A cancer care electronic medical record highly integrated into clinicians' workflow: users' attitudes pre-post implementation.

The purpose was to study users' attitudes towards an electronic medical record (EMR) closely integrated into the clinicians' cancer care workflow. The EMR, implemented in an ambulatory cancer care centre, was designed as a care pathway information system providing real-time support to the coordination of shared care processes involving all the care personnel. Mixed method pre-post study design was used. The study population consisted of all care personnel. A survey measured the quality attributes of the EMR, the clinical information it produces, the perceived usefulness of the system for supporting clinical data management tasks and the perceived impacts in terms of access and quality of care. The survey shows that users' attitudes towards the EMR (response rate of 71%) measured after the go-live were positive ranging from 3.42 to 3.95 on a 5-point scale. Besides, the content analysis of 33 pre-post interviews revealed five main themes: magnitude of the changes caused by the EMR; its innovative potential; its positive benefits; an ongoing growth in users' expectancies; and the burden associated with the time required to operate the EMR. In sum, the study shows that users can largely apply innovative uses of information technologies that automate their clinical processes.

Making molehills out of a mountain: experience with a new scheduling strategy to diminish workload variations in response to increased treatment demands.

PURPOSE: A new scheduling strategy was implemented. Before implementation, treatments and planning computed tomography (ct) imaging were both scheduled at the same time. Maximal wait times for treatment are defined by the Quebec Ministry of Health's plan of action according to treatment aim and site. After implementation, patients requiring rapid treatment (priorities 0-3) continued to have their treatments scheduled at the same time as their planning ct; treatments for priority 4 (P4) patients were scheduled only after the treatment plan was approved. That approach aims to compensate for unexpected increases in planning workload by relocating less delay-sensitive cases to other time slots. We evaluated the impact on the patient experience, workload in various sectors, the care team's perception of care delivery, access to care, and the department's efficiency in terms of hours worked per treatment delivered. METHODS: Three periods were defined for analysis: the pre-transitional phase, for baseline evaluation; the transitional phase, during which there was an overlap in the way patients were being scheduled; and the post-transitional phase. Wait times were calculated from the date that patients were ready to treat to the date of their first treatment. Surveys were distributed to pre- and post-transitional phase patients. Care team members were asked to complete a survey evaluating their perception of how the change affected workload and patient care. Operational data were analyzed. RESULTS: We observed a 24% increase in the number of treatments delivered in the post-transitional phase. Before implementation, priority 0-3 patients waited a mean of 7.9 days to begin treatments (n = 241); afterward, they waited 6.3 days (n = 340, p = 0.006). Before implementation, P4 patients waited a mean 15.1 days (n = 233); after implementation, they waited 16.1 days (n = 368, p = 0.22). Surveys showed that patients felt that the time it took to inform them of treatment appointments was acceptable in both phases. No significant change in overtime hours occurred in dosimetry (p = 0.7476) or globally (p = 0.4285) despite the increased number of treatments. However, departmental efficiency improved by 16% (p = 0.0001). CONCLUSIONS: This new scheduling strategy for P4 cases resulted in improved access to care for priority 0-3 patients. Departmental efficiency was improved, and overtime hours did not increase. Patient satisfaction remained high.

Rapid, one-pot procedure to synthesise 103Pd:Pd@Au nanoparticles en route for radiosensitisation and radiotherapeutic applications.

The radioisotope palladium (103Pd), encapsulated in millimetre-size seed implants, is widely used in prostate cancer brachytherapy. Gold nanoparticles (Au NPs) distributed in the vicinity of 103Pd radioactive implants, strongly enhance the therapeutic dose of radioactive implants (radiosensitisation effect). A new strategy under development to replace millimetre-size implants, consist in injecting radioactive NPs in the affected tissues. The development of 103Pd@Au NPs distributed in the diseased tissue, could increase the uniformity of treatment (compared with massive seeds), while enhancing the radiotherapeutic dose to the cancer cells (through Au-mediated radiosensitisation effect). To achieve this goal, it is necessary to develop a rapid, efficient, one-pot and easy-to-automatise procedure, allowing the synthesis of core-shell Pd@Au NPs. The novel synthesis route proposed here enables the production of Pd@Au NPs in not more than 4 h, in aqueous media, with minimal manipulations, and relying on biocompatible and non-toxic molecules. This rapid multi-step process consists of the preparation of ultra-small Pd NPs by chemical reduction of an aqueous solution of H2PdCl4 supplemented with ascorbic acid (AA) as reducing agent and 2,3-meso-dimercaptosuccinic acid (DMSA) as a capping agent. Pd conversion yields close to 87% were found, indicating the efficiency of the reaction process. Then Pd NPs were used as seeds for the growth of a gold shell (Pd@Au), followed by grafting with polyethylene glycol (PEG) to ensure colloidal stability. Pd@Au-PEG (TEM: 20.2 ± 12.1 nm) formed very stable colloids in saline solution as well as in cell culture medium. The physico-chemical properties of the particles were characterised by FTIR, XPS, and UV-vis. spectroscopies. The viability of PC3 human prostate cancer cells was not affected after a 24 h incubation cycle with Pd@Au-PEG NPs to concentrations up to 4.22 mM Au. Finally, suspensions of Pd@Au-PEG NPs measured in computed tomography (CT) are found to attenuate X-rays more efficiently than commercial Au NPs CT contrast media. A proof-of-concept was performed to demonstrate the possibility synthesise radioactive 103Pd:Pd@Au-PEG NPs. This study reveals the possibility to synthesise Pd@Au NPs rapidly (including radioactive 103Pd:Pd@Au-PEG NPs), and following a methodology that respects all the strict requirements underlying the production of NPs for radiotherapeutic use (rapidity, reaction yield, colloidal stability, NPs concentration, purification).

Tailored biological retention and efficient clearance of pegylated ultra-small MnO nanoparticles as positive MRI contrast agents for molecular imaging.

A majority of MRI procedures requiring intravascular injections of contrast agents are performed with paramagnetic chelates. Such products induce vascular signal enhancement and they are rapidly excreted by the kidneys. Unfortunately, each chelate is made of only one paramagnetic ion, which, taken individually, has a limited impact on the MRI signal. In fact, the detection of molecular events in the nanomolar range using T1-weighted MRI sequences requires the design of ultra-small particles containing hundreds of paramagnetic ions per contrast agent unit. Ultra-small nanoparticles of manganese oxide (MnO, 6-8 nm diameter) have been developed and proposed as an efficient and at least 1000× more sensitive "positive" MRI contrast agent. However no evidence has been found until now that an adequate surface treatment of these particles could maintain their strong blood signal enhancement, while allowing their rapid and efficient excretion by the kidneys or by the hepatobiliairy pathway. Indeed, the sequestration of MnO particles by the reticuloendothelial system followed by strong uptake in the liver and in the spleen could potentially lead to Mn2+-induced toxicity effects. For ultra-small MnO particles to be applied in the clinics, it is necessary to develop coatings that also enable their efficient excretion within hours. This study demonstrates for the first time the possibility to use MnO particles as T1 vascular contrast agents, while enabling the excretion of >70% of all the Mn injected doses after 48 h. For this, small, biocompatible and highly hydrophilic pegylated bis-phosphonate dendrons (PDns) were grafted on MnO particles to confer colloidal stability, relaxometric performance, and fast excretion capacity. The chemical and colloidal stability of MnO@PDn particles were confirmed by XPS, FTIR and DLS. The relaxometric performance of MnO@PDns as "positive" MRI contrast agents was assessed (r1 = 4.4 mM-1 s-1, r2/r1 = 8.6; 1.41 T and 37 °C). Mice were injected with 1.21 µg Mn per kg (22 µmol Mn per kg), and scanned in MRI up to 48 h. The concentration of Mn in key organs was precisely measured by neutron activation analysis and confirmed, with MRI, the possibility to avoid RES nanoparticle sequestration through the use of phosphonate dendrons. Due to the fast kidney and hepatobiliairy clearance of MnO particles conferred by PDns, MnO nanoparticles can now be considered for promising applications in T1-weighted MRI applications requiring less toxic although highly sensitive "positive" molecular contrast agents.

Adjuvant regional irradiation after breast-conserving therapy for early stage breast cancer: a survey of canadian radiation oncologists.

AIMS: To document the use of adjuvant regional irradiation after breast-conserving therapy for early stage breast cancer by Canadian radiation oncologists and to identify the factors influencing their clinical decisions. MATERIALS AND METHODS: We conducted a survey to assess the above aims. In April 2008, a questionnaire was sent to 167 members of the Canadian and Quebec Associations of Radiation Oncologists with interest in breast cancer management. The answers were obtained through a dedicated website, which collected the raw data collected for analysis. RESULTS: In total, 67 radiation oncologists completed the survey, corresponding to a 40% response rate. Most respondents were experienced and high-volume providers. We identified several areas of variation in the decision-making regarding regional lymph node irradiation after breast-conserving therapy. Regarding the decision to combine regional nodal irradiation with irradiation of the breast, the number of positive nodes after axillary dissection (1-3 vs > or =4) was a crucial determinant. For patients with between one and three positive nodes and a nodal ratio of 50%, most respondents added regional irradiation. Similarly, the same nodal ratio of 50% was the main factor for inclusion of the axillary nodal region in the radiation field. However, few radiation oncologists have chosen to include the internal mammary chain in their treatment plan. The number of positive lymph nodes, the nodal ratio, the number of lymph nodes removed and the presence of extracapsular extension were the primary self-reported factors that directed the decision to offer regional radiotherapy. CONCLUSIONS: This survey showed that there is a wide variation of practices among radiation oncologists in Canada. These results support the need for treatment guidelines and provide guidance on which factors should be included in a decision-making algorithm.

Radioactive sputter cathodes for 32P plasma-based ion implantation.

The development of clinical treatments involving the use of beta-emitting millimetric and sub-millimetric devices has been a continuing trend in nuclear medicine. Implanted a few nanometers below the surface of endovascular implants, seeds or beads, beta-emitting radioisotopes can be used in a variety of biomedical applications. Recently, new technologies have emerged to enable the rapid and efficient activation of such devices. A pulsed, coaxial electron cyclotron resonance plasma reactor was designed and tested to demonstrate the feasibility of plasma-based radioactive ion implantation (PBRII). It has been shown that such plasma reactors allow for the implantation of radioisotopes (32P) into biomedical devices with higher efficiencies than those obtained with conventional ion beams. Fragments containing radioactive atoms are produced in the implanter by means of a negatively biased solid sputter cathode that is inserted into an argon plasma. Dilute orthophosphoric acid solutions (H3(32)PO4) are used for the fabrication of flat sputter targets, since they offer a high radioisotope content. However, the aggregation of the radioactive solute into highly hygroscopic ring-like deposits rather than flat, thin radioactive films is observed on certain substrates. This article describes the effect of this nonuniform distribution of the radioisotopes on the efficiency of PBRII, and presents a technique which enables a better distribution of 32P by coating the substrates with iron. The iron coating is shown to enable optimal radioisotope sputtering rates, which are essential in 32P-PBRII for the efficient activation of millimetric biomedical devices such as stents or coils.