Venous thromboprophylaxis in medical patients: an application review

OBJECTIVE: Routine thromboprophylaxis, despite its well-known effectiveness and the fact that venous thromboembolism is a potentially avoidable condition, is not fully established in clinical practice. The objectives of the present study were to determine how often thromboprophylaxis is used and the presence of thromboembolism risk factors, and to verify the appropriateness of its use in medical inpatients, assuming a long-standing national guideline as a parameter. METHODS: This was a retrospective cross-sectional study, involving inpatients with medical conditions in the adult general ward of a university hospital. The review was based on a defined guideline. RESULTS: 146 patients were included in the review. At least one risk factor for venous thromboembolism was found in 94.5%. In 130 (89%) patients, prophylactic heparin was indicated, and some kind of heparin was prescribed in 73.3%. Regarding the adequacy of prophylaxis, 53.4% of prescriptions were correct regarding prophylaxis indication and dose; 24% had incorrect dose or frequency of use; 19.2% had no prophylaxis prescription, although it was indicated; and in five cases (3.4%), the drugwas prescribed, even though itwas not indicated. CONCLUSION: Thromboprophylaxis is underused in this population, and an inappropriate dose was prescribed in 50% of cases. Therefore, future studies and interventions should include an educational program started from the emergency department care, an essential step to bring evidence closer to clinical practice.OBJETIVO: A tromboprofilaxia de rotina, a despeito de sua efetividade estar bem estabelecida e o tromboembolismo venoso ser uma condição potencialmente evitável, não se apresenta completamente consolidada na prática clínica. Os objetivos do presente estudo são: 1. Determinar a frequência da utilização da tromboprofilaxia e presença dos fatores de risco para tromboembolismo; 2. Verificar a adequação de sua utilização em pacientes clínicos internados, assumindo como parâmetro uma diretriz nacional estabelecida. MÉTODOS: Estudo retrospectivo transversal envolvendo pacientes internados por doenças clínicas em uma enfermaria geral de adultos de um hospital universitário. A análise foi baseada em diretriz definida. RESULTADOS: Foram incluídos 146 pacientes para análise. Destes, 94,5% possuíam pelo menos um fator de risco para tromboembolismo venoso. Em 130 (89%) pacientes havia indicação para uso de heparina profilática, sendo que em 73,3% dos casos estava prescrito algum tipo de heparina. Quanto à adequação da profilaxia, 53,4% das prescrições estavam corretas em relação à indicação e à dose da profilaxia; 24% apresentavam dose ou frequência incorretas; 19,2% não tinham prescrição de profilaxia, apesar de ela ser indicada; e em cinco casos (3,4%) o fármaco foi prescrito, apesar de não haver indicação. CONCLUSÃO: Existe subutilização da tromboprofilaxia nesta população, com inadequada dose prescrita em 50% dos casos. Portanto, estudos e intervenções futuros devem incluir um programa educacional que se inicie desde o atendimento em pronto-socorro, sendo essencial para aproximar a evidência à prática clínica.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de Clínica MédicaHospital Sírio-Libanês Centro de Oncologia Departamento de RadioterapiaUniversidade de São Paulo Departamento de Hematologia e HemoterapiaFaculdade de Medicina de Marília Núcleo de Epidemiologia ClínicaFAMEMAUNIFESP, EPM, Depto. de Clínica MédicaSciEL

Literature review of clinical results of total skin electron irradiation (TSEBT) of mycosis fungoides in adults

BackgroundMycosis fungoides (MF) is an extranodal, indolent non-Hodgkin lymphoma of T cell origin. Even with the establishment of MF staging, the initial treatment strategy often remains unclear.AimThe aim of this study was to review the clinical results of total skin electron beam therapy (TSEBT) for MF in adults published in English language scientific journals searched in Pubmed/Medline database until December 2012.ResultsMF is very sensitive to radiation therapy (RT) delivered either by photons or by electrons. In limited patches and/or plaques local electron beam irradiation results in good outcomes besides the fact of not being superior to other modalities. For extensive patches and/or plaques data suggest that TSEBT shows superior response rates. The cutaneous disease presentation is favorably managed with radiotherapy due to its ability to treat the full thickness of deeply infiltrated skin. For generalized erythroderma presentation, TSEBT seems to be an appropriate initial therapy. For advanced disease, palliation, or recurrence after the first radiotherapy treatment course, TSEBT may still be beneficial, with acceptable toxicity. Recommended dose is 30–36[[ce:hsp sp="0.25"/]]Gy delivered in 6–10 weeks.ConclusionTSEBT can be used to treat any stage of MF. It also presents good tumor response with symptoms of relief and a palliative effect on MF, either after previous irradiation or failure of other treatment strategies

Spine radiosurgery for the local treatment of spine metastases: Intensity-modulated radiotherapy, image guidance, clinical aspects and future directions

Many cancer patients will develop spinal metastases. Local control is important for preventing neurologic compromise and to relieve pain. Stereotactic body radiotherapy or spinal radiosurgery is a new radiation therapy technique for spinal metastasis that can deliver a high dose of radiation to a tumor while minimizing the radiation delivered to healthy, neighboring tissues. This treatment is based on intensity-modulated radiotherapy, image guidance and rigid immobilization. Spinal radiosurgery is an increasingly utilized treatment method that improves local control and pain relief after delivering ablative doses of radiation. Here, we present a review highlighting the use of spinal radiosurgery for the treatment of metastatic tumors of the spine. The data used in the review were collected from both published studies and ongoing trials. We found that spinal radiosurgery is safe and provides excellent tumor control (up to 94% local control) and pain relief (up to 96%), independent of histology. Extensive data regarding clinical outcomes are available; however, this information has primarily been generated from retrospective and nonrandomized prospective series. Currently, two randomized trials are enrolling patients to study clinical applications of fractionation schedules spinal Radiosurgery. Additionally, a phase I clinical trial is being conducted to assess the safety of concurrent stereotactic body radiotherapy and ipilimumab for spinal metastases. Clinical trials to refine clinical indications and dose fractionation are ongoing. The concomitant use of targeted agents may produce better outcomes in the future

Toxicity of Radiosurgery for Brainstem Metastases

Background Although stereotactic radiosurgery (SRS) is an effective modality in the treatment of brainstem metastases (BSM), radiation-induced toxicity remains a critical concern. To better understand how severe or life-threatening toxicity is affected by the location of lesions treated in the brainstem, a review of all available studies reporting SRS treatment for BSM was performed. Methods Twenty-nine retrospective studies investigating SRS for BSM were reviewed. Results The rates of grade 3 or greater toxicity, based on the Common Terminology Criteria for Adverse Events, varied from 0 to 9.5% (mean 3.4 ± 2.9%). Overall, the median time to toxicity after SRS was 3 months, with 90% of toxicities occurring before 9 months. A total of 1243 cases had toxicity and location data available. Toxicity rates for lesions located in the medulla were 0.8% (1/131), compared with midbrain and pons, respectively, 2.8% (8/288) and 3.0% (24/811). Conclusions Current data suggest that brainstem substructure location does not predict for toxicity and lesion volume within this cohort with median tumor volumes 0.04–2.8 cc does not predict for toxicity

حقيبة التخصص في علاج الأورام بالإشعاع: خارطة طريق عالمية في التخصص للمدربين والمتدربين (كتيب - سِّجْل)

A book gives guidance with information in radiation oncology certification from a global perspective. The idea is to help establish competency-based certification programs in radiation oncology worldwide. The portfolio provides a training roadmap that can be applied in many communities, particularly those with limited resources, to produce qualified, competent and safe radiation oncology practitioners. It is extracted from different well-established resources in this field and can be used as a general guide in tailoring and refining the programs at every accredited authority, or as a representative model and content, or through its sample tools to facilitate documentation. It refers to many resources that can be useful to trainers and trainees to achieve the required milestones in radiation oncology certification, which will further advance the level of education and practice of radiation oncology globally.يقدّم الكتاب إرشادات لنيل شهادة التخصص في علاج الأورام بالإشعاع من منظور عالمي. وتكمن الفكرة في المساعدة في إنشاء برامج اعتماد قائمة على الكفاءة في علاج الأورام بالإشعاع في جميع أنحاء العالم. توفر هذه الحقيبة خارطة طريق تدريبية يمكن تطبيقها في العديد من المجتمعات، لا سيما تلك المتصفة بالموارد المحدودة، تهدف إلى إنتاج ممارسين مؤهلين ومتمكنين وآمنين في علاج الأورام بالإشعاع، وقد انبثقت هذه الحقيبة من مصادر تخصصية عديدة في هذا المجال. يمكن استخدام هذه الحقيبة كدليل عام في تصميم وتنقيح البرامج التدريبية المعتمدة لنيل التخصص في معالجة الأورام بالإشعاع، أو كنموذج ومحتوى تمثيلي، كما يمكن من خلال أدواتها وملحقاتها تسهيل عملية التوثيق، بالإضافة إلى إنها تشير إلى العديد من المصادر العلمية المفيدة للمدربين والمتدربين؛ لتحقيق الأهداف المطلوبة في نيل شهادة التخصص في علاج الأورام بالإشعاع، بما يسهم في الارتقاء بمستوى التعليم وممارسة علاج الأورام بالإشعاع على مستوى العالم

Transformational Role of Medical Imaging in (Radiation) Oncology

Onboard, real-time, imaging techniques, from the original megavoltage planar imaging devices, to the emerging combined MRI-Linear Accelerators, have brought a huge transformation in the ability to deliver targeted radiation therapies. Each generation of these technologies enables lethal doses of radiation to be delivered to target volumes with progressively more accuracy and thus allows shrinking of necessary geometric margins, leading to reduced toxicities. Alongside these improvements in treatment delivery, advances in medical imaging, e.g., PET, and MRI, have also allowed target volumes themselves to be better defined. The development of functional and molecular imaging is now driving a conceptually larger step transformation to both better understand the cancer target and disease to be treated, as well as how tumors respond to treatment. A biological description of the tumor microenvironment is now accepted as an essential component of how to personalize and adapt treatment. This applies not only to radiation oncology but extends widely in cancer management from surgical oncology planning and interventional radiology, to evaluation of targeted drug delivery efficacy in medical oncology/immunotherapy. Here, we will discuss the role and requirements of functional and metabolic imaging techniques in the context of brain tumors and metastases to reliably provide multi-parametric imaging biomarkers of the tumor microenvironment