Improving dose delivery accuracy with EPID in vivo dosimetry: results from a multicenter study.

PURPOSE: To investigate critical aspects and effectiveness of in vivo dosimetry (IVD) tests obtained by an electronic portal imaging device (EPID) in a multicenter and multisystem context. MATERIALS AND METHODS: Eight centers with three commercial systems-SoftDiso (SD, Best Medical Italy, Chianciano, Italy), Dosimetry Check (DC, Math Resolution, LCC), and PerFRACTION (PF, Sun Nuclear Corporation, SNC, Melbourne, FL)-collected IVD results for a total of 2002 patients and 32,276 tests. Data are summarized for IVD software, radiotherapy technique, and anatomical site. Every center reported the number of patients and tests analyzed, and the percentage of tests outside of the tolerance level (OTL%). OTL% was categorized as being due to incorrect patient setup, incorrect use of immobilization devices, incorrect dose computation, anatomical variations, and unknown causes. RESULTS: The three systems use different approaches and customized alert indices, based on local protocols. For Volumetric Modulated Arc Therapy (VMAT) treatments OTL% mean values were up to 8.9% for SD, 18.0% for DC, and 16.0% for PF. Errors due to "anatomical variations" for head and neck were up to 9.0% for SD and DC and 8.0% for PF systems, while for abdomen and pelvis/prostate treatments were up to 9%, 17.0%, and 9.0% for SD, DC, and PF, respectively. The comparison among techniques gave 3% for Stereotactic Body Radiation Therapy, 7.0% (range 4.7-8.9%) for VMAT, 10.4% (range 7.0-12.2%) for Intensity Modulated Radiation Therapy, and 13.2% (range 8.8-21.0%) for 3D Conformal Radiation Therapy. CONCLUSION: The results obtained with different IVD software and among centers were consistent and showed an acceptable homogeneity. EPID IVD was effective in intercepting important errors.

Assessment of self-efficacy for caregiving in oncology: Italian validation of the caregiver inventory (CGI-I).

BACKGROUND: The Caregiver Inventory (CGI), a measure of self-efficacy for caregiving that takes into account aspects of caregiving that are neglected by current measures of caregiving, was translated into Italian and validated. METHODS: Ninety-one caregivers from a variety of locations in Italy completed the CGI-Italian (CGI-I) as well as the Hospital Anxiety and Depression Scale (HADS) and the Family Strain Questionnaire - Short Form (FSQ-SF). RESULTS: A confirmatory factor analysis based on the original CGI factor structure resulted in an adequate fit of the CGI-I using standard fit indices. Thus, the original factor structure was validated in the CGI-I: Managing Medical Information (α = 0.87), Caring for Care Recipient (α = 0.68), Caring for Oneself (α = 0.78), and Managing Difficult Interactions/Emotions (α = 0.55). The CGI-I total score was inversely related to anxiety (HADS, r = - 0.35, p = <.05), and depression (HADS, r = - 0.45, p = <.05). In addition, the CGI-I was inversely related to caregiver stress (FSQ-SF, r = - 0.39, p = <.05). Care of Oneself and Managing Difficult Interactions/Emotions emerged as the strongest and most robust negative relationships with anxiety, depression, and caregiver stress, which replicated, with similar constructs, findings from the original CGI. CONCLUSIONS: The results of this study established the CGI-I as a reliable and valid measure of self-efficacy for caregiving. This study also confirms the importance of self-care and managing difficult communication in the process of successfully navigating the demands of caregiving and in constructing interventions for caregivers who need support.

Cefoperazone plus mezlocillin for empiric therapy of febrile cancer patients.

Two dosing regimens of cefoperazone plus mezlocillin were compared in a prospective, randomized trial for therapy of febrile cancer patients. The two regimens were 5 g mezlocillin plus 2 g cefoperazone intravenously every four hours (higher dose) or 3 g mezlocillin plus 1 g cefoperazone intravenously every four hours (lower dose). Although the overall response rate was higher with the higher dose regimen (78 percent versus 66 percent, p = 0.04), the two regimens were comparable in patients with documented infections (72 percent versus 68 percent). Likewise, the two regimens were equally effective against those infections in which the pathogen could be determined (82 percent versus 82 percent). Serum bactericidal titers of at least 1:32 against a known pathogen were associated with a higher response rate than were titers of less than 1:32, but the higher dose regimen did not result in higher serum bactericidal titers. Hypoprothrombinemia was a side effect, especially with the higher dose regimen, before prophylactic vitamin K was routinely administered to patients. Since there were no major benefits with the use of the higher dose regimen of mezlocillin plus cefoperazone, the lower dose regimen is more appropriate for routine usage.

Inhibitory effect of retinoids on the generation of procoagulant activity by blood mononuclear phagocytes.

Retinoids are known to modulate several functions of mononuclear phagocytes. We have studied the effect of retinyl acetate (RAc) and retinoic acid (RA) on the production of procoagulant activity (PCA) by human peripheral blood mononuclear cells stimulated with endotoxin (1 microgram/ml, 4 or 20 h at 37 degrees C). Both compounds caused a dose-dependent reduction in the expression of cell-associated PCA (from 86 to less than 10% of control in the range of concentration comprised between 0.1 and 100 microM). This effect was also observed when the cells were exposed to retinoids for 10 min and washed before challenge with endotoxin, indicating that it is rapid and irreversible. In contrast, incubation of RAc or RA for 3 h at 37 degrees C with cells that have been already stimulated with endotoxin (20 h at 37 degrees C) remained without influence on cell PCA. The inhibitory action of retinoids was also observed when monocyte-enriched (greater than 85%) preparations or highly purified monocyte-derived macrophages (greater than 99%) were used instead of whole mononuclear cells. BW755C, an inhibitor of cyclo-oxygenase and lipoxygenase, reversed the inhibitory effect of retinoids, whereas acetylsalycilic acid, an inhibitor of cyclo-oxygenase, was inactive, suggesting the involvement of a lipoxygenase product. The inhibition of monocyte/macrophage PCA production and the subsequent reduction of cell potential for fibrin deposition might represent one of the mechanisms whereby retinoids exert their antiinflammatory and immunomodulatory activities.

Biological activity of metal complexes. I. Interaction of pt(II), pd(II) and rh(I) complexes with E. coli strains and with mice LS fibroblasts in vitro.

The effects of a number of Pt(II, Pd(II) and Rh(I) complexes against cultures of Escherichia coli (strains B, H10178, uvra-, recA-) and cultures of mice LS Fibroblasts were tested. Most of the compounds showed higher cytotoxic activity than the cis-Pt(NH3)2Cl2, the compound at present on clinical trial as antittumour drug. A new model of active compound is proposed.

Effect of cisplatin on the oxidative metabolism of polymorphonuclear leukocytes in cancer patients.

Peripheral blood polymorphonuclear leukocytes of patients with ovarian or uterine-cervix carcinoma were studied during cisplatin chemotherapy for phagocytic oxidative metabolism. In particular, superoxide production by these leukocytes after stimulation with opsonized Zymosan particles was determined. The basal value of oxidative metabolism of leukocytes from neoplastic patients was lower than in normals. Superoxide production decreased after each dose administration, but returned to normal at the end of the entire chemotherapeutic treatment. It is suggested that cisplatin treatment, despite a short-lived depression of oxidative metabolism in polymorphonuclear cells, improves this function, most probably by interfering with neoplastic growth.

[Informed consent forms in medical practice: the results of a knowledge survey]. / Il consenso informato scritto nella pratica medica: i risultati di una indagine conoscitiva.

"Federico II" University of Naples Hospital Management's Staff considered 47 informed consent forms in order to evaluate quality and quantity of the information transmitted to patients. Every form, distinguished by procedure (surgical, pharmacological, anesthesiologic or related to blood transfusions) was evaluated for the accuracy and validity of information related to: diagnosis, prognosis, diagnostic and therapeutic opportunities, expected benefits, adverse-side effects, iatrogenic risks, privacy policy on personal data. The forms were judged by information completeness criteria "conformed" or "not conformed" with standards. Our analysis demonstrate that physicians often are unaware of legal and ethical topics related to constructing informed consent forms. They usually omit crucial information or would use strict technical language. So far, we conclude Hospital Management's Staff definitively has a role in improving informed consent forms by establishing guidelines and promoting ethical issues. Final result could be to deserve stronger patient confidence in medical institutions.

[Appendiceal lithiasis: case report and review of literature]. / Calcolosi dell'appendice: caso clinico e revisione della letteratura.

Appendiceal calculi are found in a limited percentage of patients. They are in association to an elevated prevalence of necrotic appendicitis and perforation of the appendix. The Authors report a case of acute appendicitis associated to appendiceal lithiasis with perforation of the organ. They emphasize the possibility to perform a preventive appendectomy in case of incidental appendiceal lithiasis. Besides they consider the differential diagnosis of the calcified images located in the lower abdominal quadrants with the aid of the various imaging methods available today, particularity sonography and computerized tomography.

[A case of total spinal block during epidural anaesthesia]. / Un caso di blocco spinale totale durante anestesia peridurale lombare.

Most cases of total spinal block have been reported in the literature. The displacement of the catheter and the consequent dural perforation are the causes in large percentage of the patients (75%). The Authors describe this case for the importance of the causes and outcome of the patient. A 48 years old woman presented for hysterectomy for uterine fibromas. After having individualized the L3-L4 interspace, a test dose of 3 ml carbocaine 2% was injected. After that, the spinal block was obtained using ropivacaine 0.75% (total dose = 10 ml) injecting slowly, in following times, 5+5 ml of anaesthetic solution. The patient, perfectly conscious at first, presented a gradual increase of the difficulty in talking and breathing. Subsequently she showed a complete paralysis with loss of the consciousness, respiratory arrest, bilateral and symmetrical midriasis, as well as total areflexia. Endotracheal tube was placed. After eighty minutes from the end of the administration of the local anesthetic, spontaneous thoracic excursions appeared, even though of moderate ampleness, midriasis reduced. The patient recovered consciousness and sufficiently ventilated; therefore the endotracheal tube was removed.

[Anaesthesiologic problems about hyperthermic intraoperative intraperitoneal chemotherapy]. / Chemioipertermia intraperitoneale intraoperatoria: problematiche anestesiologiche.

The literature considers hyperthermic intraoperative intraperitoneal chemotherapy a safe and effective procedure for peritoneal carcinomatosis, but a technical improvement is necessary. Regional chemotherapy anticipates the "downfall" of tumoral cells in the peritoneum. The Authors considered 5 patients--female, age 27-45 years, ASA 2--operated of peritonectomy in ovaric neoplasia with peritoneal metastasis. The hyperthermic intraoperative intraperitoneal chemotherapy has been made at the end of the surgery with a hot solution (43 degrees C): 3000 ml of dextrose 1.5% with mytomicina C 25 mg e cysplatino 75 mg/m2. We considered variation of emodinamic parametres (blood pressure, central venous pressure, stroke volume, etc.) and biochemical parametres (Na, K, CI-, CO2, etc.). These parametres have been correlated with some complications: fistula, anastomotic leakage, pancreatitis and postoperative bleeding.

[Apparent life threatening event (ALTE): the role of the training in the follow-up]. / Evento apparentemente pericoloso per la vita (ALTE): il ruolo della formazione nel follow-up.

AIM: The aim of this study was to give a support to the parents of the patients with apparent life threatening event (ALTE), to learn a correct management outside the protective environment of the hospital and a prevention such events. METHODS: This was the 33rd edition of a training course called "Course of first aid and prevention of the accidents in infants", in which the recommendations of the Italian cardiopulmonary resuscitation's guidelines are treated. The course comprehended a short frontal lesson, a practice training and the compilation of a test to express one's satisfaction about the received training, using a points assessment from 1 to 10. RESULTS: The course included 385 participants (including any kind of person who may be in contact with infants) and 361 questionnaires were returned. Critical parameters were the scheme of teaching, the adequacy of contents, the teachers' technical and behavioral abilities, the adequacy of time and the communicative capacity. The learners demonstrated pleasure in variable percentages from 98% to 100%. The 79% of the learners felt the necessity to have some training again later on. CONCLUSION: Our positive experience allowed us to reflect about three concepts that we considered essential: communication, training and prevention. In fact, we think that prevention is infinitely potentiated from training and communication is its inalienable instrument.

A randomized controlled trial of pimecrolimus cream 1% in adolescents and adults with head and neck atopic dermatitis and intolerant of, or dependent on, topical corticosteroids.

BACKGROUND: There is a need for alternative treatments for atopic dermatitis (AD) of the face and neck as long-term use of topical corticosteroids (TCS) is associated with skin atrophy and telangiectasia and some patients develop allergy, intolerance or other side-effects. OBJECTIVES: This study was designed to assess the efficacy and safety of pimecrolimus cream 1% in patients with AD of the face and neck who are either dependent on, or intolerant of, TCS. METHODS: A 12-week study comprising a 6-week, double-blind, randomized, vehicle-controlled phase was conducted, followed by a 6-week, open-label phase. Two hundred patients aged 12 years or over with mild to moderate head and neck AD, intolerant of, or dependent on, TCS were randomized to either pimecrolimus cream or vehicle cream. The primary efficacy criterion was the facial investigator's global assessment score at 6 weeks. Secondary efficacy criteria were head and neck Eczema Area and Severity Index (EASI), pruritus score and eyelid dermatitis. Facial skin atrophy and telangiectasia were assessed with dermatoscopy. RESULTS: A significantly higher percentage of patients treated with pimecrolimus was cleared or almost cleared of facial AD compared with vehicle (47% vs. 16%, respectively). A statistically significant difference was also seen on head and neck EASI and pruritus score. Significantly more pimecrolimus-treated patients than vehicle-treated patients achieved clearance of eyelid dermatitis (45% vs. 19%, respectively). Among the 77 patients with skin atrophy at baseline, treatment with pimecrolimus was associated with a reversal in skin thinning. Of the 112 patients with telangiectasia at baseline, no statistically significant difference was seen between treatment groups. Adverse events occurred with similar frequency in both groups. CONCLUSION: Pimecrolimus cream 1% is effective in patients with head and neck dermatitis intolerant of, or dependent on, TCS. Reversion of skin atrophy may occur during TCS-free intervals.

[Candida albicans infection: in vitro immunity aspects]. / Infezione da Candida albicans: alcuni aspetti immunitari in vitro.

The authors have investigated the chemotactic ability of C. albicans toward macrophages and polymorphonuclears. Experiments, carried out by modified Boyden chamber, lead to isolate a chemotactic agent, considered either a moderate cytotaxin, or an excellent cytotaxigen.

[Effects of cis-platin on the contractile system of polymorphonuclear leukocytes]. / Effetti del cis-platino sul sistema contrattile di leucociti polimorfonucleati.

The effects of cis-Platinum, a new antitumor drug, on guinea pig polymorphonuclear functions related to subplasmalemmal fibrillar structures, were investigated. The compound markedly decreased chemotaxis. Zymosan particles engulfment and degranulation. The depression of these leucocyte activities adds to the already known drug induced myelotoxicity .

Modifications of macrophage chemotaxis in rats bearing the transplantable tumour reticulosarcoma 'IRE'.

Macrophage chemotactic activity was studied as a marker of the anti-inflammatory effect accompanying tumour growth. An inhibiting effect of the tumour on the macrophage mobility was observed by comparing the macrophages collected from normal rats and those from animals bearing the IRE reticulosarcoma. To explain these results, it is postulated that a MIF, or a similar inhibiting factor is released by the tumour. Both the the nature and function of such a factor(s) remain to be clarified.

Sulfide enhancement of PMN apoptosis.

Hydrogen sulfide is a toxic metabolite released by several bacterial agents under anaerobic conditions. In the present paper, we investigated the effects of sulfide on polymorphonuclear cell (PMN) apoptosis, a mechanism suggested for limiting the toxic potential of neutrophils in inflammatory sites. We showed that 1 mM sulfide (concentration not conditioning PMN viability) is able to enhance the apoptotic fate of human granulocytes by increasing: i) the number of cells containing pyknotic nuclei, ii) the internucleosomal cleavage, and, iii) the intensity of tubulin immunofluorescence staining. The sulfide effect is partially prevented by ionomycin and this finding is consistent with the hypothesis of the inhibiting role played by high levels of cytosolic calcium in PMN apoptosis modulating.

Retinoids inhibit the respiratory burst and degranulation of stimulated human polymorphonuclear leukocytes.

Retinoids exhibit a wide spectrum of activities, including antiinflammatory properties. We have investigated the effect of retinoic acid (RA) and retinyl acetate (RAc) on the production of reactive oxygen metabolites and the release of lysosomal enzymes by human polymorphonuclear leukocytes (PMN). Incubation of PMN with RAc or RA (1-100 microM) caused a dose-dependent inhibition (upto 90%) in O2- production and chemiluminescence induced by phorbol myristate acetate (PMA), N-formyl-methionyl-leucyl-phenylanaline (fMLP), opsonized zymosan or ionophore A23187. Both retinoids (1-100 microM) also inhibited, in a dose-dependent way, degranulation induced by fMLP (upto 85% at the highest concentration of RA). These inhibitory effects appear irreversible, since they persist after the drugs are removed and the cells washed before stimulation. Inhibitors of cyclo-oxygenase activity such as acetylsalicyclic acid and indomethacin did not influence the effects of RAc. In contrast, BW755, an inhibitor of both cyclooxygenase and lipoxygenase, reversed the inhibitory action of RAc, suggesting that the effect of retinoids occurs possibly through the mediation of lipoxygenase products. The modulation of PMN oxidative metabolism and degranulation might help explain the antiinflammatory properties of retinoids.

In vitro cisplatin effects on phagocyte functions.

The effects of cis-diamminedichloroplatinum (II) (cisplatin), a drug used in cancer chemotherapy, on the oxidative metabolism, endocytosis, chemotaxis and exocytosis of guinea-pig polymorphonuclear leukocytes were studied. All these functions were negatively influenced, but the same effect (50% inhibition) was observed at different drug concentrations (3 X 10(-5) M for chemotaxis, 10(-4) M for O2 consumption by FMLP and beta-glucuronidase release, 10(-3) M for O2 consumption by PMA and for zymosan engulfment). The effects of the drug can be explained by its ability to bind to membrane proteins, essentially to -SH groups.