Leadership, Leading, and Influencing Change in Cancer Education: Development and Assessment of a Pilot Leadership Workshop in Cancer Education for Interdisciplinary Healthcare Staff

Effective leaders in healthcare settings create a motivating work environment, initiate changes in practice, and facilitate interdisciplinary collaboration to advance patient-centered care. Health professionals in cancer education need leadership development to meet the continued rise in cancer cases and to keep up with the rapid biomedical and technological advances in global cancer care. In addition, leadership development in cancer education supports interprofessional collaboration, optimizes patient engagement, and provides mentorship opportunities necessary for career advancement and skill development. The identified benefits from leadership development in cancer education led to the creation of an interactive pilot leadership workshop titled "Essential Skills in Cancer Education: Leadership, Leading, and Influencing Change in Cancer Education," held at the International Cancer Education Conference in October 2020. The workshop was led by global leaders in cancer education and utilized lectures, mentorship opportunities, interactive case studies, and individual learning projects to develop leadership skills in multidisciplinary oncology professionals. Fifteen attendees from diverse educational backgrounds and levels of experience participated in the virtual leadership workshop and mentorship program. Following the workshop, participants reported an increase in knowledge regarding how to use different leadership styles, initiate changes in practice, and apply leadership skills in their career development and at their institutions. The feedback received from participants through post-workshop evaluations was overall positive and demonstrated an interest for more leadership development opportunities in cancer education. This pilot workshop shows that leadership is a valuable and teachable skill that will benefit both healthcare professionals and patients in the field of cancer education.

An automated algorithm minimising ATP failure: re-initiation to enhance anti-tachycardia pacing efficacy

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Medical Research Council, UK

Background

Re-initiation is an important mechanism of anti-tachycardia pacing (ATP) failure, whereby VT is first terminated by the initial ATP application, before being re-initiated by successive pulses. Current ICD designs are able to measure and store electrograms (EGMs) for detecting and classifying arrhythmias, which contain information that may also be used during ATP application. Developing an algorithm that automatically processes EGMs during ATP, with the goal of detecting the initial VT termination and truncating subsequent ATP pulses (which has the potential to re-initiate), may thus increase ATP efficacy.

Purpose

To develop a proof-of-concept ATP detection algorithm: Early Termination Detection Algorithm (ETDA), to automatically sense the signs of early VT termination and cease further ATP pulses based on real-time sensed EGMs from implanted devices.

Methods

A cohort of 7 porcine infarcted ventricular computational models were subject to virtual induction protocols to induce sustained VTs. Functional model properties were adjusted to provide 73 unique VT episodes (260≤VT cycle length (CL)≤480ms). For each episode, burst ATP was delivered from typical pacing sites near the right ventricle (RV) septum to evaluate its efficacy. The ATP failures and their failure mechanisms were identified, accordingly. During ATP application, five common sensing EGM vectors from implanted devices were recovered from simulations including can-to-Superior vena cava (SVC) coil, can-to-RV ring, SVC coil-to-RV coil ring, RV coil tip-to-RV coil ring and LV coil at the lateral base-to-RV tip. Our proposed ETDA utilises those EGMs for VT termination detection. Specifically, correlation coefficients (CCs) of the EGMs between two successive ATP pulses were calculated and averaged to identify sudden changes in EGM morphology that indicate VT termination (Fig A). A discriminating threshold on the CCs was chosen by comparing all re-initiation cases with detailed analysis of the actual VT termination time observed from simulation results. ETDA was then applied to all cases to identify initial termination and improvement in efficacy.

Results

Before ETDA application, ATP terminated 42 cases (58%, Fig C), with re-initiation attributing to 11 (35%) of ATP failures. Application of ETDA accurately detected VT termination in 91% of re-initiated cases, 90% of terminated cases and 81% of not-terminated cases (Fig B), which enhanced the overall ATP efficacy to 71% (P=0.08) (Fig C).

Conclusions

The real-time EGMs measured from standard ICD/CRT-D devices may be used to improve ATP efficacy through an approach such as ETDA. ETDA detects signs of early termination automatically in real time which enables identification of successful VT termination, truncating subsequent pulses that may re-initiate the VT, which enhances overall ATP efficacy.

In silico study of anti-tachycardia pacing efficacy optimisation through scar-targeted stimulation

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Medical Research Council, UK

Background

Anti-tachycardia pacing (ATP) is a reliable electrotherapy to painlessly terminate ventricular tachycardia (VT). However, ATP is often ineffective, particularly for fast VTs, which is often due to the inability of paced wavefronts to reach the re-entrant circuit, because of functional or anatomical barriers. It is thought that efficacy may be enhanced by optimised delivery closer to the re-entrant circuit driving the VT.

Purpose

To quantitatively assess the dependence of ATP efficacy upon different delivery locations with respect to the re-entrant circuit.

Methods

A cohort of 7 porcine ventricular infarct computational models were generated based on in vivo magnetic resonance imaging. Rapid-pacing protocols were applied to the cohort to induce VTs. Functional model parameters were adjusted to produce 73 episodes of sustained monomorphic VT, including 32 fast VTs (cycle length (CL)≤320ms) and 41 slow VTs (320ms-<VTCL≤<VTCL≤>480ms). Burst ATP (2 sequences of 8 pulses at 88% of VTCL) was separately delivered from 3 locations proximal to the re-entrant circuit (along the RV septum), specifically within the critical isthmus (CI), and at the Exit and Entrance sites, along with 3 locations distal to the circuit (lateral/posterior LV), based on multipolar implanted devices with LV epicardial leads, constituting 438 virtual scenarios and efficacy compared (Fig A).

Results

ATP efficacy was significantly higher for slow VTs than for fast VTs (65% vs 46%, P=0.00004) (Fig B). Separate analysis of slow VT cases revealed that delivering from distal locations to the re-entrant circuit was significantly more effective than delivering from proximal locations (72% vs 59%, P=0.04). However, for fast VT cases, the trend was reversed with proximal application (41%) being more effective than distal application (51%, P=0.15) (Fig B). Moreover, individual analysis on specific proximal locations revealed that in slow VT cases, delivering at the Exit site of VT was significantly less efficient than delivering at the Entrance site (46% vs 73%, P=0.01), with a similar (although non-significant) trend also being seen for fast VTs (44% vs 53%, P=0.5) (Fig C). Moreover, for fast VT cases, ATP delivery within the CI was overall the most effective (56%) than all other locations while this trend was not seen in slow VT cases.

Conclusions

ATP delivery proximal to the re-entrant circuit improves efficacy in fast VTs, but less so in slow VTs, where delivering from distal sites is superior. Specifically, for fast VTs, ATP delivery within the CI is the most effective. This work suggests that real-time alteration in applied ATP delivery site choice in a multipolar device (guided by the sensed VT rate by the device prior to therapy delivery) may be beneficial. Combined with the state-of-art leadless pacing technology, this also provides a clinical opportunity for patient-specific ATP delivery configuration and programming.

In-silico optimisation of ICD defibrillation efficacy by modifying lead/can configurations using a cohort of high-resolution whole-torso heart models

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Medical Research Council, UK

Background

ICD is an effective direct therapy against VT/VF by applying a strong electrical shock across the heart between the shocking coil and can. Conventionally, patients will have a shocking coil inside the right ventricle (RV) and a can at the upper left chest. However, due to infections or other conditions, the can may need to place towards the right chest. The placement of the RV coil may also vary in different cases, for example avoiding scar. However, it is unclear how defibrillation efficacy may be altered by these unavoidable modifications to conventional lead/can configurations and whether optimisation may be possible.

Purpose

To compare defibrillation efficacy of modifications of ICD configurations in a cohort of whole-torso models.

Methods

A cohort of 15 whole torso models was generated from high resolution CT data and contrast CT cardiac scans, including 5 dilated cardiomyopathy (DCM), 5 hypertrophic cardiomyopathy (HCM) and 5 structurally normal patients (Fig A). Transvenous ICDs were represented by a shocking coil inside the RV (near apex) and a (ground) can at the upper left chest as default settings. Configurations were then varied by moving the can to the right chest, moving the RV coil up the mid-septum or adding extra grounds (Superior Vena Cava (SVC) coil, coronary sinus (CS) coil (Fig A)). Defibrillation-strength shocks were applied to all models (Fig B). DFTs and mean electrical field were evaluated across the whole heart as well as specific LV, RV, RV insertion regions, along with overall impedance.

Results

Shifting the can from left to right significantly increased DFT for the whole heart (23 J vs 15 J, P=0.03) and LV (25 J vs 17 J, P=0.03) (Fig C) and reduced the mean electrical field. Moving the RV coil further up the septum did not significantly alter DFT (Fig D), but did reduce mean electrical field for all regions and reduce impedance significantly. Additional separate coils significantly reduced DFT for all regions (Fig D) by increasing mean electrical field, whilst adding both coils significantly reduced DFT the most (whole heart: 15 J vs 6 J, P=0.03) (Fig E). Impedance was increased significantly by adding SVC coil, but reduced significantly by adding CS coil. Adding both coils increased impedance slightly.

Conclusions

Although a right-sided can increases DFT by over 50%, additional leads (grounds) may mitigate this increase by increasing mean electrical field. Moving the RV coil closer to the mid-septum reduces DFT slightly, but also reduces mean electrical field and impedance significantly.

Interpolation of electrophysiology parameters using OpenEP: technology development and clinical application

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation

Background

Interpolation of data is common during clinical electrophysiology procedures. Applications include local activation mapping, voltage mapping and novel techniques including Sparkle and Coherence mapping. Nevertheless, underlying interpolation algorithms are proprietary and therefore challenging to reproduce. Importantly, direct comparison of electroanatomic datasets between system vendors is therefore not possible.

Purpose

We sought to (1) develop an open-source architecture for interpolation within the Open Electrophysiology Framework for Research (OpenEP; https://openep.io); (2) to provide three interpolation methods within this architecture and (3) to evaluate their performance against clinical data.

Method

The software architecture is shown in Figure 1A. The currently available methods are Radial Basis [1], Scattered Interpolant [2] and Local Smoothing [3]. Default parameters for each method are shown in Figure 1B.

The performance of each method was assessed using clinical left atrial mapping data, using the default options for each scheme. Following interpolation, a sample of 1000 activation/voltage points per mesh was used for analysis. For each interpolation method, correlation with clinical data was assessed using the intra-class correlation coefficient, whilst agreement was assessed using Bland Altman limits of agreement.

Results

For activation mapping, radial basis interpolation resulted in a smoother field than local smoothing, whilst scattered interpolation required more filtering of extreme values. Correlations between interpolated and original activation times were excellent for all interpolation schemes (radial basis R=0.91, p<0.0001; local smoothing R=0.95, p<0.0001; scattered interpolant R=0.92, p<0.0001). Local smoothing resulted in the narrowest 95 percent limits of agreement (-19 to +20ms), compared to radial basis (-24 to +28ms) and scattered interpolation (-22 to +25ms).

For voltage mapping, the interpolation schemes resulted in similar appearances of low voltage areas, however correlations with clinical data were weaker than for activation mapping (radial basis R=0.84, p<0.0001; local smoothing R=0.82, p<0.0001; scattered interpolant R=0.79, p<0.0001). The 95 percent limits of agreement were wide as a proportion of the mean data values, ranging from 83% (-0.8 to +0.66mV) for local smoothing to 97% (-0.78 to +0.63mV) for radial basis interpolation.

Conclusion

An extensible architecture is provided for data interpolation in OpenEP together with three interpolation methods. The methods performed wellfor local activation time interpolation but variation compared to clinical data was greater for voltage mapping. This new architecture will permit the optimisation of interpolation methods against "gold standard" simulation or histological data and facilitate comparison of datasets between system vendors.

Resequencing Study Confirms That Host Defense and Cell Senescence Gene Variants Contribute to the Risk of Idiopathic Pulmonary Fibrosis

Rationale: Several common and rare genetic variants have been associated with idiopathic pulmonary fibrosis, a progressive fibrotic condition that is localized to the lung. Objectives: To develop an integrated understanding of the rare and common variants located in multiple loci that have been reported to contribute to the risk of disease. Methods: We performed deep targeted resequencing (3.69 Mb of DNA) in cases (n = 3,624) and control subjects (n = 4,442) across genes and regions previously associated with disease. We tested for associations between disease and 1) individual common variants via logistic regression and 2) groups of rare variants via sequence kernel association tests. Measurements and Main Results: Statistically significant common variant association signals occurred in all 10 of the regions chosen based on genome-wide association studies. The strongest risk variant is the MUC5B promoter variant rs35705950, with an odds ratio of 5.45 (95% confidence interval, 4.91-6.06) for one copy of the risk allele and 18.68 (95% confidence interval, 13.34-26.17) for two copies of the risk allele (P = 9.60 × 10-295). In addition to identifying for the first time that rare variation in FAM13A is associated with disease, we confirmed the role of rare variation in the TERT and RTEL1 gene regions in the risk of IPF, and found that the FAM13A and TERT regions have independent common and rare variant signals. Conclusions: A limited number of common and rare variants contribute to the risk of idiopathic pulmonary fibrosis in each of the resequencing regions, and these genetic variants focus on biological mechanisms of host defense and cell senescence.

Prevalence of pain in the departments of surgery and oncohematology of a paediatric hospital that has joined the project "Towards pain free hospital"

BACKGROUND

Among hospitalized adults and children pain is undertreated. This study wants to assess the effectiveness of pain therapy in two departments of a large children's hospital.

MATERIALS AND METHODS

During a single day work three committees, administering a questionnaire to patients or parents, have evaluated the adherence to international recommendations (JCI and WHO) in the management of analgesic therapy. Patient demographics, prevalence and intensity (moderate and/or severe) of pain (during hospitalization, 24 hours before and at the time of the interview), analgesia (type, route, duration and frequency of administration) and Pain Management Index (=analgesic score-pain score) were recorded.

RESULTS

75 patients participated in the study (age: 2 months up to 24 years, mean 7.8 ± 6). During hospitalization 43 children (57%) had no pain while 32 (43%) have experienced pain. 22 children (29 %) had pain 24 hours before and 12 (16%) at the time of the interview. The average value of the PMI was -0.8±1.3 with a minimum of -3 and a maximum of +2: 60% (19) of the children had a PMI less than 0 (undertreated pain) while 40% (13) had a value=or>0. Out of 32 patients who needed an analgesic therapy 14 (44%) received an around-the-clock dosing, 8 (25%) an intermittent therapy and 10 (31%) no treatment.17 (77 %) were the single drug therapy and 5 (23%) the multimodal ones.

CONCLUSIONS

The prevalence of pain in the two departments is high. The main cause is that knowledge is not still well translated into clinical practice.

No evidence of asymptomatic variant CJD infection in immunodeficiency patients treated with UK-sourced immunoglobulin

Surveillance of 75 immunodeficiency patients exposed to UK-sourced immunoglobulin, including batches derived from donors who went on to develop vCJD, has not detected any clinical cases of vCJD, or of asymptomatic infection in 15 patients with available tissue samples of sufficient quality for testing.

Cross-sectional analysis of the dermoscopic patterns and structures of melanocytic naevi on the back and legs of adolescents

BACKGROUND

Junctional (flat) naevi predominate on the extremities, whereas dermal (raised) naevi are found primarily on the head, neck and trunk. Few studies have investigated the anatomical site prevalence of melanocytic naevi categorized using dermoscopy.

OBJECTIVES

To identify the prevalence of dermoscopic patterns and structures of naevi from the back and legs of adolescents.

METHODS

Dermoscopic images of acquired melanocytic naevi were obtained from the back and legs of students from a population-based cohort in Framingham, Massachusetts. Naevi were classified into reticular, globular, homogeneous or complex dermoscopic patterns. Multinomial logistic regression modelling assessed the associations between dermoscopic pattern and anatomical location.

RESULTS

In total 509 participants (mean age 14 years) contributed 2320 back naevi and 637 leg naevi. Compared with homogeneous naevi, globular and complex naevi were more commonly observed on the back than the legs [odds ratio (OR) 29·39, 95% confidence interval (CI) 9·53-90·65, P < 0·001 and OR 6·8, 95% CI 2·7-17·14, P < 0·001, respectively], whereas reticular lesions were less likely to be observed on the back than on the legs (OR 0·67, 95% CI 0·54-0·84, P = 0·001). Naevi containing any globules were more prevalent on the back than on the legs (25% vs. 3·6%, P < 0·001). Naevi containing any network were more prevalent on the legs than on the back (56% vs. 40·6%, P < 0·001).

CONCLUSIONS

These findings add to a robust body of literature suggesting that dermoscopically defined globular and reticular naevi represent biologically distinct naevus subsets that differ in histopathological growth pattern, age- and anatomical-site-related prevalence, molecular phenotype and aetiological pathways.

Resilience in families in which a member has been diagnosed with schizophrenia

Due to the extensive focus of the literature on the burden placed on families in which a member has been diagnosed with a mental illness such as schizophrenia, there is a need to identify factors that may help these families to be resilient and adapt to their crisis. The aim of this study was to identify family resilience qualities in families in which a member has been diagnosed with schizophrenia. The study comprised 42 families, represented by 33 parents and 9 siblings of the diagnosed family member. Families were recruited from three support groups within the Cape Metropolitan area, Western Cape, South Africa. Qualitative data were obtained through an open-ended question and quantitative data were collected with seven self-report questionnaires. The following family resilience qualities were identified: family income; finding support in their community; family togetherness; family communication style during crises; affirming and supportive communication patterns; family hardiness; commitment to the family; reframing crises as a challenge; and an internal locus of control within the family. The findings may be used by professionals and support group facilitators to enhance the resilience and functioning of families living with a member with schizophrenia.

ACCESSIBLE SUMMARY

With approximately 1% of the world's population diagnosed with schizophrenia, it is clear that many families are affected when a member has been diagnosed. There is a need to identify factors that may help these families to be resilient. The aim of this study was to identify family resilience qualities in families in which a member has been diagnosed with schizophrenia. The following family resilience qualities were identified as resources that helped them to adapt to the many challenges put to them: family income, finding support in their community, the availability of hospitals, churches and professionals, family togetherness, family communication, family hardiness, commitment to the family, reframing crises as a challenge, and an internal locus of control within the family. Due to the limited studies on resilience in families in which a member has been diagnosed with schizophrenia, we suggest that the current study may contribute to this literature and provide a more comprehensive look at resilience in these families. Furthermore, the current study may contribute to knowledge about factors and resources that are associated with resilience in families in which a member has been diagnosed with schizophrenia. Finally, the findings of this study may be used in interventions to help families from different cultures and socio-economic statuses to adapt and hence be resilient.

'Dentists' and the establishment of the Anglo-American profession in the eighteenth century: part 3. official recognition

This series of papers examines how the Anglo-American dental profession was established in the eighteenth century, examining its need for a name and identity, public recognition and official status. This third paper describes the introduction of the title dentist as the preferred one when used officially and politically.

Modelling the blast environment and relating this to clinical injury: experience from the 7/7 inquest

This paper addresses the computational modelling of a series of specific blast-related incidents and the relationships of clinical and engineering interpretations. The Royal Centre for Defence Medicine and the Defence Science and Technology Laboratory were tasked in 2010 by the UK Ministry of Defence to assist the Coroner's inquests into the 7 July 2005 London bombings. A three phase approach was taken. The first phase included an engineering expert in blast effects on structures reviewing photographs of the damaged carriages and bus to give a view on the likely physical effects on people close to the explosions. The second phase was a clinical review of the evidence by military clinicians to assess blast injury in the casualties. The third phase was to model the blast environment by structural dynamics experts to assess likely blast loading on victims to evaluate the potential blast loading on individuals. This loading information was then assessed by physiology experts. Once all teams (engineering, clinical and modelling/physiological) had separately arrived at their conclusions, the information streams were integrated to arrive at a consensus. The aim of this paper is to describe the methodology used as a potential model for others to consider if faced with a similar investigation, and to show the benefit of the transition of military knowledge to a civilian environment.

Increased growth inhibition of human chronic myelogenous leukemic cells by a combination of c-myb antisense oligonucleotide and 4-hydroxyperoxycyclophosphamide in vitro

Human chronic myelogenous leukemia (CML) is a unique malignancy in its cellular and molecular phenotypes. High dose therapy followed by stem cell transplantation seems to be one of the most effective treatment modalities for CML. However, allogeneic stem cell transplantation, a curative treatment modality, is limited due to the availability of matched siblings. On the other hand, the autologous stem cell harvests are contaminated with leukemic cells, and therefore a significant reduction of leukemic cells is desired before using the harvest for transplantation. Therefore in the present study, effects of a combination of a suboptimal concentration of 4-hydroxyperoxycyclophosphamide (4HC) and an optimal concentration of c-myb antisense oligonucleotide on the growth of K562 human chronic myelogenous leukemic cells in vitro were determined. The combination significantly (p<0.05) inhibited the growth of K562 cells in vitro when compared to the effects of c-myb oligonucleotide or 4HC alone. The c-myb oligonucleotide alone or in combination with low dose 4HC decreased the expression of c-myb gene as determined by RT-PCR techniques. Cellular uptake and retention of fluoresceinated oligonucleotide in control and treated K562 cells was studied using plain field laser microscopy and flow cytometry. There was an increase in cellular uptake of c-myb oligonucleotide in K562 cells as measured by plain field laser microscopy in the presence of 4HC. The combination of oligonucleotides and 4HC did not significantly decrease the number of hematopoietic stem/progenitor cells from normal hematopoietic stem cell harvests as determined by in vitro colony assays. The combination of low dose 4HC and c-myb antisense oligonucleotides can potentially be applied in CML patients, particularly for purging leukemic cells present in their hematopoietic stem cell harvests.

Oligonucleotides complementary to c-myb messenger RNA inhibit growth and induce apoptosis in human Burkitt lymphoma cells

A 24-mer (antisense) phosphorothioate oligonucleotide (ODN) corresponding to the codons 2-9 of the c-myb gene was evaluated for its effects on the growth of a human Burkitt lymphoma cell line (Raji) in vitro. Raji cells incubated with different concentrations of c-myb antisense ODN (5-15 mu g/ml) for 24-72 h showed a significant dose-dependent decrease in growth. The same concentrations of control (sense) or scrambled c-myb phosphorothioate ODNs did not inhibit Raji cell growth. The c-myb antisense ODN, but not the control ODNs, significantly decreased c-myb mRNA levels in treated cells as determined by RT-PCR. Additionally, the c-myb antisense ODN induced apoptosis of Raji cells as demonstrated by i) flow cytometry to enumerate the A(o) (apoptotic cell population) population of propidium iodide stained cells; ii) electron microscopy to evaluate the cell morphology; and iii) DNA fragmentation pattern. Thus, an antisense c-myb ODN causes significant growth inhibition of Burkitt lymphoma cells, and one mechanism of growth inhibition is the induction of apoptosis of the lymphoma cells. In addition, antisense c-myb ODN did not reduce CFU-GM or BFU-e colony-forming ability of normal hematopoietic stem/progenitor cells. Because the inhibition is sequence-specific and Burkitt lymphoma cell selective, evaluation of the therapeutic effects of c-myb antisense ODN against Burkitt lymphoma is warranted.

EPOCH-F: A salvage regimen for multiple myeloma prior to reduced intensity allogenic hematopoietic stem cell transplantation

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Background: Variation in baseline host immune status contributes to inconsistent donor engraftment and may impede maximal graft-versus-myeloma effects after reduced intensity allogenic hematopoietic stem cell transplantation (RIHSCT) for advanced multiple myeloma (MM). As no specific salvage regimen has been designed for MM patients being considered for RIHSCT, we evaluated EPOCH-F a novel salvage regimen designed to provide disease control and immune depletion. Methods: EPOCH-F is an infusional chemotherapeutic regimen consisting of etoposide, vincristine and adriamycin, with prednisone, cyclophosphamide and fludarabine given in 21 day cycles prior to RIHSCT. Targeting a CD4+ T cell count, 22 pts were treated <5 cycles of EPOCH-F. Pts proceeded to RIHSCT after adequate lymphodepletion or if there was disease progression during EPOCH-F, regardless of CD4 count. Results: Median age was 53 years (range 36–65); median time from initial therapy to transplant was 12 months (range 2–168). Median number of prior therapies was 2 (range 1–8), 63% had chemotherapy sensitive disease and 68% had received a novel agent. Pts received a median of 3 cycles (range 1–5), with manageable toxicities, mostly hematologic. Grade IV Neutropenia was seen in 77% of the administered cycles with only 6 episodes of neutropenic fever. Median lymphocyte count decreased from 1423/μL (range 335–2788) to 519/μL (range 102–1420); CD4 count decreased from 320/μL (range 130–1366) to 115/μL (30–309). In 21 evaluable pts, the ≥PR rate to EPOCH-F was 22% with 13% CR/nCR. 68% had SD and only 1 pt progressed. 20 pts underwent RIHSCT from HLA matched sibling. Median Day 100 chimerism was 100% (range 60–100, mean 95). 70% of patients achieved ≥VGPR and CR/nCR was seen in 40%. Acute GVHD (grade II-IV) was seen in 47% and chronic GVHD (grade III-IV) was seen in 52% of the pts. TRM at 100 days was 5% and 30% at 60 months. Median overall survival of patients after RIHSCT was 46.1 months. Conclusions: EPOCH-F is an active regimen which provides pre-transplantation lympho-depletion, disease control and allows consistent engraftment in multiple myeloma patients undergoing RIHSCT.

No significant financial relationships to disclose.

Ureteric stents: investigating flow and encrustation

Blockages of the ureter, e.g. due to calculi (kidney stones), can result in an increase in renal pelvic pressure. This may be relieved by inserting a stent (essentially a permeable hollow tube). However, a number of complications are associated with stent use. Stents can result in reflux (backflow of urine along the ureter), which will promote recurrent urinary infection and possible renal parenchymal damage. Furthermore, long-term stent use is associated with infection and precipitation of salts from the urine, which can lead to a build-up of crystalline deposits on the stent surface, making stent removal difficult and painful. This paper examines factors governing urine flow in a stented ureter, the implications for reflux, and the processes by which the stent surface encrusts, in particular focusing on the influence of bacterial infection. An interdisciplinary approach is adopted, involving a combination of theoretical investigations and novel experiments.

Disease-associated prion protein is not detectable in human systemic amyloid deposits

Cerebral and cardiac amyloid deposits have been reported after scrapie infection in transgenic mice expressing variant prion protein (PrP(C)) lacking the glycophosphatidylinositol anchor. The amyloid fibril protein in the systemic amyloid deposits was not characterized, and there is no clinical or pathological association between prion diseases and systemic amyloidosis in humans. Nevertheless, in view of the potential clinical significance of these murine observations, we tested both human amyloidotic tissues and isolated amyloid fibrils for the presence of PrP(Sc), the prion protein conformation associated with transmissible spongiform encephalopathy (TSE). We also sequenced the complete prion protein gene, PRNP, in amyloidosis patients. No specific immunohistochemical staining for PrP(Sc) was obtained in the amyloidotic cardiac and other visceral tissues of patients with different types of systemic amyloidosis. No protease-resistant prion protein, PrP(res), was detectable by Western blotting of amyloid fibrils isolated from cardiac and other systemic amyloid deposits. Only the complete normal wild-type PRNP gene sequence was identified, including the usual distribution of codon 129 polymorphisms. These reassuringly negative results do not support the idea that there is any relationship of prions or TSE with human systemic amyloidosis, including cardiac amyloid deposition.

Correlations among vitality, physical competence, lipid profile and measures of inflammation in transplant survivors with chronic graft versus host disease

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Background: Chronic graft vs. host disease (cGVHD) is a multi-system disorder and a late complication of cancer therapy experienced by more than 50% of survivors after allogeneic hematopoietic stem cell transplantation. An improved understanding of the underlying biology and its relation to clinical symptoms may guide the development of better treatments for cGVHD. Methods: In a prospective, cross-sectional natural history protocol we examined the associations among organ/system dysfunction, measures of physical performance and health status with clinical measures of inflammation and fat metabolism. Variables included: 1. a composite severity score (CAS) rated by clinician-specialists (skin, eyes, mouth, gastrointestinal/liver, hematological, gynecological, pulmonary function evaluations); 2.functional measures [2 minute walk time (WT), grip strength (GS), SF-36 physical component summary score (PCS), vitality (VT) subscale, maximal activity score (MAS) of the Human Activity Profile]; 3.Laboratory tests (glucose, LDH, hemoglobin, ferritin, platelets, lymphocytes, pre-albumin, cholesterol, lipoproteins (HDL, LDL), triglycerides (TG), beta-2microglobulin (B2), and CRP. Results: 43 pts (mean age 47 yrs) with prior hematologic malignancy participated (mean 3 yrs post transplant). An average of 3.5 organ systems were affected, 77% were on systemic treatment for cGVHD, and 67% had prior acute GVHD. The mean body mass index (BMI) was 25, TG 255, cholesterol 222, LDL 132. They were moderately disabled by self-report (MAS), had slower than normal WT (540 ft/min), lower than normal GS (63 pounds), PCS (36) and VT (46) than a healthy population. Using a backward selection model with a significance of 0.1, low lung diffusing capacity (p<.001) and low PCS (p=0.01) correlated with high CAS. VT correlated negatively with LDH, platelets, B2 and LDL (all p<0.01). Low GS correlated with high LDH and B2 (p=0.01). Conclusions: Reported physical function and vitality in cGVHD patients are associated with abnormal lipid profiles and markers of inflammation. Establishment of such profiles is a critical step in the development of testable and validated outcome measures and for evaluation of new therapies in cGVHD.

No significant financial relationships to disclose.

Managing waiting time for radiotherapy: A single machine unit experience

Waiting time (WT) for radiotherapy (RT) is a significant clinical problem. This paper examines various strategies for managing WT for patients treated with radical and palliative intent in the new setting of a rural single machine unit in Australia. Cohorts of patients undergoing both radical and palliative RT in Bendigo had their WT prospectively recorded. Matched cohorts from the hub centre (Peter MacCallum Cancer Centre, Melbourne) treated with palliative intent were also collated. Strategies implemented included a devoted priority meeting, palliative points system, and reallocation of appointment times. The audit was to continue until best practice guidelines were bettered. Three cohorts of patients were compared. There is a significant trend for increasing numbers of patients treated per month since the centre opened (P < 0.0001). The ratio of palliative to radical intent patients remained stable between 46 and 52%. Mean WT for palliative RT reduced from 25 days in the first cohort to 7 days in the final cohort (P < 0.0005). Waiting time for palliative RT was initially longer at Bendigo than the hub centre (P < 0.0005), but by the final cohort there was a non-significant difference favouring the Bendigo cohort (P = 0.26). Waiting time for radical treatment also improved throughout the three cohorts in Bendigo (P < 0.0005). A number of new strategies have successfully resulted in the abolition of lengthy WT for RT in Bendigo despite the increasing demand for the RT service.

Ambrosius Holbein's memento mori map for Sir Thomas More's Utopia. The meanings of a masterpiece of early sixteenth century graphic art

This paper describes how, and asks why, the Renaissance artist Ambrosius Holbein hid a skull within the overall design of his woodcut map of Sir Thomas More's Utopia. (Fig. 2) This map was prepared for the 1518 Froben edition of the book, and was probably commissioned by Erasmus of Rotterdam. Its identification now is made easier by the habits of interpretation with which all dentists are equipped thanks to their skill in dental radiology, and by the recognition of teeth appearing in an unlikely disguise.