Reduced Fractionation in Lung Cancer Patients Treated with Curative-intent Radiotherapy during the COVID-19 Pandemic

Patients treated with curative-intent lung radiotherapy are in the group at highest risk of severe complications and death from COVID-19. There is therefore an urgent need to reduce the risks associated with multiple hospital visits and their anti-cancer treatment. One recommendation is to consider alternative dose-fractionation schedules or radiotherapy techniques. This would also increase radiotherapy service capacity for operable patients with stage I-III lung cancer, who might be unable to have surgery during the pandemic. Here we identify reduced-fractionation for curative-intent radiotherapy regimes in lung cancer, from a literature search carried out between 20/03/2020 and 30/03/2020 as well as published and unpublished audits of hypofractionated regimes from UK centres. Evidence, practical considerations and limitations are discussed for early-stage NSCLC, stage III NSCLC, early-stage and locally advanced SCLC. We recommend discussion of this guidance document with other specialist lung MDT members to disseminate the potential changes to radiotherapy practices that could be made to reduce pressure on other departments such as thoracic surgery. It is also a crucial part of the consent process to ensure that the risks and benefits of undergoing cancer treatment during the COVID-19 pandemic and the uncertainties surrounding toxicity from reduced fractionation have been adequately discussed with patients. Furthermore, centres should document all deviations from standard protocols, and we urge all colleagues, where possible, to join national/international data collection initiatives (such as COVID-RT Lung) aimed at recording the impact of the COVID-19 pandemic on lung cancer treatment and outcomes.

Factors influencing acceptance of robotics in hospital pharmacy: a longitudinal study using the Extended Technology Acceptance Model

OBJECTIVES

To explore factors influencing hospital pharmacy staff acceptance of a pharmacy robotic dispensing system during implementation and over time.

METHODS

A single centred, prospective, longitudinal cohort quantitative study was conducted in an Australian tertiary public hospital using the Extended Technology Acceptance Model (ETAM). Staff were surveyed during the implementation of a pharmacy dispensing robot (May 2016) and again after working with the system for fifteen months (August 2017). Fishers exact test and correlation analysis of paired responses were used to identify significant factors influencing use of the system between the two time points.

KEY FINDINGS

Sixty four respondents completed surveys during implementation (n=64) and 34-paired surveys were collected fifteen months later. Respondents were predominantly young, female with a tertiary qualification. Initial perceptions did not change over time, with the exception of reliability. Departmental leaders had greatest influence on technology acceptance during implementation and over time. Other key factors correlating with acceptance included: how useful the robot was perceived to be; ease of use and how relevant the robot was for an individual role. Higher levels of education had a negative association with usage during implementation and age was not a factor.

CONCLUSION

This study identified critical insights influencing staff acceptance of pharmacy robots that will help inform future implementation. The influence of pharmacy leaders emerged as key influence on technology acceptance. Leveraging on this influence a communication strategy prior to implementation should include information on useful functions and known benefits of the system customised for individual roles.

Unintended cardiac irradiation during left-sided breast cancer radiotherapy

OBJECTIVE

Cardiac irradiation during left-sided breast radiotherapy may lead to deleterious cardiac side effects. Using image guided radiotherapy, it is possible to exclude the heart from treatment fields and monitor reproducibility of virtual simulation (VS) fields at treatment delivery using electronic portal imaging (EPI). Retrospectively, we evaluate the incidence of cardiac irradiation at VS and subsequent unintended cardiac irradiation during treatment.

METHODS

Patients receiving left-sided radiotherapy to the breast or chest wall, treated with a glancing photon field technique during a four-month period, were included. VS images and EPIs during radiotherapy delivery were visually assessed. The presence of any portion of the heart within the treatment field at VS or during treatment was recorded. Central lung distance and maximum heart distance were recorded.

RESULTS

Of 128 patients, 45 (35.1%) had any portion of the heart within the planned treatment field. Of these, inclusion of the heart was clinically unavoidable in 25 (55.6%). Of those with no heart included in the treatment fields at VS, 41 (49.4%) had presence of the heart as assessed on EPI during treatment.

CONCLUSION

Unintended cardiac irradiation during left-sided breast radiotherapy treatment occurs in a sizeable proportion of patients.

ADVANCES IN KNOWLEDGE

Despite the use of three-dimensional computed tomography simulation and cardiac shielding, sizeable proportions of patients receiving left-sided breast cancer radiotherapy have unintended cardiac irradiation.

How does neoadjuvant bicalutamide 150 mg monotherapy compare to lutenising hormone-releasing hormone agonist (LHRHa) therapy in localized prostate cancer treated with radical radiotherapy? A case-matched comparison of PSA kinetics and biochemical outcome

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Background: In patients treated with neoadjuvant lutenising hormone-releasing hormone agonist (LHRHa) therapy prior to radical prostate radiotherapy the PSA nadir in the first week of radiotherapy has been correlated with subsequent biochemical failure free survival (BFFS). Bicalutamide monotherapy (BC) is increasingly being used as a neoadjuvant therapy in place of LHRHa. We wished to compare the initial PSA response to neoadjuvant BC or LHRHa in this setting as well as examining subsequent biochemical failure rates.

Methods: We retrospectively reviewed the case notes of consecutive men with prostate cancer treated with BC monotherapy prior to radical prostate radiotherapy from April 2004 to December 2008 and case-matched them to men treated with neoadjuvant LHRHa. PSA levels and kinetics prior to radiotherapy and subsequent BFFS were analysed.

Results: Eighty nine men treated with BC with a median follow-up of 42 months were case matched to 89 men treated with LHRHa. There were no significant differences in age, initial PSA, Gleason, or T stage. The median nadir PSA on day 1 of radiotherapy was 2.2ng/mL (0.1-11.2) for BC patients and 0.9ng/mL (0.1-11.2) for LHRHa patients (p=0.0007). There were no significant differences in PSA velocity or doubling time during the neoadjuvant period. A PSA of <1.0ng/mL on day 1 of radiotherapy was seen in 29 (32%) and 47 (52%) of BC and LHRHa patients respectively. Biochemical failure was seen in 10 (11.2%) and 2 (2.2%) of BC and LHRHa patients respectively. PSA kinetics did not predict for subsequent BFFS at this duration of FU for men receiving neoadjuvant BC.

Conclusions: In this case-matched study, neoadjuvant BC therapy does not provide the same level of pre-radiotherapy PSA suppression when compared to neoadjuvant LHRHa. Higher biochemical failure rates are seen in patients treated with BC than LHRHa however this may be a result of prolonged castration.

No significant financial relationships to disclose.

Maintaining standards for pressure ulcer management in care homes

This article is based on a review carried out by the Scottish Commission for the Regulation of Care (Care Commission) in 2007, which examined pressure ulcer prevention, care and treatment for older people living in care homes in Scotland. Inspection, complaints and enforcement activity from 2002 to 2006 revealed many aspects of poor practice, as residents were either at risk of developing a pressure ulcer, or existing pressure ulcers were not being managed appropriately. The review highlighted six key areas where care homes were consistently not meeting best practice and recommendations were made to improve care.

Advanced Trauma Life Support (ATLS) and facial trauma: can one size fit all? Part 3: Hypovolaemia and facial injuries in the multiply injured patient

Hypovolaemic shock is a common cause of morbidity and mortality following trauma, accounting for approximately 30% to 40% of trauma deaths. Life-threatening blood loss from the maxillofacial region is uncommon, but represents one of a number of possible sites which must be rapidly identified and controlled. Bleeding from the face may not be obvious especially in awake, supine patients and it poses an obvious threat to the unprotected airway. Identification requires careful assessment. Control of bleeding in the maxillofacial region requires a number of correctly sequenced techniques. Computerized tomographic imaging is now playing an increasingly important role in identifying blood loss, especially in the chest, abdomen and pelvis. This need may potentially result in the transfer of patients, with unrecognised facial injuries, outside the relative safety of the emergency department. The concepts of the 'lethal triad' and 'biologic first hit' have resulted in new strategies in managing the profoundly shocked patient, although some of these remain controversial. Debate continues over the optimal blood pressure, fluid administration and role of surgical intervention in the actively bleeding patient. These may have an impact on the timing and extent of any proposed maxillofacial repairs, and are discussed.

Endophthalmitis as a presentation of meningococcal septicaemia

Meningococcal infections can present in diverse clinical forms ranging from fulminant, occult, chronic meningococcaemia to meningitis. Rare presentations may include conjunctivitis, sinusitis, pneumonia, pericarditis, arthritis, and osteomyelitis. We present a very unusual case of meningococcaemia presented as an endophthalmitis.

Primary hyperparathyroidism presenting as torsades de pointes

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Antibiotic pharmacoeconomics: an attempt to find the real cost of hospital antibiotic prescribing

Antibiotics account for a large part of all hospital pharmacy budgets, but the actual cost of their prescription is unknown. These costs include intravenous administration, labour, serum antibiotic assay, monitoring of haematological and biochemical indices, disposal of sharps and adverse effects. An in-house method of costing antibiotic therapy is presented, to quantify these hidden expenses. Since not only an awareness, but an accurate quantification, of hidden costs is required, a study of various hospital procedures relating directly to antibiotic therapy was undertaken in an acute medical ward; this involved the identification of particular staff members performing various procedures, consumables used and time taken. The cost of five-day courses of gentamicin, penicillin G, ampicillin, flucloxacillin, cefuroxime, ceftotaxime and erythromycin has been calculated; drug and hidden costs for each are presented graphically for comparison. The breakdown cost for gentamicin is presented to illustrate the method. The costing of adverse effects has not been attempted. We suggest that costings of this sort are used in cost-benefit analysis of antibiotic use. These calculations have been incorporated into a computer spreadsheet and this costing service will be offered to clinical areas of our hospital.

Technique for calculation of the true costs of antibiotic therapy

An in-house method for costing antibiotic therapy is presented which quantifies hidden costs including costs arising from intravenous administration, labour, serum antibiotic assay, monitoring of haematological and biochemical indices and disposal of sharp instruments. A study of various hospital procedures relating directly to antibiotic therapy was undertaken in an acute medical ward, which involved determination of staff members performing various procedures, consumables used and time taken. Results of this study facilitated accurate quantification of hidden costs of i.v. antibiotic therapy in this ward. Using these results, the cost of five-day courses of gentamicin, cefuroxime, penicillin G, flucloxacillin and erythromycin were calculated. The costing of adverse effects was not attempted. It is recommended that a costing technique of this sort is used in cost-benefit analysis of antibiotic use, as the cost of the drug alone is misleading.

Audit of hyperthyroxinaemia and thyrotoxicosis using a sensitive TSH assay

The aim of this study was determine (a) the causes of hyperthyroxinaemia and (b) the biochemical profile of thyrotoxicosis in a general hospital laboratory for one year using a sensitive TSH assay. Total T4 (TT4) and TSH were measured in all 8,382 samples and TT3, free T4, free T3 and thyroxine binding globulin (TBG) in selected cases. TT4 was elevated in 215 (2.6%). 159 (74%) were due to thyrotoxicosis; 41 (19%) to elevated TBG and 15 (7%) non-thyroidal illness. Thyrotoxicosis (serum TSH less than 0.15m U/1) occurred in 223 (2.7%) of all patients and was diagnosed with high TT4 in 159 (71%), normal due to intercurrent illness. 352 (4%) patients had suppressed TSH while all thyroid hormone values were normal. Thus TT4 may be elevated from causes other than thyrotoxicosis sufficiently frequently to necessitate routine TSH measurements. While Normal TSH measurements nearly always excludes thyrotoxicosis, suppressed values are insufficient to establish a diagnosis or monitor thyroxine replacement therapy.

Thromboblastic hyperthyroidism: sensitive monoclonal TSH assay demonstrates suppressed immunoreactive TSH

We describe a case of frank clinical hyperthyroidism due to hydatidiform mole. This is thought to be due to human chorionic gonadotrophin (hCG) or a closely related molecule produced by the tumour. hCG can cross-react with TSH in older TSH radioimmunoassays causing falsely elevated TSH levels. We demonstrate this does not occur with a chemiluminescent immunometric (monoclonal) TSH assay despite circulating hCG levels greater than 10(6) u/L.

In vitro susceptibility of Trichomonas vaginalis to 50 antimicrobial agents

We determined the susceptibilities of five strains of Trichomonas vaginalis, one of which was metronidazole resistant, to 50 antimicrobial agents. For the metronidazole-susceptible strains, the most active agents were metronidazole, tinidazole, mebendazole, furazolidone, and anisomycin. Against the resistant strain mebendazole, furazolidone, and anisomycin were the most active. Antifungal agents, beta-lactams, macrolides, aminoglycosides, and folic acid antagonists were ineffective against all strains.

Safety and immunogenicity of bovine rotavirus vaccine RIT 4237 in 3-month-old infants

To assess the safety and immunogenicity of bovine rotavirus vaccine, we administered attenuated strain RIT 4237 to 54 inner-city infants randomized to one of three groups in a double-blind fashion to receive a dose at 3 and 5 months of age of either placebo, vaccine virus at 10(7) TCID50/ml, or vaccine virus at 10(8) TCID50/ml. Vaccination began in early fall 1984, and continued through spring 1985. Forty-nine infants received one dose of vaccine or placebo; 43 received both doses of vaccine or placebo. At 2 and 3 months after vaccination, homologous geometric mean neutralizing antibody titers were significantly higher in children who received either dose of vaccine compared with placebo recipients. Cumulative seroconversion to bovine rotavirus after either dose of vaccine virus was 87% at 6 months of age. Seroconversion was significantly higher (P less than 0.01) in both vaccine groups compared with the placebo group. No ill effects were associated with vaccine administration. RIT 4237 vaccine appears to be safe and immunogenic when administered to young infants living in the United States.