Use of real-time immersive digital training and educational technologies to improve patient safety during the processing of reusable medical devices: Quo Vadis?

Hospital acquired infections stemming from contaminated reusable medical devices are of increasing concern. This issue is exaggerated with the introduction of complex medical devices like endoscopes and robotic instrumentation. Although medical device manufacturers validate their cleaning instructions for use, evidence in the literature demonstrates that effective device processing is not being performed consistently within sterile processing departments in clinical settings. The result is increased risks to patient safety. As a solution to this problem, focused one-on-one training increases compliance to the medical device manufacturer's processing instruction. However, often this is not a practical solution for the volume of healthcare staff responsible for device processing activities. This constitutes the first paper to address the blended use of educational and digital technologies to address these challenges and as a result inform safety and sustainability for the medical device sector. Cognitive learning theory is an evidence-based framework for learning. It supports the use of immersive educational experiences using emerging extended reality technologies (e.g., virtual or augmented reality) to increase learning comprehension. The delivery of educational content via these technologies provides an innovative option for repeatable leaning and training outcomes. The motivation is to decrease patient risk of contaminated reusable medical devices. The proposed approach while primary motivated by safety can also enhance sustainability and efficiency enabled by artificial intelligence and robotic instrumentation.

Periarticular calcifications

Periarticular calcification and ossification is a frequent finding on imaging and may sometimes pose a diagnostic challenge. The differential diagnoses for this radiological finding are wide and can be classified into broad groups such as idiopathic, developmental, trauma, burns, infection, tumor, connective tissue disease, crystalline, metabolic, vascular, and foreign bodies. With careful consideration of the clinical and imaging findings as well as awareness of mimickers of periarticular mineralization, the list of differential diagnoses can be narrowed down. This article aims to review the clinical-radiologic findings of periarticular calcified or ossified lesions with relevant imaging illustrations.

The impact of COVID-19 vaccination on patients with a history of heparin induced thrombocytopenia

The newly classified entity of vaccine induced thrombocytopenia and thrombosis (VITT) following AstraZeneca Vaccination is an area of ongoing investigation. The underlying pathophysiology is considered to have pathological similarities to heparin induced thrombocytopenia (HIT). It is unclear which cohorts may be particularly susceptible to developing VITT. In view of the underlying mechanism of action we undertook a retrospective analysis of patients with a history of HIT to assess whether they had been vaccinated and to assess whether any patients had experienced adverse reactions to the AstraZeneca vaccination. 20 out of 60 patients with a confirmed history of HIT received the AstraZeneca vaccination and none of these reported any features suggestive of VITT.

Substance use amongst adult patients admitted to an irish acute mental health unit

Introduction

Comorbid substance misuse in mental illness presents a significant challenge to mental health services. It may lead to higher rates of relapse, hospital admissions and poorer treatment outcomes. Up to 47% of inpatients in Irish mental health units may experience substance misuse. Despite the Irish government’s ‘Vision for Change’ policy (2006), access to specialised services remains variable.

Objectives

Evaluate: -prevalence of substance misuse at an Irish mental health unit. -quality and detail of the recorded substance misuse history. -access to specialised services for patients experiencing substance misuse.

Methods

A retrospective chart review of inpatients in a mental health unit over 12 months, was completed. Information recorded included: demographic details, diagnosis, substance use history; access to substance misuse services. Microsoft Excel was utilised for data input and analysis.

Results

267 patients were admitted over twelve months. Substance misuse was the primary diagnosis of 6% and the secondary diagnosis of 67%. 46% of patients reported current substance misuse, 52% reported historical substance misuse. Frequency and quantity of use was documented in 65% and 48% of cases respectively. 4% of patients with a substance misuse history were in current contact with addiction services.

Conclusions

Although 46% of patients reported substance misuse, only 4% were in contact with specialised addiction services. This highlights a significant unmet need. There was variability in the quality of the recorded substance misuse history. In order to fully understand comorbid substance misuse, this be addressed. The addition of a more formatted substance misuse section, to admission proformas, may help to alleviate this issue.

Prediction of Hemorrhage after Successful Recanalization in Patients with Acute Ischemic Stroke: Improved Risk Stratification Using Dual-Energy CT Parenchymal Iodine Concentration Ratio Relative to the Superior Sagittal Sinus

BACKGROUND AND PURPOSE

Brain parenchymal hyperdensity on postthrombectomy CT in patients with acute stroke can be due to hemorrhage and/or contrast staining. We aimed to determine whether iodine concentration within contrast-stained parenchyma compared with an internal reference in the superior sagittal sinus on dual-energy CT could predict subsequent intracerebral hemorrhage.

MATERIALS AND METHODS

Seventy-one patients with small infarct cores (ASPECTS ≥ 7) and good endovascular recanalization (modified TICI 2b or 3) for anterior circulation large-vessel occlusion were included. Brain parenchymal iodine concentration as per dual-energy CT and the percentage of contrast staining relative to the superior sagittal sinus were recorded and correlated with the development of intracerebral hemorrhage using Mann-Whitney U and Fisher exact tests.

RESULTS

Forty-three of 71 patients had parenchymal hyperdensity on initial dual-energy CT. The median relative iodine concentration compared with the superior sagittal sinus was significantly higher in those with subsequent intracerebral hemorrhage (137.9% versus 109.2%, P = .007). By means of receiver operating characteristic analysis, a cutoff value of 100% (iodine concentration relative to the superior sagittal sinus) enabled identification of patients going on to develop intracerebral hemorrhage with 94.75% sensitivity, 43.4% specificity, and a likelihood ratio of 1.71.

CONCLUSIONS

Within our cohort of patients, the relative percentage of iodine concentration at dual-energy CT compared with the superior sagittal sinus was a reliable predictor of intracerebral hemorrhage development and may be a useful imaging biomarker for risk stratification after endovascular treatment.

Exploring Athletic Trainers' Self-Confidence for Interpreting Results from Concussion Assessments

Purpose

To explore athletic trainers' self-confidence for interpreting results from concussion assessments.

Methods

An online survey was administered via the National Athletic Trainers’ Association (NATA) membership listserv to a cross-sectional sample of 10,000 certified athletic trainers (ATCs) employed in high school and collegiate settings. The survey included: 1) ATC demographics (i.e., age, sex, years of experience); 2) ATC concussion management practices (i.e., previous concussion training, continuing education received on concussion, concussion assessments administered); and 3) a 4-point Likert scale (1=no confidence, 4=high confidence) assessing ATC self-confidence for interpreting results from concussion assessments. A total of 725 ATCs completed the survey yielding a response rate of 7.25%; 114 were excluded for missing data and 611 ATCs were included in final analyses. Sample demographics, ATC concussion management practices, and ATC self-confidence scores were examined with demographic statistics (i.e., means, standard deviations, frequencies, percentages) for 16 commonly used concussion assessments.

Results

The sample of ATCs (mean age 38.97±14.89 years) was predominately female (59.2%) and reported an average of 10.08±7.58 years of clinical experience. Clinical examinations (63.2%) and symptom scales (61.4%) were among the most frequent assessments with high ATC self-confidence for interpretation. Vestibular/oculomotor measures (27.2%) and computerized neurocognitive testing (26.2%) were among the most frequent assessments with low ATC self-confidence for interpretation.

Conclusion

Low ATC self-confidence scores for interpreting results from vestibular/oculomotor measures and computerized neurocognitive testing highlight the importance of incorporating a multi-disciplinary team approach and including sport neuropsychologists for the proper management of concussion.

Impact of thoracic radiotherapy timing in limited-stage small-cell lung cancer: usefulness of the individual patient data meta-analysis

BACKGROUND

Chemotherapy (CT) combined with radiotherapy is the standard treatment of 'limited-stage' small-cell lung cancer. However, controversy persists over the optimal timing of thoracic radiotherapy and CT.

MATERIALS AND METHODS

We carried out a meta-analysis of individual patient data in randomized trials comparing earlier versus later radiotherapy, or shorter versus longer radiotherapy duration, as defined in each trial. We combined the results from trials using the stratified log-rank test to calculate pooled hazard ratios (HRs). The primary outcome was overall survival.

RESULTS

Twelve trials with 2668 patients were eligible. Data from nine trials comprising 2305 patients were available for analysis. The median follow-up was 10 years. When all trials were analysed together, 'earlier or shorter' versus 'later or longer' thoracic radiotherapy did not affect overall survival. However, the HR for overall survival was significantly in favour of 'earlier or shorter' radiotherapy among trials with a similar proportion of patients who were compliant with CT (defined as having received 100% or more of the planned CT cycles) in both arms (HR 0.79, 95% CI 0.69-0.91), and in favour of 'later or longer' radiotherapy among trials with different rates of CT compliance (HR 1.19, 1.05-1.34, interaction test, P < 0.0001). The absolute gain between 'earlier or shorter' versus 'later or longer' thoracic radiotherapy in 5-year overall survival for similar and for different CT compliance trials was 7.7% (95% CI 2.6-12.8%) and -2.2% (-5.8% to 1.4%), respectively. However, 'earlier or shorter' thoracic radiotherapy was associated with a higher incidence of severe acute oesophagitis than 'later or longer' radiotherapy.

CONCLUSION

'Earlier or shorter' delivery of thoracic radiotherapy with planned CT significantly improves 5-year overall survival at the expense of more acute toxicity, especially oesophagitis.

Evaluation of a 'Watch and Wait' Approach for Chemotherapy in Patients with Newly Diagnosed Advanced Non-small Cell Lung Cancer from a Diverse Community Population

AIMS

Systemic therapy in advanced non-small cell lung cancer (NSCLC) is the standard of care. The time of treatment administration has not been examined in the metastatic setting. A 'watch and wait' approach for the initiation of chemotherapy is sometimes used in clinical practice, either because of patient preference, presumed indolent disease behaviour, upfront radiotherapy or other interventions. We propose to evaluate the effect of a watch and wait approach on systemic treatment deliverability and patients' outcomes in a population-based study.

MATERIALS AND METHODS

A retrospective analysis of stage IIIB/IV NSCLC patients referred to medical oncology at the British Columbia Cancer Agency in 2009 was conducted. We defined the following: immediate chemotherapy (ICT) - chemotherapy ≤ 8 weeks from medical oncology consult; watch and wait chemotherapy (WWC) - initial observation with chemotherapy > 8 weeks from medical oncology consultation; watch and wait missed (WWM) - watch and wait patients who did not receive chemotherapy; best supportive care (BSC) - patients deemed chemotherapy ineligible. Statistical methods included Kaplan-Meier analysis, Log-rank tests and Cox proportional hazards modelling.

RESULTS

In total, 744 patients were seen by medical oncology; 355 (48%) received ICT, 173 (23%) watch and wait and 216 (29%) BSC. Of the 173 patients on a watch and wait approach, 42% missed an opportunity for chemotherapy due to poor performance status (50%), death (49%) and comorbidity (1%). The median overall survival was as follows: watch and wait 11.5 months, ICT 12.8 months and BSC 4.3 months (P < 0.0001). Controlling for confounding factors (age, gender, performance status), overall survival was longer in WWC (hazard ratio 0.73, confidence interval 0.81-1.07, P = 0.023) and lower in WWM (hazard ratio 1.68, 95% confidence interval 1.27-2.22, P < 0.0001), compared with ICT.

CONCLUSIONS

A significant proportion of watch and wait patients never receive systemic therapy, predominantly due to a decline in performance status. Patients in the ICT group were younger, had a better performance status and had non-squamous histology compared with the watch and wait group. The overall survival was longer in the patients who received ICT versus watch and wait. The watch and wait strategy is associated with a high risk of missing the opportunity for any chemotherapy and should be judiciously implemented only in carefully selected patients.

Spontaneous antibodies against Engrailed-2 (EN2) protein in patients with prostate cancer

We reported the expression of the homeodomain-containing transcription factor Engrailed-2 (EN2) in prostate cancer and showed that the presence of EN2 protein in the urine was highly predictive of prostate cancer. This study aimed to determine whether patients with prostate cancer have EN2 autoantibodies, what the prevalence of these antibodies is and whether they are associated with disease stage. The spontaneous immunoglobulin (Ig)G immune response against EN2 and for comparison the tumour antigen New York Esophageal Squamous Cell Carcinoma 1 (NY-ESO-1), were tested by enzyme-linked immunosorbent assay (ELISA) in three different cohorts of prostate cancer patients as well as a group of men genetically predisposed to prostate cancer. Thirty-two of 353 (9·1%) of the SUN cohort representing all stages of prostate cancer demonstrated EN2 IgG responses, 12 of 107 patients (11·2%) in the advanced prostate cancer patients showed responses, while only four of 121 patients (3·3%) with castrate-resistant prostate cancer showed EN2 autoantibodies. No significant responses were found in the predisposed group. Anti-EN2 IgG responses were significantly higher in patients with prostate cancer compared to healthy control males and similarly prevalent to anti-NY-ESO-1 responses. While EN2 autoantibodies are not a useful diagnostic or monitoring tool, EN2 immunogenicity provides the rationale to pursue studies using EN2 as an immunotherapeutic target.

Insecticide-treated clothes for the control of vector-borne diseases: a review on effectiveness and safety

Insecticide-treated clothing has been used for many years by the military and in recreational activities as personal protection against bites from a variety of arthropods including ticks, chigger mites, sandflies and mosquitoes. Permethrin is the most commonly used active ingredient, but others, including bifenthrin, deltamethrin, cyfluthrin, DEET (N,N-diethyl-3-methylbenz-amide) and KBR3023, have also been trialled. Treatment is usually carried out by home or factory dipping. However, new microencapsulation technologies which may prolong the activity of insecticides on clothing are now available and may help to overcome the inevitable reduction in efficacy over time that occurs as a result of washing, ultraviolet light exposure, and the normal wear and tear of the fabric. The aim of this article is to review the evidence base for the use of insecticide-treated clothing for protection against bites from arthropods and its effect on arthropod-borne pathogen transmission. Although some studies do demonstrate protection against pathogen transmission, there are surprisingly few, and the level of protection provided varies according to the disease and the type of study conducted. For example, insecticide-treated clothing has been reported to give between 0% and 75% protection against malaria and between 0% and 79% protection against leishmaniasis. Studies vary in the type of treatment used, the age group of participants, the geographical location of the study, and the pathogen transmission potential. This makes it difficult to compare and assess intervention trials. Overall, there is substantial evidence that insecticide-treated clothing can provide protection against arthropod bites. Bite protection evidence suggests that insecticide-treated clothing may be useful in the prevention of pathogen transmission, but further investigations are required to accurately demonstrate transmission reduction.

Resistive flow in a weakly interacting Bose-Einstein condensate

We report the direct observation of resistive flow through a weak link in a weakly interacting atomic Bose-Einstein condensate. Two weak links separate our ring-shaped superfluid atomtronic circuit into two distinct regions, a source and a drain. Motion of these weak links allows for creation of controlled flow between the source and the drain. At a critical value of the weak link velocity, we observe a transition from superfluid flow to superfluid plus resistive flow. Working in the hydrodynamic limit, we observe a conductivity that is 4 orders of magnitude larger than previously reported conductivities for a Bose-Einstein condensate with a tunnel junction. Good agreement with zero-temperature Gross-Pitaevskii simulations and a phenomenological model based on phase slips indicate that the creation of excitations plays an important role in the resulting conductivity. Our measurements of resistive flow elucidate the microscopic origin of the dissipation and pave the way for more complex atomtronic devices.

Undisplaced intracapsular hip fractures in the elderly: predicting fixation failure and mortality. A prospective study of 162 patients

BACKGROUND

Reported revision of internal fixation for undisplaced intracapsular hip fractures is between 12 and 17% at 1 year. This risk is greater for elderly patients, for whom mortality after such a fracture is also higher. Our purpose was to identify predictors of fixation failure and mortality for elderly patients sustaining undisplaced intracapsular hip fractures, and to assess whether their socioeconomic status affected their outcome.

METHODS

During a 3-year period we prospectively compiled a consecutive series of 162 elderly (≥65 years old) patients who underwent internal fixation for an undisplaced (Garden stage I or II) intracapsular hip fracture. Patient demographics, American Society of Anesthesiologists (ASA) grade, and posterior tilt (measured on the lateral radiograph) were recorded pre-operatively. All patients were followed up for a minimum of 1 year. Each patient's socioeconomic status was assigned by use of the Scottish Index of Multiple Deprivation. Patient mortality was established by use of the General Register Office for Scotland.

RESULTS

There were 28 failures of fixation during the study period. In Cox regression analysis, ASA grade and the presence of posterior tilt (p < 0.0001) were significant independent predictors of fixation failure. Overall unadjusted mortality at 1 year was 19% (n = 30/162). Cox regression analysis also affirmed ASA grade to be the only significant independent predictor of 1-year mortality (p = 0.003). The standardised mortality rate for the cohort was 2.3 (p < 0.001), and was significantly greater for patients less than 80 years of age (p = 0.004). Socioeconomic status did not affect outcome, but the most deprived patients sustain their fracture at a significantly younger age (p = 0.001).

CONCLUSION

We have demonstrated that ASA grade and posterior tilt of the femoral neck are independent predictors of fixation failure of undisplaced intracapsular hip fractures in elderly patients, and ASA grade was also an independent predictor of mortality.

Abstract PD07-09: Zoledronate versus ibandronate comparative evaluation (ZICE) trial - first results of a UK NCRI 1,405 patient phase III trial comparing oral ibandronate versus intravenous zoledronate in the treatment of breast cancer patients with bone metastases

Introduction Bone metastases in patients with breast cancer have serious effects on health including pain, poor mobility, skeletal fractures, spinal cord compression and the need for radiotherapy/surgery. The introduction of intravenous (IV) bisphosphonates, such as zoledronic acid (Z) has significantly delayed the onset of skeletal-related events (SRE). However, prolonged IV bisphosphonates place burdens upon patient and hospital, and can also cause renal and acute phase toxicities. Ibandronic acid (I), a third generation amino-bisphosphonate in its oral form has previously been compared with placebo and was shown to be well tolerated and effective. Indirect comparisons with IV Z indicated similar efficacy in reducing bone events, but adverse events were overall comparable with placebo. One might therefore assume that oral ibandronate would be more acceptable to patients, and the ZICE Trial is the only large scale direct randomised comparison between IV Z and oral I to report.

Methods Between January 2006 and October 2010, 1405 newly diagnosed metastatic breast cancer patients with proven bone metastases were randomised 1:1 to IV Z (4mg 15 min infusion every 3–4 weeks) or oral I (50mg per day) for up to 96 weeks. All patients were prescribed daily calcium & vitamin D supplementation, and patients with current active dental problems including infection were excluded. Patients also received chemotherapy, and or endocrine therapy as determined by their physician. The primary objective was to demonstrate non-inferiority of oral I in comparison with IV Z in terms of the SRE rate, defined as the number of SREs reported per year (using multiple event analysis). Secondary endpoints included time to 1st SRE, proportion of patients with SRE, Pain Scores, side effect profiles including ONJ and renal toxicities, quality of life and Health resources and overall survival. The trial was run under the auspices of the NCRI, sponsored by Velindre NHS Trust, coordinated by the Wales Cancer Trials Unit, funded by an educational grant from Roche and peer reviewed/endorsed by Cancer Research UK (CRUKE/04/022).

Results At the time of this analysis the last randomised patient had completed 96 weeks of therapy, median follow up was 18.4 months and total number of SREs was 865 (468 in I and 397 in Z). For the primary objective, the SRE rate was 0.543 and 0.444 in I and Z groups respectively (Hazard ratio, 1.22; 95% CI, 1.04 to 1.45; P = .017). Ibandronate failed to meet the criteria for non-inferiority to Zoledronate, but was similar in delaying time to first SRE (hazard ratio, 1.11; 95% CI, 0.94 to 1.31; P = .233). Overall survival (disease progression), was very similar between groups but renal AEs occurred more frequently with Z than I; Compliance with oral therapy was 82%. ONJ rate was very low in both arms (0.71%, I; 1.29%, Z; P = 0.28).

Conclusion Oral I is inferior to Z in terms of the SRE rate in metastatic breast cancer patients with bone metastases, but is similar to Z in delaying time to first SRE. Both drugs had acceptable safety profiles, with adverse events consistent with those reported previously.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD07-09.

SU-E-T-184: LINAC Commissioning Measurements Utilizing the Cylindrical Arc Check Phantom

PURPOSE

New devices for IMRT and VMAT QA are continually becoming available. Despite the availability of these devices they are underutilized for routine mechanical QA. In this work we take advantage of the cylindrical geometry of the Arc Check phantom to perform tests that are an integral part of commissioning and routine QA.

METHODS

The Arc Check is a cylindrical phantom with a diameter of 26.59cm and a 1386 diode array arranged on a cylindrical plane. Owing to its cylindrical design it is capable of measuring entry and exit radiation. For this experiment the Arc Check was set up using the mechanical pointer at 86.7cm SSD. The device was leveled using its inclinometer and was properly rotated to align with the lasers and cross-hair. With the phantom set up at the expected isocenter of the LINAC, 100MUs with a 10×10 field were delivered at different gantry angles, couch and collimator rotations. Each delivery was recorded individually and for each one the radiation center at the entry and exit levels of the detector were estimated. That provided the path of the radiation center through the device. The radiation path was reconstructed for each rotation individually and the coincidence of the mechanical and radiation isocenter was evaluated.

RESULTS

A procedure and MATLAB routine were developed that accepted as input the text files that are the output of the Arc Check measurement and geometrically reconstructed in 3-dimensions the isocenter and radiation central axis for each rotation. The coincidence of the radiation and mechanical isocenter was verified.

CONCLUSIONS

This work demonstrates that by utilizing the geometry of a commercially available device multiple mechanical LINAC tests that are part of routine QA can be evaluated in one single setup.

Use of haemoglobin A1c to detect impaired fasting glucose or Type 2 diabetes in a United Kingdom community based population

AIMS

To evaluate the diagnostic accuracy of haemoglobin A1c (HbA1c) in screening for impaired fasting glucose and Type 2 diabetes (T2DM).

METHODS

We screened 3904 adults aged 45-70 (mean age 58.6 [standard deviation (SD) 6.9] years, mean body mass index (BMI) 29.9 [SD 4.7]kg/m(2)), with fasting plasma glucose (FPG) and HbA1c as part of a large diabetes prevention programme. We assessed the diagnostic accuracy of HbA1c for predicting impaired fasting glucose (IFG), (defined either as FPG 5.6-6.9 mmol/l, or 6.1-6.9 mmol/l), and T2DM (FPG ≥ 7.0 mmol/l).

RESULTS

The prevalences of IFG were 13.8% (FPG 5.6-6.9 mmol/l) and 4.5% (FPG 6.1-6.9 mmol/l) and of T2DM was 2.1%. Using FPG 5.6-6.9 mmol/l as the IFG reference standard, HbA1c of 39-47 mmol/mol (5.7-6.4%) was 63% sensitive and 81% specific, and HbA1c 43-47 mmol/mol (6.1-6.4%) was 21% sensitive and 98% specific, in diagnosing IFG. HbA1c ≥ 48 mmol/mol (6.5%) was 61% sensitive and 99% specific in diagnosing T2DM. Having HbA1c 39-47 mmol/mol (5.7-6.4%), male sex, and body mass index >29.5 together increased the odds of IFG 6.5-fold (95% confidence interval (CI) 5.5-7.8) compared to the pre-test odds.

CONCLUSION

Defining 'pre-diabetes' at a lower HbA1c threshold of 39 mmol/mol (5.7%) instead of 47 mmol/mol (6.1%) increases its sensitivity in diagnosing IFG, but current American Diabetes Association definitions of 'pre-diabetes' based on HbA1c would fail to detect almost 40% of people currently classified as IFG. This has implications for current and future diabetes prevention programmes, for vascular risk management, and for clinical advice given to people with 'pre-diabetes' based on fasting glucose data.

Risk analysis and its link with standards of the World Organisation for Animal Health

Among the agreements included in the treaty that created the World Trade Organization (WTO) in January 1995 is the Agreement on the Application of Sanitary and Phytosanitary Measures (SPS Agreement) that sets out the basic rules for food safety and animal and plant health standards. The SPS Agreement designates the World Organisation for Animal Health (OIE) as the organisation responsible for developing international standards for animal health and zoonoses. The SPS Agreement requires that the sanitary measures that WTO members apply should be based on science and encourages them to either apply measures based on the OIE standards or, if they choose to adopt a higher level of protection than that provided by these standards, apply measures based on a science-based risk assessment. The OIE also provides a procedural framework for risk analysis for its Member Countries to use. Despite the inevitable challenges that arise in carrying out a risk analysis of the international trade in animals and animal products, the OIE risk analysis framework provides a structured approach that facilitates the identification, assessment, management and communication of these risks.

Simulating the bovine spongiform encephalopathy situation in Japan

Despite various measures taken by the Japanese government to protect the cattle population from exposure to the bovine spongiform encephalopathy (BSE) agent, the first case of BSE was detected in September 2001. Subsequently, BSE surveillance was enhanced, involving mandatory reporting and investigation of all clinical BSE suspects, and testing of fallen stock and all cattle slaughtered for human consumption. Tests on over nine million cattle led to the detection of 35 additional cases by the end of May 2009. Using the surveillance data and other information as input variables, models were developed to explore the possible source of introduction of BSE into Japan, evaluate the effectiveness of control measures, estimate the prevalence of BSE in different birth cohorts, predict a future BSE epidemic, and simulate the impact of changes in surveillance strategies. Despite difficulties associated with the availability and uncertainty of some of the input variables, these models provided an objective insight into the BSE situation in Japan.

Long-term follow-up of patients undergoing auto-SCT for advanced germ cell tumour: a multicentre cohort study

Failure of cisplatin-based chemotherapy in advanced germ cell tumour (GCT) is associated with a poor outcome. High-dose chemotherapy and auto-SCT is one therapeutic option, although the long-term outcome after this procedure is unclear. We conducted a multicentre cohort study of consecutive patients undergoing a single auto-SCT for GCT between January 1986 and December 2004. Of 71 subjects, median follow-up is 10.1 years. OS at 5 years is 44.7% (95% confidence interval (CI) 32.9-56.5%) and EFS is 43.5% (95% CI 31.4-55.1%). There were seven (10%) treatment-related deaths within 100 days of auto-SCT. Three (4.2%) patients developed secondary malignancies. Of 33 relapses, 31 occurred within 2 years of auto-SCT. Two very late relapses were noted 13 and 11 years after auto-SCT. In multivariate analysis, favourable outcome was associated with IGCCC (International Germ Cell Consensus Classification) good prognosis disease at diagnosis, primary gonadal disease and response to salvage chemotherapy. We conclude that auto-SCT results in successful outcome for a relatively large subgroup of patients with high-risk GCT. Late relapses may occur, a finding not previously reported.

Neptune's Story

It is conjectured that Triton was captured from a heliocentric orbit as the result of a collision with what was then one of Neptune's regular satellites. The immediate post-capture orbit was highly eccentric with a semimajor axis a approximately 10(3)R(N) and a periapse distance rp that oscillated periodically above a minimum value of about 5R(N). Dissipation due to tides raised by Neptune in Triton caused Triton's orbit to evolve to its present state in less, similar10(9) years. For much of this time Triton was almost entirely molten. While its orbit was evolving, Triton cannibalized most of the regular satellites of Neptune and also perturbed Nereid, thus accounting for that satellite's highly eccentric and inclined orbit. The only regular satellites of Neptune that survived were those that formed well within 5R(N) and they move on inclined orbits as the result of chaotic perturbations forced by Triton. Neptune's arcs are confined around the corotation resonances of one of these inner satellites. The widths and lengths of the arcs imply that the satellite's radius is at least 30/(sin i)(2/3) kilometers for i less, similar 1, where i is the angle of inclination.