Patient Preparation and Radiation Protection Guidance for Adult Patients Undergoing Radioiodine Treatment for Thyroid Cancer in the UK

Radioactive iodine is a highly effective treatment for thyroid cancer and has now been used in clinical practice for more than 80 years. In general, the treatment is well tolerated. However, it can be logistically quite complex for patients due to the need to reduce iodine intake and achieve high levels of thyroid-stimulating hormone prior to treatment. Radiation protection precautions must also be taken to protect others from unnecessary radiation exposure following treatment. It has been well documented by thyroid cancer patient support groups that there is significant variation in practice across the UK. It is clear that some patients are being asked to observe unnecessarily burdensome restrictions that make it more difficult for them to tolerate the treatment. At the instigation of these support groups, a multidisciplinary group was assembled to examine the evidence and generate guidance on best practice for the preparation of patients for this treatment and the management of subsequent radiation protection precautions, with a focus on personalising the advice given to individual patients. The guidance includes advice about managing particularly challenging situations, for example treating patients who require haemodialysis. We have also worked together to produce a patient information leaflet covering these issues. We hope that the guidance document and patient information leaflet will assist centres in improving our patients' experience of receiving radioactive iodine. The patient information sheet is available as Supplementary Material to this article.

Cross-validation of good versus poor self-reported outcome trajectory types following knee arthroplasty

OBJECTIVE

To determine whether good versus poor outcome trajectories and predictors of poor outcome obtained in a derivation study could be replicated in an independent sample of persons undergoing knee arthroplasty (KA).

METHODS

We used data from TRIO-POPULAR, a prospective cohort study of 926 participants who underwent KA in the United Kingdom. The participants were assessed preoperatively and 6-weeks, 6- and 12-months postoperatively. The Oxford Knee Score was the primary outcome and a variety of pre-operative predictors of outcome were selected. The outcome measure and the predictors were selected to most closely align with a previously published derivation study of good versus poor outcome. Confirmatory two-piece latent class growth curve analyses were used to model outcome and regression was used to identify predictors of outcome class.

RESULTS

Trajectories for the Oxford Knee Scores from TRIO-POPULAR replicated trajectories for WOMAC Pain and Function scores from the previously published derivation study. Multivariable predictors of poor outcome were pain catastrophizing (odds ratio = 1.125, 95% CI = 1.048, .206, p = 0.001) and comorbidity (odds ratio = 1.134, 95%CI = 1.049, 1.227, p = 0.002. Pain catastrophizing also predicted poor outcome in the derivation study.

CONCLUSIONS

Good and poor outcome trajectories replicated those found in the previously published derivation study. Our model-based method produces stable outcome trajectories despite using data from different countries and participants with substantively different characteristics. Predictors of poor outcome were somewhat inconsistent between the cross-validation and derivation studies. Pain catastrophizing was the only consistent poor outcome predictor.

The Impact of Intra-thoracic Anatomical Changes upon the Delivery of Lung Stereotactic Ablative Radiotherapy

AIMS

So far, the impact of intra-thoracic anatomical changes (ITACs) on patients treated with stereotactic ablative radiotherapy (SABR) for early-stage non-small cell lung cancer is unknown. Studying these is important, as ITACs have the potential to impact the workflow and reduce treatment quality. The aim of this study was to assess and categorise ITACs, as detected on cone beam computed tomography scans (CBCT), and their subsequent impact upon treatment in lung cancer patients treated with SABR.

MATERIALS AND METHODS

CBCTs from 100 patients treated with SABR for early non-small cell lung cancer were retrospectively reviewed. The presence of the following ITACs was assessed: atelectasis, infiltrative change, pleural effusion, baseline shift and gross tumour volume (GTV) increase and decrease. ITACs were graded using a traffic light protocol. This was adapted from a tool previously developed to assesses potential target undercoverage or organ at risk overdose. The frequency of physics or clinician review was noted. A linear mixed effects model was used to assess the relationship between ITAC grade and set-up time (time from first CBCT to beam delivery).

RESULTS

ITACs were observed in 22% of patients. Twenty-one per cent of these were categorised as 'red', implying a risk of underdosage to the GTV. Most were 'yellow' (51%), indicating little impact upon planning target volume coverage of the GTV. Physics or clinician review was required in 10% of all treatment fractions overall. Three patients needed their treatment replanned. The mixed effect model analysis showed that ITACs cause a significant prolongation of set-up time (Χ2(3) = 9.22, P = 0.02).

CONCLUSION

Most ITACs were minor, but associated with unplanned physics or clinician review, representing a potentially significant resource burden. ITACs also had a significant impact upon set-up time, with consequences for the wider workflow and intra-fraction motion. Detailed guidance on the management of ITACs is needed to provide support for therapeutic radiographers delivering lung SABR.

Intensity-modulated Radiotherapy for Rectal Cancer in the UK in 2020

AIMS

Preoperative (chemo)radiotherapy followed by total mesorectal excision is the current standard of care for patients with locally advanced rectal cancer. The use of intensity-modulated radiotherapy (IMRT) for rectal cancer is increasing in the UK. However, the extent of IMRT implementation and current practice was not previously known. A national survey was commissioned to investigate the landscape of IMRT use for rectal cancer and to inform the development of national rectal cancer IMRT guidance.

MATERIALS AND METHODS

A web-based survey was developed by the National Rectal Cancer IMRT Guidance working group in collaboration with the Royal College of Radiologists and disseminated to all UK radiotherapy centres. The survey enquired about the implementation of IMRT with a focus on the following aspects of the workflow: dose fractionation schedules and use of a boost; pre-treatment preparation and simulation; target volume/organ at risk definition; treatment planning and treatment verification. A descriptive statistical analysis was carried out.

RESULTS

In total, 44 of 63 centres (70%) responded to the survey; 30/44 (68%) and 36/44 (82%) centres currently use IMRT to treat all patients and selected patients with rectal cancer, respectively. There was general agreement concerning several aspects of the IMRT workflow, including patient positioning, use of intravenous contrast and bladder protocols. Greater variation in practice was identified regarding rectal protocols; use of a boost to primary/nodal disease; target volume delineation; organ at risk delineation and dose constraints and treatment verification. Delineation of individual small bowel loops and daily volumetric treatment verification were considered potentially feasible by most centres.

CONCLUSION

This survey identified that IMRT is already used to treat rectal cancer in many UK radiotherapy centres, but there is heterogeneity between centres in its implementation and practice. These results have been a valuable aid in framing the recommendations within the new National Rectal Cancer IMRT Guidance.

Prospects for Personalised Treatment of Patients with Radioiodine-avid Locally Recurrent or Metastatic Thyroid Cancer

Although most patients with metastatic or inoperable locally recurrent differentiated thyroid cancer have radioiodine-avid disease, the outcome for patients who do not achieve remission with radioiodine therapy is poor. Most centres use fixed empirical activities of radioiodine to treat these patients, which is in contrast to other areas of oncology, where there is a shift to more individualised treatment. The use of dosimetry techniques to calculate a more appropriate activity of radioiodine for each patient may increase the effectiveness of radioiodine therapy but is more complex, time-consuming and of unproven benefit. This review addresses some of the limitations of empirical radioiodine therapy, discusses existing dosimetry-based approaches to individualising therapy and proposes further work in this area. A prospective randomised controlled trial comparing empirical activities of radioiodine with activities guided by a combination of lesional dosimetry and maximum safe dose has not been carried out previously. Although considerable challenges in the design of such a study remain, a network of centres in the UK now has the potential to take this forward.

Visual Immunoprecipitate Assay Eight Hour Method for Detection of Enterohemorrhagic Escherichia coli O157:H7 in Raw and Cooked Beef (Modification of AOAC Official Method 996.09): Collaborative Study

AOAC Official Method 996.09, Visual Immunoprecipitate Assay (VIP®) for Escherichia coli O157:H7, was modified to incorporate a new enrichment protocol using BioControl EHEC8™ medium for testing raw and cooked beef. Foods were tested by VIP assay and the U.S. Department of Agriculture/Food Safety and Inspection Service (USDA/FSIS) enrichment procedure and the FDA Bacteriological Analytical Manual (BAM) isolation and confirmation techniques. A total of 15 collaborators participated. Raw and cooked ground beef were inoculated with E. coli O157:H7 at 2 different levels: a high level, where predominantly positive results were expect d, and a low level where fractional recovery was anticipated. Collaborators tested 396 test portions and controls by both methods, for a total of 792 test portions. Of the 396 paired test portions, 75 were positive and 230 were negative by both the VIP and culture methods. Eleven test portions were presumptively positive by VIP and could not be confirmed culturally; 32 were negative by VIP, but confirmed positive by culture; and 65 were negative by the culture method, but confirmed positive by the VIP method. There was no statistical difference between results obtained with the VIP for EHEC 8 h method and the culture method except for cooked beef, where the VIP had significantly higher recovery for one inoculation level.

Assurance® Enzyme Immunoassay Eight Hour Method for Detection of Enterohemorrhagic Escherichia coli O157:H7 in Raw and Cooked Beef (Modification of AOAC Official Method 996.10): Collaborative Study

AOAC Official Method 996.10, Assurance® Enzyme Immunoassay (EIA) for Escherichia coli O157:H7 (EHEC), was modified to incorporate a new enrichment protocol using BioControl EHEC8™ medium for testing raw and cooked beef. Foods were tested by EIA and the U.S. Department of Agriculture/Food Safety and Inspection Service (USDA/FSIS) enrichment conditions and the FDA Bacteriological Analytical Manual (BAM) isolation and confirmation techniques. A total of 14 collaborators participated. Raw and cooked ground beef were inoculated with E. coli O157:H7 at 2 different levels: a high level where predominantly positive results were expected, and a low level where fractional recovery was anticipated. Collaborators tested 378 test portions and controls by both the 8 h EIA and the USDA/FSIS enrichment methods, for a total of 756 test portions. Of the 378 paired test portions, 75 were positive and 212 were negative by both methods. Thirteen test portions were presumptively positive by EIA and could not be confirmed culturally; 30 were negative by EIA, but confirmed positive by culture; and 65 were negative by the culture method, but confirmed positive by the EIA method. There was no statistical difference between results obtained with the Assurance EIA for EHEC 8 h method and the culture method for raw ground beef. The Assurance EIA had a significantly higher recovery for cooked beef.

Is funding source related to study reporting quality in obesity or nutrition randomized control trials in top-tier medical journals?

BACKGROUND

Faithful and complete reporting of trial results is essential to the validity of the scientific literature. An earlier systematic study of randomized controlled trials (RCTs) found that industry-funded RCTs appeared to be reported with greater quality than non-industry-funded RCTs. The aim of this study was to examine the association between systematic differences in reporting quality and funding status (that is, industry funding vs non-industry funding) among recent obesity and nutrition RCTs published in top-tier medical journals.

METHODS

Thirty-eight obesity or nutrition intervention RCT articles were selected from high-profile, general medical journals (The Lancet, Annals of Internal Medicine, JAMA and the British Medical Journal) published between 2000 and 2007. Paired papers were selected from the same journal published in the same year, one with and the other without industry funding. The following identifying information was redacted: journal, title, authors, funding source and institution(s). Then three raters independently and blindly rated each paper according to the Chalmers method, and total reporting quality scores were calculated.

FINDINGS

The inter-rater reliability (Cronbach's alpha) was 0.82 (95% confidence interval = 0.80-0.84). The total mean (M) and s.d. of Chalmers Index quality score (out of a possible 100) for industry-funded studies were M = 84.5, s.d. = 7.04 and for non-industry-funded studies they were M = 79.4, s.d. = 13.00. A Wilcoxon matched-pairs signed-ranks test indicates no significant rank difference in the distributions of total quality scores between funding sources, Z = -0.966, P = 0.334 (two tailed).

INTERPRETATION

Recently published RCTs on nutrition and obesity that appear in top-tier journals seem to be equivalent in quality of reporting, regardless of funding source. This may be a result of recent reporting of quality statements and efforts of journal editors to raise all papers to a common standard.

Exacerbation, then clearance, of mutation-proven Darier's disease of the skin after radiotherapy for bronchial carcinoma: a case of radiation-induced epidermal differentiation?

We investigated a radiotherapy-induced flare and subsequent clearance of skin lesions of a patient with the rare, dominantly inherited genodermatosis, Darier's disease (DD). The DD gene, ATP2A2, was recently isolated and shown to be a cation pump responsible for regulating intracellular calcium homeostasis. A severe exacerbation of Darier's skin lesions developed within the radiation field when 40 Gy of palliative thoracic external-beam radiation therapy and concurrent chemotherapy (cisplatin and hydroxyurea) were delivered for non-small cell lung cancer. The DD lesions subsequently completely cleared from irradiated skin, as they did when a subsequent course of radiation alone was given for a loco-regional tumor recurrence. The two radiation therapy-treated areas of skin remained free from lesions of the skin disorder until the patient's death from progressive lung cancer 9 months later. The nucleotide sequence of the patient's ATP2A2 gene was determined by PCR-based cycle sequencing. We identified four nucleotide sequence variants in the ATP2A2 gene in this patient. Three were probable polymorphisms and the other appeared to be a novel disease-causing mutation (R751Q), situated in the transmembrane portion of the ATP2A2 protein. This finding confirmed the clinical diagnosis. Since epidermis turns over every 3-4 weeks, total and persistent clearance of the DD lesions by chemoradiotherapy suggests that this treatment induced sustained differentiation of the DD-affected skin by an unknown mechanism. Oncologists treating malignant disease in patients with DD should anticipate temporary deterioration in DD-involved irradiated skin. Radiation therapy has therapeutic potential in severe DD.

Technique for narrow-band imaging in the far ultraviolet based on aberration-corrected holographic gratings

We have developed a new family of imaging spectrometer designs that combine the imaging power of two-element telescopes with the aberration control of first-generation holographic gratings. The resulting optical designs provide high spatial resolution over modest fields of view at selectable wavelengths. These all-reflective designs are particularly suited for narrow-band imaging below 1050 A, the wavelength below which there are no transmitting materials in the UV. We have developed designs to efficiently map the spatial distribution of UV-emitting material. This mapping capability is absent in current and future astronomical instruments but is crucial to the understanding of the nature of a variety of astrophysical phenomena. Although our examples focus on UV wavelengths, the design concept is applicable to any wavelength.

Assessment of pentachlorophenol-exposed timber workers using a test-of-poisoning model

Sixty-two former New Zealand timber workers who were exposed to pentachlorophenol (PCP) at work were interviewed, examined, and assessed both by laboratory investigations and psychometrically for clinical syndromes that could be related to PCP exposure. Three such syndromes were identified: an acute complex of fever, headaches, upper and lower respiratory tract and eye irritation, skin disease, and foul smelling and discolored sweat; a chronic fatigue syndrome, beginning while still at work and frequently persisting; and a delayed encephalopathy. Neither of the sustained syndromes was considered characteristic of PCP poisoning, and many confounders were identified. An exposure index and a test-of-poisoning score had a statistically insignificant correlation.

Method and computer program for controlling the family-wise alpha rate in gene association studies involving multiple phenotypes

Multiple significance testing involving multiple phenotypes is not uncommon in the context of gene association studies but has remained largely unaddressed. If no adjustment is made for the multiple tests conducted, the type I error probability will exceed the nominal (per test) alpha level. Nevertheless, many investigators do not implement such adjustments. This may, in part, be because most available methods for adjusting the alpha rate either: 1) do not take the correlation structure among the variables into account and, therefore, tend to be overly stringent; or 2) do not allow statements to be made about specific variables but only about multivariate composites of variables. In this paper we develop a simulation-based method and computer program that holds the actual alpha rate to the nominal alpha rate but takes the correlation structure into account. We show that this method is more powerful than several common alternative approaches and that this power advantage increases as the number of variables and their intercorrelations increase. The method appears robust to marked non-normality and variance heterogeneity even with unequal numbers of subjects in each group. The fact that gene association studies with biallelic loci will have (at most) three groups (i.e., AA, Aa, aa) implies by the closure principle that, after detection of a significant result for a specific variable, pairwise comparisons for that variable can be conducted without further adjustment of the alpha level.

Outpatient reduction mammaplasty: a review of 338 consecutive cases

Reduction mammaplasty is usually accomplished under general anesthesia, often with an overnight stay. With cost-containment pressures, the ability to perform this surgery in an outpatient setting would have obvious benefits. We present a series of 338 patients who have undergone bilateral reduction mammaplasty over a 3-year period. Two hundred eighty-six cases (84.6%) were performed on an outpatient basis and 52 (15.4%) were inpatients. Patient age ranged from 13 to 82 years. Significant differences were found between the two groups regarding average age (34.3 and 42.4 years, respectively) and average total resection weights (1,486.1 gm and 1,895.6 gm, respectively). The maximum total resection weight was 6,000 gm in the outpatient group and 7,140 gm in the inpatient group. Surgical techniques included inferior pedicle (N = 273), central mound (N = 54), and free nipple graft (N = 11). There were no substantial differences in the incidence of minor complications, including wound separation, seromas, hypertrophic scars, infection, and hypopigmentation. Autologous transfusion was utilized in 18 patients early in the series. Of the 175 patients (52%) who returned a follow-up questionnaire, all considered their outpatient experience a positive one. In addition, 33% of the inpatients who responded (N = 8/24) felt their hospital stay was unnecessary. Outpatient surgery resulted in a savings of $1,500 to $2,500 when compared to an overnight stay. Reduction mammaplasty can be performed safely in an outpatient setting and is not necessarily limited by age or extent of resection.

Pharmacokinetics of pirmenol in young and elderly subjects

The steady state pharmacokinetics of pirmenol was compared in twelve healthy young (aged 18 to 45 y) and 11 elderly subjects (over 65 y) subjects given pirmenol HCl 100 mg every 12 h for a total of 14 doses. In addition, the single-dose pharmacokinetics of pirmenol was determined following a 100 mg oral dose in the young subject group for comparison with the results of repeated administration. In the young subjects, the mean single-dose and steady-state CLR of pirmenol were similar; however, Ae was 29% higher and CL/f was 22% lower at steady state than after the single dose. Steady-state (fourteenth dose) Cmin, Cmax, tmax, lambda z, Ae, CL/f, CLR and V values were similar in the young and elderly subjects. Based on pharmacokinetic considerations, the dosage of pirmenol is unlikely to differ in young and elderly subjects.

Review of neonatal screening programme for phenylketonuria

OBJECTIVE

To review the neonatal screening programme during 1984-8.

DESIGN

Analysis of data from screening laboratories and paediatricians.

SUBJECTS

All live births in United Kingdom.

MAIN OUTCOME MEASURES

Structure of programme; number of infants tested and number with phenylketonuria; number of infants missed; ages at testing and treatment.

RESULTS

The proportion of infants tested approached 100%. The incidence of phenylketonuria was 11.7/100,000 births (445 subjects): 273 had classic phenylketonuria and three had defects of cofactor metabolism. One child with phenylketonuria was known to have been missed compared with three in 1979-83 and six in 1974-8. Seven subjects had been missed over the 15 years due to negative test results. All seven had been tested with the bacterial inhibition assay, although only 53% of infants had been so tested; the difference between the expected and observed proportion was significant (Fisher's exact test, p = 0.017). Eleven infants with classic phenylketonuria were not tested by 14 days of age and 23 (8%) did not start treatment until after 20 days, an improvement compared with 36 (15%) in 1979-83. There were, however, wide regional variations (0% to 27% treated after 20 days).

CONCLUSION

The screening programme achieves high coverage and effectiveness, although some children are still missed. A national practice for screening may help reduce regional variations.

Management of oil of citronella poisoning

The management for ingestion of oil of citronella, an essential oil, has traditionally been rigorous, including dilution with milk or oil, and gastric lavage or emesis, taking care to prevent aspiration. Recently our Centre handled five oil of citronella poisonings and their outcomes led us to review our management protocol which had been based on information from standard poisoning texts. The source data used to determine the human toxicity of oil of citronella and the appropriate management of poisoning included a case report of a fatal ingestion of oil of citronella in a child. On scrutiny, however, the management of this poisoning included now out-moded techniques, giving rise to uncertainties in establishing the true cause of the child's death. Our own experiences indicate that advice given in standard texts based on poisoning cases managed with out-moded techniques should be carefully evaluated.

Fetal damage due to maternal phenylketonuria: effects of dietary treatment and maternal phenylalanine concentrations around the time of conception (an interim report from the UK Phenylketonuria Register)

In 94 infants born to women with PKU, birth weight and head circumference were inversely and linearly related to the mothers' phenylalanine concentrations close to conception; with each 200 mumols/L rise in phenylalanine concentrations, birth weight fell by 98 g and head circumference by 0.46 cm. This relationship was highly significant and appeared to be the same whether or not the mother received a low phenylalanine diet. Even in the 28 infants whose mothers conceived on a strict low phenylalanine diet, birth weights and head circumferences, corrected for sex and gestation, were a little below the population norms (3421 g and 34.7 cm compared with 3600 g and 35.2 cm respectively) although the differences were not statistically significant. Optimal fetal growth occurred only in infants whose mothers had phenylalanine concentrations close to the normal range at conception. Dietary treatment started after conception did not appear to confer any benefit.