep and behavioral health data, as well as share data using adaptive data transfer protocols when Wi-Fi or cellular data are unavailable. The AIRE (Autonomous Connectivity Independent System for Remote Environments) prototype offers a novel self-management and supervised tool to augment capabilities for prospective monitoring, detection, and intervention for emerging sleep, fatigue, and behavioral health issues that are common in military and nonmilitary high-tempo occupations (eg, submarines, long-haul flights, space stations, and oil rigs) where medical expertise is limited.

Associations of health care staff burnout with negative health and organizational outcomes in the U.S. military health system

RATIONALE

Burnout is a personal and occupational phenomenon that has been associated with negative physical and psychological outcomes in medical staff. Additionally, there are implications for healthcare organizations, as those staff who are burned out are more likely to have lower productivity or leave the organization. As with the Covid-19 pandemic, future national emergencies and potentially large-scale conflicts will require similar and likely even larger scale responses from the U.S. Military Health System, thus it is important to understand burnout in this population so that the readiness of the staff and the military can remain at a high level.

OBJECTIVE

This assessment was designed to examine levels of burnout among United States Military Health System (MHS) staff working at Army installations and the factors that influence the development of burnout.

METHODS

Anonymous data was collected from 13,558 active-duty U.S. Soldiers and civilian MHS employees. Burnout was measured using the Copenhagen Burnout Inventory and the Mini-Z.

RESULTS

Results showed nearly half of staff who responded (48%) reported being burned out, an increase since last measured in 2019 (31%). Factors related to increased burnout included concerns about work/life balance and workload, low job satisfaction and feeling disconnected from others. Burnout was associated with increases in adverse physical and behavioral health (BH) outcomes.

CONCLUSIONS

Results indicate that burnout is a common problem across MHS Army staff and is related to significant adverse health consequences for the individual and reduced retention of staff for the organization. These findings highlight the need to address burnout through policies that standardize health care delivery policies and practices, providing support to leadership to promote a healthy workplace, and individual support to those who experience burnout.

Implementation of 26 Gy in five fractions over 1 week adjuvant radiotherapy for breast cancer: Prospective report of acute skin toxicity and consideration of resource implications

PURPOSE

In March 2020, a 1-week adjuvant breast radiotherapy schedule, 26 Gy in 5 fractions, was adopted to reduce the risk of COVID19 for staff and patients. This study quantifies acute toxicity rates and the effect on linac capacity.

MATERIALS AND METHODS

This is a report of consecutive patients receiving ultrafractionated breast radiotherapy ( ± sequential boost) Mar-Aug 2020. Virtual consultations assessed acute skin toxicity during treatment and weeks 1, 2, 3 and 4 post treatment using CTCAE V5 scoring criteria. The number of linac minutes saved was estimated accounting for boost and DIBH use.

RESULTS

In total, 128/135 (95%) patients, including 31/33 boost patients, completed at least 3/5 assessments. 0/128 (0%) reported moist desquamation not confined to skin folds or minor bleeding (Grade 3), 41/128 (32%) reported brisk erythema, moist desquamation confined to skin folds or breast swelling (Grade 2), 62/128 (48%) reported faint erythema or dry desquamation (Grade 1) as their worst skin toxicity, with the remaining 20% reporting no skin toxicity. The highest prevalence of grade 2 toxicity occurred week 1 following treatment (20%), reducing to 3% by week 4. There was no difference in toxicity between those who received a boost versus not (p = 1.00). Delivering this schedule to 135 patients over six months saved 21,300 linac minutes and 1485 hospital visits compared to a 3-week schedule.

CONCLUSION

Rapidly implementing ultrahypofractionated breast radiotherapy is feasible and acute toxicity rates are acceptable even when followed by boost.

0341 Digital Health Technology to Support Autonomous Sleep Monitoring and Management in Multi-Domain Operational (MDO) Environments

Introduction

Sleep and fatigue management strategies can substantially impact the Armed Forces’ readiness and fitness. These strategies can be implemented with behavioral health personnel and Wi-Fi connectivity to support real-time assessment, monitoring, and intervention. However, these resources are not readily available in multi-domain operational (MDO) environments. An autonomous Wi-Fi-independent digital sleep and fatigue management tool (DSFMT) could offer a critical advantage in detecting, monitoring, and providing just-in-time sleep and fatigue recommendations for Soldiers and support unit performance. We describe how we adapted a validated sleep-focused clinical decision support platform into a DSFMT for use in MDO environments.

Methods

Semi-structured interviews were conducted with 6 Army Key Opinion Leaders (KOLs) to assess perceived utility of a DSFMT and identify key requirements. We also conducted a literature review to identify evidence-based sleep optimization and fatigue mitigation strategies in real or simulated military environments, or occupations with high sleep disruption. Directives for sleep and fatigue management from all branches of the U.S. Armed Forces were reviewed.

Results

KOLs were enthusiastic about the proposed DSFMT and emphasized three requirements: (1) brief and actionable content; (2) tap into Soldiers’ competitive nature; (3) provide unit level metrics to the medic. Five sleep education topics (e.g., consequences of insufficient sleep) and eight evidence-based sleep self-optimization strategies (e.g., sleep banking) were identified and included in the digital content. The resulting DSFMT consists of a smartphone-based Soldier App that captures self-reported sleep and fatigue data and offers individualized feedback and self-management strategies, and a Medic App that displays aggregate unit-level sleep and fatigue status. The apps operate when connected to Wi-Fi and have capabilities for offline data collection and transfer via Bluetooth.

Conclusion

We created an initial prototype of an autonomous Wi-Fi-independent DSFMT that can be used in MDO environments and meets KOL requirements. 246 Soldiers have field tested this prototype. Findings from ongoing acceptability and feasibility analyses will inform the next iteration.

Support (If Any)

This project is partially funded by MTEC-19-02-TeleSleep-001-2019-406. The opinions and assertions contained herein are those of the authors and do not necessarily reflect the views of the U.S. Army or the U.S. Department of Defense.

Proton pump inhibitors and histamine-2 receptor antagonists on the risk of pancreatic cancer: a systematic review and meta-analysis

BACKGROUND

Proton pump inhibitors (PPI) and histamine-2 receptor antagonists (H2RA) have been widely used for multiple purposes. Recent studies have suggested an association between these medications and the risk of pancreatic cancer. However, the results have been inconclusive.

AIM

We, therefore, conducted a study to assess the risk of developing pancreatic cancer in patients who used PPI and H2RA.

DESIGN

A systematic review and meta-analysis.

METHODS

A literature search was performed using MEDLINE and EMBASE databases from inception through February 2019. Studies that reported risk ratio comparing the risk of pancreatic cancer in patients who received PPI or H2RA versus those who did not receive treatments were included. Pooled risk ratios (RR) and 95% confidence intervals (CI) were calculated using a random-effect generic inverse variance method. Sensitivity analysis, excluding one study at a time, was performed.

RESULTS

After screening abstracts from the searching methods, seven studies (six case-control studies and one cohort study) were included in the analysis with total 546 199 participants. Compared to patients who did not take medications, the pooled RR of developing pancreatic cancer in patients receiving PPI and H2RA were 1.73 (95% CI: 1.16-2.57) and 1.26 (95% CI: 1.02-1.57), respectively. However, the sensitivity analysis of PPI changed the pooled RR to 1.87 (95% CI: 1.00-3.51) after a study was dropped out. Likewise, H2RA sensitivity analysis also resulted in non-significant pooled RR.

CONCLUSIONS

This meta-analysis did not find the strong evidence for the associations between the use of PPI and H2RA and pancreatic cancer.

Prescription opioid use among individuals with serious mental illness

Prevalence and correlates of prescription opioid use were explored in individuals with serious mental illness (SMI) by examining a sample of adults from two inner city community psychiatry clinics. Of 271 participants, 12.9% (n = 35) were on a prescribed opioid. Being on an opioid was significantly associated with history of heroin use and active prescription sedative-hypnotic use, including benzodiazepine use. Concurrent use of opioids with sedative-hypnotics was significantly associated with suicidal ideation. The results highlight risks of prescription opioid use in those with SMI, particularly in combination with prescription sedative-hypnotics.

Abstract P3-10-16: Competing mortality risks: Cardiovascular risk versus risk of metastatic disease in breast cancer patients receiving adjuvant therapy

Background

Breast cancer is the most commonly diagnosed cancer in women in Ireland. The 5 year net survival is over 80%. Most women diagnosed with breast cancer do not die from the disease and instead cardiovascular disease (CVD) remains the most frequent cause of death. Many breast cancer patients are older and have established CVD risk factors. They are at further risk of a cardiovasular (CV) event due to exposure to anthracyclines, HER2 targeted agents, endocrine therapy and radiotherapy. In this study, we aimed to compare the 10 year risk of breast cancer mortality versus that of a CV event or death in an oncology day ward population at our centre through the use of online prognostic risk calculators. Furthermore, we sought to investigate the predicted outcome of lifestyle changes on their overall CV risk and level of interest in addressing these risk factors.

Methods

This was a cross cohort study of all breast cancer patients attending for adjuvant chemotherapy at our institution from September 2015 to September 2016. To calculate patients' 10 year CVD risk, we used the JBS3 online calculator. Using this calculator we could also predict patient's lifetime CV risk. To calculate patients' 10 year mortality risk from breast cancer we used NHS predict! These calculators incorporate several variables which we identified from chart review, the use of questionnaires and the performance of a serum lipid test.

Results

101 subjects were identified. All patients (pts) completed questionnaires. Eighteen pts were excluded from CV risk analysis due to lack of lipid profile. Of 83 pts, 83% (n=69) were >50 years of age and 17% (n=14) pts were <50 years of age. The median age in the >50 age group (grp) was 59 and 42 in the <50 age grp. The median BMI in the >50 and <50 grp was 29.2 and 26.4 respectively. Forty-two percent (n=29) of pts in the >50 grp were smokers/ex smokers and 49% (n=7) were in the <50 grp. Twenty-nine percent (n=20) in the >50 grp were on statins and 25% (n=17) were on antihypertensives. Fifty-two percent (n=36) of pts in the >50 grp and 66% (n=10) received anthracyclines. Fifty percent in both grps received left sided radiotherapy. Ninety five percent (n=63) were on endocrine therapy in the >50 grp and 93% (n=13) in the <50 grp. Forty-one percent in the >50 grp (n=28) and 29% (n=4) of patients in the <50 grp received Trastuzumab. In the >50 grp, 13% (n=9) were found to have a high 10 year cardiovascular risk (>20% risk of CV event) and 28% were found to be at moderate risk (n=19). Ten percent of patients were found to have a CV risk that exceeded their breast cancer mortality risk (n=7). Even though the 10 year CV risk was low in patients <50, their median lifetime risk was calculated at 52%. Eighty seven percent of pts were interested in receiving advice on reducing their cardiovascular risk. The predicted median 10 year cardiovascular risk of age>50 patients in the high risk group post CV risk modification was 8.8% (+/-5.6) versus 28% (+/-8) at baseline.

Conclusion

This patient population has significant CV risk factors at baseline. Benefits predicted with CV risk intervention model and significant patient interest indicates that formalised CV risk prevention strategy is needed.

Citation Format: Prior L, Featherstone H, Nugent K, Lim M, Kelly C. Competing mortality risks: Cardiovascular risk versus risk of metastatic disease in breast cancer patients receiving adjuvant therapy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-10-16.

Heritability of complex white matter diffusion traits assessed in a population isolate

INTRODUCTION

Diffusion weighted imaging (DWI) methods can noninvasively ascertain cerebral microstructure by examining pattern and directions of water diffusion in the brain. We calculated heritability for DWI parameters in cerebral white (WM) and gray matter (GM) to study the genetic contribution to the diffusion signals across tissue boundaries.

METHODS

Using Old Order Amish (OOA) population isolate with large family pedigrees and high environmental homogeneity, we compared the heritability of measures derived from three representative DWI methods targeting the corpus callosum WM and cingulate gyrus GM: diffusion tensor imaging (DTI), the permeability-diffusivity (PD) model, and the neurite orientation dispersion and density imaging (NODDI) model. These successively more complex models represent the diffusion signal modeling using one, two, and three diffusion compartments, respectively.

RESULTS

We replicated the high heritability of the DTI-based fractional anisotropy (h(2)  = 0.67) and radial diffusivity (h(2)  = 0.72) in WM. High heritability in both WM and GM tissues were observed for the permeability-diffusivity index from the PD model (h(2)  = 0.64 and 0.84), and the neurite density from the NODDI model (h(2)  = 0.70 and 0.55). The orientation dispersion index from the NODDI model was only significantly heritable in GM (h(2)  = 0.68).

CONCLUSION

DWI measures from multicompartmental models were significantly heritable in WM and GM. DWI can offer valuable phenotypes for genetic research; and genes thus identified may reveal mechanisms contributing to mental and neurological disorders in which diffusion imaging anomalies are consistently found. Hum Brain Mapp 37:525-535, 2016. © 2015 Wiley Periodicals, Inc.

Persistent and Unusual Respiratory Findings after Prolonged Glutaraldehyde Exposure

Glutaraldehyde is commonly used in endoscopy labs to clean and disinfect instruments. It can cause direct irritation of the skin and the upper and lower airways. Health care workers are also at risk for the development of irritant-induced or sensitizer-induced occupational asthma when exposed to this chemical. Herein, we report on a patient who had frequent exposures to glutaraldehyde over one year while working in an endoscopy lab and developed chronic upper and lower respiratory tract symptoms. Multiple spirometric tests during her evaluation revealed variable results including restrictive pattern with a response to bronchodilators, obstructive pattern with a paradoxic bronchoconstrictive response to bronchodilators, and obstructive pattern with a partial response to bronchodilators. These results indicate that the distribution of inflammation and bronchial responsiveness can vary in a single patient with glutaraldehyde-induced occupational asthma. Therefore, the evaluation may be more difficult than might be expected in patients with occupational asthma, and some patients will need multiple pulmonary function tests to characterize their airway disease.

Perfusion shift from white to gray matter may account for processing speed deficits in schizophrenia

Reduced speed of cerebral information processing is a cognitive deficit associated with schizophrenia. Normal information processing speed (PS) requires intact white matter (WM) physiology to support information transfer. In a cohort of 107 subjects (47/60 patients/controls), we demonstrate that PS deficits in schizophrenia patients are explained by reduced WM integrity, which is measured using diffusion tensor imaging, mediated by the mismatch in WM/gray matter blood perfusion, and measured using arterial spin labeling. Our findings are specific to PS, and testing this hypothesis for patient-control differences in working memory produces no explanation. We demonstrate that PS deficits in schizophrenia can be explained by neurophysiological alterations in cerebral WM. Whether the disproportionately low WM integrity in schizophrenia is due to illness or secondary due to this disorder deserves further examination.

Multimodal white matter imaging to investigate reduced fractional anisotropy and its age-related decline in schizophrenia

We hypothesized that reduced fractional anisotropy (FA) of water diffusion and its elevated aging-related decline in schizophrenia patients may be caused by elevated hyperintensive white matter (HWM) lesions, by reduced permeability-diffusivity index (PDI), or both. We tested this hypothesis in 40/30 control/patient participants. FA values for the corpus callosum were calculated from high angular resolution diffusion tensor imaging (DTI). Whole-brain volume of HWM lesions was quantified by 3D-T2w-fluid-attenuated inversion recovery (FLAIR) imaging. PDI for corpus callosum was ascertained using multi b-value diffusion imaging (15 b-shells with 30 directions per shell). Patients had significantly lower corpus callosum FA values, and there was a significant age-by-diagnosis interaction. Patients also had significantly reduced PDI but no difference in HWM volume. PDI and HWM volume were significant predictors of FA and captured the diagnosis-related variance. Separately, PDI robustly explained FA variance in schizophrenia patients, but not in controls. Conversely, HWM volume made equally significant contributions to variability in FA in both groups. The diagnosis-by-age effect of FA was explained by a PDI-by-diagnosis interaction. Post hoc testing showed a similar trend for PDI of gray mater. Our study demonstrated that reduced FA and its accelerated decline with age in schizophrenia were explained by pathophysiology indexed by PDI, rather than HWM volume.

Leflunomide-induced interstitial lung disease (a systematic review)

BACKGROUND

Leflunomide, a disease modifying anti-rheumatic drug in use since 1998, causes interstitial lung disease (ILD) and other pulmonary complications.

METHODS

We undertook a systematic review of literature of PubMed (March 2013) to identify the published literature pertaining to pulmonary toxicity associated with leflunomide.

RESULTS

We identified 41 relevant articles detailing four population studies and case reports/series on an additional 42 patients. Available data were reviewed and summarized.

CONCLUSIONS

Leflunomide can cause ILD. Most of these patients present within three months of starting leflunomide with acute symptoms for a week or less. Bilateral ground glass opacities and diffuse alveolar damage are the most common radiologic and histopathologic findings, respectively. Patients with pre-existing ILD are particularly at risk for this complication, and leflunomide should be avoided in this population. Activated charcoal and cholestyramine significantly decrease the half-life of the drug because of its enterohepatic circulation and should be considered in cases with acute toxicity.

Persistent respiratory symptoms following prolonged capsaicin exposure

Capsaicin causes direct irritation of the eyes, mucous membranes, and respiratory tract. It is used in self-defense, in crowd control, and as a less lethal weapon in police work. Controlled trials suggest that capsaicin has minimal serious acute effects. Herein, we report a woman who had a 20-minute exposure to capsaicin during a jail riot. She subsequently developed episodic dyspnea and cough, and increased sensitivity to scents, perfumes, and cigarette smoke. She has not had wheezes on physical examination or abnormal pulmonary function tests. Her response to inhaled steroids and long-acting beta-agonists has been incomplete. She appears to have developed airway sensory hyperreactivity syndrome after the inhalation of capsaicin, which likely injured sensory nerves and/or caused persistent neurogenic inflammation.

Use and safety of conducted electronic devices: what is known?

Conductive electronic devices (CED), such as Taser and stun guns, are sold worldwide for use by security services, although they have also been used for self-defence and even for torture. CED are promoted as non-lethal weapons which can potentially save lives. However, there are multiple reports of deaths temporally associated with CED use. These weapons have definite physiological effects in normal volunteers, especially when accompanied by exertion. Medical examiners often report that deaths followed physical encounters which included the use of CED were due to natural causes, excited delirium and/or drug intoxication. These cases present complex situations in which multiple factors potentially contribute to the death, including electric shocks which cause neuromuscular incapacitation, severe pain and anxiety. Public health officials, physicians and hospital personnel need to be aware that individuals controlled with CED are at increased risk of death. We need better recording of incidents worldwide to understand the extent and outcomes of CED use.

Factors affecting chronic obstructive pulmonary disease early rehospitalization

The Centers for Medicare and Medicaid Services has identified early rehospitalization of patients with chronic obstructive pulmonary disease (COPD) exacerbations as a performance measure for hospital care. We retrospectively reviewed patients with COPD who were admitted to University Medical Center, Lubbock, Texas, USA, between October 2010 and March 2011. There were 81 COPD patients with 103 hospitalizations. The mean age was 73.9 years. Pulmonary function tests using the Global initiative for chronic Obstructive Lung Disease criteria had been done in 36 patients (44.4%) and revealed 1 mild (2.8%), 7 moderate (19.4%), 20 severe (55.6%), and 8 very severe (22.2%) cases. Only 38.4% of the patients had prior influenza vaccine. Most patients were treated with antibiotics (81.8%) and corticosteroids (87.9%). The mean length of stay was 4.9 days, and 4 patients died. Most of the patients were discharged home (63.6%) with a median follow-up interval of 14 days. Thirty-two percent did not have long-acting bronchodilators and/or inhaled corticosteroids prescribed on discharge. There were 14 early rehospitalizations within 30 days. Logistic regression analysis indicated that a history of coronary artery disease (odds ratio (OR) 6.4, 95% confidence interval (CI) 1.1–37.4) and unilateral pulmonary infiltrates (OR 12.8, 95% CI 1.9–86.4) significantly increased the early rehospitalization rates. Acute exacerbations of COPD in patients with a history of ischemic heart disease or unilateral pulmonary infiltrates are at increased risk for early readmission. These risk factors should be identified during hospitalization; early follow-up or other interventions may reduce readmissions. Influenza vaccine, maintenance bronchodilators and/or inhaled corticosteroids, and pulmonary function tests were underused, and these standards of care should be provided to improve care.

STARR with Contour Transtar: prospective multicentre European study

OBJECTIVE

The stapled transanal rectal resection (STARR) in patients with defecation disorders is limited by the shape and capacity of the circular stapler. A new device has been recently developed, the Contour Transtar stapler, in order to improve the safety and effectiveness of the STARR technique. The study has been designed to confirm this declaration.

METHOD

From January to June 2007 a prospective European multicentre study of consecutive patients with defecation disorder caused by internal rectal prolapse underwent the new STARR technique. The assessment of perioperative morbidity and functional outcome after 6 weeks, 3 and 12 months was documented by different scores.

RESULTS

In all 75 patients, median age 64, the Transtar procedure was performed with 9% intraoperative difficulties, 7% postoperative complications and no mortality. The mean reduction of the ODS score was -15.6 (95%-CI: -17.3 to -13.8, P < 0.0001), mean reduction of SSS was -12.6 (95%-CI: -14.2 to -11.2; P < 0.0001). 41% stated improvement of their continence status by CCF score, only 4 patients (5%) had deterioration.

CONCLUSION

The Transtar procedure is technically demanding, with good functional results similar to the conventional STARR.

Postextubation pulmonary edema: a case series and review

We report a series of patients with postextubation pulmonary edema who had no obvious risk factors for the development of this syndrome.

METHODS

Patients identified by the pulmonary consultation service at an academic medical center were reviewed.

RESULTS

Fourteen cases were collected and analyzed. The average age was 34.5 years; 12 patients were male. The average BMI was 25.5. None had documented previous lung disease. Most operations were scheduled as outpatient procedures, and the type of surgery ranged from an incision and drainage of a bite wound to an open reduction-internal fixation of the radius. None of the patients had upper airway surgery. The length of surgeries ranged from 27 to 335 min. Laryngospasm was the most commonly identified obstructing event postextubation. Treatment involved airway support when needed, supplemental oxygen, and diuretics.

CONCLUSIONS

It would appear that all patients, especially young men, are at risk for the development of this syndrome and that the pathogenesis remains uncertain in many cases.

X-ray phase imaging: Demonstration of extended conditions for homogeneous objects

We discuss contrast formation in a propagating x-ray beam. We consider the validity conditions for linear relations based on the transport-of-intensity equation (TIE) and on contrast transfer functions (CTFs). From a single diffracted image, we recover the thickness of a homogeneous object which has substantial absorption and a phase-shift of --0.37 radian.

Coherence transport through imperfect x-ray optical systems

The latest generation of synchrotron sources, so-called third generation sources, are able to produce copious amounts of coherent radiation. However it has become evident that the experimental systems that have been developed are unable to fully utilize the coherent flux. This has led to a perception that coherence is lost while the radiation is transported down the beamline. However it is well established that the degree of coherence must be preserved, or increased, by an experimental system, and so this apparent "decoherence" must have its origin in the nature of the measurement process. In this paper we use phase space methods to present an argument that the loss of useful coherent flux can be attributed to unresolved speckle in the x-ray beam.

X-ray vortex beams: A theoretical analysis

The recent demonstration that an optical vortex could be generated at x-ray wavelengths brings this interesting topological phenomenon into an entirely new regime with several possible applications. We examine the analytic propagation of an optical vortex generated in a synchrotron x-ray beam line. We compare the results obtained with the existing experimental data and further consider the generation and interpretation of mixed vortex-edge discontinuities which might be considered as non-integer charge vortices.