An Audit for Radiotherapy Planning and Treatment Errors From a Low-Middle-Income Country Centre

AIMS

To report the findings of an audit for radiotherapy errors from a low-middle-income country (LMICs) centre. This would serve as baseline data for radiotherapy error rates, their severity and causes, in such centres where modern error reporting and learning processes still do not exist.

MATERIALS AND METHODS

A planned cross-sectional weekly audit of electronic radiotherapy charts at the radiotherapy planning and delivery step for all patients treated with curative intent was conducted. Detailed analysis was carried out to determine the step of origin of error, time and contributing factors. They were graded as per indigenous institutional (TMC) radiotherapy error grading (TREG) system and the contributing factors identified were prioritised using the product of frequency, severity and ease of detection.

RESULTS

In total, 1005 consecutive radically treated patients' charts were audited, 67 radiotherapy errors affecting 60 patients, including 42 incidents and 25 near-misses were identified. Transcriptional errors (29%) were the most common type. Most errors occurred at the time of treatment planning (59.7%), with "plan information transfer to the radiation oncology information system" being the most frequently affected sub-step of the radiotherapy process (47.8%). More errors were noted at cobalt units (52/67; 77.6%) than at linear accelerators. Trend analysis showed an increased number of radiotherapy incidents on Fridays and near-misses on Mondays. Trend for increased radiotherapy errors noted in the evening over other shifts. On severity grading, most of the errors (54/60; 90%) were clinically insignificant (grade I/II). Inadequacies and non-adherence towards standard operating procedures, poor documentation and lack of continuing education were the three most prominent causes.

CONCLUSION

Preliminary data suggest a vulnerability of LMIC set-up to radiotherapy errors and emphasises the need for the development of longitudinal prospective processes, such as voluntary reporting and a continued education system, to ensure robust and comprehensive safe practises on par with centres in developed countries.

Characterization of a novel seed protein of Prosopis cineraria showing antifungal activity

An antifungal protein with a molecular mass of 38.6 kDa was isolated from the seed of Prosopis cineraria. The protein was purified using ammonium sulphate precipitation, ion exchange chromatography and gel filtration. The antifungal activity of purified protein was retained up to 50 °C for 10 min. The MALDI TOF mass spectroscopy revealed 15 assorted peptides. The molecular weight of the antifungal protein is different from antifungal proteins reported in seeds of other leguminous plants. The purified protein exerted antifungal activity against post-harvest fruit fungal pathogens Lasiodiplodia theobromae and Aspergillus fumigatus, isolated from the rotten fruits. The antifungal properties of this novel antifungal protein can be potentially exploited to manage post-harvest fungal disease of fruits through alternative means to reduce use of hazardous chemicals.

Abstract P6-02-02: Uridine diphosphate glucose dehydrogenase is required for hyaluronic acid production and breast cancer invasion

This abstract was withdrawn by the authors.

Role of pleural fluid adenosine deaminase activity and lymphocytosis in the etiological diagnosis

Background: Pleural effusion is a common medical condition with many possible underlying etiologies. However, Tuberculosis is the most common cause of pleural effusion especially in countries like Nepal. Pleural uid lymphocytosis is seen in tuberculosis, malignancy and few auto-immune diseases. Adenosine Deaminase activity (ADA) level in tubercular pleural effusion is markedly increased compared to non-tubercular effusions. ADA estimation being a simple colorimetric method is suitable for the rapid diagnosis of tubercular effusion. This study aims to correlate the diagnostic ef cacy of ADA with the value of differential count (lymphocytosis) in establishing different etiology of pleural effusion. Materials and Methods: This is a cross sectional study of 50 cases with pleural effusion carried out in the department of Pathology, Green city hospital for the duration of Twenty one month’s dating from October 2014 to July 2016 AD. Results: Of all, tubercular pleural effusion accounted for 26%. ADA level was raised (≥40U/L) in 92% of Tubercular pleural effusion. The sensitivity and speci city of ADA alone to diagnose tubercular pleural effusion was 92% each and when lymphocytosis alone was considered sensitivity was 85% with speci city of 32% whereas the combined effect of both ADA with lymphocytosis was 100% (sensitivity) and 87% (speci city), 83% (positive predictive value) and 100% (negative predictive value) respectively with statistically signi cant p value (<0.05). Conclusion: We can conclude that the combination of pleural uid differential count (lymphocytosis >50%) and ADA level >40U/L provides with much more positive result than each component alone in differentiating tubercular effusion from other etiologies. 

Fine needle aspiration cytology of head and neck lesions and its correlation with histopathology

Background: Fine needle aspiration cytology is a minimally invasive technique used in the initial diagnosis of different types of lesions located in head and neck region commonly originating from cervical lymph node, thyroid gland, salivary glands and soft tissues. The objective of this study was to evaluate the diagnostic accuracy, sensitivity and speci city of FNAC in various head and neck lesions in correlation with their histopathological examination. Materials and methods: A hospital based prospective study was conducted among 209 patients with palpable head and neck region swellings in the Department of Pathology, Bhaktapur Cancer Hospital and the Department of Pathology, Nepal Medical College from August 2014 to July 2015. FNAC were done from palpable masses of head and neck regions. Data entry and analysis were done using SPSS 17. Result: There were 209 FNAC cases enrolled, out of which lymph node lesions (n=128) were the most common lesions followed by thyroid (n=40), other soft tissues (n=27) and salivary gland (n=14). Reactive lymph nodes, colloid goiter, epidermoid cyst and sialadenosis were the predominant diagnosis of lymph nodes, thyroid gland, soft tissues and salivary gland respectively. Highest accuracy, sensitivity and speci city were observed in thyroid gland, salivary gland and soft tissues. However, four false negative results for malignancy were reported in lymph node lesions. Conclusion: Head and neck region swellings are the commonly encountered conditions. FNAC being highly accurate, sensitive and speci c makes it useful and reliable procedure for screening and diagnosis of palpable masses in head and neck region. 

Association of milk components with intra-mammary inflammation in Jaffrabadi buffaloes

Aim:

To study the alteration of major milk components such as milk fat, protein, lactose, solid not fat (SNF) and total solids (TS) and their association with different degree of intra-mammary inflammation (IMI) in Jaffrabadi buffaloes.

Materials and Methods:

Milk samples (n=1516) were collected from Jaffrabadi buffaloes separately from each quarter. Milk samples were analyzed for milk fat, protein, lactose, SNF and TS percent on the same day using milk analyzer “LACTOSCAN.” Milk samples were checked for IMI by California mastitis test (CMT), and the results were expressed as negative (0), +, ++, and +++ CMT score. The traits of milk components which showed significant difference (p<0.05) between samples from inflamed and non-inflamed quarters were analyzed by receiver operating characteristic (ROC) analysis to see the accuracy and degree of association with IMI.

Results:

Among several milk components, milk protein and lactose percent showed a significant difference (p<0.05) between milk samples from normal and inflamed quarters. Though, during the early stage of mammary gland inflammation milk protein percent remained significantly high (p<0.05), later with an increase in the degree of severity of inflammation it did not show any difference. Milk samples from normal udder quarters had significantly higher lactose percent than inflamed quarters (p<0.05). Milk lactose percent decreased gradually with an increase in the degree of severity of inflammation. ROC analysis revealed that milk samples having lactose content below the threshold values had significantly higher chances to come from inflamed udder quarters (p<0.05). Though, the value of the area under curve (AUC) indicated that milk lactose was significantly associated with IMI (p<0.05), the accuracy was moderate (AUC=0.71-0.75).

Conclusions:

The results of the present study indicated that milk lactose percent gradually and significantly reduced during IMI and can be used as a marker for identification of IMI in buffaloes. However, ROC analysis further confirmed that using milk lactose IMI can be identified with moderate accuracy.

Histopathological evaluation of carcinoma of breast

Background: Carcinoma of breast has become the major public health problem among females in developing as well as developed countries. InNepal it comprises 6% of total cancers cases and often diagnosed at advanced stage. Surgical removal or modified radical mastectomy (MRM) is the most commonly used tools for disease management. The objective of this study is to identify the clinical, macroscopic and microscopic features of MRM specimens.Materials and methods: This prospective cross-sectional study was carried out at Department of Pathology, Bhaktapur Cancer Hospital, Bhaktapur, Nepal. Macroscopic and microscopic examination provided the tumor size, stage, grade, lymph node status, lympho-vascular invasion and perineural invasion. Data were collected and analyzed using SPSS 16.Results: The study comprised 112 breast cancer patients of which 109 (97.3%) were females and 3 (2.7%) were males. Invasive ductal carcinoma no specific type was the most common type of breast carcinoma. (84 cases) accounting 75% of total cases. Carcinoma with medullary features was second most common (6 cases) comprising 5.4% cases followed by lobular, papillary, apocrine, mucinious and NST mixed types. Grade II tumors were most frequent grade observed in 76.79% cases followed by Grade I (12.50%) and Grade III (10.71%).Conclusion: As a conclusion invasive ductal carcinoma was the most common histological type breast cancer and the tumors were found at T2 and N3 stage i.e maximum at grade II. Our study provides prognostic significance of histo-pathological information in breast cancer management.

Impact of urothelial carcinoma with divergent differentiation on tumor stage

Background: Urinary bladder cancer is classified as urothelial or non-urothelial. Ninenty percent of bladder cancer are urothelial and has propensity for divergent differentiation. Squamous differentiation is associated with unfavourable prognostic features. The aim of this study is to determine the significance of urothelial carcinoma with divergent differentiation in relation to tumor stage and lymphovascular as well as perineural invasion in radical cystectomy and partial cystectomy specimen.Materials and methods: This prospective study was done among 51 patients who underwent radical cystectomy or partial cystectomy at Bhaktapur Cancer Hospital from 1st August 2013 to 31st December 2015. Received specimen was grossed following standard protocol and histopathological evaluation was done in relation to tumor type, depth of invasion, Lymphovascular and perineural invasion.Results: Pure urothelial carcinoma comprises 47.1% of cases. Among the divergent differentiation, urothelial carcinoma with squamous differentiation was the commonest one (39.2%) followed by glandular differentiation (5.9%), sarcomatoid differentiation (3.9%), clear cell variant (2.0%) and squamous along with sarcomatoid variant (2.0%). Statistical significant correlation was found between urothelial carcinoma with divergent differentiation and tumor stage (p<0.012). Statistically significant correlation was also found between urothelial carcinoma with divergent differentiation and lymphovascular invasion (p=0.012) as well as perineural invasion (p=0.037).Conclusion:  Most common divergent differentiation was squamous differentiation. Urothelial carcinoma with divergent differentiation was associated with higher stage and lymphovascular as well as perineural invasion. So it is mandatory to search for the divergent differentiation in urothelial carcinoma as this may be associated with unfavourable prognosis.

Metabolic indicators for retention of fetal membranes in Zebu and crossbred dairy cattle

The present study assessed the peripartum metabolic profile of Karan Fries crossbred (Holstein Friesian × Tharparkar) and Zebu (Sahiwal) cows in relation to expulsion of fetal membranes. Peripheral blood concentrations of glucose, total protein, total cholesterol, blood urea nitrogen, non-esterified fatty acid (NEFA) and β-hydroxy butyric acid (BHBA) were determined (from 30 days before and 2 days after calving) in cows that expelled fetal membranes normally (n = 13; 7 crossbred and 6 Zebu cows) and in cows that developed retention of fetal membranes (RFM; n = 13; 7 crossbred and 6 Zebu cows). In both breeds, the cows that developed RFM had significantly lower concentrations of cholesterol, glucose and total protein, while the concentrations of NEFA, BHBA and blood urea nitrogen were significantly (P < 0.05) higher than those in cows that normally expelled the fetal membranes. In crossbred cows affected with RFM, the concentrations of NEFA increased significantly (P < 0.05) from Day 14 prepartum to Day 2 postpartum and the concentrations of BHBA increased from Day 7 prepartum to Day 2 after calving. Similarly, in Zebu cows, NEFA and BHBA concentrations increased significantly (P < 0.05) between Day 5 prepartum and Day 2 postpartum in RFM cows. Using receiver operator characteristic analysis, we observed that the concentrations of NEFA and BHBA before calving were highly related to the RFM. It may be inferred that monitoring the levels of NEFA and BHBA during prepartum period would help in identifying the cows at the risk of developing RFM.