Entire Treatment Chain Research Articles

Structural Requirements for the Outpatient Treatment of Benign Diseases of the Uterus.

In many cases, outpatient surgical treatment of benign diseases of the uterus has advantages over inpatient care. This has been demonstrated by the healthcare situation in other countries. However, the prerequisite for the provision of outpatient services is that this does not lead to any impairment in the quality of care or of patient safety. The ultimate goal should not be to reduce costs but rather to maintain and, ideally, improve the quality of care. This requires that services are not just defined by the surgical procedure but also by the entire treatment chain, including, for example, psychosocial support, and are remunerated accordingly. It is particularly worrying that the final decision as to whether an outpatient operation is possible is not the responsibility of the operating unit, but of the "Medizinischer Dienst," with the corresponding options and threats of sanctions. This situation is unique internationally and requires a paradigm shift. Furthermore, structural prerequisites must be maintained which currently only exist inadequately in Germany. Since a substantial proportion of planned outpatient operations require immediate or secondary inpatient treatment, there must be a barrier-free transition between the outpatient and inpatient sectors. This will require the creation of networks between outpatient service providers and one or more hospitals that are equipped and competent to manage even complex complications. It is important to create structures that, with intensive involvement of the operating unit, include adequate preoperative evaluation and patient education as well as needs-oriented postoperative care at home. The current separation of sectors is a significant hinderance. Moreover, when expanding and promoting outpatient surgery, the aspect of training and further education of specialist staff must be taken into account, as well as cross-sectoral quality assurance. Based on a review of the international literature, this article presents 13 recommendations for adequate structures when providing outpatient services which should serve as a prerequisite for the greatest possible guarantee of patient safety.

Genetische Tumordiagnostik und Personalisierte Medizin aus der System-Perspektive

High-quality studies are necessary and feasible in personalised medicine in order to evaluate the benefits across the entire treatment chain of biomarker tests and resulting treatments in regard to patient-relevant endpoints. With the introduction of genome sequencing in oncology, a considerable number of new treatment concepts with mostly low-quality evidence can be expected. High quality requirements, interdisciplinary cooperation structures, knowledge-generating care and the connection of patient care at the expense of the statutory health insurance funds, with research at the expense of the manufacturers or public funding, are necessary.

A novel end-to-end test for combined dosimetric and geometric treatment verification using a 3D-printed phantom.

The dosimetric and geometric accuracy are important components to ensure safe patient treatment in radiation therapy. Therefore, these components must be checked during quality control. This work presents a possible solution for the determination of the geometric isocenter deviation in the entire treatment chain. Additionally, the dose measurement of the established end-to-end test workflow measured in the same procedure as the geometric deviation is described. An in-house designed end-to-end test phantom went through the entire procedure of a standard patient treatment and the dosimetric and geometric accuracy were determined. At 3 linear accelerators (linac), the phantom was positioned either with cone beam computed tomography or with surface guidance. In this position, a Winston-Lutz test was performed and the deviations of the gantry, collimator and couch isocenter measurements to the phantom position were determined. Additionally, a dose measurement in the phantom was performed and compared to the dose predicted in the treatment planning system. To validate the results obtained with the in-house designed phantom, comparative measurements with commercial phantoms were performed. According to the performed end-to-end test, 2 out of the 3 linacs showed isocenter variations larger than 1 mm for collimator and gantry rotations and larger than 2 mm for couch rotations. With an isocenter variation of less than 1 mm for collimator and gantry rotations, 1 linac fulfilled the tolerance for stereotactic treatments without couch rotation. With couch rotation, an isocenter variation of less than 2 mm was detected at this linac, which fulfilled the tolerance for IMRT treatments. The mean dose deviation between measurement and treatment planning system was 1.82% ± 1.03%. The results acquired with the UMM phantom did not show statistically significant deviations to those acquired with relevant other commercial phantoms. The novel end-to-end test procedure allows for a combined dosimetric and geometric treatment evaluation. Besides the commonly performed dose end-to-end test the geometric isocenter deviation within a patient treatment workflow was evaluated and categorized for IMRT or SBRT.

Oriented Fermentation of Food Waste towards High-Value Products: A Review

Food waste has a great potential for resource recovery due to its huge yield and high organic content. Oriented fermentation is a promising method with strong application prospects due to high efficiency, strong robustness, and high-value products. Different fermentation types lead to different products, which can be shifted by adjusting fermentation conditions such as inoculum, pH, oxidation-reduction potential (ORP), organic loading rate (OLR), and nutrients. Compared with other types, lactic acid fermentation has the lowest reliance on artificial intervention. Lactic acid and volatile fatty acids are the common products, and high yield and high purity are the main targets of food waste fermentation. In addition to operational parameters, reactors and processes should be paid more attention to for industrial application. Currently, continuously stirred tank reactors and one-stage processes are used principally for scale-up continuous fermentation of food waste. Electro-fermentation and iron-based or carbon-based additives can improve food waste fermentation, but their mechanisms and application need further investigation. After fermentation, the recovery of target products is a key problem due to the lack of green and economic methods. Precipitation, distillation, extraction, adsorption, and membrane separation can be considered, but the recovery step is still the most expensive in the entire treatment chain. It is expected to develop more efficient fermentation processes and recovery strategies based on food waste composition and market demand.

End-to-end delivery quality assurance of computed tomography–based high-dose-rate brachytherapy using a gel dosimeter

PurposeThe purpose of this study was to develop a novel quality assurance (QA) program to check the entire treatment chain of image-guided brachytherapy with dose distribution evaluation in a single setup and irradiation using a gel dosimeter. Methods and MaterialsA polymer gel was used, and the readout was performed by magnetic resonance scanning. A CT-based treatment plan was generated using the Oncentra planning system (Elekta, Sweden), and irradiation was performed three times using an afterloading device with an Ir-192 source. The dose-response curve of the gel was created using 6-MV X-ray, which is independent of the source beams. Planar gamma images on a coronal plane along the source transport axis were calculated using the measured dose as a reference, and the calculated doses were used in several error simulations (no error; 2.0 or 2.5 mm systematic and random source dwell mispositioning; and dose error of 2%, 5%, 10%, and 20%). ResultsThe dose-R2 (spin-spin relaxation rate) conversion table revealed that the uncertainty and dose resolution of 6-MV X-ray were better than those of Ir-192 and also constant between the three measurements. With the 3%/1 mm criteria, there were statistically significant differences between each pair of settings except dose error of 2% and 5%. ConclusionThis work depicts a simple and efficient end-to-end test that can provide a clinically useful tool for QA of image-guided brachytherapy. In this QA program, air kerma strength and dwell position setting could also be verified. This test can also distinguish between different types of error.

Patient complaints following bariatric surgery 2012-18.

We examined complaints submitted to the Norwegian System of Patient Injury Compensation (NPE) following bariatric surgery, including the background for the complaint, the proportion of patients whose complaints were upheld, and the characteristics of complaints that were upheld. All complaints relating to bariatric surgery performed in the period 2012-18 were reviewed and categorised according to symptoms, findings and events relevant to the outcome of the complaint. Anonymous summaries from the experts' statements were reviewed and categorised according to year of decision, gender, age, basis for compensation or rejection, and whether the intervention was carried out in the public or private health service. Forty-four (26%) of a total of 171 applications for patient injury compensation were upheld. These applications represented 25patients who had surgery in the public health service (19% upheld) and 19patients who were operated on in the private health service (51% upheld). The single most common reason for a complaint being upheld (n = 18) was lack of indication for bariatric surgery. More post-bariatric surgery complaints were upheld for lack of indication than for surgical errors. Proper patient selection, good preoperative preparation, good information and shared decision-making are important factors for achieving the best possible bariatric surgery outcome. An interdisciplinary team that monitors patients over time can help ensure the quality of the entire treatment chain.

\u201cI did not know it was so important to take it the whole time\u201d \u2212 self-reported barriers to medical treatment among individuals with asthma

BackgroundAsthma is an extensive public health problem and inadequate disease control is not uncommon. Individuals’ self-perceived barriers to medical treatment for the entire treatment chain (from seeking care for symptoms to using a medicine) have seldom been studied for chronic diseases such as asthma. The aim of this study was to explore self-perceived barriers to medical treatment among individuals with asthma within the framework of AAAQ (availability, accessibility, acceptability and quality).MethodsIndividuals with asthma visiting the asthma nurse at a primary health care centre, and who currently had a prescription for anti-asthmatic medicines, were informed about the study. The nurse asked the persons for their consent to be contacted by an interviewer. The interview guide was constructed from the elements of AAAQ exploring self-perceived barriers to asthma treatment. Interviews were conducted in Swedish, English, Arabic and Persian. They were transcribed verbatim and a manifest content analysis was conducted.ResultsFourteen interviews were conducted. There was a large variation in both age and reported number of years with asthma. Self-perceived barriers to asthma treatment were experienced throughout the whole treatment chain. Barriers that emerged were health care accessibility, perceived quality of care, beliefs about medicines, life circumstances, knowledge gap about asthma and medicines, practical obstacles to using medicines, and experiences with treatment. The self-perceived barriers cover all four elements of AAAQ, but there are also some barriers that go beyond those elements (life circumstances and practical obstacles to using medicines).ConclusionsSelf-perceived barriers among individuals with asthma cover the whole treatment chain. We want to highlight the inadequate information/education of patients leading to knowledge gaps about both disease and the effect of medicines, and also the perceived unsatisfactory treatment at the PHCC, which could partly be counteracted if patients know what to expect from health care visits.

Sludge bio-drying followed by land application could control the spread of antibiotic resistance genes

The process of sludge bio-drying has been adopted in response to the increasing amount of residual sewage sludge. It has been demonstrated that sludge bio-drying effectively reduces both antibiotic resistance genes (ARGs) and mobile genetic elements (MGEs), whereas ermF, tetX, and sulII become enriched in response to the dynamic development of the microbial community. The present study further demonstrated that the land application of sludge bio-drying products under current application rate did not cause an increase in the abundance of quantified ARGs in the soil but the persistence of ARB should be paid attention. Although land application introduced ermF, tetX, and tetG into the soil, these soon decreased to control levels. Furthermore, the decay rate varied between soil types, with red soil being the most persistent based on kinetics modeling. The fate of ARGs could also be attributed to the dynamics of the microbial community during land application, and the genus Parasegetibacter, which can degrade extracellular DNA, might play a key role in the control of ARGs. In summary, sludge bio-drying following land application could constitute an effective means of controlling the spread of ARGs, and microbial community changes contributed the most to the fate of the ARGs during the entire treatment chain (residual sewage sludge → bio-drying process → land application).

Multi-institutional evaluation of end-to-end protocol for IMRT/VMAT treatment chains utilizing conventional linacs

We conducted a multi-institutional assessment of a recently developed end-to-end monthly quality assurance (QA) protocol for external beam radiation therapy treatment chains. This protocol validates the entire treatment chain against a baseline to detect the presence of complex errors not easily found in standard component-based QA methods. Participating physicists from 3 institutions ran the end-to-end protocol on treatment chains that include Imaging and Radiation Oncology Core (IROC)-credentialed linacs. Results were analyzed in the form of American Association of Physicists in Medicine (AAPM) Task Group (TG)-119 so that they may be referenced by future test participants. Optically stimulated luminescent dosimeter (OSLD), EBT3 radiochromic film, and A1SL ion chamber readings were accumulated across 10 test runs. Confidence limits were calculated to determine where 95% of measurements should fall. From calculated confidence limits, 95% of measurements should be within 5% error for OSLDs, 4% error for ionization chambers, and 4% error for (96% relative gamma pass rate) radiochromic film at 3% agreement/3 mm distance to agreement. Data were separated by institution, model of linac, and treatment protocol (intensity-modulated radiation therapy [IMRT] vs volumetric modulated arc therapy [VMAT]). A total of 97% of OSLDs, 98% of ion chambers, and 93% of films were within the confidence limits; measurements were found outside these limits by a maximum of 4%, < 1%, and < 1%, respectively. Data were consistent despite institutional differences in OSLD reading equipment and radiochromic film calibration techniques. Results from this test may be used by clinics for data comparison. Areas of improvement were identified in the end-to-end protocol that can be implemented in an updated version. The consistency of our data demonstrates the reproducibility and ease-of-use of such tests and suggests a potential role for their use in broad end-to-end QA initiatives.

End-to-end test for computed tomography-based high-dose-rate brachytherapy.

PurposeOne of the important developments in brachytherapy in recent years has been the clinical implementation of complex modern technical procedures. Today, 3D-imaging has become the standard procedure and it is used for contouring and precise position determination and reconstruction of used brachytherapy applicators. Treatment planning is performed on the basis of these imaging methods, followed by data transfer to the afterloading device. Therefore, checking the entire treatment chain is of high importance. In this work, we describe an end-to-end test for computed tomography (CT)-based brachytherapy with an high-dose-rate (HDR) afterloading device, which fulfills the recommendation of the German radiation-protection-commission.Material and methodsThe treatment chain consists of a SOMATOM S64 CT scanner (Siemens Medical), the treatment planning system (TPS) BrachyVision v.13.7 (VMS), which utilizes the calculation formalism TG-43 and the Acuros algorithm v. 1.5.0 (VMS) as well as GammaMedplus HDR afterloader (VMS) using an Ir-192 source. Measurement setups for common brachytherapy applicators are defined in a water phantom, and the required PMMA applicator holders are developed. These setups are scanned with the CT and the data is imported into the TPS. Computed TPS reference dose values for significant points located on the side of the applicator are compared with dose measurements performed with a PinPoint 3D chamber 31016 (PTW Freiburg).ResultsThe deviations for the end-to-end test between computed and measured values are shown to be ≤ 5%, when using an implant needle or vaginal cylinder. Furthermore, it can be demonstrated that the test procedure provides reproducible results, while repositioning the applicators without carrying out a new CT-scan.ConclusionsThe end-to-end test presented allows a practice-oriented realization for checking the whole treatment chain for HDR afterloading technique and CT-imaging. The presented phantom seems feasible for performing periodic system checks as well as to verify newly introduced brachytherapy techniques with sufficient accuracy.

Design, manufacture, and evaluation of an anthropomorphic pelvic phantom purpose-built for radiotherapy dosimetric intercomparison

An anthropomorphic pelvic phantom was designed and constructed to meet specific criteria for multicenter radiotherapy dosimetric intercomparison. Three dimensional external and organ outlines were generated from a computed tomography image set of a male pelvis, forming the basis of design for an anatomically realistic phantom. Clinically relevant points of interest were selected throughout the dataset where point-dose values could be measured with thermoluminescence dosimeters and a small-volume ionization chamber. Following testing, three materials were selected and the phantom was manufactured using modern prototyping techniques into five separate coronal slices. Time lines and resource requirements for the phantom design and manufacture were recorded. The ability of the phantom to mimic the entire treatment chain was tested. The phantom CT images indicated that organ densities and geometries were comparable to those of the original patient. The phantom proved simple to load for dosimetry and rapid to assemble. Due to heat release during manufacture, small air gaps and density heterogeneities were present throughout the phantom. The overall cost for production of the prototype phantom was comparable to other commercial anthropomorphic phantoms. The phantom was shown to be suitable for use as a "patient" to mimic the entire treatment chain for typical external beam radiotherapy for prostate and rectal cancer. The phantom constructed for the present study incorporates all characteristics necessary for accurate Level III intercomparison studies. Following use in an extensive Level III dosimetric comparison over a large time scale and geographic area, the phantom retained mechanical stability and did not show signs of radiation-induced degradation.

Dagkirurgi og anestesi

Most surgical procedures in Norway are performed on an ambulatory basis. Many types of health professionals are involved and need training in how to handle these patients. The paper reviews important aspects of handling ambulatory surgical patients. The authors' research, clinical experience from ambulatory anaesthesiology and literature identified through a non-systematic search in Medline and EMBASE form the basis for the article. With the advent of modern techniques, anaesthesia is no longer a limiting factor for whether surgery can be performed on an ambulatory basis or not. The decision to hospitalize a patient after elective surgery is based on limitations in the patient's general health, daily functioning and psychosocial status or the type of surgical procedure planned. When assessing whether surgery can be elective or not it is valuable to consider the entire treatment chain and ask the following questions: Can this patient who has undergone this procedure be expected to cope with transport and staying at home or in a hotel the same day as the operation, when escorted by an adult until the next day? - and is it safe? To ensure good planning and performance, it is important that the anaesthetist has access to up-to-date information on planned surgical procedures, the patient's general health, use of medication, allergies and level of daily functioning.

JEM Spotlight: Monitoring the treatment efficiency of a full scale ozonation on a sewage treatment plant with a mode-of-action based test battery

Tertiary treatment of wastewater with ozone is a promising technique for removing residual micropollutants that remain after secondary biological treatment. We monitored the performance of a full-scale ozonation reactor on a sewage treatment plant in Switzerland with a screening battery of bioassays. Six toxicity endpoints were selected that covered non-specific toxicity, as well as selected receptor-mediated modes of action and reactive toxicity. Non-specific toxicity was assessed with two bioassays, the bioluminescence inhibition of the marine luminescent bacterium Vibrio Fischeri and the growth inhibition of the green algae Pseudokirchneriella subcapitata. Treatment efficiency was around 90% for the secondary treatment, but only 65% and 76% for the ozonation step in the two non-specific endpoints, respectively. This finding is consistent with this type of oxidation reaction because ozone only modifies the organic molecules but does not mineralize them fully leaving residual toxicity of the transformation products. In contrast, the specific receptor-mediated endpoints of inhibition of photosystem II in algae and estrogenicity were largely reduced by ozonation. While compounds inhibiting photosynthesis proved to be rather recalcitrant toward biological treatment with only 47% removal, an additional 86% removal by ozonation yielded an overall treatment efficiency in the entire treatment chain of 89%. The effect on estrogenicity, quantified with the yeast estrogen screen, was even more significant: A treatment efficiency of 95% in the secondary treatment, 86% during ozonation plus a small effect by biological sand filtration yielded an overall treatment efficiency of 99.5%. Insecticides that inhibit acetylcholinesterase were fairly resistant to degradation, but an overall treatment efficiency of 91% was achieved in two steps: 72% in biological treatment and 60% during ozonation. Finally, no significant genotoxicity was observed with the umuC test after ozonation, while the influent showed a genotoxic response when it was enriched by a factor of 15 to 60. Treatment efficiency increased with the ozone dose and remained virtually unchanged over ozone doses above 500 g ozone per kg dissolved organic carbon. The reduction of toxicity can be rationalized by the chemical oxidation processes likely to occur for each group of chemicals that are typical for a given mode of toxic action. For comparison, tertiary treatment with powdered activated carbon was also evaluated, which poses a viable alternative to ozonation with respect to removal of micropollutants.

Special-needs student’s psychiatric treatment chain:

Objectives. The problems of children and adolescents have increased innumber and severity during the last years. The purpose of the study was toexplore the need for, and the utilisation and functionality of, the specializedpsychiatric health care services available to children and adolescentsof comprehensive and senior secondary school age. The main object ofthe study was to describe a special-needs pupil’s psychiatric pathway ofcare, and to evaluate its functionality and the need for multi-professionalco-operation from the perspective of the networked experts and clients.Study design. Qualitative study employing data and methodological triangulation, questionnaires, multiple constituency evaluations and content analysis.Methods. Data were collected from 112 (82 %) comprehensive schools and senior secondary schools, with a total of 18,532 students, in Oulu Province, Finland, during the period 1998 – 2002. Thirty-seven (97 %) special schools had a total of 1276 students. The data for the first and second sub-studies were collected with a questionnaire. The data for the third sub-study were obtained from documents concerning the need for, and the use and functionality of services provided and evaluated by the key groups of actors. The data sets were evaluated using the multiple constituency methods in co-operative evaluation sessions, which were video-taped. The data for the fourth sub-study consisted of tape-recorded interviews of the study subjects. The phenomenon under study was approached from a number of evaluative perspectives, and data and methodological triangulation was used. Multiple constituency evaluation and content analysis were used as research methods.Results. As evaluated by comprehensive school and senior secondary school teachers, both the incidence and the severity of students’ conduct and emotional disorders have increased over the past few years. Special school students with conduct disorders and mental health problems were referred for examinations and treatment into the treatment chain of child and adolescent psychiatry similarly to other school-aged children and adolescents. Special schools had a constant need for child and adolescent psychiatric services, but there were no direct connections with specialized health care. At all schools, efforts were made by teachers and parents to help students with the assistance of school health care and social work professionals. Whenever students failed to get the requisite help from specialized health care, their problems remained the family’s responsibility. The parents in these situations felt that they had been left alone, without understanding what it was all about and without knowing where to go for help. Nevertheless, the data also included many positive experiences of fluent co-operation and easy availability of help for the student. The findings showed that there is a lot of expertise and a sincere desire to work for the benefit of children and adolescents. The lack of coordination of the entire treatment chain did, however, wear down the self-esteem of the students in need of help, as well as the meagre resources of their parents and the help-providing key actors. All stages of research highlighted the evident need for closer co-operation between the key groups of the network responsible for the treatment chain and the need for social work and health care liaison persons, who could be contacted quickly. It was also suggested that the key groups participating in the treatment chain should be provided joint training and mentoring. The outreach outpatient clinic coordinated by the Clinic of Child Psychiatry was considered extremely important, because it provided specialized expertise locally at the municipal level.Conclusions. The major problems in the functionality of the psychiatric treatment chain were the availability of services and the flow of information. The pupils’ coping was impaired by their crumbling self-esteem and the slow provision of help. In spite of the legislation, the rehabilitation of special-need pupils and the collaboration between schools and mental health authorities are not optimal.

Absolute dose verifications in small photon fields using BANG™ gel

Polymer gel dosimeters change their magnetic resonance (MR) and optical properties with the absorbed dose when irradiated and are suitable for narrow photon beam dosimetry in radiosurgery. Such dosimeters enable relative and absolute 3D dose verifications in order to check the entire treatment chain from imaging to dose application during commissioning and quality assurance.For absolute 3D dose verifications in radiosurgery using Gamma Knife B, commercially available BANG™ Gels (BANG 25 Gy and BANG 3 Gy) together with dedicated phantoms were chosen in order to determine the potential of absolute gel dosimetry in radiosurgery.