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Aims To report late toxicity and long-term outcomes of intensity-modulated radiotherapy (IMRT)-based stereotactic ablative body radiotherapy (SABR) in patients with ultra-central lung tumours. Materials and Methods This is a single-institution retrospective analysis of patients treated with SABR for ultra-central tumours between May 2008 and April 2016. Ultra-central location was defined as tumour (GTV) abutting or involving trachea, main or lobar bronchi. Respiratory motion management and static-field dynamic-IMRT were used, with dose prescribed homogeneously (maximum Results Sixty-five per cent of patients had inoperable primary non-small cell lung cancer and 35% had lung oligometastases. The median age was 72 (range 34–85) years. The median gross tumour volume and planning target volume (PTV) were 19.6 (range 1.7–203.3) cm3 and 57.4 (range 7.7–426.6) cm3, respectively. The most commonly used dose fractionation was 60 Gy in eight fractions (n = 51, 87.8%). Median BED10 for D98%PTV and D2%PTV were 102.6 Gy and 115.06 Gy, respectively. With a median follow-up of 26.5 (range 3.2–100.5) months, fatal haemoptysis occurred in five patients (8.7%), of which two were directly attributable to SABR. A statistically significant difference was identified between median BED3 for 4 cm3 of airway, for patients who developed haemoptysis versus those who did not (147.4 versus 47.2 Gy, P = 0.005). At the last known follow-up, 50 patients (87.7%) were without local recurrence. Freedom from local progression at 2 and 4 years was 92 and 79.8%, respectively. The median overall survival was 34.3 (95% confidence interval 6.1–61.6) months. Overall survival at 2 and 4 years was 55.1 and 41.2%, respectively. Conclusion In patients with high-risk ultra-central lung tumours, IMRT-based SABR with homogenous dose prescription achieves high local control, similar to that reported for peripheral tumours. Although fatal haemoptysis occurred in 8.7% of patients, a direct causality with SABR was evident in only 3%. Larger studies are warranted to ascertain factors associated with outcomes, especially toxicity, and identify patients who would probably benefit from this treatment.

There is a strong need to connect agricultural research to social movements and community-based food system reform efforts. Participatory research methods are a powerful tool, increasingly used to give voice to communities overlooked by academia or marginalized in the broader food system. Plant breeding, as a field of research and practice, is uniquely well-suited to participatory project designs, since the basic process of observing and selecting plants for desirable traits is accessible to participants without formal plant breeding training. The challenge for plant breeders engaged in participatory research is to consider not only how their work incorporates farmer input in developing new varieties, but also how it interacts with broader questions of food sovereignty, food justice, diversity and democratization in the food system. This article examines these issues in the context of the Seed to Kitchen Collaborative, a participatory variety evaluation and breeding project at the University of Wisconsin-Madison.

Introduction Biological therapy in the form of Anti-TNFα drugs have significantly changed the management of Juvenile Idiopathic Arthritis. Infliximab is a monoclonal TNF-α-inhibiting antibody used in children with refractory arthritis and uveitis. Many patients continue to have active disease despite therapy. Studies have shown benefit of dose intensification in several conditions, including inflammatory bowel disease, psoriasis, and idiopathic uveitis. A number of children in Scotland with refractory disease have been treated with larger doses (10 mg/kg 4 weekly) of Infliximab than is standard practice (6 mg/kg 6–8 weekly). Aims To review indication, duration, treatment response and adverse effects of high dose Infliximab for JIA. Methods Thirteen children across three centres were treated with high dose Infliximab between May 2011 and January 2018. A retrospective review of electronic clinical notes was conducted. Results 85% of cases were female. Mean age at diagnosis was 5.22 years. 38% of patients had polyarticular JIA, 46% had oligoarticular JIA, 8% had TINU syndrome, and 8% had isolated idiopathic uveitis. 85% of patients had uveitis as part of their disease spectrum. Previous treatment included Methotrexate (85%), Prednisolone (38%), Methylprednisolone (31%), MMF (17%), Adalimumab (15%), Tocilizumab (8%), Azathioprine (8%), Ciclosporin (8%), Chlorambucil (8%) and Etanercept (8%). All patients had been treated with Infliximab 6 mg/kg, with 2 patients (16%) also being treated with 8 mg/kg. Median time on conventional dose was 1.72 years (0.19–4.50 years). Reason for increasing dose was refractory uveitis in 77%, refractory synovitis in 15% and not documented in 1 patient. Median time on higher dose was 0.69 years (0–3.46 years). One patient had a single dose. 62% of patients experienced no adverse effects. Adverse effects reported were nausea/vomiting (15%), nephropathy (8%), skin issues (8%) and anaphylaxis (8%). 38% of patients continue on high dose Infliximab. Reasons for discontinuing were remission of symptoms (13%), no or minimal improvement (38%), patient wishing to self-administer drugs (13%), drug reaction (25%) and worsening symptoms (13%). Conclusions High dose Infliximab was well tolerated in the majority of patients, with minimal severe side effects. In the future, understanding what level of infliximab is effective in uveitis may help tailor the dose more effectively.

Background Surgical-site infection (SSI) is associated with significant healthcare costs. To reduce the high rate of SSI among patients undergoing colorectal surgery at a cancer centre, a comprehensive care bundle was implemented and its efficacy tested. Methods A pragmatic study involving three phases (baseline, implementation and sustainability) was conducted on patients treated consecutively between 2013 and 2016. The intervention included 13 components related to: bowel preparation; oral and intravenous antibiotic selection and administration; skin preparation, disinfection and hygiene; maintenance of normothermia during surgery; and use of clean instruments for closure. SSI risk was evaluated by means of a preoperative calculator, and effectiveness was assessed using interrupted time-series regression. Results In a population with a mean BMI of 30 kg/m2, diabetes mellitus in 17·5 per cent, and smoking history in 49·3 per cent, SSI rates declined from 11·0 to 4·1 per cent following implementation of the intervention bundle (P = 0·001). The greatest reductions in SSI rates occurred in patients at intermediate or high risk of SSI: from 10·3 to 4·7 per cent (P = 0·006) and from 19 to 2 per cent (P < 0·001) respectively. Wound care modifications were very different in the implementation phase (43·2 versus 24·9 per cent baseline), including use of an overlying surface vacuum dressing (17·2 from 1·4 per cent baseline) or leaving wounds partially open (13·2 from 6·7 per cent baseline). As a result, the biggest difference was in wound-related rather than organ-space SSI. The median length of hospital stay decreased from 7 (i.q.r. 5–10) to 6 (5–9) days (P = 0·002). The greatest reduction in hospital stay was seen in patients at high risk of SSI: from 8 to 6 days (P < 0·001). SSI rates remained low (4·5 per cent) in the sustainability phase. Conclusion Meaningful reductions in SSI can be achieved by implementing a multidisciplinary care bundle at a hospital-wide level.

Tungsten coil atomic emission spectrometry (WCAES) allows for simultaneous sensitive multielement determinations, but is limited by the lack of isothermality around the atomizer and by matrix effects. A better control of temperatures during the heating cycle, and atomizer surface modification can minimize these limitations and improve precision and accuracy. In this work, a simple, fast and effective voltamperometric method is used to determine atomizer surface temperatures in real time during all steps of a WCAES heating cycle. An optical microscope and an analytical balance are used to determine length-to-area ratios (L/A) of brand new and conditioned coils. The calculated L/A values are then used to determine atomizer surface temperatures simply by monitoring the potential across the coil with a digital multimeter. Tungsten filaments extracted from 150 W, 15 V microscope light bulbs are used as atomizers. Conditioned coils reach higher surface and gas phase temperatures when compared with brand new ones. Aluminum, Ca, Cr, Mn and V were used as test elements. The combination of atomizer conditioning, temperature control and optimization of pyrolysis and atomization steps resulted in higher sensitivities and better precision in most cases. Different matrices were evaluated, and less intense effects were observed in V determinations. A systematic optimization of pyrolysis temperature and time for specific matrices may improve WCAES performance for different elements. Adopting temperature-based heating programs rather than current- or voltage-based ones facilitates transferability of procedures and allows for a broader and simpler application of tungsten coil-based methods.

Pseudohypoaldosteronism type I (PHAI) is sometimes dominantly inherited and is characterized by mutations causing a near-absence of mineralocorticoid receptors in the kidneys.1 This leads to salt-wasting and hyperkalemia, despite increased aldosterone levels. It starts in infancy but eases toward adulthood. There is also a recessive form2 of PHAI that is more severe, associated with loss of function mutations of epithelial sodium (Na+) channels (ENaC) in the late distal tubules (DTs), the connecting tubule and collecting ducts, and also in other tissues expressing the ENaC. It starts in the newborn, with life-threatening salt-wasting and hyperkalemia. Salt supplements of ≤45 g/d are required indefinitely, together with control of hyperkalemia. More than 100 cases of these forms of PHAI have by now been described. PHAII is also inherited, but can be sporadic, in which hyperkalemia despite a normal glomerular filtration rate is the cardinal presenting feature. There is also acidosis and a low plasma renin level and a high incidence of hypertension. Plasma aldosterone levels are low to mildly but inadequately increased. This disease was named PHAII by Schambelan et al,3 but it has also been known as Familial Hyperkalemia and Hypertension, Gordon Syndrome, and Chloride Shunt Syndrome. The first case was described in 1964 by Paver and Pauline.4 In 1968, their patient, a white man aged 18 years, came under my care. He had a plasma potassium (K+) of 8.2 mmol/L, a normal glomerular filtration rate, acidosis, and a blood pressure of 180/120 mm Hg.5 Although Paver and Pauline4 found that he had an extreme cold pressor response, we did not find it so in 1968, but meanwhile it may have been affected by treatment. Renal biopsy was normal. Plasma renin level was low, and plasma aldosterone was low normal. A 4-day balance study …

The authors describe the first four years (1995-1998) in which the University of California, San Francisco School of Medicine operated an evaluation system to monitor students' professional behaviors longitudinally through their clinical rotations. The goals of this system are to help "turn around" students found to have behaved unprofessionally, to demonstrate the priority placed by the school on the attainment of professional behavior, and to give the school "muscle" to deal with issues of professionalism. A student whose professional skills are rated less than solid at the end of the clerkship receives a "physicianship report" of unprofessional behavior. If the student receives such a report from two or more clerkships, he or she is placed on academic probation that can lead to dismissal even if passing grades are attained in all rotations. Counseling services and mentoring by faculty are provided to such students to improve their professional behaviors. From 1995 to 1998, 29 reports of unprofessional behavior on the part of 24 students were submitted to the dean's office; five students received two reports. The clerkship that submitted the most reports was obstetrics-gynecology. The most common complaint for the five students who received two reports was a poor relationship with the health care team. Four of these students had their difficulties cited in their dean's letters and went on to residency; the fifth voluntarily withdrew from medical school. The authors describe the students' and faculty members' responses to the system, discus lessons learned, difficulties, and continuing issues, review future plans (e.g., the system will be expanded to the first two years of medical school), and reflect on dealing with issues of professionalism in medical school and the importance of a longitudinal (i.e., not course-by-course) approach to monitoring students' behaviors. The authors plan to compare the long-range performances of students identified by the evaluation system with those of their classmates.

Blood banks can utilize ISO-9000 to standardize the level of quality within the organization. This standardization can be cross-referenced with the existing quality system in the blood bank, more specifically the quality systems required by the Food and Drug Administration and the American Association of Blood Banks, to provide for higher-quality products and services.

The story is told of how several Chilean anthropologists and Bolivian colleagues helped the Jalq'a people to revive their traditional handicrafts as a model for microregional development. The quest was initially undertaken to find out about "potolo" weavings. The Jalq'a people were found in numbers totaling 25,000 impoverished and with very high infant mortality rates, low incomes, and social disorganization. although the traditional woven dresses were still worn, the color combinations and motifs had lost their originality and precision. The story was told about how during the 1960s and 1970s the poor cash economy had forced people to sell their textiles to tourists and traders for lower than market value. Eventually it became apparent that there were no longer models of the traditional garments to inspire new generations. Upon the anthropologists arrival and inquiries, it was related that local interest to revive production of these native textiles was still there. The craft revival took root because of the interest in the people not just as artisans but as people, and rapport was established. The background of the anthropologists is related. A grassroots support organization (GSO) was formed to assist in economic development that was rooted in the life of the community. The pace was set by participants and a few women at first were trained in commercial production. A shaman was asked to conduct a ritual ceremony which involved calling upon the mountain deities, the Mallkus, to give them a sign. The Mallkus agreed the project was good and the Jalq'a must conserve their language and culture and textiles. New workshops were blessed in a similar way. In the first workshop the challenge was for the women to determine how to make the many strange animals that appeared in Jalq'a designs; a photographic archive was put together and the hand-dyed colors restored with some difficulty. The exhibit of the textiles after several years led to new respect for the Jalq'a and indigenous peoples and a means of recognition for further sales. Women's status and Irupampa socioeconomic status has improved; migration to urban areas has been slowed. The experiences of the Navajo in the US has been helpful in the Jalq'a efforts in international marketing. GSO has been able to provide guidance to others in learning about their spinning machines, quality control system, and marketing strategy.

I GA NEPHROPATHY is the most frequent primary glomerular disease in the world,1 but its precise pathogenesis remains obscure. There is a well-recognized association between exacerbations of IgA nephropathy and infections of mucosal surfaces rich in IgA such as the upper respiratory and gastrointestinal tracts. However, although breast milk and colostrum are also rich sources of IgA and secretory component,2 there has been only a single case report relating exacerbations of IgA nephropathy to episodes of mastitis. 3 Here we describe another such case, in which macroscopic hematuria developed during three of four episodes of mastitis in a lactating woman with IgA nephropathy.

Editor—We share Berger’s frustration with clinical audit in its current form.1 Between 1995 and 1997 we tried to introduce clinical audit into nursing homes in Wakefield. There are 24 registered homes with nearly 1000 beds—equivalent to an entire hospital—and their quality of care has obvious and lasting relevance to the quality of life for residents. The project coordinator (JC) introduced the concept of clinical audit to local homes, provided training, and helped each home conduct an audit of its own choosing. One home refused to participate. The other 23 were receptive, but in five no progress was made because of staff changes. Eleven topics were audited by 15 homes; the other three conducted pseudo-audits that were actually management activities, such as stock control. The 11 topics were: reporting of accidents; procedures of staff changeover; continence care, activities and stimulation of residents (3 homes); individual keyworker system, where each resident has a named worker on their case; compliance with safety standards in the workplace; quality of laundry; planning of food and menus (2 homes); ordering and planning of drug treatments; moving and handling; and quality of written care plans (2 homes). A year after they began, most of these audits remained incomplete, and only three are likely to have brought about improvements that are perceptible to residents. These are small benefits for the effort and resources invested, and we are pessimistic about auditing topics that may be on the health authority’s agenda but that homes are reluctant to address. We are aware of 16 audit exercises in UK nursing homes (3 from peer reviewed sources). These suggest that clinical audit may have more success if it is combined with both external leverage (such as the cycle of registration and inspection) and an internal product champion (such as an enthusiastic matron). Even then, it is a weak lever for quality improvement in the face of so many pressures. Many homes are struggling to cope with dependent residents, staff shortages, and financial difficulties. It is unrealistic to expect clinical audit in isolation to change this climate. Yet if we were to go back to first principles and design an ideal mechanism for quality assurance for nursing homes or any other health unit, it would look uncannily similar to audit. It would be adequately funded, be professionally led, set explicit standards, involve regular review, and so on. This suggests that we should not despair of audit but confront the forces that impair quality.

This paper examines gross interstate migration flows for five periods for the years between 1969 and 1978. The analysis is based upon a newly available data source -- Federal income tax returns. Approximately 90% of the US population is covered by this data series. The matching of Internal Revenue Service (IRS) returns between filing dates enables the determination both of the origin and of the destination of migrants, with few of the risks of geographic miscoding present. These data illustrate that despite divergent economic fluctuations over the past nine years, the patterns of interstate migration have remained virtually unchanged. With few exceptions, the number of migrants either leaving or entering a particular state comprise identical proportions over time. Unlike migration data obtained from the Current Population Survey which enables the study of regional mobility only, the IRS data document current state-to-state flows that can be constructed on an annual basis. Comparisons are also made with the Current Work History Sample. In addition, these data offer considerable evidence that current residence has a significant impact on the selection of a destination. The resistance of migration patterns to large economic and social shifts during the period examined also implies that the explanation of individual migration determinants and the forecasting of aggregate migration flows should be treated as separate research questions. The potential of the data for the addition of further demographic detail and for use in forecasting also is considered.