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A case of disseminated herpes zoster in an immunocompetent child (2023)

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Type of publication:
Conference abstract

Author(s):
*Jacob M.A.; *Kelly S.

Citation:
British Journal of Dermatology. Conference: 103rd Annual Meeting of the British Association of Dermatologists. Liverpool United Kingdom. 188(Supplement 4) (pp iv156-iv157), 2023. Date of Publication: June 2023

Abstract:
Herpes zoster (HZ) caused by the reactivation of varicella-zoster virus (VZV) affects mainly the adult population. The incidence is low in children (0.45 cases per 1000 individuals annually), especially in the immunocompetent. It is said to be disseminated when there are >20 lesions outside the primary and adjacent affected dermatome. We present this case to highlight a rare complication of cutaneous dissemination in a previously healthy child with HZ, following in utero exposure to varicella at 28 weeks' gestation. A 15-year-old boy presented with painful blisters in the T2 dermatome of 1 week's duration, which later spread to trunk, extremities and face. This was associated with fever and neuralgia. There was no previous history of varicella and no recent contact history. He had no significant past medical history and was not on any medications. Antenatal history revealed that his mother had varicella at 28 weeks' gestation and was treated with aciclovir. He was febrile on admission (39degreeC). There were coalesced vesiculopustules and crusted lesions with marked perilesional erythema in the T2 dermatome. In addition, disseminated vesicular lesions were seen on the trunk, extremities and face. Remaining systemic examination was unremarkable. C-reactive protein was elevated. Complete blood count and renal function tests were normal. Liver function tests, namely alanine transaminase and 7gamma;-glutamyl transferase were elevated. Blood culture showed no growth. Varicella-zoster IgG was positive. Viral swab (polymerase chain reaction) from the skin lesions was positive for varicella-zoster DNA. Infectious serology for HIV, hepatitis B and hepatitis C was negative. Antinuclear antibody and antineutrophil cytoplasmic antibodies were negative. A clinical diagnosis of HZ with cutaneous dissemination was made, and he was treated with intravenous aciclovir. Intravenous antibiotics were added for suspected secondary bacterial infection. Disseminated zoster is less common in children and mainly occurs in patients with underlying immunodeficiency like HIV, immunosuppressive drug use or malignancy. In immunocompetent children, this can happen when primary infection (varicella) has occurred in utero or the first year of life due to the low response in specific varicella-zoster virus immunity. Complications like cutaneous dissemination due to viraemia are rare in healthy children, but can affect 2-10% of immunocompromised patients. It occurs 3-4 days after the onset of dermatomal lesions. It is important to look for other complications, especially in the immunocompromised, as viraemia can affect the brain, kidneys, lung and liver. Sequelae like postherpetic neuralgia is rare, but it is important to follow-up these children to look for its development.

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Focused transoesophageal TOE (fTOE): A new accreditation pathway (2023)

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Type of publication:
Journal article

Author(s):
Rubino A.; Peck M.; *Miller A.; Edmiston T.; Klein A.A.; Orme R.; Sankar V.; Fletcher N.; O'Keeffe N.; Skinner H.

Citation:
Journal of the Intensive Care Society. Date of Publication: 2023. [epub ahead of print]

Abstract:
The concept of a focused ultrasound study to identify sources of haemodynamic instability has revolutionized patient care. Point-of-care ultrasound (POCUS) using transthoracic scanning protocols, such as FUSIC Heart, has empowered non-cardiologists to rapidly identify and treat the major causes of haemodynamic instability. There are, however, circumstances when a transoesphageal, rather than transthoracic approach, may be preferrable. Due to the close anatomical proximity between the oesophagus, stomach and heart, a transoesphageal echocardiogram (TOE) can potentially overcome many of the limitations encountered in patients with poor transthoracic ultrasound windows. These are typically patients with severe obesity, chest wall injuries, inability to lie in the left lateral decubitus position and those receiving high levels of positive airway pressure. In 2022, to provide all acute care practitioners with the opportunity to acquire competency in focused TOE, the Intensive Care Society (ICS) and Association of Anaesthetists (AA) launched a new accreditation pathway, known as Focused Transoesophageal Echo (fTOE). The aim of fTOE is to provide the practitioner with the necessary information to identify the aetiology of haemodynamic instability. Focused TOE can be taught in a shorter period of time than comprehensive and teaching programmes are achievable with support from cardiothoracic anaesthetists, intensivists and cardiologists. Registration for fTOE accreditation requires registration via the ICS website. Learning material include theoretical modules, clinical cases and multiple-choice questions. Fifty fTOE examinations are required for the logbook, and these must cover a range of pathology, including ventricular dysfunction, pericardial effusion, tamponade, pleural effusion and low preload. The final practical assessment may be undertaken when the supervisors deem the candidate's knowledge and skills consistent with that required for independent practice. After the practitioner has been accredited in fTOE, they must maintain knowledge and competence through relevant continuing medical education. Accreditation in fTOE represents a joint venture between the ICS and AA and is endorsed by Association of Cardiothoracic Anaesthesia and Critical care (ACTACC). The process is led by TOE experts, and represents a valuable expansion in the armamentarium of acute care practitioners to assess haemodynamically unstable patients.

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Cardiovascular disease morbidity is associated with social deprivation in subjects with familial hypercholesterolaemia (FH): a study comparing FH individuals in UK primary care and the UK Simon Broome register linked with secondary care records (2022)

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Type of publication:
Conference abstract

Author(s):
Iyen B.; Qureshi N.; Roderick P.; *Capps N.; Durrington P.N.; McDowell I.F.W.; Cegla J.; Soran H.; Schofield J.; Neil H.A.W.; Kai J.; Weng S.; Humphries S.E.

Citation:
Atherosclerosis Plus. Conference: HEART UK 35th Annual Medical & Scientific Conference. Virtual. 49(Supplement 1) (pp S4-S5), 2022. Date of Publication: October 2022

Abstract:
Background: Measures of social deprivation are associated with higher cardiovascular diseases (CVD) morbidity and mortality. To determine if this is also seen in subjects with Familial Hypercholesterolaemia (FH), CVD morbidity has been examined in participants in the UK primary care database (CPRD) and in the UK Simon Broome (SB) register using linkage to the UK secondary care Hospital Episodes Statistics (HES). Method(s): A composite CVD outcome was analysed (first HES outcome of coronary heart disease, myocardial infarction, stable or unstable angina, stroke, TIA, PVD, heart failure, PCI and CABG). The measure of socio-economic status/deprivation used was the English index of multiple deprivation (IMD). Cox proportional hazards regression estimated hazards ratios (HR) for incident CVD and mortality [95% CI] in each IMD quintile. <br/>Result(s): We identified 4,309 patients with FH in UK CPRD primary care database (followed from 1988 to 2020), free from CVD, and 2988 SB register participants, with linked secondary care HES records. In both groups, the prevalence of FH was considerably lower in the most deprived quintile (60% in CPRD and 52% in SB). CPRD patients in the most deprived quintile (IMD-5) had the highest prevalence of obesity and of smoking compared to those from IMD quintiles 1,2,3 and 4 (p-value for trend, all <0.001). Compared to least deprived, the most deprived individuals had the highest risk of composite CVD (unadjusted HR 1.71 [CI 1.22-2.40]), however, on adjustment for smoking and alcohol consumption, there were no statistical differences in CVD risk between socio-economic groups. In the FH Register patients there was an increase in the incidence rates and hazards ratios for composite CVD with increasing quintiles of deprivation. After adjustment for age, sex, smoking and alcohol consumption, this effect remained statistically significant (quintile 5 vs 1, HR = 1.83 [1.54-2.17]. Conclusion(s): Patients with FH are underdiagnosed in lower socio-economic groups. In both CPRD and the SB Register the most deprived FH patients had the highest risk of CVD and mortality, but in CPRD but not in the SB register this was largely explained by smoking and alcohol consumption. Clinicians should adopt more effective strategies to detect FH in lower socio-economic groups, and to optimise risk factor management and to support lifestyle changes and medication adherence for this group.

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Formative Objective Structured Clinical Examinations (OSCEs) as an Assessment Tool in UK Undergraduate Medical Education: A Review of Its Utility (2023)

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Type of publication:
Journal article

Author(s):
*Al-Hashimi, Khalid; Said, Umar N; Khan, Taherah N.

Citation:
Cureus. 15(5):e38519, 2023 May.

Abstract:
The Objective Structured Clinical Examination (OSCE) is a globally established clinical examination; it is often considered the gold standard in evaluating clinical competence within medicine and other healthcare professionals' educations alike. The OSCE consists of a circuit of multiple stations testing a multitude of clinical competencies expected of undergraduate students at certain levels throughout training. Despite its widespread use, the evidence regarding formative renditions of the examination in medical training is highly variable; thus, its suitability as an assessment has been challenged for various reasons. Classically, Van Der Vleuten's formula of utility has been adopted in the appraisal of assessment methods as means of testing, including the OSCE. This review aims to provide a comprehensive overview of the literature surrounding the formative use of OSCEs in undergraduate medical training, whilst specifically focusing on the constituents of the equation and means of mitigating factors that compromise its objectivity.

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Treatment and outcomes of patients with gastrointestinal toxicity following immunotherapy: A large multi-center retrospective study in the United Kingdom by the National Oncology Trainees Collaborative for Healthcare Research (NOTCH) (2022)

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Type of publication:
Conference abstract

Author(s):
Swaminathan M.; Angelakas A.; Baxter M.; Cotton J.; Dobeson C.B.; Feeney L.; Gault A.C.; Hughes D.J.; Jones C.; Lee R.; Mughal S.A.; *Parikh S.P.; Pritchard M.; Rodgers L.J.; Rowe M.P.; Salawu A.T.; Shotton R.; Tinsley N.; Tivey A.; Olsson-Brown A.C.;

Citation:
Immuno-Oncology and Technology. Conference: ESMO Immuno-Oncology Congress 2022. Geneva Switzerland. 16(Supplement 1) (no pagination), 2022. Article Number: 100230. Date of Publication: December 2022.

Abstract:
Background: Immune checkpoint inhibitors (ICIs) have revolutionised the treatment of many cancers, but their use has been associated with the development of gastrointestinal (GI) toxicities such as colitis and hepatitis. Method(s): A multi-center retrospective study across 12 National Health Service centers across the United Kingdom (UK) was conducted by the UK National Oncology Trainees Collaborative for Healthcare Research (NOTCH) over a 2-year period. The study included patients receiving ICIs for malignant melanoma, non-small lung cancer and renal cell cancer as standard of care. Occurrence of clinically significant (>=grade 2) GI toxicity was assessed and correlated with subsequent treatment and outcomes. Multiple logistic regression was used to assess correlation. For overall survival (OS), Kaplan-Meier and log-rank tests were utilised. Result(s): The cohort included 2049 patients. 1230 (60%) were male with a median age of 66. Colitis occurred in 182 (8.9%) patients and hepatitis in 129 (6.3%). Of the patients where treatment was recorded, 129 (70.9%) received treatment with systemic steroids alone and 37 (20.3%) required second-line immunosuppressants (IS) in the colitis group. In the hepatitis group, 101 (78.3%) had steroids alone with 19 (14.7%) having IS. Improved OS was found in patients who experienced colitis (HR 2.59 95%CI: 2.15 to 3.11, p<0.0001) and hepatitis (HR 2.26, 95%CI: 1.84 to 2.79, p=<0.0001) compared to those with no adverse events. Pre-existing autoimmune disease (p=0.02) and combination ICIs (p=0.006) were predictors of colitis that required IS whilst grade 2 and 3 hepatitis (p<0.001) were predictors of hepatitis needing IS. The use of IS did not affect OS significantly in the colitis group (p=0.372) but did correlate with survival in the hepatitis group (p=0.037). Patients that were able to continue treatment with ICIs after toxicity had an increased OS in both groups (p<0.001). Conclusion(s): Patients with GI toxicity following treatment with ICIs have improved OS. The use of IS did not significantly affect OS which suggests they should continue to be utilised in the treatment of GI toxicity. Legal entity responsible for the study: United Kingdom National Oncology Trainees Collaborative for Healthcare Research (NOTCH).

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Stepped-wedge randomized controlled trial of laparoscopic ventral mesh rectopexy in adults with chronic constipation (2021)

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Type of publication:
Conference abstract

Author(s):
Grossi U.; *Lacy-Colson J.; Brown S.; Cross S.; Eldridge S.; Scott S.M.; Taheri S.; Knowles C.

Citation:
Colorectal Disease. Conference: 16th Scientific and Annual Meeting of the European Society of Coloproctology, ESCP 2021. Virtual. 23(Supplement 2) (pp 3), 2021. Date of Publication: October 2021.

Abstract:
Aim: Effectiveness of laparoscopic ventral mesh rectopexy (LVMR) in patients with defecatory disorders secondary to internal rectal prolapse (IRP) is poorly evidenced. A UK-based multicentre randomized controlled trial (RCT) was designed to determine the clinical efficacy of LVMR compared to controls at medium-term follow-up. Method(s): A stepped-wedge RCT design permitted observer-masked data comparisons between patients awaiting LVMR with those who had undergone surgery.Adult participants with radiologically confirmed IRP refractory to conservative treatment were randomized to 3 arms with different delays before surgery. Efficacy outcome data were collected at equally stepped time points (12, 24, 36, 48, 60, and 72 weeks). Clinical efficacy of LVMR compared to controls was measured as a 1.0-point reduction in PAC-QOL and PAC-SYM scores at 24 weeks. Secondary outcome measures included 14-day diary data, GAD7, PHQ9, St Marks incontinence score, PISQ12, CC-BRQ, and BIPQ. Result(s): Of 42 eligible patients, 28 (67%) females were randomized from 6 institutions. Nine were assigned to the T0 arm, 10 to T12, and 9 to T24. There were no substantial differences in baseline characteristics between the 3 arms. Compared to baseline, significant reduction in PAC-QOL and PAC-SYM scores were observed at 24 weeks post-surgery (-1.09 [95%CI -1.76, -0.41], P = 0.0019, and -0.92 [-1.52, -0.32], P = 0.0029). As opposed to PAC-QOL (-1.38 [-2.94, 0.19], P = 0.0840 at 72 weeks), improvements in PAC-SYM scores persisted to 72 weeks (-1.51 [-2.87, -0.16], P = 0.0289). Compared to baseline, no differences were found on secondary outcomes, except for significant improvements on CC-BRQ and BIPQ at 24 and 48 weeks. Conclusion(s): There was evidence of a short-term effect of LVMR for IRP up to 36 weeks. Improvements in quality of life declined over follow-up up to 72 weeks.

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Global Level of Harm experienced by Bariatric Surgeons for Bariatrics surgical interventions: An exploration of predictors (2022)

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Type of publication:
Conference abstract

Author(s):
Cheruvu C.; Bangash A.H.; Isik A.; Parmar C.; Galanis M.; Yang W.; Kok J.H.H.; *Bandyopadhyay S.K.; Di Maggio F.; Atici S.D.; Abouelazayem M.; Viswanath Y.K.S.

Citation:
British Journal of Surgery. Conference: AUGIS Annual Scientific Meeting. Aberdeen United Kingdom. 109(Supplement 9) (pp ix17-ix18), 2022. Date of Publication: December 2022.

Abstract:
Background: COVID-19 pandemic has taken the world by surprise with the depth and breadth of its effect on all walks of life, bariatric surgery being no exception. With the scientific literature hitherto unable to comment and ascertain the influence of the COVID-19 pandemic on bariatric surgery and the level of harm experienced by bariatric surgeons, we- TUGS 'Level of Harm' collaborative group- attempted to gauge the effect of the said pandemic on bariatrics surgery specifically vis a vis the level of harm experienced by bariatric surgeons due to the pandemic. Method(s): A virtual questionnaire- developed on both: Google forms and Survey Monkey- was circulated via TUGS social media platforms to reach bariatric consultant surgeons, fellows and residents practising throughout the world in a bid to explore the influence of the COVID-19 pandemic on their surgical practice including but not limited to the annual surgical volume including re-do surgeries volume and postoperative complications. Moreover, they were also requested to categorise their respective level of harm vis a vis bariatric surgical interventions they undertake. After de-identification of the data, SPSS (V.26) was adopted to undergo statistical analysis. After exploring the dataset by descriptive analyses, the Chi-square test was applied to pursue the association of categorical variables with the reported level of harm. A double-sided p-value of less than 0.05 was considered statistically significant. Result(s): 16.8% of the respondents (21/125) indicated no harm vis a vis bariatrics surgery work whereas a comparative 18.4% of the respondents (23/125) reported moderate harm with significant worsening of symptoms. None of those who indicated less than 10% increase in surgery waitlisted patients being subjected to endoscopic interventions (0/14) reported Moderate Harm for bariatrics surgery work with significant worsening of symptoms whereas 1 in every 3 of those who indicated between 10% to 25% increase in surgery waitlisted patients being subjected to endoscopic interventions (5/15) reported such level of harm for bariatrics surgery work. (p < 0.001) Upon exhaustive sub-group analysis, it was uncovered that 33.6% of bariatrics surgical professionals perceived no harm (no evidence of change in clinical condition) during gastric band or related surgery work with only 4% perceiving Moderate Harm (significant worsening of symptoms/ comorbidities control/ minor increase in medications) for such surgical interventions. All of those who reported No harm for gastric band or related surgical work reported that Single anastomosis duodeno-ileal bypass (SADI-S) accounts for 10% of their practice whereas none of those who indicated that SADI-S accounts for more than 10% of their practice reported No harm for such surgical work. (p = 0.019) Conclusion(s): The global snapshot illustrates a trend of low harm vis a vis bariatrics surgery work in surgical professionals practising in the private sector with a lesser number of patients developing COVID-19 postoperatively and no postoperative COVID-19 related mortality. The patient being subjected to endoscopic intervention portends a higher level of harm for bariatrics surgical work- strict adherence to criteria and safety protocols being a logical inference. For gastric band and related surgery work, preoperative COVID-19 testing appears to be influenced by confounders in its effect on the surgeon's level of harm for the said interventions warranting further exploration. SADI-S, at a cut-off of 10%, exhibits strong interaction with the surgeon's level of harm for gastric band insertion and relation surgery work. Women surgical professionals came out to exhibit equivalent mental resilience and technical prowess at par with their male colleagues when it came to bariatrics surgical intervention

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Folliculitis decalvans managed with long pulsed Nd:YAG; our experience and a review of the literature (2022)

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Type of publication:
Conference abstract

Author(s):
*Oh S.; *Badrol S.; *Tzortzis S.; El Shimy N.; Murdoch S.;

Citation:
Lasers in Medical Science. Conference: British Medical Laser Association Annual Conference, BMLA 2022. Edinburgh United Kingdom. 37(9) (pp 3769), 2022. Date of Publication: December 2022.

Abstract:
Background Folliculitis decalvans (FD) is a rare inflammatory disorder predominantly of the scalp that can progress to cicatrical alopecia. Mainstay treatment is antibiotics; however, resolution is difficult, and relapse is common. Only three cases of FD treated with neodymium:yttrium aluminum garnet (Nd:YAG) laser exist in the literature. We present two cases of recalcitrant FD managed with long pulsed Nd:YAG laser and a literature review. Study Design Retrospective case series of two patients with FD treated with long pulsed Nd:YAG laser. Results The first case was a 49-year-old male with Fitzpatrick skin type II. Previous unsuccessful treatment included oral doxycycline and isotretinoin. A course of eight sessions of Nd:YAG laser (CynergyTM, Cynosure) was performed with settings of 50J/cm<inf>2</inf>, 20msec pulse duration, and 10mm spot size. Complete resolution of FD was achieved and remained stable without adjuvant treatment at 6 months post laser. The second case was a 46-year-old male with Fitzpatrick skin type IV with 9-years history of FD. Previously, oral antibiotics (clindamycin, rifampicin, erythromycin, ciprofloxacin) as well as dapsone, intralesional triamcinolone and acitretin treatment was trialled without success. A total of four successful treatments with Nd:YAG laser was completed with settings of 30J/cm<inf>2</inf>, 40msec pulse duration, and 15mm spot size. Treatment is ongoing. Conclusion Our experience of Nd:YAG laser treatment of FD have been positive. All cases from literature report full resolution of FD maintained without adjuvant treatment between 6 months to 1.5 years after final treatment. Treatment with Nd:YAG laser is an option for patients suffering from recalcitrant FD.

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All sleep and no play? An audit and service evaluation of children undergoing radiological imaging (2022)

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Type of publication:
Conference abstract

Author(s):
*Muneer K.

Citation:
Archives of Disease in Childhood. Conference: Royal College of Paediatrics and Child Health Conference, RCPCH 2022. Liverpool United Kingdom. 107(Supplement 2) (pp A120-A121), 2022. Date of Publication: August 2022.

Abstract:
Aims The use of sedation in children for radiological imaging is common practice in Paediatrics. However, the risks need to be weighed against the benefits of imaging under sedation. Play therapy has been considered as an alternative to sedation in a cooperative child. This study explored the safety, efficacy and adherence of practice to local trust guidelines for sedation of children (derived from the NICE Sedation under 19s guidelines) and highlighted play therapy as a potential alternative for selected children requiring radiological imaging. Methods Data was gathered retrospectively from a 6 month period with the help of the Trust's medical records department. There were 36 children who underwent sedation for various imaging modalities and 19 children who had imaging done utilising play therapy over the same period. The information gathered from the resources used was collated in an excel database for the purpose of comparative analysis. Results 1. The assignment of patients was based on their clinical presentation, urgency and medical background 2. Children receiving sedation were predominantly below the age of 3 years while those in the play group were between 6-9 years 3. The youngest child to receive sedation was 3 months old and the youngest to have successful MRI using play therapy was 3 years 5 months 4. The success rate of Sedation was 92% vs. 86% for play therapy 5. 83% underwent MRI, 11% DMSA and 6% MAG3 under sedation. 95% had MRI and 5% CT in the play group 6. 14% required a repeat dose of medication for sedation 7. None had complications secondary to sedation 8. One had MRI Head done under sedation and later MRI Spine successfully under play therapy at 3 years 5 months 9. Where all documents were available for analysis, the adherence to local guidelines for sedation was 100% Conclusion 1. Sedation is a safe and effective option available in a DGH setting for young children needing relatively urgent radiological imaging to establish diagnosis where the benefits generally outweigh the risks. 2. Play therapy is a suitable alternative for cooperative children who can be adequately prepared. 3.Healthcare teams and parents need to be made more aware of these options in the future.

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Quality of life and two-year results of a randomized phase III study of dysphagiaoptimized intensity modulated radiotherapy (DO-IMRT) versus standard IMRT (SIMRT) in head and neck cancer (2022)

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Type of publication:Conference abstract

Author(s):Nutting C.; Rooney K.; Foran B.; *Pettit L.; Beasley M.; Finneran L.; Roe J.; Tyler J.; Roques T.; Cook A.; Petkar I.; Bhide S.; Srinivasan D.; Boon C.; De Winton E.; Frogley R.; Sydenham M.A.; Emson M.; Hall E.

Citation:Journal of Clinical Oncology. Conference: Annual Meeting of the American Society of Clinical Oncology, ASCO 2022. Online. 40(16 Supplement 1) (no pagination), 2022. Date of Publication: June 2022

Abstract:Background: Most newly diagnosed oro- & hypopharngeal cancers (OPC, HPC) are treated with (chemo) RT with curative intent but at the consequence of adverse effects on quality of life. We investigated if using DO-IMRT to reduce RT dose to the dysphagia/aspiration related structures (DARS) improved swallowing function compared to S-IMRT. Method(s): Patients with T1-4, N0-3, M0 OPC/HPC were randomised 1:1 to S-IMRT (65 Gray (Gy)/30 fractions (f) to primary & nodal tumour; 54Gy/30f to remaining pharyngeal subsite & nodal areas at risk of microscopic disease) or DO-IMRT. The volume of the superior & middle pharyngeal constrictor muscle (PCM) (OPC) or inferior PCM (HPC) lying outside the high-dose target volume was set a mandatory mean dose constraint in DO-IMRT. Treatment allocation was by minimisation balanced by centre, use of induction/concomitant chemotherapy, tumour site & AJCC stage. Primary endpoint was mean MD Anderson Dysphagia Inventory (MDADI) composite score 12 months after RT. Secondary endpoints included University of Washington (UW)-Qol, Performance Status Scale Head & Neck (PSS-HN) domain scores (range: 0-100), swallow volume, swallow capacity and local control. Result(s): 112 patients (56 S-IMRT, 56 DO-IMRT) were randomised from 22 UK & Ireland centres from 06/2016 – 04/2018. 111/112 had RT doses as prescribed (1 patient died before RT). Outcome measures at 12 and 24 months are summarised below. DO-IMRT had higher MDADI scores at 12 (p = 0.04) and 24 (p = 0.07) months. Clinically important improvements in swallowing function were seen in patients receiving DO-IMRT using PSS-HN domains and the UW-QoL tool. Conclusion(s): DO-IMRT improved patient reported swallowing function compared with S-IMRT. Improvements were seen in overall MDADI as well as functional scores in both PSS-HN and UW-QoL.

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