Full Prescription Research Articles

The impact of cost sharing on antidepressant use among older adults in British Columbia.

Antidepressant therapies are underused among older adults and could be further curtailed by patient cost-sharing requirements. The authors studied the effects of two sequential cost-sharing policies in a large, stable population of all British Columbia seniors: change from full prescription coverage to 10-25 dollars copayments (copay) in January 2002 and replacement with income-based deductibles and 25% coinsurance in May 2003. PharmaNet data were used to calculate monthly dispensing of antidepressants (in imipramine-equivalent milligrams) among all British Columbia residents age 65 and older beginning January 1997 through December 2005. Monthly rates of starting and stopping antidepressants were calculated. Population-level patterns over time were plotted, and the effects of implementing cost-sharing policies on antidepressant use, initiation, and stopping were examined in segmented linear regression models. Implementation of the copay policy was not associated with significant changes in level of antidepressant dispensing or the rate of dispensing growth. Subsequent implementation of the income-based deductible policy also did not lead to a significant change in dispensing level but led to a significant (p=.02) decrease in the rate of growth of antidepressant dispensing. The copay policy was associated with a significant (p=.01) drop in the frequency of antidepressant initiation among persons with depression. Income-based deductibles reduced the rate of increase in antidepressant initiation over time. Implementation of the copay and income-based deductible policies did not have significant effects on stopping rates. Introducing new forms of medication cost sharing appears to have the potential to reduce some use and initiation of antidepressant therapy by seniors. The clinical consequences of such reduced use need to be clarified.

Full prescription coverage of value following MI

Full prescription coverage of value following MI

A potential method for in vivo range verification in proton therapy treatment

Proton therapy potentially offers excellent dose conformality and reduction in integral dose. The superior dose distribution is, however, much more sensitive to the radiological depth along the beam path than for photon fields. Variations in this depth due to inaccurate planning calculation, setup uncertainty, respiration-induced organ motion, etc, could result in either an ‘undershooting’, missing the distal portion of the target volume entirely, or an ‘overshooting’, delivering the full prescription dose to the normal tissue beyond the target volume. In vivo dose verification plays an important role in the quality assurance of the treatments. The point dose measurements widely used for photon treatments are, however, insufficient for protons due to the particular characteristics of the proton depth–dose distribution. In this work, we explore a method for in vivo range verifications in proton treatments using range-modulated passive scattering fields. The method utilizes the time dependence of the dose distribution delivered by these fields. By measuring the time dependence of the dose rate at any point in the target volume, the residual range of the beam at this point can be obtained with millimeter accuracy.

Full prescription coverage of value following MI

Full prescription coverage of value following MI

Treatment of older adult patients diagnosed with rheumatoid arthritis: Improved but not optimal

The National Committee on Quality Assurance has determined that all patients with rheumatoid arthritis (RA) should be treated with disease-modifying antirheumatic drugs (DMARDs). Our objective was to determine the rate and predictors of DMARD use in a cohort of elderly patients with RA. We analyzed health care utilization data for 5,864 Medicare beneficiaries with RA who also participated in a state-run pharmaceutical benefit program in Pennsylvania. Patients with RA were defined as those with at least 3 diagnoses of RA (International Classification of Diseases, Ninth Revision code 714.xx) at least 1 week apart who were enrolled in these programs for at least 12 months during 1995-2004. Multivariate logistic regression was used to assess predictors of synthetic or biologic DMARD use in the 12 months after cohort entry. Thirty percent of patients filled a DMARD prescription during 12 months of followup. Frequency of DMARD use increased steadily over time: 24% received DMARDs in 1996 compared with 43% in 2003 (P for trend <0.001). Of patients with at least 1 rheumatologist visit, 41% received a DMARD in 1996 compared with 70% in 2003 (P < 0.001). After the introduction of biologic DMARDs in 1998, 6% of all patients with RA received a biologic, including 12% who saw a rheumatologist. Patients ages 75-84 were 52% less likely to receive DMARDs (95% confidence interval [95% CI] 46-58%) and patients ages >or=85 were 74% less likely (95% CI 69-79%) compared with patients ages 65-74. In this cohort of patients in the community with full prescription drug coverage, most patients diagnosed with RA did not receive a DMARD during the 12 months after cohort entry. Older patients and those not seeing a rheumatologist were less likely to receive a DMARD and may provide a target for quality improvement interventions.

TH-C-AUD-06: Breathing Interplay Effects During Proton Beam Spot Scanning: Simulation and Statistical Analysis

Purpose: The transition from passive scattering to active scanning in protonradiation therapy introduces the problem of interplay effects, when elements of beam motion have a similar time scale to intrafractional tumor motion. This can lead to unacceptable deviation from the planned dose in a given fraction. The sum of fields over an entire treatment leads to a predictable broadening of the penumbra, but the limited number of fractions may not provide enough repetition to satisfactorily wash out interplay effects. A possible solution is the ‘repainting’ of each field several times at lower dose rate. This study looks at the dosimetric effect of interplay and compares different ‘repainting’ methods. Materials & Methods: The broadening of the penumbra and the dose shift due to breathing asymmetry are characterized via simulation over a set of clinically relevant permutations including tumor amplitude, breathing period, energy change time, proton beam spot size, location within the field, and degree of breathing asymmetry. Several repainting methods are developed and compared for the conditions of worst‐case delivery error. Breathing motion, normal to the beam direction, is modeled with an asymmetric sine function.. Results: The broadening of the penumbra depends only on the amplitude of tumor motion, and is responsible for narrowing the full prescription isodose volume and widening the low dose penumbra by as much as 2cm for large tumor amplitudes (3cm peak‐to‐peak). The systematic isodose shift by 10%–15% of the tumor amplitude was observed due to motion asymmetry. Of the five re‐painting techniques studied, Breath Sampling Repainting was most effective in reducing dose errors with a minimal addition to treatment time. Conclusions:Dose repainting is necessary in treatment of moving tumors with scanned proton beams. The dosimetric uncertainty can be reduced with certain ‘repainting’ techniques.

A Genetically Determined Dose–Volume Histogram Predicts for Rectal Bleeding among Patients Treated With Prostate Brachytherapy

To examine whether possession of genetic alterations in the ATM (ataxia telangiectasia) gene is associated with rectal bleeding in a dose-dependent and volume-dependent manner. One hundred eight prostate cancer patients who underwent brachytherapy using either an (125)I implant, a (103)Pd implant, or the combination of external beam radiotherapy with a (103)Pd implant and had a minimum of 1 year follow-up were screened for DNA sequence variations in the 62 coding exons of the ATM gene using denaturing high-performance liquid chromatography. Rectal dose was reported as the volume (in cubic centimeters) of rectum receiving the brachytherapy prescription dose. The two-sided Fisher exact test was used to compare differences in proportions. A significant correlation between the presence of any ATM sequence alteration and Grade 1 to 2 proctitis was obtained when the radiation dose to rectal tissue was quantified. Rectal bleeding occurred in 4 of 13 patients (31%) with a variant versus 1 of 23 (4%) without a genetic alteration for patients who had <0.7 cm(3) of rectal tissue receiving the implant prescription dose (p = 0.05). Of patients in whom 0.7-1.4 cm(3) of the rectum received the implant prescription, 4 of 11 (36%) with an ATM alteration exhibited Grade 1 to 2 proctitis, whereas 1 of 21 (5%) without a variant (p = 0.04) developed this radiation-induced late effect. The possession of genetic variants in the ATM gene is associated with the development of radiation-induced proctitis after prostate cancer radiotherapy for patients who receive the full prescription dose to either a low or a moderate volume of rectal tissue.

Evaluating prescribing competencies and standards used in nurse independent prescribers’ prescribing consultations

Background Independent prescribing of medicines by nurses is widely considered to be part of advanced nursing practice, and occurs within an episode of patient care that can be completed independently by a nurse. Nurse prescribers therefore require the competencies necessary to manage a consultation—such as history taking and diagnostic skills—and subsequently need to decide on any appropriate medicine to be prescribed. Safe prescribing should also involve an accurate, legible and comprehensive written prescription and documentation of the consultation in the patient’s records. However, the extent to which nurse independent prescribers use prescribing competencies and standards in practice had not been researched prior to this study. Aim To describe the frequency with which nurses use a range of prescribing competencies in their prescribing consultations, in order to provide a measure of the quality and safety of nurses’ independent prescribing practices. Design and methods Across 10 case study sites, 118 nurse independent prescribers’ prescribing consultations were analysed using non-participant observation and a structured checklist of prescribing competencies. Documentary analysis was also undertaken of a) prescriptions written ( n =132) by nurses and b) the record of the prescribing episode in patient records ( n =118). Sample and setting 118 prescribing consultations of 14 purposively selected nurse independent prescribers working in primary and secondary care trust case study sites in England. Findings Nurse independent prescribers were issuing a prescription every 2.82 consultations; nurses used a range of assessment and diagnosis competencies in prescribing consultations, but some were employed more consistently than others; nurses almost universally wrote full and accurate prescription scripts for their patients; nurses recorded each of their prescribing consultations, but some details of the consultation and the prescription issued were not always consistently recorded in the patient records. Conclusion The findings from this observation study provide evidence about the quality and safety of nurses’ prescribing consultations in England.

63: A Genetically Determined Dose Volume Histogram Predicts for Rectal Bleeding Among Patients Treated With Prostate Brachytherapy

63: A Genetically Determined Dose Volume Histogram Predicts for Rectal Bleeding Among Patients Treated With Prostate Brachytherapy

Ocular motor triad with single vision contact lenses compared to spectacle lenses

Aim Theoretically myopes are required to exert more accommodation and vergence when wearing single vision contact lenses compared to glasses and hypermetropes less. This study aims to quantify the effects clinically. Method Thirty subjects (21 female, nine male, average age 21.0 ± 2.2 years) with a range of refractive errors (−7.87 D to +3.50 D) viewed in a random order, static targets at 0.1, 0.5, 1.0, 2.0, 3.0, 4.0 and 5.0 D accommodative demand that were matched for angular subtense. The subjects were fully corrected with spectacles and daily disposable contact lenses to their full prescription. Accommodation was monitored objectively with the PowerRefractor and Shin-Nippon SRW5000 and vergence and pupil size with the PowerRefractor. Results Myopes exerted greater accommodative effort for viewing near targets with contact lenses than glasses and hypermetropes less ( r 2 = 0.35, p = 0.001 PowerRefractor). Myopes also exerted greater vergence effort for viewing near targets with contact lenses than glasses and hypermetropes less ( r 2 = 0.22, p < 0.01). Conclusion Theoretical calculation of the accommodative and vergence requirements with glasses compared to contact lenses reflect clinical findings, although there is reasonable variability between individuals.

Angiotensin inhibition after myocardial infarction: Does drug class matter?

Angiotensin converting enzyme-inhibitors (ACEI) and angiotensin-II-receptor blockers (ARB) are equally efficacious in reducing mortality after MI, although the latter are far more costly. Little is known about their relative use after MI in typical care settings, and about their relative effectiveness outside the clinical trial setting. To assess temporal trends in the relative use of ACEI and ARB after myocardial infarction, and to test for differences in 1-year survival between users of these drug classes. Retrospective closed cohort study. Medicare beneficiaries who survived >90 days after myocardial infarction, had full prescription drug coverage, and who filled a prescription for either ACEI or ARB within 90 days of myocardial infarction. Relative use of ACEI versus ARB over time. Adjusted relative 1-year mortality between ACEI and ARB users. Between 1995 and 2004, 14,190 patients met inclusion criteria. Mean age was 80 years, 75% were female, and 90% were white. Overall, 88% received an ACEI, and 12% an ARB, with the proportion receiving an ARB increasing from 2% (1995) to 25% (2004; P<.001). Multivariate-adjusted 1-year mortality did not differ between ARB and ACEI users (HR: 1.04; 95% confidence interval: 0.88 to 1.22). The findings were similar for new users of ACEI/ARB, and for those with preexisting heart failure. ARB users had the same 1-year mortality after myocardial infarction as ACEI users in routine care. Use of more costly ARB has increased dramatically over time, to a quarter of ACEI/ARB users, despite the lack of a therapeutic advantage for most patients.

Measuring Outcomes of Swimmers' Non-Regulation during Practice: Relationships between Self-Report, Coaches' Judgments, and Video-Observation

The purpose of this investigation was to further validate measures for three behavioral items that coaches claimed to reflect outcomes of non-regulation by swimmers during training. Measures for 33 competitive swimmers were collected for behaviors that reflected a lack of motivation to comply with a coach's full training volume prescription in (1) warm-up, and in the (2) remaining workout, as well for (3) the off-task durations of swimmers in warm-up. Measures were collected concurrently via self-report and video-observation at nine practices across five weeks of training. Coaches rated swimmers for levels of (a) on-task behavior in warm-up, and (b) initiative, motivation and discipline in the workout. Self-reported and observed measures were separately contrasted with low and high motivation groups, based on coach ratings. Results showed that when coaches rated swimmers low on self-regulated behaviors the swimmers had in fact completed less of the prescribed swim volume. Likewise, swimmers who spent a lot of time out-of-stroke in warm-up were not self-regulated, according to coach ratings. In a supplementary analysis, self-reported measures for missed volume during warm-up were contrasted with veridical measures obtained by video observation for a sub-set of 16 swimmers. Findings indicated that self-report at the end of workout was inaccurate and/or biased due to distorted memory processes and self-presentation influences. Discussion focused on the future use of valid and observable measures representing outcomes of non-regulation in applied sport intervention research.

Maternal use of Loratadine during pregnancy and risk of hypospadias in offspring

To examine the risk of hypospadias after exposure to loratadine and other antihistamines during pregnancy, we conducted a population-based case-control study in four Danish counties, which account for 30% of the Danish population (approximately 1.6 M). We obtained data on maternal use of antihistamines from prescription databases, and data on birth outcomes from the Danish Medical Birth Registry (MBR) and the Hospital Discharge Registry (HDR). A total of 65,383 male births with a full prescription history of the mother in the study period from 1989-2002 were available for analysis. Within this cohort, we identified cases with a diagnosis of hypospadias, and 10 selected controls per case without such a diagnosis (matched on birth month, gender and year of birth). We identified 227 cases of hypospadias recorded in the HDR within six months postpartum and 2270 controls. One case (0.4%) and eight (0.4%) controls were exposed to loratadine in the first trimester and up to 30 days before the time of conception. The adjusted odds ratio (OR) for hypospadias among users of loratadine relative to non-users was 1.4 (95% CI: 0.2-11.2) and the corresponding OR for other antihistamines was 1.9 (95% CI: 0.7-5.7). In this study, maternal exposure to loratadine did not appear to be associated with an increased risk of hypospadias when compared with other antihistamines, although it should be noted that the statistical precision of the risk estimates might be limited.

Daily Dose Recalculation Using Megavoltage CT Images During Tomotherapy for Localized Prostate Cancer: Dosimetric Analysis for the Prostate Gland, Rectum and Bladder for the Full Treatment Course

Purpose/Objective: To evaluate the dosimetric consequences of daily anatomical changes on the prostate gland, rectum and bladder. Materials/Methods: Five prostate cancer patients treated to 78 Gy at 2 Gy per fraction with helical tomotherapy constituted the study sample. Prior to each daily fraction, intraprostatic markers detected on a megavoltage CT (MVCT) are registered with the simulation kilovoltage CT (kVCT) for image guidance. The daily MVCTs can also be used to recalculate delivered doses. The recalculation technique uses the intended delivery and the MVCT image to calculate the dose distribution in the anatomy of the day, hence allows a full evaluation of the dosimetric impact of anatomical changes throughout the treatment course. This process was previously tested and verified in phantom studies to be accurate within 0.5%. The MVCT numbers were calibrated in terms of electron densities allowing the use of MVCTs for dose calculations. The entire treatment course (39 fractions per patient) was retrospectively analyzed for all 5 patients. A total of 195 MVCT sets were studied. The rectum and bladder were recontoured on each of the 195 daily MVCTs. The prostate contours were transferred from the original kVCT image set and altered only in position and shape if necessary. For each treatment fraction, DVHs were calculated based on the new contours and recalculated dose distributions. The volume of rectum and bladder that received the prescription dose (in ccs) and the dose to 95% of the prostate volume (D95) were scored. Results: Fig. 1, 2 and 3 show the average (±S.D) and range of daily rectal and bladder volumes receiving full prescription dose and the D95 for each patient. It is clear that the prostate D95 was remarkably constant throughout the course of treatment for all patients indicating adequate coverage of the target regardless of daily variations in the patients′ pelvic anatomy. However, there was remarkable variation in the rectal volumes receiving the prescription fraction dose, varying in some patients (e.g. patient #2) more than in others (e.g. patient #1). There was a trend for higher rectal doses with rectal distention. Distention pushed a larger rectal volume into the high dose region that was occupied by the prostate on the planning kVCT. The prostate D95 also tended to increase with rectal distention. This may be due to the presence of rectal gas and a subsequent reduction in attenuation for beams entering the prostate posteriorly. In the patient with the largest variation in rectal volumes, the degree of rectal distention was unpredictable. Bladder volumes changes were also noticeable, but of lesser magnitude compared to the rectum. Conclusions: Daily anatomical deformations have dosimetric consequences for the rectum, bladder and prostate. Rectal deformation is the most consequential. Daily recalculation of delivered doses using megavoltage images enables a complete dosimetric evaluation of an entire treatment course with external beam radiotherapy.

La., N.M., Differ On Training Needed For Psychologists To Prescribe

La., N.M., Differ On Training Needed For Psychologists To Prescribe

Stereotactic radiotherapy for localized low-grade gliomas in children: Final results of a prospective trial

To evaluate the efficacy of stereotactic radiotherapy (SRT) for small, localized, pediatric brain tumors and to determine the patterns of failure. A total of 81 patients were enrolled in an institutional review board-approved prospective Dana-Farber Cancer Institute protocol between 1992 and 1998. Of the 81 patients, 50 had low-grade astrocytoma, 23 had residual or recurrent craniopharyngioma, 4 had posterior fossa ependymoma, and 4 had other histologic types. All patients underwent biopsy for diagnosis, with the exception of patients with neurofibromatosis and radiographic evidence of an optic system tumor. The neurocognitive outcome for all patients was also an endpoint of the study and will be reported separately. This report focused on the patients with low-grade gliomas only. Of the 50 patients, 26 were males and 24 females; the median age was 9 years (range, 2-26 years). The indications for treatment of patients with low-grade gliomas were progression during or after chemotherapy or progression after surgery alone. SRT was delivered using a dedicated 6-MV linear accelerator. Immobilization was accomplished with a removable head-frame. CT and MRI fusion was used for treatment planning. The target volume generally included the preoperative tumor plus a 2-mm margin for the planning target volume. The median collimator size was 47.25 mm (range, 30-60 mm). Three to nine arcs were used to deliver a mean total dose of 52.2 Gy in 1.8-Gy daily fractions. With a median follow-up of 6.9 years (range, 0.9-10.2 years), the progression-free survival rate was 82.5% at 5 years and 65% at 8 years. The overall survival was 97.8% at 5 years and 82% at 8 years. Six patients had local progression. Two of the patients with local progression had pathologic progression to anaplastic astrocytoma 3 and 7 years after initial SRT. Five patients, all with optic system/hypothalamic primary tumors, developed central nervous system dissemination 1.0-7.4 years after SRT. One patient developed a presumed radiation-induced primitive neuroectodermal tumor 6 years after initial treatment. Six patients died, three of dissemination, two of progression to higher grade tumors, and one of a secondary radiation-induced tumor. All 6 cases of local progression were within the primary tumor bed at the time of progression and had received the full prescription dose. No marginal failures occurred. Stereotactic radiotherapy provides excellent local control for children with small, localized low-grade glial tumors. Marginal failures have not been observed, supporting the use of limited margins to minimize late sequelae using stereotactic immobilization and planning techniques.

A Medicare database review found that physician preferences increasingly outweighed patient characteristics as determinants of first-time prescriptions for COX-2 inhibitors

Objective Although innovative drugs may be underprescribed by some physicians, it is possible that rapid adoption after market introduction may lead to prescribing such drugs to patients without a clear indication. We sought to quantify the relative contributions of patient vs. physician factors to the decision to prescribe selective cyclooxygenase-2 (COX-2) inhibitors during the first 2 years of their availability. Methods A cohort of 37,957 Medicare beneficiaries who were enrolled in the Pharmaceutical Assistance Contract for the Elderly in Pennsylvania was identified. All patients had started using nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) or selective COX-2 inhibitors between January 1, 1999, and December 31, 2000, and had no prior NSAID use. All had full prescription drug coverage, including NSAIDs and selective COX-2 inhibitors. Subsequent prescriptions were not considered. We quantified the amount of variation in first-time COX-2 prescribing that could be explained by predictors of gastrointestinal (GI) toxicity, other patient characteristics, or physician preferences. Explained variation was calculated as the R 2 (standardized to range from 0 to 1) from unconditional logistic regression and random intercept mixed effects logistic regression, fitted separately in each of eight consecutive 3-month periods. Results COX-2 inhibitors were adopted as the preferred NSAID by 55% of physicians within 180 days after they were marketed. In new NSAID users, COX-2 prescribing was twice as dependent on physician prescribing preferences ( R 2 = 60%) as on the combined predictors of GI toxicity ( R 2 = 3%) and other patient factors ( R 2 = 30%). The ratio of COX-2 prescribing explained by physician preferences over the contribution of patient factors increased from 2 to more than 10 over a 24-month period. Conclusions First-time COX-2 inhibitor prescribing was somewhat dependent on patient factors in the first quarter of marketing, but the proportional influence of physician preferences increased substantially over the following 2 years, raising the question of why physician factors and not patient risk factors influence COX-2 inhibitor prescribing.

Intensity-modulated radiotherapy for soft tissue sarcoma of the thigh

purpose Fracture of the femur is one of the late complications of adjuvant radiotherapy for patients with soft tissue sarcomas of the thigh, who receive external beam irradiation after limb-sparing surgery. When the target volume approximates the femur, it is often inevitable that a large segment of the femur will receive full prescription dose with conventional radiation techniques. We report the dosimetric feasibility of intensity- modulated radiation therapy (IMRT) techniques to achieve adequate target coverage and bone sparing. Methods and materials Treatment planning was performed using both three-dimensional conformal radiotherapy (3D-CRT) and IMRT techniques for 10 patients with soft tissue sarcoma of the thigh with tumor approaching the femur. None of the patients had bony involvement. For all patients, the gross total volume (GTV) and the femur were contoured. The clinical target volume (CTV) was defined as the GTV with a 1.5-cm margin axially, except at the bone interface where the bone interface was used as CTV if the 1.5-cm axial margin extended beyond the bone interface. In the superior-inferior direction, the CTV margin placed around the GTV varied from 5 to 10 cm. The planning target volume (PTV) was defined as the CTV with 5-mm margin all around. The 3D conformal technique consisted primarily of two to three beams with wedges or partial transmission blocks as compensators. For the IMRT technique, five coplanar beams were used, chosen so as to spare much of the surrounding soft tissue and to clear the other extremity or groin areas. IMRT plans were designed to adequately treat the planning target volume and spare the femur as much as possible. Results Dose distributions and dose–volume histograms were analyzed. PTV coverage was comparable with both IMRT and 3D-CRT plans. Dose distributions were more conformal with IMRT, however, especially for patients with large variations of contours. The volume of the femur receiving at least full prescription (63 Gy) V100 decreased on average by approximately 57%, from 44.7 ± 16.8% with 3D-CRT to 18.6 ± 9.2% with IMRT ( p < 0.01). For 3 patients with a GTV surrounding <50% of the circumference of the femur, the reduction in the V100 to the femur ranged from 61% to 79%. The hot spots in the femur, as measured by D05 (the dose encompassing 5% of volume), reduced on average from 67.2 ± 1.8 Gy with 3D-CRT to 65.0 ± 1.2 Gy with IMRT ( p < 0.01). The mean dose to the femur was on average 38.5 ± 11.5 Gy with IMRT, compared with 40.9 ± 12.7 Gy with 3D-CRT. The volume of the surrounding soft tissues, defined as the ipsilateral limb excluding the PTV and the femur, receiving at least prescription dose (63 Gy) was reduced on average by about 78%, from 997 ± 660 cc with 3D-CRT to 201 ± 144 cc with IMRT ( p < 0.01). The D05 to the surrounding soft tissues was on average 58.7 ± 4.7 Gy with IMRT, compared to 67.8 ± 1.3 Gy with 3D-CRT ( p < 0.01), a reduction of approximately 13%. The mean dose to the surrounding soft tissues was comparable in both plans. The volume of the skin (from surface to 5 mm depth) receiving prescription dose (63 Gy) declined by roughly 45%, from 115 ± 40 cc with 3D-CRT to 61 ± 20 cc with IMRT ( p < 0.01), with IMRT providing full skin dose coverage to scars. The hot spots in the skin decreased from 68.0 ± 1.7 Gy with 3D-CRT to 65.2 ± 1.2 Gy with IMRT ( p < 0.01). The mean dose to the skin lessened from 51.5 ± 4.7 Gy with 3D- CRT to 44.0 ± 4.2 Gy with IMRT ( p < 0.01), a reduction of 14%. Conclusions Intensity-modulated radiation therapy techniques can reduce the dose to the femur without compromising target coverage by achieving concave dose distributions around the interface of the PTV and the femur. At the same time, IMRT can reduce the hot spots significantly in the surrounding soft tissues and skin. Whether such dosimetric improvements can translate into reduction of complications and/or improving local control needs to be investigated.

Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency Care

Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency Care

A Case Study on the Economics of Thinning in the Wildland Urban Interface

Abstract This is a case study, supplemented by an economic model, of one 85 ac ponderosa pine (Pinus ponderosa) dominated stand, called Unit 16, that was treated during the summer of 2001. Unit 16 is located in the Greater Flagstaff Forests Partnership's Fort Valley project area of the Coconino National Forest and is part of the Flagstaff, AZ wildland urban interface. The silvicultural prescription was a full restoration prescription anchored to the presettlement condition and was limited by a 16 in. dbh cutting cap. The operational strategy for the merchantable material was hand felling, limbing, topping, bucking in the forest, and forwarding of logs to the landing for loading on waiting trucks. The nonmerchantable trees were cut and rough piled, along with limbs and tops. The economic model estimated the logging contractor's costs to total $124,117. His total revenue stream during the summer of 2001 was detrimentally impacted by two unforeseen changes in his market. His normal purchaser of wood from small trees &lt;8.0 in. dbh was unable to purchase this wood and his other market reduced its purchase price by 11%. As a result, his projected income went from providing a small profit of $7,857 to a loss of $3,284. Costs to the Forest Service to prepare the unit and to conduct postthinning activities were estimated to total $31,9160. Net costs to the Greater Flagstaff Forests Partnership in the form of a service contract with the logger totaled $17,000. West. J. Appl. For. 19(1):60–65.