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Immunomodulatory properties of macrolides: overview and his the potential role of microorganisms in the development of rosacea prehypertension in young adults purchase indapamide no prescription. In the treatment of in ammatory and pustular acne: ef cacy arrhythmia management cheap indapamide 2.5mg mastercard, tolerability and terventions for rosacea arrhythmia of heart buy indapamide 2.5mg line. Ef cacy of topical azithromycin ophthalmic solution 1% in the on human meibomian gland epithelial cells hypertension in pregnancy order indapamide line. Perioral dermatitis: aetiology and treatment with Multicenter open-label study evaluating the ef cacy of azithromycin tetracycline. The effect of doxy treatment of ocular surface disease from posterior blepharitis. J Dtsch Dermatol Ges 2011;9(11): and ef cacy of topical azithromycin ophthalmic solution 1. Azithromycin trial of fusidic acid gel and oxytetracycline for recurrent blepharitis and 1. The scienti c context and basis of the pharmacologic manage [743] Nemeth J, Fodor E, Lang Z, Kosina-Hagyo K, Berta A, Komar T, et al. A status report on the use of subantimicrobial-dose doxycy Ophthalmol 2012;96(11):1380e5. Impact of conjunctival folds on central tear meniscus Effects of subantimicrobial-dose doxycycline in the treatment of moderate height. Dev Ophthalmol antibiotic use prior to breast cancer diagnosis and breast tumour charac 2008;41:138e58. Blepharospasm: a review of 264 Action Mechanisms of Amniotic Membrane in the Treatment of Neuro patients. Jpn J Pharmacol essential blepharospasm on dry eye disease and ocular in ammation. Tear production and drainage after botu dependency in scarless fetal wound healing. Plast Reconstr Surg linum toxin A injection in patients with essential blepharospasm. Surgical Treatment of Parenchymatous Opthalmoxe Short-term changes in tear volume after blepharoptosis repair. Dev Oph [768] Watanabe A, Selva D, Kakizaki H, Oka Y, Yokoi N, Wakimasu K, et al. Microvascular autologous chemosis following blepharoplasty: a 10-year retrospective review of 892 transplantation of partial submandibular gland for severe keratoconjuncti cases in a single-surgeon series. Innervation and secretory function of transplanted human submandibular [771] Shao Chunyi, Fu Yao, Lu Linna, Chen Junzhao, Shen Qin, Zhu Huimin, et al. Dynamic Changes of Tear Fluid After Cosmetic Transcutaneous Lower [801] Lasudry J. Experimental approach to surgical treatment of lacrimal insuf Blepharoplasty Measured by Optical Coherence Tomography. Am J Oph ciency by microvascular submandibular salivary gland autotransplantation. Plast Reconstr Surg submandibular gland transfer for the management of xerophthalmia; an 2010;125(2):709e18. Amylase in mare lacrimale in patients with plantation for ocular surface reconstruction in Stevens-Johnson syndrome. Transplantation of the autologous [775] Barabino S, Rolando M, Bentivoglio G, Mingari C, Zanardi S, Bellomo R, et al. Role of amniotic membrane transplantation for conjunctival reconstruction Ophthalmology 1998;105(2):327e35. Options follow-up after submandibular gland transplantation in severe dry eyes and adjuvants in surgery for pterygium: a report by the American Academy secondary to cicatrizing conjunctivitis. Salivary gland scintigraphy using tech- Opin Allergy Clin Immunol 2004;4(5):435e9. Eur J Nucl Med 1998;25(2): membrane transplantation as a new therapy for the acute ocular manifes 128e31. Treatment of acute Stevens-Johnson syndrome and toxic nerve palsy or salivary gland transplantation. Br J Ophthalmol 2002;86(1): epidermal necrolysis using amniotic membrane: a review of 10 consecutive 43e6. Accelerated secondary to submandibular gland transplantation: transcutaneous atropine Restoration of Ocular Surface Health in Dry Eye Disease by Self-Retained gel. Evidence for the presence of to control hypersecretion from a transplanted autologous submandibular L. Proteomic analysis of resolvin-D1 on human corneal epithelial cells: in vitro study. J In amm secretion from human transplanted submandibular gland replacing lacrimal (Lond) 2014;11(1):6. Br J [842] de Paiva Cintia S, Schwartz C Eric, Gjorstrup Per, P ugfelder Stephen C. Labial salivary gland transplantation for corneal nerve regeneration after experimental surgery and treatment with severe dry eye due to chemical burns and Stevens-Johnson syndrome. Minor salivary calcitonin gene-related peptide-positive nerves, and increased wound glands and labial mucous membrane graft in the treatment of severe sym healing induced by pigment epithelial-derived factor plus docosahexaenoic blepharon and dry eye in patients with Stevens-Johnson syndrome. Relation between dietary n-3 and n-6 fatty acids and clinically diagnosed dry Tear uid osmolarity as a potential marker of hydration status. In uence of modest changes in 3 Tear Film Lipids Correlate With Clinical Measures of Dry Eye. Invest whole-body hydration on tear uid osmolarity: important considerations for Ophthalmol Vis Sci 2016;57(6):2472e8. Is Correlations between nutrient intake and the polar lipid pro les of meibo whole-body hydration an important consideration in dry eye The role of omega-3 dietary supplementation in blepharitis and World Rev Nutr Diet 2009;99:1e16. N-3 polyunsaturated fatty acids and in ammation: from molec prospective, randomized, double-masked, placebo-controlled clinical trial of ular biology to the clinic. The importance of the ratio of omega-6/omega-3 essential domized, double-masked study to evaluate the effect of omega-3 fatty acids fatty acids. The effect of dietary supplementation with n-3 polyunsaturated fatty [853] Kawakita T, Kawabata F, Tsuji T, Kawashima M, Shimmura S, Tsubota K. Short-term consumption of oral omega-3 and dry eye lymphocyte proliferation: comparison between young and older women. Effects of a nutraceutical formula Th2 dichotomy in diabetic pregnancy and macrosomia. J Autoimmun tion based on the combination of antioxidants and u-3 essential fatty acids 2006;26(4):268e77. Effectiveness and tolerability of dietary supplementation with a~ cytokine production by essential fatty acids. Immunology 1997;92(2): combination of omega-3 polyunsaturated fatty acids and antioxidants in the 166e72. Prostaglandins Leukot Essent Fatty Acids for Dry Eye in Young and Middle-Aged Visual Display Terminal Users. A effects of docosahexaenoic and eicosapentaenoic acid on human meibomian Randomized, Double-Masked, Placebo-Controlled Clinical Trial of Two Forms gland epithelial cells. Effect of Oral Re-esteri ed Omega-3 Nutritional Supplementation on Nutrition for the eye: different susceptibility of the retina and the lacrimal Dry Eyes. Omega-3 essential fatty acids therapy for dry eye syndrome: a eye induced by scopolamine in a rat model. Possible Association Between Dry [870] Aragona P, Bucolo C, Spinella R, Giuffrida S, Ferreri G. Effect of oral linoleic and gamma-linolenic acid administration disturbs tear lm and ocular surface. Clinical Effect of Improvement of dry eye symptoms with polyunsaturated fatty acids. J Fr Antioxidant Glasses Containing Extracts of Medicinal Plants in Patients with Ophtalmol 2006;29:868e73. Br J Ophthalmol [874] Brignole-Baudouin F, Baudouin C, Aragona P, Rolando M, Labetoulle M, 2002;86(4):418e23.
Stricture formation and stone recurrence account for nearly all longterm complications arterial line cheap indapamide online. Timing of laparoscopic surgery in acute biliary pancreatitis depends upon the severity of the disease can high blood pressure medication cause joint pain indapamide 1.5 mg free shipping. However blood pressure medication and cranberry juice order indapamide 1.5 mg on line, in patients with severe pancreatitis blood pressure medication recommendations buy discount indapamide 1.5mg line, laparoscopic cholecystectomy, when performed within the 1st week after the onset of symptoms, as other authors have observed [27], places patients at increased risk of operative morbidity and technical complications. In these patients, the management of complications of pancreatitis is strongly advisable before cholecystectomy. Delaying surgery for more than a week after hospitalization, in our experience, does not adversely affect technical difficulty. Delaying surgery for several weeks in severe acute pancreatitis allows acute inflammation to settle down and might allow stones in the 14 Acute Pancreatitis common bile duct to clear spontaneously. If common bile duct stones are found at cholangiogram they should be treated laparoscopically if at all possible. In most instances, it should be possible to retrieve the stones via the cystic duct, since acute pancreatitis is usually caused by the migration of small stones. If this is not feasible, one alternative is to perform a laparoscopic choledochotomy. These cases have a rather long hospital stay and delayed return to work, but their level of pain is diminished. Our current impression is that this procedure is possible though technically demanding. In severe acute pancreatitis, or when signs of infection are present, most experts recommend broad-spectrum antibiotics. Complications of acute pancreatitis Acute pancreatitis complications may be divided as systemic and local. Pancreatic phlegmon, pancreatic abscess, pancreatic pseudocyst, pancreatic ascites and involvement of adjacent organs, with hemorrhage, thrombosis, bowel infarction, obstructive jaundice, fistula formation, or mechanical obstruction are local complications. Etiology,incidence and survival of acute pancreatitis in olmested county, Minnosota. Early prediction of severity in acute pancreatitis by urinary trypsinogen activation peptide: a multicentre study. Initial management of acute pancreatitis: critical issues during the first 72 hours. Early localization of necrosis by contrast-enhanced computed tomography can predict outcome in severe pancreatitis. The role of magnetic resonance cholangiography in the management of patients with gallstone pancreatitis. Imaging and clinical prognostic indicators of acute pancreatitis: a comparative insight. Prediction of mortality in acute pancreatitis: asystematic review of the published evidence. Controlled trial of urgent endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy versus conservative treatment for acute pancreatitis due to gallstones. Acute gallstone pancreatitis: timing of laparoscopic cholecystectomy in mild and severe disease. Indeed, the incidence of cases caused by medication use is much lower than of those caused by biliary disorder or alcohol. On the other hand, the total incidence of acute pancreatitis in developed countries continues to rise as does the exposition of general population to medication. From that time, the number of reported cases has increased steadily until these days. A further increase in the incidence of drug-induced acute pancreatitis may be expected and seems to be actually present in recent scientific papers on the topic. This also means that it is nearly impossible to obtain sufficiently large cohorts with similar patient characteristics. From that point of view, every case of drug-induced pancreatitis should be documented as well as possible, and also reported to a pharmacovigilance system for further evaluation. Epidemiology It is usually estimated that drug use accounts for 2% of all the causes of acute pancreatitis. It must be pointed out that the diagnosis might be underestimated, particularly for the difficulties in diagnosing this etiology. The B-type of adverse drug reactions occurs with a frequency lower than 1:10,000, so their record in the first three phases of clinical drug investigation is almost impossible. The number of cases reported to pharmacovigilance databases and of published case reports is increasing so rapidly that any number will be obsolete by the time it manages to be printed. The mortality of 9% among the cases analyzed shows a tendency to report the most severe cases, whilst the majority of mild-to-moderate cases remain unreported. A Medline search of the English literature revealed 1,214 case reports with 120 suspected drugs between 1955 and 2006 (Badalov et al. Our study, published in 2010, included 170 acute pancreatitis cases Acute Pancreatitis Induced by Drugs 19 hospitalized in a tertiary hospital during a period of two years. Obviously, the incidence found in these studies is higher than in the general population. The discrepancy in the published results demonstrates, in particular, the fact that the importance of drug-induced pancreatic injury will be different in the general population than among the cases reported in surgical or medical departments. It is also clearly improper to suppose that this disease can have similar incidence in all countries because of its dependence on the consumption of causative drugs and, secondarily, the dependence on the incidence of diseases treated with these medications. The only way how to determine the real incidence of drug-induced acute pancreatitis is to perform prospective multicenter studies targeted at the etiology of non-alcoholic, non-biliary acute pancreatitis. Etiology the pathogenesis of acute pancreatitis is probably very uniform differing only by the initial injury mechanism. It consists of three steps: (i) premature activation of trypsin in acinar cells; (ii) intrapancreatic inflammation; and (iii) extrapancreatic inflammation (Banks & Freeman, 2006). The mechanisms by which drugs initiate a cascade of damaging events remain shrouded in mystery. However, it should be borne in mind that the same is true for the vast majority of responses independent of drug dose. Two possible mechanisms of pancreatic injury caused by drugs are usually recognized, but in our opinion, at least three more possible mechanisms should be also mentioned: a. Simple direct toxic injury of pancreatic tissue, similar to the hepatic injury caused by some drugs or their metabolites. Although acute pancreatitis sometimes develops under the condition of an overdose of some drugs, its incidence remains so rare that an underlying predisposition must play a role in these cases. Genetic differences in metabolism are usually supposed to be the most probable predisposing factor here. It is supposed mainly in valproate, but possibly also in didanosine, tamoxifen, chlorothiazide and estrogens. The frequently mentioned lack of hypersensitivity symptoms (rash, fever, lymphadenopathy and eosinophilia) is of no major importance as it is rare in the majority of immune-mediated organ damage and cannot be considered pathognomic. Unfortunately, there is as little evidence available for this hypothesis as there is for the others. Several drugs involved in acute pancreatitis have been implicated as causing cholestatic liver injury. Codeine, morphine and possibly some other drugs can cause spasm of sphincter of Oddi. An interesting relationship between rofecoxib-induced cholestatic hepatitis and acute pancreatitis was observed (Sato et al, 2006). Best indapamide 2.5 mg. How To Use Blood Pressure Monitor Cuff Tutorial By DrKea.
Two circular electrodes ellipses were t to the circumference of the head model with a radius of 0 blood pressure pregnancy range generic indapamide 1.5mg with amex. Next arteriovenous graft generic indapamide 1.5 mg, both el mm were placed on the skull near the left (eLc) and right lipses were split by the midline into two semi-ellipses prehypertension bp 1.5 mg indapamide mastercard. Following the experiments reported by R plane blood pressure medication good or bad generic 1.5 mg indapamide amex, which after projection onto the skin surface pro Grossman et al. Finally, 33 electrode con gurations were created Three studies were performed using the human head by selecting the four points corresponding to one angle model described above. This resulted in a data set of 3,333 constructed by building four cylindrical electrodes with 1 simulated elds (33 con gurations times 101 current ra cm radius, 3 mm height, and conductivity of 1. Each pair of bottom electrodes equidistant to the top electrodes was selected 3In Grossman et al. In order to com stimulus current patterns to maximize the eld strength pare results for the three structures, areas of equal volume in three regions of interest (described in section 2. Spherical areas of equal volume were selected3 electrodes without additional constraints, an exhaustive from the head of the hippocampus and center of the pal search method can nd globally optimal current patterns lidum. Therefore, we created a In Study 3, a large number of con gurations was sim set of 88 electrode positions on our human head model by ulated with 21 current ratios. A simulation of 1 mA stimulation was per dian eld strength in the three target regions. We will report the resulting ing any two of these elds provides an approximation for median eld strength in the target as a measure of suc the eld produced by the corresponding electrode pair. To provide a measure of focality, we Using this procedure, 3,828 unique electrode pairs were integrated the volume of all brain elements outside of the created. The resulting electric elds of each pair were target region that reached a eld strength higher than 0. For each of these con gurations, we cal age of the total non-targeted brain volume. From these val aspects of our studies are included in the supplementary ues, we constructed several parameters of interest. First, material and those gures are denoted by using the let in order to remove outliers, the maximum eld strength in ter S before the gure number. In all simulations except the brain or in a target region was de ned as the median those in Study 3, each electrode con guration consisted of value of the top 0. For these visualiza this study was an attempt to replicate in silico the in tions, we chose Elim = 0. In addition to whole-brain analyses, in Studies 1 and 4Note that the labels of the elds only refer to the side of the head 3, stimulation effects were analyzed for three brain struc on which the respective electrodes are placed; the eld itself spreads tures of interest. Numbered lines indicate ratios that elicited the largest movements in the Grossman et al. The E and E elds combined to produce an peak was on the side of the head that received the lowest L R interference eld following Eq. S3 L R strengths and directions, which generally happened near and S4 for results for intermediate R values). Close to the midline, high strengths were located super cially near the electrodes est eld strengths were reached for R close to 1; towards (maximum: 0. Field strengths are displayed on a plane through the electrodes (all placed in the coronal plane), viewing towards the posterior direction. Equal current amplitudes, R = 1, are shown in free pref free pref the middle row, indicated with a surrounding box. Note that since we are displaying electric eld strength, values will be high in areas with low conductivity (such as the skull) and low for highly conductive regions. Visualizations of the stimulated brain volume creased strongly as R diverged from 1, while an oppo demonstrate that higher eld strengths and larger vol site but much smaller effect occurred for Efree (Fig. The anterior were two large super cial regions beneath the electrodes peaks were much larger than the posterior peaks, likely and a smaller deep area above the ventricles. On a top view of the head model, each con guration is represented by four identically colored spheres. The four electrodes of one con guration were placed symmetrically around the midline with equal angles to the coronal plane; the set of four was moved from anterior to posterior by varying the angle between the electrode locations and the coronal plane from -80 to 80 degrees. The best-performing current pat trode pair move closer together, more current is shunted terns (combination of con guration and ratio) were deter through the skin and skull and less current enters the mined for target regions in the head of the left hippocam brain. By contrast, in Study 2c, which might explain the higher eld strengths in the for the two electrodes in one pair (oscillating at the same fre free mer. Each con guration consisted of the same two top electrodes (black spheres) and one pair of bottom electrodes (identically colored spheres) placed underneath. For motor cortex, the amount of stimulated the highest values were not at the target. The large set of con gurations and current ratios, the current two pairs being parallel maximized the directional agree patterns were selected that produced the highest median eld ment between the two elds, while the pairs being close strengths in three spherical target regions. This resulted in higher elds for su Right pallidum per cial as compared to deep targets. Given a limited amount of current and no ad Left motor cortex ditional constraints, theoretically a bipolar con guration Median E (V/m) 0. Our murine model did not have a skin layer and elec trodes were placed directly on the skull, while in the Grossman et al. On an ex threshold, overestimation due to the omission of the skin tended schematic of the 10-10 system (three rings were added would not change our conclusion that muscle twitching around the standard schematic, shown in Fig. To ilar to the free-direction results, but electrode placement achieve the same eld strength in human motor cortex as was different. Thus while the mice experiments and sim dominated by the eld component in the preferred direc ulations were informative, our results suggest that they tion. Second, the volume of non were performed with various con gurations of four elec targeted brain tissue that was stimulated when target trodes. Finally, modalities produced elds expected to achieve modula effects of current ratio on the maximum and stimulated tion in all three target regions. In particular this was With this comprehensive set of con gurations, it is un by placing two electrode pairs on opposite sides of the likely that much higher eld strengths can be achieved head. Notably, the peak eld strength will always be bounded by the summed moves towards the electrode pair with the lower input eld strengths of the input elds, which, with a total in current. An input current of 38 mA per stimulated large areas outside of the target region. In addition, as noted above, our simu preferred direction is likely to be possible in hippocam lation of their experimental results was consistent with pus as well. Notably, stimulation of non-targeted areas was much smaller for the preferred direction as com 6These values were determined using square pulse step currents and pared to the free-direction case, and the highest values may differ for sinusoidal current. For comparison ever we do not study how these elds would affect neu purposes, we performed additional simulations with the rons, neuronal populations, or neural circuits. Practically con gurations they used and assumed some parameters achievable temporal interference elds at the difference not described in their report (Fig. The two sets of frequency were strong enough to achieve spiking activity simulations show globally similar results with peaks in in mice in Grossman et al. Hodgin-Huxley point neuron model recently reported in Another approach with potential for focused deep an unpublished manuscript posted on bioRxiv (Cao and stimulation from transcranial electrodes was reported in Grover, 2017) suggested complex dependence on carrier V or oslakos M (2018). In this study, interleaved short frequency, difference frequency, and a number of mutu pulses from different electrodes were used to achieve ally interfering elds. While this method was suc rameters such as the inclusion of anisotropy, details of the cessful at maximizing the eld strength in speci c re lateral ventricles, and skull conductivity inhomogeneity. For max fects while delivering high eld strengths, our approach imum feasible verisimilitude, in this report we used a could be extended with a constraint on the non-targeted model that included both those properties.
The merit of this classification is in its precision regarding the outcome of a mistake hypertension bradycardia 2.5mg indapamide for sale. It is based on an a priori analysis of the potential harm caused by the misadministration arrhythmia beta blocker purchase indapamide 1.5 mg without prescription. It also makes the distinction between events (levels 0 and 1) hypertension migraine generic indapamide 1.5mg on line, incidents (levels 2 and 3) and accidents (levels 4 and above) pulse pressure variation normal values buy discount indapamide 2.5 mg on-line. One important 303 category is missing here, as the scale only focuses on overdosage and makes no mention of underdosage. This is not appropriate because underdosage can also be the cause of patient death because of the failure to control the disease. Joint efforts should be fostered at the international level to try and create a common scale for sentinel events and an appropriate taxonomy or classification to separate them in meaningful categories. This is needed to allow for grouping of events of a similar nature, and to help in the identification of common cause and of common areas for improvement. It is an additional difficulty to the radiotherapy sector that any accident resulting in patient harm gets wide negative publicity, while other mishaps in the hospital rarely make it to the front pages. They often result from a widespread systemic failure of the quality system and, as such, will paradoxically offer little information that can be useful in the daily management of quality. At the centre of all accidents lies a lack of expertise and understanding of the radiotherapy process due to deficiencies in training and continuous education. Another common feature is the absence of any provision for possible errors that could prevent radiotherapy incidents and accidents, and a complete lack of sensitivity to safety issues. Responsibilities are managerial in the first place, at the level of the radiotherapy department as well as at the hospital and regional levels. Very often understaffing is present, reflecting the absence of understanding on the part of upper management of the necessity to care for quality and to invest sufficiently in safety. It is difficult to convince administrators of the need to expand staff for defensive reasons. This is not productive, because the outcome of such investment is the absence of accidents. If education is the key to the safe management of radiotherapy, it should start with the health authorities and then cascade down to the hospital and the department levels. It is otherwise difficult to motivate radiotherapy operators if their environment does not take into account their needs. One recent example are the measures taken in France after the severe accident at a hospital in Epinal, France, in 2006. The radiotherapy department of the hospital in Epinal had a severe shortage of medical physicists. This shortage was actually not peculiar to Epinal, but was prevalent in virtually all French radiotherapy departments. As lessons learned from this event, specific needs have been identified and quantified, and 20 young medical physicists have been admitted to training programmes. Particular attention is paid to departments with a low volume of activity; they are often encouraged to merge with larger departments to gain some critical mass in workforce and expertise. In 1931, Herbert Heinrich, a pioneer in industrial safety, published a book entitled Industrial Accident Prevention: A Scientific Approach. Because many accidents share common root causes, addressing more commonplace accidents that cause no injuries can prevent accidents that cause injuries. Because incidents tend to be frequent, there is a lot to be learned by reporting, recording and analysing them, having as the ultimate goal the design of corrective measures, protocol alterations or equipment improvement. Quality is not a goal; it is a way to manage with a permanent concern for optimal results. It is a working culture to be spread to the entire radiotherapy field of activity. It is widely recognized that quality audits constitute a vital component of quality management in radiotherapy [20. The main reason why quality audits are considered an important activity is that they help to review the quality of radiotherapy services and improve them. Without some form of auditing, it would be difficult to determine whether radiotherapy services are safe and effective for cancer treatment. In other words, a quality audit in radiotherapy is a method of reviewing whether the quality of activities in a radiotherapy department adheres to the standards of good practices to ensure that the treatment to the cancer patient is optimal. Overall, audits lead to improvements of professional practices and the general quality of services delivered. There are many recommendations regarding quality in radiotherapy practice, both national and international. Practices vary depending on the economic level of States, including specific procedures, equipment and facilities, as well as available resources. Good practices evolve with research developments, including new clinical trial results, progress in evidence based medicine and developments in radiotherapy technology. Quality audits involve the process of fact finding and comparing the findings against criteria for good practices in radiotherapy. Various issues and gaps may be identified by the auditors in the audit process, for example insufficiencies in structure, inadequacies in technology or deviations in procedures. This way the weak points or areas of concern are documented and recommendations for the audited centre are formulated that address these areas with the purpose of improving quality. It should be clarified here that quality audits differ fundamentally from regulatory inspections, i. Therefore, it is up to the audited centre to decide on the implementation of the audit recommendations. Careful analysis and acceptance of the audit recommendations 309 may help the centre to establish and implement a programme for improvement. A feedback system should normally be incorporated into the audit scheme in order to monitor the improvements as they are being introduced. With this scheme, the auditing system stimulates and promotes continual improvement for the benefit of the patient, as audits in radiotherapy typically use a patient centred approach, and they are focused on the quality of services provided to patients. Overall, the role of audits is to give confidence and provide assurance that the best possible quality of care is being delivered with the resources available. In general, the focus of a radiotherapy audit should cover the following topics: (a) Infrastructure, i. Many guidelines and recommendations exist that describe the infrastructure and resources required for the organization and operation of radiotherapy services [20. Similarly, the clinical and physical processes pertaining to the activities and decisions taken within the radiotherapy chain are described, including the parameters most relevant to radiotherapy outcomes. When auditing radiotherapy practices, it may be difficult to compare typical outcome parameters (survival, disease free survival, local control, toxicity, quality of life or population outcomes) among clinics because of the large number of complicating factors and uncertainties, such as geographical differences, patient selection, biological and therapeutic factors, and the time delay between the treatment and the audit of the outcome [20. Criteria for the audit of radiotherapy outcomes may be easier to define in the context of an individual clinic and implement through internal audit [20. It is generally considered that the findings of the audit and its results are confidential between the auditing organization and the audited centre. In general, quality audits can review the overall radiotherapy practice through a comprehensive audit, or selected parts of the practice that are important to achieve the desired treatment outcome, through a partial audit. Audits can be external or internal, depending on whether the auditing organization is external to the audited centre or is part of the centre. Audits can be proactive or reactive, depending on whether the interest of the audited centre rests in continual improvement of its practices or the audit is invited as a reaction to specific problems or issues, such as suspected or reported radiotherapy incidents. The different types and levels of radiotherapy audits are discussed briefly below. A comprehensive audit in radiotherapy involves the entire clinical pathway of the patient, including all interrelated steps of radiotherapy. Typically, a comprehensive audit entails a review of infrastructure as well as of patient related and equipment related procedures, including radiation safety and patient protection. |
