Brachytherapy workflow for locally advanced cervical cancer: A survey of Canadian Medical Physicists

PURPOSE

To report on brachytherapy (BT) workflows for image-based treatments of locally advanced cervical cancer (CC) in Canada.

METHODS

Medical Physicists in every Canadian cancer center were contacted and those with a CC-BT program were emailed a 44-item electronic questionnaire surveying workflow patterns including: fractionation schedules, prescription, equipment, imaging, and treatment delivery.

RESULTS

Of 47 centers contacted, all 34 who performed CC-BT participated in the survey. Brachytherapy boost, following external beam treatments, was delivered using high-dose-rate (HDR); one center also used pulsed-dose-rate. Intracavitary and/or interstitial treatments were done in 47% centers for 25-80% of their patients. All centers used image-based planning: CT (32%), CT planned with MRI for contouring (47%), MRI (18%), or cone beam CT (3%). For those performing volume-based planning (74%), the contours commonly included Clinical Target Volume (CTV)-High Risk (HR), CTV-Intermediate Risk, rectum, sigmoid, and bladder. The most common HDR dose-fractionation schedule was 7 [4.6 - 10] Gy in 4 [3 - 6] fractions with radiobiological dose prescriptions performed in 62% centers. Medical physics contribution was significant during most activities along the BT treatment pathway in all centers, especially in planning (88%), second checks (68%), and during treatment delivery (88%).

CONCLUSIONS

Compared to previous surveys, there is an increasing trend in the use of image-based volumetric planning, interstitial procedures, and radiobiological dose prescription. Cervical cancer brachytherapy in Canada is becoming more streamlined with the use of international practice guidelines. Involvement of medical physicists is vital to all stages of CC-BT, including program implementation, routine quality control, dosimetry, and treatment delivery.

A site-specific standard for comparing dynamic solar ultraviolet protection characteristics of established tree canopies

A standardised procedure for making fair and comparable assessments of the ultraviolet protection of an established tree canopy that takes into account canopy movement and the changing position of the sun is presented for use by government, planning, and environmental health authorities. The technique utilises video image capture and replaces the need for measurement by ultraviolet radiometers for surveying shade quality characteristics of trees growing in public parks, playgrounds and urban settings. The technique improves upon tree shade assessments that may be based upon single measurements of the ultraviolet irradiance observed from a fixed point of view. The presented technique demonstrates how intelligent shade audits can be conducted without the need for specialist equipment, enabling the calculation of the Shade Protection Index (SPI) and Ultraviolet Protection Factor (UPF) for any discreet time interval and over a full calendar year.

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Tree shade UPF measurements are presented using video capture analysis of moving canopies

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A standard method for making accurate assessments of tree shade has been developed

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Tree shade comparisons are made without the need for specialist equipment

A novel method for detection of IFN-lambda 3 binding to cells for quantifying IFN-lambda receptor expression

Type III interferons (IFN-lambdas) are important antiviral cytokines that also modulate immune responses acting through a unique IFN-λR1/IL-10R2 heterodimeric receptor. Conflicting data has been reported for which cells express the IFN-λR1 subunit and directly respond to IFN-λs. In this study we developed a novel method to measure IFN-λ3 binding to IFN-λR1/IL-10R2 on the surface of cells and relate this to a functional readout of interferon stimulated gene (ISG) activity in various cell lines. We show that Huh7.5 hepatoma cells bind IFN-λ3 at the highest levels with the lowest Kd(app), translating to the highest induction of various ISGs. Raji and Jurkat cell lines, representing B and T cells, respectively, moderately bind IFN-λ3 and have lower ISG responses. U937 cells, representing monocytes, did not bind IFN-λ3 well and therefore, did not have any ISG induction. Importantly, knockdown of IFNLR1 in Huh7.5 cells decreased our binding signal proportionally and reduced ISG induction by up to 93%. IFN-λ3 responsiveness increased over time with maximal ISG responses seen at 24h for all but one gene. These data confirm our new IFN-λ3 binding assay can be used to quantify IFN-λ receptor surface expression on a variety of cell types and reflects IFN-λ3 responsiveness.

A novel method for the detection of IFN-lambda 3 binding to cells to quantify IFN-lambda receptor expression on epithelial and immune cell subsets

Type III interferons (IFN-lambdas) are important antiviral cytokines that also modulate immune responses by acting through a unique IFN-λR1/IL-10R2 heterodimeric receptor. Conflicting data has been reported for which human cells express the IFN-λR1 subunit and directly respond to IFN-λ. Since the commercially available anti-IFN-λR1 flow cytometry antibodies we tried were suboptimal, we developed a novel method to measure IFN-λ3 binding to IFN-λR1/IL-10R2 on the surface of cells via flow cytometry. We found that Huh7.5 hepatoma cells bound IFN-λ3 to the greatest extent with the lowest Kd(app) (83.2nM), and had the corresponding highest induction of IFN stimulated genes (ISGs). Raji and Jurkat cell lines, representing B and T cells, respectively, moderately bound IFN-λ3 and had lower ISG responses. U937 cells, representing monocytes, did not bind IFN-λ3 and therefore, did not have detectable ISG induction. We confirmed that IFN-λ3 was bound to the surface of cells through imaging flow cytometry. Importantly, lentivirus shRNA knockdown of IFNLR1 in Huh7.5 cells decreased our binding signal proportionally and reduced ISG induction by up to 93%. IFN-λ3 responsiveness increased over time with maximal ISG responses seen at 24 hrs for all but one gene. We next applied our assay to human peripheral blood mononuclear cells and saw that only specific immune cell subsets bound IFN-λ3 (eg. plasmacytoid dendritic cells and B cells). These data confirm our new IFN-λ3 binding assay can be used to quantify where the IFN-λ receptor is expressed and reflects IFN-λ3 responsiveness. Knowing which cells express the IFN-λ receptor will be crucial for determining how IFN-λ3 modulates the adaptive immune response.

An exploration of the experience of mental health service users when they decide they would like to change or withdraw from prescribed medications

This paper reports on a collaborative research project initiated by service user representatives and led by clinicians from the mental health service in Derbyshire. The study explored the experiences of mental health service users when they either changed or terminated their use of mental health-related medications. Three focus groups were conducted with mental health service users from across the county. An inductive thematic analysis identified six key themes, three of which are reported here: the 'two faces' of service provision, describing the positive and negative experiences of services; the general practice/mental health divide, relating to the lack of continuity between the two services; and becoming an informed service user, where participants discussed the importance of seeking information. It is important that mental health professionals always consider presenting their 'best face' to service users, and facilitate the prescribing process with general practitioners. The findings also highlight the potential for supporting service users in using different sources of information to become more informed about medication.

Long-term study of re-infection following successful eradication of Helicobacter pylori infection

BACKGROUND

'Re-infection' with Helicobacter pylori after eradication has been estimated to occur in 0-14% of patients, although most so-called 're-infections' occur within the first year following 'eradication' and many may actually be due to recrudescence of a temporarily suppressed infection.

AIM

To study the true re-infection rate, we have studied re-infection rates after eradication therapy by excluding the first year's data, minimizing the possible confounding effect of recrudescence.

METHODS

All patients tested for H. pylori infection following eradication therapy between 1987 and 2004 were evaluated. Testing was carried out by urea breath test and gastric biopsy. Patients were included if they were found to be negative for H. pylori infection by testing at least 1 year following eradication and underwent at least one further test for H. pylori.

RESULTS

1162 patients met the inclusion criteria with median post-eradication follow-up of 3 years (1.5-14) including 4668 tests; 3319 years of follow-up were analysed. Thirteen cases of re-infection occurred (re-infection rate 0.4% per year).

CONCLUSIONS

This large study of H. pylori re-infection avoided cases of recrudescence by excluding the first post-eradication year. True re-infection is probably less common than previously thought.

Host inflammatory response to NiCr, CoCr, and Ti in a soft tissue implantation model

The inflammatory response to nickel chromium (NiCr), cobalt chromium (CoCr), and titanium (Ti) implants at 7 and 28 days was investigated using real-time PCR analysis along with histological and immunohistochemical staining. Contrasting inflammatory profiles were found in response to the different metal compositions. The inflammatory profile induced by CoCr remained consistent and elevated during the 28-day period with high cell counts associated with the implants and a progressive recruitment of T lymphocytes. The response to NiCr was also elevated, but with an initially low T-lymphocyte infiltration that increased by the later time period. Ti indicated an early increased inflammatory response that had reduced by 28 days. Changes in gene expression demonstrated that Ti induced very low levels of expression of the three inflammatory cytokine genes. NiCr initiated a significant upregulation in gene expression for IL-6 and TNF-alpha. CoCr resulted in the highest upregulation of IL-2 indicative of T-lymphocyte activation to this material.

Flow cytometric measurement of phagocytosis reveals a role for C3b in metal particle uptake by phagocytes

A methodology for the quick and efficient study of phagocytosis has been developed. It uses the flow cytometer to exploit the change in size and granularity that occurs in cells upon the ingestion of particulate material. The numbers of cells that have phagocytosed particles can be calculated from the distinct shift in regions that occurs. The method also allows the factors governing phagocytosis to be studied in detail through the use of blocking agents or antibodies. Blood-derived monocytes were studied to investigate the role of complement in metal particle phagocytosis to further understand aseptic loosening. Factor C3b was found to be fundamental to the opsonization and phagocytosis of metal particles by monocytes.

Transitional cell carcinoma of the bladder mimicking lobular carcinoma of the breast: a discohesive variant of urothelial carcinoma

AIMS

To describe a series of 10 cases of transitional cell carcinoma which show morphological features which mimic lobular carcinoma of the breast and diffuse carcinoma of the stomach.

METHODS AND RESULTS

Ten cases were identified from the files at Southampton University Hospitals NHS Trust and from the authors' consultation files. Immunostains were performed and clinical information was obtained. Eight of the patients were male and two female. Ages ranged from 52 to 77 years at presentation. All of the tumours showed areas where the tumour was composed of uniform cells with a discohesive single-cell, diffusely invasive growth pattern. In areas the tumour cells were arranged in linear single-cell files and in separate areas solid sheets of discohesive cells. In all of the cases some tumour cells showed prominent intracytoplasmic vacuoles. In addition to this pattern, four cases showed typical transitional cell carcinoma or carcinoma in situ. The majority of the tumours expressed cytokeratin 20 but not oestrogen receptors.

CONCLUSION

This study highlights a pattern of diffusely invasive transitional cell carcinoma not previously described and one which is important to recognize in order to avoid misdiagnosis of metastatic lobular carcinoma of the breast, especially in small biopsies.

A study of tissue interface membranes from revision accord knee arthroplasty: the role of T lymphocytes

Despite four decades of advances in the design of orthopaedic devices aseptic loosening remains a major cause for the revision of total joint arthroplasty. This study used the techniques of immunohistochemistry and reverse transcription polymerase chain reaction to identify the inflammatory cell types, cytokines and chemokines within the interface tissue surrounding failed Accord Knee prostheses. Many T cells were identified within the tissue: however, the classical marker of activation, CD25 was expressed on very few cells. Molecular analysis failed to detect the synthesis of either Th1 or Th2 cytokines. These results suggest that the T cells are being actively recruited to the site of inflammation along the chemokine gradients but are not participating in a classical immune response.

February 2001: A 74 year old man with a history over 3 months of increasing dyspnea and malaise

The February COM: A man of 78 years with idiopathic late-onset cerebellar ataxia developed renal failure in association with a high ESR and positive pANCA. This was complicated by a subclinical spinal subarachnoid hemorrhage which was related to necrotizing inflammation of small leptomeningeal vessels. Renal cortical infarcts were due to similar inflammation in arcuate and interlobular arteries. Spinal subarachnoid hemorrhage is rare and usually due to rupture of an arteriovenous malformation. However, an immunogenic connective tissue disorder should be considered in the differential diagnosis. In this case, the histology and results of an autoantibody screen support a diagnosis of microscopic polyangiitis.

Nursing in outpatient child and adolescent mental health

This article examines the role of nurses within outpatient child and adolescent mental health services (CAMHS). The authors highlight employment trends towards generic skills-based appointments such as 'clinic workers', and asserts that nurses with specialist training have the skills to fulfill an important role in CAMHS teams but are not fully recognised for their nursing contribution.

Bath PUVA: an effective treatment for psoriasis

At the Psoriasis Education and Research Centre, PUVA baths were introduced as an alternative therapy in 1990. Psoriatic patients soaked for 15 minutes in a solution of tap water and Ultra MOP. Forty-five patients were followed for 30 treatments. Skin types were recorded and progress was documented by PASI (Psoriasis Area and Severity Index) scores. Side effects and total amount of UVA received were documented. The purpose of this study was to record the efficacy of our protocol for PUVA baths on different skin types while evaluating all aspects of the treatment.

Presence of putative neurotransmitters in the myenteric plexus of the gastrointestinal tract and in the musculature of the urinary bladder of the ferret

The innervation of the musculature in the ferret stomach, ileum, colon and urinary bladder was investigated using immunohistochemistry in noncolchicin-treated tissues. In the gastrointestinal tract two main subpopulations of myenteric neurones were found: cholinergic neurones expressing choline acetyltransferase (ChAT), which made up 68, 67 and 67% of the neurones in the stomach, ileum and colon, respectively, and nitrergic neurones containing nitric oxide synthase and NADPH-diaphorase (stomach: 23%, ileum: 21%, colon: 26%). In the stomach, cholinergic neurones expressed substance P (SP, 2% of all neurones), dopamine-beta-hydroxylase (DBH, 19%) but not tyrosine hydroxylase (TH) or vasoactive intestinal polypeptide (VIP), while nitrergic neurones contained VIP and neuropeptide Y (NPY). TH- but not DBH-immunoreactivity was observed in 4% of gastric neurones. Intense immunoreactivity in the musculature suggests that part of ChAT/SP- and NOS/NPY/VIP-positive neurones function as motorneurones. In the ileum, a high number (32%) of DBH-positive neurones was demonstrated. About half of the SP-positive neurones in the ileum also contained calcitonin gene-related peptide (CGRP). In the urinary bladder, only few intramural ganglia were observed. The smooth muscle was densely innervated by ChAT, NPY and DBH immunoreactive fibres. The data showed that the innervation of the ferret viscera exhibited similarities but also differences as compared with other mammalian species. Some of the chemical coding of myenteric neurones is remarkably similar to that observed in other mammals.

A computer-generated shift report

To maintain quality patient care while reducing overtime costs, a change in the traditional verbal shift report was needed. A pilot study examined alternate methods, format changes, benefits and nursing recommendations. Using a computer-generated nursing care plan cover sheet, a change was made to an automated written shift report.

Effect of postoperative low-dose dopamine on renal function after elective major vascular surgery

OBJECTIVE

To determine the effect on renal function of postoperative low-dose dopamine in volume-replete patients after elective, major vascular abdominal surgery.

DESIGN

Randomized, double-blind, placebo-controlled trial.

SETTING

Intensive care unit of a referral hospital in Brisbane, Australia.

PATIENTS

37 patients having elective repair of an abdominal aortic aneurysm or having aortobifemoral grafting; 18 received dopamine, and 19 received placebo. Two patients were excluded from the 5-day analysis because of perioperative death.

INTERVENTIONS

Patients were randomly assigned to receive either placebo or a low-dose infusion of dopamine (3 micrograms/kg per minute) in saline. Patients in both groups were given sufficient crystalloid to maintain a urine flow of more than 1 mL/kg per hour during the first 24 postoperative hours. Care in the intensive care unit was otherwise usual and was the same for each group.

MEASUREMENTS

Plasma creatinine levels, urea levels, and creatinine clearance were measured preoperatively and postoperatively (at 24 hours and 5 days). Urine flow and the volume of crystalloid during the first 24 hours were recorded.

RESULTS

Two postoperative deaths occurred in the dopamine group (from renal failure and myocardial infarction). Four patients had myocardial infarction, three of whom received dopamine. Plasma creatinine levels remained unchanged in both groups. At 24 hours, the mean plasma urea level decreased by 1.07 mmol/L in the dopamine group compared with 1.84 mmol/L in the placebo group, a difference of 0.77 (95% CI, -0.12 to 1.67). The mean 24-hour creatinine clearance increased by 0.165 mL/s (9.89 mL/min) in the dopamine group and by 0.199 mL/s (11.98 mL/min) in the placebo group (P > 0.2). Urine volumes were slightly higher in those receiving dopamine (1.83 mL/kg compared with 1.6 mL/kg, a difference of 0.23 [CI, -0.18 to 0.64]). None of these differences were statistically or clinically significant.

CONCLUSIONS

Within the limits of the small size of the study, low-dose dopamine appeared to offer no advantage to euvolemic patients after elective abdominal aortic surgery. However, patients with acute oliguric renal failure were not included in the study.

Spontaneous Clostridium perfringens lung abscess unresponsive to penicillin

Clostridial necrotising pneumonia is a rare complication of aspiration, bronchial tumour or foreign body, pulmonary infarction, trauma and debilitating medical conditions. Although spontaneous clostridial pneumonia has been reported previously, close scrutiny of those case reports suggests that most of the patients had a recognised predisposing cause. We report a case of true spontaneous Clostridium perfringens pneumonia complicated by septic shock, pneumothorax and pulmonary necrosis. The patient responded poorly to conventional treatment with benzylpenicillin, and although the addition of metronidazole produced dramatic resolution of the sepsis, lobectomy was required to effect cure.

Centromeric satellite DNA in the newt Triturus cristatus karelinii and related species: its distribution and transcription on lampbrush chromosomes

Two abundant satellite DNA sequences have been identified in and cloned from the DNA of Triturus cristatus karelinii. The smaller of these with a repeat unit of 33 base pairs (bp) is designated TkS1, the larger with 68 bp is designated TkS2. These satellites are also present in DNA from T.c. cristatus, T.c. carnifex and T. marmoratus but in substantially lower copy number. In situ hybridisations to lampbrush chromosomes of T.c. karelinii and T.c. cristatus have shown that the satellites are concentrated in the heterochromatic centromere bars of T.c. karelinii and in a region around the centromere granule in T.c. cristatus. The satellites also bind specifically to the centromere regions of mitotic metaphase chromosomes. They do not bind to the heteromorphic arms of chromosome 1, which have previously been shown to be rich in highly repeated DNA. DNA/RNA-transcript in situ hybrids to lampbrush chromosomes with TkS1 suggest that this sequence is occasionally transcribed on lampbrush loops near the centromeres.

Brain maturation followed by computed tomography

Computed tomography scans of normal infants were analyzed by computer methods to determine the average brain tissue density during development. A 20% increase was found from term to 20 weeks of age (29 to 35 Hounsfield units); then no further significant change was found over the next 60 weeks. The increase in density parallels the known increase in dry weight of the tissue, but calculations indicate that biochemical changes, such as the accumulation of lipids, are also important.