Contouring of emerging organs-at-risk (OARS) of the female pelvis and interobserver variability: A study by the Italian association of radiotherapy and clinical oncology (AIRO).

Purpose: To provide straightforward instructions for daily practice in delineating emerging organs-at-risk (OARs) of the female pelvis and to discuss the interobserver variability in a two-step multicenter study. Methods and materials: A contouring atlas with anatomical boundaries for each emerging OAR was realized by radiation oncologists and radiologists who are experts in pelvic imaging, as per their knowledge and clinical practice. These contours were identified as quality benchmarks for the analysis subsequently carried out. Radiation oncologists not involved in setting the custom-built contouring atlas and interested in the treatment of gynecological cancer were invited to participate in this 2-step trial. In the first step all participants were supplied with a selected clinical case of locally advanced cervical cancer and had to identify emerging OARs (Levator ani muscle; Puborectalis muscle; Internal anal sphincter; External anal sphincter; Bladder base and trigone; Bladder neck; Iliac Bone Marrow; Lower Pelvis Bone Marrow; Lumbosacral Bone Marrow) based on their own personal knowledge of pelvic anatomy and experience. The suggested OARs and the contouring process were then presented at a subsequent webinar meeting with a contouring laboratory. Finally, in the second step, after the webinar meeting, each participant who had joined the study but was not involved in setting the benchmark received the custom-built contouring atlas with anatomical boundaries and was requested to delineate again the OARs using the tool provided. The Dice Similarity Coefficient (DSC) and the Jaccard Similarity Coefficient (JSC) were used to evaluate the spatial overlap accuracy of the different volume delineations and compared with the benchmark; the Hausdorff distance (HD) and the mean distance to agreement (MDA) to explore the distance between contours. All the results were reported as sample mean and standard deviation (SD). Results: Fifteen radiation oncologists from different Institutions joined the study. The participants had a high agreement degree for pelvic bones sub-structures delineation according to DICE (IBM: 0.9 ± 0.02; LPBM: 0.91 ± 0.01). A moderate degree according to DICE was showed for ovaries (Right: 0.61 ± 0.16, Left: 0.72 ± 0.05), vagina (0.575 ± 0.13), bladder sub-structures (0.515 ± 0.08) and EAS (0.605 ± 0.05), whereas a low degree for the other sub-structures of the anal-rectal sphincter complex (LAM: 0.345 ± 0.07, PRM: 0.41 ± 0.10, and IAS: 0.4 ± 0.07). Conclusion: This study found a moderate to low level of agreement in the delineation of the female pelvis emerging OARs, with a high degree of variability among observers. The development of delineation tools should be encouraged to improve the routine contouring of these OARs and increase the quality and consistency of radiotherapy planning.

A semi-automatic planning technique for whole breast irradiation with tangential IMRT fields.

PURPOSE: To implement a semi-automatic planning technique for whole breast irradiation with two tangential IMRT fields and to test the produced dose distribution against clinical 3DCRT plans, for introducing the technique in clinical practice. METHODS: The Auto-Planning module of the Pinnacle3 (Philips) treatment planning system was used for generating a Treatment Technique on left-sided breast cancer patients treated in free breathing or in deep inspiration breath hold (DIBH) and to right-sided breast cancer patients. The technique was evaluated against 3DCRT clinical plans in terms of dosimetric plan parameters. Plan robustness toward patient displacements was assessed on a subset of patients by inducing shifts to the isocenter. RESULTS: A statistically significant improvement in target coverage and dose homogeneity was observed for autoIMRT. No statistically significant differences were observed for ipsilateral organs, except for the ipsilateral lung in left DIBH, where slightly lower Dmean and V18% are registered for autoIMRT. Slightly higher Dmean doses (although far below the constraints) to contralateral organs were observed for autoIMRT plans. AutoIMRT plans were shown to be as robust as 3DCRT plans toward isocenter shifts, with a maximum decrease in CTV coverage of -2.2% and -2.1% for autoIMRT and 3DCRT, respectively. Average planning times were 40 min for 3DCRT and 6 min for IMRT plans. CONCLUSIONS: The developed autoIMRT technique was proven to be advantageous for target coverage and homogeneity and sufficiently robust towards isocenter displacements. The use of automated planning consistently reduces the planning workload with improvements in plan quality.

[Pharmacotherapeutic follow-up in hospitalised paediatric patients: adapting Dáder methodology]. / Seguimiento farmacoterapéutico en pacientes pediátricos hospitalizados: adaptación de la metodología Dáder.

OBJECTIVES: To adapt the DA inverted exclamation mark der methodology to identify and resolve drug related problems (DRP) in pediatric inpatients by disigning a normalized work procedure (NWP). To establish a pilot plan of pharmacotherapeutic follow-up to evaluate the NWP created. METHODS: The DA inverted exclamation mark der methodology is taken as a base adapting it to the characteristics and needs of pediatric inpatients and a NWP for their pharmacotherapeutic follow-up is created. A pilot plan consisting in a prospective longitudinal follow-up study is designed. The population and setting of the study are all the inpatients during one month in a room at the Municipal Childrenâs Hospital. RESULTS: The NWP is composed by the following steps: Previous phase: patient selection; follow-up phase: data compilation, information analysis (situation state, study phase, global evaluation), pharmaceutical intervention; results; clinical sessions; record documents. Pilot plan: 21 patients were studied; 71.4% of them presented at least 1 DRP during hospitalization period and 27 DRP were identified in all studied cases; 51.9% of DRP were effectiveness problems, 37.0% were related to safety and 11.1% to necessity; 55.6% of the health problems were resolved. CONCLUSIONS: The elaboration of the NWP allowed to adapt the DA inverted exclamation mark der methodology at the hospital setting. The pilot plan was very useful in carrying out the pharmacotherapeutic follow-up of pediatric inpatients thus showing the necessity of pharmacistâs participation in the health team to improve the quality of the inpatientâs pharmacologic treatments.

Efficacy of femoral intra-arterial administration of teicoplanin in gram-positive diabetic foot infections.

In this study the efficacy and safety femoral intra-arterial administration of teicoplanin in the treatment of diabetic foot infections caused by gram-positive bacteria were evaluated. Twenty-five hospitalized diabetic patients with foot ulcers or with foot ulcers and metatarsophalangeal osteomyelitis were included in the study. In the ulcers Staphylococcus aureus was present alone in 16 patients and was associated with Pseudomonas aeruginosa in 2 patients, with Candida albicans in 2, and with coagulase-negative Staphylococcus in 1 patient. In 4 patients other gram-positive bacteria were isolated. All isolated strains were resistant to various antibiotics tested. Teicoplanin, 200 mg, was administered once a day by femoral intra-arterial injection for an average period of 14.72 +/- 7.16 days (range ten to thirty-six days). Six patients were treated with an additional antibiotic intramuscularly or intravenously because of a mixed infection. At the end of the therapy microbiological assessment confirmed that gram-positive infection was eliminated in all patients. Clinical outcome demonstrated that healing occurred in 18 patients (72%) and improvement in 7 patients (28%). No adverse drug reactions were observed during the treatment. The results demonstrate that femoral intra-arterial administration of teicoplanin was highly effective in skin- and bone-infected lesions in the diabetic foot. This method may represent a further advantage in management of this severe diabetic complication.

[Flowmetric, thermometric and rheologic studies in obliterating arterial diseases of the lower extremities treated with buflomedil]. / Studio flussimetrico, termometrico e reologico nelle arteriopatie obliteranti degli arti inferiori trattate con buflomedil.

Ten subjects with peripheral arterial occlusive disease were treated with buflomedil, analysing the effect of every single intravenous administration of the drug, and the effect of the administration repeated for a period of 5 days. This controlled study was aimed at evaluating the state of the peripheral blood flow, not just relating to the flowmetric parameters, but also to those more directly connected to the metabolic and functional conditions of the microcirculation. During every single administration, blood flow, skin and muscular temperatures were recorded. As concerned the drug's chronic effect, endurance limit, skin and muscular temperatures, whole blood viscosity, plasma viscosity and red cell filterability were recorded before beginning the treatment and after 15 days. The results of this study show that during a single buflomedil infusion no modifications have been observed in blood flow and muscular temperature, whereas skin temperature showed a slight increase. On the contrary, after a 15 days treatment, muscular temperature and endurance limit significantly increased, without flowmetric changes. A significant decrease in values of blood viscosity at high shear-rate was recorded too. The overall results seem to indicate that after treatment with buflomedil there is an improvement of the metabolic muscular conditions, probably due to a stimulant effect of the drug on microcirculatory blood flow.