Role of the Neuroradiologist and Neurosurgeon in Contouring with the Clinical Oncologist for Stereotactic Radiosurgery.

AIM: To evaluate the value of a multidisciplinary team (MDT), including a neuroradiologist and a neurosurgeon, review of contouring in stereotactic radiosurgery (SRS). MATERIALS AND METHODS: A sequential audit of all patients receiving intracranial SRS at local institution was conducted. Lesions were contoured first by a clinical oncologist, then reviewed/edited by the MDT. The initial contour was compared with the final contour using Jaccard conformity (JCI) and geographical miss indices (GMI). The dosimetric impact of a contouring change was assessed using plan metrics to both original and final contours. RESULTS: In total, 113 patients and 142 lesions treated over 22 months were identified. The mean JCI was 0.92 (0.32-1.00) and 38% needed significant editing (JCI <0.95). The mean GMI was 0.03 (0.0-0.65) and 17% showed significant miss (GMI >0.05). Resection cavities showed more changes, with lower JCI and higher GMI (P < 0.05). There was no significant improvement on JCI or GMI shown over time. The dosimetric analysis indicated a strong association of conformity metrics with planning target volume dose metrics; a 0.1 change in gross tumour volume conformity metric association with a 6-17% change in dose to 95% of the resulting planning target volume. Greater association was seen in the resection cavity, suggesting the geographical nature of a typical contouring error gives rise to greater potential change in dose. Clinical outcomes compared well with published series. The median survival was 20 months; the local relapse-free rate in the treated areas was 0.89 (0.8-0.94) at 40 months; the radionecrosis-free rate at 40 months was 0.9 (0.83-0.95) with a median of 17 months to developing radionecrosis. CONCLUSIONS: This work highlights that MDT contour review adds significant value to SRS and the approach translates into reduced local recurrence rates at the local institution compared with previously published data. No improvement in clinical oncologist contouring over time was shown, indicating that a collaborative approach is needed regardless of the experience of the clinical oncologist. MDT input is recommended in particular for contouring of resection cavities.

1st metatarso-phalangeal joint arthroplasty with ROTO-glide implant.

BACKGROUND: Total joint replacement of the 1st metatarso-phalangeal Joint (MTPJ) has been controversial as arthrodesis remains a good option for patients with end stage 1st MTPJ arthritis. We present a multi centre service evaluation of the ROTO-glide device METHODS: 33 ROTO-glide procedures were carried out in 30 patients across 7 sites within the UK. Exclusion criteria - hallux valgus and arthritis, age below 45 years and over 80 years, inflammatory joint disease. Patient assessed pre and post operatively with AOFAS and Oxford forefoot (MOXFQ) scores and plain radiographs. All patients carried out the same post operative protocol RESULTS: Average age at patients was 58.6 years (45-77). Follow up average was 16.9 months (12-29). Pre-op AOFAS scores average 41.4 (17-67) and post op average 76 (29-100) and the MOXFQ summary index decreased from an average of 43 (20-64) pre op to an average of 17 (0-51) post op. Average total range of motion pre operatively was 32° and post operatively was 61°. There were 2 post operative complications but no revisions were necessary. CONCLUSIONS: The early results of this multi centre service evaluation of the ROTO-glide 1st MTPJ replacement support its continued use and evaluation of the prosthesis further.

A treatment algorithm for mass heat casualties.

Although thankfully rare,heat related illness has significant implications for the effective fighting force available to commanders. This is especially pertinent in the current theatres of operations, as previously soldiers have not routinely been subjected to the rigors of operating in hot climates. In addition to Iraq and Afghanistan, various training exercises are undertaken throughout the world where extreme temperatures may be encountered. Individual medical officers may be faced with heat casualties remote from all but the most basic facilities or the number of heat casualties may overwhelm limited resources. We present a simple treatment algorithm that has been used successfully in the treatment of mass heat casualties.

Reproductive health needs: comparing women at high, drug-related risk of HIV with a national sample.

Women who inject drugs or have injection drug-using sex partners are at high risk of acquiring human immunodeficiency virus (HIV) infection and of transmitting HIV perinatally. Many of these women need standard reproductive health care services, specialized HIV care, pre- and postnatal care, and drug treatment, but the extent of the unmet need for such health services is unknown. Large-scale national surveys that estimate drug use do not include reproductive health topics and vice versa. In addition, such surveys typically employ a household sampling method that tends not to include drug-using women. This paper presents evidence from three convenience samples that a high-risk population of women who use drugs has limited access to reproductive health services, and that this population is not represented in the National Survey of Family Growth (NSFG), the national survey that informs public policy regarding reproductive health care in the United States. Policy makers would be well served by regular surveillance of the multiple service needs of women with HIV-risk-related behaviors.

The Women and Infants Demonstration Project: an integrated approach to AIDS prevention and research.

The Women and Infants Demonstration Project is a multisite, behavioral intervention research effort funded by the Centers for Disease Control. The project is evaluating a theory-based, integrated intervention model to increase the use of condoms for prevention of both sexually transmitted diseases (STDs) and unintended pregnancy among women and their partners at risk of infection with HIV. The importance of utilizing carefully targeted, credible and persistent risk reduction interventions to effect lasting behavior change has become evident over the last ten years of the AIDS epidemic. The theory-based intervention components being evaluated in this intervention study involve one-on-one stage-tailored outreach; the development and distribution of community-tailored HIV prevention materials, called role-model stories; and the development of organizational and peer networking, all within a community mobilization framework. This article describes each of the intervention components being evaluated during this 5-year study. Such an intervention effort represents an important contribution in the design of community-level AIDS prevention intervention efforts which support individual-level behavioral changes by women at risk for HIV and other sexually transmitted infections.

PIP: The Women and Infants Demonstration Project is a multi-site, behavioral intervention research effort currently being funded by the US Centers for Disease Control. The project is evaluating a theory-based, integrated intervention model to increase condom use for the prevention of sexually transmitted diseases (STD) and unintended pregnancy among women and their partners at risk of infection with HIV. The theory-based intervention components being evaluated in the study involve one-on-one stage-tailored outreach; the development and distribution of community-tailored HIV prevention materials, known as role model stories; and the development of organizational and peer networking, all within a community mobilization framework. Each of the intervention components being evaluated is described.

Weight gain prevention and smoking cessation: cautionary findings.

OBJECTIVES: Weight gain is a consistent sequela of smoking cessation. A successful intervention might attract smokers who fear weight gain. If the gain causes smoking relapse, such an intervention might reduce smoking relapse risk. METHODS: Using a sample of 158 smokers who completed a 2-week smoking treatment program, we compared an innovative weight gain prevention intervention with both a nonspecific treatment and standard treatment. Subjects were assessed on weight and smoking behavior and followed for 1 year. RESULTS: A disturbing, unexpected finding was that subjects in both the innovative and nonspecific conditions had a higher risk of smoking relapse than did standard treatment subjects. Some differences were observed between abstinent and smoking subjects in weight gain by treatment condition. CONCLUSIONS: Both active interventions may have been so complicated that they detracted from nonsmoking. Also, caloric restriction may increase the reinforcing value of nicotine, a psychoactive drug, thereby increasing smoking relapse risk. The magnitude of weight gain after smoking cessation may not merit interventions that increase smoking risk. Perhaps attitudinal modifications are the most appropriate.

Changes in food intake and activity after quitting smoking.

Quitting smoking often results in weight gain. The causes of the gain are not known. The present study evaluated changes in calories, total sugars, sucrose, fat, protein, and nonsugar carbohydrates as well as changes in activity levels after quitting smoking. Ninety-five subjects were randomly assigned to either early (Week 2) or late (Week 6) quit dates. Subjects were assessed on weight, food intake, activity levels, and smoking levels at baseline, at Weeks 4 and 8, and at Weeks 12 and 26 postquit. The results indicated significant increases in calories, sucrose, and fats 2 weeks after the quit date. Changes for total sugars were less consistent. Activity levels did not change significantly. Early caloric increases predicted weight gain at 26 weeks for abstinent women. No relation was found for abstinent men, but interpretation of this finding is weakened by a small subsample size. Abstinent subjects gained over 9 lb by 26 weeks postquit. Despite this gain, Week 26 results showed that caloric intake for abstinent women was approximately equal to that observed at baseline, whereas that for abstinent men had dropped significantly.

Quitting smoking.

Four factors which influence smoking treatment outcome are identified: environmental variables, client characteristics, process variables, and specific treatment approaches. Important environmental factors are stress and social support. Of client characteristics, sex is the best predictor of treatment success. Men are more likely to quit and maintain abstinence than women. However, the majority of women alter their smoking habits during pregnancy. Low-income persons and ethnic minorities are underrepresented among subjects in treatment studies and have larger percentages of smokers in the population at large. Extraverted smokers are more likely to begin to smoke and have difficulty quitting. Also, the more anxious, poorly adjusted smoker has more trouble quitting than the less troubled smoker. The higher the client's sense of self-efficacy, the better the chance of that person entering treatment and doing well. Furthermore, smokers who take in lower levels of nicotine are more successful at quitting. Many process questions are suggested. Few have been approached empirically. The effectiveness of ex-smokers as therapists in smoking cessation programs has not been systematically investigated, even though the smoking history of therapists is a question frequently asked by clients. We suggest that the skill and empathy of group leaders is more important than smoking history. Smoking therapists should be aware of nonspecific treatment factors such as positive expectations, social reinforcement, and self-disclosure which may have a powerful influence on the efficacy of smoking treatment. Specific treatment approaches were classified into three categories: low-contact approaches, including educational, self-help, and minimal treatment approaches; psychological treatments; and pharmacological treatment. Education, self-help, and minimal treatment approaches are thought to be accretively effective when the large size of the audience is considered. Also, innovative treatments which address the influence of social support systems and physiological addition are promising treatments for individuals requiring a structured or intensive method of quitting.

Prevention of murine rotavirus infection with chicken egg yolk immunoglobulins.

Passive protection of infant mice against murine rotavirus was achieved with use of immunoglobulins from the eggs of chickens. Immunoglobulins were obtained by vaccinating hens with simian rotavirus, collecting the eggs after a high level of immunoglobulins was reached in the hen's serum, and isolating the water-soluble fraction from these eggs. The water-soluble fraction was then given twice daily to three-day-old mice to protect them from infection with murine rotavirus. The protection was found to decrease the infection rate from 90% to 15% with use of a standard dose of virus.