An international approach to estimating the indications and number of eligible patients for carbon ion radiation therapy (CIRT) in Australia

BACKGROUND AND PURPOSE

To establish the treatment indications and potential patient numbers for carbon ion radiation therapy (CIRT) at the proposed national carbon ion (and proton) therapy facility in the Westmead precinct, New South Wales (NSW), Australia.

METHODS

An expert panel was convened, including representatives of four operational and two proposed international carbon ion facilities, as well as NSW-based CIRT stakeholders. They met virtually to consider CIRT available evidence and experience. Information regarding Japanese CIRT was provided pre- and post- the virtual meeting. Published information for South Korea was included in discussions.

RESULTS

There was jurisdictional variation in the tumours treated by CIRT due to differing incidences of some tumours, referral patterns, differences in decisions regarding which tumours to prioritise, CIRT resources available and funding arrangements. The greatest level of consensus was reached that CIRT in Australia can be justified currently for patients with adenoid cystic carcinomas and mucosal melanomas of the head and neck, hepatocellular cancer and liver metastases, base of skull meningiomas, chordomas and chondrosarcomas. Almost 1400 Australian patients annually meet the consensus-derived indications now.

CONCLUSION

A conservative estimate is that 1% of cancer patients in Australia (or 2% of patients recommended for radiation therapy) may preferentially benefit from CIRT for initial therapy of radiation resistant tumours, or to boost persistently active disease after other therapies, or for re-irradiation of recurrent disease. On this basis, one national carbon ion facility with up to four treatment rooms is justified for Australian patients.

Transparency and sustainability in global commodity supply chains

Over the last few decades rapid advances in processes to collect, monitor, disclose, and disseminate information have contributed towards the development of entirely new modes of sustainability governance for global commodity supply chains. However, there has been very little critical appraisal of the contribution made by different transparency initiatives to sustainability and the ways in which they can (and cannot) influence new governance arrangements. Here we seek to strengthen the theoretical underpinning of research and action on supply chain transparency by addressing four questions: (1) What is meant by supply chain transparency? (2) What is the relevance of supply chain transparency to supply chain sustainability governance? (3) What is the current status of supply chain transparency, and what are the strengths and weaknesses of existing initiatives? and (4) What propositions can be advanced for how transparency can have a positive transformative effect on the governance interventions that seek to strengthen sustainability outcomes? We use examples from agricultural supply chains and the zero-deforestation agenda as a focus of our analysis but draw insights that are relevant to the transparency and sustainability of supply chains in general. We propose a typology to distinguish among types of supply chain information that are needed to support improvements in sustainability governance, and illustrate a number of major shortfalls and systematic biases in existing information systems. We also propose a set of ten propositions that, taken together, serve to expose some of the potential pitfalls and undesirable outcomes that may result from (inevitably) limited or poorly designed transparency systems, whilst offering guidance on some of the ways in which greater transparency can make a more effective, lasting and positive contribution to sustainability.

The Topobiology of Chemical Elements in Seabird Feathers

The highly organized morphogenesis of bird feathers holds important phylo- and ontogenetic information on the evolution of birds, organogenesis, tissue regeneration, and the health status of individual animals. Altered topobiological patterns are regularly used as retrospective evidence for disturbed developmental trajectories due to the past exposure to environmental stressors. Using the most advanced high-resolution (5–70 µm) X-ray fluorescence microscopy (XFM), we describe in the feathers from three species of Procellariiformes hitherto unknown, depositions of elements (Zn, Ca, Br, Cu, Fe) that are independent of pigmentation or any underlying variation in density or polymer structure. In the case of Zn, the pattern across several species of Procellariiformes, but not other species, consisted of highly regular bands of Zn numbering 30–32, which may reflect the estimated number of days of active feather growth or the duration of the moult period. Thus, speculatively, the highly consistent Zn pattern might be the result of a so far unknown diurnal systemic regulation rather than local heterogeneity amongst the follicular stem cells.

pING family of conjugative plasmids from the extremely thermophilic archaeon Sulfolobus islandicus: insights into recombination and conjugation in Crenarchaeota

A novel family of conjugative plasmids from Sulfolobus comprising the active variants pING1, -4, and -6 and the functionally defective variants pING2 and -3, which require the help of an active variant for spreading, has been extensively characterized both functionally and molecularly. In view of the sparse similarity between bacterial and archaeal conjugation and the lack of a practical genetic system for Sulfolobus, we compared the functions and sequences of these variants and the previously described archaeal conjugative plasmid pNOB8 in order to identify open reading frames (ORFs) and DNA sequences that are involved in conjugative transfer and maintenance of these plasmids in Sulfolobus. The variants pING4 and -6 are reproducibly derived from pING1 in vivo by successive transpositions of an element from the Sulfolobus genome. The small defective but mobile variants pING2 and -3, which both lack a cluster of highly conserved ORFs probably involved in plasmid transfer, were shown to be formed in vivo by recombinative deletion of the larger part of the genomes of pING4 and pING6, respectively. The efficient occurrence of these recombination processes is further evidence for the striking plasticity of the Sulfolobus genome.

Quality assurance for nursing and midwifery education: an analysis of the approach in England

The main purpose of this paper is to discuss conceptual and policy developments for external quality assurance for nurse and midwifery education in England. The current framework was implemented in the academic year 1998/99, and is the subject of a three year evaluation commissioned by the English National Board for Nursing, Midwifery & Health Visiting (ENB). The methods which are being used to evaluate the quality assurance arrangements will be discussed within the context of nursing and midwifery education and practice. The ultimate aim of professionally accredited nursing and midwifery education is to ensure the development of practitioners who are fit for purpose, practice and award. It follows that the quality assurance processes should have the capacity to demonstrate the extent to which professional education meets this aim. This paper will discuss this issue, with particular emphasis on the collaborative review process which is being undertaken by the Quality Assurance Agency and the statutory body for nursing, midwifery and health visiting education. The paper concludes with a discussion of the changes proposed by the government for nursing and midwifery education, and considers the potential impact for quality assurance of health care education.

Stimulation of bone formation in vitro and in rodents by statins

Osteoporosis and other diseases of bone loss are a major public health problem. Here it is shown that the statins, drugs widely used for lowering serum cholesterol, also enhance new bone formation in vitro and in rodents. This effect was associated with increased expression of the bone morphogenetic protein-2 (BMP-2) gene in bone cells. Lovastatin and simvastatin increased bone formation when injected subcutaneously over the calvaria of mice and increased cancellous bone volume when orally administered to rats. Thus, in appropriate doses, statins may have therapeutic applications for the treatment of osteoporosis.

The genetic element pSSVx of the extremely thermophilic crenarchaeon Sulfolobus is a hybrid between a plasmid and a virus

A new Sulfolobus islandicus strain, REY15/4, harboured both a novel fusellovirus, SSV2, and a small plasmid, pSSVx. The plasmid spread in S. solfataricus P1 together with the virus after infection with either the supernatant of a culture of REY15/4 or purified virus. Spreading of the plasmid required co-transfection with either SSV2 or the related SSV1 as helpers. Virus purified from REY15/4 constituted a mixture of two sizes of particles, one with the dimensions of a normal fusellovirus and the other smaller. Cloned SSV2 produced only the larger particles and only SSV2 DNA, indicating that the smaller particles contained pSSVx packaged into capsids made up of SSV2 components. The 5.7 kb genome of pSSVx revealed regions of high sequence similarity to the cryptic Sulfolobales plasmids pRN1, pRN2 and pDL10. Thus, pSSVx belongs to the family of pRN plasmids that share a highly conserved region, which probably constitutes the minimal replicon. They also contain a variable region showing no sequence similarity. In pSSVx, this region contains three open reading frames (ORFs), two of which are juxtapositioned and show high sequence similarity to a tandem of ORFs in fusellovirus genomes. Neither pRN1 nor pRN2, which lack this tandem, spread in the presence of the fuselloviruses, which implies that the sequences of these ORFs enable pSSVx to use the packaging system of the viral helpers for spreading.

Investigation of diurnal variation in sustained exercise performance

Human performance generally varies in phase with the circadian curve in body temperature. This relationship between performance and core body temperature may be disrupted when exercise causes a pronounced rise in body temperature. In this study the authors compared responses to exercise in the morning and in the evening when pre-exercise body temperature differed significantly. Rectal temperature was measured pre-exercise and throughout a cycle ergometer test at 70% VO2 max in seven males (aged 19-24 years). The test was performed at 08:30 and 17:30 h, balanced for order with 3 days minimum between tests. Onset of sweating, weight loss and time to exhaustion were recorded. Metabolic measures (VO2, VE and RER) and heart rate were recorded pre-exercise and during exercise. Rectal temperature and skin temperature at three sites were also measured. Rectal temperature and heart rate were lower in the morning than in the evening by 0.6 degree C and 7 beats min-1 (p < 0.01), respectively. The lower body temperature in the morning persisted throughout exercise, the final rectal temperature being 38.6 (SD = 0.2) degrees C in the morning and 39.2 (SD = 0.5) degrees C in the evening. No effects of time of day were observed for VO2, VE, and RER but heart rate values during exercise were lower in the morning for 30 min (p < 0.05). Sweat onset occurred sooner at 08:30 h (7.57, SD = 0.90 min) compared to 17:30 h (8.71, SD = 2.20 min) (p < 0.05). Time to exhaustion ranged from 48 to 72 min, but did not vary with time of day (p > 0.05). It is concluded that continuous submaximal exercise is not necessarily disadvantaged by a morning timing.

Genetic elements in the extremely thermophilic archaeon Sulfolobus

This minireview summarizes what is known about genetic elements in the archaeal crenarchaeotal genus Sulfolobus, including recent work on viruses, cryptic plasmids, a novel type of virus satellite plasmids or satellite viruses, and conjugative plasmids (CPs), mostly from our laboratory. It does not discuss IS elements and transposons.

Calibration of a prototype in vivo total body composition analyser using 14 MeV neutron activation and the associated particle technique

A prototype in vivo total body composition analyser has been constructed for determining the total body contents of nitrogen (TBN), carbon (TBC) and oxygen (TBO) in young experimental animals such as sheep or pigs by 14 MeV neutron activation using a commercially available associated particle sealed tube neutron generator (APSTNG). The instrument was calibrated by scanning phantoms of different sizes in the mass range 10-36 kg, filled with a mixture of elements as found in a normal human body. Good agreement was found between the measured and expected values of N, O and C when two phantoms of similar dimensions but of different composition were scanned. With four 15 cm x 15 cm cross section and 45 cm long NaI(T1) gamma detectors and a radiation dose of approximately 20 microSv due to neutrons, the expected precisions for a 28 kg animal, CV% (based on counting statistics) are N: 9.3, C: 2.3 and O: 1.4.

Focusing of X-rays by Total External Reflection from a Paraboloidally Tapered Glass Capillary

The first observation of a true geometrical focus of X-rays well beyond the exit of a paraboloidally tapered glass monocapillary is reported. An intensity gain of 250 +/- 20 into a 6 x 9 mum pinhole for 8 keV X-rays and transmission efficiencies of more than 90% below 20 keV were observed.

Application of the associated particle technique for the whole-body measurement of protein, fat and water by 14 MeV neutron activation analysis--a feasibility study

A small and compact sealed tube neutron generator with an integral alpha particle detector has been used for applying the associated particle technique for prompt-gamma 14 MeV neutron activation analysis of total body carbon (TBC), total body nitrogen (TBN) and total body oxygen (TBO). Ground sheep meat samples in the weight range 20-40 kg and of varying composition have been scanned using two 12.5 cm diameter x 10 cm Nal(Tl) crystals for gamma-ray detection. The content of protein, fat and water was calculated from their fractional content of C, N and O using a four-compartment model of body composition, which included minerals. The precision for measuring TBC, TBN and TBO has been obtained from the mean count rates of ten repeat irradiations of the same sample. The accuracy has been confirmed by comparison against chemical analysis. The reproducibilities for measuring TBN have been found to be comparable to those obtained when the same samples were analysed using prompt-gamma thermal-neutron activation analysis in an existing body composition facility. Based on the results obtained, we conclude that an instrument comprising the neutron generator and four 15 cm x 15 cm x 45 cm NaI(Tl) gamma ray detectors can be assembled to determine, in vivo, protein, fat and water in an approximately 41 kg sample with precisions of 4.4%, 5.0% and 2.1% (CV) respectively within a 15 min scan. The radiation dose equivalent delivered due to neutrons would be approximately 0.03 mSv.

Effects of time of day on self-paced performances of prolonged exercise

Pre-exercise body temperature varies throughout the day due to its circadian rhythm. This study aimed to compared responses to sustained exercise in the morning and in evening. Rectal temperature was measured pre-exercise and throughout a 60 min test on a cycle ergometer against a fixed frictional resistance in seven males (aged 19-24 years). The subjects were instructed to work as hard as possible over the entire exercise period but could vary the pedal frequency at any time. Power output was calculated by computer, utilising an optical detection device to monitor flywheel revolutions. Tests were performed at 08:30 and 17:30 h, balanced for order with at least 72 hours between tests. Rectal temperature was lower pre-exercise in the morning (37.2 degrees C) than at evening (37.8 degrees C). This differences was reduced to 0.3 degrees C by the end of exercise. Mean power output was similar for the two times of day for the whole exercise period. A higher power output in the evening over the first half of the test was compensated for by a greater performance in the morning over the second 30 min (p < 0.05). It seems that the pacing of endurance performance is affected in the morning, but without any overall effect at least for the duration examined and at the ambient environmental temperature of 17-19 degrees C.

Whole body measurement of C, N and O using 14 MeV neutrons and the associated particle time-of-flight technique

Our aim has been to construct a portable prototype instrument for measuring the whole body composition in vivo of growing lambs in terms of fat. protein and water by determining the mass of carbon, nitrogen and oxygen present. A small and compact sealed tube neutron generator which has the capability of exploiting the associated particle time-of-flight technique has been used for prompt gamma 14 MeV neutron activation analysis of C, N and O. This technique allows only gamma rays generated by neutron reactions within a defined volume to be recorded and offers a superior signal-to-noise ratio over existing prompt gamma neutron activation techniques. Based on the results obtained from irradiating a 41.4 kg meat phantom, we anticipate that an instrument comprising the neutron generator and four 15 x 15 x 45 cm Nal(TI) gamma ray detectors can be assembled to determine in vivo, protein, fat and water with precisions of 4.1, 5.4 and 1.2% (CV), respectively, within a 15 min scan. The radiation dose delivered would be ~0.03 mSv.

A rheumatologic perspective on rehabilitation of shoulder problems in the older individual

Shoulder dysfunction is a common but complex clinical problem among the aged. The shoulder is a diarthrodial joint that is designed to complement the elbow and wrist in stabilizing the arm and the hand. This complex joint has the greatest range of motion (ROM) of any joint in the human body. Unfortunately, the aging process increases the shoulder's vulnerability to many pathological conditions that decrease its ROM and interfere with self-care tasks. While initial therapy is typically managed by the primary care physician, the complexity of this problem often requires consultation across disciplines to assure pertinent management. This article provides an overview of rheumatologic considerations specific to geriatric persons with shoulder dysfunction. The differential diagnosis and issues of treatment and rehabilitation are discussed.

A feasibility study of in vivo 14-MeV neutron activation analysis using the associated particle technique

The feasibility of using the time correlated associated particle technique for in vivo 14-MeV neutron activation analysis has been investigated. Gamma rays following neutron inelastic scattering with nitrogen, carbon, and oxygen have been measured with a 12.5 x 10-cm NaI (T1) detector. The results have been scaled to a proposed facility comprising four such detectors past which the subject would be scanned. Based on counting statistics, the precision of estimation of these elements has been determined to be 2.1%, 1.0%, and 1.1%, respectively, for experimental measurements on a sample containing physiological concentrations of the major body elements. The average body dose level would be restricted to 0.3 mSv.

Training inspiratory resistance in Duchenne dystrophy using adapted computer games

Computer games were modified to encourage respiratory effort by two groups of patients with Duchenne muscular dystrophy. One group trained during the first six months of the study, the other during the second six months. Inspiratory effort was increased by their having to breathe through a mask to both start and continue the games. Pulmonary function tests were done at the beginning of the trial and six, 12 and 18 months later, when forced vital capacity, respiratory muscle endurance and strength were measured. Although there were some individual improvements, over-all the results were not statistically significant.

The effect of isoxicam-aspirin combinations on the polyurethane sponge implantation model in the rat

1 Anti-inflammatory effects of isoxicam alone and in combination with aspirin were studied in rats using the polyurethane sponge implantation model of acute inflammation. 2 Dose-response studies were performed to delineate a suppressive (high) and non-suppressive (low) dose of isoxicam prior to studying these doses in combination with aspirin. 3 The results indicate that a combination of aspirin with isoxicam does not have an additive anti-inflammatory effect. 4 The interference demonstrated by aspirin with the anti-inflammatory effects of other NSAIDs such as indomethacin is also demonstrated with aspirin/isoxicam combinations.

Assessment of nonsteroidal anti-inflammatory drug combinations by the polyurethane sponge implantation model in the rat

The anti-inflammatory effect of single doses and combinations of aspirin and commonly used nonsteroidal anti-inflammatory drugs was investigated by the polyurethane sponge implantation model of acute inflammation. Dose response curves were performed to delineate a suppressive (high) and nonsuppressive (low) dose of each drug prior to studying these doses in combination with aspirin. The results suggest that a combination of aspirin in either high or low dose does not increase the anti-inflammatory effect of other nonsteroidal anti-inflammatory drugs in this model of inflammation.

Effects of cobalt-chrome alloy wear particles on the morphology, viability and phagocytic activity of murine macrophages in vitro

Metallic wear particles were prepared from orthopaedic cobalt-chrome alloy by milling in medium supplemented with 20% foetal calf serum to maintain particle dispersion. The size distribution of particles was determined by sedimentation and centrifugation and particle concentration was assessed using light extinction. Monolayers of mouse peritoneal macrophages were exposed to metal particles at different concentrations for varying periods. After 4 h of exposure to particle concentrations exceeding 30 micrograms/ml there was a progressive decline in cell viability, and light and electron microscopy showed that surviving cells had assumed remarkably smooth profiles and contained abundant endocytosed metal. Phagocytic uptake of polystyrene spherules was inhibited markedly by exposure to metal particles even at concentrations at which macrophages remained 100% viable, and preceded the reduction of viability at higher concentrations. The findings are consistent with a pathological role for the metallic wear particles observed frequently within macrophages in the synovial tissues around loose artificial joints in humans.

Fibrinolytic effects of intracoronary streptokinase administration in patients with acute myocardial infarction and coronary insufficiency

Serial coagulation studies were obtained in 25 patients treated with intracoronary streptokinase infusion for myocardial infarction (23 patients) or coronary insufficiency (two patients) to determine the frequency of systemic fibrinolytic activity. Clotting studies were obtained before and after infusion and at 4-hour intervals until normalization. Intracoronary thrombolysis was successful in 20 of 23 patients (87%) with myocardial infarction. Streptokinase dosage in this study was 201,000 +/- 74,000 IU (+/- SD). Systemic fibrinolytic activity, defined as greater than 70% reduction of fibrinogen using a functional assay (Claus method), occurred in 22 of 25 patients (88%) and was present at a mean streptokinase dosage of 119,000 +/- 52,000 IU. Fibrinogen in the total population decreased from 342 +/- 80 to 87 +/- 94 mg% (p less than 0.0001). In patients with systemic effect, the mean fibrinogen level after infusion was 17% of baseline, increased to 43% at 24 hours, and returned to normal at 30 hours. Plasminogen decreased to 7% of baseline activity after infusion (p less than 0.0001), was 44% of baseline at 24 hours, and returned to normal at 48 hours. Intraprocedural sampling during infusion showed reduction of fibrinogen by 25% after 30,000 IU (p less than 0.0005) and by 71% at 120,000 IU (p less than 0.0001); plasminogen decreased by 50% after 30,000 IU (p less than 0.0001) and by 84% at 120,000 IU (p less than 0.0001). Prothrombin time increased from 11.5 +/- 0.8 seconds to 22.0 +/- 7.8 seconds after infusion (p less than 0.0001) and returned to normal at a mean of 18 +/- 11 hours after infusion. Partial thromboplastin time was markedly prolonged (greater than 100 seconds) after infusion, returned to less than or equal to 2 times control at 5 +/- 2 hours, and returned to normal at 9 +/- 4 hours after infusion. Fibrinogen degradation products were less than 10 micrograms/ml before infusion, increased to greater than 40 micrograms/ml after infusion, and remained greater than 40 micrograms/ml in 40% of patients at 24 hours after infusion. These data indicate that systemic fibrinolytic activity occurs in a high percentage of patients with "low-dose" intracoronary streptokinase infusion and that coagulation variables may be altered for 24-48 hours after infusion.

The role of catheter surface morphology and extractable cytotoxic material in tissue reactions to urethral catheters

Batches of urethral catheters associated with stricture formation during clinical usage were found to be amongst those causing marked acute and chronic inflammation after subcutaneous implantation in rats. The degree of inflammation did not correlate with the surface roughness of catheters assessed by scanning electron microscopy, but showed an excellent correlation with the cytotoxic effects of soluble extracts from catheters on macrophage monolayers in tissue culture. The findings suggest that stricture formation may be chemically induced and may not relate to surface roughness of catheters.

Absence of metabolic bone disease in the proximal femur in patients with fracture of the femoral neck

A clinical, radiological and histopathological study of femoral heads from 125 patients with fracture of the neck of the femur and from 30 cadavers was carried out to identify various risk factors. The findings showed that the Singh index was unreliable as a radiological indicator of the bone content of the femoral heads; that the bone content of the femoral head in patients sustaining a fracture of the femoral neck did not differ from that of the controls; that osteomalacia was not found in any of the heads examined; and that the distribution of trabecular microfractures did not support the hypothesis that fracture of the neck was the result of progressive fatigue. It was concluded that the single most important factor leading to fracture in this Australian population was injury caused by falls and that such injury was frequently associated with other disease processes.