Quality indicators in radiation oncology: proposal of the Spanish Society of Radiation Oncology (SEOR) for a continuous improvement of the quality of care in oncology.

PURPOSE: Current cancer treatment options include surgical intervention, radiotherapy, and chemotherapy. The quality of the provision of each of them and their effective coordination determines the results in terms of benefit/risk. Regarding the radiation oncology treatments, there are not stabilised quality indicators to be used to perform control and continuous improvement processes for healthcare services. Therefore, the Spanish Society of Radiation Oncology has undertaken a comprehensive project to establish quality indicators for use with the information systems available in most Spanish healthcare services. METHODS: A two-round Delphi study examines consensus of several possible quality indicators (n = 28) in daily practice. These indicators were defined after a bibliographic search and the assessment by radiation oncology specialists (n = 8). They included aspects regarding treatment equipment, patient preparation, treatment, and follow-up processes and were divided in structure, process, and outcome indicators. RESULTS: After the evaluation of the defined quality indicators (n = 28) by an expert panel (38 radiation oncologist), 26 indicators achieved consensus in terms of agreement with the statement. Two quality indicators did not achieve consensus. CONCLUSIONS: There is a high degree of consensus in Spanish Radiation Oncology specialists on which indicators in routine clinical practice can best measure quality. These indicators can be used to classify services based on several parameters (patients, equipments, complexity of the techniques used, and scientific research). Furthermore, these indicators allow assess our current situation and set improvements' objectives.

Clinical Audit of the Radiotherapy Process in Rectal Cancer: Clinical Practice Guidelines and Quality Certification Do Not Avert Variability in Clinical Practice.

BACKGROUND: The therapeutic approach to cancer is complex and multidisciplinary. Radiotherapy is among the essential treatments, whether used alone or in conjunction with other therapies. This study reports a clinical audit of the radiotherapy process to assess the process of care, evaluate adherence to agreed protocols and measure the variability to improve therapeutic quality for rectal cancer. METHODS: Multicentre retrospective cohort study in a representative sample of patients diagnosed with rectal cancer in the Institut Català d'Oncologia, a comprehensive cancer centre with three different settings. We developed a set of indicators to assess the key areas of the radiotherapy process. The clinical audit consisted of a review of a random sample of 40 clinical histories for each centre. RESULTS: The demographic profile, histology and staging of patients were similar between centres. The MRI reports did not include the distance from tumour to mesorectal fascia (rCRM) in 38.3% of the cases. 96.7% of patients received the planned dose, and 57.4% received it at the planned time. Surgery followed neoadjuvant treatment in 96.7% of the patients. Among this group, postoperative CRM was recorded in 65.5% of the cases and was negative in 93.4% of these. With regard to the 34.5% (n = 40) of cases where no CRM value was stated, there were differences between the centres. Mean follow-up was 3.4 (SD 0.6) years, and overall survival at four years was 81.7%. CONCLUSIONS: The audit revealed a suboptimal degree of adherence to clinical practice guidelines. Significant variability between centres exists from a clinical perspective but especially with regard to organization and process.

Multiclass method for antimicrobial analysis in animal feeds by liquid chromatography-tandem mass spectrometry.

A rapid multiclass method that covers 50 antimicrobials from 13 different families in animal feeds was developed. Samples were extracted using a mixture of methanol, acetonitrile and a McIlvaine buffer combined with sonication. Feed extracts were simply diluted prior to injection, since the clean-up strategies that were tested, based on either solid-phase extraction or dispersive solid-phase extraction, were ineffective at minimizing matrix-related signal suppression/enhancement. Analysis was carried out by liquid chromatography coupled to tandem mass spectrometry using an electrospray ionization source operating in positive and negative modes. For the quantification, matrix-fortified standard calibration curves were used to compensate for matrix effects and losses in sample preparation. The method was validated in-house in pig, poultry and cattle feed matrices and showed satisfactory performance characteristics. Thus, the proposed approach was suitable for application in a routine high-throughput laboratory for the official control of feeds.

Correlation of precursor and product ions in single-stage high resolution mass spectrometry. A tool for detecting diagnostic ions and improving the precursor elemental composition elucidation.

Monitoring of common diagnostic fragments is essential for recognizing molecules which are members of a particular compound class. Up to now, unit resolving tandem quadrupole mass spectrometers, operating in the precursor ion scan mode, have been typically used to perform such analysis. By means of high-resolution mass spectrometry (HRMS) a much more sensitive and selective detection can be achieved. However, using a single-stage HRMS instrument, there is no unequivocal link to the corresponding precursor ion, since such instrumentation does not permit a previous precursor selection. Thus, to address this limitation, an in silico approach to locate precursor ions, based on diagnostic fragments, was developed. Implemented as an Excel macro, the algorithm rapidly assembles and surveys exact mass data to provide a list of feasible precursor candidates according to the correlation of the chromatographic peak shape profile and other additional filtering criteria (e.g. neutral losses and isotopes). The macro was tested with two families of veterinary drugs, sulfonamides and penicillins, which are known to yield diagnostic product ions when fragmented. Data sets obtained from different food matrices (fish and liver), both at high and low concentration of the target compounds, were investigated in order to evaluate the capabilities and limitations of the reported approach. Finally, other possible applications of this technique, such as the elucidation of elemental compositions based on product ions and corresponding neutral losses, were also presented and discussed.

Loss of A, B, and H antigens in oral cancer

Los antígenos ABH, productos de la interacción de dos sistemas genéticos Hh y ABO, están sujetos a leyes de herencia y pueden estar localizados no sólo en los eritrocitos sino también en la mayoría de las células humanas. El objetivo del este trabajo fue investigar la expresión de antígenos ABH en pacientes con lesiones orales pre-malignas y malignasorales. Se trabajó con muestras incluidas en tacos de parafina de pacientes con lesiones orales. Los pacientes fueron clasificados en 2 grupos: a) Pacientes con lesiones premalignas y malignas diagnosticadas clí-nica y anatopatológicamente y b) pacientes con lesiones benignas. Sei nvestigaron los antígenos ABH por la técnica de inmunoadherencia específica modificada. Se utilizó la adherencia al tejido vascular como control positivo y al tejido adiposo como control negativo. Los resultados fueron valorados de forma semicuantitativa desde adherencia fuertemente positiva a negativa. Hemos encontrado una significativa relación entre la expresión antigénica ABH y el grado de malignidad de las lesiones analizadas (P Yates= 0.005). Una pérdida de reactividad ABH en los sitios de mayor invasividad tumoral se correlaciona con el grado del desarrollo del tumor, el grado histológico y su malignidad (AU)

In most human carcinomas, including oral carcinoma, a significant event is decreased expression of histo-blood-group antigens A,B and H. The mechanisms of aberrant expression of blood-group antigens are not clear in all cases. The aim of this work was to investigate the association of ABO blood groups with oral cancer. We studied the expression of ABH antigen in tissues of premalignant lesions and in diagnosed malignant tumors. In total, 132 patients were examined, half of whom suffered from oral pre-cancerous and cancerous lesions, while the other half were the control group (benign lesions).All tumors were histologically confirmed. We found a significant relationship between antigen expression and the malignancy of the lesions analyzed (P Yates= 0.005). A loss of ABH reactivity within the most invasive sites of the tumors correlated significantly with the stage of tumor development and histological grade of malignancy. These findings support the view that features regarding the cells of deeper parts of the carcinomas are very important for the clinical behavior of the tumors and that loss of ABH-antigen expression is linked to the stage of the tumor and invasion of carcinoma cells (AU)

Effect of membrane-bound IgG and desialysation in the interaction of monocytes with senescent erythrocytes.

Determination of the erythrocyte lifespan is a complex process affected by many cellular parameters. In the present study we measured and characterised the red blood cell (RBC) membrane proteins, mainly band 3, and quantified membrane-bound IgG in senescent RBC (SeRBC) and young RBC (YRBC). We also investigated, through a functional assay, the interaction between SeRBC and peripheral blood monocytes. We applied this erythrophagocytosis assay to study the phagocytosis of desialysed RBC. The results obtained showed no changes in the protein content between SeRBC and YRBC and no differences when examining membrane proteins by SDS-PAGE. Then, considering that the accumulation of autologous IgG on RBC membrane provides a direct mechanism for the removal of SeRBC, we measured the IgG content of intact RBC using an enzyme-linked anti-immunoglobulin test finding that the number of IgG molecules bound to SeRBC was significantly higher than that observed for YRBC. The increase observed in the percentage of erythrophagocytosis with SeRBC and sensitised RBC (SRBC) confirmed the involvement of autologous IgG in the selective removal of erythrocytes. We also observed a higher percentage of monocytes with phagocytosed and adherent RBC (AM) obtained with neuraminidase-treated RBC than those obtained with YRBC. This finding suggests that a decrease in sialic acid content of SeRBC may be involved in physiological erythrophagocytosis.

Rabdomiólisis grave por virus Coxsackie B complicada con síndrome compartimental / Serious rhabdomyolysis dueto Coxsackie B virus complicated with compartment syndrome

La rabdomiólisis como complicación de un síndrome compartimental agudo es algo habitual, pero lo contrario es infrecuente. Presentamos el caso de un hombre de 74 años con una infección aguda por virus Coxsakie B que desarrolló una rabdomiólisis con un nivel de creatinfosfocinasa (CPK) máximo de 161.757 UI/l. Se complicó con un fracaso renal agudo y con un síndrome compartimental de la pierna derecha. La función renal se normalizó en unas semanas, pero a consecuencia del síndrome compartimental desarrolló un pie equino, a pesar de la realización de fasciotomías, precisando una ortesis para deambular. El síndrome compartimental es una complicación a tener en cuenta en rabdomiólisis graves, porque puede pasar desapercibida con facilidad, y se puede asociar a secuelas

Rhabdomyolysis as a complication of an acute compartimental syndrome is somewhat common, but on the contrary, is rare. We present the case of a 74 year man with acute infection by Coxsackie B virus who developed a rhabdomyolysis with a maximum CPK of 161, 757 IU/l. It became complicated with acute renal failure and compartment syndrome of the right leg. Renal function normalized in a few weeks, however, due to the compartment syndrome, he developed an equinus foot in spite of the performance of fasciotomies and required an orthesis to walk. Compartment syndrome is a complication to be considered in serious rhabdomyolysis because it may go unnoticed easily and can be associated to sequels

[Cardiogenic shock associated with inappropriate nutritional regimen: refeeding syndrome]. / Shock cardiogénico asociado a un programa nutricional inapropiado: síndrome de realimentación.

Situations of cardiac arrest have been reported in under-nourished patients with protein and calorie deficits when the provision of nutrients was initiated in an uncontrolled manner. The recognition of the association between the provision of food in these circumstances and the serious clinical consequences, generally heartbeat disorders, has led this condition to be described as "re-feeding syndrome". The case presented here is of severe acute respiratory failure and cardiogenic shock in a 44-year-old female patient with severe protein and calorie malnutrition associated with the start of hyperproteic nutritional support. Treatment with inotropic-vasoactive drugs and diuretics together with a progressive nutritional programme brought about the complete reversal of her heart failure and the concomitant endocrine-metabolic syndrome.

Shock cardiogénico asociado a un programa nutricional inapropiado: síndrome de realimentación / Cardiogenic shock associated with an inappropriate nutritional programme: re-feeding syndrome

Se han comunicado situaciones de paro cardíaco en pacientes con desnutrición proteico-calórica en los que se iniciaba aporte de nutrientes de manera incontrolada. El reconocimiento de la asociación entre el aporte de alimentos en estas circunstancias y los eventos clínicos graves, generalmente trastornos del ritmo cardíaco, llevó a describirlo como “síndrome de realimentación”. Presentamos un caso de influencia respiratoria aguda grave y shock cardiogénico en una paciente de 44 años con desnutrición proteico-calórica grave asociado al inicio de un soporte nutricional hiperproteico. El tratamiento con drogas inotrópicas-vasoactivas y diuréticos junto con un programa nutricional progresivo consiguió la reversión completa de la insuficiencia cardíaca y del síndome endocrino-metabólico concomitante (AU)

Situations of cardiac arrest have been reported in under-nourished patients with protein and calorie deficits when the provision of nutrients was initiated in an uncontrolled manner. The recognition of the association between the provision of food in these circumstances and the serious clinical consequences, generally heartbeat disorders, has led this condition to be described as "re-feeding syndrome". The case presented here is of severe acute respiratory failure and cardiogenic shock in a 44-year-old female patient with severe protein and calorie malnutrition associated with the start of hyperproteic nutritional support. Treatment with inotropic-vasoactive drugs and diuretics together with a progressive nutritional programme brought about the complete reversal of her heart failure and the concomitant endocrine-metabolic syndrome (AU)

A Dc- phenotype encoded by an RHCE-D(5-7/8)-CE hybrid allele.

BACKGROUND AND OBJECTIVES: The Rh system is genetically controlled by the homologous RHD and RHCE genes that encode the RhD and RhCcEe polypeptides, respectively. Deletions, point mutations and rearrangements between both genes are responsible for the great polymorphism of this system. The aim of this work was to analyse the genetic basis of a Dc- phenotype. MATERIALS AND METHODS: DNA samples from the Dc- propositus and family members were obtained from peripheral blood. RHCE intron 4-exon 5 and RH exons 4, 5, 6 and 7 were analysed by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). Exon 9 was studied by PCR-sequence-specific primers (SSP). The RH locus was further analysed by using a PCR designed for a hybrid allele. RESULTS: No RHCE-specific fragments were found when analysing exons 5, 6 and 7 of the RH locus from the propositus' DNA, while exons 4 and 9 of both RH genes were present. CONCLUSIONS: The results obtained indicated that the Dc- phenotype is encoded by a novel RHCE-D(5-7/8)-CE hybrid allele.

Study of phagocytosis of senescent erythrocytes in young and elderly individuals.

There is a decrease in the percentage contribution of a heavy density fraction of red blood cells to whole blood with increasing age. The aim of this study was to investigate in the young and elderly the interaction between monocytes and different erythrocyte suspensions: senescent red blood cells, erythrocytes stored with or without serum, and desialylated red blood cells. The results obtained with senescent red blood cells and erythrocytes stored with serum show the involvement of autologous IgG in the selective removal of erythrocytes. These values were higher in elderly individuals, indicating that this process increases with age. Our observation suggest that desialylation is not involved in the increased removal of erythrocytes observed in elderly individuals.

Early detection of RhD status in pregnancies at risk of hemolytic disease of the newborn.

The aim of this work was to investigate the presence of the RHD gene in fetal cells obtained from amniotic fluid. We studied 65 samples of amniotic fluid, 11 from RhD-negative mothers sensitized with anti-D alloantibodies. The fetal origin of the DNA was confirmed with the analysis of 1 VNTR locus and 3 STR loci in DNA samples from amniotic fluid and maternal blood. The RHD genotyping was performed in non-contaminated samples (n=62) using a multiplex polymerase chain reaction strategy that yields three amplification products from RhD-positive phenotypes (intron 4 of both RHCE and RHD genes and exon 10 of the RHD gene) and I DNA fragment from RhD-negative phenotypes (intron 4 of the RHCE gene). We genotyped 54 RhD-positive fetuses (8 from RhD-negative sensitized mothers) and 8 RhD-negative fetuses (3 from RhD-negative sensitized mothers). The fetal DNA genotyping allows the diagnosis, from a single amniocentesis, of fetuses at real risk of hemolytic disease of the newborn. When the fetus is determined to be RhD-negative invasive procedures can be avoided.

Senescent erythrocytes: factors affecting the aging of red blood cells.

Human red blood cells (RBC) have a well-defined lifespan of 120 days affected by many cellular parameters. The aim of the present study was to investigate through a functional assay the effect of some factors in the interaction of erythrocytes with monocytes: heat rigidification, equilibration at different pH and desialyzation. We also studied the interaction between stored RBC and peripheral blood monocytes with this functional erythrophagocytosis assay. Blood samples from 30 volunteer donors were investigated. 1) Senescent (Se) and Young (Y) RBC were obtained by differential centrifugation. 2) Erythrocyte suspensions: Aliquots of each sample were subjected to the following treatments: a) Rigidification by heat (RRBC), b) Equilibration at different pH (5.34, 6.30, 7.33, 9.20) and c) Desialyzation with neuraminidase and trypsin. The functional assay was performed incubating monocytes obtained by glass adherence with these suspensions of RBC. Whole blood samples (n = 20) were stored during different periods of time (0, 7, 14, 21, 28, 35 and 42 days). The erythrophagocytosis assay was performed during six weeks incubating isologous monocytes with RBC from every unit. Negative and positive controls were performed using non sensitized (NSRBC) and sensitized with IgG anti-RhD (SRBC) red cells. The percentage of active monocytes (AM) obtained were: 1) YRBC: 2.8 +/- 0.9 and SeRBC: 17.5 +/- 2.1; 2a) RRBC: 3.0 +/- 0.9; 2b) 10.9 +/- 0.9, 15.5 +/- 0.8, 3.1 +/- 1.0, 4.0 +/- 1.1; 2c) 11.1 +/- 1.4 and 3.9 +/- 1.0; SRBC 32.1 +/- 1.7 and NSRBC: 2.8 +/- 1.5. The % of AM with SeRBC was higher (p < 0.001) than those obtained with NSRBC. The data of AM with RRBC were significantly lower (p < 0.001) than those obtained with SeRBC and SBRC, indicatingthat heat rigidification of RBC does not increase phagocytosis by monocytes. The values of AM obtained from the suspensions of erythrocytes equilibrated at different pH indicate that the acidification of RBC increases the interaction with monocytes. The % AM with neuraminidase treated RBC was higher than those observed with YRBC and NSRBC (p < 0.001). No modifications were observed with trypsin treated RBC. These results suggest that the loss of sialic acid may be involved in the physiological phagocytosis. The values of AM of stored whole blood were: 2.3 +/- 1.3, 2.7 +/- 1.3, 4.4 +/- 1.6, 6.7 +/- 1.2, 9.6 +/- 1.0, 11.7 +/- 0.8 and 13.0 +/- 1.2. The results showed a significant increase in the % of AM as a function of the preservation time from 2,3 +/- 1,3 for the first day to 13,0 +/- 1,2 for the 42nd day (p < 0.001). The data obtained in this ex vivo model show a significant increase (p<0.001) in the phagocytosis of RBC equilibrated at low pH, desialinized (greater than 80%) with neuraminidase and stored for over 28 days. These factors would be involved in erythrocyte removal via phagocytosis during tissular homeostasis.

Erythrophagocytosis assay in patients with autoimmune hemolytic anemia.

The aim of this paper is to evaluate the erythrophagocytosis assay (EA) in patients with autoimmune hemolytic anemia (AIHA). Direct antiglobulin test (DAT), indirect antiglobulin test (IAT) and EA were performed in blood samples from 46 patients with presumed AIHA. The EA was carried out incubating patients' erythrocytes and peripheral blood monocytes. A total of 200 monocytes were analysed to determine the percentage of active phagocytic cells (% APC). In 9 of these patients the applied treatment was evaluated by DAT, IAT and EA. In 14 transfusion requirements, the compatibility tests and EA were performed. For EA, patients' monocytes were incubated with erythrocytes from previously selected units sensitized with patients' sera. The % of APC was 32.1 +/- 1.7 in 35 patients with positive DAT and 17.8 +/- 1.3 in 11 patients with negative DAT. This last value was significantly higher than that with negative controls (3.7 +/- 0.3)(p < or = 0.01). As regards the applied treatment, patients with a successful response (n = 6) showed a significant decrease in the initial % APC (31.8 +/- 1.6 to 15.3 +/- 2.4; p < or = 0.05) while DAT and IAT remained positive. In those patients who required blood transfusion the compatibility tests were positive with all the units to be transfused, whereas the % APC varied for each one. Blood units were selected according to the lower % APC.

[Rh system genotyping in amniotic fluid]. / Genotipificación del sistema RH en líquido amniótico.

The aim of this work was to determine the presence of the RHD gene in fetal cells obtained from amniotic fluid (AF). We studied 65 samples of AF, 11 from RhD- mothers sensitized with anti-D. The fetal origin of the DNA was confirmed with the analysis of 1 VNTR locus and 3 STR loci in DNA samples from AF and maternal blood. The RHD genotyping was performed in non contaminated samples (n = 62) using a multiplex PCR strategy that yields 3 amplification products from RhD+ phenotypes and 1 DNA fragment from RhD- phenotypes. We genotyped 54 RhD+ fetuses (8 from RhD- sensitized mothers) and 8 RhD- fetuses (3 from RhD- sensitized mothers). Fetal DNA genotyping allows the diagnosis, from a single amniocentesis, of fetuses at real risk of hemolytic disease of the newborn. When the fetus is determined to be RhD- all invasive procedures can be avoided.

Erythrophagocytosis assay in patients with autoimmune hemolytic anemia.

The aim of this paper is to evaluate the erythrophagocytosis assay (EA) in patients with autoimmune hemolytic anemia (AIHA). Direct antiglobulin test (DAT), indirect antiglobulin test (IAT) and EA were performed in blood samples from 46 patients with presumed AIHA. The EA was carried out incubating patients erythrocytes and peripheral blood monocytes. A total of 200 monocytes were analysed to determine the percentage of active phagocytic cells (

APC). In 9 of these patients the applied treatment was evaluated by DAT, IAT and EA. In 14 transfusion requirements, the compatibility tests and EA were performed. For EA, patients monocytes were incubated with erythrocytes from previously selected units sensitized with patients sera. The

of APC was 32.1 +/- 1.7 in 35 patients with positive DAT and 17.8 +/- 1.3 in 11 patients with negative DAT. This last value was significantly higher than that with negative controls (3.7 +/- 0.3)(p < or = 0.01). As regards the applied treatment, patients with a successful response (n = 6) showed a significant decrease in the initial

APC (31.8 +/- 1.6 to 15.3 +/- 2.4; p < or = 0.05) while DAT and IAT remained positive. In those patients who required blood transfusion the compatibility tests were positive with all the units to be transfused, whereas the

APC varied for each one. Blood units were selected according to the lower

APC.

Genotipificación del sistema RH en líquido amniótico. / [Rh system genotyping in amniotic fluid]

The aim of this work was to determine the presence of the RHD gene in fetal cells obtained from amniotic fluid (AF). We studied 65 samples of AF, 11 from RhD- mothers sensitized with anti-D. The fetal origin of the DNA was confirmed with the analysis of 1 VNTR locus and 3 STR loci in DNA samples from AF and maternal blood. The RHD genotyping was performed in non contaminated samples (n = 62) using a multiplex PCR strategy that yields 3 amplification products from RhD+ phenotypes and 1 DNA fragment from RhD- phenotypes. We genotyped 54 RhD+ fetuses (8 from RhD- sensitized mothers) and 8 RhD- fetuses (3 from RhD- sensitized mothers). Fetal DNA genotyping allows the diagnosis, from a single amniocentesis, of fetuses at real risk of hemolytic disease of the newborn. When the fetus is determined to be RhD- all invasive procedures can be avoided.