Indo-Asians in Canada are at increased risk for cardiovascular diseases. There is a need for cultural and language specific educational materials relating to this risk. During this project we developed and field tested the acceptability of a hypertension public education pamphlet tailored to fit the needs of an at risk local Indo-Asian population, in Calgary, Alberta, Canada.A community health board representing Calgary's Indo-Asian communities identified the culturally specific educational needs and language preferences of the local population. An adaptation of an existing English language Canadian Public Hypertension Recommendations pamphlet was created considering the literacy and translation challenges. The adapted pamphlet was translated into four Indo-Asian languages. The adapted pamphlets were disseminated as part of the initial educational component of a community-based culturally and language-sensitive cardiovascular risk factor screening and management program. Field testing of the materials was undertaken when participants returned for program follow-up seven to 12 months later.Fifty-nine English-speaking participants evaluated and confirmed the concept validity of the English adapted version. 28 non-English speaking participants evaluated the Gujarati (N = 13) and Punjabi (N = 15) translated versions of the adapted pamphlets. All participants found the pamphlets acceptable and felt they had improved their understanding of hypertension.Involving the target community to identify health issues as well as help to create culturally, language and literacy sensitive health education materials ensures resources are highly acceptable to that community. Minor changes to the materials will be needed prior to formal testing of hypertension knowledge and health decision-making on a larger scale within this at risk community. Cardiovascular diseases (CVD) are a leading cause of morbidity and mortality worldwide. Canadian data have suggested that Indo-Asians  have significantly higher rates of CVD morbidity and mortality compared with several other ethnicities ,2. CanadThe higher prevalence of undetected and or inadequately managed risk factors including diabetes, central obesity, hypertension (HBP) and dyslipidemias, begin to explain the higher CVD risk profile ,5,6. RecIndo- Asians are among the fastest growing minority populations in Canada. The 2006 Canadian census  determinBarriers to optimal health play a major role and include access, language and lower health literacy. Such obstacles may limit knowledge and appreciation of the ramifications of CVD and its modifiable risk factors -16. HealThis project represents the first step in a two-phase project aimed at increasing health literacy, hypertension knowledge, and health decision-making in an Indo-Asian population in Calgary, Alberta, Canada. This first phase was aimed at tailoring and evaluating the acceptability of adapted and translated versions of an existing English evidence-based public education pamphlet focused on hypertension.http://www.hypertension.ca], the 2007 Public Hypertension Recommendations pamphlet uses evidence-based messaging to educate Anglo and Francophone Canadians about hypertension, its risk factors, prevention and treatment. It is a four page document split into three major sections. The first section, "Things you need to know about blood pressure and hypertension", describes what blood pressure and hypertension are, the cardiovascular consequences of poorly controlled hypertension and that hypertension can be prevented and controlled. The second section, "Do's and Don'ts" details the factors and activities  that promote a lower blood pressure and the factors  that promote higher blood pressure. Alongside these comments are colourful and simple pictures and green (Go) and red (Stop) signs. The third section, "Finding out about your blood pressure", provides information on where to get blood pressure measured, the purchase of a blood pressure device (machine), how to measure blood pressure at home and information on the need for and importance of medications and medication adherence in the treatment and control of hypertension. Pictograms inform the reader of what the numbers are for normal and high blood pressure, along with a sample of validated blood pressure devices that can be purchased in order to measure blood pressure at home.Designed and updated annually by Blood Pressure Canada [20, The English pamphlet was tailored to the Indo-Asian audience using standardized principles for development of culturally, language and literacy appropriate patient educational materials -25. Revi© 2007 Flesch-Kincaid scale [The readability of the original (US grade-level 9) and adapted English (US grade-level six) pamphlets were confirmed using two different scales: manually, by the Fry method  and elecid scale .Five lay adult members of the Indo-Asian community (none of whom were part of the key informant team and each of whom were English speaking and reading) volunteered to review the adapted (grade-level six) pamphlet. Using the learner verification and revision  intervieThe adapted English educational pamphlet was returned to the community members originally consulted, who once again reviewed it for cultural appropriateness, the 17 item check list and SAM prior to translation. Health Board members identified Gujarati and Punjabi as primary, and Hindi, and Dari as secondary languages of importance. Translations were done by Calgary Health Region Diversity Services  certifieTwo separate 14-item semi-structured evaluation tools Tables  were devEach evaluation tool was assessed by a focus group composed of 5 volunteer members of the target Indo-Asian community who had read the pamphlets. The groups were instructed to review the questions in the tools to ensure that the themes of concept validity, acceptability, and comprehension in the pamphlets were clearly being assessed. Additionally, focus groups evaluated whether the questions being asked would be understood by other community members, particularly those whose preferred language was not English. Minor revisions were made accordingly.Three hundred and seventy five educational pamphlets were disseminated  to the local Indo-Asian population at 6 local religious and community centers as part of the educational component of a community-based culturally and language-sensitive CVD risk factor screening and management program  . CommuniThe evaluation tools were administered in the participants' language of choice by trained bilingual CHAMP volunteers at follow-up CHAMP sessions . The time between initial and follow-up screening sessions allowed for participants to visit their physician and for changes to risk factor management and lifestyle changes to be undertaken. Answers to the open ended questions were directly translated by the multi-lingual CHAMP volunteers and recorded in English. If program staff were not absolutely clear on the meaning of the words or phrases used by participants, extra time was taken to (probe) discuss and clarify the meanings.Data from the closed-ended questions were presented as proportions. Qualitative responses to the open ended questions were transcribed verbatim and analysed by two of the investigators  using thematic content analysis . TranscrThis study was approved by the Conjoint Ethics Committee of the University of Calgary.After reviewing the original English pamphlet, the key informant team identified the following as potential barriers to the general community members' understanding: the inability of some community members to speak or read in English or their native language, the high volume of information presented in the pamphlet, the high technical level of information, and a lack of cultural appropriateness (particularly of the lifestyle advice provided). Using the 17- point checklist which assesses the organization, writing style, appearance and appeal of the materials and the SAM, which has been validated for English print materials in South East Asians , and scoTwo other pictograms were inserted that demonstrate various blood pressure measurements and their significance . In the do's and Don'ts section, tick marks were placed beside the "Do" actions as key informants indicated that some of the more elderly community members may not drive and recognize the significance of the green "go" or red "stop" signs. Some information, for example the section on "white coat and masked" hypertension and details about various anti-hypertensive medications was removed in order to reduce the excess of information.th grade level [Reading grade level of the material was assessed to be at the 6de level ,26.No significant changes were made to the adapted English pamphlet prior to its being sent for translation.The local Health authority was unable to provide translation for the Dari version of the pamphlet. After a national search for a certified translator failed to locate one, a local community member enlisted to provide this service. The certified and experienced translators provided a very literal translation of the materials. This proved to be suboptimal as our bilingual community members who performed the back translation thought that numerous words and phrases were inappropriate, not understandable or did not convey the real meaning for the less acculturated community members. A prime example was the direct translation of the words "processed foods" (in reference to hidden sources of high sodium content in the diet). According to the bilingual community members consulted, this did not hold a valid meaning for many non-bilingual Indo-Asian community members and "food sold in containers" would hold more meaning.Follow-up sessions were held in the same 6 venues as the initial screening sessions. Of the 375 participants originally screened, 248 qualified for a follow-up screening  and 100 returned for repeat screening. Ninety-nine of the 100 participants that attended follow-up sessions agreed to participate in this study. There were no significant baseline demographic, risk factor or language preference differences between this group that returned for follow-up screening  vs. the other 148 that qualified for recall screening but did not return for follow-up screening. 89/99 had read one or more of the pamphlets (90% attention). Group 1 (Table could not read"). No Hindi speaking participants attended the follow-up sessions.Fifty-nine participants  participants indicated that the adapted English pamphlet helped them better understand the meaning of high blood pressure than did the original English pamphlet."Prefer more pictures", "The original was very technical" and "Not sure why". Interestingly, 53 (89.8%) of participants indicated that the increased number of pictures in the adapted version helped them to better understand the written information. Three participants felt that the adapted pamphlet was missing information  dealing broadly with heart disease, stroke and their risk factors, these materials are unique as hypertension-specific educational materials that are appropriately translated for the Indo-Asian community. As such, these materials have the potential to address the awareness, prevention and treatment gap for hypertension in this high risk population.Extensive literature and web-based search revealed that other than resources provided by the Heart and Stroke Foundation . Furthermore, the Fry [Secondly, we did not evaluate the literacy skills of our participants prior to their evaluating the educational materials. Careful review of the literature revealed no validated methods of testing literacy levels in Indo-Asians. However, one study  piloted  the Fry , and Fle the Fry  are two  the Fry ,24.Coupled with the simplified pictures and diagrams, we were able to achieve a high degree of attention  and acceptability in this population that clearly encompassed a broad range of literacy levels.Thirdly, only three participants evaluated the Dari and none evaluated the Hindi versions, thus not allowing us to form any conclusions on these versions. Future interventions will strive to include more Hindi and Dari speaking participants in order to evaluate these educational materials.Finally, because the participants in this small study (n = 100) were self-selected and not recruited in an epidemiological fashion, they are unlikely to fully represent the diversity within the Calgary Indo-Asian community itself. This may have lead to a bias favouring the characteristics of the particular groups represented herein, thus limiting the generalisability of study findings beyond this research setting. Additionally, this study design excluded those participants that cannot read. Larger, epidemiologically designed and controlled studies of health information delivery  need to be undertaken in order to include those who cannot read, those whose language has no written form  and thosThere is an abundance of literature guiding the development of health educational materials for low literate and multi-cultural populations. However, the vast majority of this research involves evaluating health educational materials that are written (or illustrations captioned) in English. Furthermore, there is a dearth of literature on health education research in hypertension for Indo-Asians. However, review of the most relevant literature reveals a consistent emphasis on the importance of cultural assessments, involving the target audience and the importance of accounting for low rates of literacy, even in the learner's native language ,24,29,33The importance of involving our target audience in this health education and research was best exemplified in a British study of South Asians with diabetes . The colOur five step iterative approach to the development and evaluation of the materials mirrored, in part that of Makosky and Daley . For theWe hired certified and experienced translators that unfortunately provided a very literal translation of the materials. This difficulty was addressed in our study by the process of back translation. This challenge was minimized in other studies ,37,38 byThe goal of this project was to tailor and evaluate the acceptability of the adapted and translated versions of an existing English version educational pamphlet. We did not formally evaluate the superiority of the adapted against the original English version. The adapted English version was designed following the recommendations of the 12 member key informant team. They had carefully reviewed the original version following the 17 point checklist of attributes and the SAM protocols along with making suggestions aimed at rendering it more culturally appropriate. Further, along with the readability assessment, and the informal assessment by the 56 English reading community members, the adapted version was considered at least equivalent to the original. Paradoxically, 90% of the individuals who originally stated that the original was no more difficult to understand than the adapted version stated that the pictures in the adapted version helped them to better understand the written information. This finding suggests at minimum, that the adapted version was equivalent or even superior to the original version. However, the question arises as to whether the original version even required adaptation for the English reading target audience. Further testing (below) will help to address this question.All participants who read the translated versions of the pamphlet (Group 2) appreciated receiving the information in their language of preference and, like those in Group 1, found that the pictures helped to increase their understanding of the information. Further probing revealed that it was the additional pictures in the adapted version that assisted with a better understanding. This finding is supported by 2 review articles ,40 showiGiven the high level of acceptability of these materials, we believe the materials  are ready for formal randomized controlled testing among English and non-English literate ethnic community members to determine whether the adapted version is superior to the original version and to determine the effect upon change in hypertension knowledge and health decision-making of each version.th grade level or below) literacy skills. Since the majority of patient health information is written at a 10th grade or higher [A recent survey in Canada  suggester higher , a clearr higher ,39,40 suThe principles and methods of cross-cultural adaptation and translation of educational materials used in this study follow published guidelines ,41 and hth grade readability level, simplifying the pictures and finally, ensuring cultural appropriateness of the educational materials are fundamental to improving health literacy and patient engagement. If individuals do not have the capacity to obtain, process and understand basic health information, they will not be able to make appropriate health decisions.It is imperative to involve the target community in identifying the key health issues as well as in the creation and review processes for health education materials ,23,24. IHealth literacy is fundamental to patient engagement and the potential for improved health outcomes. Involvement of the target community throughout the complete process of needs assessment through an evidence-based four step development and evaluation protocol is critical for the success and acceptability of culturally, language and literacy sensitive health education materials. This process may be useful to other researchers who wish to develop targeted multicultural public educational materials for multiple purposes, within a broad range of multiethnic communities internationally.Improved community access to health education can be achieved utilizing trained local community volunteers at well frequented, geographically and culturally appropriate gathering places.The authors declare they have no competing interests. Funding agencies played no role in the design of the study or in any aspects of data collection, analysis, interpretation and reporting.CJ conceived of the study and along with SM, AOA, and MS made substantial contributions to conception and design, and acquisition, analysis and interpretation of data. CJ, SM, KK, and MS were involved in drafting the manuscript, and along with S Mahon and NC were involved with revising it critically for important intellectual content. All authors have given final approval of the version to be published.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/11/24/prepub


Pulmonary interstitial emphysema is a life-threatening form of ventilator-induced lung injury. We present one of the few reported adult cases of pulmonary interstitial emphysema in a woman with respiratory failure admitted to our intensive care unit.An 87-year-old Caucasian woman with a diagnosis of community-acquired pneumonia was admitted to our intensive care unit requiring invasive ventilation. The combination of a poor oxygenation index and bilateral alveolar/interstitial infiltrates on a chest radiograph fulfilled the criteria for adult respiratory distress syndrome; the cause was thought to be a combination of the direct pneumonic pulmonary injury and extrapulmonary severe sepsis. By day seven, the fraction of inspired oxygen, peak airway and positive end expiratory pressures weaned sufficiently to allow an uncomplicated percutaneous tracheostomy. On day 10, problems with ventilation necessitated recruitment maneuvers with a Mapleson C circuit, after which dramatic surgical emphysema was noted. An upper airway bronchoscopy showed no obvious tracheal wall injury, and computed tomography of her chest showed extensive surgical emphysema, perivascular emphysema and peribronchial emphysema, which were consistent with a diagnosis of pulmonary interstitial emphysema. Over the following days, despite protective ventilatory strategies and intercostal tube thoracostomy, lung compliance along with oxygenation deteriorated and our patient died on day 14.The development of pulmonary interstitial emphysema is a rare but real risk when caring for patients with worsening lung compliance on the intensive care unit. Improved awareness of the condition, early protective ventilation strategies and timely treatment of any of the lethal complications will hopefully result in improved survival from the condition in adults. Pulmonary interstitial emphysema (PIE) is a barotrauma-related life-threatening condition, not uncommon to the neonatologist caring for pre-term babies. For the intensivist, despite being confronted by significant compliance issues resulting from the fibroproliferative phase of adult respiratory distress syndrome (ARDS) on a daily basis, PIE in the critically ill adult is an extremely rare occurrence. The infrequency of PIE on the intensive care unit means that recognition of the condition, knowledge of its clinical sequelae, and its management among physicians is poor. We present the case of a woman admitted to our unit, who developed PIE, and died. We believe this to be one of the only few reported adult cases of barotrauma-related PIE.2/FiO2) of < 26.6 kPa, which required invasive ventilation. The criteria for ARDS were met and the cause was thought to be a combination of the direct pneumonic pulmonary injury and extrapulmonary severe sepsis. With protective lung ventilation, low dose methylprednisolone, antibiotic therapy and a negative fluid balance, gradual improvement was made; over the following five days respiratory parameters weaned sufficiently to allow an uncomplicated percutaneous tracheostomy to be performed. On day 10, a period of desaturation required recruitment maneuvers with a Mapleson C circuit that resulted in notable surgical emphysema. The cause was thought to be a tracheal injury sustained at the time of tracheostomy insertion. An adjustable flange tube was positioned under bronchscopic guidance just proximal to the carina in an attempt to limit any further tracking of air through the potential tracheal defect. Despite these measures, a high alveolar-arterial oxygen gradient and peak airway pressures persisted. A chest radiograph showed more homogenous central pulmonary alveolar shadowing. An upper airway bronchoscopy showed no obvious tracheal wall injury and computed tomography (CT) of her chest showed extensive surgical emphysema and a small anterior left sided pneumothorax. On further review of the CT scan, it was felt that the perivascular and peribronchial emphysema was consistent with a diagnosis of pulmonary interstitial emphysema  and non-invasive high-flow continuous positive airway pressure (CPAP). By the fourth day, our patient had deteriorated, with a chest radiograph showing bilateral alveolar and interstitial infiltrates and a ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen  and ARDS . HoweverRecruitment maneuvers are commonly undertaken on the intensive care unit. They are vital for increasing the functional residual capacity above the closing capacity, and therefore providing improved lung compliance and oxygenation. When undertaking recruitment maneuvers and interpreting peak airway pressures, it is important to remember the differential lung time constants encountered throughout the diseased lungs. These variations result in an uneven distribution of pressure across the alveoli, and areas of lung with long time constants are at high risk of barotrauma. It is these areas that are at particular risk of developing PIE when exposed to the shearing forces experienced during IPPV.The development of PIE is a rare but real risk when caring for patients with worsening lung compliance. Improved awareness of the condition, early protective ventilation strategies and timely treatment of any lethal complications will hopefully result in improved survival from the condition in adults.Written informed assent was obtained from the patient's next of kin for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.TJ was involved in the care of the patient. PS and TJ analyzed the case history and CT scans. PS and TJ were involved in drafting the manuscript and both authors read and approved the final manuscript.


Patient surveys constitute a valuable source of information in patient-focused health care. The objective of this study was to develop and validate a standardized, patient centered, quantitative instrument to assess parent satisfaction in ambulatory pediatric care to be used in quality management and benchmarking activities, the Child-ZAP.A preliminary version of the survey (38 items) was conducted in n = 19 pediatric practices. After psychometric testing a modified Child-ZAP was tested in a second survey (n = 20 new pediatric practices). Data from n = 979 patients were available for analysis.The final version of the Child-ZAP contains eight dimensions, three "Child-Scales" and five "Parent-Scales". Confirmatory factor analysis confirms the three hypothesized child dimensions as well as the five parent dimensions. The factorial structure is confirmed in subgroups of younger and older children.With satisfactory to good results for validity and reliability testing, the final Child-ZAP is applicable in pediatric ambulatory care for children of all age groups. The patient's experience in health care institutions should be considered and incorporated into every stage of the health care process . Only thThe dimensions of patient satisfaction have been described recently . HoweverZufriedenheit in der Arztpraxis") is distributed free of charge in collaboration with the German Association of Statutory Health Insurance Physicians. When it comes to pediatric care, publicly available psychometrically sound instruments addressing processes of care from the patients’ perspective become short: we used a standardized questionnaire or parents assessment of pediatric hospital care [The German ZAP outpatient satisfaction questionnaire is a standardized instrument to assess process-related patient satisfaction in outpatient care, which was developed in 1999 and validated by questioning adults, treated in general and specialized medical practices . The ZAPtal care . The partal care ,16.The goal of the present study was to adapt two existing questionnaires to a survey of parents whose children are seen in pediatric and adolescent primary care practices: the ZAP questionnaire and the questionnaire of parent satisfaction with hospital care ). The noThe parent survey was designed to assess aspects of both the child-physician and the parent-physician relationship. Byczkowski et al. 2010) found a large degree of corresponding assessments between adolescent patients and their parents regarding patient satisfaction. Further, we decided against the use of different versions for various age groups to ensure that the questionnaire can be widely used for parents of children of all ages in every day pediatric outpatient care [10 found The Child-ZAP was developed from the validated ZAP questionnaire for adults  which coThe preliminary version of the Child ZAP contained six scales (24 items) for parent assessment of parent-physician interaction (self-report), three scales (14 items) for parent assessment of child-physician interaction (proxy report), and three global items .The preliminary version was then subjected to psychometric testing and modified accordingly into a second and final version of the Child ZAP, which then was tested in the main study with a random sample from selected pediatric and adolescent primary care practices. The results of the psychometric analysis, based on data gathered in the main study, are presented below.The parents were instructed to answer the questions based on their overall satisfaction with the pediatrician in general, i.e., not merely based on the last doctor visit. This was included to ensure that the participants responded independent of their current doctor’s appointment. All items were rated on a four-point scale ranging from "very satisfied" to "very unsatisfied". Two scales, the proxy report scales "Child - Information" and "Child - Involvement" were coded with an additional response "Does not apply". The rationale behind this decision was the assumption that it would not always be possible or appropriate to provide information to very young children or involve them in decision making.The questionnaire also contained supplementary questions on the current doctor visit and on socio-demographic characteristics of the parents and their children.We decided to test the instrument in 20 practices in Northern Germany. In collaboration with the German Association of Pediatric and Adolescent Physicians (Berufsverband der Kinder- und Jugendärzte e.V.), all respective physicians in Lower Saxony, Bremen and Hamburg (n = 750) were invited to take part in the study. Of 222 practices who responded positively, 20 practices were randomly selected.No specific inclusion criteria were used for recruiting parents. However staff members were instructed to ensure that the participants were sufficiently fluent in German. Each practice received 100 questionnaires (including a letter and a stamped return envelope each), which were distributed randomly. The staff members instructed the parents to fill out the questionnaire at home and to return the questionnaire anonymously to the Hannover Medical School (MHH). The data collection for the preliminary study took place in winter 2007/2008, and for the main study in May 2009.Participating doctors and patients were informed about the study. The Ethics Committee of the MHH approved the study .To identify potential methodological weaknesses of the instrument and to reduce the number of items if possible, the preliminary study data collected in 19 pediatric practices were used to perform item and factor analyses considering wording quality criteria  and statistical criteria . The factorial structure of the preliminary version revealed high construct validity. However, considering the above mentioned criteria 5 items were removed from the questionnaire in order to reduce its length.The optimized instrument consisted of three scales (14 items) for parent assessment of the child's interaction, information and involvement in decision making and five scales (19 items) for assessment of the parents' own experience .The questionnaire items are shown in Table The final psychometric analysis consisted of item analyses  and tests of reliability and validity of the scales/subscales. Reliability was measured using a standardized coefficient of internal consistency . Construct validity was assessed by confirmatory factor analysis, which has been shown to be an adequate method for testing theoretically assumed factor structures of multidimensional scales ,22. Two To determine whether the measurement model was appropriate for both younger and older children, the model previously defined for the overall sample was analysed in two parallel groups: children up to age 6 and children older than 6 years of age. Three models were compared with the unconstrained baseline model.Model 1 referred to the assumption that there would be no statistically significant differences in any of the estimated parameters within the individual subsamples.Model 2 was based on the assumption that the parameter estimates would differ only in terms of the error variance and that there would be no statistically significant differences between both subsamples in terms of the regression coefficients of the latent constructs for the observed individual items and of the inter-correlation of the latent constructs.The third model implied that there would be no statistically significant differences in the regression coefficients of the latent constructs of the observed individual items in both subsamples.Stability of the measurement model is not given unless the chi-square statistic of the model does not differ significantly from that of the unconstrained model .The test of model quality was performed using the chi-square statistic, the comparative fit index (CFI), the Tucker-Lewis index (TLI), the Root Mean Square Error of Approximation (RMSEA), and the Standardized Root Mean Square Residual (SRMR). Model adaptation was determined to be acceptable based on the following criteria: non-statistically significant difference in chi-square statistic, high CFI (> 0.95), high TLI (> 0.95), low RMSEA (< 0.06), and low SRMR (< 0.11) -29.An initial assessment of the convergent reliability was obtained by calculating correlations (Spearman correlation coefficient) between the subscales and the global items for satisfaction. We compared subscale means along different categories of wait times and consultation length by one way analysis of variance.All statistical analyses were performed using SPSS for Windows V.17 and AMOS17 software.A total of 979 valid questionnaires were available for analysis . More than 90% of the questionnaires were completed by the mothers . This tendency was most pronounced in the subscales "Child – Interaction" and "Child - Information". Ceiling effects were much less pronounced in all other scales. The internal consistency of the child-subscales was acceptable to good  with CroA confirmatory factor analysis of the dimensionality of the construct "patient satisfaction", as derived from the preliminary study data, was conducted using main study data . The regression weights of the individual items of the respective scales on the latent factors, the squared multiple correlations of the individual item, and the correlations of the latent factors with each other are presented in . Conversely, the proportion of residual variance not explained by the model were low (RMSEA 0.6/046 and SRMR 0.038/0.049). Thus, the values were within the recommended range. The chi-square statistic of the two models was highly significant. However, considering the large sample size, this should not be overrated .The results of the test of stability of the measurement model are shown in Table All subscales featured a positive and statistically significant correlation with the three global items overall satisfaction with the pediatrician, quality of care, and trust in the physician Table . The subAs shown in  and statistical reasons, it was decided not to shorten the tool. Moreover, the Child-ZAP was not reduced any further, because it is designed for quality assurance in outpatient pediatric practices. Thus, not only the scale scores, but also the results at single item level is of interest and important, for example, for the scale "professional competence", which consists of the items "collaboration with other medical faculties", "thoroughness and diligence in examinations" and "readiness to refer the child." For this reason and due to specific requirements in outpatient pediatric practice the child-ZAP is significantly longer than the original adult ZAP.Although the ceiling effects were pronounced and corresponded to the "high" patient satisfaction observed in other studies ,33, theyFurther, it has to be noted that the participating practices and parents were not randomly selected, and not representative of the population. Although we provided an instruction for this random distribution, it was not possible to control that this was done correctly. Thus, a selection bias can not be ruled out. It would be desirable to validate the questionnaire in a population-based sample.The relatively high percentage of missing values for the parent scale "professional competence" appears to be problematic. However, the two items on the "professional competence" scale that resulted in the high number of missing responses concerned the parent's opinion of the pediatrician's collaboration with other medical facilities and the pediatrician's readiness to refer the child. Thus, it can be assumed that many parents who did not provide a valid answer to these items did not have any experience regarding the physician's readiness to refer the patient or collaborate with other facilities, and are not able to answer these questions. As the probability of parents having such an experience presumably increases with their child’s age, missing responses for these questions are most likely for parents of younger children. Post-hoc analyses of our data showed, that this assumption is supported by the decrease of percentage of missing data with increasing age of the child (data not shown).Basically it can be assumed that the pediatric and adolescent primary care physicians were motivated to participate in the study. The response rate of nearly 50% is comparable to similar patient surveys in German private practices. ,35,36.When assessing the process quality from the patient’s point of view in pediatric and adolescent primary care rather than in adult health care, both the parents’ as well as the child’s perspective must be included. Therefore, the notion of "patient satisfaction in pediatric and adolescent primary care" is more complex than in adult primary care. This was taken into account while developing questions and scales which explicitly relate to the interaction between the physician and the child as well as to experiences and opinions of the accompanying parent.The inclusion of the patient partnership in decision making as a component of health care process quality assessments, particularly patient satisfaction surveys, is a recent development ,11, and The fact that in a questionnaire used in outpatient pediatric practice, only the parents were interviewed, may at first seem strange. However, given the fact that more than half of the target population can not be interviewed directly due to their age, this decision appears to be justified. In addition, studies in which self-assessments of children and assessments by their parents are compared show a high correlation between these two measures -41.The proposed instrument to assess patient satisfaction in pediatric and adolescent primary care practices shows psychometric qualities which justify its use in quality management. Due to specific circumstances in pediatric and adolescent primary care practice (child and adult interviewees), the Child ZAP is longer than the original adult version of the ZAP. Its modular design and feasible procedure allow for a flexible implementation of the survey instrument which meets various requirements of quality management. Considering the cultural diversity of patients seen in pediatric and adolescent medicine, a translation of the Child ZAP into other languages, such as Turkish, Serbian, Russian and English would be desirable.2: Chi-Square-Statistic; Child ZAP: Patient satisfaction in pediatric outpatient settings from the parents’ perspective; CHINFO: Child-Subscale "Information; CHINT: Child-Subscale "Interaction"; Df: Degrees of freedom; M: Mean; MHH: Hannover Medical School; MV: Missing values; ParDM: Parent-Subscale "Parent-Decision making"; ParInfo: Parent-Subscale "Parent-Information"; PFacil: Parent-Subscale "Practice facilities"; POrg: Parent-Subscale "Practice organization"; ProfComp: Parent-Subscale "Professional competence"; RMSEA: Root Mean Square Error of Approximation; SD: Standard deviation; SRMR: Standardized Root Mean Square Residual; TLI: Tucker-Lewis index; ZAP: Patient satisfaction with ambulatory care.CFI: Comparative fit index; ChDM: Child-Subscale "Decision making"; Chi'The authors declare that they have no competing interests. NW is Member of the Board of German Association of Pediatric Physicians (BVKJ).EMB and MLD designed and oversaw the study, EMB and MP performed the statistical analysis, SV developed the questionnaire and organized the data collection, EMB, MLD and MP wrote the manuscript, NW recruited the participating physicians and critically revised the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/12/347/prepubFigure S1. Child ZAP: Confirmatory factor analysis of the "Child" scales (unrestricted baseline model).Click here for fileFigure S2. Child ZAP: Confirmatory factor analysis of the "Parent" scales (unrestricted baseline model).Click here for fileFigure S3. Child ZAP: Wait time at the practice.Click here for fileFigure S4 Child ZAP: Physician contact time.Click here for file


However, the advent of numerous immunological and molecular methods has facilitated the study of BRSV enormously. The knowledge gained from these studies has also provided the opportunity to develop safe, stable, attenuated virus vaccine candidates. Nonetheless, many aspects of the epidemiology, molecular epidemiology and evolution of the virus are still not fully understood. The natural course of infection is rather complex and further complicates diagnosis, treatment and the implementation of preventive measures aimed to control the disease. Therefore, understanding the mechanisms by which BRSV is able to establish infection is needed to prevent viral and disease spread. This review discusses important information regarding the epidemiology and molecular epidemiology of BRSV worldwide, and it highlights the importance of viral evolution in virus transmission.The bovine respiratory syncytial virus (BRSV) is an enveloped, negative sense, single-stranded RNA virus belonging to the pneumovirus genus within the family Paramyxoviridae. BRSV has been recognized as a major cause of respiratory disease in young calves since the early 1970s. The analysis of BRSV infection was originally hampered by its characteristic lability and poor growth  The bovine respiratory syncytial virus (BRSV) has been recognized as a pathogen in cattle responsible of an acute respiratory disease syndrome in beef and dairy calves since the early 1970s . The impPneumovirus genus within the subfamily Pneumovirinae, family Paramyxoviridae [BRSV is an enveloped, non-segmented, negative-stranded RNA virus belonging to the oviridae . The BRSoviridae .BRSV is closely related to human RSV (HRSV), and the epidemiology and pathogenesis of infection between these two viruses share some similarities and also many differences . The simUnderstanding of the global epidemiology and molecular epidemiology of BRSV has significantly improved over recent years. In this review, we discuss various aspects of the epidemiology and molecular epidemiology of BRSV as well as their relationship with viral evolution.BRSV infection is widely spread around the world, most likely as a direct result of the movement of cattle . RegardlBRSV outbreaks commonly occur during winter . Thus, cBRSV outbreaks can become epidemics affecting animals in all age groups. However, the age distribution of BRSV infection seems to be a function of exposure. In other words, herds that have been previously exposed to the virus tend to experience infections that are limited to younger, more susceptible animals. In consequence, morbidity is commonly high during the occurrence of outbreaks . ImportaThe mechanisms that are responsible for the survival of the virus within a given population are not fully understood. Controversial information has been reported about viral persistence. Nonetheless, chronicity has been proposed as a mechanism that might play role in disease spread . BRSV caThe prevalence of the disease varies greatly in North America. For instance, in the United States, original studies conducted during the early 1970s showed a frequency of infection of 67% among adult cattle . HoweverIn Canada, initial reports have shown that the overall frequency of BRSV infection might be nearly 36% ,17. HoweIn Europe, shortly after the virus’s discovery, it was reported to have widely circulated in different parts of the continent . In SwedIn Africa, Ethiopia and South Africa have also been shown to have high incidences of BRSV infection ,46,47,48Thus, more information is required to understand the mechanisms that allow for viral survival in a given geographical region. Monitoring of outbreaks among herds is likely to provide valuable information that might help us to understand in greater detail the epidemiology of BRSV infection.Limited information is available regarding the molecular epidemiology of BRSV infection. However, the rapidly changing field of DNA sequencing might help to unveil the molecular mechanisms exploited by BRSV to assure transmission. Additionally, the field of phylogenetics has contributed to identify the existence of diverse BRSV genotypes and their genetic relationship while helping understand the molecular basis of BRSV genetic history ,51. PhylThe occurrence of antigenic variation among BRSV isolates was first suggested by the lack of reaction between a polyclonal serum made against one particular viral strain, which failed to recognize a different isolate . FurtherThe study of the molecular epidemiology of BRSV began with the identification of the nucleotide sequences of the glycoprotein (G), fusion (F), nucleocapsid (N), matrix (M), phosphoprotein (P), small hydrophobic (SH) and M2 proteins during the early 1990s ,65,66,67More comprehensive studies, which analyzed the reaction patterns against anti-BRSV G protein and the genetic diversity occurring in a larger segment of the G protein gene from several isolates obtained from different geographical regions, showed that the intragroup genetic variation among BRSV strains ranged between 88% and 100% . The corA large-scale study addressing the global molecular epidemiology and evolution of BRSV included 54 European and North American isolates, in addition to previously reported sequences . The stu4 to 10.1x104 substitutions per nucleotide. These findings suggest that BRSV populations evolve as complex and dynamic mutant swarms, despite the virus’s apparent genetic stability.Importantly, BRSV intrahost population has been shown to exist as a complex mixture of viral variants, ambiguously referred as “quasispecies” . AnalyseMolecular epidemiology approaches have shown the circulation of identical viruses among animals within the same herds, especially during the occurrence of outbreaks . However–2011) occurring among 30 different herds [The global molecular epidemiology of BRSV has remained elusive. Only sparse reports addressing the distribution of BRSV groups are available in the literature. Consequently, the molecular characterization of BRSV isolates from representative regions of the world is still rather incomplete. A study conducted in Japan in the early 2000s reported the circulation of strains belonging to subgroup III. The isolates were further subdivided into two distinctive lineages . Unfortunt herds . The repnt herds . Thus, bIn summary, the study of the molecular epidemiology of BRSV has evolved considerably over the past two decades. The information generated by the study of the molecular characterization, phylogenetics and evolution of BRSV strains have broadly advanced our understanding of the molecular mechanisms controlling virus transmission and disease spread. However, this field requires extensive research to unveil the means exploited by the virus to attain persistence in a given population. The establishment of molecular surveillance of BRSV in different geographical regions will likely improve the identification of outbreaks, resulting in the implementation of preventive measures aimed to control the disease. The advent of next-generation sequencing platforms on the eve of the “DNA-sequencing era” could also provide a unique opportunity for the discovery of the underlying processes responsible for viral replication and survival in the host.BRSV has been recognized as an important cause of respiratory disease in cattle for nearly four decades. The characteristic heterogeneity of the viral genome and its low fidelity in replication are some of the most important features that the virus exploits to assure its survival and persistence within the host. The instability of the viral particle usually leads to unsuccessful attempts to isolate viral strains in the laboratory from clinical specimens. Consequently, molecular approaches are rapidly becoming the gold standard for the correct identification and characterization of BRSV in clinical cases. As result, the field of the molecular epidemiology of BRSV has gained significant strength and has further enhanced our knowledge about BRSV distribution and transmission patterns worldwide. The arrival of new and more sophisticated molecular methods, including next-generation sequencing, will most likely help to unveil the genetic makeup of the circulating viral population in different geographical regions, as well as the mechanisms on which the virus relies for survival, persistence and transmission.


Impressive advances in computers and materials science have fueled a broad-based confluence of basic science breakthroughs. These advances are making us reformulate our learning, teaching and credentialing methodologies and research and development frontiers. We are now in the age of molecular medicine. In the entire field of health care, a paradigm shift from population-based solutions to individual specific care is taking place. These trends are reshaping the practice of medical physics. In this short presentation, examples are given to illustrate developments in image-guided intensity-modulated and adaptive helical tomotherapy, enhanced application of intensity modulation radiotherapy (IMRT) using adaptive radiotherapy and conformal avoidance. These advances include improved normal tissue sparing and permit dose reconstruction and verification, thereby allowing significant biologically effective dose escalation and reduced radiation toxicity. The intrinsic capability of helical TomoTherapy for megavoltage CT imaging for IMRT image-guidance is also discussed. Finally developments in motion management are described. It is a great pleasure and honor to be invited to deliver the Dr. Ramaiah Naidu oration. In the early thirties of the twentieth century, Dr. Naidu established the foundations of medical physics. He was a post-doctoral fellow of Madame Curie and was the first medical physicist at the Tata Memorial Hospital, Bombay, where he installed a Radon production facility. He implemented a similar facility at the Sloan Kettering Memorial Institute in New York. If he were here today, he would be amazed how the field has changed. During the last decade, the complexity of detection, planning and delivery tools for medical services has increased exponentially. The computer age has been a double-edged sword. It has significantly enhanced our capabilities while also increasing the potential for greater risks in the delivery of our services. New technology not only requires a highly skilled medical physicist - it also requires continuous updating of knowledge and skills and integration of new technological developments in our practice. There are new challenges in all of the following areas: Learning, teaching, research and development and clinical services.In the past the pace of change was slow and we used to become a qualified individual for life. In the current age of rapid change, we will need to be responsive to these changes and to be accountable to the high expectation of our clients (patients). The competencies required in the practice of clinical medical physics have grown: a professional medical physicist needs communication, managerial and scholastic competence and should also be a collaborator and advocate. To meet these obligations, training and education we receive to qualify as a certified medical physicist would require a continuous process of maintenance of certificate. It would need to be responsive to change. It would need to be an educational initiative for continuous personal development (CPD), an activity designed to enhance knowledge, skills, attitudes and competencies, required for practice. It would need to be documented and have measurable outcomes from engaging in CPD. The overall goal would be to improve practice performance, enhance the quality of patient care, safety. Moreover, nowadays all the scientific fields, similar to medical physics, are approaching a multidisciplinary paradigm. In order to keep up with the development of any field, an individual has to learn the latest changes in technology and other related skills, viz., imaging sciences, algorithm design, or use of soft computing techniques.Our knowledge base in the last decade has increased dramatically (The American Association of Physicists in Medicine report # 79) and continues to expand significantly. How and what we teach impacts many health sciences professionals. We teach medical physicists, radiation therapists, radiation oncologists and radiologists. Unfortunately our teaching methods have not changed and are archaic. We need to develop clinically relevant teaching tools, incorporate modern web-based technology and use interactive processes to teach clinically relevant material that reflects professional needs. The American Association of Physicists in Medicine (AAPM), American Board of Radiology (ABR) and American Society for Therapeutic Radiation Oncology (ASTRO) are all developing new syllabi and teaching tools. Some specific challenges we face are:Retaining highly regarded facultyDeclining federal funding for research supportLarge class sizesRealigning to the new era of medicine with focus on molecular biology and genomicsImaging to emphasize function and biological interactions, micro-imaging and pinpoint therapySpace needs for larger training programsIn the long run, with these efforts we may claim to have trained better health sciences professionals based on higher board scores or decreased mistakes; however, the real differences can be measured only in the quality of care delivered to patients.Significant physical and biochemical developments in the radiation oncology related fields have created potential for dose escalation in the delivery of radiation treatments. Some of these developments are based upon new compounds and models and many are from new imaging tools shown in During the last 30 years, radiobiological modeling has evolved on many frontiers. The concepts of nominal standard dose2 gave waThe need for safe delivery of inhomogeneous dose distributions without increasing risks to normal structures has provided an impetus to the development of imaging tools coupled to radiation delivery systems. Examples of some of these are given in in vivo using remote imaging devices . Molecular imaging as now envisioned actually exploits creative synergies between these hierarchies of signal sources, resulting in fusions between these biological scales. Molecular imaging is a rapidly evolving area, with a focus on monitoring gene expression Technological developments in computers and accelerator designs, particularly inverse treatment planning and dynamic multi-leaf collimation systems (dMLCs), have given the radiotherapy community the ability to deliver conformal and intensity-modulated radiation therapy (IMRT) treatments. With the implementation of image-guided radiation therapy (IGRT), there is a potential to delivImage-guided IMRT is redefining the practice of radiation oncology. Traditional methods of implementing beam intensity modulation have included individually designed compensators, static multi-leaf collimators (MLC), dynamic MLC and sequential  tomotherapy. Helical TomoTherapy providesIn contrast to standard radiotherapy, helical TomoTherapy  deliversOne of the significant features of the helical TomoTherapy unit is the presence of an integrated online MVCT unit. This permits verification of patient positioning, target tumor/organ registration to assess internal motion (including geometric shift and shape/volume changes) and reconstruction of delivered dose. These capabilities offer the radiation oncology team the ability to verify and adjust the therapeutic plan as needed during the course of treatment. This concept is referred to as adaptive radiotherapy. These ca13Newly developed dose reconstruction tools use data acquired during the delivery of a treatment to determine the actual three-dimensional dose deposited. At the time of treatment on the TomoTherapy unit, the incident energy fluence is computed from the signal detected at the exit detectors. An accurate, anatomically detailed 3D representation of the patient is also obtained. A transfer matrix then converts this signal to incident energy fluence. In other words, the matrix determines the energy fluence emitted from the MLC from the signal at the detector. The integrated CT detectors present in the TomoTherapy unit provide detailed information about the primary projection, as well as the scatter characteristics of every projection. Pathlength and detector-to-patient distance are computed from the MVCT image. Leakage and transmission plus tongue and groove penumbra are also included in the calculation. This fluence corrected for some additional MLC effects is used in the treatment dose distribution computation. Effectively, this provides an accurate daily delivered dose record, which can be compared directly with the planned dose distribution.The ability to accurately reconstruct the 3D dose distribution permits a quantitative comparison of desired and actual dose distributions delivered to the patient. An example illustrating this issue is described in et al.[et al.[The comparison of desired dose distributions to the actual delivered dose distributions is based on the methods of Van Dyk et al. and Low l.[et al. The two The × value provides a measurement of quality for every voxel, indicating if they are within the desired tolerance or how far they deviate from that tolerance. Typical tolerance values in IMRT are 3% and 3 mm for DD and DTA respectively. The smaller the × value, the more accurately the compared isodose distributions are aligned. To facilitate the spatial identification of problem areas, color-wash images of × maps can be displayed Figure –d. FigurWith helical TomoTherapy, MVCT images can be registered using a full mutual information algorithm, bone extracted feature fusion (EFF) and bone and tissue EFF algorithms, with uniform down-sampling of the MVCT images along the x and z axes (to provide a time-saving by a factor of up to 4) with and without the rotational registration components. These particular algorithms take into account any changes in patient anatomy between the reference image and fusion image when the image registration is carried out.The advances in adaptive radiotherapy, conformal avoidance and enhanced localization and immobilization have provided an impetus for novel time dose fractionation dose delivery schemes to improve local control and possibly increase survival rates. These dose-fractionation regimens are target specific  and provide significant sparing of normal tissues, increase the total dose and dose per fraction, and reduce the number of fractions delivered to reduce the overall treatment time.Many IMRT approaches rely on increasing the number of beam directions and modulating beam intensity such that multiple tiny sub-beams are created. While this improves dose distributions, the clinical applicability of such pencil beams requires immense precision; the slightest patient/organ/tumor motion is likely to result in unintended errors. Therefore, although highly irregular dose distributions and dose volume histograms (DVHs) can be created, their clinical application is uncertain. Some of the patient immobilization and motion management systems to address this issue are described below.et al.[Noninvasive head frame systems often rely on external contours of the head and face and have immobilization errors of 2-4 mm in favorable circumstances. Such systems include the Heidelberg system, which has a reported accuracy of 2 mm; the Laitet al.–20 have To demonstrate the clinical relevance of optical guidance, an early implementation of this system is illustrated in Figures The system described above works well as long as the rigid body approximation holds, as is the case for intracranial lesions. However, outside the cranium, soft-tissue targets can move relative to rigid fixation points  between the times of image acquisition, treatment planning and treatment delivery. Real time imaging is useful in determining target location at the time of treatment delivery. A system based on 3D-ultrasound guidance  can be used to correct for these misalignments at the time of treatment. Ultrasound is chosen because it is a flexible and inexpensive imaging modality that can easily be adapted for use in a radiation therapy treatment room. The interpretation of two-dimensional ultrasound images can be challenging and is highly dependent on the skill of the operator in manipulating the transducer and mentally transforming the 2D images into a 3D structure. Three-dimensional ultrasound imaging overcomes this limitation. The 3D ultrasound data sets are generated through optical tracking of free-hand acquired 2D ultrasound images. The position and angulation of the ultrasound probe are determined using an array of four infrared light-emitting diodes (IRLEDs) attached to the probe. An infrared camera is used to determine the positions of the IRLEDs and this information is input to the computer workstation. The position of each image plane can therefore be determined using the IRLEDs and an ultrasound volume can be reconstructed by coupling the position information with the images. In addition to building the 3D image volume, optical guidance is used to determine the absolute position of the ultrasound image volume in the treatment room coordinate system. Because the relative positions of the 3D-image volume and the ultrasound are fixed, knowledge of the probe position in the treatment room coordinate system at the time of image acquisition is sufficient to determine the position of the image volume relative to the linac isocenter. The image-to-probe relationship is determined by a calibration step performed at the time of system installation. In this Currently, ultrasound is being used in conjunction with MVCT. We are presently conducting a comparison of ultrasound with MVCT. Ultimately, it may be that MVCT alone will be the only image guidance necessary.Two strategies have emerged to deal with the problem of respiratory motion. One strategy is to ‘immobilize’ the lung during one phase of respiration and to gate radiation to this phase. This requires the ability of patients to hold breath for a short period of time, which may be difficult in patients with respiratory cancers. The second strategy is to radiate at a predetermined period during respiration using dynamic aperture tracking. Online verification of the correct phase of respiration requires a respiratory monitoring device. Another An attempt is made here to give an overview of some of the recent developments. The concepts of motion synchronization of treatment delivery will be elaborated. During the last 5 years, there has been significant development in breathing-synchronized delivery (BSD) of 4-D optimized IMRT treatment plans.–35 Due tIn BSD, patient breathing and treatment delivery are synchronized by instructing the patient to breathe following a breathing guide. We have previously developed a 4-D TomoTherapy treatment technique based on BSD. We have extended the application of BSD into conventional radiation treatment using dMLCs. Dynamic 4D-CT images are acquired for treatment planning, and the images at full exhalation phase are used as treatment planning images. A typical IMRT treatment plan is developed that yields dynamic leaf sequences for sliding window delivery of IMRT. Average target trajectory is obtained by deformable image registration of 4-D data sets and is smoothed by Fourier filtering. Assuming the patient breathes with a reproducible breathing pattern and a constant dose delivery rate, the treatment process is corre-lated with the breathing phase in BSD treatment planning. Figures A custom-built mobile  phantom The BSD technique described for use with dMLC is similar to the method of real-time tracking. This method basically needs no hard-ware modification and avoids the difficulties of real-time tracking. Unlike cardiac motion, breathing motion, to some extent, can be voluntarily controlled by some patients. Studies have shown that many patients may be able to maintain a regular breathing pattern with some instruction. We are currently developing a patient train-ing device to allow more practice for the patient. Since BSD allows continuous air exchange, it is better tolerated than breath-hold gating.We realize that breathing motion is an extremely challenging frontier in the delivery of precision radiotherapy and is a function of several physiological, behav-ioral and mechanical processes. Even though we may have developed an idealized 4D-CT/PET and patient-guiding cycle based on optimized IMRT treatment, its delivery is significantly susceptible to the above-mentioned processes during the delivery of the plan. The baseline filling of the lung has also been identified as a significant factor in the determination of the daily position of the target volume, which makes daily pretreatment imaging indispensable. We believe that further refinement of the BSD technique will be possible using the on-board imaging verification processes offered by TomoTherapy and kilovoltage cone-beam CT.The availability of new imaging modalities before and during radiotherapy planning and delivery has allowed us to launch new tools at every major step of the treatment process. Radiation therapy is unique among the cancer treatment modalities because it can be modulated in the four dimensions of time and space. Modulation in the time domain gives rise to the time-dose-fractionation problem, and this continues to be one of the most fruitful avenues for further improvement of the therapeutic ratio in radiation oncology. Spatial modulation has been greatly facilitated by recent technological advances in image guidance based treatment planning and delivery. Progress in functional and molecular imaging, together with an improved understanding of the patterns of spread of cancer, provides the tools that will allow us to prescribe 4D radiation therapy that is optimized in the individual patient. All of these developments, combined with progress in biological and chemical targeting of cancer cells, provide not only challenging and exciting research opportunities but also a real hope that more cancer patients will be cured .Between-patient differences can be identified and exploited with ever-greater finesse by ever-finer levels of an ever-increasing inventory of covariates, which now include an increasing number of biological and biochemical measures on continuous scales, as well as the coarser nominal and ordinal demographic measures  of the past.Moreover, within-patient differences across time, e.g., the circadian variations in patient physiology and the infra-treatment organ motion that continually scans the target volume across the steep dose gradients of the IMRT radiation fields during each daily treatment can now be tracked and their effects either exploited or compensated for: Modern (‘adaptive’) radiotherapy can now routinely ‘hit a moving target.’ All of this diversity of information is very patient specific, and we are challenged to seek individual patient-specific solutions  instead Clinical implementation of IMRT, especially image-guided IMRT, is in a state of rapid evolution. Helical TomoTherapy, one the latest steps in this evolution, is an IMRT system whose design incorporates aspects such as infinite beam angle optimization and MVCT-based delivery verification. These features have the potential to permit the full clinical development of adaptive radiotherapy and conformal avoidance. To realize the ultimate goal of improving clinical outcomes for our patients, appropriate patient immobilization, optimized target localization, conformal avoidance of sensitive normal structures and radiobiologically-guided dose escalation are required. The clinical implementation of helical TomoTherapy and the consequent issues raised (such as radiation dose rates and dose homogeneity) present questions and opportunities that may change the current paradigm in radiation oncology.


A 20-year-old man presented with 90% total body surface area third-degree burns from a gasoline fire in his basement. He underwent extensive fascial excisions of his burn wounds, including his neck and upper chest . All wouWhat is the cause and pathophysiology of the condition?What is the morbidity associated with them?What are the management options?How does the surgical treatment differ in the burn patient?The patient has a persistent tracheocutaneous fistula (TCF) which is a well-recognized complication of long-term tracheostomies. Removal of the tracheostomy tube usually results in rapid narrowing of the stoma, followed by spontaneous closure of the overlying skin; however, the tract may be more prone to fistula formation depending on the duration of cannulation. Longer periods of cannulation predispose the tract to epithelialization, reducing the ability to close. Kulber and Passy,3The morbidity of persistent TCFs has both functional and cosmetic aspects. A TCF can cause difficulty in phonation and swallowing, skin irritation, intolerance to submersion due to aspiration risk, and ineffective clearance of secretions. In addition, unsightly deformities can lead to self-stigmatization.2The best method of management of TCFs is prevention. The need for tracheostomy must be continuously evaluated, and they should be removed expeditiously when no longer needed. However, burned patients may require long-term tracheostomies because of the multitude of surgical procedures and intensive care. Other management options include curettage and application of silver nitrate. In addition, electrocautery of the epithelial tract has been used to remove granulation tissue and its bioburden while promoting healthy tissue for wound contracture and ultimate healing. Several successful surgical techniques have been described including primary closure, fistulectomy with primary closure, and fistulectomy with closure by secondary intention. Bishop et alThe fundamental principle of a TCF repair in a burned patient is skin preservation which adds a degree of complexity. In the patient described, a tracheostomy tube remained for more than a year prior to decannulation. The difficulty in closing a persistent stoma in a burned patient is due to the lack of mobility of surrounding tissues from extensive scarring in addition to the lack of subcutaneous tissue that occurs with fascial excision. Moreover, cultured epithelial autograft skin is fragile making dissection of the muscle and skin all the more challenging.Bilateral, curvilinear incisions were performed on each side of the stoma allowing us to preserve the skin, dissect, and mobilize the sternohyoid muscles medially  and 4. B


Penile fracture is an uncommon urologic emergency, and is the traumatic rupture of the tunica albuginea covering the corpus cavernosa. This usually occurs following blunt trauma sustained during coitus, masturbation or self-manipulations to hide or suppress an erection. Clinical diagnosis can often be easily made with typical history and examination findings. However, the patient may present atypically and/or with a suspicion of associated urethral injury. The roles of various diagnostic investigations are being evaluated in these situations.We report the case of a 31-year-old African man with penile fracture and suspected associated urethral injury that occurred after self-manipulations to hide an erection.Penile ultrasound and sonourethrography provide useful additional diagnostic information to supplement clinical history and physical examination findings and can be performed easily, at low cost and with no delays to surgery. Penile fracture is an uncommon urologic emergency, and is the traumatic rupture of the tunica albuginea (TA) covering the corpus cavernosum (CC). It results when blunt trauma to the erect penis results in a rapid build-up of pressure in the engorged CC, which overwhelms the tensile strength of the TA; this often follows trauma during coitus, masturbation or self-manipulations to hide or suppress an erection ,2. SeverA 31-year-old African man presented to our emergency unit with a four-hour history of penile swelling and voiding difficulty. He had earlier tried to suppress an erection before his routine morning religious rituals by kneading on his erect penis. He heard a popping sound with associated minimal pain and sudden detumescence. He noticed no bleeding per urethra but subsequently had difficulty with voiding and urinary frequency. On physical examination, he had a grossly swollen and deformed penis with deviation to the right side Figure  and 3A,BBlunt trauma to the erect penis may generate pressures in excess of 1500mmHg within the CC, resulting in rupture of the TA . MasturbThe patient often reports a popping sound, mild to severe pain and sudden detumescence ,2. This Radiologic evaluations have been described for patients with penile fracture and these include retrograde urethrography, cavernosography, magnetic resonance imaging (MRI), penile ultrasound and sonourethrography -9. RetroOur patient had both penile ultrasound and sonourethrography performed in the same sitting about an hour after presentation to the emergency unit. This was a simple, non-time-consuming procedure, and inexpensive at a cost of US$7. It identified the area of tear in the TA with the associated hematoma and ruled out urethral injury as there was no evidence of hematoma seen in the corpus spongiosum or extravasation of the fluid used in distending the urethra during real-time sonourethrography. Our patient additionally had retrograde urethrography, which also revealed no urethral injury but unlike the sonourethrogram was associated with radiation exposure, was more invasive with risks of allergic reaction to contrast and gave no information about the tear in TA or associated hematoma. It was also six times the cost of the sonourethrogram and penile ultrasound put together.Early surgery for penile fracture has been advocated to prevent the significantly greater complications seen with delayed surgery -3. Our pEvaluation of penile fracture by penile ultrasound and sonourethrography gives additional useful diagnostic information to that obtained from clinical history and examination in patients with atypical presentations and or suspected associated urethral injury. The penile ultrasound and sonourethrography can be performed easily, at relatively low cost and results in no delays to surgery.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The author declares that there are no competing interests.


Zenker diverticulum is often observed in elderly patients complaining of dysphagia and regurgitation. Endoscopic transoral stapling was introduced in the 90’s as an alternative to standard open diverticulectomy and cricopharyngeal myotomy for the treatment of Zenker diverticulum. Aim of this study was to evaluate the results of this procedure in patients over 75 years of age.®) was routinely used to improve traction of the septum inside the stapler jaws. Patients OLDER and YOUNGER than 75 years were compared for perioperative variables and long-term outcomes using Chi-squared test, Student’s t test and Kaplan Meier analysis with log-rank test. Recurrence was defined as a relapse of the symptoms requiring reoperation.Between 2002-2010, 73 patients  underwent transoral stapling. The operation was performed under general anesthesia using a Weerda diverticuloscope and one or more cartridges of linear endostapler. Since 2008, a retention suture (EndostitchResults are shown in Table Transoral settotomy is safe and effective even in elderly patients, with short and long-term outcomes similar to younger patients. Because of the low incidence of postoperative complications and the higher rate of long-term satisfaction, the technique should be proposed as the first approach for the treatment of Zenker diverticulum in elderly patients.