VIPoma: an unsuspecting culprit of severe secretory diarrhoea in a human immunodeficiency virus-infected patient.

A 35-year-old man with known human immunodeficiency virus experienced chronic diarrhoea for 18 months. He presented to multiple hospitals with profuse secretory diarrhoea and life-threatening electrolyte disturbances. Infectious and non-infectious aetiologies were considered, with focussed history and investigations ultimately leading to a diagnosis of VIPoma. Initiation of somatostatin analogue therapy followed by surgical resection led to complete resolution of symptoms and markedly improved quality of life.

The effect of chair-based pedal exercises for older people admitted to an acute hospital compared to standard care: a feasibility study.

Background: chair-based pedal exercises potentially offer a simple method of improving physical activity in older people admitted to hospital. Objective: to assess the feasibility of using chair-based pedal exercisers on acute medical wards for older people. To study if there is any effect on muscle strength, mobility and time spent physically active. Subjects: fifty participants ≥65 years who were able to pedal admitted to acute medical wards for older people in a UK hospital. Methods: participants were randomised to either pedal for 5 min three times a day with minimal supervision; or standard care. Outcome data (compliance with exercise and change in lower limb muscle strength, mobility and level of physical activity) were collected on day 7 or on discharge, whichever came 1st. Results: there were no significant differences in baseline characteristics between the intervention and standard care group. Participants remained in the study for an average of 5 days. None in the intervention group adhered to the prescribed exercise duration. The intervention group completed a median of 152 revolutions, or a median total pedal time of 5 min during the entire study period. There were no differences in change in lower limb muscle strength, mobility score or the percentage of time spent active between the two groups. Conclusion: pedal exercises with minimal supervision are not feasible as a single intervention to improve physical activity in older people admitted to hospital. There may be a role for it as part of a multifaceted strategy to improve physical activity in hospital.

Active surveillance for the management of localized prostate cancer: Guideline recommendations.

INTRODUCTION: The objective is to provide guidance on the role of active surveillance (AS) as a management strategy for low-risk prostate cancer patients and to ensure that AS is offered to appropriate patients assessed by a standardized protocol. Prostate cancer is often a slowly progressive or sometimes non-progressive indolent disease diagnosed at an early stage with localized tumours that are unlikely to cause morbidity or death. Standard active treatments for prostate cancer include radiotherapy (RT) or radical prostatectomy (RP), but the harms from over diagnosis and overtreatment are of a significant concern. AS is increasingly being considered as a management strategy to avoid or delay the potential harms caused by unnecessary radical treatment. METHODS: A literature search of MEDLINE, EMBASE, the Cochrane library, guideline databases and relevant meeting proceedings was performed and a systematic review of identified evidence was synthesized to make recommendations relating to the role of AS in the management of localized prostate cancer. RESULTS: No exiting guidelines or reviews were suitable for use in the synthesis of evidence for the recommendations, but 59 reports of primary studies were identified. Due to studies being either non-comparative or heterogeneous, pooled meta-analyses were not conducted. CONCLUSION: The working group concluded that for patients with low-risk (Gleason score ≤6) localized prostate cancer, AS is the preferred disease management strategy. Active treatment (RP or RT) is appropriate for patients with intermediate-risk (Gleason score 7) localized prostate cancer. For select patients with low-volume Gleason 3+4=7 localized prostate cancer, AS can be considered.

Ecological modelling and toxicity data coupled to assess population recovery of marine amphipod Gammarus locusta: Application to disturbance by chronic exposure to aniline.

A population agent-based model of marine amphipod Gammarus locusta was designed and implemented as a basis for ecological risk assessment of chemical pollutants impairing life-history traits at the individual level. We further used the model to assess the toxic effects of aniline (a priority hazardous and noxious substance, HNS) on amphipod populations using empirically-built dose-response functions derived from a chronic bioassay that we previously performed with this species. We observed a significant toxicant-induced mortality and adverse effects in reproductive performance (reduction of newborn production) in G. locusta at the individual level. Coupling the population model with the toxicological data from the chronic bioassay allowed the projection of the ecological costs associated with exposure to aniline that might occur in wild populations. Model simulations with different scenarios indicated that even low level prolonged exposure to the HNS aniline can have significant long-term impacts on G. locusta population abundance, until the impacted population returns to undisturbed levels. This approach may be a useful complement in ecotoxicological studies of chemical pollution to transfer individual-collected data to ecological-relevant levels.

A survey of radiation treatment planning peer-review activities in a provincial radiation oncology programme: current practice and future directions.

OBJECTIVES: To describe current patterns of practice of radiation oncology peer review within a provincial cancer system, identifying barriers and facilitators to its use with the ultimate aim of process improvement. DESIGN: A survey of radiation oncology programmes at provincial cancer centres. SETTING: All cancer centres within the province of Ontario, Canada (n=14). These are community-based outpatient facilities overseen by Cancer Care Ontario, the provincial cancer agency. PARTICIPANTS: A delegate from each radiation oncology programme filled out a single survey based on input from their multidisciplinary team. OUTCOME MEASURES: Rated importance of peer review; current utilisation; format of the peer-review process; organisation and timing; case attributes; outcomes of the peer-review process and perceived barriers and facilitators to expanding peer-review processes. RESULTS: 14 (100%) centres responded. All rated the importance of peer review as at least 8/10 (10=extremely important). Detection of medical error and improvement of planning processes were the highest rated perceived benefits of peer review (each median 9/10). Six centres (43%) reviewed at least 50% of curative cases; four of these centres (29%) conducted peer review in more than 80% of cases treated with curative intent. Fewer than 20% of cases treated with palliative intent were reviewed in most centres. Five centres (36%) reported usually conducting peer review prior to the initiation of treatment. Five centres (36%) recorded the outcomes of peer review on the medical record. Thirteen centres (93%) planned to expand peer-review activities; a critical mass of radiation oncologists was the most important limiting factor (median 6/10). CONCLUSIONS: Radiation oncology peer-review practices can vary even within a cancer system with provincial oversight. The application of guidelines and standards for peer-review processes, and monitoring of implementation and outcomes, will require effective knowledge translation activities.

A Practice-based Taxonomy for Radiation Treatment Errors.

PURPOSE: An absence of a common language for incident classification limits knowledge sharing within and between organizations in the radiotherapy community. This challenge provided the motivation to develop a clinically relevant taxonomy for radiotherapy errors. MATERIALS AND METHODS: This was a multicenter, prospective study that consisted of three phases: (1) an initial version of the taxonomy was developed based on the World Health Organization Conceptual Framework for the International Classification for Patient Safety and taxonomy models from radiotherapy and other industries; (2) the taxonomy was evaluated using actual incident data from a single practitioner and revised; and (3) face validity testing of the taxonomy was performed by two additional practitioners from different radiotherapy centers using simulated incident cases. RESULTS: The taxonomy consisted of seven classes: incident nature, impact, incident type, stage of origin, stage of discovery, contributing factors, and preventative strategies. Each class was divided into subcategories containing increasingly detailed information. A total of 191 consecutive incidents were classified in phase 2 to ensure no further revision to the taxonomy was required. In phase 3, low interobserver agreement (<60%) was obtained for most classes of the taxonomy in the first face validity test. After revisions were made to the taxonomy based on practitioners' feedback, a second face validity test yielded a high degree of agreement (70%-93%) for all classes. CONCLUSIONS: Our multiphase, iterative approach has yielded a workable and multidimensional set of incident classifiers that can be scaled to accommodate local, regional and discipline-specific requirements. Opportunities exist to implement this taxonomy in institutional and national incident databases to facilitate incident learning within and between institutions.

Mangrove forest composition and structure in Las Perlas Archipelago, Pacific Panama

Mangrove forest is an important ecosystem that provides many services, but in Panama, as in other countries, they are under threat due to a variety of human activities. Nowadays, large areas of mangroves continue to be lost without been described and lack of management strategies. This study focused on the mangrove structure in the two largest islands, Isla del Rey and Isla San Jose, of Las Perlas Archipelago (LPA), Pacific Panama. Assessment of Landsat satellite imagery revealed loss of mangroves in the LPA of 965ha in the period 1974-1986, and 248ha in the period 1986-2000. The majority of the loss (>77%) from the two study islands was due to timber extraction and agricultural development. In May 2006, permanent plots following the CARICOMP protocol were established at two sites on Isla del Rey (R1 and R2) and one site on Isla San Jose (SJ) where standardized metrics such as species, height and diameter at breast height of adult trees and seedlings were recorded. Forest structure differed at the three sites, although R1 and R2 were most similar. At R1, Laguncularia racemosa was the important species and R2 was dominated by Pelliciera rhizophorae. Examination of the forest structure and classified imagery indicated that these sites are spatially dynamic and appear to be rejuvenating. The forest structure would indicate that the sites have been growth-limited previously by human activities and possibly by other factors. SJ was dominated by Rhizophora mangle and appears to have a mature forest with large adult trees and few seedlings. It does not appear to have shown the same extent of spatial regrowth as the other two sites between 1986 and 2000 and is relatively static. The establishment of permanent plots and monitoring will be useful as part of the management plan, as the LPA shows a variety of mangrove structures and could be subject to further coastal development. Rev. Biol. Trop. 58 (3): 857-869. Epub 2010 September 01.

Los bosques de manglar son ecosistemas importantes que proveen muchos servicios, pero éstos están bajo la amenaza de una variedad de actividades humanas y grandes áreas de manglar continúan perdiéndose en Panamá. Este estudio está enfocado en la estructura de manglar de las dos islas más grandes del Archipiélago de Las Perlas en el Pacifico Panameño (LPA), la Isla del Rey y la Isla San José. La evaluación de las imágenes del satélite Landsat revela la pérdida de manglares en LPA de 965ha en el periodo entre 1974-1986, y de 286ha en el periodo 1986-2000. La mayor parte de la pérdida (>77%) en las dos islas estudiadas fue debida a la extracción de madera y al desarrollo agrícola. En mayo de 2006, se establecieron parcelas permanentes siguiendo el protocolo de CARICOMP en dos sitios en la isla del Rey (R1 y R2) y un sitio en la Isla San José (SJ) donde especies, altura y diámetro a la altura de la copa de árboles adultos y jóvenes fueron registradas. La estructura del bosque difirió en los tres sitios, sin embargo R1 y R2 fueron los más similares. En R1, Laguncularia racemosa fue la especie más dominante y Pelliceria rhizophora en R2. El análisis de la estructura del bosque y de imágenes clasificadas indicó que estos sitios son espacialmente dinámicos y parecen estar regenerándose. La estructura del bosque indica que el crecimiento en los sitios ha estado limitado por las actividades humanas y posiblemente por otros factores. SJ fue dominado por Rhizophora mangle y parece tener un bosque maduro con árboles adultos grandes y pocos jóvenes. Éste sitio no parece mostrar la misma extensión de rebrote espacial de los otros dos sitios entre 1986-2000 y es relativamente estático. El establecimiento de parcelas permanentes y el monitoreo serán útiles en la implementación del plan de manejo, ya que los manglares del LPA tienen una variedad estructural y podrían estar sujetos a un mayor desarrollo costero.

Mangrove forest composition and structure in Las Perlas Archipelago, Pacific Panama.

Mangrove forest is an important ecosystem that provides many services, but in Panama, as in other countries, they are under threat due to a variety of human activities. Nowadays, large areas of mangroves continue to be lost without been described and lack of management strategies. This study focused on the mangrove structure in the two largest islands, Isla del Rey and Isla San Jose, of Las Perlas Archipelago (LPA), Pacific Panama. Assessment of Landsat satellite imagery revealed loss of mangroves in the LPA of 965ha in the period 1974-1986, and 248ha in the period 1986-2000. The majority of the loss (>77%) from the two study islands was due to timber extraction and agricultural development. In May 2006, permanent plots following the CARICOMP protocol were established at two sites on Isla del Rey (R1 and R2) and one site on Isla San Jose (SJ) where standardized metrics such as species, height and diameter at breast height of adult trees and seedlings were recorded. Forest structure differed at the three sites, although R1 and R2 were most similar. At R1, Laguncularia racemosa was the important species and R2 was dominated by Pelliciera rhizophorae. Examination of the forest structure and classified imagery indicated that these sites are spatially dynamic and appear to be rejuvenating. The forest structure would indicate that the sites have been growth-limited previously by human activities and possibly by other factors. SJ was dominated by Rhizophora mangle and appears to have a mature forest with large adult trees and few seedlings. It does not appear to have shown the same extent of spatial regrowth as the other two sites between 1986 and 2000 and is relatively static. The establishment of permanent plots and monitoring will be useful as part of the management plan, as the LPA shows a variety of mangrove structures and could be subject to further coastal development.

Standardized synoptic cancer pathology reporting: a population-based approach.

Cancer pathology reports contain information which is critical for patient management and for cancer surveillance, resource planning, and quality purposes. The College of American Pathologists (CAP) has defined scientifically validated content of checklists that form the basis for synoptic cancer pathology reporting. We outline how the CAP standards were implemented in a large Canadian province over a 3-year period resulting in improvements in rates of synoptic reporting and completeness of cancer pathology reporting.

Calcifications are potential surrogates for prostate localization in image-guided radiotherapy.

PURPOSE: To investigate the feasibility of using calcifications as surrogates for the prostate position during cone-beam computed tomography (CBCT) image-guided radiotherapy. METHODS AND MATERIALS: The twice-weekly CBCT images taken during the treatment course of 4 patients were retrospectively studied for the stability of the calcifications. The geometric center of three fiducial markers was used as the reference. The planning CT images of 131 prostate patients recently treated with external beam radiotherapy at our center were reviewed to estimate the calcification occurrence rate. Analysis was conducted using the Varian Eclipse treatment planning system. Two patients were treated using prostate calcifications as the landmark in on-line registration. Both the Varian standard and the low-dose CBCT modes were used for imaging. RESULTS: The calcifications were found to be stable during the treatment course. At the 95% confidence interval, the difference between the distance from an identified calcification to the fiducial markers on CBCT and the distance on the planning CT scans was 0.2 +/- 2.0 mm, 0.8 +/- 2.2 mm, and 0.4 +/- 2.4 mm in the left-right, anteroposterior, and superoinferior direction, respectively. Of the 131 patients, 46 (35%) had well-defined calcifications either inside the prostate or near the borders. Our experience in treating the first 2 patients demonstrated that the calcifications are easily distinguished on low-dose scans and that calcification registration can be precisely performed. CONCLUSION: The results of our study have shown that calcifications can be reliable markers of prostate position and allow for precise image guidance with a low-imaging dose. With this approach, potentially about one-third of prostate patients could benefit from precise image guidance without the invasive use of markers.

Waiting times for radiation therapy in Ontario.

BACKGROUND: The mass media and clinical journals have reported lengthy waiting times after surgery before initiation of radiation therapy (RT) for cancer across Canada. We aimed to describe the length of time between the last date of surgery or biopsy or chemotherapy and first date of RT. METHODS: This is a population-based study measuring waiting times for RT in Ontario among all patients with potentially curable cancer of the cervix, tonsil and larynx and a random sample of women who had had breast cancer resection, whose first date of RT fell between Sept. 1, 2001, and Aug. 31, 2002. Abstraction of original health care records provided each patient's demographics, cancer stage and cancer treatment (last surgery, consultation, simulation, first RT). Last dates of chemotherapy before RT were obtained from abstraction or from Ontario Health Insurance Plan (OHIP) files, and last dates of surgery before RT were compared with dates in the Canadian Institute for Health Information (CIHI) Discharge Abstract Database. RESULTS: Waiting times between the last date of surgery or chemotherapy and the first date of RT varied significantly among the health regions of Ontario. Increasing age, but not the presence of comorbidity, was associated with longer waiting times. Women who did not receive postoperative chemotherapy before RT for breast cancer waited significantly longer than all others. CONCLUSION: Measurement of waiting times for cancer RT must discount time during which adjuvant intravenous chemotherapy is administered after surgery and before RT. There appears to be a formal or informal process by which those at highest risk begin RT most rapidly.

Travelling for radiation cancer treatment: patient satisfaction.

This study was conducted for the purpose of describing cancer patients' satisfaction with their care when they had to travel unexpectedly away from home for treatment. Ontario initiated a rereferral program for cancer patients who needed radiation therapy when the waiting lists in southern Ontario became lengthy. Patients travelled to the United States or northern Ontario for their care. A standardized survey containing 25 items with five-point Likert scale responses was mailed to all patients who participated in the rereferral program, following completion of their treatment. Items covered patient experiences before leaving home, in preparing for travel, and staying at the cancer facilities away from home. A total of 466 (55.8%) patients returned the survey. Overall, patients were satisfied with their care. However, there were a number of areas identified by patients where improvements could be made. These areas included access to support prior to leaving home, access to information about supportive care services while away from home, and sensitivity to personal needs in making arrangements for travel. Provision of information and support are important to cancer patients having to travel for cancer treatment.

Does the private sector have a role in Canadian healthcare?

The current system of public pay with primarily public management for essential healthcare services has largely been successful. The Romanow and Kirby reports have made compelling arguments for expanding the definition of essential healthcare services to include, among other things, medications. The problem facing Canadians is that expanding services is not feasible under the current structure, as it is not affordable. The rigid adherence to a 45-year-old definition of system structure is hampering our ability to innovate. In an increasingly unresponsive system, the introduction of private management, through the judicious use of private contracts, can improve efficiency and increase accountability, while maintaining the important principle of public funding.

The changing costs of radiation treatment for early prostate cancer in Ontario: a comparison between conventional and conformal external beam radiotherapy.

PURPOSE: Prostate cancer represents a large part of the workload for radiation oncology departments in Canada. Recent evidence suggests that conformal external beam radiotherapy improves results. The planning and treatment process for conformal patients requires a greater amount of resources that are in short supply in Ontario. An understanding of these differences is important to provide an accurate estimate of future radiation needs of the province. These differences can be quantified in a cost model that portrays the direct costs of delivering external beam radiotherapy in Ontario. With a developed cost model, a prospective direct cost comparison between standard four field external beam radiotherapy versus conformal radiotherapy in early stage prostate carcinoma was designed. METHODS: Activity based costing has been used to create a model of radiotherapy related costs for prostate cancer. A process map was developed which separated the process in five activities for conventional radiotherapy and six activities for dose escalated conformal radiotherapy. Time was recognized as the important cost driver within each activity. The time required for pre-treatment preparation (CT planning, dosimetry, simulation, and other preparatory work) and actual treatment times were collected prospectively. Treatment times were collected in 414 patients. The annual costs of capital equipment purchase costs and specialized construction of hospital space for radiotherapy equipment were amortized using a 6% discount rate plus the cost of annual maintenance. Indirect costs were not included in this cost analysis. RESULTS: An activity based costing model using time as the primary cost driver reflects the additional costs of conformal over conventional external beam radiotherapy. The costs of single phase and double phase six field conformal therapy with 42 fractions delivered was 7867 Canadian dollars and 8227 Canadian dollars per patient. Four field single phase conformal therapy with 28 fractions costs 5723 Canadian dollars. The cost of conventional radiotherapy over 33 fractions was 3068 Canadian dollars. The majority of the cost differences arose from the cost of the additional time needed for treatment per day as well as the extra fractions per patient when compared to conventionally treated patients. The average treatment times per fraction for six field conformal, four field conformal and four field conventional have the median times of 22.72, 20.63 and 11.07 minutes respectively. Planning costs for conformal radiotherapy were up to three times the cost of conventional therapy. CONCLUSIONS: The direct costs of dose escalated conformal external beam radiotherapy are over 2.5 times that of conventional external beam radiotherapy for early stage prostate cancer. These direct costs are a reflection of the additional capital and human resources needed to provide state-of-the-art radiation therapy in the province of Ontario. Planning for radiation oncology needs should consider the additional costs of conformal external beam radiotherapy.

Travelling for radiation cancer treatment: patient perspectives.

Radiation treatment for cancer requires patients to receive frequent administrations and attend the treatment facility on a daily basis for several weeks. Travelling for radiation treatment has the potential to add to the distress an individual may be feeling. This study utilized in-depth interviews to capture 118 patients' perspectives about travelling for cancer treatment. Four themes emerged during the analysis of the data: (1) waiting was the most difficult part of the experience; (2) the idea of travelling for treatment was distressing; (3) travelling for treatment was tiring and posed difficulties for patients; and (4) being away from home had both benefits and drawbacks. Given the inevitability of travelling for radiation treatment, and the issues that arises for patients, supportive strategies need to be designed and implemented.