A quality assurance technique for the static multileaf collimator mode based on intrinsic base lines

AbstractThe inspection of the static leaf positions of Multileaf Collimator (MLC) devices is essential for safe radiotherapy deliveries in both static and dynamic modes. The purpose of this study was to develop a robust, accurate and generic algorithm to measure the individual static MLC leaf positions. This was performed by extracting leaf tip locations from the radiographic film image and measuring their relative distance from a reference line on the film. The reference line was created with a selected set of MLC leaf sides. The film scaling was created and verified using the physical leaf width. The average measured distance corresponds to a leaf width of 10 mm was 9.95 ± 0.09 mm. The estimated reproducibility of the leaf tips location was ±0.26 mm. The code accuracy was checked by intentionally positioning set of leaves with small errors (1 mm), and the detected deviations from the expected positions ranged from −0.25 mm and +0.32 mm. The algorithm includes two self testing functions in order to detect failures of leaf positioning due to poor film quality and to avoid the potential systematic errors attributable to the improper collimator setting. The code is promising to be more efficient with Gafchromic and Electronic Portal Imaging Device (EPID)

Serum OX40 ligand: a potential marker of atopic dermatitis disease severity in children

Background: OX40 ligand (OX40L) and OX40 are members of the tumor necrosis factor (TNF) and TNF receptor (TNFR) super families respectively. Recent studies have indicated the critical involvement of OX40/OX40L interaction in the pathogenesis of atopic dermatitis. To our knowledge, no data could be cited in literature concerning OX40L levels in serum or in other biological fluids of atopic dermatitis children. Objective: This study was done to explore the expression of OX40L in the serum of atopic dermatitis children with respect to disease activity and severity. Methods: This follow-up, case-control longitudinal study was conducted on 64 children as a stratified non-random sample; 34 with atopic dermatitis and 30 healthy children. Serum concentrations of OX40L were measured by sandwich enzyme immunoassay. The severity of atopic dermatitis was assessed according to the Leicester Sign Score (LSS), Simple Scoring System (SSS), Scoring Atopic Dermatitis (SCORAD) index, and Objective SCORAD. Results: Serum OX40L levels (pg/ml) in atopic dermatitis patients were significantly elevated as compared to controls (176.6 ± 45.9) whether during flare (1007 ± 241.5) or quiescence (699 ± 198.5). There were significant positive correlations between serum OX40L levels and each of the LSS, SSS and SCORAD indices of atopic dermatitis disease severity, while it was insignificant regarding the objective SCORAD. However, when atopic dermatitis children were classified according to the objective SCORAD index of severity into mild, moderate and severe, it was found that the mean serum level in the severe group was significantly higher than the corresponding values of the mild or the moderate group. OX40L levels did not correlate with serum total IgE or absolute eosinophils count. Serum total LDH levels correlated positively with each of the serum OX40L levels and the LSS and SCORAD indices of severity. Conclusions: Serum OX40L level is an objective reliable marker of atopic dermatitis severity in children. It may be useful for follow up and may help to improve research and management of this disease. Blockade of interactions between OX40 on Th2 cells and OX40L on activated dendritic cells using an OX40L-specific monoclonal antibody could represent a novel strategy for the treatment of atopic dermatitis.Keywords: Atopic dermatitis, LSS, OX40, OX40L, SCORAD, SSS, TNFEgypt J Pediatr Allergy Immunol 2009;7(1):15-2

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10&nbsp;years; 78.2% included were male with a median age of 37&nbsp;years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

The diagnostic value of diffusion-weighted magnetic resonance imaging in characterization of musculoskeletal soft tissue tumors

Purpose: To assess the utility of diffusion-weighted (DW) images and magnetic resonance imaging (MRI) in the detection and characterization of musculoskeletal soft tissue tumours (STTs) and in the determination of whether these tumours are benign or malignant. Patients and methods: A prospective study was performed between March 2016 and March 2017 that included all patients referred to the radio-diagnosis department for evaluation of musculoskeletal STTs. Contrast-enhanced MRI and DW images were performed for all included patients, and diagnoses were confirmed by biopsy and histopathological examination. Results: The apparent diffusion coefficient (ADC) of benign STTs was significantly higher than that of malignant (mean ± SD, −1.43 ± 0.56 × 10−3 mm2/s versus 0.74 ± 0.18 × 10−3 mm2/s, respectively (P < 0.001), ADC cut off value ≤1.10 × 10−3 mm2/s with a sensitivity of 83.3%, specificity of 72.7%, and PPV and NPP of 80%; the area under the receiver operating characteristic curve was = 0.892 (SE = 0.084, 95% CI (P < 0.001) and the Youden's index was calculated 58.4. Conclusion: To date, MRI has been considered the method of choice for the characterization of musculoskeletal STTs; however, DW-MRI with ADC mapping is a rapidly, valuable, non-invasive, non-contrast tool for reliably differentiating between benign and malignant STTs

HIV Knowledge and Stigmatizing Attitude towards People Living with HIV/AIDS among Medical Students in Jordan

The stigmatizing attitude towards people living with HIV/AIDS (PLWHA) can be a major barrier to effective patient care. As future physicians, medical students represent a core group that should be targeted with focused knowledge and adequate training to provide patient care without prejudice. The aim of the current study was to examine HIV/AIDS knowledge, and the stigmatizing attitude towards PLWHA, among medical students in Jordan. The current study was based on a self-administered online questionnaire, which was distributed during March–May 2021, involving students at the six medical schools in Jordan, with items assessing demographics, HIV/AIDS knowledge, and HIV/AIDS stigmatizing attitude, which was evaluated using the validated HIVstigma scale. The total number of respondents was 1362, with predominance of females (n = 780, 57.3%). Lack of HIV/AIDS knowledge among the study participants was notable for the following items: HIV transmission through breastfeeding (40.8% correct responses), HIV is not transmitted through saliva (42.6% correct responses), and vertical transmission of HIV can be prevented (48.8% correct responses). Approximately two-thirds of the respondents displayed a positive attitude towards PLWHA. For six out of the 14 HIV/AIDS knowledge items, lack of knowledge was significantly correlated with a more negative attitude towards PLWHA. Multinomial regression analysis showed that a significantly more negative attitude towards PLWHA was found among the preclinical students compared to the clinical students (odds ratio (OR): 0.65, 95% confidence interval (CI): 0.43–0.97, p = 0.036); and that affiliation to medical schools that were founded before 2000 was associated with a more positive attitude towards PLWHA compared to affiliation to recently founded medical schools in the country (OR: 1.85, 95% CI: 1.42–2.42, p < 0.001). About one-third of medical students who participated in the study displayed a negative attitude towards PLWHA. Defects in HIV/AIDS knowledge were detected for aspects involving HIV transmission and prevention, and such defects were correlated with a more negative attitude towards PLWHA. It is recommended to revise the current medical training curricula, and to tailor improvements in the overall HIV/AIDS knowledge, which can be reflected in a more positive attitude towards PLWHA, particularly for the recently established medical schools in the country