Dose-response relationships of intestinal organs and excessive mucus discharge after gynaecological radiotherapy

Background The study aims to determine possible dose-volume response relationships between the rectum, sigmoid colon and small intestine and the ‘excessive mucus discharge’ syndrome after pelvic radiotherapy for gynaecological cancer. Methods and materials From a larger cohort, 98 gynaecological cancer survivors were included in this study. These survivors, who were followed for 2 to 14 years, received external beam radiation therapy but not brachytherapy and not did not have stoma. Thirteen of the 98 developed excessive mucus discharge syndrome. Three self-assessed symptoms were weighted together to produce a score interpreted as ‘excessive mucus discharge’ syndrome based on the factor loadings from factor analysis. The dose-volume histograms (DVHs) for rectum, sigmoid colon, small intestine for each survivor were exported from the treatment planning systems. The dose-volume response relationships for excessive mucus discharge and each organ at risk were estimated by fitting the data to the Probit, RS, LKB and gEUD models. Results The small intestine was found to have steep dose-response curves, having estimated dose-response parameters: γ : 1.28, 1.23, 1.32, D : 61.6, 63.1, 60.2 for Probit, RS and LKB respectively. The sigmoid colon (AUC: 0.68) and the small intestine (AUC: 0.65) had the highest AUC values. For the small intestine, the DVHs for survivors with and without excessive mucus discharge were well separated for low to intermediate doses; this was not true for the sigmoid colon. Based on all results, we interpret the results for the small intestine to reflect a relevant link. Conclusion An association was found between the mean dose to the small intestine and the occurrence of ‘excessive mucus discharge’. When trying to reduce and even eliminate the incidence of ‘excessive mucus discharge’, it would be useful and important to separately delineate the small intestine and implement the dose-response estimations reported in the study

Antibiotic prescribing for respiratory tract complaints in Malta : a 1 year repeated cross-sectional surveillance study

Objectives: To determine the 1 year antibiotic prescribing patterns by GPs for acute respiratory tract complaints (aRTCs) in Malta. Methods: In this repeated cross-sectional surveillance study, GPs collected data for patients seen for aRTCs during a designated 1 week period each month, between May 2015 and April 2016. GPs received three text reminders during surveillance weeks and were contacted by phone at most four times during the year. GPs also received 3 monthly individual- and aggregate-level feedback reports on their antibiotic prescribing patterns. Descriptive statistics were used to examine patient, consultation and clinical characteristics, and to describe GPs’ prescribing patterns. Results: Participating GPs (n = 33) registered 4641 patients with an aRTC, of whom 2122 (45.7%) received an antibiotic prescription. The majority (99.6%) of antibiotics prescribed were broad-spectrum and the most commonly prescribed antibiotics were macrolides (35.5%), followed by penicillins with a β-lactamase inhibitor (33.2%) and second-generation cephalosporins (14.2%). Specifically, co-amoxiclav (33.2%), clarithromycin (19.6%), azithromycin (15.1%) and cefuroxime axetil (10.9%) represented 78.8% of all antibiotics prescribed. Patients with tonsillar exudate (99.1%), purulent sputum (84%), otorrhoea (78%), tender cervical nodes (74.4%) and fever (73.1%) received most antibiotics. The diagnoses that received the highest proportion of antibiotic treatment were tonsillitis (96.3%), otitis media (92.5%) and bronchitis (87.5%). Wide variation in the choice of antibiotic class by diagnosis was observed. Conclusions: GP antibiotic prescribing in Malta is high. The abundant use of broad-spectrum antibiotics, particularly macrolides, is of particular concern and indicates that antibiotics are being used inappropriately. Efforts must be made to improve GP awareness of appropriate antibiotic prescribing.peer-reviewe

Factors associated with antibiotic prescribing in patients with acute respiratory tract complaints in Malta : a 1-year repeated cross-sectional surveillance study

Objective: To identify factors that influence general practitioners’ (GPs’) oral antibiotic prescribing for acute respiratory tract complaints (aRTCs) in Malta. Design: Repeated, cross-sectional surveillance. Setting: Maltese general practice; both public health centres and private GP clinics. Participants: 30 GPs registered on the Malta Medical Council’s Specialist Register and 3 GP trainees registered data of 4831 patients of all ages suffering from any aRTC. Data were collected monthly between May 2015 and April 2016 during predetermined 1-week periods. Outcome measures: The outcome of interest was antibiotic prescription (yes/no), defined as an oral antibiotic prescription issued for an aRTC during an in-person consultation, irrespective of the number of antibiotics given. The association between GP, practice and consultation-level factors, patient sociodemographic factors and patient health status factors, and antibiotic prescription was investigated. Results: The antibiotic prescription rate was 45.0%. Independent factors positively associated with antibiotic prescribing included female GP sex (OR 2.3, 95% CI 1.22 to 4.26), GP age with GPs ≥60 being the most likely (OR 34.7, 95% CI 14.14 to 84.98), patient age with patients ≥65 being the most likely (OR 2.3, 95% CI 1.71 to 3.18), number of signs and/or symptoms with patients having ≥4 being the most likely (OR 9.6, 95% CI 5.78 to 15.99), fever (OR 2.6, 95% CI 2.08 to 3.26), productive cough (OR 1.3, 95% CI 1.03 to 1.61), otalgia (OR 1.3, 95% CI 1.01 to 1.76), tender cervical nodes (OR 2.2, 95% CI 1.57 to 3.05), regular clients (OR 1.3, 95% CI 1.05 to 1.66), antibiotic requests (OR 4.8, 95% CI 2.52 to 8.99) and smoking (OR 1.4, 95% CI 1.13 to 1.71). Conversely, patients with non-productive cough (OR 0.3, 95% CI 0.26 to 0.41), sore throat (OR 0.6, 95% CI 0.53 to 0.78), rhinorrhoea (OR 0.3, 95% CI 0.23 to 0.36) or dyspnoea (OR 0.6, 95% CI 0.41 to 0.83) were less likely to receive an antibiotic prescription. Conclusion: Antibiotic prescribing for aRTCs was high and influenced by a number of factors. Potentially inappropriate prescribing in primary care can be addressed through multifaceted interventions addressing modifiable factors associated with prescription.peer-reviewe

Late symptoms in long-term gynaecological cancer survivors after radiation therapy: a population-based cohort study.

BACKGROUND: We surveyed the occurrence of physical symptoms among long-term gynaecological cancer survivors after pelvic radiation therapy, and compared with population-based control women. METHODS: We identified a cohort of 789 eligible gynaecological cancer survivors treated with pelvic radiation therapy alone or combined with surgery in Stockholm or Gothenburg, Sweden. A control group of 478 women was randomly sampled from the Swedish Population Registry. Data were collected through a study-specific validated postal questionnaire with 351 questions concerning gastrointestinal and urinary tract function, lymph oedema, pelvic bones and sexuality. Clinical characteristics and treatment details were retrieved from medical records. RESULTS: Participation rate was 78% for gynaecological cancer survivors and 72% for control women. Median follow-up time after treatment was 74 months. Cancer survivors reported a higher occurrence of symptoms from all organs studied. The highest age-adjusted relative risk (RR) was found for emptying of all stools into clothing without forewarning (RR 12.7), defaecation urgency (RR 5.7), difficulty feeling the need to empty the bladder (RR 2.8), protracted genital pain (RR 5.0), pubic pain when walking indoors (RR 4.9) and erysipelas on abdomen or legs at least once during the past 6 months (RR 3.6). Survivors treated with radiation therapy alone showed in general higher rates of symptoms. CONCLUSION: Gynaecological cancer survivors previously treated with pelvic radiation report a higher occurrence of symptoms from the urinary and gastrointestinal tract as well as lymph oedema, sexual dysfunction and pelvic pain compared with non-irradiated control women. Health-care providers need to actively ask patients about specific symptoms in order to provide proper diagnostic investigations and management

A qualitative national focus group study of the experience of living with lymphoedema and accessing local multiprofessional lymphoedema clinics

Aim. The aim of this study was to explore people’s experiences of living withlymphoedema and to assess the impact of access to local lymphoedema clinics ontheir condition and thus their lives.Background. A chronic condition caused by reduced lymphatic function,lymphoedema leads to swelling, pain and mobility problems and can adverselyaffect quality-of-life. It is of international concern as its prevalence is rising. Yetlymphoedema awareness is limited, diagnostic delay common and access tospecialist treatment restricted. The concept of local lymphoedema clinics isgaining support and in 2011 the All Wales Lymphoedema Service was founded.However, empirical investigation of local lymphoedema services remains limited.Design. A qualitative exploratory study consisting of focus group interviews inevery Welsh lymphoedema clinic (n=8).Methods. A convenience sample of adults living with lymphoedema in Wales wasrecruited. Data were collected in digitally recorded focus groups during July andAugust 2013. Interviews were fully transcribed and analysed using a qualitativecontent approach.Findings. Fifty-nine people participated in eight focus groups. Analysis revealedthree themes: Living with lymphoedema is a battle; delays in obtaining a correctdiagnosis and the positive impact of lymphoedema clinics on participants’ lives.Locally accessible clinics made meaningful differences to peoples’ lymphoedema,engendered positive outcomes and improved engagement with and adherence tolymphoedema self-management.Conclusions. Local specialist lymphoedema clinics can make a positive difference.They may be cost-effective and further investigation, including economicevaluation is necessary

Self-reported fecal incontinence and quality of life among gynecological cancer survivors

Gastrointestinal symptoms following pelvic radiotherapy are common; however, selfreported descriptions of gastrointestinal symptoms and their impact on daily life among gynecological cancer survivors are rare in the literature. The aim of this thesis was to investigate the prevalence of long-lasting gastrointestinal symptoms after pelvic radiotherapy among gynecological cancer survivors and to explore its impact on quality of life. In addition, we wanted to study the perception of being part of a study encompassing an extensive study-specific questionnaire. We identified 789 eligible women in the Stockholm and Gothenburg areas, treated with pelvic radiotherapy during the period 1991–2003, alone or as part of combined treatment, for gynecological cancer. As controls, we randomly recruited 478 women, frequencymatched by age and residence from the Swedish Population Registry. We collected data in 2006 by means of a study-specific, validated, postal questionnaire including 351 questions covering symptoms from the pelvic region. We asked about demographics, psychological and quality of life issues as well as social functioning. Participation rate was 78 percent for cancer survivors and 72 percent for controls. To obtain links between long-lasting symptoms and quality of life, we provided detailed characteristics of the gynecological cancer survivors. The mean age was 64.4 years (range 28 to79 years) and the average follow-up period after completion of radiotherapy was 86.1 months (range 30 to 183 months). The most common diagnosis was endometrial cancer (59 percent) followed by cervical cancer (23 percent). Treatment included surgery in 90 percent of the survivors. In 26 of 32 self-reported gastrointestinal symptoms we found a statistically significant increased age-adjusted relative risk (RR) for the cancer survivors, when compared to control women. The greatest age-adjusted absolute risk difference between cancer survivors and control women was observed for the symptom “defecation urgency with fecal leakage” with a prevalence of 49 percent among cancer survivors and 12 percent among controls. The highest age-adjusted RR 11.9 (95% CI: 3.8–37.8), was for the symptom “emptying of all stools into clothing without forewarning”. The symptom “emptying of all stools into clothing without forewarning” was reported by 70 cancer survivors (12 percent), with lowered quality of life in 74 percent of the 70 cancer survivors. This symptom kept the survivors from going to parties (RR 11.8; 95% CI 6.6-21.1), travelling (RR 9.3; 95% CI 5.3-16.5), affected work ability (RR 7.9; 95% CI 3.8-16.4), hindered their sexual life (RR 9.2; 95% CI 4.8-17.6), and changed them as persons (RR 4.9; 95% CI 2.9-8.1). To assess the perception of participation in a study-specific questionnaire survey we also included a cohort of 491 cystectomized urinary bladder cancer survivors. Among the total cohort (N=1068), 95 percent reported that the study was valuable and 54 percent felt they had been positively affected by their participation. This thesis shows quality of life would drastically improve if gynecological cancer survivors could get rid of their gastrointestinal symptoms. For future survivors, we can learn about threshold dose of ionizing radiation with relevant risk-organs, to avoid inducing the gastrointestinal symptoms. For today´s survivors, we can learn to designeffective interventions

Patient safety in connection with the use of a standardized communication tool in shift handover

Bakgrund Inom hälso- och sjukvården är en bra och fungerande kommunikation mellan medarbetarn aen av de viktigaste förutsättningarna för god och säker vård, då bristande kommunikation är en av de främsta orsakerna till vårdskada. Genom att tillämpa kommunikationsverktyget Situation, Bakgrund, Aktuellt tillstånd och Rekommendation [SBAR] kan kommunikationen effektiviseras och patientsäkerheten kan öka enligt flera studier. SBARär en lättanvänd och konkret modell som är användbar vid överrapportering och ger vårdgivare en möjlighet att enkelt sammanfatta viktig patientinformation. Syfte Syftet med denna studie var att utifrån ett patientsäkerhetsperspektiv beskriva sjuksköterskans följsamhet av kommunikationsverktyget SBAR vid muntlig överrapportering på en akutmottagning. Metod Metoden som användes var en direkt, strukturerad, icke-deltagande observationsstudie.Studien ägde rum på en akutmottagning där totalt 28 observationer av muntlig överrapportering genomfördes. Ett observationsprotokoll utformat utifrån akutmottagningens modifierade SBAR-modell användes under observationerna. Resultat Vid de observerade överrapporteringarna rapporterades i genomsnitt 5,2 kategorier utav observationsprotokollets 30 möjliga under samma överrapportering. Resultatet visade att patientens namn, sökorsak och symtom rapporterades i de flesta fallen. Vidare nämndes tidigare sjukdomar och prover eller provsvar i knappt hälften av fallen. Ett fåtal rapportörer tog upp patientens vitalparametrar och endast en återkoppling på informationen given under överrapporteringen observerades. Varken behandlingsinskränkning,upplysningsskydd, eventuella allergier eller smittorisker nämndes vid någon avobservationerna. Slutsats Följsamheten av kommunikationsverktyget SBAR vid muntlig överrapportering på den aktuella akutmottagningen vid observationstillfällena visade sig vara bristfällig.Patientsäkerheten kan äventyras då viktig information, såsom eventuella allergier,utelämnas

Evaluating alternative refrigerants for the room air conditioner market

This study aimed to facilitate evaluation of alternative refrigerants for the air conditioner market. In order to achieve this target, two objectives were set. The first being the identification of alternative refrigerant with regard to regulations and trends. The second being enabling of thermodynamic evaluation of refrigerants for single components in air conditioners via design and installation of a test rig. A literature review was conducted to investigate the regulations, standards and trends for nine regions with high market shares. Furthermore, refrigerant substitutes for R410A and R22 where identified. The literature showed strong indications that a global HFC phase down is on the horizon, but that the approach and urge for such a phase down varies between regions where three main priorities could be seen; efficiency, GWP values and safety. Comparing these priorities with simulated refrigerant characteristics such as Carnot efficiency, GWP values, volumetric capacity and the liquid density using RefProp, identified alternatives. Further the literature showed that the lower flammability limit (LFL) and the amount of charge allowed were limiting factors for flammable refrigerant. There are many new refrigerants that could have less charge for the same capacity the LFL however restricts the refrigerants like R290, R441A and R443A only to be used in small systems. A test rig was designed and constructed in order to enable testing of single components in air conditioners. To verify the test rig, tests conducted with an evaporator using two refrigerants: R410A and R32. The reliability and validity of the tests was studied by comparing the results from the air side and refrigerant side, via uncertainty calculations using the GUM method and by a thermodynamic evaluation. The results of the repetition tests showed an expanded uncertainty, with a confidence interval of 95%, of 26 W for a cooling capacity of 2190W for R410A (Q̇evap,R410A=2190±26W). For R32 the expanded uncertainty was 27W for a cooling capacity of 2795W (Q̇evap,R32=2795±27W). Also the test rig was verified to be used for analyzing detailed evaluation of evaporators such as looking at heat transfer and the differential pressure drop. Further the study presented six conclusions: When evaluating refrigerants regional priorities between efficiency, safety and GWP values, refrigerant characteristics and type of unit need to be considered. Safety standards need to be more acceptable towards flammable refrigerants in order to meet low GWP targets. The change in market trends leads to new roles for the refrigerant and compressor suppliers and put higher demand on air conditioner manufacturers to consider refrigerant characteristics in product development. The importance of experimental thermodynamic evaluation on refrigerants effect on single components is increasing. Performance of different refrigerant for single components can be evaluated for optimizing cycle performance. Leapfrogging in the developing world can lead to a faster introduction of low GWP refrigerants.

OTEC for Tarawa

Ocean Thermal Energy Conversion, OTEC, a technology using the temperature difference between cold deep seawater and warm surface water, can extract the work in the form of electricity. OTEC gives also synergies of drinkable fresh water. The temperature difference has an impact on the efficiency of the technology, which means that the feasibility of OTEC is geographically limited.   The project intends to explore the possibility of replacing the atoll Tarawa’s present electricity generation with an OTEC plant and to explore synergies. In the present situation all of Tarawa’s electricity is generated by fossil fuels. Tarawa is located at the equator in the Pacific Ocean and has geographical as well climatically conditions for the installation of an OTEC facility.   There are three different types of systems: open, closed and hybrid. Through mathematical models, based on a literature study, the systems are modeled with the program EES (Engineering Equation Solver). After evaluation a system is proposed, which is considered to meet Tarawas needs, mainly of electricity and fresh water standpoint. The hybrid system was considered to be the system that met the needs after calculations had been made. The hybrid cycle is effective in electricity generation and has the most important synergy effect of freshwater production. The results show that it is possible to cover both Tarawa’s present need of electricity and fresh water, according to the UN's recommendations. Electricity costs have been calculated and the results show that an OTEC facility is a cost effective option when the price of oil does not fall below 35 U.S.$/Barrel. An OTEC facility has the opportunity to raise living standards as the supply of fresh water is deficient in Tarawa.   Very limited amounts of carbon dioxide is released into the atmosphere during production, which means that the environmental benefits are huge compared to today's production by fossil fuels, the largest single source of carbon emissions. Since there are no commercial facilities at the present, additional studies and trials are needed before the technology becomes realizable.Ocean Thermal Energy Conversion, OTEC, är en teknik som genom att utnyttja temperaturdifferensen mellan kallt djuphavsvatten och varmt ytvatten kan utvinna arbete i form av elektricitet. OTEC har även synergieffekter som drickbart färskvatten. Då temperaturdifferensen har inverkan på effektiviteten är användningsområdet för OTEC geografiskt begränsat.   Projektet avser att undersöka möjligheterna att ersätta atollen Tarawas nuvarande elproduktion med en OTEC-anläggning samt att utreda synergier. I dagsläget sker all Tarawas elproduktion med fossila bränslen. Tarawa är beläget vid ekvatorn mitt i Stilla havet och har geografiska förutsättningar för en installation av en OTEC-anläggning.   Det finns tre olika system: öppet-, slutet- och hybrid. Genom matematiska modeller, baserade på en litteraturstudie, modelleras systemen i programmet EES (Engineering Equation Solver). Efter evaluering föreslås det system som anses uppfylla Tarawas behov, främst ur el- och färskvattensynpunkt. Hybridsystemet anses vara det system som uppfyller behoven efter beräkningar. Hybridcykeln är effektiv i elproduktionen samt har de viktiga synergieffekterna som färskvattenproduktion. Resultaten visar på att det är möjligt att täcka både Tarawas nuvarande elbehov samt färskvattenbehov, enligt FN’s rekommendationer. Elkostnaderna beräknas och resultatet visar att en OTEC-anläggning är ett kostnadseffektivt alternativ då priset på olja inte understiger 35 US$/Fat. En OTEC-anläggning har möjlighet att höja levnadsstandarden på platser där tillgången på färskvatten är bristfällig.   Då endast begränsande mängder koldioxid släpps ut i atmosfären vid elproduktion är miljövinsterna stora jämfört med dagens förbränning av fossila bränslen, som är den enskilt största källan till koldioxidutsläpp.   Det finns inte några kommersiella anläggningar i dagsläget behövs ytterligare studier och försök innan tekniken blir realiserbar