Dosimetric Comparison of Ultra-Hypofractionated and Conventionally Fractionated Radiation Therapy Boosts for Patients with High-Risk Prostate Cancer.

Recent comparison of an ultra-hypofractionated radiotherapy (UF-RT) boost to a conventionally fractionated (CF-RT) option showed similar toxicity and disease control outcomes. An analysis of the treatment plans for these patients is needed for evaluating calculated doses for different organs, treatment beam-on time, and requirements for human and financial resources. Eighty-six plans for UF-RT and 93 plans for CF-RT schemes were evaluated. The biologically equivalent dose, EQD2, summed for the first phase and the boost, was calculated for dose-volume parameters for organs at risk (OARs), as well as for the PTV1. ArcCHECK measurements for the boost plans were used for a comparison of planned and delivered doses. Monitor units and beam-on times were recorded by the Eclipse treatment planning system. Statistical analysis was performed with a significance level of 0.05. Dosimetric parameter values for OARs were well within tolerance for both groups. EQD2 for the PTV1 was on average 84 Gy for UF-RT patients and 76 Gy for CF-RT patients. Gamma passing rate for planned/delivered doses comparison was above 98% for both groups with 3 mm/3% distance to agreement/dose difference criteria. Total monitor units per fraction were 647 ± 94 and 2034 ± 570 for CF-RT and UF-RT, respectively. The total delivery time for boost radiation for the patients in the UF-RT arm was, on average, four times less than the total time for a conventional regimen with statistically equal clinical outcomes for the two arms in this study.

Hip arthoplasty in a forester after numerous tick bites.

Arthritis is one of the most important symptoms of late-stage borreliosis, observed in approximately 60% of untreated patients with Lyme disease. In several percent of them, this manifestation is of interest to orthopedic surgeons. The authors present a case of a patient, working as a forester, who underwent left hip replacement arthroplasty having contracted a Borrelia burgdorferi infection in the past, and who was hospitalized 12 years before in the infectious ward due to suspected neuroborreliosis for which he was treated with Ceftriaxone 2 × 2.0 g intravenously for 4 weeks. At that time, a tomographic examination of the spinal cord revealed herniated nuclei at levels L4/L5 and L5/S1, which filled the left lateral recess, narrowing the intervertebral holes and compressing the nerve roots on the left side of L4 and L5. In September 2019, total hip replacement in the patient's left hip joint was performed. It is concluded that an active role of neuroborreliosis in this process of hip joint destruction may be suggested. Int J Occup Med Environ Health. 2021;34(5):693-9.

Chloroquine in controlling biological infections.

From the middle of the 17th century, Cinchona tree's bark, which contains quinine, was used as an anti-malarial agent. It wasn't until the midtwentieth century that chloroquine was synthesized, followed by its further derivatives. Chloroquine inhibits protozoan polymerase activity, leading to an increase in heme, which is toxic to Plasmodium. The sensitivity of the protozoan to chloroquine depends on its ability to accumulate the drug in aquatic vacuolas. The medicine is also directly toxic to protozoa of the genus Entamoeba histolytica. The immunomodulatory properties of chloroquine have led to its use in collagen diseases, rheumatic disease, chronic rheumatoid and ankylosing arthritis and autoimmune skin disease. Chloroquine has recently been shown to be effective in controlling infection caused by the new Corona virus 2019- nCov (SARS-CoV-2). The drug inhibits viral infectivity by increasing endosomal pH in cells and blocking virus-cell interference by glycosylating SARS-CoV-2 cell receptors. Chloroquine has been shown to be able to bind sialic acid and gangliosides effectively by blocking the combination of virus S protein with gangliosides, which prevents the infection from starting. The effectiveness of the drug in the first stage of infection by SARS-CoV-2 was confirmed in clinical observations and the drug was included in the developed therapeutic recommendations.

Elasticity Dominated Surface Segregation of Small Molecules in Polymer Mixtures.

We study the phenomenon of migration of the small molecular weight component of a binary polymer mixture to the free surface using mean field and self-consistent field theories. By proposing a free energy functional that incorporates polymer-matrix elasticity explicitly, we compute the migrant volume fraction and show that it decreases significantly as the sample rigidity is increased. A wetting transition, observed for high values of the miscibility parameter can be prevented by increasing the matrix rigidity. Estimated values of the bulk modulus suggest that the effect should be observable experimentally for rubberlike materials. This provides a simple way of controlling surface migration in polymer mixtures and can play an important role in industrial formulations, where surface migration often leads to decreased product functionality.

Clinicians' views and experiences of interventions to enhance the quality of antibiotic prescribing for acute respiratory tract infections.

BACKGROUND: Evidence shows a high rate of unnecessary antibiotic prescriptions in primary care in Europe and the United States. Given the costs of widespread use and associated antibiotic resistance, reducing inappropriate use is a public health priority. OBJECTIVE: We aimed to explore clinicians' experiences of training in communication skills and use of a patient booklet and/or a C-reactive protein (CRP) point-of-care test to reduce antibiotic prescribing for acute respiratory tract infections (RTIs). DESIGN: We used a qualitative research approach, interviewing clinicians who participated in a randomised controlled trial (RCT) testing two contrasting interventions. PARTICIPANTS: General practice clinicians in Belgium, England, The Netherlands, Poland, Spain and Wales participated in the study. APPROACH: Sixty-six semi-structured interviews were transcribed verbatim, translated into English where necessary, and analysed using thematic and framework analysis. KEY RESULTS: Clinicians from all countries attributed benefits for themselves and their patients to using both interventions. Clinicians reported that the communication skills training and use of the patient booklet gave them greater confidence in addressing patient expectations for an antibiotic by providing answers to common questions and supporting the clinician's own explanations. Clinicians felt the booklet could be used for a variety of patients and for different types of infections. The CRP test was viewed as a tool to decrease diagnostic uncertainty, to support non-prescription decisions, and to reassure patients, but was only necessary when clinicians were uncertain about the need for antibiotics. CONCLUSION: Providing clinicians with training and support tools for use in practice was received positively and was valued by clinicians across countries. Interventions seemed to have influenced behaviour by increasing clinician knowledge about illness severity and prescribing, increasing confidence in making non-prescribing decisions when antibiotics were unnecessary, and enabling clinicians to anticipate positive outcomes when making such decisions. Addressing such determinants of behaviour change enabled interventions to be relevant for clinicians working across different contexts.

Clinical characteristics of patients with myocardial infarction treated in the regional hospital of Radomszczanski District in 2007-2009.

BACKGROUND: Cardiovascular diseases are responsible for about 50% of deaths in Poland. The clinical picture of coronary heart disease has been changing over recent years. AIM: To assess the changes of the clinical characteristics of myocardial infarction (MI) in the population of Radomszczanski District in 2007-2009. METHODS: The retrospective analysis included 756 patients aged between 29 and 93 years (306 women), who were hospitalised due to MI in the Department of Cardiology, District Hospital in Radomsko from 1 January 2007 to 31 December 2009. The following parameters were analysed: frequency of ST elevation MI (STEMI) and non ST elevation MI (NSTEMI) hospitalisations in subsequent years, age, gender, traditional risk factors (hypertension, diabetes, obesity, hypercholesterolaemia, hypertriglyceridaemia, smoking), comorbidities (atrial fibrillation, previous stroke and MI, chronic renal insufficiency) and all-cause in-hospital mortality. RESULTS: Observations have shown that during 2007-2009 the number of hospitalised STEMI increased (p = 0.011) while the number of hospitalised NSTEMI decreased (p = 0.011). The incidence of hypertension, diabetes, obesity, and dyslipidaemia did not change over the three years analysed (p > 0.05). In Radomszczanski District, compared to the Polish population, hypertension, obesity and previous MI occurred less frequently, especially in patients with NSTEMI. The incidence of smoking and diabetes was comparable to that in the Polish population with MI. Frequency of risk factors did not change over three years. CONCLUSIONS: Despite the increase of the hospitalised STEMI/NSTEMI ratio, the incidence of risk factors did not change in the population of Radomszczanski District over the analysed period.

Exploring patients' views of primary care consultations with contrasting interventions for acute cough: a six-country European qualitative study.

BACKGROUND: In a pan-European randomised controlled trial (GRACE INTRO) of two interventions, (i) a point-of-care C-reactive protein test and/or (ii) training in communication skills and use of an interactive patient booklet, both interventions resulted in large reductions in antibiotic prescribing for acute cough. AIMS: This process evaluation explored patients' views of primary care consultations using the two interventions in six European countries. METHODS: Sixty-two interviews were conducted with patients who had participated in the GRACE INTRO trial. Interviews were transcribed verbatim and translated into English where necessary. Analysis used techniques from thematic and framework analysis. RESULTS: Most patients were satisfied with their consultation despite many not receiving an antibiotic. Patients appeared to accept the use of both intervention approaches. A minority, but particularly in the trial arm with both interventions, reported that they would wait longer before consulting for cough in future. CONCLUSIONS: Patients perceived that both interventions supported the general practitioner's (GP's) prescribing decisions by helping them understand when an antibiotic was, and was not, needed. Patients consulting with acute cough had largely positive views about the GP's enhanced communication skills, which included understanding their concerns, and the use of a near-patient test as an additional investigation.

Evaluation of a tailored implementation strategy to improve the management of patients with chronic obstructive pulmonary disease in primary care: a study protocol of a cluster randomized trial.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) remains a major health problem, strongly related to smoking. Despite the publication of practice guidelines on prevention and treatment, not all patients with the disease receive the recommended healthcare, particularly with regard to smoking cessation advice where applicable. We have developed a tailored implementation strategy for enhancing general practitioners' adherence to the disease management guidelines. The primary aim of the study is to evaluate the effects of this tailored implementation intervention on general practitioners' adherence to guidelines. METHODS/DESIGN: A pragmatic two-arm cluster randomized trial has been planned to compare care following the implementation of tailored interventions of four recommendations in COPD patients against usual care. The study will involve 18 general practices (9 in the intervention group and 9 in the control group) in Poland, each with at least 80 identified (at the baseline) patients with diagnosed COPD. The nine control practices will provide usual care without any interventions. Tailored interventions to implement four recommendations will be delivered in the remaining nine practices. At follow-up after nine months, data will be collected for all 18 general practices. The primary outcome measure is physicians' adherence to all four recommendations: brief anti-smoking advice, dyspnea assessment, care checklist utilization and demonstration to patients of correct inhaler use. This measurement will be based on data extracted from identified patients' records. Additionally, we will survey and interview patients with chronic obstructive pulmonary disease about the process of care. DISCUSSION: The results of this trial will be directly applicable to primary care in Poland and add to the growing body of evidence on interventions to improve chronic illness care. TRIAL REGISTRATION: This trial has been registered with Clinical Trials Protocol Registration System. TRIAL NUMBER: NCT01893476.

Trust, openness and continuity of care influence acceptance of antibiotics for children with respiratory tract infections: a four country qualitative study.

BACKGROUND: Clinician-parent interaction and health system influences on parental acceptance of prescribing decisions for children with respiratory tract infections (RTIs) may be important determinants of antibiotic use. OBJECTIVE: To achieve a deeper understanding of parents' acceptance, or otherwise, of clinicians' antibiotic prescribing decisions for children with RTIs. METHODS: Qualitative interviews with parents of child patients who had recently consulted in primary care with a RTI in four European countries, with a five-stage analytic framework approach (familiarization, developing a thematic framework from interview questions and emerging themes, indexing, charting and interpretation). RESULTS: Fifty of 63 parents accepted clinicians' management decisions, irrespective of antibiotic prescription. There were no notable differences between networks. Parents ascribed their acceptance to a trusting and open clinician-patient relationship, enhanced through continuity of care, in which parents felt able to express their views. There was a lack of congruence about antibiotics between parents and clinicians in 13 instances, mostly when parents disagreed about clinicians' decision to prescribe (10 accounts) rather than objecting to withholding antibiotics (three accounts). All but one parent adhered to the prescribing decision, although some modified how the antibiotic was administered. CONCLUSIONS: Parents from contrasting countries indicated that continuity of care, open communication in consultations and clinician-patient trust was important in acceptance of management of RTI in their children and in motivating adherence. Interventions to promote appropriate antibiotic use in children should consider a focus on eliciting parents' perspectives and promoting and building on continuity of care within a trusting clinician-patient relationship.

Strategies to promote prudent antibiotic use: exploring the views of professionals who develop and implement guidelines and interventions.

BACKGROUND: A variety of interventions have been developed to promote prudent antibiotic use, especially for respiratory tract infections (RTIs); however, it is not yet clear which are most acceptable and feasible for implementation across a wide range of contexts. This study elicited the views of experts, professionals who develop and implement guidelines and interventions, from five countries, on the development of RTI guidelines and interventions for implementing them. OBJECTIVES: The aim was to determine whether there are common features of interventions which experts consider useful in changing health professionals' behaviour, or whether there are important contextual differences in views. METHODS: Fifty semi-structured interviews explored experts' views and experiences of strategies across five countries. Interviews were carried out in person or over the phone, transcribed verbatim and translated into English, if not already in English, for analysis. RESULTS: Themes were remarkably consistent across the countries, and these could be summarized as five sets of recommendations: guidelines should be developed by health care professionals to better fit GPs' needs; address GP concerns about recommendations and explain the need for guidelines; design flexible interventions to increase feasibility across primary care practice; provide interventions which engage GPs; and provide consistent messages about antibiotic use for patients, professionals and the public. CONCLUSIONS: Key features need to be addressed when developing future guidelines and interventions in order to improve their implementation. Consistency in experts' views across countries indicates the potential for the development of interventions which could be implemented on a multinational scale with widespread support from key opinion leaders.

General practitioners' views on the acceptability and applicability of a web-based intervention to reduce antibiotic prescribing for acute cough in multiple European countries: a qualitative study prior to a randomised trial.

BACKGROUND: Interventions to promote prudent antibiotic prescribing by general practitioners (GPs) have often only been developed for use in one country. We aimed to develop an intervention which would be appropriate to implement in multiple European countries in order to offer greater benefit to practice whilst using fewer resources. The INTRO (INternet TRaining for antibiOtic use) intervention needed to deliver training to GPs in the use of C-Reactive Protein (CRP) near patient tests to help diagnose acute cough and in communication skills to help explain prescribing decisions to patients. We explored GPs' views on the initial version of INTRO to test acceptability and potentially increase applicability for use in multiple countries before the start of a randomised trial. METHOD: 30 GPs from five countries (Belgium, England, the Netherlands, Poland and Spain), were interviewed using a "think aloud" approach. GPs were asked to work through the intervention and discuss their views on the content and format in relation to following the intervention in their own practice. GPs viewed the same intervention but versions were created in five languages. Data were coded using thematic analysis. RESULTS: GPs in all five countries reported the view that the intervention addressed an important topic, was broadly acceptable and feasible to use, and would be a useful tool to help improve clinical practice. However, GPs in the different countries identified aspects of the intervention that did not reflect their national culture or healthcare system. These included perceived differences in communication style used in the consultation, consultation length and the stage of illness at which patient typically presented. CONCLUSION: An online intervention to support evidence-based use of antibiotics is acceptable and feasible to implement amongst GPs in multiple countries. However, tailoring of the intervention to suit national contexts was necessary by adding local information and placing more emphasis on the fact that GPs could select the communication skills they wished to use in practice. Using think aloud methods to complement the development of interventions is a powerful method to identify regional contextual barriers to intervention implementation.

Clinical influences on antibiotic prescribing decisions for lower respiratory tract infection: a nine country qualitative study of variation in care.

OBJECTIVES: There is variation in antibiotic prescribing for lower respiratory tract infections (LRTI) in primary care that does not benefit patients. This study aims to investigate clinicians' accounts of clinical influences on antibiotic prescribing decisions for LRTI to better understand variation and identify opportunities for improvement. DESIGN: Multi country qualitative interview study. Semi-structured interviews using open-ended questions and a patient scenario. Data were subjected to five-stage analytic framework approach (familiarisation, developing a thematic framework from the interview questions and emerging themes, indexing, charting and mapping to search for interpretations), with interviewers commenting on preliminary reports. SETTING: Primary care. PARTICIPANTS: 80 primary care clinicians randomly selected from primary care research networks based in nine European cities. RESULTS: Clinicians reported four main individual clinical factors that guided their antibiotic prescribing decision: auscultation, fever, discoloured sputum and breathlessness. These were considered alongside a general impression of the patient derived from building a picture of the illness course, using intuition and familiarity with the patient. Comorbidity and older age were considered main risk factors for poor outcomes. Clinical factors were similar across networks, apart from C reactive protein near patient testing in Tromsø. Clinicians developed ways to handle diagnostic and management uncertainty through their own clinical routines. CONCLUSIONS: Clinicians emphasised the importance of auscultation, fever, discoloured sputum and breathlessness, general impression of the illness course, familiarity with the patient, comorbidity, and age in informing their antibiotic prescribing decisions for LRTI. As some of these factors may be overemphasised given the evolving evidence base, greater standardisation of assessment and integration of findings may help reduce unhelpful variation in management. Non-clinical influences will also need to be addressed.

GPs' views in five European countries of interventions to promote prudent antibiotic use.

BACKGROUND: A variety of interventions have been developed to promote a more prudent use of antibiotics by implementing clinical guidelines. It is not yet clear which are most acceptable and feasible for implementation across a wide range of contexts. Previous research has been confined mainly to examining views of individual interventions in a national context. AIM: To explore GPs' views and experiences of strategies to promote a more prudent use of antibiotics, across five countries. DESIGN AND SETTING: Qualitative study using thematic and framework analysis in general practices in Belgium, France, Poland, Spain, and the UK. METHOD: Fifty-two semi-structured interviews explored GPs' views and experiences of strategies aimed at promoting a more prudent use of antibiotics. Interviews were carried out in person or over the telephone, transcribed verbatim, and translated into English where necessary for analysis. RESULTS: Themes were remarkably consistent across the countries. GPs had a preference for interventions that allowed discussion and comparison with local colleagues, which helped them to identify how their practice could improve. Other popular components of interventions included the use of near-patient tests to reduce diagnostic uncertainty, and the involvement of other health professionals to increase their responsibility for prescribing. CONCLUSION: The study findings could be used to inform future interventions to improve their acceptability to GPs. Consistency in views across countries indicates the potential for development of an intervention that could be implemented on a European scale.

[Current problems in the diagnosis and treatment of patients with myocarditis]. / Aktualne problemy w rozpoznawaniu i leczeniu chorych na zapalenie miesnia sercowego.

Myocarditis as inflammatory cardiomyopathy is considered to be the primary group acquired cardiomyopathy. It is a disease of diverse etiology, which involves inflammation cardiomyocytes, interstitial tissue, vessels and sometimes the pericardium. The prevalence is not accurately known. Myocarditis is caused by many etiological factors: viruses, bacteria, protozoa and parasites. The presence of eosinophilic myocarditis is related to chemical compounds, including many drugs. This disease, although known for a long time still poses many problems in everyday medical practice. Clinical course of the disease and frequent process of transition dilated cardiomyopathy, tends to isolate the three phases of the disease: viral, autoimmune and dilated cardiomyopathy. These phases arise from the close link between viral infection and the accompanying immune response (especially contagious infection). In fact, the secondary immune response leads to activation of cytotoxic cells (CD8), which gives rise to antibodies directed against cardiomyocytes. Diagnosis of this disease is difficult and expensive, uses methods: direct (culture), molecular (PCR, hybridization) and imaging methods (echocardiography, MRI). Treatment of myocarditis depends on the phase and the etiology of the disease. In phase includes nonspecific viral antiviral agents, and avoidance of potentially harmful immunosuppression. The therapy is used among other immunoglobulins, statins, and patients in the phase dilated cardiomyopathy should be treated as idiopathic dilated cardiomyopathy and congestive heart failure. Myocarditis is one of the few units of cardiac disease for which there are no uniform standards of medical practice.

Flat histogram version of the pruned and enriched Rosenbluth method.

In this Letter we present a flat histogram algorithm based on the pruned and enriched Rosenbluth method. This algorithm incorporates in a straightforward manner microcanonical reweighting techniques, leading to "flat histogram" sampling in the chosen parameter space. As an additional benefit, our algorithm is completely parameter free and, hence, easy to implement. We apply this algorithm to interacting self-avoiding walks, the generic lattice model of polymer collapse.