Quality of care assessment for non-small cell lung cancer patients: transforming routine care data into a continuous improvement system.

PURPOSE: The complexity of cancer care requires planning and analysis to achieve the highest level of quality. We aim to measure the quality of care provided to patients with non-small cell lung cancer (NSCLC) using the data contained in the hospital's information systems, in order to establish a system of continuous quality improvement. METHODS/PATIENTS: Retrospective observational cohort study conducted in a university hospital in Spain, consecutively including all patients with NSCLC treated between 2016 and 2020. A total of 34 quality indicators were selected based on a literature review and clinical practice guideline recommendations, covering care processes, timeliness, and outcomes. Applying data science methods, an analysis algorithm, based on clinical guideline recommendations, was set up to integrate activity and administrative data extracted from the Electronic Patient Record along with clinical data from a lung cancer registry. RESULTS: Through data generated in routine practice, it has been feasible to reconstruct the therapeutic trajectory and automatically calculate quality indicators using an algorithm based on clinical practice guidelines. Process indicators revealed high adherence to guideline recommendations, and outcome indicators showed favorable survival rates compared to previous data. CONCLUSIONS: Our study proposes a methodology to take advantage of the data contained in hospital information sources, allowing feedback and repeated measurement over time, developing a tool to understand quality metrics in accordance with evidence-based recommendations, ultimately seeking a system of continuous improvement of the quality of health care.

A Case Report of Falciform Ligament Appendagitis.

Falciform ligament appendagitis is an extremely rare form of intra-abdominal focal fat infarction. It usually presents with vigorous abdominal pain and mimics other more common acute abdominal pain-associated diseases. Better recognition of this entity avoids misdiagnoses and unnecessary surgical treatment. We present the case of a 73-year-old woman admitted to the emergency department for abdominal pain, nausea, and vomiting. She had a fever and a diffuse tender abdomen with upper right quadrant pain. Laboratory investigation showed leukocytosis and high C-reactive protein. CT revealed a heterogeneous increased density of fat adjacent to the falciform ligament. Falciform ligament appendagitis was diagnosed and antibiotic and anti-inflammatory treatment resulted in complete recovery. This case highlights the need to raise awareness and better recognize falciform ligament appendagitis to avoid unnecessary surgical interventions.

Unusual Vulvar, Perineal, and Uterine Leiomyomas: A Case Report.

Vulvar leiomyomas are extremely rare smooth muscle tumors that are easily mistaken for other lesions, as the differential diagnosis must consider a wide spectrum of benign and malignant lesions. We present the case of a 52-year-old woman with a three-year history of progressive abdominal distension and pain and an enlarging vulvar mass distorting the labia majora and causing gait disturbance. Imaging confirmed an enormous pelvic mass originating in the uterus, compatible with a leiomyoma/sarcoma, and large perineal and vulvar masses with similar characteristics. Histopathology after surgical removal revealed benign abdominal, vulvar, and perineal leiomyomas. This case highlights the rarity and diagnostic challenges of extra-uterine leiomyomas, particularly those in the vulvar region.

AL Amyloidosis and Multiple Myeloma: A Complex Scenario in Which Cardiac Involvement Remains the Key Prognostic Factor.

Monoclonal gammopathies (MGs) are a wide range of diseases that may evolve or progress over time. Comorbidity plays a critical role in this setting. The co-occurrence of two MGs is not a rare event. The evidence on the association of systemic light chain (AL) amyloidosis and multiple myeloma (MM) is scarce and controversial. Herein we aim to address this topic in a large series of patients of a referral center. All consecutive AL amyloidosis patients treated at our center from January 2005 to April 2023 were prospectively enrolled in a clinical and epidemiological registry. 141 patients diagnosed with AL amyloidosis were included, of which 7 (5%) had localized whereas 134 presented with systemic disease. The heart was the most frequently affected organ (90.3%). 25 patients (18.7%) fulfilled the IMWG diagnostic criteria of MM (AL/MM). Time-dependent association between AL and MM showed that the synchronous pattern is more frequent than the appearance of a second primary malignancy. The diagnostic delay was six months (m). Patients with AL/MM had a poorer median overall survival (OS) than AL-only patients (35.5 m, CI 95% 0-88.9, vs. 52.6 m, CI 95% 16.7-88.5), but this difference was not statistically significant. The prognosis in AL is dominated by the heart involvement, which is massive in this series. In our Cox regression model, only three prognostic variables remain as independent prognostic factors: age, N-terminal pro-brain natriuretic peptide (≥8500 ng/L), and undergoing an autologous stem cell transplant, whereas left ventricular ejection fraction shows a marginal effect. More and large studies focusing on the AL/MM association are needed to uncover the characteristics and prognostic impact of this association.

Modular MA-XRF Scanner Development in the Multi-Analytical Characterisation of a 17th Century Azulejo from Portugal.

A modular X-ray scanning system was developed, to fill in the gap between portable instruments (with a limited analytical area) and mobile instruments (with large analytical areas, and sometimes bulky and difficult to transport). The scanner has been compared to a commercial tabletop instrument, by analysing a Portuguese tile (azulejo) from the 17th century. Complementary techniques were used to achieve a throughout characterisation of the sample in a complete non-destructive approach. The complexity of the acquired X-ray fluorescence (XRF) spectra, due to inherent sample stratigraphy, has been resolved using Monte Carlo simulations, and Raman spectroscopy, as the most suitable technique to complement the analysis of azulejos colours, yielding satisfactory results. The colouring agents were identified as cobalt blue and a Zn-modified Naples-yellow. The stratigraphy of the area under study was partially modelled with Monte Carlo simulations. The scanners performance has been compared by evaluating the images outputs and the global spectrum.

Periodic Fever with Pharyngitis, Aphthous Stomatitis and Cervical Adenitis Syndrome: A Rare Cause of Fever in Adults.

Periodic fever with pharyngitis, aphthous stomatitis and cervical adenitis (PFAPA syndrome) is a common cause of periodic fever in children and usually manifests as episodes of fever recurring with a clockwork periodicity. Although rare after adolescence, adult patients with PFAPA syndrome may present with a wider range of symptoms and may lack the clockwork periodicity of fever. A 24-year-old patient presented with a 4-year history of periodic fever with pharyngitis and cervical adenitis. She also complained of vomiting, fatigue and sporadically presented with aphthous stomatitis. During crises, laboratory evaluation showed a moderate elevation of inflammatory markers. Blood cultures and ANA titres were negative. Immunoglobulins and serum ferritin levels were normal. After other causes of periodic fever had been excluded, a diagnosis of PFAPA syndrome was made. LEARNING POINTS: PFAPA syndrome is characterized by periodic fever accompanied by pharyngitis, aphthous stomatitis and cervical adenitis.It is a common cause of periodic fever in children but can also present in adults with a wider range of clinical manifestations.Establishing a firm diagnosis of PFAPA syndrome may avoid excessive work-up and potentially harmful treatment.

Assessment of Toxic Metals and Hazardous Substances in Tattoo Inks Using Sy-XRF, AAS, and Raman Spectroscopy.

Synchrotron radiation X-ray fluorescence spectroscopy, in conjunction with atomic absorption and Raman spectroscopy, was used to analyze a set of top brand tattoo inks to investigate the presence of toxic elements and hazardous substances. The Cr, Cu, and Pb contents were found to be above the maximum allowed levels established by the Council of Europe through the resolution ResAP(2008)1 on requirements and criteria for the safety of tattoos and permanent makeup. Raman analysis has revealed the presence of a set of prohibited substances mentioned in ResAP(2008)1, among which are the pigments Blue 15, Green 7, and Violet 23. Other pigments that were identified in white, black, red, and yellow inks are the Pigment White 6, Carbon Black, Pigment Red 8, and a diazo yellow, respectively. The present results show the importance of regulating tattoo ink composition.

Analytical characterization of the palette and painting techniques of Jorge Afonso, the great 16th century Master of Lisbon painting workshop.

In this work, a study on a set of paintings from the most significant altarpiece assigned to Master Jorge Afonso (c. 1470-1540) painting workshop is presented. This altarpiece is composed by fourteen paintings made to the church of Convento de Jesus, in Setúbal, Portugal, and was made circa 1517-19/1530, according to art-history. This set of paintings is compared to one of the other most important Portuguese altarpieces from the 16th century: the panels of the Round Church of the Convento de Cristo, in Tomar, made circa 1510-1515. The aim of this study is to characterize the wooden support, pigments, ground layers materials and technique used in Jorge Afonso workshop by means of complementary analyses. A dendrochronological approach was made in order to corroborate (or not) the historical date initially assigned. Infrared photography (IRP) and reflectography (IRR) allowed the study of the underdrawing technique and macro photography (MP) was used to recognize overlapping layers technique. Cross-sections from the paintings were examined by optical microscopy (OM), and analyzed by µ-X-ray diffraction (µ-XRD), Energy Dispersive X-ray Fluorescence spectroscopy (EDXRF), Scanning Electron Microscopy with Energy Dispersive X-ray Spectroscopy (SEM-EDS), micro-Raman spectroscopy (µ-Raman), micro-Fourier Transform Infrared spectroscopy (µ-FTIR), Pyrolysis Gas Chromatography Mass Spectrometry (py-GC/MS). The characterization of the palette and ground layers and the study of the overlapping of paint layers brought a new insight of the adopted painting techniques by the most important group of painters working in Portugal in the 16th century - the Lisbon workshop, leaded by Master Jorge Afonso.

Senile Systemic Amyloidosis: An Underdiagnosed Disease.

Senile systemic amyloidosis is caused by a non-mutated form of transthyretin with the heart being the major organ involved. This infiltrative cardiomyopathy usually presents as slowly progressive heart failure. An 82-year-old female patient was admitted for newly diagnosed heart failure. A year later she presented with decompensated heart failure and syncope. Inpatient work-up showed persistently elevated troponin and N-terminal-pro BNP levels, rapid progression to severe left ventricular concentric hypertrophy, and sinus pauses on the Holter. Cardiac MRI revealed diffuse late gadolinium enhancement in the left ventricle. The demonstration of amyloid protein with the clinical findings and complementary investigations allowed for the diagnosis of senile systemic amyloidosis. LEARNING POINTS: Senile systemic amyloidosis is a rare disease with a common clinical presentation that is probably underdiagnosed in patients with heart failure with preserved systolic function.A new unexplained heart failure diagnosis, increased ventricular wall thickness and particularly low voltage on the ECG should raise the suspicion of cardiac amyloidosis.Histopathological evidence of amyloid deposition elsewhere and typical advanced imaging features can support the diagnosis, rendering endomyocardial biopsy no longer mandatory.

Synchronous presentation of two rare forms of extrapulmonary tuberculosis.

Tuberculosis (TB) remains one of the leading infectious causes of death throughout the world. Extrapulmonary forms, namely adrenalitis and prostatitis, are rare presentations of TB and pose a difficult diagnostic challenge, given their non-specific manifestations. The authors present a case of a 42-year-old man with long-standing symptoms of fatigue, anorexia, weight loss, nightly fever and sudoresis. He also suffered from sporadic vomiting and episodic hypotension, and had skin hyperpigmentation, as well as frequent urination, perineal discomfort and pain at ejaculation. Laboratory investigation confirmed primary adrenal failure. On CT scan there were two hypodense right adrenal nodules and bilateral lung condensations with a tree-in-bud pattern. Another hypodense nodule was seen in the prostate. TB was diagnosed by isolatingMycobacterium tuberculosisfollowing cultures of bronchoalveolar lavage, bronchial secretions, urine and ejaculate. Antibacillary treatment resolved the infectious lesions but the patient remained on corticosteroid replacement therapy for ongoing adrenal failure.

Malignant Otitis Externa and Stroke.

Malignant otitis externa (MOE) is an aggressive but benign entity which evolves into skull base osteomyelitis. An 81-year-old female patient was admitted for left hemiparesis and homonymous hemianopia. She complained of headache radiating to the right cervical area. A recent history of recurrent otitis media was present. Head and neck imaging showed an ischemic infarction (right temporo-occipital) and a parapharyngeal soft tissue mass originating in an external and medial ear infection. Culture samples revealed Pseudomonas aeruginosa infection leading to the diagnosis of Malignant otitis externa (MOE). Parenteral antibacterial therapy and hyperbaric oxygen therapy resulted in improvement. LEARNING POINTS: Malignant otitis externa is an aggressive and life-threatening disease which must be identified early and treated promptly for therapeutic success.Although starting as an outer ear infection (typically caused by Pseudomonas aeruginosa) local spread can involve noble head and neck structures leading to variable signs and symptoms.Modern imaging techniques can help define structure involvement (MRI) and may help identify disease activity and prognosis (nuclear medicine).

Microscopy and X-ray spectroscopy analyses for assessment of gilding and silvering techniques of Portuguese illuminated manuscripts.

The objects of this study are various local charters (cartas de foral, in Portuguese) granted by Dom Manuel I, King of Portugal (1495-1521), which substituted for medieval ones and were intended to achieve an administrative unification. These are luxuriously illuminated manuscripts, and our study aims at obtaining a better understanding of the gilding and silvering techniques applied to the parchments, in which the forais were written, between 1500 and 1520. The combined use of microscopy and X-ray spectroscopy analyses allowed us to identify the vestigial materials used for making the parchments, including products such as salt (NaCl), lime (CaO), pumice stone (SiO2+Al2O3), and chalk (CaCO3). Chalk was employed as a whitening agent to give the parchment its final color and opacity. Shell-gold and shell-silver mixed in with animal glue or gum binding media were directly applied on type 1 and 3 forais, while very thin gold leaves (<1 µm) were applied over lead-based tempera grounds (50-180 µm thick) in type 2 forais. Silver was always employed in its finest form without a further protective layer (thus its recursive state of corrosion), while gold was used in various alloy grades.

White spots on Smoke rings by Bruce Nauman: a case study on contemporary art conservation using microanalytical techniques.

The artwork "Smoke Rings: Two Concentric Tunnels, Non-Communicating" by Bruce Nauman represents a case study of corrosion of a black patina-coated Al-alloy contemporary artwork. The main concern over this artwork was the widespread presence of white spots on its surface. Alloy substrate, patina, and white spots were characterized by means of energy-dispersive X-ray fluorescence and scanning electron microscopy with energy-dispersive spectroscopy. Alloy substrate was identified as an aluminum alloy 6,000 series Al-Si-Mg. Patina's identified composition confirmed the documentation provided by the atelier. Concerning the white spots, zircon particles were found on patina surface as external elements.

Micro-analytical study of a rare papier-mâché sculpture.

The analysis of a Portuguese "papier-mâché" sculpture depicting Saint Anthony is presented in this case study. Several questions were addressed such as the characteristics of the support, pigments used, and artistic technique in order to establish a possible timeline for its production. Qualitative analyses of the cross-sections and of the paper support were performed by optical microscopy using reflected light. Two polychrome layers from different periods and a rag pulped support were identified on the sculpture. The use of micro X-ray fluorescence and Raman microscopy techniques enabled the differentiation of coloring materials used in both polychromies. Semi-quantitative analyses of the gilded samples were also performed by scanning electron microscopy in combination with energy-dispersive spectroscopy allowing the determination of a common Au-Ag-Cu alloy with differences in the purity of the gold. The identified coloring materials lead us to believe that the sculpture was produced in the 19th century, being overpainted in the first half of the 20th century.

Spectroscopic characterization of a contemporary Indian miniature painting.

A case study on a contemporary Indian miniature was carried out through the application of different spectroscopic techniques. Painting support, pigments, and dyes were largely characterized by means of energy dispersive x-ray fluorescence and Raman microspectroscopy directly on the artwork. Regarding golden motifs and silvered areas, for which these techniques have not provided enough information, scanning electron microscopy coupled with energy dispersive x-ray spectroscopy was used as a complementary technique. The painting support was identified as the Bombyx mori silk. Among the colorant matters, several pigments were identified such as chrome yellow, lithopone, hematite, lamp black, mica-titania pearlescent pigment, and tin-based metallic silver, and dyes such as phthalocyanine blue and the recent synthetic pigment red PR9 naphthol AS. All this materials will provide evidence in the support of the contemporary production of the artwork for future studies.

Spectroscopic characterization of a masterpiece: the Manueline foral charter of Sintra.

The foral charter attributed by D. Manuel I of Portugal, in 1514, to the village of Sintra was studied using Energy Dispersive X-ray Fluorescence spectrometry, Raman and Infrared micro-spectroscopies. A complete characterization of the pictorial materials used in the production of this masterpiece allowed the identification of iron gall inks used in the written text; pigments such as malachite, azurite, lead white, cinnabar, yellow ochre, gold, silver and carbon black in the illuminations and letterings; filler and binder used in the production of coloring materials and inks. Gum and calcium carbonate were the most recurrent binder and filler identified in this study. Silvering and gilding were mostly obtained by applying ground silver and gold on parchment.

[Risk factors for Clostridium difficile infections in hospitalized patients]. / Factores de riesgo de infección por Clostridium difficile en pacientes hospitalizados.

BACKGROUND AND OBJECTIVES: To identify risk factors, and to estimate the crude effects attributable to hospital acquired Clostridium difficile infection (CDI). PATIENTS AND METHODS: Case-control study matched by age, gender, and admission date. Patient and healthcare risk factors were evaluated. Hospital stays and mortality were compared. RESULTS: Thirty-eight cases and 76 controls were included (mean age 73 years). Cases presented worse Charlson index (P .02), higher pre-infection stay (median 10 vs. 5.5 days) and had received antibiotic treatment more frequently (89.5 vs. 40.7%) than their control counterparts. Albuminemia < 3.5 gr/dL (OR 7.1; 1.4-37), having received cephalosporins (OR 10.1; 1.8-55.1), quinolones (OR 9.4; 1.1-41.1), or proton pump inhibitors (OR 6.6; 1.1-41.1) were associated with an independent higher risk of CDI. Total hospital stay (31 vs. 5.5 days), as well as crude mortality, was higher for cases than for control patients (31.6 vs. 6.6%). CONCLUSIONS: Receiving cephalosporins, quinolones and proton pump inhibitors, as well as hyponutrition, increase the risk of CDI. CDI is associated with relevant crude effects on mortality and excess of stay.

Investigation of the composition of historical and modern Italian papers by energy dispersive X-ray fluorescence (EDXRF), X-ray diffraction (XRD), and scanning electron microscopy energy dispersive spectrometry (SEM-EDS).

In this work, a study concerning the composition of Italian papers from the seventeenth to the twentieth centuries was carried out using energy dispersive X-ray fluorescence spectrometry (EDXRF), X-ray diffraction (XRD), and scanning electron microscopy coupled to energy dispersive spectrometry (SEM-EDS). The analyzed samples consisted of papers employed for drawing, writing, printing, and absorbance. Observations carried out by SEM magnified the typical paper morphology. EDXRF in combination with XRD and SEM-EDS allowed the determination of calcite, gypsum, kaolin, talc, magnesite, and dolomite, used as fillers in the production of the papers studied herein. The inks present in the handwritten and printed papers, investigated by SEM-EDS and µ-EDXRF, were synthetic, Fe based, and iron gall inks.