Challenges and impact of patient obesity in radiation therapy practice.

INTRODUCTION: The prevalence of obesity is rapidly increasing globally and has tripled between 1975 and 2016. Obesity is reported within the literature as having a significant impact on medical practice, professionals, imaging departments and healthcare systems. It is not known how this epidemic will impact radiation therapists' working environment and practice. The aim of this study is to explore the perceived challenges and impacts of patient obesity on radiation therapy practice from the perception of radiation therapists. METHODS: All radiation therapists working in the Republic of Ireland were invited to participate. Two focus groups were conducted with 6 and 7 participants respectively. A seven staged method of analysis, using a computerised long table approach was developed and used to analyse the data and create themes related to radiation therapists' perception of managing obese patients. RESULTS: Perceived challenges from the radiation therapists were difficulties; (1) Setting up the patient (2) Imaging (3) communication and emotional impact. CONCLUSION: An array of concerns were raised during this research about the increase and impact of obese patients on radiation therapists working environment. This study suggests that obese patients can present additional challenges to radiation therapists' current work practices. It is imperative that we recognise the additional challenges this patient cohort add to daily workflow. Further research is needed to identify the common key issues and how to manage this specific patient group. IMPLICATIONS FOR PRACTICE: At the moment there are no specific management strategies/policies in place for managing obese patients; this study suggests that it is something we need to consider implementing as standard in radiation therapy departments.

Transverse technique: complementary approach to measurement of first-trimester uterine artery Doppler.

OBJECTIVES: To define a protocol for the first-trimester assessment of uterine artery pulsatility index (UtA-PI) using the new transverse technique, to evaluate UtA-PI measured using the transverse approach vs that obtained using the conventional sagittal approach and to determine if accelerated onsite training (in both methods) of inexperienced sonographers can achieve reproducible UtA-PI measurements comparable with those obtained by an experienced sonographer. METHODS: This was a prospective observational study of women with a singleton pregnancy attending for routine combined first-trimester screening at 11 to 13 + 6 weeks' gestation. The study consisted of two parts, each conducted at a different center (Part 1 in Calgary, Canada and Part 2 in Hong Kong). In Part 1, UtA-PI measurements were performed using the transverse and sagittal techniques by four sonographers trained in both methods, in 10 cases each, and measurement indices (PI), time required and subjective difficulty in obtaining satisfactory measurements were compared. The one sample t-test and Wilcoxon signed rank test were used when appropriate. Bland-Altman plots were used to assess measurement agreement, and intraclass correlation coefficient (ICC) was used to evaluate measurement reliability. A target plot was used to assess measures of central tendency and dispersion. In Part 2, one experienced and three inexperienced sonographers prospectively measured UtA-PI using both approaches in 42 and 35 women, respectively. Inexperienced sonographers underwent accelerated onsite training by the experienced sonographer. Measurement approach and sonographer order were on a random basis. ICC, Bland-Altman and Passing-Bablok analyses were performed to assess measurement agreement and reliability and effect of accelerated training. RESULTS: In Part 1, no difference was observed between the two techniques in mean time to acquire the measurements (118 s for sagittal vs 106 s for transverse; P = 0.38). The four sonographers reported that the transverse technique was subjectively easier to perform (P = 0.04). Bias and ICC for mean UtA-PI between sagittal and transverse measurements were -0.05 (95% limits of agreement, -0.48 to 0.37) and 0.94, respectively. Measurements obtained using the transverse technique after correcting for gestational age were significantly closer to the expected distribution than those obtained using the sagittal technique. In Part 2, there were no significant differences in median UtA-PI measured using the different approaches for both experienced and inexperienced sonographers (P > 0.05 for all sonographers). Mean UtA-PI measurement reliability between approaches was high for the experienced (ICC = 0.92) and inexperienced (ICC > 0.80) sonographers. UtA-PI measurement approaches did not deviate from linearity, while bias ranged from -0.10 to 0.07. The median time required was similar between the techniques (56.1 s for sagittal vs 49.3 s for transverse; P = 0.054). CONCLUSIONS: This novel transverse approach for the measurement of UtA-PI in the first trimester appears to be comparable with the sagittal approach in terms of reliability, reproducibility and time required, and may be easier to perform. Providing accelerated onsite training can be helpful for improving the reliability of UtA-PI measurements and could potentially facilitate the broad implementation of first-trimester pre-eclampsia screening. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Remifentanil patient-controlled analgesia effect-site target-controlled infusion compared with morphine patient-controlled analgesia for treatment of acute pain after uterine artery embolization.

BACKGROUND: Post-procedural pain control after uterine artery embolization (UAE) of urethral leiomyomata remains a major problem. METHODS: This double-blind, randomized study tested the possibility to obtain a quicker onset of analgesia by using effect-compartment controlled remifentanil patient-controlled analgesia (remifentanil TCI-PCA) than by using i.v. morphine PCA. Both systems were connected to an i.v. catheter. Active drug or matching placebo administration was activated by a single push-button. Pain was assessed using a numerical rating scale (NRS) from 0 to 10. RESULTS: NRS values were lower in the remifentanil group (with a possible difference from two to seven points on the scale) during the initial 4 h post-embolization. After the fourth hour, the NRS values were identical between the groups. No major respiratory or haemodynamic side-effect was observed. CONCLUSIONS: Remifentanil PCA-TCI with a slow and progressive adapted algorithm without any associated premedication or co-medication is feasible in young healthy women undergoing UAE.

Growth patterns of Labrador Inuit youth: I. Height and weight.

The purpose of this study was to describe standing height and body weight recorded in 1991 from 32% (n = 100) of the Labrador Inuit youth aged between 5-18 years living in Nain. The results demonstrated that females are taller than males until the age of 13 years. Growth in height seemed to level off at 15 years in females and 16 years in males. The greatest increase in height was between the ages of 11-13 years for females and 13-15 years for males. The largest increase in weight was between 12-16 years for both sexes. The data was compared with National Center for Health Statistics Growth Curves of United States youth. For this sample, height of the Labrador Inuit lies between the 10th and 50th percentiles, and weight lies between the 50th and 75th percentiles, while weight for height lies between the 75th and 95th percentiles. These results were similar to other studies of Inuit youth from Alaska, Canada and Greenland. In fact, the growth pattern of high weight for height demonstrated in Labrador seems to be typical of the Inuit population. Comparison of this data with that of stature recorded for Labrador Inuit between 1880-1928, although derived from small samples, suggests that a secular trend of increase in height with time for both sexes has occurred.

Total joint replacement of the hip and knee.

Total hip and knee replacements are among the most common orthopedic surgical procedures performed on patients with arthritis. The procedures are highly successful in appropriately selected patients. The authors approach total joint replacement from a medical perspective, emphasizing indications, contraindications, preoperative evaluation, clinical outcome, and potential complications.

Chronic fatigue syndrome.

The chronic fatigue syndrome (CFS) is a poorly understood condition with nonspecific signs and symptoms, especially debilitating fatigue. Most patients can pinpoint the onset of their illness and usually describe a flu-like state. The search for an etiologic agent has focused on a number of viruses such as Epstein-Barr, enteroviruses, retroviruses, and human herpesvirus-6. Evidence supports persistent viral infection in a small percentage of CFS patients. Immunologic abnormalities do exist in CFS, which indicate the presence of immune activation in CFS patients. Although abnormal muscle biopsies have been found in some patients with CFS, strength and endurance appear normal, but perception of exertion may be abnormal. Patients with chronic fatigue have a high incidence of premorbid and concurrent psychiatric disorders, and on physical examination many often have reproducible tender points similar to fibromyalgic patients. Clinical evaluation should rule out other potential causes of fatigue, but elaborate diagnostic tests are seldom required. Presently, no specific treatment exists for CFS. A cognitive behavioral approach with or without the use of tricyclics has been advocated. Patients should be encouraged to maintain functional status and should not be discouraged from exercise. Several medications have been tried but with no definite clinical benefit.

Molecular cloning of the terminal hairpin of vaccinia virus DNA as an imperfect palindrome in an Escherichia coli plasmid.

The genome of vaccinia virus is a linear duplex molecule of approximately 185 kb with hairpins at each end that link the complementary strands. The hairpins, which exist in two forms that are inverted and complementary in sequence, were isolated as XbaI restriction fragments and converted to a linear intermolecular duplex structure by denaturation and reannealing. The latter was then stably cloned as a 142-bp imperfect palindrome in an Escherichia coli plasmid. The insert was excised from the plasmid and the palindrome was extended on both sides by ligating it to the adjacent vaccinia virus DNA segment. The resulting fragment was cloned as a 278-bp imperfect palindrome. Restriction endonuclease analysis and DNA sequencing indicated the absence of any deletions or rearrangements. After excision from the plasmid, the palindrome was converted by heating and rapid cooling to the original two hairpin forms. In this manner, large quantities of vaccinia virus telomeres may be obtained for physical and biochemical studies.

Deletion of a 9,000-base-pair segment of the vaccinia virus genome that encodes nonessential polypeptides.

Deletions contained within the genomes of unstable and stable variants of vaccinia virus (strain WR) were analyzed. Restriction endonuclease mapping and hybridization to specific 32P-labeled DNA probes indicated that more than 6 X 10(6) daltons of DNA were deleted from the variants. In each case, the deletion occurred on the left side of the genome and started very close to the junction of the inverted terminal repetition and unique sequence. Both variants also contained a new SstI side on the right side of the genome. Hybridization selection and cell-free translation experiments indicated that these variants lost the ability to synthesize at least eight early mRNA's mapping within the deleted region. Although the deleted DNA was not essential for replication of the WR strain of vaccinia virus under laboratory conditions of infection, it presumably has a defined role under other circumstances. This conclusion was based on the conservation within the Elstree strain of vaccinia, the Utrecht strain of rabbitpox, and the Brighton strain of cowpox virus of sequences homologous to the deleted DNA. Moreover, mRNA's that hybridized to the deleted vaccinia virus DNA segment and encoded similar size polypeptides were made in cells infected with rabbitpox and cowpox viruses.

Instability and reiteration of DNA sequences within the vaccinia virus genome.

The sequence arrangement within the nontranscribed portion of the inverted terminal repetition of the vaccinia virus genome exists in quasi-stable and unstable forms that are not distinguishable on the basis of viral infectivity. The unstable forms, which composed about 20% of a serially passaged stock of virus, were recognized by terminal heterogeneity on restriction endonuclease analysis. Instead of a single terminal fragment from each end of the genome, an array of eight or more fragments differing in size by 1650-base-pair increments was detected. This feature was not eliminated by repeated plaque purification, indicating that the population of DNA molecules with various numbers of reiterations can rapidly evolve from the DNA of a single virus particle. However, at each successive round of plaque purification, about 20% of the unstable isolates revert back to the more stable form. Stable forms are characterized by the presence of a set of 13-17 tandem 70-base-pair repeats on each side of a 435-base-pair intervening sequence near both ends of the genome. In contrast, the unstable forms possess sets of tandem repeats and intervening sequences that alternate many times in series. The transition between the two genomic forms and the evolution of the unstable form appear to be mediated by recombinational events.

Temporal extrapolation of unimodal and multimodal stimulus sequences in retarded and nonretarded persons.

Retarded adolescents, CA-matched nonretarded adolescents, and MA-matched nonretarded children attempted to match the repetition rate of 10-second stimulus sequences presented under four modality switching conditions and at two pusle frequencies. Error magnitudes were least for the CA-matched subjects and under the faster pulse rate increased from the no-switching to maximum-switching condition in all groups. Error increases from the no-switching to maximum-switching condition were preponderantly underestimations. No differences between groups were obtained for a switching condition in which the modality-sequence pattern was aperiodic. A hypothesis of longer psycholoical refractory periods in retarded adolescents was rejected in favor of one explaining their inferior performance on sequential enumeration and tracking tasks in terms of inefficient organizational abilities.

Antibody production and interaction with lymphoid cells in relation to tumor immunity in the Moloney sarcoma virus system.

The temporal development of antibodies to Moloney sarcoma virus (MSV)-induced antigens in relation to tumor progression was followed with the membrane immunofluorescence (MF) and antibody-dependent normal lymphocyte cytotoxicity (ADNLC) assays. Antibody was detected at 14 days following virus infection by MF. In mice that developed primary tumors which regressed, MF titers developed to high levels following a period between 2 and 4 weeks post-innoculation during which the titers remained at low and constant levels. The increase in MF titers corresponded closely on a temporal basis to the initiation of the regression process. In contrast, antibody remained at low levels in those mice that developed progressively growing tumors. ADNLC was detected in the sera of regressor mice approximately 6 weeks post-inoculation but was not detectable at any of the time interavals in sera from mice with progressively growing tumors. Attempts to enhance the cytotoxic activity of normal spleen cells directly with immune serum were unsuccessful. The synergistic effect of serum on the cytotoxic activity of immune lymphocytes was less pronounced than with normal lymphocytes in this system. Temporal studies indicated that there was an inverse relationship between the development of cellular immunity and the capablility of these cells to be activated in the ADNLC assay.