Painful left bundle branch block syndrome successfully treated by His-bundle pacing.

Painful left bundle branch block (LBBB) syndrome is a rare cause of episodic chest pain associated with transient LBBB in the absence of flow-limiting coronary artery disease and myocardial ischaemia on functional testing. The aetiology of this phenomenon is not clear, but in many reported cases, these transient episodes of LBBB are rate related. The mechanism of chest pain is not well understood. Still, it is postulated that sudden loss of the ventricular contraction synchrony, which happens in LBBB, will induce a different perception of heartbeat in the brain with possible translation to the chest pain. Various treatment modalities were attempted in the past, including exercise training, medical therapy with beta-blockers and calcium channel blockers or device therapy with right ventricle pacing, biventricular pacing and lately, His-bundle pacing. This case report presents a woman with intermittent episodes of typical angina with periodic LBBB changes on her ECG. Telemetry monitoring and treadmill exercise tests show a 100% association between angina episodes and LBBB changes on ECG. Her transthoracic echocardiogram shows normal left ventricle structure and function, and her coronary angiogram shows no flow-limiting coronary artery disease. She has been successfully treated by His-bundle pacing, and her symptoms entirely resolved on her serial follow-up.

Evaluation of a pixelated large format CMOS sensor for x-ray microbeam radiotherapy.

PURPOSE: Current techniques and procedures for dosimetry in microbeams typically rely on radiochromic film or small volume ionization chambers for validation and quality assurance in 2D and 1D, respectively. Whilst well characterized for clinical and preclinical radiotherapy, these methods are noninstantaneous and do not provide real time profile information. The objective of this work is to determine the suitability of the newly developed vM1212 detector, a pixelated CMOS (complementary metal-oxide-semiconductor) imaging sensor, for in situ and in vivo verification of x-ray microbeams. METHODS: Experiments were carried out on the vM1212 detector using a 220 kVp small animal radiation research platform (SARRP) at the Helmholtz Centre Munich. A 3 x 3 cm2 square piece of EBT3 film was placed on top of a marked nonfibrous card overlaying the sensitive silicon of the sensor. One centimeter of water equivalent bolus material was placed on top of the film for build-up. The response of the detector was compared to an Epson Expression 10000XL flatbed scanner using FilmQA Pro with triple channel dosimetry. This was also compared to a separate exposure using 450 µm of silicon as a surrogate for the detector and a Zeiss Axio Imager 2 microscope using an optical microscopy method of dosimetry. Microbeam collimator slits with range of nominal widths of 25, 50, 75, and 100 µm were used to compare beam profiles and determine sensitivity of the detector and both film measurements to different microbeams. RESULTS: The detector was able to measure peak and valley profiles in real-time, a significant reduction from the 24 hr self-development required by the EBT3 film. Observed full width at half maximum (FWHM) values were larger than the nominal slit widths, ranging from 130 to 190 µm due to divergence. Agreement between the methods was found for peak-to-valley dose ratio (PVDR), peak to peak separation and FWHM, but a difference in relative intensity of the microbeams was observed between the detectors. CONCLUSIONS: The investigation demonstrated that pixelated CMOS sensors could be applied to microbeam radiotherapy for real-time dosimetry in the future, however the relatively large pixel pitch of the vM1212 detector limit the immediate application of the results.

Predicting survival following surgical resection of lung cancer using clinical and pathological variables: The development and validation of the LNC-PATH score.

INTRODUCTION: The aim of this study was to develop and validate a simple prognostic scoring system using readily available clinical and pathological variables that could stratify patients according to the risk of death following lung cancer resection. We hypothesized that by using additional pathological variables not accounted for by pathological stage alone coupled with markers of overall fitness a new prognostic tool could be developed. METHODS: Multivariable logistic regression analysis of pathological and other clinical variables from patients undergoing surgical resection of non-small cell lung cancer (NSCLC) were used to determine factors independently associated with 2-year overall survival and so derive the scoring system. The model was then validated in an external multi-centre dataset. RESULTS: Using multivariable logistic regression on a large dataset (n = 1,421) the 'LNC-PATH' (Lymphovascular invasion, N-stage, adjuvant Chemotherapy, Performance status, Age, T-stage, Histology) prognostic score was devised and then validated using an external dataset (n = 402). This can be used to risk stratify patients into low, moderate and high-risk groups with a statistically significant difference between the three groups in their survival distributions. 83.8% of patients in the low-risk group survived two years after surgery compared to 55.6% in the moderate-risk group and 26.2% in the high-risk group. The score was shown to perform moderately well with an Area Under the Receiver Operating Characteristic curve (AUROC) value of 0.76 (95% CI: 0.73-0.79) and 0.70 (95% CI: 0.64-0.76) in the derivation and validation cohorts respectively. DISCUSSION: The LNC-PATH score predicts 2-year overall survival after surgery for NSCLC. This may allow the development of risk stratified follow-up protocols in survivorship clinics which could be the subject of future prospective studies.

Prevalence of nodal metastases in lymph node stations 8 & 9 in a large UK lung cancer surgical centre without routine pre-operative EUS nodal staging.

INTRODUCTION: Endoscopic ultrasound (EUS) allows access to the inferior mediastinal lymph node stations (8 and 9) which are beyond the reach of endobronchial ultrasound (EBUS). The addition of EUS to EBUS procedures requires cost and resource investment. This study sought to describe the prevalence of station 8/9 nodal metastases from intra-operative lymph node sampling in a UK region where routine pre-operative EUS is not available. METHODS: A retrospective review of all lung cancer resections at the University Hospital South Manchester from 2011 to 2014. Surgical variables, pre-operative PET variables and survival outcomes were collected and analysed. RESULTS: 1421 surgical resections were performed in the study period. Lymph node stations 8 and/or 9 were sampled in 52% (736/1421) of patients. Overall, there were 34 patients with lymph node metastases at station 8/9. This represents 2.4% of the study populations and 4.6% of patients in whom stations 8/9 were sampled intra-operatively. Of those patients with station 8/9 metastases, 65% (22/34) had multi-station N2 disease and the majority of the additional N2 disease was present in EBUS-accessible areas (lymph node stations 2, 4 and 7). Two percent (16/736) of patients in whom station 8/9 lymph nodes were sampled intra-operatively had N2 disease that was only accessible endoscopically with EUS. There was no significant difference in overall survival in patients with pathological N2 disease stratified according to whether stations 8/9 were involved or not. CONCLUSIONS: The prevalence of lymph node metastases in stations 8/9 in this UK surgical centre where routine pre-operative EUS is not performed is low at approximately 5%. Given the identification of N2 disease in two-thirds of these patients can potentially be achieved through EBUS alone, this questions whether the resource implications of EUS are justified by the impact on patient management.

Consensus statement: a framework for safe and effective intubation by paramedics.

This consensus statement provides profession-specific guidance in relation to tracheal intubation by paramedics - a procedure that the College of Paramedics supports. Tracheal intubation by paramedics has been the subject of professional and legal debate as well as crown investigation. It is therefore timely that the College of Paramedics, through this consensus group, reviews the available evidence and expert opinion in order to prevent patient harm and promote patient safety, clinical effectiveness and professional standards. It is not the purpose of this consensus statement to remove the skill of tracheal intubation from paramedics. Neither is it intended to debate the efficacy of intubation or the effect on mortality or morbidity, as other formal research studies will answer those questions. The consensus of this group is that paramedics can perform tracheal intubation safely and effectively. However, a safe, well-governed system of continual training, education and competency must be in place to serve both patients and the paramedics delivering their care.

Adequacy of Intraoperative Nodal Staging during Surgical Resection of NSCLC: Influencing Factors and Its Relationship to Survival.

INTRODUCTION: Adequate intraoperative lymph node sampling is a fundamental part of lung cancer surgery, but adherence to standards is not well known. This study sought to measure the adequacy of intraoperative lymph node sampling at a regional Thoracic Surgery Centre and a tertiary lung cancer center in the United Kingdom. METHODS: This retrospective study analyzed the pathological reports from NSCLC resections over the 4-year period 2011-2014. Adequacy of sampling was assessed against International Association for the Study of Lung Cancer recommendations of at least three mediastinal lymph node stations: station 7 in all patients, station 5 or 6 in left upper lobe tumors, and station 9 in lower lobe tumors. The influence of clinical variables (age, tumor T stage, type of surgery, and laterality) on adequacy of sampling and the effect of adequacy on overall survival were also assessed. RESULTS: A total of 1301 NSCLC resections were performed from January 11, 2011, to December 31, 2014. Adequate intraoperative lymph node sampling increased significantly from 14% (22 of 160) in 2011 to 53% (206 of 390) in 2014 (p = 0.001). Secondary analysis of clinical variables also revealed that patients with T1a or T4 tumors, those undergoing sublobar resections, those undergoing video-assisted thoracic surgery resections, and those undergoing left-sided resections have significantly higher rates of inadequate lymph node sampling. Overall, there was no statistically significant difference in survival between patients with adequate versus inadequate intraoperative lymph node sampling or when survival was stratified according to overall stage. There was worse survival in inadequate sampling for patients with pN2 disease than for patients with pN2 disease and adequate sampling. CONCLUSION: This study provides a much-needed benchmark of current thoracic surgical practice in lung cancer in the United Kingdom and important granularity to facilitate changes to improve adequacy of staging.

Ultra-high bandwidth quantum secured data transmission.

Quantum key distribution (QKD) provides an attractive means for securing communications in optical fibre networks. However, deployment of the technology has been hampered by the frequent need for dedicated dark fibres to segregate the very weak quantum signals from conventional traffic. Up until now the coexistence of QKD with data has been limited to bandwidths that are orders of magnitude below those commonly employed in fibre optic communication networks. Using an optimised wavelength divisional multiplexing scheme, we transport QKD and the prevalent 100 Gb/s data format in the forward direction over the same fibre for the first time. We show a full quantum encryption system operating with a bandwidth of 200 Gb/s over a 100 km fibre. Exploring the ultimate limits of the technology by experimental measurements of the Raman noise, we demonstrate it is feasible to combine QKD with 10 Tb/s of data over a 50 km link. These results suggest it will be possible to integrate QKD and other quantum photonic technologies into high bandwidth data communication infrastructures, thereby allowing their widespread deployment.

Development of a quarterly referral productivity report.

The Office of Physician Relations at The University of Texas M. D. Anderson Cancer Center (MDACC) has developed a dynamic referral productivity reporting tool for its Multidisciplinary Care Centers (MCC). The tool leverages information within the institution's Enterprise Information Warehouse (EIW) using business intelligent software Hyperion Intelligent Explorer Suite 8.3. the referral productivity reports are intended to provide each MCC with detailed referral and registration data outlining how, and from where, patients arrive here for treatment. The reports supports operational and strategic initiatives aimed at improving referral processes and market related program development.