Incident learning is recognized as an invaluable tool for improving the quality and safety of treatments. The consensus recommendations in this report are intended to facilitate the implementation of such systems within individual clinics as well as on broader national and international scales.

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Fas (CD95) is a membrane surface receptor, which, in the lungs, is expressed in macrophages, neutrophils, and epithelial cells. In mice, Fas activation leads to a form of lung injury characterized by increased alveolar permeability. We investigated whether Fas-mediated lung injury occurs primarily as a result of Fas activation in myeloid cells (such as macrophages) or in nonmyeloid cells (such as epithelial cells). Chimeric mice lacking Fas in either myeloid or nonmyeloid cells were generated by transplanting marrow cells from lpr mice (which lack Fas) into lethally irradiated C57BL/6 mice (MyFas− group) or vice versa (MyFas+ group). Additional mice transplanted with marrow cells from their same strain served as controls (Fas+ ctr and Fas− ctr groups). Sixty days after transplantation, the mice received intratracheal instillations of the Fas-activating mAb Jo2 (n = 10/group), or an isotype control Ab (n = 10/group), and were euthanized 24-h later. Only animals expressing Fas in nonmyeloid cells (Fas+ ctr and MyFas−) showed significant increases in lung neutrophil content and in alveolar permeability. These same mice showed tissue evidence of lung injury and caspase-3 activation in cells of the alveolar walls. Despite differences in the neutrophilic response and lung injury, there was no statistical difference in the lung cytokine concentrations (KC and MIP-2) among groups. We conclude that Fas-mediated lung injury requires expression of Fas on nonmyeloid cells of the lungs. These findings suggest that the alveolar epithelium is the primary target of Fas-mediated acute lung injury, and demonstrate that apoptotic processes may be associated with neutrophilic inflammation.

While ultrasound guided prostate brachytherapy has gained wide acceptance as a primary treatment tool for prostate cancer, quality assurance of the ultrasound guidance system has received very little attention. Task Group 128 of the American Association of Physicists in Medicine was created to address quality assurance requirements specific to transrectal ultrasound used for guidance of prostate brachytherapy. Accurate imaging guidance and dosimetry calculation depend upon the quality and accuracy of the ultrasound image. Therefore, a robust quality assurance program for the ultrasound system is essential. A brief review of prostate brachytherapy and ultrasound physics is provided, followed by a recommendation for elements to be included in a comprehensive test phantom. Specific test recommendations are presented, covering grayscale visibility, depth of penetration, axial and lateral resolution, distance measurement, area measurement, volume measurement, needle template/electronic grid alignment, and geometric consistency with the treatment planning computer.

TRUS is a conceptually appealing alternative to CT-based dosimetry, offering the substantial practical advantage of being readily available intraoperatively. To test the feasibility and reliability of seed identification on post-implant TRUS using standard two-dimensional images, ten patients treated with I-125 or Pd-103 brachytherapy were studied. A set of transverse images (6 MHz) were taken immediately following completion of the implant procedure. Original thermal images were sent to four physicians and the sources were identified independently by placing marks on a cellophane overlay, with grids to match the axial TRUS images. The number and type of seed implanted were not revealed to the investigators. Instead, they were instructed to mark the positions of what they would consider, with reasonable certainty, to be seeds. The overlays were then manually compared for source identification and agreement between observers regarding each alleged source. The actual number of implanted seeds ranged from 44 to 108 (median: 60). In contrast, the mean number of seeds allegedly identified per patients ranged from 26 to 82 (median: 43). The average percent of the seeds allegedly identified per patient ranged from 51% to 83% (mean: 74%). The four physician investigators--KW, JS, BH, and GM--identified an alleged median of 90%, 44%, 63%, and 91% of the total seeds, respectively. There were five instances in which investigators alleged more seeds than were actually implanted. The consistency of seed identification among the investigators was evaluated by noting how many investigators identified each bright spot on the images. The percent of bright spots identified by all four investigators ranged from 8% to 33% (median: 20%). Despite considerable interest among some of our clinical and commercial colleagues in developing TRUS-based intraoperative post-implant dosimetry, the use of TRUS-based seed identification for post-implant dosimetry should be viewed with skepticism.

SUMMARY Sexual function was evaluated in 34 patients with low-risk prostate cancer (PSA ≤ 10, Gleason score ≤ 6, clinical stage T1/T2) undergoing brachytherapy in a phase III prospective randomized trial comparing iodine-125 ( 125 I) to palladium-103 ( 103 Pd). The mean and median International Index of Erectile Function (IIEF) scores for the entire group were 14.2 and 16.5, respectively, and there was no difference between these scores when stratified by isotope. IIEF scores < 6, 6 to 11, and ≥ 12 were recorded in 35% (12/34), 6% (2/34), and 59% (20/34) of patients, respectively. Hematospermia, orgasmalgia (pain at the time of orgasm), and alteration in intensity of orgasm were documented in 26% (9/34), 15% (5/34), and 38% (13/34) of patients, respectively, but these side effects were of limited duration for most patients. There was no relationship between radiation dose to the neurovascular bundles (NVB), which averaged 209% of the prescribed prostate dose, and the development of postbrachytherapy impotence. All four impotent patients who used sildenafil responded favorably. With a median follow-up of 13 months, 65% of patients undergoing prostate brachytherapy maintained sexual function without pharmacologic support. Including sildenafil responses, 76.5% of patients sustained erections sufficient for sexual intercourse.

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