How Long Does Contouring Really Take? Results of the Royal College of Radiologists Contouring Surveys

AIMS

The success and safety of modern radiotherapy relies on accurate contouring. Understanding the time taken to complete radiotherapy contours is critical to informing workforce planning and, in the context of a workforce shortfall, advocating for investment in technology and multi-professional skills mix. We aimed to quantify the time taken to delineate target volumes for radical radiotherapy.

MATERIALS AND METHODS

The Royal College of Radiologists circulated two electronic surveys via email to all clinical oncology consultants in the UK. The individual case survey requested anonymous data regarding the next five patients contoured for radical radiotherapy. The second survey collected data on respondents' usual practice in radiotherapy contouring.

RESULTS

The median time to contour one radiotherapy case was 85 minutes (IQR = 50-131 minutes). Marked variability between and within tumour sites was evident: paediatric cancers took the most time (median = 210 minutes, IQR = 87.5 minutes), followed by head and neck and gynaecological cancers (median = 120 minutes, IQR = 71 and 72.5 minutes respectively). Breast cancer contouring required the least time (median = 43 minutes, IQR = 60 minutes). Radiotherapy technique, inclusion of nodes and 4D CT planning were associated with longer contouring times. A non-medical professional was involved in contouring in 65% of cases, but clinical oncology consultants were involved in target volume delineation in 90% of cases, and OARs in 74%. Peer review took place in 46% of cases with 56% of consultants reporting no time for peer review in their job plan.

CONCLUSION

Contouring for radical radiotherapy is complex and time-consuming, and despite increasing involvement of non-medical professionals, clinical oncology consultants remain the primary practitioners. Peer review practice is variable and time is often a limiting factor. Many factors influence the time required for contouring, and departments should take these factors and the need for peer-review into account when developing job plans.

An Overview of Real-World Data Infrastructure for Cancer Research

AIMS

There is increasing interest in the opportunities offered by Real World Data (RWD) to provide evidence where clinical trial data does not exist, but access to appropriate data sources is frequently cited as a barrier to RWD research. This paper discusses current RWD resources and how they can be accessed for cancer research.

MATERIALS AND METHODS

There has been significant progress on facilitating RWD access in the last few years across a range of scales, from local hospital research databases, through regional care records and national repositories, to the impact of federated learning approaches on internationally collaborative studies. We use a series of case studies, principally from the UK, to illustrate how RWD can be accessed for research and healthcare improvement at each of these scales.

RESULTS

For each example we discuss infrastructure and governance requirements with the aim of encouraging further work in this space that will help to fill evidence gaps in oncology.

CONCLUSION

There are challenges, but real-world data research across a range of scales is already a reality. Taking advantage of the current generation of data sources requires researchers to carefully define their research question and the scale at which it would be best addressed.

CT vs. MRI: Which is More Accurate in Grading Rectal Wall Infiltration after Hydrogel Spacer Placement for Prostate Cancer Patients?

PURPOSE/OBJECTIVE(S)

The purpose of this study was to evaluate the incidence and severity of rectal wall infiltration (RWI) in prostate cancer patients after rectal hydrogel spacer implantation, a commonly used procedure to minimize rectal radiation exposure during prostate radiotherapy. The study aimed to determine correlation of RWI using computed tomography (CT) scans and magnetic resonance imaging (MRI) scans in order to determine the optimal post-placement imaging modality.

MATERIALS/METHODS

This retrospective study was conducted on 370 patients diagnosed with localized prostate cancer who underwent rectal hydrogel spacer placement from 2020 to 2022. CT scans were performed on all patients, with a smaller subset also undergoing MRI scans. The images were independently evaluated by three radiation oncologists to grade RWI levels using a standardized scoring system based on CT and MRI images after hydrogel placement. The levels were categorized as 0 (no RWI), 1 (focal RWI), 2 (moderate RWI), and 3 (significant RWI).

RESULTS

Any grade of RWI was identified in 79.8% of men with the majority (41%) being RWI grade 1. The median time for CT scans was 9 days after hydrogel spacer placement and 14.5 days for MRI scans. For the subset of patients with both CT and MRI scans after spacer (mostly SpaceOAR Vue), RWI was detected in 58.33% of patients based on CT and 61.11% of patients based on MRI. Table 1 shows the mean percentage of patients with each score of RWI for each imaging modality. MRI was more likely to lead to a designation of RWI of any grade compared to CT and more often led to detection of RWI grades 2-3.

CONCLUSION

Our findings demonstrate that the incidence and severity of RWI may be higher than previously reported in clinical trials and that MRI may be a more sensitive imaging modality. Caution is needed in the utilization of rectal spacer gels given the potential for complications with misplacement prior to radiation therapy. Further study is warranted to determine the potential impact of low-grade RWI on the safety of subsequent treatment.

Internal and external workload in national and international netball competition

Differences in workload exist between netball playing positions and competition levels, but no research has compared workloads experienced by the same elite players during national and international competitions. This study collected internal (heart rate) and external (PlayerLoad·min-1) workload data per match quarter from 44 players during a national competition and 12 players during an international competition. Nine players played in both competitions. Linear mixed models compared percentage of match quarter in each heart rate zone and PlayerLoad·min-1 between competitions for each playing position. Workloads against low- and high-ranked international opponents were also compared. Internal workloads were greater in national compared to international competition for GD and WD positions. PlayerLoad·min-1 was significantly higher by 8-13% in the national competition for positions WD and C, and by 5-8% in the international competition for GD and GA. Positional differences may indicate a role of the team's tactical style of play. Workloads were generally greater against higher- rather than lower-ranked international opponents. These results indicate that tactical factors in combination with playing position and opposition characteristics should be considered when preparing physically for matches.

Health Services Research in Brachytherapy: Current Understanding and Future Challenges

Brachytherapy is an integral component of cancer care. Widespread concerns have been expressed though about the need for greater brachytherapy availability across many jurisdictions. Yet, health services research in brachytherapy has lagged behind that in external beam radiotherapy. Optimal brachytherapy utilisation, to help inform expected demand, have not been defined beyond the New South Wales region in Australia, with few studies having reported observed brachytherapy utilisation. There is also a relative lack of robust cost and cost-effectiveness studies, making investment decisions in brachytherapy even more uncertain and challenging to justify, despite its key role in cancer control. As the range of indications for brachytherapy expands, providing organ/function preservation for a wider range of diagnoses, there is an urgent need to redress this balance. By outlining the work undertaken in this area to date, we highlight its importance and explore where further study is required.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Real-world application of tumor mutational burden-high (TMB-high) and microsatellite instability (MSI) confirms their utility as immunotherapy biomarkers

Introduction

Microsatellite instability (MSI) testing and tumor mutational burden (TMB) are genomic biomarkers used to identify patients who are likely to benefit from immune checkpoint inhibitors. Pembrolizumab was recently approved by the Food and Drug Administration for use in TMB-high (TMB-H) tumors, regardless of histology, based on KEYNOTE-158. The primary objective of this retrospective study was real-world applicability and use of immunotherapy in TMB/MSI-high patients to lend credence to and refine this biomarker.

Methods

Charts of patients with advanced solid tumors who had MSI/TMB status determined by next generation sequencing (NGS) (FoundationOne CDx) were reviewed. Demographics, diagnosis, treatment history, and overall response rate (ORR) were abstracted. Progression-free survival (PFS) was determined from Kaplan–Meier curves. PFS1 (chemotherapy PFS) and PFS2 (immunotherapy PFS) were determined for patients who received immunotherapy after progressing on chemotherapy. The median PFS2/PFS1 ratio was recorded.

Results

MSI-high or TMB-H [≥20 mutations per megabase (mut/MB)] was detected in 157 adults with a total of 27 distinct tumor histologies. Median turnaround time for NGS was 73 days. ORR for most recent chemotherapy was 34.4%. ORR for immunotherapy was 55.9%. Median PFS for patients who received chemotherapy versus immunotherapy was 6.75 months (95% confidence interval, 3.9-10.9 months) and 24.2 months (95% confidence interval, 9.6 months to not reached), respectively (P = 0.042). Median PFS2/PFS1 ratio was 4.7 in favor of immunotherapy.

Conclusion

This real-world study reinforces the use of TMB as a predictive biomarker. Barriers exist to the timely implementation of NGS-based biomarkers and more data are needed to raise awareness about the clinical utility of TMB. Clinicians should consider treating TMB-H patients with immunotherapy regardless of their histology.

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This retrospective study examined the real-world use of immune checkpoint inhibitors (ICIs) in TMB/MSI-high patients with a diverse set of cancer types.

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TMB is an emerging tumor-agnostic biomarker for response to treatment with ICIs that may expand personalized cancer care.

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ICIs remain underutilized as a first-line therapy for TMB/MSI-H patients without specific histologic approval for ICIs.

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The PFS2 to PFS1 ratio was 4.7, favoring immunotherapy over chemotherapy even as a second-line therapy.

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Our study reinforces the real-world evidence that TMB is a valid surrogate marker for MSI and can predict response to ICIs.

948 Feasibility Study of a Drive-Through Influenza Vaccination Clinic for Patients-At-Risk & Their Contacts

Background

There are 3-5 million cases of severe influenza-like illness globally each year, and up to 650,000 related deaths. This high prevalence rate proves to be a heavy burden on the healthcare system with >3,000 hospitalisations and >150 ICU admissions annually. Immunisation is gold-standard for the prevention of influenza outbreaks. The HSE Influenza Immunisation Strategy allocates vaccines to be administered in primary care to patients at-risk and their contacts. However, due to the COVID-19 pandemic, this has become a logistical challenge. We aimed to design and test a drive-through influenza vaccine clinic at a large GP practice in Cork.

Method

We designed and implemented an online booking system for at-risk patients and their contacts. 1-minute drive-through time slots were available to book for up to 6 people per vehicle. The primary measurement was the number of patients vaccinated with a secondary measurement of time spent vaccinating these patients.

Results

The pilot clinic occurred on 10/10/2020 with over 600 patients-at-risk & their contacts receiving the influenza vaccination over a time period of 10 hours. The capacity of this clinic was limited by the supply of vaccines. We estimate that 1,800 people could be vaccinated over the same time period with adequate vaccine supply.

Conclusions

A drive-through influenza vaccination clinic can be efficiently run using an online booking system and serves as a safe, efficient, and convenient way for patients-at-risk & their contacts to receive vaccinations. This system can be rolled out efficiently each winter for influenza vaccination and could be expanded to deliver mass vaccination for SARS-CoV-2.

The Prognosis in Palliative care Study II (PiPS2): A prospective observational validation study of a prognostic tool with an embedded qualitative evaluation

Background

Prognosis in Palliative care Study (PiPS) models predict survival probabilities in advanced cancer. PiPS-A (clinical observations only) and PiPS-B (additionally requiring blood results) consist of 14- and 56-day models (PiPS-A14; PiPS-A56; PiPS-B14; PiPS-B56) to create survival risk categories: days, weeks, months. The primary aim was to compare PIPS-B risk categories against agreed multi-professional estimates of survival (AMPES) and to validate PiPS-A and PiPS-B. Secondary aims were to assess acceptability of PiPS to patients, caregivers and health professionals (HPs).

Methods and findings

A national, multi-centre, prospective, observational, cohort study with nested qualitative sub-study using interviews with patients, caregivers and HPs. Validation study participants were adults with incurable cancer; with or without capacity; recently referred to community, hospital and hospice palliative care services across England and Wales. Sub-study participants were patients, caregivers and HPs. 1833 participants were recruited. PiPS-B risk categories were as accurate as AMPES [PiPS-B accuracy (910/1484; 61%); AMPES (914/1484; 61%); p = 0.851]. PiPS-B14 discrimination (C-statistic 0.837) and PiPS-B56 (0.810) were excellent. PiPS-B14 predictions were too high in the 57–74% risk group (Calibration-in-the-large [CiL] -0.202; Calibration slope [CS] 0.840). PiPS-B56 was well-calibrated (CiL 0.152; CS 0.914). PiPS-A risk categories were less accurate than AMPES (p<0.001). PiPS-A14 (C-statistic 0.825; CiL -0.037; CS 0.981) and PiPS-A56 (C-statistic 0.776; CiL 0.109; CS 0.946) had excellent or reasonably good discrimination and calibration. Interviewed patients (n = 29) and caregivers (n = 20) wanted prognostic information and considered that PiPS may aid communication. HPs (n = 32) found PiPS user-friendly and considered risk categories potentially helpful for decision-making. The need for a blood test for PiPS-B was considered a limitation.

Conclusions

PiPS-B risk categories are as accurate as AMPES made by experienced doctors and nurses. PiPS-A categories are less accurate. Patients, carers and HPs regard PiPS as potentially helpful in clinical practice.

Study registration

ISRCTN13688211.

Prognostic tools or clinical predictions: Which are better in palliative care?

PURPOSE

The Palliative Prognostic (PaP) score; Palliative Prognostic Index (PPI); Feliu Prognostic Nomogram (FPN) and Palliative Performance Scale (PPS) have all been proposed as prognostic tools for palliative cancer care. However, clinical judgement remains the principal way by which palliative care professionals determine prognoses and it is important that the performance of prognostic tools is compared against clinical predictions of survival (CPS).

METHODS

This was a multi-centre, cohort validation study of prognostic tools. Study participants were adults with advanced cancer receiving palliative care, with or without capacity to consent. Key prognostic data were collected at baseline, shortly after referral to palliative care services. CPS were obtained independently from a doctor and a nurse.

RESULTS

Prognostic data were collected on 1833 participants. All prognostic tools showed acceptable discrimination and calibration, but none showed superiority to CPS. Both PaP and CPS were equally able to accurately categorise patients according to their risk of dying within 30 days. There was no difference in performance between CPS and FPN at stratifying patients according to their risk of dying at 15, 30 or 60 days. PPI was significantly (p<0.001) worse than CPS at predicting which patients would survive for 3 or 6 weeks. PPS and CPS were both able to discriminate palliative care patients into multiple iso-prognostic groups.

CONCLUSIONS

Although four commonly used prognostic algorithms for palliative care generally showed good discrimination and calibration, none of them demonstrated superiority to CPS. Prognostic tools which are less accurate than CPS are of no clinical use. However, prognostic tools which perform similarly to CPS may have other advantages to recommend them for use in clinical practice (e.g. being more objective, more reproducible, acting as a second opinion or as an educational tool). Future studies should therefore assess the impact of prognostic tools on clinical practice and decision-making.

Neutron Diffraction Study of Macrostress and Microstress in Al-Al2O3-Based Corrosion Protection Coating Obtained by Cold Spray (Dynamic Metallization)

Protective coatings based on an Al-Al2O3 metal matrix composite (MMC) were sprayed using dynamic metallization (DM), a low-pressure cold spray variant. A series of samples approximately 1 mm in thickness were sprayed using different spray process parameters (temperature, velocity) and different feedstock powder compositions (Al, Zn, Al2O3). This resulted in MMCs of different phase compositions and slightly different physical conditions of coating formation. The through-thickness residual stresses that accumulate in coatings during the spray process were studied using neutron diffraction in all phases comprising the MMCs. The overall residual stress in the coating (macrostress) was compressive, which is in good agreement with the data on residual stress observed in other cold spray coatings, accumulating as a result of the peening process. However, due to the slightly elevated spray temperature characteristic of DM in comparison with other cold spray variants, thermal stresses are also present and play an equally important role in the accumulation of residual stress in each phase. Because of the multi-phase composition and thermal mismatch between the metal and ceramic components of the MMC, inter-phase microstresses also accumulate. A micro-mechanical explanation of the observed tensile microstress in Al/Zn versus compressive stress in Al2O3 is proposed.

Pravastatin for early-onset pre-eclampsia: a randomised, blinded, placebo-controlled trial

Objective

Women with pre‐eclampsia have elevated circulating levels of soluble fms‐like tyrosine kinase‐1 (sFlt‐1). Statins can reduce sFlt‐1 from cultured cells and improve pregnancy outcome in animals with a pre‐eclampsia‐like syndrome. We investigated the effect of pravastatin on plasma sFlt‐1 levels during pre‐eclampsia.

Design

Blinded (clinician and participant), proof of principle, placebo‐controlled trial.

Setting

Fifteen UK maternity units.

Population

We used a minimisation algorithm to assign 62 women with early‐onset pre‐eclampsia (24⁺⁰–31⁺⁶ weeks of gestation) to receive pravastatin 40 mg daily (n = 30) or matched placebo (n = 32), from randomisation to childbirth.

Primary outcome

Difference in mean plasma sFlt‐1 levels over the first 3 days following randomisation.

Results

The difference in the mean maternal plasma sFlt‐1 levels over the first 3 days after randomisation between the pravastatin (n = 27) and placebo (n = 29) groups was 292 pg/ml (95% CI −1175 to 592; P = 0.5), and over days 1–14 was 48 pg/ml (95% CI −1009 to 913; P = 0.9). Women who received pravastatin had a similar length of pregnancy following randomisation compared with those who received placebo (hazard ratio 0.84; 95% CI 0.50–1.40; P = 0.6). The median time from randomisation to childbirth was 9 days (interquartile range [IQR] 5–14 days) for the pravastatin group and 7 days (IQR 4–11 days) for the placebo group. There were three perinatal deaths in the placebo‐treated group and no deaths or serious adverse events attributable to pravastatin.

Conclusions

We found no evidence that pravastatin lowered maternal plasma sFlt‐1 levels once early‐onset pre‐eclampsia had developed. Pravastatin appears to have no adverse perinatal effects.

Tweetable abstract

Pravastatin does not improve maternal plasma sFlt‐1 or placental growth factor levels following a diagnosis of early preterm pre‐eclampsia #clinicaltrial finds.

Pravastatin does not improve maternal plasma sFlt‐1 or placental growth factor levels following a diagnosis of early preterm pre‐eclampsia #clinicaltrial finds.

Hypofractionated Radiotherapy in Oesophageal Cancer for Patients Unfit for Systemic Therapy: A Retrospective Single-Centre Analysis

AIMS

Chemoradiotherapy (CRT) is established as a superior treatment option to definitive radiotherapy in the non-surgical management of oesophageal cancer. For patients precluded from CRT through choice or comorbidity there is little evidence to guide delivery of single-modality radiotherapy. In this study we outline outcomes for patients unfit for CRT who received a hypofractionated radiotherapy (HRT) regimen.

MATERIALS AND METHODS

A retrospective UK single-centre analysis of 61 consecutive patients with lower- or middle-third adenocarcinoma (OAC; 61%) or squamous cell carcinoma of the oesophagus managed using HRT with radical intent between April 2009 and 2014. Treatment consisted of 50 Gy in 16 fractions (n = 49, 80.3%) or 50-52.5 Gy in 20 fractions (n = 12, 19.7%). Outcomes were referenced against a contemporaneous comparator cohort of 80 (54% OAC) consecutive patients managed with conventionally fractionated CRT within the same centre.

RESULTS

Three-year and median overall survival were, respectively, 56.9% and 29 months with HRT compared with 55.5% and 26 months for CRT; adjusted hazard ratio 0.79 (95% confidence interval 0.48-1.28). Grade 3 and 4 toxicity rates were low at 16.4% (n = 10) for those receiving HRT and 40.2% (n = 32) for the CRT group. In patients with OAC, CRT delivered superior overall survival (hazard ratio 0.46; 95% confidence interval 0.25-0.85) and progression-free survival (hazard ratio 0.45; 95% confidence interval 0.23-0.88) when compared with HRT.

CONCLUSIONS

The HRT regimen described here was safe and tolerable in patients unable to receive CRT, and delivered promising survival outcomes. The use of HRT for the treatment of oesophageal cancer, both alone and as a sequential or concurrent treatment with chemotherapy, requires further study. New precision radiotherapy technologies may provide additional scope for improving outcomes in oesophageal cancer using HRT-based approaches and should be evaluated.

Nuclear forensic analysis of a non-traditional actinide sample

Nuclear forensic publications, performance tests, and research and development efforts typically target the bulk global inventory of intentionally safeguarded materials, such as plutonium (Pu) and uranium (U). Other materials, such as neptunium (Np), pose a nuclear security risk as well. Trafficking leading to recovery of an interdicted Np sample is a realistic concern especially for materials originating in countries that reprocesses fuel. Using complementary forensic methods, potential signatures for an unknown Np oxide sample were investigated. Measurement results were assessed against published Np processes to present hypotheses as to the original intended use, method of production, and origin for this Np oxide.

Wide Variation in the Use of Radiotherapy in the Management of Surgically Treated Rectal Cancer Across the English National Health Service

AIMS

Radiotherapy is an important treatment modality in the multidisciplinary management of rectal cancer. It is delivered both in the neoadjuvant setting and postoperatively, but, although it reduces local recurrence, it does not influence overall survival and increases the risk of long-term complications. This has led to a variety of international practice patterns. These variations can have a significant effect on commissioning, but also future clinical research. This study explores its use within the large English National Health Service (NHS).

MATERIALS AND METHODS

Information on all individuals diagnosed with a surgically treated rectal cancer between April 2009 and December 2010 were extracted from the Radiotherapy Dataset linked to the National Cancer Data Repository. Individuals were grouped into those receiving no radiotherapy, short-course radiotherapy with immediate surgery (SCRT-I), short-course radiotherapy with delayed surgery (SCRT-D), long-course chemoradiotherapy (LCCRT), other radiotherapy (ORT) and postoperative radiotherapy (PORT). Patterns of use were then investigated.

RESULTS

The study consisted of 9201 individuals; 4585 (49.3%) received some form of radiotherapy. SCRT-I was used in 12.1%, SCRT-D in 1.2%, LCCRT in 29.5%, ORT in 4.7% and PORT in 2.3%. Radiotherapy was used more commonly in men and in those receiving an abdominoperineal excision and less commonly in the elderly and those with comorbidity. Significant and substantial variations were also seen in its use across all the multidisciplinary teams managing this disease.

CONCLUSION

Despite the same evidence base, wide variation exists in both the use of and type of radiotherapy delivered in the management of rectal cancer across the English NHS. Prospective population-based collection of local recurrence and patient-reported early and late toxicity information is required to further improve patient selection for preoperative radiotherapy.

Smartphone, Smart Surgeon, what about a 'Smart Logbook'?

BACKGROUND

Mobile phone applications (Apps) have become a vital assistant to medical personnel in today's technologically advanced era. The utility of Apps with case logbook capabilities has not yet been explored.

OBJECTIVE

To assess and evaluate all currently available surgical and procedural case logbook Apps.

METHOD

A comprehensive search was conducted in April 2015 on the Android Play Store, iTunes (Apple App Store, iOS), and BlackBerry World for surgical and/or procedural logbooks. The search terms'surgical logbook', 'logbook', 'procedure logbook' and 'surgical log' were used. Apps which could not be utilized as a surgical/procedural logbook were excluded. Each App was individually assessed and rated using preset criteria, by the unit consultant, registrars, and medical officer.

RESULTS

In total, 2 740 Apps were assessed. After applying our exclusion criteria, only 16 Apps were relevant, and 11 suitable for critical review. Data sizes ranged from 510Kb to 12.2Mb. Costing of the Apps ranged from ZAR 0.00 to ZAR 105.32. The overall study scores revealed the following top five rated Apps: Surgical Logbook by Surgilog; Surgeon Logbook Pro; Surgery Notebook, Surgical Logbook, and Universal Logbook.

CONCLUSION

The current mobile Apps available are efficient in replacing traditional case logbooks. The use of the 'Smart Logbook' may become common practice in the life of the modern-day surgeon.

Validation of reference materials for uranium radiochronometry in the frame of nuclear forensic investigations

The results of a joint effort by expert nuclear forensic laboratories in the area of age dating of uranium, i.e. the elapsed time since the last chemical purification of the material are presented and discussed. Completely separated uranium materials of known production date were distributed among the laboratories, and the samples were dated according to routine laboratory procedures by the measurement of the (230)Th/(234)U ratio. The measurement results were in good agreement with the known production date showing that the concept for preparing uranium age dating reference material based on complete separation is valid. Detailed knowledge of the laboratory procedures used for uranium age dating allows the identification of possible improvements in the current protocols and the development of improved practice in the future. The availability of age dating reference materials as well as the evolvement of the age dating best-practice protocol will increase the relevance and applicability of age dating as part of the tool-kit available for nuclear forensic investigations.

Undetectable pregnancy-associated plasma protein-A in antenatal serum Down's syndrome screening: a case of assay interference

Serum pregnancy-associated plasma protein-A (PAPP-A) is measured in Down's syndrome screening, routinely offered to women in pregnancy. We present the case of an undetectable pregnancy-associated plasma protein-A concentration on the PerkinElmer AutoDELFIA system where immunoassay interference was suspected. Investigations performed, including dilution and recovery studies and antibody-blocking tube incubations, all yielded serum pregnancy-associated plasma protein-A concentrations of <25 mU/L. Pregnancy-associated plasma protein-A was also undetectable on two alternative pregnancy-associated plasma protein-A assays. An experimental manual Delfia procedure suggested the site of interference was between the secondary antibody and the pregnancy-associated plasma protein-A molecule. This case of negative interference in the PerkinElmer pregnancy-associated plasma protein-A assay produced a falsely high Down's syndrome risk that might have led to an unnecessary invasive procedure with the potential for fetal loss. This highlights the need for Down's syndrome screening laboratories to be vigilant to immunoassay interference due to the significant impact of the results on patient decision outcome.

Maternal serum CA 19-9 and CA 15-3 levels in pregnancies affected by trisomy 21

OBJECTIVES

To investigate the levels of tumour markers CA 19-9 and CA 15-3 in the first trimester maternal serum of euploid control and trisomy 21 pregnancies.

METHODS

Maternal serum marker levels of 69 trisomy 21 and 388 euploid controls were quantified by the Kryptor analyser, and levels were compared between the two groups after analysis for confounding factors. Monte Carlo simulation was carried out to determine the effect of adding potential markers to the combined test.

RESULTS

Neither marker was affected by gestational age; however, CA 19-9 required correction for maternal weight. CA 19-9 was significantly increased in trisomy 21 pregnancies (0.98 MoM in euploid, 1.16 MoM in trisomy 21, p = 0.024). Levels of CA 15-3 were not found to differ significantly (1.03 MoM in euploid, 1.09 in trisomy 21, p = 0.130). Detection rates were unaffected by addition of CA 19-9 to the combined test.

CONCLUSION

Although a small significant increase in CA 19-9 levels was found in trisomy 21 group, it is unlikely to be of any use as part of a trisomy 21 screening tool.

Energy expenditure in US automotive technicians and occupation-specific cardiac rehabilitation

BACKGROUND

The standard exercise protocol for patients in a traditional cardiac rehabilitation (rehab) programme may not be adequate for preparing manual workers for a safe return to work, as these activities bear little resemblance to the physical movements and force exertion required in most industrial jobs.

AIMS

To measure the energy expenditure as metabolic equivalents (METs) required for automotive technicians, to compare this MET level with that normally attained in traditional cardiac rehab programmes and to suggest cardiac rehab exercises for automotive technicians based on specificity of training.

METHODS

Automotive technicians who volunteered to participate had their MET levels measured while they performed a defined series of work tasks in the service department of an automobile dealership. Their daily walking distance was also determined.

RESULTS

Thirty-six of 95 eligible subjects participated; a response rate of 38%. Mean peak MET level was 7.1, less than the 8 METs target training goal often used in traditional cardiac rehab programmes. However, patients' outcome MET levels in cardiac rehab are usually measured by a treadmill stress test, whereas the subjects reached 7.1 METs while performing work tasks. The subjects walked an average of 5 km during a normal workday.

CONCLUSIONS

Because MET level measurements are work specific, automotive technicians in a cardiac rehab programme should strive to reach and maintain a level of >7 METs while performing specific training exercises that mimic the work tasks they must do throughout the day. They can also benefit from traditional endurance training such as treadmill walking.