Cervical Brachytherapy Exchange: Steps Toward Oncology Capacity Building in Botswana

To help share technical knowledge of brachytherapy and the care of patients with cervical cancer in Botswana, a series of visits was organized by two centers in the United States, Massachusetts General Hospital and the University of Pennsylvania. As a result of those visits, necessary future steps were recognized. Such clinical visits are important for facilitating the exchange of knowledge and learning between institutions in developing and developed countries.In the past three decades, the number of cervical cancer cases globally has increased from an estimated 378,000 cases in 1980 to 454,000 in 2010, with 17% of these cases in Sub-Saharan Africa [1]. Sub-Saharan Africa is burdened by more than 60% of all human immunodeficiency virus (HIV) cases in the world [2]. With increased utilization of antiretroviral therapy as HIV-infected patients live longer, rates of malignancies in this population are rising [3]. HIV-infected women have a higher risk of human papillomavirus (HPV) infection and, consequently, the development of invasive cervical cancer [4]. In Botswana, where 18% of the population is HIV positive, cervical cancer is the leading cause of cancer-related death in women.Because of the lack of widespread screening, a majority of patients in Botswana present with advanced disease at diagnosis. The primary treatment for locally advanced cervical cancer is radiation therapy (RT) with or without cisplatin-based chemotherapy. Curative RT generally consists of external-beam RT delivered with either a linear accelerator or a cobalt-60 unit with brachytherapy.Brachytherapy is an essential component of the treatment of cervical cancer and increases the likelihood of cure; however, it is not readily accessible in Africa [5]. A recent review highlighted that only 20 countries in Africa have brachytherapy services; 75% of these facilities are concentrated in Northern Africa and in South Africa [6]. Brachytherapy is commonly delivered using low-dose-rate or high-dose-rate (HDR) sources. Using a HDR source allows for more rapid completion of treatment and a higher volume of treatments in an outpatient setting but requires specialized equipment and shielding, imaging, software, and training for the physician, the physicist, and support staff [7].Local practitioners in Botswana and international collaborators [8, 9] identified cervical cancer as one of several areas for high focus. In Botswana, Gaborone Private Hospital (GPH), the only radiation oncology facility, acquired an HDR brachytherapy unit in February 2011 and started its treatment program in 2012, drawing patients countrywide. To help share technical knowledge of brachytherapy and the care of patients with cervical cancer, a series of visits was organized from Massachusetts General Hospital (MGH), followed by the University of Pennsylvania. Visits were focused on clinical care, brachytherapy planning, and nursing. Exchange at GPH was conducted through participation in clinical care with the radiation oncologist and nurses and highlighted insertion techniques and symptom management, treatment planning with physicists and dosimetrists, and focused didactics on clinical issues of interest to the staff. MGH facilitated a donation of applicators to GPH through Mick Nuclear (Mick Radio-Nuclear Instruments, Inc., Mount Vernon, NY, http://www.micknuclear.com).As a result of these visits, the following necessary future steps were recognized: procurement of an ultrasound machine for visualization during insertions; standardization of treatment-approval, safety, and quality-assurance processes; development of patient education material; and future exposure and training in interstitial brachytherapy technique for gynecological cancers.By 2030, more than 70% of cancer patients will be diagnosed in the developing world [10]. In addition to the implementation of screening programs, cancer-care capacity building is essential to address the increasing burden of disease. Clinical visits such as those described are an important step in the effort to build capacity while facilitating the exchange of knowledge and learning between institutions in developing and developed countries. There are many other examples of similar collaborations between Western academic institutions and providers in low- and middle-income countries to establish effective facilities for cancer treatment, and such exchanges should be forged with a long-term relationship in mind.     

Fifteen year overall survival rates after autologous stem cell transplantation for AL amyloidosis

In appropriately selected patients with AL amyloidosis, autologous stem cell transplant (ASCT) is an established treatment modality with excellent outcomes and decreasing transplant related mortality (TRM) over time. We report on 15-year overall survival (OS) in 159 patients undergoing ASCT from 1996 to 2003, with median follow up of 17.1 years. Day 100 TRM was 13.2% (n = 21). The OS of ≥15 years was observed in 30% (47/159) of patients. Patients surviving ≥15 years were younger (53 vs 56 years, P = .02), less likely to have lambda as the involved light chain (62% vs 78%, P = .03) and were less likely to have heart involvement (32% vs 56%, P = .005). Median OS of patients with heart involvement vs not was 4.0 vs 11.1 years, P = .006 and actuarial 15-year OS was 23% vs 43%, respectively. A higher proportion of patients with OS ≥15 years received full-dose melphalan conditioning (81% vs 61%, P = .01), and achieved day 100 complete response (CR) (64% vs 24%, P < .001). Median OS amongst patients who achieved CR vs not was 19.3 vs 5.4 years, P < .001. Heart involvement, receiving full-dose melphalan and achieving CR remained independent predictors of OS. AL amyloidosis and related complications were the cause of death in 52% of patients overall (1-5 years post-transplant: 81%; 5-10 years: 62% and 10-15 years: 55%). These results reinforce the key role of ASCT in AL amyloidosis. With improvements in TRM and more options for relapsed disease, we expect the long-term survival post-transplant to improve significantly in the future.     

So you want to be a neurosurgeon: a career resource guide for successful navigation

Neurosurgery is not just about head injuries and brain tumors. It is a specialty that currently stands at the forefront of biomedical and technological developments. Modern neurosurgery requires not only creativity and perseverance on behalf of your patients but also clinical acumen, surgical judgment, and technical expertise. This career resource guides the reader through the pathway to a practice in neurosurgery.     

Neurocysticercosis presenting as bipolar disorder: a case report

Neurocysticercosis is the most common neuro-parasitosis caused by the larval stage of Taenia solium. The most common manifestations include seizures and hydrocephalus. Psychiatric abnormalities are relatively rare but depressive symptoms are frequent in patients with neurocysticercosis. However, mania as a presentation is relatively rare. Pregnancy and the postpartum period are relatively vulnerable times and they can lead to reactivation of existing neurocysterci lesions. We are discussing the case of a 23-year-old female patient with neurocysticercosis leading to the reactivation of lesions in the peripartum and postpartum period leading to bipolar affective disorder. Improvement in the patient was seen with a combination of antipsychotics, antihelmintics, antiepileptics and steroids, along with improved radiological signs of neurocysterci lesions. Although neurocysticercosis is a common illness, its prevalence presenting as a manic episode is merely 2.6% and, hence, missed easily. Therefore, it is important to rule out organic aetiology in patients even with a classic presentation of bipolar affective disorder and those having any other neurological symptoms and signs.     

Rapid Testing Using the Verigene Gram-Negative Blood Culture Nucleic Acid Test in Combination with Antimicrobial Stewardship Intervention against Gram-Negative Bacteremia

Rapid identification of microorganisms and antimicrobial resistance is paramount for targeted treatment in serious bloodstream infections (BSI). The Verigene Gram-negative blood culture nucleic acid test (BC-GN) is a multiplex, automated molecular diagnostic test for identification of eight Gram-negative (GN) organisms and resistance markers from blood culture with a turnaround time of approximately 2 h. Clinical isolates from adult patients at the University Maryland Medical Center with GN bacteremia from 1 January 2012 to 30 June 2012 were included in this study. Blood culture bottles were spiked with clinical isolates, allowed to incubate, and processed by BC-GN. A diagnostic evaluation was performed. In addition, a theoretical evaluation of time to effective and optimal antibiotic was performed, comparing actual antibiotic administration times from chart review (“control”) to theoretical administration times based on BC-GN reporting and antimicrobial stewardship team (AST) review (“intervention”). For organisms detected by the assay, BC-GN correctly identified 95.6% (131/137), with a sensitivity of 97.1% (95% confidence interval [CI], 90.7 to 98.4%) and a specificity of 99.5% (95% CI, 98.8 to 99.8%). CTX-M and OXA resistance determinants were both detected. Allowing 12 h from Gram stain for antibiotic implementation, the intervention group had a significantly shorter duration to both effective (3.3 versus 7.0 h; P < 0.01) and optimal (23.5 versus 41.8 h; P < 0.01) antibiotic therapy. BC-GN with AST intervention can potentially decrease time to both effective and optimal antibiotic therapy in GN BSI.     

Juvenile ossifying fibroma diagnosed on fine needle aspiration cytology: A diagnostic challenge

Preoperative diagnosis of jaw lesions is not always possible on the basis of clinico‐radiological findings alone and needs to be confirmed before attempting any surgical intervention. Fibro‐osseous lesions of the jaw comprise a spectrum of diseases which include cement‐osseous dysplasia, fibrous dysplasia, and ossifying fibroma. The cytomorphological distinction between these individual entities is difficult. We present a case of maxillary fibro‐osseous lesion in an adolescent girl diagnosed and categorized as juvenile ossifying fibroma preoperatively on cytology and confirmed on histopathology. Although aspirates are usually paucicellular in fibro‐osseous lesions, certain cytological features if present in cellular cytosmears can offer further categorization and a definitive diagnosis may be possible in light of clinico‐radiological correlation. Diagn. Cytopathol. 2015;43:75–79. © 2014 Wiley Periodicals, Inc.