Pediatric Experience and Outcomes from the First Single-Vault Compact Proton Therapy Center

The first single-vault compact proton therapy center opened in 2013, utilizing a gantry-mounted synchrocylotron. The center was placed within a large academic radiation oncology department with a high priority for pediatric cancer care. Here we performed a retrospective study of pediatric (≤21 years) patients treated with proton therapy at our institution between 2013-2022. Patient, tumor, and treatment characteristics were obtained including race, socioeconomic status, insurance type, distance travelled, need for anesthesia, and outside referrals for proton therapy. In total, 250 pediatric patients were treated with proton therapy comprising 18% of our proton patient volume. Median follow-up was 3.1 years, 38.4% were female and 83% were white. The majority of cases were CNS (69.6%) and a large number of patients (80/250, 32%) required craniospinal irradiation. Anesthesia was required for 39.6% of patients. Average distance travelled for treatment was 111 miles and 23% of patients were referred from outside institutions for proton therapy. Insurance type was private/commercial for 61.2% followed by Medicaid for 32%. We found that 23% of patients lived in census tracts with >25% of people living below the national poverty line. Overall survival at 3 years was excellent at 83.7% with better outcomes for CNS patients compared to non-CNS patients. There were no cases of secondary malignancy at this early time point. As the world's first compact proton therapy center, we found that proton therapy increased our pediatric volume and provided proton therapy to a diverse group of children in our region. These data highlight some of the expected patient and tumor characteristics and necessary resources for providing pediatric proton beam therapy.

Arsenic doping and diffusion in CdTe: a DFT study of bulk and grain boundaries

The doping of CdTe with As is a method which is thought to increase cell efficiency by increasing electron hole concentrations. This doping relies on the diffusion of As through CdTe resulting in As_Tesubstitution. The potential effectiveness of this is considered through kinetic and electronic properties calculations in both bulk and Σ3 and Σ9 grain boundaries using Density Functional Theory. In bulk zinc-blende CdTe, isolated As diffuses with barriers <0.5 eV and with similar barriers through wurtzite structured CdTe, generated by stacking faults, suggesting that As will not be trapped at the stacking faults and hence the transport of isolated As will be unhindered in bulk CdTe. Substitutional arsenic in bulk CdTe has little effect on the band gap except when it is positively charged in the AX-centre position or occurring as a di-interstitial. However in contrast to the case of chlorine, arsenic present in the grain boundaries introduces defect states into the band gap. This suggests that a doping strategy whereby the grain boundaries are first saturated with chlorine, before single arsenic atoms are introduced, might be more beneficial.

The Use of Pb Isotope Ratios to Determine Environmental Sources of High Blood Pb Concentrations in Children: A Feasibility Study in Georgia

The incidence of lead (Pb) poisoning in children in Georgia has been identified as a major health concern, with a recent national survey identifying that 41% of children aged 2-7 years had blood lead concentrations (BLCs) greater than the blood lead reference value (BLRV) of ≥5 µg dL^-1. This study collected samples of blood, spices, paint, soil, dust, flour, tea, toys, milk, and water from 36 households in Georgia where a child had previously been identified as having a BLC > BLRV. The Pb concentrations of these samples were determined and compared to Georgian reference values. Samples from 3 households were analysed for their Pb isotope composition. The Pb isotope composition of the environmental and blood samples were compared to identify the most likely source(s) of Pb exposure. This approach identified that some spice and dust samples were the likely sources of Pb in the blood in these cases. Importantly, some soil, paint, and dust sources with high Pb concentrations could be discounted as contributing to blood Pb based on their distinct isotope composition. The data presented demonstrate the significant contribution that Pb surveillance and Pb isotope ratio analyses can make to managing Pb exposure in regions where high BLCs are identified.

In flux: Annual transport and deposition of suspended heavy metals and trace elements in the urbanised, tropical Red River Delta, Vietnam

Due to the depositional environment, river deltas are said to act as filters and sinks for pollutants. However, many deltas are also densely populated and rapidly urbanizing, creating new and increased sources of pollutants. These sources pose the risk of tipping these environments from pollution sinks to sources, to the world's oceans. We provide detailed seasonal and annual assessments of metal contaminants in riverine suspended particulate matter (SPM) across the densely populated Red River Delta (RRD), Vietnam. The global contributions of elements from the RRD are all <0.2% with many elemental fluxes <0.01%, suggesting the RRD is not a major source of elemental pollution to the ocean. However, 'hotspots' of metal pollution due to human activity and the impacts of tropical storm Son Tinh (July 2018) exceed both national level regulations and international measures of toxicity (e.g. enrichment factors). There is widespread 'extreme pollution' of Cd (enrichment factor >40) and concentrations of As higher than national regulation limits (>17 mg/Kg) at all sites other than one upstream, agricultural-dominated tributary in the dry season. These 'hotspots' are characterised by high inputs of organic matter (e.g. manure fertiliser and urban wastewater), which influences elemental mobility in the particulate and dissolved phases, and are potentially significant sources of pollution downstream. In addition, in the marine and fresh water mixing zone, salinity effects metal complexation with organic matter increasing metals in the particulate phase. Our calculations indicate that the delta is currently acting as a pollutant sink (as determined by high levels of pollutant deposition ∼50%). However, increased in-washing of pollutants and future projected increases in monsoon intensity, saline intrusion, and human activity could shift the delta to become a source of toxic metals. We show the importance of monitoring environmental parameters (primarily dissolved organic matter and salinity) in the RRD to assess the risk of transport and accumulation of toxic metals in the delta sediments, which can lead to net-increases in anthropogenic pollution in the coastal zone and the incorporation of toxic elements in the food chain.

Emergency department care-related causal factors of in-patient deterioration

ObjectiveThe aim of this study was to determine factors related to emergency department (ED) care causing in-patient deterioration.MethodsThis retrospective cohort study examined in-patient records using the human factors classification framework for patient safety in a regional health service in New South Wales, Australia, between March 2016 and February 2017. Deterioration was defined as either the initiation of a medical emergency team call, cardiac arrest or unplanned admission to the intensive care unit.ResultsOf the 1074 patients who deteriorated within 72 hours of admission via the ED, the care received in the ED was a contributing factor for 101 patients (9%). The most common human causal factors were poor communication between staff, medical management errors, delayed treatment, medical documentation errors, nursing management errors and unclear policies or guidelines. Communication issues occurred the most when patients had more comorbidities (P = 0.039) and were more likely to occur in the presence of a medical documentation error (odds ratio 4.4; 95% confidence interval 1.7-11.3). Unclear policies or guidelines as a factor was most frequent with a surgical diagnosis (34.5% vs 15.7% for surgical vs medical, respectively; P = 0.038) and in patients ≥80 years of age (30.0% vs 21.8% for age ≥80 vs <80 years, respectively; P = 0.027).ConclusionQuality monitoring and interventions that consider human factors are required to address preventable in-patient deterioration.What is known about the topic?The ED represents the hospital's point of contact for potentially life-threatening conditions. Adverse event rates for emergency admissions are more than double those of non-emergency admissions. Patients are at particular risk of deterioration on discharge from the ED to the ward in the first 72 hours. Predicting which patients will deteriorate following transfer to the ward remains challenging, with care in the ED hypothesised to play a role.What does this paper add?This paper reveals that in-patient deterioration relating to ED care could be reduced through the routine identification of causal factors within a human factors framework in any patient deterioration event and subsequent evidence-informed interventions to address these factors. It is also extrapolated that the implementation of any intervention should be informed by behaviour-change principles.What are the implications for practitioners?It is implied that there is a need for the clarification and revision of policies and guidelines pertaining to the management of elderly patients, education regarding the critical importance of the often clinically masked vital sign deviations in younger patients and improved communication between staff, especially regarding patients with more comorbidities. Reviews of adverse events, such as patient deterioration, should incorporate a human factors analysis. Regular collation of data following adverse events should occur, with interventions considering all aspects of the factors that led to the event.

241 IMPLEMENTATION OF AN INTRACEREBRAL CEREBRAL HAEMORRHAGE CARE BUNDLE

Background

Mortality for Intracerebral haemorrhage (ICH) is 31% (Irish National Audit Stroke, 2019). An ICH care bundle focusing on acute anticoagulation reversal, blood pressure lowering, and a neurosurgical care pathway was associated with improved survival. Translating evidence-based medicine into clinical practice is challenging. The aim of this study was to determine feasibility and outcomes of implementation of a care bundle.

Methods

An ICH care bundle was developed using an iterative process involving expert stakeholder review of the evidence-based literature. A pre-and-post quasi-experimental research design was employed to evaluate this intervention. Baseline data were collected before implementation (January 2016-June 2018). Implementation took place in a staged manner in a single university teaching hospital with multiple ‘Plan Do Study Act cycles’ (June 2018 to January 2021). Data on compliance, process measures and outcomes were collected.

Results

Systolic blood pressure (first 24-hours) and anticoagulant reversal were significantly better controlled post-implementation (χ2 (1, N = 91) = 5.34, P = 0.02), (χ2 (1, N = 25) = 5.85, P = 0.016), respectively. DNAR orders were significantly lower in the post-implementation group (χ2 (1, N = 25) = 5.85, P = 0.029). However, ‘Do Not Actively Resuscitate’ status did not significantly differ when accounting for low GCS as a surrogate measure for poor prognosis (χ2 (1, N = 34) = 0.00, P = 0.966). Modified Rankin Scale on discharge did not differ significantly pre-and-post-implementation (z = −0.075, P = 0.94). A greater proportion of patients survived in the post-implementation group; however, this was not statistically significant (χ2 (1, N = 133) = 0.77, P = 0.38). Length of stay significantly increased post implementation.

Conclusion

An ICH care bundle was developed based on expert stakeholder feedback. The feasibility of implementing this bundle of care was demonstrated in a real-world clinical practice setting. A cluster-randomized trial or a large registry study is the next step to evaluate the overall impact of this care bundle on patient outcomes.

Implementation strategy fidelity evaluation for a multidisciplinary Chest Injury Protocol (ChIP)

Background

Blunt chest wall injuries can lead to complications, especially without early intervention. A blunt Chest Injury Protocol (ChIP) was developed to help improve the consistency of evidence-based care following admission to the emergency department. Implementation strategy fidelity is the extent to which the strategies of implementation are delivered in line with the intended plan. The aim of this study was to assess fidelity to the strategies of the implementation plan developed for ChIP.

Methods

A retrospective evaluation of strategies used for implementation was performed, specifically the behaviour change techniques (BCTs). BCTs were used as part of an implementation plan derived based on the Behaviour Change Wheel from results from a staff survey at two hospitals.

Levels of implementation or adaptation for BCTs were scored by implementers as follows: ‘Were the behaviour change interventions implemented?’ (0 = ‘not implemented’, 1 = partially implemented, and 2 = fully implemented); ‘Were adaptations made to the implementation plan?’, scored 1 (many changes from plan) to 4 (just as planned). Free text explanation to their responses was also collected with supporting evidence and documentation (such as emails, implementation checklists, audit reports, and incident reports).

Results

There was high overall fidelity of 97.6% for BCTs partially or fully implemented. More than three quarters (32/42, 76.2%) of the BCTs were fully implemented with an additional 9/42 (21.4%) partially implemented. BCTs that were not fully implemented were social support, feedback on behaviour, feedback on outcomes of behaviour, adding objects to the environment, and restructuring the environment. The modes of delivery with poorer implementation or increased adaptations were clinical champions and audit/feedback.

Conclusions

This study describes the evaluation of implementation strategy fidelity in the acute care context. The systematic use and application of the behaviour change wheel was used to develop an implementation plan and was associated with high implementation strategy fidelity. A fidelity checklist developed during the implementation process may help implementers assess fidelity.

Trial registration

Trial registered on ANZCTR. Registration number ACTRN12618001548224, date approved 17/09/2018

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00189-8.

Consistently unreliable: Oil spill data and transparency discourse

Our recent research reveals enormous discrepancies in oil spill data disclosed by regulatory institutions and corporate sources in Nigeria. Federal agencies as well as major international oil corporations publish inconsistent and sometimes contradictory figures, often employing different spatial or regional categorizations. Uncertainties pertaining to data veracity in the Niger Delta, alongside the thin scientific record inflect deeply contentious debates regarding the country's oil industry. For advocacy organizations, the result is that those seeking to monitor oil spills may spend hours trying to square and cross-reference uneven information, time that could otherwise be spent assessing the scale of impacts and analyzing the complex structural causes surrounding them. Scholarly work in other jurisdictions indicates that the staging of non-transparent, incoherent and/or intentionally misleading data on oil spill risks is not unique to Nigeria, leading to a kind of epistemological vertigo in studying this sector.

Inert gas bubble formation in magnetron sputtered thin-film CdTe solar cells

Cadmium telluride (CdTe) solar cells are deposited in current production using evaporation-based tech- niques. Fabricating CdTe solar cells using magnetron sputtering would have the advantage of being more cost-efficient. Here, we show that such deposition results in the incorporation of the magnetron working gas Ar, within the films. Post deposition processing with CdCl2 improves cell efficiency and during which stacking faults are removed. The Ar then accumulates into clusters leading to the creation of voids and blisters on the surface. Using molecular dynamics, the penetration threshold energies are determined for both Ar and Xe, with CdTe in both zinc-blende and wurtzite phases. These calculations show that more Ar than Xe can penetrate into the growing film with most penetration across the (111) surface. The mechanisms and energy barriers for interstitial Ar and Xe diffusion in zinc-blende are determined. Barriers are reduced near existing clusters, increasing the probability of capture-based cluster growth. Barriers in wurtzite are higher with non-Arrhenius behaviour observed. This provides an explanation for the increase in the size of voids observed after stacking fault removal. Blister exfoliation was also modelled, showing the formation of shallow craters with a raised rim.

Comprehensive validation of halcyon 2.0 plans and the implementation of patient specific QA with multiple detector platforms

Purpose

To perform a comprehensive validation of plans generated on a preconfigured Halcyon 2.0 with preloaded beam model, including evaluations of new features and implementing the patient specific quality assurance (PSQA) process with multiple detectors.

Methods

A total of 56 plans were generated in Eclipse V15.6 (Varian Medical System) with a preconfigured Halcyon treatment machine. Ten plans were developed via the AAPM TG‐119 test suite with both IMRT and VMAT techniques. 34 clinically treated plans using C‐arm LINAC from 24 patients were replanned on Halcyon using IMRT or VMAT techniques for a variety of sites including: brain, head and neck, lung, breast, abdomen, and pelvis. Six of those plans were breast VMAT plans utilizing the extended treatment field technique available with Halcyon 2.0. The dynamically flattened beam (DFB), another new feature on Halcyon 2.0, was also used for an AP/PA spine and four field box pelvis, as well as ten 3D breast plans. All 56 plans were measured with an ion chamber (IC), film, portal dosimetry (PD), ArcCHECK, and Delta4. Tolerance and action limits were calculated and compared to the recommendations of TG‐218.

Results

TG‐119 IC and film confidence limits met those set by the task group, except for IMRT target point dose. Forty‐four of 46 clinical plans were within 3% for IC measurements. Average gamma passing rates with 3% dose difference and 2mm distance‐to‐agreement for IMRT/VMAT plans were: Film – 96.8%, PD – 99.9%, ArcCHECK – 99.1%, and Delta4 – 99.2%. Calculated action limits were: Film – 86.3%, PD – 98.4%, ArcCHECK – 96.1%, and Delta4 – 95.7%. Extended treatment field technique was fully validated and 3D plans with DFB had similar results to IMRT/VMAT plans.

Conclusion

Halcyon plan deliveries were verified with multiple measurement devices. New features of Halcyon 2.0 were also validated. Traditional PSQA techniques and process specific tolerance and action limits were successfully implemented.

Unusual case of antiphospholipid syndrome presenting as adrenal insufficiency

A 64-year-old man presented to the emergency department with generalised fatigue and dizzy spells. His background history includes a previous admission with right leg deep vein thrombosis, provoked by pneumonia. Laboratory results showed evidence of hyponatremia and hyperkalaemia. A synacthen test was performed that indicated hypoadrenalism. CT of his abdomen revealed enlarged adrenal glands bilaterally. Adrenal antibodies and positron emission tomography (PET) scan were performed to assess the cause of enlarged adrenals. PET scan showed no evidence of increased uptake. Adrenal antibodies were found to be negative. Tuberculous (TB) adrenalitis was the principle differential diagnosis. TB QuantiFERON was strongly positive. Following 9 months of TB treatment, surveillance CT scan indicated a significant reduction in adrenal gland size. However, subsequent events culminated in a retrospective review of CT scans questioning the initial clinical diagnosis and suggesting that the observed adrenal gland enlargement was secondary to bilateral adrenal infarction and haemorrhage. Equally, the subsequently observed marked reduction in adrenal gland size was not secondary to an assumed response to TB therapy, but rather the sequela of infracted atrophied adrenal glands, as a manifestation of the underlying antiphospholipid syndrome (APS). The case highlights the importance of recognising adrenal insufficiency in patients with a history of APS. It also illustrates the role of multidisciplinary meetings in the management of such complex cases.

Crude Fat, Diethyl Ether Extraction, in Feed, Cereal Grain, and Forage (Randall/Soxtec/Submersion Method): Collaborative Study

A method for determining crude fat in animal feed, cereal grain, and forage (plant tissue) was collaboratively studied. Crude fat was extracted from the animal feed, cereal grain, or forage material with diethyl ether by the Randall method, also called the Soxtec method or the submersion method. The proposed submersion method considerably decreases the extraction time required to complete a batch of samples. The increase in throughput is very desirable in the quest for faster turnaround times and the greater efficiency in the use of labor. In addition, this method provides for reclamation of the solvent as a step of the method. The submersion method for fat extraction was previously studied for meat and meat products and was accepted as AOAC Official Method 991.36. Fourteen blind samples were sent to 12 collaborators in the United States, Sweden, Canada, and Germany. The within-laboratory relative standard deviation (repeatability) ranged from 1.09 to 9.26% for crude fat. Among-laboratory (including within) relative standard deviation (reproducibility) ranged from 1.0 to 21.0%. The method is recommended for Official First Action.

Crude Fat, Hexanes Extraction, in Feed, Cereal Grain, and Forage (Randall/Soxtec/Submersion Method): Collaborative Study

A method for determining crude fat in animal feed, cereal grain, and forage (plant tissue) was collaboratively studied. Crude fat was extracted from the animal feed, cereal grain, or forage material with hexanes by the Randall method, also called the Soxtec method or the submersion method. The use of hexanes provides for an alternative to diethyl ether for fat extractions. The proposed submersion method considerably decreases the extraction time required to complete a batch of samples compared to Soxhlet. The increase in throughput is very desirable in the quest for faster turnaround times and the greater efficiency in the use of labor. In addition, this method provides for reclamation of the solvent as a step of the method. The submersion method for fat extraction was previously studied for meat and meat products and was accepted as AOAC Official Method 991.36. Fourteen blind samples were sent to 14 collaborators in the United States, Sweden, Canada, and Germany. The within-laboratory relative standard deviation (repeatability) ranged from 1.23 to 5.80% for crude fat. Among-laboratory (including within) relative standard deviation (reproducibility) ranged from 1.88 to 14.1%. The method is recommended for Official First Action.

Effect of Excess Iodine Intake from Iodized Salt and/or Groundwater Iodine on Thyroid Function in Nonpregnant and Pregnant Women, Infants, and Children: A Multicenter Study in East Africa

BACKGROUND

Acute excess iodine intake can damage the thyroid, but the effects of chronic excess iodine intake are uncertain. Few data exist for pregnant and lactating women and infants exposed to excessive iodine intake.

METHODS

This was a multicenter cross-sectional study. At study sites in rural Kenya and urban Tanzania previously reporting iodine excess in children, urinary iodine concentration (UIC), thyrotropin, total thyroxine, and thyroglobulin (Tg) were measured in school-age children (SAC), women of reproductive age, pregnant (PW) and lactating women, and breast-feeding and weaning infants. In a national study in Djibouti, UIC was measured in SAC and PW. At all sites, daily iodine intake was estimated based on UIC, and iodine concentration was measured in household salt and drinking water.

RESULTS

The total sample size was 4636: 1390, 2048, and 1198 subjects from Kenya, Tanzania, and Djibouti, respectively. In Kenya and Tanzania: (i) median UIC was well above thresholds for adequate iodine nutrition in all groups and exceeded the threshold for excess iodine intake in SAC; (ii) iodine concentrations >40 mg of iodine/kg were found in approximately 55% of household salt samples; (iii) iodine concentrations ≥10 μg/L were detected in 9% of drinking water samples; (iv) Tg was elevated in all population groups, but the prevalence of thyroid disorders was negligible, except that 5-12% of women of reproductive age had subclinical hyperthyroidism and 10-15% of PW were hypothyroxinemic. In Djibouti: (i) the median UIC was 335 μg/L (interquartile range [IQR] = 216-493 μg/L) in SAC and 265 μg/L (IQR = 168-449 μg/L) in PW; (ii) only 1.6% of Djibouti salt samples (n = 1200) were adequately iodized (>15 mg/kg); (iii) the median iodine concentration in drinking water was 92 μg/L (IQR = 37-158 μg/L; n = 77). In all countries, UIC was not significantly correlated with salt or water iodine concentrations.

CONCLUSIONS

Although iodine intake was excessive and Tg concentrations were elevated, there was little impact on thyroid function. Chronic excess iodine intake thus appears to be well tolerated by women, infants, and children. However, such high iodine intake is unnecessary and should be avoided. Careful evaluation of contributions from both iodized salt and groundwater iodine is recommended before any review of iodization policy is considered.

Fitness to plead: Development and validation of a standardised assessment instrument

The ability of an individual to participate in courtroom proceedings is assessed by clinicians using legal ‘fitness to plead’ criteria. Findings of ‘unfitness’ are so rare that there is considerable professional unease concerning the utility of the current subjective assessment process. As a result, mentally disordered defendants may be subjected unfairly to criminal trials. The Law Commission in England and Wales has proposed legal reform, as well as the utilisation of a defined psychiatric instrument to assist in fitness to plead assessments. Similar legal reforms are occurring in other jurisdictions. Our objective was to produce and validate a standardised assessment instrument of fitness to plead employing a filmed vignette of criminal proceedings. The instrument was developed in consultation with legal and clinical professionals, and was refined using standard item reduction methods in two initial rounds of testing (n = 212). The factorial structure, test-retest reliability and convergent validity of the resultant instrument were assessed in a further round (n = 160). As a result of this iterative process a 25-item scale was produced, with an underlying two-factor structure representing the foundational and decision-making abilities underpinning fitness to plead. The sub-scales demonstrate good internal consistency (factor 1: 0·76; factor 2: 0·65) and test-retest stability (0·7) as well as excellent convergent validity with scores of intelligence, executive function and mentalising abilities (p≤0·01 in all domains). Overall the standardised Fitness to Plead Assessment instrument has good psychometric properties. It has the potential to ensure that the significant numbers of mentally ill and cognitively impaired individuals who face trial are objectively assessed, and the courtroom process critically informed.

Effect of Continuous Digital Hypothermia on Lamellar Inflammatory Signaling When Applied at a Clinically-Relevant Timepoint in the Oligofructose Laminitis Model

BACKGROUND

Although continuous digital hypothermia (CDH) protects lamellae from injury in the oligofructose (OF) model of sepsis-related laminitis (SRL), conflicting results exist from these studies regarding effects of CDH on lamellar inflammatory events.

HYPOTHESIS/OBJECTIVES

To determine the effect of CDH on lamellar inflammatory events in normal and OF-treated horses when instituted at a clinically relevant time point (onset of clinical signs of sepsis in this model).

ANIMALS

Standardbred geldings (n = 15) aged 3-11 years were used.

METHODS

In a randomized, controlled discovery study, animals were administered either OF (OF group, n = 8) or water (CON group, n = 8) by nasogastric tube and CDH was initiated in one forelimb (ICE) 12 hours later. Lamellar tissue samples were collected 24 hours after initiation of CDH (ICE and ambient [AMB] forelimbs). Lamellar mRNA concentrations of inflammatory mediators and lamellar leukocyte numbers were assessed using qPCR and immunohistochemistry, respectively; values from four sample groups (CON AMB, OF AMB, CON ICE, and OF ICE) were analyzed using mixed model linear regression.

RESULTS

Although lamellar mRNA concentrations of multiple inflammatory mediators (IL-1β, IL-6, CXCL1, MCP2, COX-2) were increased after OF administration (OF AMB group versus CON AMB; P < 0.05), only 2 inflammatory mediators (IL-6 and COX-2) and lamellar leukocyte numbers were decreased with CDH (OF ICE versus OF AMB; P < 0.05).

CONCLUSIONS AND CLINICAL IMPORTANCE

Continuous digital hypothermia initiated at a time point similar to that commonly used clinically (clinical onset of sepsis) resulted in a more focused inhibition of inflammatory signaling.

Not Another ACS Rule Out

CASE

A 50 year old African-American woman with diabetes, hypertension, and hyperlipidemia presented with progressively worsening retro-sternal chest pain, exacerbated by activity and relieved by rest. She also endorsed a thirty-pound unintentional weight loss, and dysphagia. She was dysarthric with left-sided Bell's Palsy and a palpable left axillary lymph node. She had been evaluated at several hospitals in the previous months for similar typical chest pain. Her troponin values were normal, and an EKG showed T-wave inversions in leads I and aVL. On echocardiography, her ejection fraction was 45 percent with anterolateral hypokinesis. She was treated for NSTEMI, and an angiogram showed 95 percent stenosis of the right coronary artery. A modified barium swallow study revealed weakened swallowing with aspiration of thin liquids. An MRI Brain demonstrated scattered T2/ FLAIR hyper-intense foci in the subcortical white matter and focal meningeal thickening. ANA, dsDNA, ANCA, and Lyme antibodies were all negative, and a chest CT showed hilar lymphadenopathy. Cardiac MRI demonstrated scattered foci of delayed enhancement in the mid-myocardium and sub-epicardium without infarction. An endobronchial biopsy of hilar lymph nodes showed two small epithelioid granulomas, consistent with Sarcoidosis. She was started on high-dose corticosteroids with rapid improvement. A repeat modified barium swallow study was normal and a repeat echocardiogram demonstrated recovered ejection fraction of 55 percent with improved wall motion in the septum and apex. Additionally, her left-sided Bell's Palsy and dysarthria improved after several days of therapy.

DISCUSSION

To our knowledge, this report is the third case of multi-organ Sarcoidosis presenting as ACS. This case depicts the simultaneous presentation of neurologic, pharyngeal, pulmonary, and cardiac Sarcoidosis. Myocardial involvement in Sarcoidosis is rare and usually presents as conduction abnormalities with arrhythmia rather than ACS. Though her symptoms were consistent with Sarcoidosis, she had multiple risk factors for coronary atherosclerosis including diabetes, hypertension, and hyperlipidemia. This case highlights the importance of including Sarcoidosis in the differential diagnosis for patients with recurrent typical chest pain of uncertain etiology.

Effect of Delayed Digital Hypothermia on Lamellar Inflammatory Signaling in the Oligofructose Laminitis Model

Background

In the oligofructose (OF) model of sepsis‐related laminitis (SRL), digital hypothermia (“cryotherapy”) initiated before the onset of clinical signs is reported not only to limit lamellar injury, but also to cause marked inhibition of lamellar inflammatory signaling.

Hypothesis/Objectives

Because hypothermia also has been reported to be protective when not initiated until the onset of lameness in the OF model of SRL, we hypothesized that the lamellar protection conferred by hypothermia is caused by local lamellar inhibition of inflammatory signaling as described when hypothermia was initiated earlier in the disease process.

Animals

Eight Standardbred geldings aged 3–11 years with no lameness and no abnormalities of the feet detectable by gross or radiographic examination.

Methods

Using the OF model of SRL, lamellar mRNA concentrations of proinflammatory cytokines, chemokines, and endothelial adhesion proteins were compared between samples from treated limbs (CRYO, submerged in ice water for 36 hour starting at the onset of lameness), untreated limbs (NON‐CRYO, opposite limb from CRYO limbs maintained at ambient temperature), and untreated limbs from normal horses in which laminitis was not induced (CON).

Results

Although OF administration resulted in increases in lamellar mRNA concentrations of several inflammatory mediators in NON‐CRYO limbs (vs CON), digital hypothermia had no significant effect on these increases.

Conclusions and Clinical Importance

The lack of inflammatory inhibition in lamellar tissue samples in our study indicates that the protective effects of digital hypothermia instituted at the onset of clinical signs of laminitis do not arise from inhibition of inflammatory pathways.

Informing etiologic research priorities for squamous cell esophageal cancer in Africa: A review of setting-specific exposures to known and putative risk factors

Esophageal squamous cell carcinoma (ESCC) is one of the most common cancers in most Eastern and Southern African countries, but its etiology has been understudied to date. To inform its research agenda, we undertook a review to identify, of the ESCC risk factors which have been established or strongly suggested worldwide, those with a high prevalence or high exposure levels in any ESCC-affected African setting and the sources thereof. We found that for almost all ESCC risk factors known to date, including tobacco, alcohol, hot beverage consumption, nitrosamines and both inhaled and ingested PAHs, there is evidence of population groups with raised exposures, the sources of which vary greatly between cultures across the ESCC corridor. Research encompassing these risk factors is warranted and is likely to identify primary prevention strategies.

A Direct Oral Anticoagulant as a Cost Effective Alternative to Warfarin for Treatment of Provoked Venous Thrombosis

In Ireland, Warfarin is the primary anticoagulant prescribed in the secondary prevention of provoked DVT. We completed a comprehensive cost analysis of a trial group of 24 patients treated with Rivaroxaban (between November 2013 and December 2014), versus a control group treated with Warfarin (between January 2008 and November 2013). The groups were matched for gender (3/7 M/F ratio), DVT type (5 proximal, 19 distal DVTs), provoking factor (20 traumatic, 4 atraumatc), and age. We calculated the cost for each group based on drug administration and clinic costs (labour, sample analysis, and additional costs). Warfarin patients attended clinic 14.58 times; Rivaroxaban patients attended 2.92 times. Overall, the cost per patient on Rivaroxaban is €273.30 versus €260.68 with warfarin. This excludes patient costs which would further increase cost of Warfarin therapy.

What are the risks and knowledge deficits for prescribing and administering opioids in the ward environment? A quality project on assessing and improving knowledge

Investigations into Medical Emergency Team (MET) calls and related clinical incident reviews at a large district teaching hospital provided evidence that over sedation can be a significant issue post opioid administration and that safe and effective pain management requires accurate opioid knowledge and patient assessment skills. The aim of the study was to develop education that was directed at identified knowledge deficits, and to evaluate the impact of this tailored education program on knowledge of safe prescribing and administration of opioids. Knowledge levels were explored using a structured questionnaire in a pre and post-test design. A convenience sample of 34 nurses and 5 junior medical officers across three surgical wards in a tertiary referral hospital had their knowledge assessed. Results showed significant improvement when repeat questionnaires were given two weeks post-delivery of education. Mean scores were 68% at baseline and 89% two weeks post completion of the education program. The greatest improvement in scores was recorded for drug knowledge including dose, half-life and administration. The findings from this study suggest that the opioid education program is effective in improving the knowledge of safe prescribing and administration of opioids, however further studies are required.

Delayed seizure-like activity following analytically confirmed use of previously unreported synthetic cannabinoid analogues

Synthetic cannabinoid use has become widespread, leading to increased burdens on health care providers. Symptoms range from agitation and psychosis to seizures and acute kidney injury. We report a case where a patient was assessed and treated twice within 12 h for seizures following synthetic cannabinoid intoxication. Blood sample determinations showed low concentrations of analogues not previously reported, some of which are legal. Clinicians should be aware that synthetic cannabinoids may cause an array of severe health consequences. Given the ever evolving structure of available analogues, clinicians must also be prepared for other unexpected adverse effects.

Inflammatory bowel disease and thromboembolism. Is inflammation at the centre of the clot?

Thromboembolic events are well recognised in patients with inflammatory bowel disease (IBD). We present three cases which highlight the need for vigilance with respect to this complication. We also propose that consideration be given to re-evaluating disease activity in those patients who develop thromboembolic complications.

Confusion and altered behaviour? Cause

We describe the case of a 65-year-old man who presented with confusion and change in behaviour, and describe the investigative steps that were taken before a diagnosis was made. This patient was eventually diagnosed with leptomeningeal carcinomatosis secondary to a previously undiagnosed oesophageal carcinoma.