Prevalence of missed nursing care and its association with work experience: A cross-sectional survey.

Background: Nurses faced with multiple demands in hospitals are often compelled to prioritize nursing care. Knowledge of missed nursing care provides insight into whether necessary nursing care is delivered, what is missed, and the reasons for missed nursing care. This insight is essential to support evidence-based policy and practice to improve patient care, enhance nursing practice, and optimize the work environment. Research on factors influencing missed nursing care is imperative to implement targeted strategies. However, studies investigating work experience as a predictor are inconclusive, and no identified studies have examined how nurses' work experience is associated with different elements of missed nursing care. Objectives: To investigate the prevalence and reasons for missed nursing care and whether nurses' work experience was associated with missed nursing care. Design: The design was cross-sectional, using the Danish version of the MISSCARE survey. Setting: The study was conducted at a public Danish university hospital with 1,150 beds and approximately 10,350 employees. Participants: Across 34 surgical, medical, and mixed bed wards for adults, 1,241 nurses were invited by email to respond anonymously to the Danish MISSCARE survey. Of these nurses, 50.3% responded, and 42.6% fully completed the questionnaire. Methods: A total score mean and a mean score were calculated and then compared between experience (≤5 years/>5 years) in a linear regression model adjusting for unequally distributed variables. Results: More than two thirds of the nurses reported that emotional support, patient bathing, ambulation, mouth care, interdisciplinary conferences, documentation, and assessing effectiveness of medication were frequently missed elements of nursing care. The most significant reasons for missed nursing care were an inadequate number of nurses, an unexpected rise in patient volume, urgent patient situations, heavy admission, and discharge activity. Nurses with work experience of less than 5 years reported more missed nursing care, especially within fundamental care. Conclusions: Nursing elements to avoid potentially critical situations and nursing related to treatment observations were rarely missed, while nursing care elements visible only to the patient and the nurse were most often missed. By increasing transparency and explicitness within nursing care, the results enable critical evaluation of prioritization of nursing care elements. The number of staff not balancing the number and acuity of patients was the main reason for missed nursing care. The perception of missed nursing care was most pronounced in less experienced nurses. The study contributes to the global research community to achieve a broader understanding of missed nursing care. Tweetable abstract: Nursing to avoid potentially critical situations and treatment observations are prioritized over fundamental care, perceived mainly by less experienced nurses.

A national repository of complete radiotherapy plans: design, Results, and experiences.

BACKGROUND: Previously, many radiotherapy (RT) trials were based on a few selected dose measures. Many research questions, however, rely on access to the complete dose information. To support such access, a national RT plan database was created. The system focuses on data security, ease of use, and re-use of data. This article reports on the development and structure, and the functionality and experience of this national database. METHODS AND MATERIALS: A system based on the DICOM-RT standard, DcmCollab, was implemented with direct connections to all Danish RT centres. Data is segregated into any number of collaboration projects. User access to the system is provided through a web interface. The database has a finely defined access permission model to support legal requirements. RESULTS: Currently, data for more than 14,000 patients have been submitted to the system, and more than 50 research projects are registered. The system is used for data collection, trial quality assurance, and audit data set generation.Users reported that the process of submitting data, waiting for it to be processed, and then manually attaching it to a project was resource intensive. This was accommodated with the introduction of triggering features, eliminating much of the need for users to manage data manually. Many other features, including structure name mapping, RT plan viewer, and the Audit Tool were developed based on user input. CONCLUSION: The DcmCollab system has provided an efficient means to collect and access complete datasets for multi-centre RT research. This stands in contrast with previous methods of collecting RT data in multi-centre settings, where only singular data points were manually reported. To accommodate the evolving legal environment, DcmCollab has been defined as a 'data processor', meaning that it is a tool for other research projects to use rather than a research project in and of itself.

Acceptability Among Frontline Staff Toward Distributing an Anonymous Alcohol Survey in Emergency Departments: A Mixed Methods Study.

ABSTRACT: Emergency departments (EDs) serve as the front line when patients encounter the hospital system. Limited data are available of patients' alcohol habits collected during Danish ED visits, and no studies have, to our knowledge, examined frontline staffs' (registered nurses and medical secretaries) acceptability to deliver anonymous alcohol surveys to patients. We aimed at examining the proportion of survey respondents and the prevalence of patients' alcohol habits and also exploring frontline staff acceptability of the distribution of an anonymous survey regarding patients' alcohol habits in EDs. Intendedly, all eligible patients ≥18 years old entering two EDs in March 2019 should receive a survey based on the Alcohol Use Disorder Identification Test. The study was an explanatory, sequential, mixed methods design, and results were analyzed with descriptive statistics and a deductive content analysis based on the theoretical framework of acceptability. In total, 15% (n = 1,305) of the total 8,679 patients in the EDs returned the survey. Qualitative analysis of interviews (n = 31) with staff showed that they had been reluctant to distribute the survey primarily because of ethical concerns of anonymity, freedom of choice, and being nonjudgmental toward patients. Hence, patients with no obvious alcohol problems were more likely to receive the survey. Still, we found that 23% of the respondents had an Alcohol Use Disorder Identification Test score ≥ 8. Results indicate that frontline staffs' recognition of patients' alcohol use is inadequate, and findings show a low degree of acceptability among staff to deliver an anonymous survey, which is in line with earlier described barriers toward screening activities in EDs.

Development of a national deep learning-based auto-segmentation model for the heart on clinical delineations from the DBCG RT nation cohort.

BACKGROUND: This study aimed at investigating the feasibility of developing a deep learning-based auto-segmentation model for the heart trained on clinical delineations. MATERIAL AND METHODS: This study included two different datasets. The first dataset contained clinical heart delineations from the DBCG RT Nation study (1,561 patients). The second dataset was smaller (114 patients), but with corrected heart delineations. Before training the model on the clinical delineations an outlier-detection was performed, to remove cases with gross deviations from the delineation guideline. No outlier detection was performed for the dataset with corrected heart delineations. Both models were trained with a 3D full resolution nnUNet. The models were evaluated with the dice similarity coefficient (DSC), 95% Hausdorff distance (HD95) and Mean Surface Distance (MSD). The difference between the models were tested with the Mann-Whitney U-test. The balance of dataset quantity versus quality was investigated, by stepwise reducing the cohort size for the model trained on clinical delineations. RESULTS: During the outlier-detection 137 patients were excluded from the clinical cohort due to non-compliance with delineation guidelines. The model trained on the curated clinical cohort performed with a median DSC of 0.96 (IQR 0.94-0.96), median HD95 of 4.00 mm (IQR 3.00 mm-6.00 mm) and a median MSD of 1.49 mm (IQR 1.12 mm-2.02 mm). The model trained on the dedicated and corrected cohort performed with a median DSC of 0.95 (IQR 0.93-0.96), median HD95 of 5.65 mm (IQR 3.37 mm-8.62 mm) and median MSD of 1.63 mm (IQR 1.35 mm-2.11 mm). The difference between the two models were found non-significant for all metrics (p > 0.05). Reduction of cohort size showed no significant difference for all metrics (p > 0.05). However, with the smallest cohort size, a few outlier structures were found. CONCLUSIONS: This study demonstrated a deep learning-based auto-segmentation model trained on curated clinical delineations which performs on par with a model trained on dedicated delineations, making it easier to develop multi-institutional auto-segmentation models.

A Danish version of the MISSCARE survey: Translation and validation.

BACKGROUND: Measuring missed nursing care in clinical settings may serve as an important indicator for improving patient safety and nursing staff retention. Internationally, several tools exist, with the MISSCARE Survey being the most frequently used and validated; however, no tools are available in the Danish language. AIM: This study aimed at translating the MISSCARE Survey from US English to Danish and evaluate its psychometric properties. METHODS: The translation followed the recommended method, that is forward-and-backward translation, involving clinical experts and a professional, native English-speaking translator. The final version was approved by the survey's original developer. Face validity was tested among 10 nurses and 1 practical nurse. Nursing staff from 34 selected departments at Aarhus University Hospital's (n = 1241) were invited to participate in a pilot test in November 2020. The survey consisted of a demographic section, a section of 'nursing elements' (Part A) and section of 'reasons' (Part B). Acceptability was assessed on Part A and B. Reliability was tested by Cronbach's alpha, and psychometric properties were investigated using Confirmatory Factor Analysis (Part B). RESULTS: The face-validity test resulted in minor contextual changes and the addition of a 'not applicable' response option in Part A. The pilot test had a 42.6% response rate (n = 529). Acceptability was good, with 1-10 missing responses per item in Part A and 0-20 missing responses in Part B. The numbers of 'not applicable' responses ranged from 0 to 81. The overall Cronbach's alpha was 0.81. Factor-loading ranges were 0.62-0.48 for 'communication', 0.79-0.39 for 'materials and resources', and 0.50-0.35 for 'labour', suggesting an acceptable fit with the theoretical model. CONCLUSION: The MISSCARE Survey was successfully translated into Danish. The psychometric properties confirmed the questionnaire as a valid and reliable tool for measuring missed nursing care in Danish hospital settings.

Selection criteria for early breast cancer patients in the DBCG proton trial - The randomised phase III trial strategy.

BACKGROUND AND PURPOSE: Adjuvant radiotherapy of internal mammary nodes (IMN) improves survival in high-risk early breast cancer patients but inevitably leads to more dose to heart and lung. Target coverage is often compromised to meet heart/lung dose constraints. We estimate heart and lung dose when target coverage is not compromised in consecutive patients. These estimates are used to guide the choice of selection criteria for the randomised Danish Breast Cancer Group (DBCG) Proton Trial. MATERIALS AND METHODS: 179 breast cancer patients already treated with loco-regional IMN radiotherapy from 18 European departments were included. If the clinically delivered treatment plan did not comply with defined target coverage requirements, the plan was modified retrospectively until sufficient coverage was reached. The choice of selection criteria was based on the estimated number of eligible patients for different heart and lung dose thresholds in combination with proton therapy capacity limitations and dose-response relationships for heart and lung. RESULTS: Median mean heart dose was 3.0 Gy (range, 1.1-8.2 Gy) for left-sided and 1.4 Gy (0.4-11.5 Gy) for right-sided treatment plans. Median V17Gy/V20Gy (hypofractionated/normofractionated plans) for ipsilateral lung was 31% (9-57%). The DBCG Radiotherapy Committee chose mean heart dose ≥ 4 Gy and/or lung V17Gy/V20Gy ≥ 37% as thresholds for inclusion in the randomised trial. Using these thresholds, we estimate that 22% of patients requiring loco-regional IMN radiotherapy will be eligible for the trial. CONCLUSION: The patient selection criteria for the DBCG Proton Trial are mean heart dose ≥ 4 Gy and/or lung V17Gy/V20Gy ≥ 37%.

Knee Injuries in Normal-Weight, Overweight, and Obese Runners: Does Body Mass Index Matter?

OBJECTIVE: To investigate whether the proportion of running-related knee injuries differed in normal-weight, overweight, and obese runners. DESIGN: Comparative study. METHODS: Data from 4 independent prospective studies were merged (2612 participants). The proportion of running-related knee injuries out of the total number of running-related injuries was calculated for normal-weight, overweight, and obese runners, respectively. The measure of association was absolute difference in proportion of running-related knee injuries with normal-weight runners as the reference group. RESULTS: A total of 571 runners sustained a running-related injury (181 running-related knee injuries and 390 running-related injuries in other anatomical locations). The proportion of running-related knee injuries was 13% lower (95% confidence interval: -22%, -5%; P = .001) among overweight runners compared with normal-weight runners. Similarly, the proportion of running-related knee injuries was 12% lower (95% confidence interval: -23%, -1%; P = .042) among obese runners compared with normal-weight runners. CONCLUSION: Overweight and obese runners had a lower proportion of running-related knee injuries than normal-weight runners. J Orthop Sports Phys Ther 2020;50(7):397-401. doi:10.2519/jospt.2020.9233.

Carrier prevalence and risk factors for colonisation of multiresistant bacteria in Danish emergency departments: a cross-sectional survey.

OBJECTIVES: The aim of this study was to describe the carrier prevalence and demographic variation of four different multiresistant bacteria (MRB) among acute patients in Danish emergency departments (EDs): methicillin-resistant Staphylococcus aureus (MRSA), carbapenemase-producing enterobacteria (CPE), extended-spectrum beta-lactamase-producing enterobacteria (ESBL) and vancomycin-resistant enterococci (VRE), and to analyse the association of MRB carriage to a range of potential risk factors. DESIGN: Multicentre descriptive and analytic cross-sectional survey. SETTING: Eight EDs and four clinical microbiology departments in Denmark. PARTICIPANTS: Adults visiting the ED. MAIN OUTCOME MEASURES: Swabs from nose, throat and rectum were collected and analysed for MRSA, ESBL, VRE and CPE. The primary outcome was the prevalence of MRB carriage, and secondary outcomes relation to risk factors among ED patients. RESULTS: We included 5117 patients in the study. Median age was 68 years (54-77) and gender was equally distributed. In total, 266 (5.2%, 95% CI 4.6 to 5.8) were colonised with at least one MRB. No significant difference was observed between male and female patients, between age groups and between university and regional hospitals. Only 5 of the 266 patients with MRB were colonised with two of the included bacteria and none with more than two. CPE prevalence was 0.1% (95% CI 0.0 to 0.2), MRSA prevalence was 0.3% (95% CI 0.2 to 0.5), VRE prevalence was 0.4% (95% CI 0.3 to 0.6) and ESBL prevalence was 4.5% (95% CI 3.9 to 5.1). Risk factors for MRB carriage were previous antibiotic treatment, previous hospital stay, having chronic respiratory infections, use of urinary catheter and travel to Asia, Oceania or Africa. CONCLUSION: Every 20th patient arriving to a Danish ED brings MRB to the hospital. ESBL is the most common MRB in the ED. The main risk factors for MRB carriage are recent antibiotic use and travel abroad. TRIAL REGISTRATION NUMBER: NCT03352167;Post-results.

Cross sectional study of multiresistant bacteria in Danish emergency departments: prevalence, patterns and risk factors for colonization (AB-RED project).

BACKGROUND: Multiresistant bacteria (MRB) is an increasing problem. Early identification of patients with MRB is mandatory to avoid transmission and to target the antibiotic treatment. The emergency department (ED) is a key player in the early identification of patients who are colonized with MRB. There is currently sparse knowledge of both prevalence and risk factors for colonization with MRSA, ESBL, VRE, CPE and CD in acutely admitted patients in Western European countries including Denmark. To develop evidence-based screening tools for identifying carriers of resistant bacteria among acutely admitted patients, systematic collection of information on risk factors and exposures is required. Since a geographical variation is suspected, it is desirable to include emergency departments across the country. The aim of this project is to provide a comprehensive overview of prevalence and risk factors for MRSA, ESBL, VRE, CPE and CD colonization in patients admitted to Danish ED's. The objectives are to describe the prevalence and demography of resistance, co-infections, to identify risk factors for carrier state and to develop and validate a screening tool for identification of carriers. METHODS: Multicenter descriptive and analytic cross-sectional survey from January-May 2018 of around 10.000 acutely admitted patients > 18 years in 8 EDs for carrier state and risk factors for antibiotic resistant bacteria. Information about the background and possible risk factors for carrier status together with swabs from the nose, throat and rectum is collected and analyzed for MRSA, ESBL, VRE, CPE and CD. The prevalence of the resistant bacteria are calculated at hospital level, regional level and national level and described with relation to residency, sex, age and risk factors. A screening model for identification of carrier stage of resistant bacteria is developed and validated. DISCUSSION: The study will provide the prevalence of colonized patients with resistant bacteria on arrival to the ED and variation in demographic patterns, and will develop a clinical tool to identify certain risk groups. This will enable the clinician to target antibiotic treatments and to reduce the in-hospital spreading of resistant bacteria. This knowledge is important for implementing and evaluating antimicrobial stewardships, screening and infection control strategies. TRIAL REGISTRATION: Clinicaltrials.gov : NCT03352167 (registration date: 20. November 2017).

Levels of regulatory B cells do not predict serological responses to hepatitis B vaccine.

This study investigated the immunomodulatory influence of IL10 producing B regulatory cells, Bregs (CD19+CD24hiCD38hi) to standard Twinrix® vaccination. We also investigated HBsAg specific T-cell mediated IFN-γ responses to Twinrix® which in theory could provide effective immunity despite low anti-HBs titer. A total of 309 hepatitis B negative health care students and workers completed a standard Twinrix® vaccination schedule (0, 1 and 6 months). Depending on the vaccination response the participants were divided in to non-, low- and high responders according to anti-HBs titer (<10, <100 and >1000 mIU/mL respectively) two months after completed vaccination schedule. Blood samples from baseline and after vaccination from all non- and low-responders (23 participants) and the same number of high-responders were used for flow cytometric analyses of IL10 producing Bregs and T-cell mediated IFN-γ responses. A decrease in levels of IL10 producing Bregs was observed after vaccination in high responders compared to non- and low-responders. Compiling non-and low-responders against high-responders showed a lower T-cell mediated IFN-γ response at baseline in non-and low-responders when stimulated with Engerix® vaccine. In contrary no positive correlation between IL10 producing Bregs or IFN-γ positive T-cells and anti-HBs titer was observed. Hence this study cannot prove that levels of IL10 producing Bregs or IFN-γ positive T cell affect HBV vaccine response.

[Severe cervical kyphosis causing sudden inspiratory stridor].

An 85-year-old woman was brought to an accident and emergency department with breathing difficulties accompanied by inspiratory stridor. She was being treated for hypertension and severe osteoporosis which had caused thoracal and cervical fractures of the columna. Intubation was initiated as she desaturated and deteriorated despite maximum oxygen therapy. The intubation revealed a subglottic stenosis as a consequence of a recent osteoporotic fracture in the cervical columna. This represents a rare cause of respiratory failure as all other cardial, pulmonary and allergic aetiologies had been eliminated.

Local infiltration analgesia is not improved by postoperative intra-articular bolus injections for pain after total hip arthroplasty.

BACKGROUND AND PURPOSE: The effect of postoperative intra-articular bolus injections after total hip arthroplasty (THA) remains unclear. We tested the hypothesis that intra-articular bolus injections administered every 6 hours after surgery during the first 24 hours would significantly improve analgesia after THA. PATIENTS AND METHODS: 80 patients undergoing THA received high-volume local infiltration analgesia (LIA; 200 mg ropivacaine and 30 mg ketorolac) followed by 4 intra-articular injections with either ropivacaine (100 mg) and ketorolac (15 mg) (the treatment group) or saline (the control group). The intra-articular injections were combined with 4 intravenous injections of either saline (treatment group) or 15 mg ketorolac (control group). All patients received morphine as patient-controlled analgesia (PCA). The primary outcome was consumption of intravenous morphine PCA and secondary outcomes were consumption of oral morphine, pain intensity, side effects, readiness for hospital discharge, length of hospital stay, and postoperative consumption of analgesics at 3, 6, and 12 weeks after surgery. RESULTS: There were no statistically significant differences between the 2 groups regarding postoperative consumption of intravenous morphine PCA. Postoperative pain scores during walking were higher in the treatment group from 24-72 hours after surgery, but other pain scores were similar between groups. Time to readiness for hospital discharge was longer in the treatment group. Other secondary outcomes were similar between groups. INTERPRETATION: Postoperative intra-articular bolus injections of ropivacaine and ketorolac cannot be recommended as analgesic method after THA.

Interleukin-37 Expression Is Increased in Chronic HIV-1-Infected Individuals and Is Associated with Inflammation and the Size of the Total Viral Reservoir.

Interleukin-37 (IL-37) is a recently identified cytokine with potent antiinflammatory and immunosuppressive functions. The objective of this study was to compare levels of IL-37 mRNA in immunological subgroups of chronic human immunodeficiency virus-1 (HIV-1)-infected individuals and noninfected controls, to determine IL-37's association with biomarkers of inflammation and reservoir size. This was a cross-sectional study. The HIV-1-infected patients were categorized in three subgroups depending on their combination antiretroviral therapy (cART) treatment status and CD4(+) T-cell count. Quantitative RT-PCR was used for the detection of IL-37 mRNA and HIV-1 DNA in peripheral blood mononuclear cells (PBMCs). Biomarkers in plasma were quantified by enzyme-linked immunosorbent assay (ELISA), whereas T-cell activation was determined by flow cytometry. Lastly, lipopolysaccharide (LPS) stimulations of patients PBMCs were carried out to determine differences in IL-37 mRNA response between the subgroups. Sixty HIV-1-infected patients and 20 noninfected controls were included in the study. Steady-state IL-37 mRNA levels in PBMCs were significantly higher in HIV-1-infected individuals compared with noninfected controls: 2.4-fold (p ≤ 0.01) cART-naïve subjects; 3.9-fold (p ≤ 0.0001) inadequate immunological responders; and 4.0-fold (p ≤ 0.0001) in immunological responders compared with non-infected controls. Additionally, levels of the monocyte inflammatory marker sCD14 correlated with IL-37 mRNA (p = 0.03), whereas there was no association with T-cell activation. Finally, we observed a significant correlation between total viral HIV-1 DNA and IL-37 mRNA in PBMCs (p < 0.0001). Collectively, our data shows that the level of IL-37 mRNA is affected by chronic HIV-1-infection. A relationship with the activation of the monocyte compartment is suggested by the correlation with sCD14 and, interestingly, IL-37 could be related to the size of the total viral HIV-1 reservoir.

Need for improvements in the surveillance and management of chronic viral hepatitis in HIV patients followed in a Danish outpatient clinic.

OBJECTIVES: The aim of this study was to assess hepatitis B virus (HBV) and hepatitis C virus (HCV) surveillance and management in HIV patients currently followed in an outpatient clinic at a Danish University Hospital. METHODS: Patient data, including demographic characteristics, clinical findings, and hepatitis serology, were reviewed at baseline. Patients with incomplete or non-updated serology within the last 2 y were retested in the next 6 months, and the results were reviewed again at follow-up. RESULTS: At baseline, 84% and 74% of the 574 HIV patients were found to have incomplete and/or non-updated HBV and HCV serology, respectively. At follow-up, updated HBV serology was achieved in 535 (93%) patients; 15 (3%) patients were found to have a chronic active infection and 156 (27%) had a resolved infection, whereas 65 (11%) were vaccinated against HBV and 299 (52%) were non-immune. No patients were found to have developed chronic HBV infection following HIV diagnosis (equal to 3649 patient-y). Updated HCV serology revealed that 25 (4%) had a chronic active HCV infection and 15 (3%) had a resolved HCV infection. The anti-HCV incidence rate was 0.27/100 patient-y. A liver pathology assessment had not been performed within the last 2 y in 80% of the HBV and 32% of the HCV co-infected patients. CONCLUSIONS: Hepatitis screening and assessment had been inadequately performed. New cases of chronic hepatitis seem to occur infrequently. However, a more proactive hepatitis surveillance and management strategy integrated into the overall HIV health care program is warranted.

Study protocol: Rehabilitation including Social and Physical activity and Education in Children and Teenagers with Cancer (RESPECT).

BACKGROUND: During cancer treatment children have reduced contact with their social network of friends, and have limited participation in education, sports, and leisure activities. During and following cancer treatment, children describe school related problems, reduced physical fitness, and problems related to interaction with peers. METHODS/DESIGN: The RESPECT study is a nationwide population-based prospective, controlled, mixed-methods intervention study looking at children aged 6-18 years newly diagnosed with cancer in eastern Denmark (n=120) and a matched control group in western Denmark (n=120). RESPECT includes Danish-speaking children diagnosed with cancer and treated at pediatric oncology units in Denmark. Primary endpoints are the level of educational achievement one year after the cessation of first-line cancer therapy, and the value of VO2max one year after the cessation of first-line cancer therapy. Secondary endpoints are quality of life measured by validated questionnaires and interviews, and physical performance. RESPECT includes a multimodal intervention program, including ambassador-facilitated educational, physical, and social interventions. The educational intervention includes an educational program aimed at the child with cancer, the child's schoolteachers and classmates, and the child's parents. Children with cancer will each have two ambassadors assigned from their class. The ambassadors visit the child with cancer at the hospital at alternating 2-week intervals and participate in the intervention program. The physical and social intervention examines the effect of early, structured, individualized, and continuous physical activity from diagnosis throughout the treatment period. The patients are tested at diagnosis, at 3 and 6 months after diagnosis, and one year after the cessation of treatment. The study is powered to quantify the impact of the combined educational, physical, and social intervention programs. DISCUSSION: RESPECT is the first population-based study to examine the effect of early rehabilitation for children with cancer, and to use healthy classmates as ambassadors to facilitate the normalization of social life in the hospital. For children with cancer, RESPECT contributes to expanding knowledge on rehabilitation that can also facilitate rehabilitation of other children undergoing hospitalization for long-term illness. TRIAL REGISTRATION: Clinical Trials.gov: file. NCT01772849 and NCT01772862.

Delineation of target volumes and organs at risk in adjuvant radiotherapy of early breast cancer: national guidelines and contouring atlas by the Danish Breast Cancer Cooperative Group.

UNLABELLED: During the past decade planning of adjuvant radiotherapy (RT) of early breast cancer has changed from two-dimensional (2D) to 3D conformal techniques. In the planning computerised tomography (CT) scan both the targets for RT and the organs at risk (OARs) are visualised, enabling an increased focus on target dose coverage and homogeneity with only minimal dose to the OARs. To ensure uniform RT in the national prospective trials of the Danish Breast Cancer Cooperative Group (DBCG), a national consensus for the delineation of clinical target volumes (CTVs) and OARs was required. MATERIAL AND METHODS: A CT scan of a breast cancer patient after surgical breast conservation and axillary lymph node (LN) dissection was used for delineation. During multiple dummy-runs seven experienced radiation oncologists contoured all CTVs and OARs of interest in adjuvant breast RT. Two meetings were held in the DBCG Radiotherapy Committee to discuss the contouring and to approve a final consensus. The Dice similarity coefficient (DSC) was used to evaluate the delineation agreement before and after the consensus. RESULTS: The consensus delineations of CTVs and OARs are available online and a table is presented with a contouring description of the individual volumes. The consensus provides recommendations for target delineation in a standard patient both in case of breast conservation or mastectomy. Before the consensus, the average value of the DSC was modest for most volumes, but high for the breast CTV and the heart. After the consensus, the DSC increased for all volumes. CONCLUSION: The DBCG has provided the first national guidelines and a contouring atlas of CTVs and OARs definition for RT of early breast cancer. The DSC is a useful tool in quantifying the effect of the introduction of guidelines indicating improved inter-delineator agreement. This consensus will be used by the DBCG in our prospective trials.

Time trends in socio-economic factors and risk of hospitalisation with infectious diseases in pre-school children 1985-2004: a Danish register-based study.

The purpose of this study was to examine socio-economic differences in the risk of hospitalisation among children aged 0-5 years in Denmark from 1985 to 2004. All children born between 1985 and 2004 (n=1,278,286) were followed for hospital admissions for infectious diseases from the 29th day of life until the children reached the age of 6 years or the end of 2004, whichever came first. Information on parental socio-economic position (education, labour market attachment and household income) was gathered through record linkage with administrative registries. Infections were grouped into upper respiratory, lower respiratory, gastrointestinal, ear and fever infections. The data were analysed using Cox regression. Children of parents on sick leave or early retirement had an increased risk of being hospitalised with an infection compared with children of employed parents. A clear inverse educational gradient in risk of offspring hospitalisation was also found. From 1985 to 2004 the inverse associations between parental education and risk of hospitalisation grew stronger, whereas the comparatively weaker association between household income and risk of offspring hospitalisation decreased in magnitude. The association between socio-economic status and hospitalisation was strongest for lower respiratory, gastrointestinal and ear infections. This study documented a socially patterned hospitalisation of pre-school children in Denmark. Future studies should investigate possible explanations for the increased risk among children from families with low socio-economic status.

Effects of adrenergic agents on intracellular Ca2+ homeostasis and metabolism of glucose in astrocytes with an emphasis on pyruvate carboxylation, oxidative decarboxylation and recycling: implications for glutamate neurotransmission and excitotoxicity.

Glucose and glycogen are essential sources of energy for maintaining glutamate homeostasis as well as glutamatergic neurotransmission. The metabolism of glycogen, the location of which is confined to astrocytes, is affected by norepinephrine (NE), and hence, adrenergic signaling in the astrocyte might affect glutamate homeostasis with implications for excitatory neurotransmission and possibly excitotoxic neurodegeneration. In order to study this putative correlation, cultured astrocytes were incubated with 2.5 mM [U-(13)C]glucose in the presence and absence of NE as a time course for 1 h. Employing mass spectrometry, labeling in intracellular metabolites was determined. Moreover, the involvement of Ca(2+) in the noradrenergic response was studied. In unstimulated astrocytes, the labeling pattern of glutamate, aspartate, malate and citrate confirmed important roles for pyruvate carboxylation and oxidative decarboxylation in astrocytic glucose metabolism. Importantly, pyruvate carboxylation was best visualized at 10 min of incubation. The abundance and pattern of labeling in lactate and alanine indicated not only an extensive activity of malic enzyme (initial step for pyruvate recycling) but also a high degree of compartmentalization of the pyruvate pool. Stimulating with 1 µM NE had no effect on labeling patterns and glycogen metabolism, whereas 100 µM NE increased glutamate labeling and decreased labeling in alanine, the latter supposedly due to dilution from degradation of non-labeled glycogen. It is suggested that further experiments uncovering the correlation between adrenergic and glutamatergic pathways should be performed in order to gain further insight into the role of astrocytes in brain function and dysfunction, the latter including excitotoxicity.