DIBH reduces right coronary artery and lung radiation dose in right breast cancer loco-regional radiotherapy.

To determine whether deep inspiratory breath-hold (DIBH) reduces dose to organs-at-risk (OAR), in particular the right coronary artery (RCA), in women with breast cancer requiring right-sided post-mastectomy radiotherapy (PMRT) including internal mammary chain (+IMC) radiotherapy (RT). Fourteen consecutive women requiring right-sided PMRT + IMC were retrospectively identified. Nodal delineation was in accordance with European Society for Radiology and Oncology (ESTRO) guidelines and tangential chest wall fields marked. Patients were planned with Anisotropic Analytical Algorithm using free-breathing (FB) and DIBH datasets. Dose was calculated using Acuros External Beam algorithm. FB and DIBH dose comparisons were analyzed for heart, RCA and right lung, as were chest wall and IMC planning target volumes (PTVs). DIBH vs FB resulted in median decreases of: the RCA mean dose by 0.6Gray (Gy) (interquartile range (IQR) 0.1, 1.9) (p = 0.002), RCA max dose by 1.8Gy (IQR 0.8, 6.1) (p = 0.002), and V5Gy by 2.9% (IQR 0.0, 37.2) (p = 0.016). RCA data indicated no statistically significant dosimetric reduction ≥10Gy. A median reduction of 1.7Gy (c -0.0, 7.1) (p = 0.019) in maximum heart dose was recorded with DIBH vs FB; no significant difference was observed in other heart and left anterior descending coronary artery parameters. The median reduction in right lung mean dose was 2.8Gy for DIBH vs FB plans (IQR 1.6, 3.6) (p = 0.001); significant median reductions of V5Gy, V20Gy, and V30Gy were all achieved with DIBH. Chest wall PTV coverage did not significantly differ between DIBH and FB plans; IMC dosimetric coverage improved with use of DIBH (V47.5Gy, V45Gy, V42Gy). DIBH reduced OAR dose in right-sided PMRT + IMC patients. A novel finding was that DIBH decreased RCA dose. Heart and right lung dose were also decreased with DIBH, whilst optimally dosed PTVs were maintained.

Incidental finding of a human-like tusavirus in a lamb with lip lesions and fatal pneumonia.

Tusaviruses in the genus Protoparvovirus of family Parvoviridae were first identified in a diarrhoeic Tunisian child in 2014. Thereafter, high prevalence of a genetically similar virus was demonstrated in faeces from caprine and ovine species in Hungary. Here, we describe an investigation into the cause of scabby lip lesions in a 6 month-old lamb, submitted from a farm experiencing weight loss and scouring in lambs in England. Transmission electron microscopy visualised small circular particles of 18 and 22 nm in diameter in lip lesions identified as tusavirus and flumine parvovirus by Next Generation Sequencing. Liver, kidney, lung, small intestine content and faeces were also strongly positive for the tusavirus DNA as well as 10 % of faecal samples of the flock collected 2 months after the initial lip sampling. NS1 and VP1 amino acid sequences of this tusavirus displayed 99.5 and 92.89 % identity to those of a human tusavirus, respectively. These amino acid identities were at 95.5 and 89.68 % when compared to those of a goat tusavirus. Phylogenetic analysis of the NS1 and VP1 also grouped the virus in the genus Protoparvovirus and close to tusaviruses detected in human, ovine and caprine species. Wider surveillance of the virus indicated a broader geographical distribution for the virus in England. Histology of the lip tissue revealed localised areas of epidermal hyperplasia and hyperkeratosis affecting haired skin, with mild leucocyte infiltration of the subjacent dermis, but no changes to implicate virus involvement. Flumine parvovirus was concluded to be an environment contaminant. Broader studies in prevalence of these virus in UK sheep flocks and human population, animal models and experimental infections could provide insights into the pathogenesis of these novel viruses and their zoonotic potential.

Early mobilisation is associated with lower subacute blood pressure and variability in ICH: A retrospective cohort study✰.

BACKGROUND: Very early rehabilitation after stroke appears to worsen outcome, particularly in intracerebral haemorrhage (ICH). Plausible mechanisms include increased mean blood pressure (BP) and BP variability. AIMS: To test associations between early mobilisation, subacute BP and survival, in observational data of ICH patients during routine clinical care. METHODS: We collected demographic, clinical and imaging data from 1372 consecutive spontaneous ICH patients admitted between 2 June 2013 and 28 September 2018. Time to first mobilisation (defined as walking, standing, or sitting out-of-bed) was extracted from electronic records. We evaluated associations between early mobilisation (within 24 h of onset) and both subacute BP and death by 30 days using multifactorial linear and logistic regression analyses respectively. RESULTS: Mobilisation at 24 h was not associated with increased odds of death by 30 days when adjusting for key prognostic factors (OR 0.4, 95% CI 0.2 to 1.1, p = 0.07). Mobilisation at 24 h was independently associated with both lower mean systolic BP (-4.5 mmHg, 95% CI -7.5 to -1.5 mmHg, p = 0.003) and lower diastolic BP variability (-1.3 mmHg, 95% CI -2.4 to -0.2 mg, p = 0.02) during the first 72 h after admission. CONCLUSIONS: Adjusted analysis in this observational dataset did not find an association between early mobilisation and death by 30 days. We found early mobilisation at 24 h to be independently associated with lower mean systolic BP and lower diastolic BP variability over 72 h. Further work is needed to establish mechanisms for the possible detrimental effect of early mobilisation in ICH.

Haemonchus contortus: an overview.

This focus article was prepared by Amanda Carson, Rudolf Reichel, Suzie Bell, Rachael Collins and Jasmine Smith of the APHA Small Ruminant Species Expert Group, and Dave Bartley from the Moredun Research Institute.

Surgical Performance of En Bloc Total Capsulectomy Breast Implant Removal With Uninterrupted Breastfeeding.

INTRODUCTION: A 28-year-old woman was able to maintain lactation for her 21-month-old child through the process of an En Bloc Total Capsulectomy Breast Implant Removal. This case study is important as it exemplifies collaborative care to achieve maintenance of lactation through a surgical procedure. MAIN ISSUE: The participant was providing human milk to her 21-month-old child 4 times per day through breastfeeding and pumping and bottle feeding, and desired to continue lactation through explant surgery. The participant was experiencing Breast Implant Illness, yellowing of the skin and whites of the eyes, bottoming out of the right implant, severe capsular contracture of the right implant causing constant pain, limited mobility of the right arm and shoulder, and concern about an active recall on the brand implant she received. MANAGEMENT: The lactation management began 3 weeks prior to the procedure with the participant expressing enough milk prior to the surgery to allow for human milk feeding from a bottle during the 7-day recovery period as desired. The surgical team and IBCLC selected an appropriate bra for recovery to allow for both appropriate surgical site healing and ease of access for pumping. Exclusive pumping was utilized until surgical drains were removed, after which the participant was able to reintroduce breastfeeding. CONCLUSION: En Bloc Total Capsulectomy Breast Implant Removal can be performed while an individual is lactating without complication, given the appropriate multidisciplinary support. A temporary reduction of ease and efficiency of milk removal is possible post-operatively, in this case resolving within 24 hr.

Outpatient Management of Epistaxis During COVID-19 to Reduce Inpatient Stay: A Quality Improvement Project.

Introduction In March 2020, new guidelines allowed patients with epistaxis to be discharged home with nasal packs in situ to reduce the risk of inpatient coronavirus disease 2019 (COVID-19) transmission rates. Our objective is to review how successful these new guidelines have been and whether they could be safely maintained in future practice. Methods This was a retrospective data analysis at a local tertiary ENT referral hospital. The study group consisted of patients admitted with epistaxis over one year. The "Pack and Home" criteria pathway was implemented. We reviewed this pathway six months pre- (loop 1) and six months post- (loop 2) introduction. Primary outcome measures included compliance with the "Pack and Home" criteria and length of inpatient admissions. Results A total of 131 patients required nasal packing, with 72 patients (55%) in loop 1 and 59 patients (45%) in loop 2. In loop 1, all 72 patients (100%) were admitted for inpatient care. However, in loop 2, 21 patients (36%) were discharged home with nasal packs in situ and 59 patients (64%) were admitted. Of those discharged, two patients were represented after 48 hours with rebleeding. The average total length of inpatient stay in loop 1 was significantly higher at 45.7 hours and 29.6 hours in loop 2 (p<0.05). All discharged patients attended their outpatient appointment in under three days. Conclusion The "Pack and Home" criteria can successfully identify patients who are suited for an outpatient management pathway. This could reduce surgical inpatient stay and the way we manage epistaxis.

A Case of Recurrent Isolated Uvula Oedema Secondary to Obesity and Obstructive Sleep Apnoea.

A 34-year-old male presented as an emergency with sudden onset globus, stertor and choking whilst asleep. He had similar previous episodes that self-resolved. The patient's observations were all within normal range. On examination, he had a grossly enlarged, non-erythematous uvula and there were no signs of respiratory distress or stridor. He was managed with intravenous dexamethasone and an attempt at needle aspiration of the uvula was made but there was no clinical improvement in the patient's condition. Despite no improvement with therapy, he was monitored overnight for any signs of airway compromise and discharged the following morning. His symptoms completely resolved on follow-up in the otolaryngology clinic a week later. He was diagnosed with Quincke's oedema caused by his obesity and background of obstructive sleep apnoea. We discuss the various aetiologies, assessment, and management of Quincke's oedema.

Research demographics of Australian medical radiation practitioners.

INTRODUCTION: Advancement within the Medical Radiation Profession has seen an increased need for Medical Radiation Practitioners (MRPs) to develop research skills to provide and access relevant and accurate information to maintain best practice. The aim of this study was to ascertain the current research demographics of Australian Medical Radiation Practitioners (MRPs), determine perceived barriers to participating in research and to establish needs-based initiatives to support MRPs in undertaking research. METHODS: A quantitative and qualitative cross-sectional survey of Australian MRPs using an electronic survey tool was distributed between November and December 2020. Participants were recruited via an invitation email sent to Australian Society of Medical Imaging and Radiation Therapy (ASMIRT) members. A chain-referral sampling technique was adopted for data collection. RESULTS: A total of 431 participants responded to the survey, representing 2.3% of Australian MRPs. The majority of respondents had a bachelor's degree or higher (71.9%) with 8.4% having postgraduate research qualifications (PhD- 3.2%; Professional Doctorate- 0.7%; Masters- 4.5%). Of the respondents, 15.4% plan to undertake postgraduate research in the future, with 68.2% having no plans for postgraduate research. Respondents identified lack of time (47.0%), lack of interest (33.4%), cost (24.2%) and workplace support (23.9%) as contributing factors for not undertaking postgraduate research. CONCLUSION: The number of MRPs who have been awarded or will be awarded a postgraduate degree has increased over recent decades. However, many still indicate a lack of interest in being actively involved in research. Targeted support mechanisms should be implemented to address perceived or real barriers to continue to grow research capacity within the profession.

Predicting selection-response gradients of heat tolerance in a widespread reef-building coral.

Ocean temperatures continue to rise owing to climate change, but it is unclear whether heat tolerance of marine organisms will keep pace with warming. Understanding how tolerance scales from individuals to species and quantifying adaptive potentials is essential to forecasting responses to warming. We reproductively crossed corals from a globally distributed species (Acropora tenuis) on the Great Barrier Reef (Australia) from three thermally distinct reefs to create 85 offspring lineages. Individuals were experimentally exposed to temperatures (27.5, 31 and 35.5°C) in adult and two critical early life stages (larval and settlement) to assess acquired heat tolerance via outcrossing of offspring phenotypes by comparing five physiological responses (photosynthetic yields, bleaching, necrosis, settlement and survival). Adaptive potentials and physiological reaction norms were calculated across three stages to integrate heat tolerance at different biological scales. Selective breeding improved larval survival to heat by 1.5-2.5× but did not result in substantial enhancement of settlement, although population crosses were significantly different. Under heat stress, adults were less variable compared with larval responses in warmer reefs than in the cooler reef. Adults and offspring also differed in their mean population responses, likely underpinned by heat stress imposing strong divergent selection on adults. These results have implications for downstream selection during reproduction, evidenced by variability in a conserved heat tolerance response across offspring lineages. These results inform our ability to forecast the impacts of climate change on wild populations of corals and will aid in developing novel conservation tools such as the assisted evolution of at-risk species.

Safety culture and incident learning systems in radiation oncology: Staff perceptions across Australia and New Zealand.

INTRODUCTION: Radiation therapy has a highly complex pathway and uses detailed quality assurance protocols and incident learning systems (ILSs) to mitigate risk; however, errors can still occur. The safety culture (SC) in a department influences its commitment and effectiveness in maintaining patient safety. METHODS: Perceptions of SC and knowledge and understanding of ILSs and their use were evaluated for radiation oncology staff across Australia and New Zealand (ANZ). A validated healthcare survey tool (the Hospital Survey on Patient Safety Culture) was used, with additional specialty-focussed supporting questions. A total of 220 radiation oncologists, radiation therapists and radiation oncology medical physicists participated. RESULTS: An overall positive SC was indicated, with strength in teamwork (83.7%), supervisor/manager/leader support (83.3%) and reporting events (77.1%). The weakest areas related to communication about error (63.9%), hospital-level management support (60.5%) and handovers and information exchange (58.0%). Barriers to ILS use included 'it takes too long' and that many respondents must use multiple reporting systems, including mandatory hospital-level systems. These are generally not optimal for specific radiation oncology needs. Varied understanding was indicated of what and when to report. CONCLUSION: The findings report the ANZ perspective on ILS and SC, highlighting weaknesses, barriers and areas for further investigation. Differences observed in some areas suggest that a unified state, national or bi-national ILS specific to radiation oncology might eliminate multiple reporting systems and reduce reporting time. It could also provide more consistent and robust approaches to incident reporting, information sharing and analysis.

Watery mouth disease in lambs.

This focus article has prepared by Rachael Collins and Amanda Carson of the APHA Small Ruminant Expert Group.

Evaluating incident learning systems and safety culture in two radiation oncology departments.

INTRODUCTION: Radiation oncology patient pathways are complex. This complexity creates risk and potential for error to occur. Comprehensive safety and quality management programmes have been developed alongside the use of incident learning systems (ILSs) to mitigate risks and errors reaching patients. Robust ILSs rely on the safety culture (SC) within a department. The aim of this study was to assess perceptions and understanding of SC and ILSs in two closely linked radiation oncology departments and to use the results to consider possible quality improvement (QI) of department ILSs and SC. METHODS: A survey to assess perceptions of SC and the currently used ILSs was distributed to radiation oncologists, radiation therapists and radiation oncology medical physicists in the two departments. The responses of 95 staff were evaluated (63% of staff). The findings were used to determine any areas for improvement in SC and local ILSs. RESULTS: Differences were shown between the professional cohorts. Barriers to current ILS use were indicated by 67% of respondents. Positive SC was shown in each area assessed: 69% indicated the departments practised a no-blame culture. Barriers identified in one department prompted a QI project to develop a new reporting system and process, improve departmental learning and modify the overall ILS. CONCLUSION: An understanding of SC and attitudes to ILSs has been established and used to improve ILS reporting, feedback on incidents, departmental learning and the QA program. This can be used for future comparisons as the systems develop.

The impact of radiation therapist-led structured peer review meetings on compliance to Radiation Oncology Practice Standards.

INTRODUCTION: Regular tumour-specific peer review meetings (TPRMs) were established by our group during 2016. A dedicated Quality Assurance Radiation Therapist (QART) was employed in 2018 to co-ordinate the meetings and for each patient, complete the Peer Review Audit Tool (PRAT) of the Royal Australian and New Zealand College of Radiologists (RANZCR). The aim of the current quality assurance study was to investigate the impact of the TPRMs and appointment of the QART on compliance to relevant RANZCR Radiation Oncology Practice Standards (ROPS). METHODS: Tumour-specific peer review meetings for eight tumour sites were assessed across our group's three hospitals from January 2017 to December 2019. Data from meetings were collected using the PRAT or from paper-based minutes and assessed against four ROPS (ROPS 3, 4, 8 and 9). Compliance with each of the four standards was measured by presence of the required documentation and presentation at TPRM, as recorded by the PRAT. RESULTS: There was an increase in the overall number of peer review cases audited from 173 in the 2017 calendar year to 469 in 2018 and 619 in 2019, representing 7%, 18% and 22% of all treatment courses started during these years, respectively. Staging was the most incompletely documented item across all years for audited patients. The request for radiation treatment plan modifications increased year-on-year: modifications were requested for 5% of plans in 2017 (8/172), 18% in 2018 (81/452) and 19% (119/619) in 2019. CONCLUSION: This study has shown that an increase in the number of cases for peer-review audit corresponded to the QART-facilitated TPRMs. Application of the PRAT has identified radiation treatment plan modifications that would otherwise go undetected and without opportunity to improve the quality of patients' treatment or avoid harm.

Paralysis from an ear infection: a severe case of otitis externa leading to acute complete cervical cord syndrome.

We report a case of a generally fit and well 54-year-old man who presented with a 2-day history of worsening left-sided otorrhea, headache, neck stiffness, vomiting and fever on the background of a 7-week history of otitis externa (OE). His condition progressed dramatically as he developed symptoms consistent with acute complete cervical cord syndrome with radiological evidence of skull base osteomyelitis, parapharyngeal, retropharyngeal and paravertebral abscesses and sigmoid sinus thrombus. Ultimately, he made a significant, although not complete, recovery. This case is unique in demonstrating how OE can develop into a potentially life threatening condition. It emphasises the importance of early diagnosis and treatment of OE, the recognition of 'red flag' symptoms and highlights the importance of a multidisciplinary team approach when managing complex complications of OE.

Identification of Mycoplasma species and related organisms from ruminants in England and Wales during 2005-2019.

BACKGROUND: Mycoplasma species have been associated with economically important diseases affecting ruminants worldwide and include contagious bovine pleuropneumonia (CBPP), contagious caprine pleuropneumonia (CCPP) and contagious agalactia, listed by the World Organisation for Animal Health (OIE). The Mycoplasma Team at the Animal and Plant Health Agency provides an identification service for Mycoplasma and Ureaplasma species of veterinary importance to the United Kingdom (UK), supporting the detection of new and emerging pathogens, as well as contributing to the surveillance of endemic, and the OIE listed diseases exotic to the UK. Mycoplasma and other Mollicutes species were identified from diagnostic samples from farmed ruminants in England and Wales using a combination of culture and 16S rRNA gene-based PCR-denaturing gradient gel electrophoresis, submitted between 2005 and 2019. RESULTS: A total of 5578 mollicutes identifications, which include mycoplasmas and the related acholeoplasmas and ureaplasmas, were made from farmed ruminant animals during the study period. Throughout the study period, the pathogen Mycoplasma bovis was consistently the most frequently identified species, accounting for 1411 (32%) of 4447 molecular identifications in cattle, primarily detected in the lungs of pneumonic calves, followed by joints and milk of cattle showing signs of arthritis and mastitis, respectively. M. bovirhinis, M. alkalescens, M. dispar, M. arginini and Ureaplasma diversum, were also common. Mixed species, principally M. bovis with M. alkalescens, M. arginini or M. bovirhinis were also prevalent, particularly from respiratory samples. The non-cultivable blood-borne haemoplasmas Candidatus 'Mycoplasma haemobos' and Mycoplasma wenyonii were identified from cattle, with the latter species most often associated with milk-drop. M. ovipneumoniae was the predominant species identified from sheep and goats experiencing respiratory disease, while M. conjunctivae preponderated in ocular samples. The UK remains free of the ruminant mycoplasmas listed by OIE. CONCLUSIONS: The continued high prevalence of M. bovis identifications confirms its ongoing dominance and importance as a significant pathogen of cattle in England and Wales, particularly in association with respiratory disease. M. ovipneumoniae has seen a general increase in prevalence in recent years, notably in coughing lambs and should therefore be considered as a primary differential diagnosis of respiratory disease in small ruminants.

APHA thin ewe investigation project.

This focus article has been prepared by Suzi Bell, Amanda Carson, Rachael Collins, Lizzy Dunnett, Rudolf Reichel and Moyna Richey of the APHA Small Ruminant Expert Group.

Adult nasal chondromesenchymal hamartoma: a rare and benign tumour with aggressive malignant transformation.

Nasal chondromesenchymal hamartoma (NCMH) is an extremely rare benign tumour of the nasal cavity predominantly described in infants. We report a case involving a 48-year-old woman who had been diagnosed with NCMH a year earlier and now re-presented with a short history of progressive nasal blockage, recurrent epistaxis and orbital apex syndrome. Histopathology was suggestive of malignant transformation into sinonasal sarcoma. However, following multidisciplinary team (MDT) discussions, including second and third opinions from external departments, the histological diagnosis was revised to 'NCMH with bizarre stromal cells'. Despite this, the lesion demonstrated malignant features of rapid, invasive growth and was treated with palliative radiotherapy. The patient later developed radiological evidence of lung and liver metastases with subsequent pulmonary emboli. Shortly after this, she passed away. This case is unique in its diagnostic challenge, with ambiguous histopathological findings, and highlights the importance of an MDT approach when managing complex sinonasal tumours.

Improving the Management of Post-Operative Hypocalcaemia in Thyroid Surgery.

Hypocalcaemia is a frequent, and potentially dangerous complication of total thyroidectomy occurring secondary to devascularisation of the parathyroid glands. This quality improvement (QI) project was undertaken in a large Ear, Nose and Throat (ENT) department in the East of England over a one year period. The project aimed to improve postoperative guideline compliance by optimising the recognition and management of patients at risk of hypocalcaemia. This process focussed on improving parathyroid hormone (PTH) and calcium blood testing, prophylactic calcium prescribing and the subsequent monitoring and management of hypocalcaemia. A baseline audit was conducted to determine the initial guideline compliance. The QI process subsequently involved the introduction of a new intraoperative PTH pathway and the amendment of trust guidelines. In addition, there was a focus on improving clinician awareness of guidelines, junior doctor education, communication between operating surgeons and junior doctors and the optimisation of patient handover. The project saw a significant improvement in the monitoring of hypocalcaemia (from 22.2% to 83.3% for patients with an intermediate risk of hypocalcaemia) and in the prescribing of prophylactic calcium supplements from 7.5% to 43.5%. The measurement of PTH at four hours improved from 42.5% to 52.2%. By optimising postoperative care, this QI project improved patient safety as well as impacting on the duration, and overall cost, of inpatient stay.

Radiation therapist-led telephone follow-up: identifying patients who require post-treatment care.

INTRODUCTION: Radiation therapists implemented telephone follow-up (TFU) in 2015 as an additional point of care post-treatment. The purpose of this study was to determine whether TFU identified patients who required additional post-treatment care before the next scheduled review. METHODS: Between January 2015 and July 2016, all patients who were prescribed curative intent treatment aged 18 years or over were called 10 days post-radiation therapy (RT). Eight questions were developed and included asking patients how they were coping, if their side effects were improving, if they needed to contact the hospital and if more dressings were required. Patients who could not be contacted after two attempts were excluded from the study. Microsoft Excel and Statistical Package for Social Sciences (SPSS) were used to analyse the responses. RESULTS: Data were collected from 850 patients. A total of 28/846 (3%) of patients reported they were not coping after RT, with 26/830 (3%) reporting their side effects were getting worse. A total of 97/826 (12%) of patients felt they needed to contact the hospital because they were unwell. This study identified 104/677 (15%) of patients who responded required more dressings, with 67/104 (65.7%) and 10/104 (9.8%) of this cohort identified in the breast, and head and neck groups, respectively. CONCLUSION: Radiation therapist-led TFU has shown to be beneficial in identifying a small cohort of breast and head and neck cancer patients who required additional care post-radiation treatment.