Incidental pulmonary nodules may lead to a high proportion of early-stage lung cancer: but it requires more than a high CT volume to achieve this

Background

The management of pulmonary nodules plays a critical role in early detection of lung cancer. Computed tomography (CT) has led to a stage-shift towards early-stage lung cancer, but regional differences in survival rates have been reported in Denmark. This study aimed to evaluate whether variations in nodule management among Danish health regions contributed to these differences.

Material and Methods

The Danish Health Data Authority and Danish Lung Cancer Registry provided data on CT usage and lung cancer stage distribution, respectively. Auditing of lung cancer stage IA patient referrals and nodule management of stage IV lung cancer patients was conducted in seven Danish lung cancer investigation centers, covering four of the five Danish health regions. CT scans were performed up to 2 years before the patients' diagnosis from 2019 to 2021.

Results

CT usage has increased steadily in Denmark over the past decade, with a simultaneous increase in the proportion of early-stage lung cancers, particularly stage IA. However, one Danish health region, Region Zealand, exhibited lower rates of early-stage lung cancer and overall survival despite a CT usage roughly similar to that of the other health regions. The audit did not find significant differences in pulmonary nodule management or a higher number of missed nodules by radiologists in this region compared to others.

Conclusion

This study suggests that a high CT scan volume alone is not sufficient for the early detection of lung cancer. Factors beyond hospital management practices, such as patient-related delays in socioeconomically disadvantaged areas, may contribute to regional differences in survival rates. This has implications for future strategies for reducing these differences.

Increased use of computed tomography in Denmark: stage shift toward early stage lung cancer through incidental findings

BACKGROUND

Computed tomography (CT) examinations are increasingly used worldwide and incidental findings are growing likewise. Lung cancer stage at diagnosis is pivotal to survival. The earliest stage of lung cancer, stage IA is in most cases asymptomatic. Potentially, increased use of clinical CTs could induce a stage shift toward earlier lung cancer diagnosis.

MATERIALS AND METHODS

Data on the number of CT thorax in Denmark and the stage distribution of Danish lung cancer patients 2013-2020 were acquired from, respectively, the Danish Health Data Authority and the Danish Lung Cancer Registry. Clinical auditing of stage IA lung cancer patients was performed in the period 2019-2021 in a Danish region to assess the reasons for referral. Auditing of stage IV lung cancer patients was done to see whether a CT thorax was performed in a two-year period before diagnosis.

RESULTS

All regions showed an increase in CTs per 1000 inhabitants. However, the number of CTs performed in 2013 differed by more than 50% among regions, and the increase per year also differed, from an increase of 1.9 to 3.4 more examinations per year. A significant correlation between CTs and fraction of stage IA lung cancers was seen in four out of the five regions. The audit of stage IA lung cancer cases revealed that 86.8% were incidental findings. Audit of stage IV lung cancer found that 4.3% had a nodule/infiltrate on a previous CT within a 2-year period prior to the diagnosis of lung cancer that was the probable origin of stage IV lung cancer.

CONCLUSION

The study found that the vast majority of early-stage lung cancers were incidental findings. It highlights that follow-up algorithms of incidental findings should be used in accordance with guidelines and it should be unequivocally how the CT follow-up of pulmonary infiltrates is managed.

Pfizer-BioNTech vaccine side effects among healthcare workers in Malta

Background

COVID-19 vaccination is critical to protect healthcare workers (HCWs) from serious infection. The first vaccine approved for emergency use was the Pfizer-BioNtech vaccine. European countries received their first supplies at the end of December 2020. The European country of Malta started its vaccination roll-out immediately targeting HCWs. The aim of this study was to evaluate side effects.

Methods

An anonymous online Google Forms survey was disseminated to all HCWs via work e-mail addresses (29th March to 9th April 2021). This gathered demographic data and side-effects regarding pain, redness, and swelling at the injection site, fever, chills, fatigue, muscle/joint pains, headache, vomiting, and diarrhea severity following each dose (Likert scale). Descriptive, comparative, and multiple binary regression analyses were performed.

Results

There were 1480 responses (response rate 30.30%). The commonest side-effect (SE) was pain at the injection site (88.92% CI95%:87.21-90.42), with the majority reporting it as mild (51%) and moderate (43%). Fatigue reported by 72.97% (CI95%:70.65-75.17), with 42% reporting it as mild and 41% as moderate. Headaches reported by 44.28% (CI95%:41.74-46.80), with 51% claiming to be mild and 34% as moderate. Females had significantly (p = <0.01 respectively) more pain (OR:1.90), redness (OR:2.49), swelling at the injection site (OR:1.33), fever (OR:1.74), chills (OR:2.32), fatigue (OR:2.43), muscle (OR:1.54) and joint pains (OR:2.01), headache (OR:2.07) and vomiting (OR:3.43) when adjusted for age and HCW role. Younger individuals (18-34 years) reported higher SE rates than older adults. Localised SE was reported following both vaccine doses, unlike systemic SE that was mostly reported following second doses.

Conclusions

Females and young adults appeared to be more susceptible to SE among this study's cohort, however the nature of these SE was mostly mild or moderate. This is encouraging and should allay vaccine apprehension/hesitancy.

Key messages

Vaccination benefits outweigh the minor side effects experienced. Caring physicians should be notified of the female higher susceptibility to side effects.

Vaccination should be encouraged among all eligible population.

Cubic, hexagonal and tetragonal FeGe x phases (x = 1, 1.5, 2): Raman spectroscopy and magnetic properties

There is currently an emerging drive towards computational materials design and fabrication of predicted novel materials. One of the keys to developing appropriate fabrication methods is determination of the composition and phase. Here we explore the FeGe system and establish reference Raman signatures for the distinction between FeGe hexagonal and cubic structures, as well as FeGe2 and Fe2Ge3 phases. The experimental results are substantiated by first principles lattice dynamics calculations as well as by complementary structural characterization such as transmission electron microscopy and X-ray diffraction, along with magnetic measurements.

Validation of a non-motor fluctuations questionnaire in Parkinson's disease

INTRODUCTION

Non-motor fluctuations (NMF) in Parkinson's disease (PD) remain poorly recognized but have a high impact on patients' quality of life. The lack of assessment tools limits our understanding of NMF, compromising appropriate management. Our objective was to validate a hetero-questionnaire for NMF in PD patients at different stages of the disease: without treatment, without motor fluctuations, with motor fluctuations.

METHODS

We included patients in 15 centers in France. Our questionnaire, NMF-Park, resulted from previous studies, allowing us to identify the more pertinent NMF for evaluation. Patients reported the presence (yes or no) of 22 selected NMF, and their link with dopaminergic medications. The assessment was repeated at one and two years to study the progression of NMF. We performed a metrological validation of our questionnaire.

RESULTS

We included 255 patients (42 without treatment, 88 without motor fluctuations and 125 with motor fluctuations). After metrological validation, three dimensions of NMF were found: dysautonomic; cognitive; psychiatric. The sensory/pain dimension described in the literature was not statistically confirmed by our study.

DISCUSSION

Our questionnaire was validated according to clinimetric standards, for different stages of PD. It was clinically coherent with three homogeneous dimensions. It highlighted a link between fatigue, visual accommodation disorder, and cognitive fluctuations; and the integration of sensory/pain fluctuations as part of dysautonomic fluctuations. It focused exclusively on NMF, which is interesting considering the described differences between non-motor and motor fluctuations.

CONCLUSION

Our study validated a hetero-questionnaire of diagnosis for NMF for different stages of PD.

Addressing childhood obesity - Are we doing enough?

Background

The prevalence of childhood overweight and obesity is increasing worldwide, with Malta having one of the highest rates among European countries. Childhood obesity is likely to track into adulthood, and can have multiple physical and psychological health outcomes. It also causes a substantial economic burden on society. A cross-sectional study that aimed to identify barriers to maintaining a healthy weight among children attending primary school, and to assess the level of support for a range of policies aimed at addressing childhood obesity as expressed by their parents/guardians, was conducted in Malta.

Methods

Data were collected using a paper-based questionnaire that was distributed to a stratified random sample of parents whose children attended free State schools, subsidised Church schools and fee-paying Independent primary schools in Malta and Gozo in 2018. Data were analysed using SPSSv25.

Results

Responses from 1169 parents were received. There was a dissonance between the most common barriers identified, that were primarily related to the food environment, and the policies that received the most support. Providing more spaces for safe physical activity was the most supported policy (94% in favour). Participants were least supportive of taxation policies, a phenomenon also observed in other countries. The level of support for policies varied significantly by various demographic and socioeconomic factors.

Conclusions

Recommendations were developed to inform future policies and strategies to address obesity. Policymakers need to take bold, possibly controversial decisions to mitigate against the barriers faced by the population in accessing healthy food and being physically active. Given the globalised nature of media advertising and the food system, a joint international effort is necessary to address this epidemic, such as stricter audio-visual media advertising regulations, food reformulation and mandatory standardised food labels.

Key messages

The majority of participants supported most of the proposed policies to address obesity. Taxation policies received the least support. Most policies supported are trans-sectoral, therefore a health-in-all policies approach and international collaboration are necessary.

APPLICATION OF THE EUROPEAN PROTOCOL IN THE EVALUATION OF DIGITAL MAMMOGRAPHY UNITS WITH TUNGSTEN TARGET TUBES

The performance of the first direct digital mammography unit in Gozo General Hospital, the Hologic Selenia Dimensions 2D, was assessed by applying the European Protocol for quality control in mammography screening. This system employs a Tungsten anode in association with a Rhodium or Silver filter, depending on the compressed breast thickness. The objective of this article was to apply the European Protocol in the evaluation of this system in terms of dose, image quality and detector performance and determine whether this system is suitable for use in the national breast-screening program.

The relation of the vaginal microbiota to early pregnancy development during in vitro fertilization treatment-A meta-analysis

An abnormal vaginal microbiota composition has been shown to lead to pre-term births, miscarriage, and problems with conceiving. Studies have suggested that dysbiosis reduces successful early pregnancy development during IVF. However, conflicting reports exist. This meta-analysis aims to answer the following question: what is the aggregated effect found by studies investigating the influence of the vaginal microbiota composition on early pregnancy rates after IVF treatment? A systematic review was performed using the Medline and EMBASE databases, using search terms for healthy vaginal microbiota, abnormal vaginal microbiota, fertility and pregnancy. The search resulted in six included articles. Of these, all six were used for further meta-analysis. The main outcome measures were the clinical pregnancy rate, determined through ultrasound proven fetal heartbeat and/or hCG results before 10 weeks gestation, in relation to the vaginal microbiota composition. We found a correlation between abnormal vaginal microbiota and lower rates of early pregnancy development after IVF treatment (OR = 0.70, 95% CI = 0.49 - 0.99). One study showed the reverse correlation. However, heterogeneity between study methodologies in various forms was found. In conclusion, women with an abnormal vaginal microbiota are roughly 1.4 times less likely to have a successful early pregnancy development after IVF treatment when compared to women with normal microbiota.

Infection prevention and control measures and tools for the prevention of entry of carbapenem-resistant Enterobacteriaceae into healthcare settings: guidance from the European Centre for Disease Prevention and Control

Background

Infections with carbapenem-resistant Enterobacteriaceae (CRE) are increasingly being reported from patients in healthcare settings. They are associated with high patient morbidity, attributable mortality and hospital costs. Patients who are “at-risk” may be carriers of these multidrug-resistant Enterobacteriaceae (MDR-E).

The purpose of this guidance is to raise awareness and identify the “at-risk” patient when admitted to a healthcare setting and to outline effective infection prevention and control measures to halt the entry and spread of CRE.

Methods

The guidance was created by a group of experts who were functioning independently of their organisations, during two meetings hosted by the European Centre for Disease Prevention and Control. A list of epidemiological risk factors placing patients “at-risk” for carriage with CRE was created by the experts. The conclusions of a systematic review on the prevention of spread of CRE, with the addition of expert opinion, were used to construct lists of core and supplemental infection prevention and control measures to be implemented for “at-risk” patients upon admission to healthcare settings.

Results

Individuals with the following profile are “at-risk” for carriage of CRE: a) a history of an overnight stay in a healthcare setting in the last 12 months, b) dialysis-dependent or cancer chemotherapy in the last 12 months, c) known previous carriage of CRE in the last 12 months and d) epidemiological linkage to a known carrier of a CRE.

Core infection prevention and control measures that should be considered for all patients in healthcare settings were compiled. Preliminary supplemental measures to be implemented for “at-risk” patients on admission are: pre-emptive isolation, active screening for CRE, and contact precautions. Patients who are confirmed positive for CRE will need additional supplemental measures.

Conclusions

Strengthening the microbiological capacity, surveillance and reporting of new cases of CRE in healthcare settings and countries is necessary to monitor the epidemiological situation so that, if necessary, the implemented CRE prevention strategies can be refined in a timely manner. Creating a large communication network to exchange this information would be helpful to understand the extent of the CRE reservoir and to prevent infections in healthcare settings, by applying the principles outlined here.

This guidance document offers suggestions for best practices, but is in no way prescriptive for all healthcare settings and all countries. Successful implementation will result if there is local commitment and accountability. The options for intervention can be adopted or adapted to local needs, depending on the availability of financial and structural resources.

Electronic supplementary material

The online version of this article (10.1186/s13756-017-0259-z) contains supplementary material, which is available to authorized users.

ALTERNATIVE FIGURES-OF-MERIT IN DIGITAL MAMMOGRAPHY

The aim of this study is to explore the use of a quality (Q) factor in digital mammography as a figure-of-merit. Q factors take a reference value into account and can be compared to a theoretical value. They are also intended to summarise the performance of any unit based on a number. The mean glandular dose (MGD)-normalised Q factors were also introduced based on the relationship of the Q factors with MGD. Interestingly, the automatic exposure control exposures did not render the maximum normalised Q factor values as expected, which could indicate the need for further optimisation. It was also noted that the Q factors and the CDMAM-related quality parameters can be confidently predicted for a given MGD which in turn may be compared to the measured values. This might be another way to consider or perform optimisation in digital mammography.

Pregnancy outcomes and impact of pregnancy on graft function in women after kidney transplantation

BACKGROUND

Kidney transplantation facilitates pregnancy in women with end-stage kidney disease; however, the impact of pregnancy on short and longer-term graft function is uncertain.

METHODS

Obstetric, fetal, and graft outcomes for pregnancies from a large Australian transplant unit (1976-2015) were reviewed.

RESULTS

There were 56 pregnancies in 35 women with mean age at conception 30.4 ± 0.6 years and mean transplant-pregnancy interval 5.5 ± 0.5 years. The live birth rate was 78.9%. Preterm birth (<37 weeks) occurred in 56.5%. Hypertensive disorders affected 76% of women (pre-eclampsia in 30%). Median prepregnancy serum creatinine (SCr) was 100 μmol/L (interquartile range (IQR), 80, 114 μmol/L). One-third had deterioration in graft dysfunction during pregnancy; of these, 63.2% did not return to baseline. At 2 years post-partum, median SCr was 96.4 μmol/L (IQR, 81.5-124.3). Women with prepregnancy SCr > 110 μmol/L had increased risk of pre-eclampsia (OR 4.4; 95% CI 1.2-16.8; P = .03), but not preterm birth (OR 5.4; 95% CI 0.5-53; P = .04) or low birth-weight babies (OR 1.2; 95% CI 0.5-2.9; P = .04). Women with SCr > 140 μmol/L preconception had worst SCr trajectory, including higher rates of graft loss.

CONCLUSIONS

Kidney transplantation pregnancies remain at high risk of obstetric complications, particularly pre-eclampsia. Prepregnancy graft function can be used to predict risk of adverse pregnancy outcomes and deterioration in graft function during and after delivery.

Oncological outcomes in an Australian cohort according to the new prostate cancer grading groupings

Background

A new 5-tiered grading grouping system has recently been endorsed for reporting of prostate cancer (PCa) grade to better reflect escalating risk of progression and cancer death. While several validations of the new grade groupings have been undertaken, most have involved centralised pathological review by specialist urological pathologists.

Methods

Participants included 4268 men with non-metastatic PCa diagnosed between 2006 and 2013 from the multi-institutional South Australia Prostate Cancer Clinical Outcomes Collaborative registry. PCa-specific survival and biochemical recurrence-free survival were compared across the five grade groups using multivariable competing risk regression.

Results

For the entire cohort, risk of PCa death increased with increasing grade groups (at biopsy) Adjusted subdistribution-hazard ratios [sHR] and 95% confidence intervals [95%CI] were: 2.2 (1.5–3.6); 2.5 (1.6–4.2); 4.1 (2.6–6.7) and 8.7 (4.5–14.0) for grade groups II (pattern 3 + 4), III (pattern 4 + 3), IV (total score 8) and V (total score 9–10) respectively, relative to grade group I (total score < =6). Clear gradients in risk of PCa death were observed for radical prostatectomy (RP), but were less clear for those who had radiotherapy (RT) with curative intent and those who were managed conservatively. Likewise, risk of biochemical recurrence increased across grade groups, with a strong and clear gradient for men undergoing RP [sHR (95%CI): 2.0 (1.4–2.8); 3.8 (2.9–5.9); 5.3 (3.5–8.0); 11.2 (6.5–19.2) for grade groups II, III, IV and V respectively, relative to grade group I], and a less clear gradient for men undergoing RT.

Conclusion

In general, the new five-tiered grade groupings distinguished PCa survival and recurrence outcomes for men with PCa. The absence of a clear gradient for RT may be due to heterogeneity in this patient group.

A comparison between the dynamics of horizontal and vertical axis offshore floating wind turbines

The need to further exploit offshore wind resources in deeper waters has led to a re-emerging interest in vertical axis wind turbines (VAWTs) for floating foundation applications. However, there has been little effort to systematically compare VAWTs to the more conventional horizontal axis wind turbine (HAWT). This article initiates this comparison based on prime principles, focusing on the turbine aerodynamic forces and their impact on the floating wind turbine static and dynamic responses. VAWTs generate substantially different aerodynamic forces on the support structure, in particular, a potentially lower inclining moment and a substantially higher torque than HAWTs. Considering the static stability requirements, the advantages of a lower inclining moment, a lower wind turbine mass and a lower centre of gravity are illustrated, all of which are exploitable to have a less costly support structure. Floating VAWTs experience increased motion in the frequency range surrounding the turbine [number of blades]×[rotational speed] frequency. For very large VAWTs with slower rotational speeds, this frequency range may significantly overlap with the range of wave excitation forces. Quantitative considerations are undertaken comparing the reference NREL 5 MW HAWT with the NOVA 5 MW VAWT.

The role of cytokines in postmenopausal osteoporosis

Postmenopausal osteoporosis is a silent systemic progressive disease characterised by a decrease in bone mass per unit volume. This condition compromises the physical strength of the skeleton and increases the susceptibility to fractures on minor trauma. The imbalance between bone formation and bone resorption is known to be responsible for postmenopausal bone loss. Estrogen deficiency contributes to bone loss by increasing the production of pro-inflammatory cytokines by bone marrow and bone cells. Clinical and molecular evidence indicates that estrogen-regulated cytokines exert regulatory effects on bone turnover implicating their role as being the primary mediators of the accelerated bone loss at menopause. The current perspective on the role and interaction of cytokines such as IL-1, IL-4, IL-6, IL-17, TNF, IFN-γ and TGF-β in bone loss linked with estrogen deficiency is reviewed. Current treatment options and emerging drug therapies in the management of postmenopausal osteoporosis are also evaluated.

Mammography equipment performance, image quality and mean glandular dose in Malta

In this first Maltese national mammography survey, the effectiveness of direct digital (DR) mammography in breast cancer screening has been confirmed. Patient data were made available from three clinics out of the participating nine. A dose survey of mean glandular dose (MGD) calculated for 759 patients examined in the state-owned mammography facilities was performed. An MGD national diagnostic reference level was set at 1.87 mGy for patients with breast compression thicknesses (BCT) between 5.0 and 7.0 cm. This range was selected since patient data were retrieved from three clinics only and the results showed that other international BCT reference levels may be unsuitable for the Maltese population. In fact, the overall average BCT was 5.75 ± 1.4 cm. The survey results have shown that the technical standard of mammographic equipment in the Malta National Breast Screening Programme is on a par with other countries, including its Western European counterparts.

The role of cytokines in skin aging

Cutaneous aging is one of the major noticeable menopausal complications that most women want to fight in their quest for an eternally youthful skin appearance. It may contribute to some maladies that occur in aging which, despite not being life-threatening, affect the well-being, psychological state and quality of life of aged women. Skin aging is mainly affected by three factors: chronological aging, decreased levels of estrogen after menopause, and environmental factors. Aged skin is characterized by a decrease in collagen content and skin thickness which result in dry, wrinkled skin that is easily bruised and takes a longer time to heal. Cytokines play a crucial role in the manifestation of these features of old skin. The pro-inflammatory cytokine tumor necrosis factor-alpha inhibits collagen synthesis and enhances collagen degradation by increasing the production of MMP-9. It also lowers the skin immunity and thus increases the risk of cutaneous infections in old age. Deranged levels of several interleukins and interferons also affect the aging process. The high level of CCN1 protein in aged skin gives dermal fibroblasts an 'age-associated secretory phenotype' that causes abnormal homeostasis of skin collagen and leads to the loss of the function and integrity of skin. Further research is required especially to establish the role of cytokines in the treatment of cutaneous aging.

A study to determine the differences between the displayed dose values for two full-field digitalmammography units and values calculated using a range of Monte-Carlo-based techniques:a phantom study

Modern full-field digital mammography (FFDM) units display the mean glandular dose (MGD) and the entrance or incident air kerma (K) to the breast following each exposure. Information on how these values are calculated is limited and knowing how displayed MGD values compare and correlate to conventional Monte-Carlo-based methods is useful. From measurements done on polymethyl methacrylate (PMMA) phantoms, it has been shown that displayed and calculated MGD values are similar for thin to medium thicknesses and appear to differ with larger PMMA thicknesses. As a result, a multiple linear regression analysis on the data was performed to generate models by which displayed MGD values on the two FFDM units included in the study may be converted to the Monte-Carlo values calculated by conventional methods. These models should be a useful tool for medical physicists requiring MGD data from FFDM units included in this paper and should reduce the survey time spent on dose calculations.

The role of cytokines in cardiovascular disease in menopause

Various studies suggest that increased levels of pro-inflammatory cytokines play a key role in the declining ovarian function and the resulting complications associated with menopause. In this review article, the authors outline the role of pro- and anti-inflammatory cytokines in cardiovascular disease during menopause.

The use of a figure-of-merit (FOM) for optimisation in digital mammography: a literature review

The use of image quality parameters in digital mammography such as contrast-to-noise ratio (CNR), signal-to-noise ratio (SNR) and detective quantum efficiency (DQE) has been widespread, with the intention of detector evaluation and/or quantitative evaluation of the system performance. These parameters are useful in ensuring adequate system performance when tests are done against international standards or guidelines. Parameters like CNR are relative quantities that lie within a range that is manufacturer and system dependent. The use of a figure-of-merit (FOM) is a relatively new concept as a tool in digital mammography permitting quantitative assessment in terms of image quality and patient dose. This review summarises the available evidence for the use and applicability of an FOM in digital mammography.

The Rh(100)-(3 × 1)-2O structure

The O adsorption on Rh(100) has been studied using high resolution core level spectroscopy, low energy electron diffraction and scanning tunnelling microscopy. In addition to the well known (2 × 2), (2 × 2)-pg and c(8 × 2) structures at coverages of 0.25, 0.5 and 1.75 ML respectively, an intermediate (3 × 1) structure with a coverage of 2/3 ML is identified.

The GOFURTGO Study: AGITG phase II study of fixed dose rate gemcitabine-oxaliplatin integrated with concomitant 5FU and 3-D conformal radiotherapy for the treatment of localised pancreatic cancer

Background:

Locally advanced inoperable pancreatic cancer (LAPC) has a poor prognosis. By increasing intensity of systemic therapy combined with an established safe chemoradiation technique, our intention was to enhance the outcomes of LAPC. In preparation for phase III evaluation, the feasibility and efficacy of our candidate regimen gemcitabine–oxaliplatin chemotherapy with sandwich 5-fluorouracil (5FU) and three-dimensional conformal radiotherapy (3DCRT) needs to be established.

Methods:

A total of 48 patients with inoperable LAPC without metastases were given gemcitabine (1000 mg m⁻² d1 + d15 q28) and oxaliplatin (100 mg m⁻² d2 + d16 q28) in induction (one cycle) and consolidation (three cycles), and 5FU 200 mg m⁻² per day over 6 weeks during 3DCRT 54 Gy.

Results:

Median duration of sustained local control (LC) was 15.8 months, progression-free survival (PFS) was 11.0 months, and overall survival was 15.7 months. Survival rates for 1, 2, and 3 years were 70.2%, 21.3%, and 12.8%, respectively. Global quality of life did not significantly decline from baseline during treatment, which was associated with modest treatment-related toxicity.

Conclusion:

Fixed-dose gemcitabine and oxaliplatin, combined with an effective and safe regimen of 5FU and 3DCRT radiotherapy, was feasible and reasonably tolerated. The observed improved duration of LC and PFS with more intensive therapy over previous trials may be due to patient selection, but suggest that further evaluation in phase III trials is warranted.

Not just an individual journey: social aspects of recovery

BACKGROUND

Recent literature on recovery describes the process as deeply personal and unique to each individual. While there are aspects of recovery that are unique to each individual, this article argues that focusing solely on these overlooks the fact that recovery unfolds within a social and interpersonal context.

MATERIALS

Drawing from qualitative data, this article describes aspects of recovery that involve the contributions of others, the social environment and society.

DISCUSSION

These aspects of recovery include relationships, adequate material conditions and responsive services and supports.

CONCLUSION

The authors consider the implications of these social factors for transforming psychiatric research and theory as well as for recovery-orientated practice.

Not just an individual journey: social aspects of recovery

BACKGROUND

Recent literature on recovery describes the process as deeply personal and unique to each individual. While there are aspects of recovery that are unique to each individual, this article argues that focusing solely on these overlooks the fact that recovery unfolds within a social and interpersonal context.

MATERIALS

Drawing from qualitative data, this article describes aspects of recovery that involve the contributions of others, the social environment and society.

DISCUSSION

These aspects of recovery include relationships, adequate material conditions and responsive services and supports.

CONCLUSION

The authors consider the implications of these social factors for transforming psychiatric research and theory as well as for recovery-orientated practice.

Burden of antimicrobial resistance in European hospitals: excess mortality and length of hospital stay associated with bloodstream infections due to Escherichia coli resistant to third-generation cephalosporins

OBJECTIVES

This study determined excess mortality and length of hospital stay (LOS) attributable to bloodstream infection (BSI) caused by third-generation-cephalosporin-resistant Escherichia coli in Europe.

METHODS

A prospective parallel matched cohort design was used. Cohort I consisted of patients with third-generation-cephalosporin-resistant E. coli BSI (REC) and cohort II consisted of patients with third-generation-cephalosporin-susceptible E. coli BSI (SEC). Patients in both cohorts were matched for LOS before infection with patients free of the respective BSI. Thirteen European tertiary care centres participated between July 2007 and June 2008.

RESULTS

Cohort I consisted of 111 REC patients and 204 controls and cohort II consisted of 1110 SEC patients and 2084 controls. REC patients had a higher mortality at 30 days (adjusted odds ratio = 4.6) and a higher hospital mortality (adjusted hazard ratio = 5.7) than their controls. LOS was increased by 8 days. For SEC patients, these figures were adjusted odds ratio = 1.9, adjusted hazard ratio = 2.0 and excess LOS = 3 days. A 2.5 times [95% confidence interval (95% CI) 0.9-6.8] increase in all-cause mortality at 30 days and a 2.9 times (95% CI 1.2-6.9) increase in mortality during entire hospital stay as well as an excess LOS of 5 days (95% CI 0.4-10.2) could be attributed to resistance to third-generation cephalosporins in E. coli BSI.

CONCLUSIONS

Morbidity and mortality attributable to third-generation-cephalosporin-resistant E. coli BSI is significant. If prevailing resistance trends continue, high societal and economic costs can be expected. Better management of infections caused by resistant E. coli is becoming essential.

[Chorea-acanthocytosis without acanthocytes]

INTRODUCTION

Chorea-acanthocytosis (ChAc) is one of the neuroacanthocytosis syndromes which form a group of disorders characterized by the association of neurological abnormalities and spiculated red blood cells called acanthocytes. ChAc patients exhibit involuntary movements, psychiatric abnormalities and progressive cognitive deterioration. We report a case of ChAc in which blood smears failed to demonstrate acanthocytes.

CASE REPORT

A 26-year-old man presented since two years with hyperkinetic movements. The family history was non contributive, parents were consanguineous. Neurological examination revealed choreatic hyperkinesia and dystonia, predominant in the orofacial region. Mild cognitive decline and behavior abnormalities were noted with repetitive activities. Brain MRI showed striatal atrophy. Molecular testing for Huntington's disease was negative. Routine biological screening was normal except for elevated CPK and LDH. Copper and ceruloplasmin blood levels were normal, as well as purine metabolism and lipoproteins. Further screening for metabolic diseases showed no significant abnormality. Expression of Kell antigens was normal. In several blood smears no acanthocytes were seen. Electromyographic studies showed slight neuropathic changes. Despite the absence of acanthocytes, chorein western blot was performed on blood samples which revealed an absent or markedly reduced level of chorein in erythrocyte membranes. A mutation of the ChAc gene was thus likely so the diagnosis of ChAc was retained. Genetic studies for VPS13A are pending.

DISCUSSION

ChAc is an autosomal recessive disorder due to mutations of the VPS13A gene coding for chorein. Absence or late appearance of acanthocytes in ChAc has been described in a few case reports. In conclusion ChAc is a rare disorder in which the presence of acanthocytes is not mandatory. In case of doubt, chorein western blot can be useful.

Accrediting radiation technique in a multicentre trial of chemoradiation for pancreatic cancer

Before a multicentre trial of 3-D conformal radiotherapy to treat cancer of the pancreas, participating clinicians were asked to complete an accreditation exercise. This involved planning two test cases according to the study protocol, then returning hard copies of the plans and dosimetric data for review. Any radiation technique that achieved the specified constraints was allowed. Eighteen treatment plans were assessed. Seven plans were prescribed incorrect doses and two of the planning target volumes did not comply with protocol guidelines. All plans met predefined normal tissue dose constraints. The identified errors were attributable to unforeseen ambiguities in protocol documentation. They were addressed by feedback and corresponding amendments to protocol documentation. Summary radiobiological measures including total weighted normal tissue equivalent uniform dose varied significantly between centres. This accreditation exercise successfully identified significant potential sources of protocol violations, which were then easily corrected. We believe that this process should be applied to all clinical trials involving radiotherapy. Due to the limitations of data analysis with hard-copy information only, it is recommended that complete planning datasets from treatment-planning systems be collected through a digital submission process.

User involvement in community mental health services--principles and practices

Although user involvement has been the vision of mental health care for the last decades, there are indications of this vision remaining as rhetoric rather than reality in many clinical settings. The objective of this paper is to raise some fundamental questions associated with user involvement. Four challenges are examined: assumptions about the nature of the problems, the power of defining 'true knowledge', the power domination in service provision and community mental health care as an accommodating arena for maximizing the service user role. Finally, some strategies are suggested in order to overcome barriers towards realizing the intentions of user involvement.

The phenomenon of making decisions during the experience of early breast cancer

Breast cancer patients are faced with many decisions about their treatment, relationships and lives. The aims of this study were: to provide an understanding of the phenomenon of making decisions during the experience of early breast cancer, and to describe the types of decisions these patients are typically faced with. Previous research has focused largely on describing the different ways patients behave when making choices about treatment. However, few studies provide an understanding of the range of decisions women are likely to face, or describe what the experience of making these decisions is like. Hermeneutic phenomenology was used to inform the research. In-depth interviews were conducted with 18 breast cancer patients who had completed treatment. This study provides an understanding of the broad range of decisions with which women may be faced, and presents a new interpretation of what the experience of making decisions is like for women diagnosed with breast cancer. Five existential themes were found to be representative of the experience of making decisions: being challenged, getting ready, surviving, sharing the challenge and interrogating the future. Health professionals can use the understandings presented to improve their therapeutic relationships with patients and further assist women as they work through their experience of breast cancer.

Feasibility study on the MammoSite in early-stage breast cancer: Initial experience

The aims of this study were to evaluate the feasibility, practicality, efficacy and safety of the delivery of accelerated partial breast irradiation using the MammoSite for the boost phase. Six patients aged 53-69 years with stage T1N0, T2N0, Grade I-II invasive ductal carcinoma received 9-10 Gy prescribed at 1 cm from the MammoSite balloon surface in two fractions of 4.5-5 Gy 6 h apart. The MammoSite was inserted 20-37 days postoperatively. External beam radiation therapy to the whole breast commenced 1-5 days after accelerated partial breast irradiation. The maximum skin dose ranged from 3 to 9 Gy. The skin-cavity distance ranged from 7 to 19 mm. Local discomfort resolved as the scar healed spontaneously within 3-5 days. No Grade III or higher acute toxicity or local infection was recorded. The ease of insertion and accuracy of dosimetry makes the MammoSite suitable for use in properly selected women with early-stage breast cancer in a trial setting.

Symptomatic myoclonus

A huge number of neurological disorders are associated with myoclonus. This paper describes these disorders whose diagnosis partly relies on the presence of myoclonus. The diagnostic approach is related to certain clinical features of myoclonus, which, after their integration in the clinical context, help orientate towards diagnosis. Myoclonus is frequent during dementia. Although its presence is well-known to take part in the diagnosis of Creutzfeldt-Jakob disease (CJD), myoclonus can also be present to a significant degree in Alzheimer's disease and Lewy body dementia (LBD), which raises a diagnostic issue. Both its clinical and electrophysiological features may help differential diagnosis, given that myoclonus with fast-evolving dementia and focal neurological signs should favor the diagnosis of CJD. Myoclonus in a context of progressive ataxia suggests one clinical form of the Ramsay-Hunt syndrome (progressive myoclonic ataxia, PMA), whose most frequent causes are: coeliac disease, mitochondriopathies, some spino-cerebellar degenerations, and some late metabolic disorders. In addition to ataxia and myoclonus, the presence of opsoclonus directs diagnosis toward the opsoclonus-myoclonus syndrome (OMS), whose origin, in adult, is idiopathic or paraneoplastic. Palatal tremor (myoclonus) with ataxia may represent either a sporadic pattern, which often reflects the evolution of degenerative or lesional disorders, or a familial pattern in some degenerative affections or metabolic diseases. Of more recent knowledge is the association of progressive ataxia, myoclonus, and renal failure, which corresponds to a recessive autosomic disease. In a context of encephalopathy, myoclonus is frequent in metabolic or hydro-electrolytic disorders, and in brain anoxia. One should distinguish these various forms of myoclonus which may occur in the acute post-anoxic phase, from those occurring as sequels at a later stage, i.e. the Lance and Adams syndrome whose clinical aspects are also multiple. Myoclonus is less frequent during toxic or drug exposures. Irrespective of its acute or insidious onset, Hashimoto's encephalopathy is accompanied by myoclonus and tremor. Myoclonus may also be present during encephalic and/or spinal infectious disorders. Myoclonus with focal neurological signs may be observed in thalamic lesions, responsible for unilateral asterixis or unilateral myoclonus superimposed on dystonic posture. Segmental spinal myoclonus or propriospinal myoclonus may be associated with several spinal-cord disorders. Myoclonus associated with peripheral nerve lesions is exceptional or even questionable for some of these.