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L. Milok, M.S., Ph.D.

Co-Director, Washington State University Elson S. Floyd College of Medicine

All pathology reports (both positive and negative) must be reviewed by the reporter to ensure all eligible cases are identified. The reporter should request that all cytology, hematology, bone marrow biopsies, and autopsies be included. Both computerized and manual methods of reviewing pathology reports must include a way to track reports to ensure that every report has been included in the review. Facilities that send all pathology specimens to outside labs should keep a log of all specimens, to include date sent out, date received, and the diagnosis. Note: If a hospital sends a specimen to another hospital to be read, and the patient is never seen at the reading facility, only the hospital that performed diagnostic procedures or administered treatment for a cancer diagnosis is responsible for reporting the case. The reading facility should document this process in their policy and procedure for consistency. Radiation Oncology For facilities with radiation oncology departments, a procedure must be established to identify patients receiving radiation therapy. Different options, such as providing copies of the treatment summary, a treatment card, or even a daily appointment book may be available to identify these cases. Many cancer patients are seen in the outpatient department, hematology clinic, laboratory, emergency room, nuclear medicine, and diagnostic radiology and oncology departments. A method to identify reportable cases from these departments must also be established. The registrar/reporter must establish a policy and procedure for identifying patients who receive chemotherapy in these settings if affiliated with their facility. If reportable cases are identified at the time of discharge, the complete medical record may not be available at the time the case is abstracted. A suspense file should be compiled of all cases identified as eligible or potentially eligible for abstracting. The suspense file can be something as simple as a manila folder to hold the various casefinding source documents (monthly disease index, pathology reports and outpatient log sheets and so forth) in alphabetical order and/or by date of diagnosis to assess timeliness of the abstracting process. The list should include patient name, date of birth, social security number, medical record number, admission date, casefinding source, and the reason the case was not reportable. Attachment B (page 72) is a sample form that can be used as a history file of the non-reportable cases. Another method would be to develop an electronic spreadsheet that can be sorted alphabetically, such as Excel or Word. Reporters using Web Plus may create and use a form such as the sample Attachment B, or make a not reportable notation for each case on the disease index. If a patient has active disease and/or is on cancer directed therapy, the case must be reported, unless it is a non-reportable condition. This case is not reportable since there is no indication that the patient has current disease. The discharge summary and face sheet states history of cancer and there is no other information within the chart to indicate active or stable disease. This case is not reportable because the patient has a history of cancer with no evidence of active disease. The patient had a mastectomy for breast cancer 8 years ago and there is no evidence of recurrent or metastatic disease. This case is not reportable because there is no indication that the patient has current disease. This case is not reportable because there is no information regarding whether the patient has current lung cancer. The physician orders state prostate cancer, but the bone scan report states no evidence of disease. Do not report this case since there is no evidence of disease and no mention of current treatment. The discharge summary states that the patient has recently been diagnosed with prostate cancer and is in the process of deciding treatment options.

Concomitant use with angiotensin-converting enzyme inhibitors or cotrimoxazole in renal transplant patients can lead to an exaggerated leukopenic response. Allopurinol, an agent used to treat gout, significantly inhibits the metabolism of azatihioprine; therefore, the dose of azathioprine must be reduced by 60 to 75 percent. The most common adverse effects include diarrhea, nausea, vomiting, abdominal pain, leukopenia, and anemia. Antibodies the use of antibodies plays a central role in prolonging allograft survival. They are prepared either by immunization of rabbits or horses with human lymphoid cells (producing a mixture of polyclonal antibodies directed against a number of lymphocyte antigens), or by hybridoma technology (producing antigen-specific, monoclonal antibodies). Hybrid cells are selected and cloned, and the antibody specificity of the clones is determined. Clones of interest can be cultured in large quantities to produce clinically useful amounts of the desired antibody. The polyclonal antibodies, although relatively inexpensive to produce, are variable and less specific, which is in contrast to monoclonal antibodies, which are homogeneous and specific. Antithymocyte globulins Thymocytes are cells that develop in the thymus and serve as T-cell precursors. The antibodies developed against them are prepared by immunization of large rabbits or horses with human lymphoid cells and, thus, are polyclonal. They are primarily employed, together with other immunosuppressive agents, at the time of transplantation to prevent early allograft rejection, or they may be used to treat severe rejection episodes or corticosteroid-resistant acute rejection. Rabbit formulations of polyclonal antithymocyte globulin are more commonly used over the horse preparation due to greater potency. The antibodies bind to the surface of circulating T lymphocytes, which then undergo various reactions, such as complement-mediated destruction, antibody-dependent cytotoxicity, apoptosis, and opsonization. The antibody-bound cells are phagocytosed in the liver and spleen, resulting in lymphopenia and impaired T-cell responses. The antibodies are slowly infused intravenously, and their half-life extends from 3 to 9 days. Because the humoral antibody mechanism remains active, antibodies can be formed against these foreign proteins. It is also used to deplete T cells from donor bone marrow prior to transplantation. Circulating T cells are depleted; thus, their participation in the immune response is decreased. It is therefore customary to premedicate the patient with methylprednisolone, diphenhydramine, and acetaminophen to alleviate the cytokine release syndrome. The symptoms can range from a mild, flu-like illness to a life-threatening, shock-like reaction. Central nervous system effects, such as seizures, encephalopathy, cerebral edema, aseptic meningitis, and headache, may occur. The serum half-life of daclizumab is about 20 days, and the blockade of the receptor is 120 days. No clinically relevant antibodies to the drugs have been detected, and malignancy does not appear to be a problem. Alemtuzumab is currently approved for the treatment of refractory B-cell chronic lymphocytic leukemia. Preliminary results are promising, with low rates of rejection with a prednisone-free regimen.

Local thoracic external beam photon radiation therapy for individuals with extensive stage disease is not an established approach, however, in selected individuals it may be considered, such as those with clinically apparent disease only at the primary site and complete response elsewhere. Concerns regarding neurocognitive defects are obviated by avoiding high dose per fraction treatment and concurrent chemotherapy. In selected individuals with extensive disease, a shorter course, such as 20 Gy in 5 fractions may be appropriate. Higher doses have not proved beneficial and are associated with more neurocognitive deficits. Abstract #10: Tolerability and safety of thoracic radiation and immune checkpoint inhibitors among patients with lung cancer. Prophylactic cranial irradiation for patients with small-cell lung cancer in complete remission. Correspondence: Routine use of intensity-modulated radiotherapy for locally advanced non-small-cell lung cancer is neither choosing wisely nor personalized medicine. Systematic review evaluating the timing of thoracic radiation therapy in combined modality therapy for limited-stage small cell lung cancer. Outcomes of risk-adapted fractionated stereotactic radiotherapy for stage I non-small cell lung cancer. Positron emission tomography for target volume definition in the treatment of non-small cell lung cancer. Long-term observations of the patterns of failure in patients with unresectable non-oat cell carcinoma of the lung treated with definitive radiotherapy. Postoperative radiotherapy in non-small-cell lung cancer: systematic review and meta-analysis of individual patient data from nine randomised controlled trials. Palliative thoracic radiotherapy in lung cancer: An American Society for Radiation Oncology evidence-based clinical practice guideline. Prophylactic cranial irradiation for lung cancer patients at high risk for development of cerebral metastasis: results of a prospective randomized trial conducted by the Radiation Therapy Oncology Group. Twice daily compared to once-daily thoracic radiotherapy in limited small-cell lung cancer treated concurrently with cisplatin and etoposide. Solitary plasmacytomas of the bone generally involve the axial skeleton and account for almost seventy percent of clinical presentations. The remaining are extramedullary lesions generally presenting in the upper aerodigestive tract. The optimal radiation dose for the treatment of these lesions is not well known, with doses ranging from 30 Gy to 60 Gy in the published literature. Thirty-three were treated with a combination of radiation therapy and chemotherapy. Sixty percent of the patients who did not receive radiation therapy relapsed locally, while only 12% of the radiation therapy group experienced local relapse. A 10-year probability of disease progression to multiple myeloma was 36% for extramedullary plasmacytoma and 72% for solitary plasmacytoma of bone. Considerable care must be taken in the workup of a suspected solitary plasmacytoma to ensure that other lesions and hence, a diagnosis of multiple myeloma, are not present. Following a positive biopsy of the lesion, a full multiple myeloma evaluation should be performed. Bone marrow aspirate and biopsy are mandatory to document the lack of clonal cells for a diagnosis of solitary plasmacytoma. A variant of solitary plasmacytoma, when there are fewer than 10% of clonal plasma cells is termed solitary plasmacytoma with minimal bone marrow involvement. In addition to the previous workup, diagnostic imaging plays an important role in securing the diagnosis. Following confirmation of the diagnosis, surgery may play a role in certain definitive clinical presentations or is performed for clinical presentations requiring neurologic decompression or stabilization of a weight-bearing bone prior to the performance of radiation therapy.

Prehospital transport is classified as primary transport and later movement within or between facilities is designated as secondary transport. Reasons for movement include gaining access to healthcare via emergency Patient Case: A 45 year old man is involved in a high speed motor vehicle collision. He becomes unstable during initial assessment in the emergency department requiring intravascular volume resuscitation and endotracheal intubation. Identified injuries include blunt chest trauma, pelvic fractures and extremity fractures. He is stabilized and arrangements are made for aeromedical transport by helicopter to a regional trauma center for further management. On arrival to the trauma center he requires a series of transports within the hospital. These include movement between the emergency department and intensive care unit with transport to specialized areas for diagnostic imaging, angiographic embolization of pelvic hemorrhage and operative repair of orthopedic injuries. Modes of transport vary greatly and include the use of mobile beds, transport litters, ground vehicles, and rotary wing or fixed wing aircraft. While the indications, modes, and sites of transport are variable, the general concepts governing safe and effective movement of critically ill and injured patients share many of the same principles. The transport is performed with attention to transfer of care at the conclusion along with proper documentation. A mechanism should be in place to track critical events as well as any other pertinent process or quality improvement information. It is imperative that transport personnel understand the operation, potential limitations and how to troubleshoot the transport equipment they utilize. Ideally, transport equipment will be interoperable with all equipment across a given system. This includes issues such as compatible cables, device interfaces and infusion tubing sets and cartridges. The process of patient transport is well suited for the use of checklists to standardize care and avoid errors of omission. A significant body of literature demonstrates that physiologic derangements occur during all phases of transport and transport increases the risk for adverse outcomes. Adverse events may reflect deterioration in one or more physiologic variables or critical situations. The incidence of adverse events clearly depends on how adverse events are defined and not all events will require an intervention. However, some studies have reported an incidence of adverse events as high as 70% associated with patient transport. Several studies have reported complications related to gas exchange with manually assisted ventilation. Brain injured patients are particularly sensitive to alterations in oxygenation and ventilation that can result. Recent data suggests that patients with elevated intracranial pressure may be at especially increased risk for events during transport and many of these will meet criteria for treatment. Team -Adequately trained and experienced -Detailed handoff to transport team Equipment -All equipment operational -Portable power supply/ batteries charged -Alarm limits checked and set -Lines and tubes simplified, secured and labeled -Oxygen supply with back-up -Transport pack with emergency drugs and supplies Patient -Stabilized on transport stretcher -Monitors in placed and operational/ equipment secured -Ventilation adequate/ assessment of gas exchange if using transport ventilator -Appropriate sedation/ neuromuscular blockade (if indicated) -Measures to prevent heat loss Communication -Transfer documents prepared -Full physician and nursing report to receiving location Documentation -Vital signs/ notation of events during transport -Adverse events/ process improvement Table 1. However systems factors are often identified including human factors relating to knowledge, judgment and technical performance, process problems such as inadequate communication, insufficient protocols and lack of training, as well as multiple problems with transport equipment. Prehospital and interhospital transport are associated with an increased risk of occupational injury and death for providers related to the inherent 42 risks associated with the mode of transportation, design limitations of the vehicles and vulnerability associated with delivering care in the transport environment. Prehospital Transport Prehospital care is provided by emergency medical personnel in the setting of out of hospital illness or injury. The scope of care, standardized practices and equipment are specialized for the clinical environment and may differ from those employed during secondary transport. Prehospital transport typically occurs in the setting of an integrated emergency medical system. Triage decisions regarding the transport destination of a particular patient are important. Available evidence demonstrates improved outcomes for patients triaged to dedicated centers for conditions including trauma, acute coronary syndromes and stroke. Undertriage, the referral of patients who may benefit from specialized care erroneously to lower acuity centers, may adversely affect outcome. Likewise, over-triage, transferring patients not needing specialized care to dedicated centers, may result in overcrowding and misuse of resources.