Quality and Safety Considerations in Image Guided Radiation Therapy: An ASTRO Safety White Paper Update

PURPOSE/OBJECTIVE(S)

This updated report on image guided radiation therapy (IGRT) is based on a consensus-based white paper previously published by the American Society for Radiation Oncology (ASTRO) addressing patient safety. In the past decade, IGRT technology and procedures have progressed significantly and are now more commonly used. The use of IGRT has now extended beyond high-precision treatments, such as stereotactic radiosurgery and stereotactic body radiation therapy, and into routine clinical practice for many treatment techniques and anatomic sites. Therefore, quality and treatment planning and delivery considerations for these techniques are paramount for patient safety.

MATERIALS/METHODS

In 2021, ASTRO convened an interdisciplinary task force to assess the original IGRT white paper and update content where appropriate. Recommendations were created using a consensus-building methodology, and task force members indicated their level of agreement based on a 5-point Likert scale from "strongly agree" to "strongly disagree." A prespecified threshold of ≥75% of raters who selected "strongly agree" or "agree" indicated consensus.

RESULTS

The IGRT white paper was published (Pract Radiat Oncol. 2022 Dec) and endorsed by the American Association of Physicists in Medicine (AAPM), American Association of Medical Dosimetrists, and American Society of Radiologic Technologists. Since the first IGRT paper was published by ASTRO in 2013, significant technological advancement has taken place. New and updated considerations in personnel requirements, staffing, education and training, equipment and technological requirements, quality management and assurance, IGRT program management, and safety considerations were reported. A 17-point consensus was reached and recommended in 5 areas surrounding program development, quality assurance, quality management, treatment delivery, and vendor engagement (Table 5, Summary of key recommendations).

CONCLUSION

This IGRT white paper builds on the previous version and uses other guidance documents to primarily focus on processes related to quality and safety. IGRT requires an interdisciplinary team-based approach, staffed by appropriately trained specialists, as well as significant personnel resources, specialized technology, and implementation time. A thorough feasibility analysis of resources is required and should be discussed with all personnel before undertaking new imaging techniques. A comprehensive quality-assurance program must be developed to ensure IGRT is performed safely and effectively. As IGRT technologies continue to improve or emerge, existing practice guidelines should be updated regularly according to the latest AAPM Task Group reports. Patient safety in the application of IGRT is everyone's responsibility, and professional organizations, regulators, vendors, and end-users must demonstrate strong commitments to ensure that the highest levels of safety are achieved.

Listening to core surgical trainees who drop out

What can we learn from surgeons who leave?

Does the source of referral affect outcomes for paediatric testicular torsion?

INTRODUCTION

This single centre study retrospectively analysed the intraoperative findings relative to source of referral for emergency scrotal explorations performed in a tertiary level paediatric surgery department.

METHODS

All patients who underwent emergency scrotal exploration under the care of paediatric surgeons in our unit between April 2008 and April 2016 were identified. Clinical data were obtained from contemporaneous records.

RESULTS

Over the 8-year study period, 662 boys underwent emergency scrotal exploration: 6 (1%) were internal referrals, 294 (44%) attended our emergency department (ED) directly, 271 (41%) were referred from primary care and 91 (14%) were transferred from other hospitals. Excluding procedures in neonates, testicular torsion was present in 100 cases (15%). Testicular detorsion with bilateral 3-point testicular fixation was performed in 66 (66%) and orchidectomy with contralateral fixation in 34 (34%) where the torted testis was non-viable intraoperatively. The orchidectomy rate in the presence of torsion was 23% in ED referrals (12/52), 43% in primary care referrals (12/28) and 50% for transfers (10/20). The difference in rates between ED referrals and patients transferred from other hospitals was significant (p=0.026). There was no significant difference in median age between any of the groups (p=0.10).

CONCLUSIONS

Boys undergoing emergency scrotal exploration had a higher orchidectomy rate when transferred from other hospitals to our unit. This difference was statistically significant when compared with boys presenting directly to our ED. This supports advice from The Royal College of Surgeons of England for undertaking paediatric scrotal explorations in the presenting hospital when safe to do so rather than delaying the care of these patients by transferring them to a tertiary paediatric surgical unit.

Variable patterns of neuropsychological performance in HIV-1 infection

Based upon prior findings with group means, a "prototypical pattern" of neuropsychological results with HIV infection has emerged: impaired executive functioning, motor skills, speed of information processing, and learning, with intact memory retention, most language skills, and visuospatial functioning. We examined neuropsychological results from 553 HIV+ adults to determine the number of patterns seen among individuals with HIV infection. Factor analysis of a relatively comprehensive neuropsychological battery identified 6 component factors: verbal memory (VeM), visual memory (ViM), processing speed (PS), attention/working memory (A/WM), executive function (EF), and motor (M). These factor scores were submitted to hierarchical cluster analysis, to determine the appropriate number of clusters or patterns in the cohort. Final cluster membership was then determined by K-means analysis, based on the Lange, Iverson, Senior, and Chelune (2002) method. A 6-cluster solution was found to be most appropriate. The definitions of the clusters were based upon ipsative scoring of factor scores to indicate relative strengths and weaknesses (independent of overall level of performance): Cluster 1: strong EF; Cluster 2: strong M, weak VeM and EF; Cluster 3: strong PS, weak ViM and EF; Cluster 4: strong VeM, weak M; Cluster 5: strong A/WM; Cluster 6: strong VeM, weak EF. Neuropsychological-impairment rates differed across clusters, but all 6 clusters contained substantial numbers of impaired and unimpaired individuals. Cluster membership was not explained by demographic variables or psychiatric or neuromedical confounds. Thus, there does not appear to be a single, prototypical pattern of neuropsychological impairment associated with HIV infection for this battery of representative neuropsychological tests.

Hospital in-patients with diabetes: increasing prevalence and management problems

AIMS

To re-assess the prevalence, management problems, clinical outcomes and discharge summaries of hospital in-patients with diabetes.

METHODS

Case records of all patients occupying in-patient beds were audited on a single weekday in 2003 in a large urban hospital and repeated after 3 months. Data was compared with an identical audit 12 years previously.

RESULTS

Over 12 years the number of beds available for admission (1191) had reduced by 25% with a bed occupancy of 97%. Diabetes prevalence had increased from 7.0% to 11.1% (P < 0.01) (97% Type 2). Diabetes management was considered inappropriate in 29%, more than in 1991 (20%). After 3 months, discharge summaries had been completed on 75% of patients but diabetes was mentioned in only 53%.

CONCLUSION

The prevalence of in-patient diabetes (11.1%) was over 50% greater and diabetes management was suboptimal in more patients than in 1991. In many length of stay was prolonged and almost half of the discharge summaries did not mention diabetes. These findings have major implications for service delivery and resource planning.

Analysis of the UV-induced melanogenesis and growth arrest of human melanocytes

Cultured human melanocytes derived from different skin types responded to frequent treatment with ultraviolet (UV) light with increased melanin synthesis, decreased proliferation, and morphologic signs of aging. These effects were augmented by increased frequency of irradiation with 15.5 mJ/cm2 UV light. Stimulation of melanogenesis by UV light involved an increase in tyrosinase activity, without any change in the amounts of either tyrosinase or tyrosinase-related protein (TRP)-1, and a decrease in the amount of TRP-2, as determined by Western blot analysis. These results are different from the mechanisms by which other melanogenic agents, such as cholera toxin and isobutyl methylxanthine, stimulated melanogenesis, whereby the amounts of tyrosinase, TRP-1 and TRP-2 were increased. The decrease in the amount of TRP-2 might be significant in that it might alter the properties of the newly synthesized melanin. The UV irradiation protocol that was followed blocked melanocytes in G2-M phase of the cell cycle without compromising cellular viability. Following three rounds of UV irradiation, melanocytes could recover from the growth arrest and resume proliferation. Treatment with 0.1 microM alpha-melanocyte stimulating hormone (alpha-MSH) postirradiation enhanced the melanogenic effect of UV light and stimulated the melanocytes to proliferate. The effects of alpha-MSH on the UV-induced responses and their implications on photocarcinogenesis are being further investigated. Analyzing the mechanisms by which UV light exposure affects normal melanocytes might lead to a better understanding of how these cells undergo malignant transformation, and why individuals with different skin types differ in their susceptibility to skin cancers.

A rapid and specific method for measuring chloramphenicol degradation in aqueous solution following autoclaving

An HPLC method is reported for the measurement of chloramphenicol and its degradation product following autoclaving. The procedure, using a reversed-phase column and potassium phosphate solution as the solvent, is shown to be suitable for monitoring chloramphenicol degradation in intrathecal injections after sterilisation.