Where do AMU nurses perceive their educational needs? Results of the 20:10 project.

UNLABELLED: Our aim was to identify the perceived educational needs of nurses working in acute medicine to enable development of a training curriculum specifically for this staff group. METHODS: Post-graduate nurses from North Wales were invited to list 20 conditions and 10 skills for which they felt under prepared for their work in acute medicine. A workshop was then organized, attended by acute medicine nurses, medical colleagues and educationalists from two local universities to discuss initial data. RESULTS: Nurses identified particular needs for education around presenting symptoms with perceived deficits in knowledge or training. We found a heavy emphasis on respiratory and cardiac conditions. There was considerable overlap with frequent diagnostic categories from non-surgical hospital discharges and with priorities for training of junior doctors. Skills were often those traditionally associated with medical staff or care of patients with critical illnesses. CONCLUSION: The 20:10 project represents the first attempt to map educational needs of nursing staff on the Acute Medical Units of a large University Health Board using self-reported needs. The identified needs will support professional development, create incentives for recruitment and guide University postgraduate developments and commissioning.

Alpha7-acetylcholine receptor antibodies in two patients with Rasmussen encephalitis.

Rasmussen encephalitis (RE) sera were screened for antibodies to human alpha7 nicotinic acetylcholine receptors (nAChRs) using electrophysiology, calcium imaging, and ligand binding assays. Sera from two of nine patients with RE blocked ACh-induced currents through alpha7 nAChRs and the ACh-induced rise in intracellular free calcium ([Ca2+]i) and inhibited (125)I-alpha-bungarotoxin binding in cells expressing alpha7 nAChRs. Thus, the alpha7 nAChR is a potential target for pathogenic antibodies in patients with RE.

Evaluation of a robotic workstation for the disabled.

Experience with potential users is vital at all stages of the design of equipment for the disabled, not least in the field of rehabilitation robotics. The development of a robotic workstation for the disabled has progressed, over a period of 6 years, from the use of a cheap educational arm, to a specially engineered robot arm and workstation. The design and specification has been refined through constant evaluation by disabled users. Trials at a spinal injuries unit have given approval to the design and appearance of the latest robot arm and workstation, and have led to modifications to the user interface and software. Further trials have taken place in a user's home to investigate in greater depth the usefulness of a robotic workstation in a practical situation. The results of these trials are presented. It is proposed to refine the design of the arm for low-volume production, easy maintenance in the field and improved appearance.

Treatment of uterine sarcomas.

During a 21-year period, 66 patients with uterine sarcomas were treated at California Medical Center. Histological diagnoses were mixed mesodermal sarcoma in 32 patients (48%), leiomyosarcoma in 24 (36%), and endometrial stromal sarcoma in 10 (15%) patients. The majority of patients (73%) had Stage I tumors. The treatment consisted of surgery alone in 27 (41%), surgery in combination with radiation therapy in 36 (55%), and radiation therapy alone in three (4%) patients. The overall 1-, 2-, and 5-year actuarial survival was 74%, 57%, and 38%, respectively. The 1-, 2-, and 5-year actuarial survival for the 27 surgery alone patients was 73%, 50%, and 25%, which compared with 75%, 61%, and 44% for the 36 surgery plus radiation therapy patients (P = 0.12). The disease-free survival was better for the surgery plus radiation therapy patients, as compared with the surgery alone group (38% vs. 18% at 5 years, P = 0.081). The 5-year survival by histology was 70% for the 10 endometrial stromal sarcoma patients, 40% for the 24 leiomyosarcoma patients, and 23% for the 32 mesodermal sarcoma patients (P = 0.064). As expected, survival depended on the stage of disease (P less than 0.0001). Treatment failure was observed in 35 (53%) patients, which included 9 (14%) with failure in the pelvis. There was no difference in the incidence of failure among patients in the three treatment groups and also in the three histologic groups. There was, however, a significant difference in the incidence of pelvic failure between surgery alone and surgery plus radiation therapy patients. In the 27 surgery alone patients, nine (33%) relapsed in the pelvis, whereas none of the 36 surgery plus radiation therapy patients had locoregional failure, P less than 0.0001. Adjuvant radiation therapy is an important treatment in the management of patients with sarcoma of the uterus.

Interstitial microwave hyperthermia combined with iridium-192 radiotherapy for recurrent tumors.

From 1985 through 1987, 44 tumors in 39 patients with recurrent cancer were treated with interstitial microwave hyperthermia (HT) combined with interstitial 192Ir radiotherapy (RT). All patients had unresectable and previously treated tumors (mean RT dose 57.6 Gy). Diagnoses were squamous cell carcinoma in 27 (62%), adenocarcinoma in 11 (25%), melanoma in 5 (11%), and soft tissue sarcoma in 1 (2%) site. Interstitial RT dose was from 25 to 50 Gy (mean 38.3 Gy). The first HT session was scheduled immediately before the loading of 192Ir, and the second was scheduled following its removal. Each session lasted 45-60 min at therapeutic temperature (42.5 degrees C). Complete response (CR) was obtained in 28 (64%) sites and partial response (PR) in 15 (34%) sites. None of the CR patients had local recurrence. Tumor volume was the most important factor influencing CR (p less than 0.001). The treated site, radiation dose, and thermal dose were not significant factors for CR (p = 0.03). The overall median survival was 39 weeks, with a 2-year survival of 22%. The treatment was well tolerated, with two patients developing focal skin necrosis.

External beam and intraluminal radiotherapy in the treatment of carcinoma of the esophagus.

During a 10-year period, 46 patients with unresectable or inoperable carcinoma of the esophagus were treated with teletherapy-brachytherapy combination at the University of Southern California School of Medicine. Stage distribution was as follows: stage I, 5 (11%) patients; stage II, 23 (50%) patients; stage III, six (13%) patients; and stage IV, 12 (26%) patients. Thirteen patients were treated for recurrent disease, including 11 patients initially treated with teletherapy and two who had had surgical resection. Radiotherapy was given by teletherapy in 33 and brachytherapy in all 46 patients. An average tumor dose was 50 Gy with teletherapy and 20 Gy per application with brachytherapy. There were 25 patients who had more than one brachytherapy application. The 5-year actuarial survival rate for 28 patients with stage I or II disease was 12%, with a median of 13 months. This compared with no 5-year survivals and a median survival of 10 months for the 18 patients with stage III or IV disease. Failure at the primary site was seen in 16 (35%) patients. Complete response was seen in 20%, partial response in 76%, and no response in 4%. Treatment was well tolerated. Complications included esophageal stenosis in two patients and tracheoesophageal fistula in one. Teletherapy-brachytherapy combination is an effective treatment in the management of unresectable or inoperable carcinoma of the esophagus.

Interstitial thermoradiotherapy for recurrent or persistent tumours.

Between 1984 and 1986, 31 sites in 27 patients with biopsy proven tumours were treated with a combination of interstitial microwave hyperthermia (HT) and iridium 192 implants (RT). The 31 sites treated included fifteen (48 per cent) head and neck, six (20 per cent) breast, four (13 per cent) vagina and cervix, and six (20 per cent) others. All patients had prior surgery, RT, or chemotherapy. Of the 31 sites treated, 19 (61 per cent) had complete response (CR) with no recurrence in the volume treated. Additionally, eight patients remained free of tumour from 3 to 24 months. Partial response (PR) was seen in 11 (36 per cent) sites while one (3 per cent) had lesser degree tumour regression. Tumour control rate correlated well with the dose of radiation, p = 0.02, and tumour volume, p = 0.02, but not with thermal dose. Treatment complications of significance occurred in one (3 per cent) site, which developed soft tissue necrosis. This study again has demonstrated the effectiveness of RT-HT combination in treatment of recurrent tumours.

Interstitial radiobrachytherapy of malignant cerebral neoplasms: rationale, methodology, prospects.

The local use of radionuclides in the management of neoplastic processes was initially considered over 80 yr ago and has enjoyed increasing enthusiasm in the treatment of somatic and central nervous system tumours during the past 30 yr. The marriage of complex neuroimaging techniques and modern stereotactic devices has markedly enhanced the technical precision of interstitial radiobrachytherapy of malignant cerebral neoplasms. In applying these techniques, it is imperative to achieve an optimal placement of radionuclide sources in order to develop a geometrically homogenous, controlled distribution of radiation. Critical considerations include determination of tumour volume and contour, and development of a homogenous dose rate (dependent upon multiple sources at varying intensity) that will not only effect tumour cell kill but do this without excessive production of radionecrosis which necessitates craniotomy because of mass. Using the Brown-Roberts-Wells (BRW) stereotactic guidance system and an image-defined, volumetrically determined target, implants of multiple iridium 192(192Ir) sources were used to establish appropriate isodose envelopes. A methodology for achieving the described objectives is detailed as it applies to a variety of malignant intracerebral neoplasms (glioblastoma multiforme, malignant astrocytoma, malignant mixed glioma, primary cerebral lymphoma, metastatic carcinoma and malignant pineal region tumours). Technical realization of precision implantation relying upon imaging data may be acheived with this method with satisfactory responses that are dependent upon histological tumour type and the morphology of the tumour distribution as related to the image. Early and late complications related to the surgical technique and radionuclide applications were less than 5%. Although encouraging, these techniques require further definition and greater data accrual before uniform application outside major medical centres can be justified. It is anticipated that improvement in results with intrinsic gliomas and other invasive neoplasms will be realized with further definition of tumour boundaries by tract biopsy techniques and concurrent utilization of hyperthermia and brain protective methods.

Carcinoma of the lip and selected sites of head and neck skin. A clinical study of 896 patients.

During a period of over 20 years, 896 patients were treated with radiation in Wadsworth Medical Center, Los Angeles, for carcinoma of the lip and selected sites of skin of the head and neck. Basal cell carcinoma (BCC) was found in 467 (52%) patients, squamous cell carcinoma (SCC) in 362 (40%), and the remaining 67 (8%) had tumors with mixed basal and squamous cell features. BCC was the most common tumor (72%) among the 646 skin cancer patients while SCC predominated (99%) among the 250 lip cancer patients. Tumor control correlated well with the size of the lesion, p less than 0.0001. Histology of the lesion also had a significant (p = 0.021) influence on the tumor control rate, which was the highest among the BCC patients when compared with SCC or mixed cell patients. This study has again demonstrated the effectiveness of radiotherapy in controlling small and intermediate size epithelial tumors of the skin and lip. Additionally, irradiation, if administered properly, results in excellent cosmesis and a low incidence of treatment complications. Severe complications of radiotherapy reported in the literature took place at the beginning of this century and are no longer pertinent in the practice of modern radiation oncology. Larger lesions remain a challenge to radiation or surgical dermato-oncologists. A lack of tumor control in such lesions frequently results in a death of patient.

Advanced carcinoma of the nasopharynx. 2. Pattern of failure in 256 patients.

Of 256 patients with advanced carcinoma of the nasopharynx, 82% presented with Stage IV disease. The 5-year survival was 15% with 83% failing within 2 years. Prognosis was related to stage (p less than 0.03), neck status (p less than 0.03), initial performance status (p less than 0.001) and radiation dose (p less than 0.003). With no pathological neck glands (N0), less than 5% failed radiotherapy. Overall, 36% had distant metastases, correlating with the N Stage (p less than 0.001) but not with the T Stage. The most frequent site of metastasis was lung, then bone and liver. Radical neck dissection failed to increase tumor control, contributing to three fatal complications. New radiotherapeutic regimens have so far failed to substantially improve the results.