Search

Aims: The treatment of prostate cancer has evolved markedly over the last 40 years, including radiotherapy, notably with escalated dose and targeting. However, the optimal treatment for localised disease has not been established in comparative randomised trials. The aim of this article is to describe the history ofprostate radiotherapy trials, including their quality assurance processes, and to compare these with the ProtecT trial.Materials and methods: The UK ProtecT randomised trial compares external beam conformal radiotherapy, surgery and active monitoring for clinically localized prostate cancer and will report on the primary outcome (disease-specific mortality) in 2016 following recruitment between 1999 and 2009. The embedded quality assurance programme consists of on-site machine dosimetry at the nine trial centres, a retrospective review of outlining and adherence to dose constraints based on the trial protocol in 54 participants (randomly selected, around 10% of the total randomised to radiotherapy, n ¼ 545). These quality assurance processes and results were compared with prostate radiotherapy trials of a comparable era.Results: There has been an increasingly sophisticated quality assurance programme in UK prostate radiotherapy trials over the last 15 years, reflecting dose escalation and treatment complexity. In ProtecT, machine dosimetry results were comparable between trial centres and with the UK RT01 trial. The outliningreview showed that most deviations were clinically acceptable, although three (1.4%) may have been of clinical significance and were related to outlining of theprostate. Seminal vesicle outlining varied, possibly due to several prostate trials running concurrently with different protocols. Adherence to dose constraints inProtecT was considered acceptable, with 80% of randomised participants having two or less deviations and planning target volume coverage was excellent.Conclusion: The ProtecT trial quality assurance results were satisfactory and comparable with trials of its era. Future trials should aim to standardise treatment protocols and quality assurance programmes where possible to reduce complexities for centres involved in multiple trials. 2016 Published by Elsevier Ltd on behalf of The Royal College of Radiologists.

This article presents and discusses new empirical data derived from CPS Monitoring of the implementation of special measures for vulnerable and intimidated witnesses (VIWs) pursuant to Part II of the Youth Justice and Criminal Evidence Act 1999. VIW Monitoring was a major undertaking, covering all CPS prosecutions in England and Wales for an entire calendar year. Its results are fully reported elsewhere. Here, we concentrate on one segment of VIW Monitoring data, reporting the outcomes of prosecutors' applications for special measures. Most such applications succeed, but a small minority is rejected, and the characteristics and reasons for these judicial refusals were recorded as part of the Monitoring process. By examining and reflecting upon the circumstances of abortive applications, no less than in contemplating the broader pattern of success which emerges from VIW Monitoring, we may hope to gain a better appreciation of the existing arrangements for securing special measures for vulnerable and intimidated witnesses, and to assess the scope, if any, for further refinements of policy or practice.

In many UK mental health services, in-patient psychiatric care is being separated from community care by having dedicated in-patient medical team. We evaluated staff satisfaction in this functionalised in-patient care. A survey was conducted amongst multidiscipli-nary staff from various teams using a questionnaire survey. On an average 14.3% of staff returned a satisfactory response for function-alisation, 57.3% had unsatisfactory response and others were undecided or perceived no change. There was no difference in responses amongst age, gender and professional groups. Mean scores of all groups were within unsatisfactory domain; however community staff compared to in-patient staff and staff with more than 5 years of experience compared to those with 1-5 years of experience returned significantly more unsatisfactory responses regarding functionalisation. Many positive and negative aspects of functionalisation were raised. The results of this evaluation suggest the need for further studies on the effectiveness of in-patient functionalisation. Short and long term clinical outcomes and the satisfaction of the patients should also be studied.

Background: The UK National Institute for Health and Clinical Excellence (NICE) guidance recommends conservative management of men with ‘low-risk' localised prostate cancer, monitoring the disease using prostate-specific antigen (PSA) kinetics and re-biopsy. However, there is little evidence of the changes in PSA level that should alert to the need for clinical re-assessment. Methods: This study compares the alerts resulting from PSA kinetics and a novel longitudinal reference range approach, which incorporates age-related changes, during the monitoring of 408 men with localised prostate cancer. Men were monitored by regular PSA tests over a mean of 2.9 years, recording when a man's PSA doubling time fell below 2 years, PSA velocity exceeded 2 ng ml–1 per year, or when his upper 10% reference range was exceeded. Results: Prostate-specific antigen doubling time and PSA velocity alerted a high proportion of men initially but became unresponsive to changes with successive tests. Calculating doubling time using recent PSA measurements reduced the decline in response. The reference range method maintained responsiveness to changes in PSA level throughout the monitoring. Conclusion: The increasing unresponsiveness of PSA kinetics is a consequence of the underlying regression model. Novel methods are needed for evaluation in cohorts currently being managed by monitoring. Meanwhile, the NICE guidance should be cautious.

Clinical outcome was analyzed among a group of 39 consecutive patients with coronary artery disease, left ventricular (LV) ejection fractions less than 30% and arrhythmias that required an automatic implantable cardioverter defibrillator (AICD) in an attempt to better define the role of the device in patients with severely depressed LV function. Twenty-nine (74%) were survivors of out-of-hospital cardiac arrest and 10 (26%) had ventricular tachycardia that was refractory to electrophysiologically guided antiarrhythmic therapy. The study group had the following demographic characteristics: 90% were men, mean age was 64 years (range 41 to 79) and mean LV ejection fraction was 21 +/- 4%. Concomitant pharmacotherapy included antiarrhythmic drugs 31 (79%), vasodilators in 22 (56%) and digoxin in 20 (51%). There was no statistical difference in baseline characteristics between survivors and nonsurvivors. Patients were followed for a mean of 24 months (range 2 to 72) from implantation. The difference between actuarial survival--77% at 1 year and 72% at 2 years--and projected survival without the AICD (patients who survive without appropriate device discharge)--30% at 1 year and 21% at 2 years--was significant (p less than 0.01 and less than 0.05 at 1 and 2 years, respectively). This study suggests that the AICD improves survival in patients with coronary artery disease despite severely depressed LV function.

Atrial fibrillation (AF) is the most common rhythm disturbance in medical practice and represents a very expensive health problem. AF can be managed with the prevention of thromboembolism and either a rate control of rhythm strategy. As both strategies have important limitations, probably a preventative strategy in patients at risk of developing arrhythmia can be a more attractive option. The renin-angiotensin system (RAS) seems to be involved in the genesis of arrhythmia by the following two mechanisms: 1. the induction of atrial fibrosis and structural remodelling by mitogen-activated protein kinase (MAPK) expression and reduction of collagenase activity; 2. the induction of electrical remodelling by shortening of the atrial effective refractory period (AERP) and of the action potential duration. For these reasons it has been hypothesized that angiotensin-converting enzyme inhibitors (ACE-Is) and angiotensin-II receptor blockers (ARBs) may play a role in preventing AF recurrence. The aim of the present review was to analyse evidence supporting the usefulness of RAS inhibition in patients with AF in order to focus on which specific subset of patients it would most favour. After reviewing the literature, we conclude that, although many studies and meta-analysis have supported the advantage of RAS block in preventing AF recurrence, it is premature to recommend the use of ACE-Is and ARBs specifically for the prevention of AF. However we believe that as these drugs are safe and manageable, they should be considered the drugs of choice in patients with AF and coexisting clinical conditions such as hypertension, coronary disease, heart failure and diabetes mellitus.

Stoma care nurse specialists are valued for their diverse expertise, but it is essential that all practitioners who regularly care for people with stomas have the opportunity to develop professionally and influence this important area of practice. The vision of a clinical and educational team from Suffolk and south Norfolk led to the development of innovative web-based learning material. The aim is to inspire nurses to engage actively with people who have a stoma. ‘Professional care of the person with a stoma’ is about caring for the whole person, physically and emotionally, from the period before surgery, to their continuing care in the community. An overview of four aspects of stoma care is presented here as a way of sharing with a wider audience the expert practice harnessed during the development of this web-based module.