Organizing and implementing a multidisciplinary fast track oncology clinic.

QUALITY PROBLEM: Patients with gastrointestinal malignancies often need multiple appointments with different medical specialists, causing waiting times to accrue. INITIAL ASSESSMENT: In our hospital, care is organized in a sequential manner, causing long waiting times. To reduce this, a fast track outpatient clinic (FTC) was implemented. CHOICE OF SOLUTION: The FTC was organized within the hospital's existing structure. Patient centered care was achieved by ensuring that the medical specialists visit the patient, implementing nurse coordinators and considering patient wishes and co-morbidities when formulating a treatment plan. IMPLEMENTATION: A mandate from the board (Top-down), ensured cooperation between different medical departments and a change in resource allocation (i.e. medical staff); a horizontal clinic across a vertical departmental structure. Brainstorm sessions between the departments led by two physicians who were going to work at the FTC (Bottom-up), assured a swift implementation of the FTC. EVALUATION: Since implementation in 2009, patient influx has tripled. Waiting time for an appointment and start of treatment was reduced from 2-4 weeks to 6 working days and from 12-14 weeks to 17 working days, respectively. This was achieved by re-allocating recourses, but without increasing existing resources. LESSONS LEARNED: The combination of a top-down and bottom-up strategy ensured participation from all involved departments, a strong foundation and a shared vision on patient centered care. The FTC facilitates sharing information between different medical specialists through both proximity and a shared electronic patient record. The implementation of the FTC comprises a change in organization, but not a change in structure.

Pharmaceutical preparation of oxygen-15 labelled molecular oxygen and carbon monoxide gasses in a hospital setting.

BACKGROUND: Clinical positron emission tomography (PET) requires safe and effective PET radiopharmaceuticals. Tracers used for measuring oxygen consumption and blood volume are [(15)O]O(2) and [(15)O]CO, respectively. In general, these oxygen-15 labelled tracers are produced using a cyclotron that accelerates deuterons onto a target filled with (14)N(2) containing a trace of oxygen. In recent years, cyclotrons have been developed that only are capable of accelerating protons. The purpose of this study was to validate and assess such a cyclotron for production and administration of oxygen-15 labelled gasses in an hospital setting. METHODS: An RDS111 cyclotron (Siemens-CTI, Knoxville, USA) was validated for bolus production of [(15)O]O(2) and [(15)O]CO gasses. In addition, equipment was developed to administer these tracers to patients. RESULTS: Both [(15)O]O(2) and [(15)O]CO gasses could be produced in sufficient amounts, whilst meeting European Pharmacopeia requirements. Although produced oxygen-15 gasses contained a minor level of (11)C contamination, in clinical studies it was possible to correct for this contamination by delayed blood counting. CONCLUSION: An 11 MeV proton cyclotron combined with an in-house developed gas delivery system allows for the production and administration of sufficient amounts of [(15)O]-gasses for routine clinical PET studies in an hospital setting.

Clinical and technical evaluation of a new self-monitoring blood glucose meter: assessment of analytical and user error.

Our study aimed to validate (against the standards of the American Diabetes Association and the International Organization for Standardization) the analytical and clinical accuracy of the new MediSense Precision Plus Electrodes on the QID system when compared with a reference method using the Abbott Vision glucose analyzer. Previous studies have shown that the overall accuracy of the device also depends on the proficiency of the operator, so we also assessed the 'ease of use' of the MediSense system, by comparing the results obtained by the patient and health care professional. Accuracy of the self-monitored blood glucose measurements was evaluated over a wide range of glucose readings (2.6-20.0 mmol/l). Between-run CVs (using the manufacturer's quality control material) were found to be 7% at 2.7 mmol/l and 4.8% at 15.5 mmol/l (n=380). We used the error-grid analysis with target range blood glucose, then separated the data into different subsets. We found that 100% of all measurements were in the clinically acceptable zones of A and B. All measured values of the MediSense QID system complied with the requirements for 'blood glucose monitoring meters', as proposed by the International Organization for Standardization. The rating of the patient questionnaire showed a good to very good overall rating and acceptance with a short instruction time. The results indicate that that the MediSense QID/Precision Plus Electrodes is a reliable and easy to use device, which can be recommended for the majority of patients with diabetes mellitus.

Transport and retention of colloidal tracers in regional lymphoscintigraphy in melanoma: influence on lymphatic mapping and sentinel node biopsy.

Sentinel node (SN) biopsy is a staging technique used to select patients for regional lymphadenectomy in melanoma. We compared the two most widely used radioactive tracers, 99mTc-colloidal albumin (99mTc-CA) and 99mTc-sulphur colloid (99mTc-SC), with respect to scintigraphy, success rate in gamma probe guided biopsy and absolute uptake in the SN. Scintigraphy was performed in six volunteers after simultaneous injection of the respective tracers in each leg. Comparison of uptake of both tracers showed a higher uptake on the 99mTc-CA side. The scintigraphic count ratio of SNs labelled with 99mTc-SC compared with 99mTc-CA was 1 to 9 28. Next, 20 patients with biopsy-proven melanoma were randomized for injection of 99mTc-CA or 99mTc-SC followed by SN biopsy. Within 20 min after the injection, focal uptake was seen in all cases of the 99mTc-CA group but in only seven of the 10 patients in the 99mTc-SC group (P < 0.05). Focal accumulations were seen in all patients of both groups after 2 h. Spill to non-SNs was seen in five of the 99mTc-CA patients and three of the 99mTc-SC patients. In all patients the SNs could be retrieved under the guidance of a gamma probe and blue dye. The uptake in the SN was significantly higher (P < 0.001) after the injection of 99mTc-CA (0.92+/-0.40%) compared with 99mTc-SC (0.34+/-0.34%). When dynamic scintigraphy is performed, 99mTc-CA is preferable. SN uptake of 99mTc-SC is less than that of 99mTc-CA but this does not adversely affect the surgical procedure.

The impact of tumour volume and other characteristics on uptake of radiolabelled monoclonal antibodies in tumour tissue of head and neck cancer patients.

Radioimmunotherapy (RIT) seems to be a realistic option for eradication of minimal residual squamous cell carcinoma of the head and neck (HNSCC), although uptake levels of radiolabelled monoclonal antibodies (MAbs) in tumour tissue vary strongly. The aim of this study was to obtain greater insight into the factors influencing the accumulation of MAbs in HNSCC. Twenty-seven HNSCC patients were injected with radiolabelled MAb E48 or U36 and underwent surgery 2 days after injection. Radioactivity was measured in tumour biopsies taken from the surgical specimen. Uptake levels were correlated with various patient, tumour and MAb characteristics, including age, sex, site, TNM stage, volume as assesssed by computed tomography or magnetic resonance imaging, degree of differentiation, antigen expression of the tumour, the particular MAb that had been injected and the MAb dose. A stepwise regression multivariate analysis showed that tumour volume is the most significant prognostic factor (P=0. 01) for MAb uptake. In conclusion, a significantly higher MAb uptake is found in small tumours as compared to larger tumours. Therefore, RIT may be particularly effective in head and neck cancer patients when used in an adjuvant setting.

Human pharmacokinetics of orally administered (24 R)-hydroxycalcidiol.

To gain an insight in the regulation of (24R)-hydroxycalcidiol, we studied the pharmacokinetics of orally administered (24R)-hydroxycalcidiol in 6 healthy subjects without calcium supplementation, in 4 healthy subjects with calcium supplementation and in 6 patients with primary hyperparathyroidism. Various quantities related to calcium and vitamin D metabolism were also monitored. In the healthy subjects without calcium supplementation, the basal (24R)-hydroxycalcidiol concentration (Cb) in serum was 2.4 +/- 0.8 nmol/l (mean +/- SD, n = 5), the terminal serum half-time (t 1/2) 7.2 +/- 1.4 days, the production rate 0.05 +/- 0.01 nmol/kg.day, and the production rate/[calcidiol] ratio (1.5 +/- 0.4 x 10(-3) l/kg.day). In the healthy subjects studied, the serum concentration vs time curves exhibited a second maximum after administration, possibly due to binding by intestinal cells or (partial) uptake by the lymph system. In the calcium-supplemented healthy subjects, the pharmacokinetic quantities were not significantly different while the area under the serum concentration-time curve and the estimated bioavailability were significantly decreased. Basal concentration (Cb), production rate and the production rate/[calcidiol] ratio were significantly lower in patients with primary hyperparathyroidism but t 1/2 was unchanged. Exogenous (24R)-hydroxycalcidiol had no clear effect on calcium and vitamin D metabolism. In conclusion, a) exogenous (24R)-hydroxycalcidiol has no clear effect on calcium and vitamin D metabolism, b) clearance and production rate of (24R)-hydroxycalcidiol are not affected by calcium supplementation, c) bioavailability is lower in the calcium-supplemented state, d) basal concentration (Cb) and production rate are significantly decreased in patients with hyperparathyroidism.