Planning Protocol Research Articles

Chronic condition management and self-management in Aboriginal communities in South Australia: outcomes of a longitudinal study

This paper describes the longitudinal component of a larger mixed methods study into the processes and outcomes of chronic condition management and self-management strategies implemented in three Aboriginal communities in South Australia. The study was designed to document the connection between the application of structured systems of care for Aboriginal people and their longer-term health status. The study concentrated on three diverse Aboriginal communities in South Australia; the Port Lincoln Aboriginal Health Service, the Riverland community, and Nunkuwarrin Yunti Aboriginal Health Service in the Adelaide metropolitan area. Repeated-measure clinical data were collected for individual participants using a range of clinical indicators for diabetes (type 1 and 2) and related chronic conditions. Clinical data were analysed using random effects modelling techniques with changes in key clinical indicators being modelled at both the individual and group levels. Where care planning has been in place longer than in other sites overall improvements were noted in BMI, cholesterol (high density and low density lipids) and HbA1c. These results indicate that for Aboriginal patients with complex chronic conditions, participation in and adherence to structured care planning and self-management strategies can contribute to improved overall health status and health outcomes. The outcomes reported here represent an initial and important step in quantifying the health benefits that can accrue for Aboriginal people living with complex chronic conditions such as diabetes, heart disease and respiratory disease. The study highlights the benefits of developing long-term working relationships with Aboriginal communities as a basis for conducting effective collaborative health research programs. WHAT IS KNOWN ABOUT THE TOPIC? Chronic condition management and self-management programs have been available to Aboriginal people in a range of forms for some time. We know that some groups of patients are keen to engage with care planning and self-management protocols and we have anecdotal evidence of this engagement leading to improved quality of life and health outcomes for Aboriginal people. WHAT DOES THIS PAPER ADD? This paper provides early evidence of sustained improvement over time for a cohort of Aboriginal people who are learning to deal with a range of chronic illnesses through accessing structured systems of support and care. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? This longitudinal evidence of improved outcomes for Aboriginal people is encouraging and should lead on to more definitive studies of outcomes accruing for people engaged in structured systems of care. Not only does this finding have implications for the overall management of chronic illness in Aboriginal communities, but it points the way to how health services might best invest their resources and efforts to improve the health status of people with chronic conditions and, in the process, close the gap between the life expectancy of Aboriginal people and that of other community groups in Australia.

Best Face Forward

Craniofacial vascularized composite allotransplantation is especially challenging when bony components are required. Matching the complex three-dimensional anatomy of the donor and recipient craniofacial skeletons to optimize bony contact and dental occlusion is a time-consuming step in the operating room. Currently, few tools exist to facilitate this process. The authors describe the development of a virtual planning protocol and patient-specific device design to efficiently match the donor and recipient skeletal elements in craniofacial vascularized composite allotransplantation. The protocol was validated in a cadaveric transplant. This innovative planning method allows a "snap-fit" reconstruction using custom surgical guides while maintaining facial height and width and functional occlusion. Postoperative overlay technology in the virtual environment provides an objective outcome analysis.

Creativity-centred design for ubiquitous musical activities: Two case studies

This study is among the first that attempt to define a methodology for creativity-centred software design in educational contexts, more specifically for musical activities in ubiquitous settings. We propose and apply a set of design techniques – the Ubimus Planning and the Ubimus Design protocols – as alternatives to experimental procedures that leave out relevant aspects of social and procedural dimensions in educational research. Two workshops were conducted to assess both technological and domain-specific requirements for support of creative musical activities. The first workshop was conducted with music teachers and school teachers that had no formal musical training. The objective of this workshop was to assess domain-specific requirements for musical creative activities by educational staff. The second workshop focused on technological support for tool development by non-musicians. This workshop yielded two software projects that involved user evaluations of creative processes. Participants in t e corresponding user studies included both musicians and non-musicians. The Ubimus Planning protocol served to raise important questions regarding technological usage by musicians and naive subjects in educational contexts. Non-technical approaches, such as those proposed by traditional soundscape activities, may not be suited for introducing non-musicians to sonic composition. Naive subjects may respond better to technologically based approaches, such as those used in ecocomposition.The Ubimus Design approach proved to be effective to test the usability of musical tools at early stages of development. Prototypes were implemented and usability studies were carried out by undergraduate IT students within a three-week time slot. Sharp differences were observed in the type of requirements expressed by musicians and non-musicians regarding creativity support tools. Nevertheless, both groups of subjects assessed the use of software prototypes within exploratory musical activities as being fun and expressive.

Decision-theoretic analysis of forensic sampling criteria using Bayesian decision networks

Sampling issues represent a topic of ongoing interest to the forensic science community essentially because of their crucial role in laboratory planning and working protocols. For this purpose, forensic literature described thorough (Bayesian) probabilistic sampling approaches. These are now widely implemented in practice. They allow, for instance, to obtain probability statements that parameters of interest (e.g., the proportion of a seizure of items that present particular features, such as an illegal substance) satisfy particular criteria (e.g., a threshold or an otherwise limiting value). Currently, there are many approaches that allow one to derive probability statements relating to a population proportion, but questions on how a forensic decision maker – typically a client of a forensic examination or a scientist acting on behalf of a client – ought actually to decide about a proportion or a sample size, remained largely unexplored to date. The research presented here intends to address methodology from decision theory that may help to cope usefully with the wide range of sampling issues typically encountered in forensic science applications. The procedures explored in this paper enable scientists to address a variety of concepts such as the (net) value of sample information, the (expected) value of sample information or the (expected) decision loss. All of these aspects directly relate to questions that are regularly encountered in casework. Besides probability theory and Bayesian inference, the proposed approach requires some additional elements from decision theory that may increase the efforts needed for practical implementation. In view of this challenge, the present paper will emphasise the merits of graphical modelling concepts, such as decision trees and Bayesian decision networks. These can support forensic scientists in applying the methodology in practice. How this may be achieved is illustrated with several examples. The graphical devices invoked here also serve the purpose of supporting the discussion of the similarities, differences and complementary aspects of existing Bayesian probabilistic sampling criteria and the decision-theoretic approach proposed throughout this paper.

The University Münster model surgery system for Orthognathic surgery. Part I – The idea behind

BackgroundWe describe a procedure for diagnosis and planning for orthognatic surgery based on international standards. A special 2D planning based on lateral cephalograms (Axis Orbital Marker Lines System) realize a transmission to the SAM 2P articulator (3D) by means of the Axis Orbital Plane.MethodsFormer intraoperative measurement of the average height of the LeFort I osteotomy plane relative to the molar occlusal plane allow to construct a virtual osteotomy plane in the lateral cephalogram. This is the basis for the development of the Axis Orbital Marker Lines System (AO-MLS).ResultsThe AO-MLS is presented graphically, and in detail, with construction guidelines. The system could be integrated into various lateral cephalometric analysis- and surgical prediction schemes. It forms the basis for a standardized transfer of the 2D planning to the 3D planning in the articulator, and vice versa. This procedure makes it possible to generate surgical planning protocols based on the model surgery, which represent the dislocations in the proximity of the real osteotomy planes.ConclusionsThe Axis Orbital Marker Lines System (software component) in conjunction with the University Münster Model Surgery System (hardware system) increases the predictability of model operations in orthognathic surgery.

Intensity modulated radiation therapy class solutions in Philips Pinnacle treatment planning for central nervous system malignancies: Standardized, efficient, and effective

Background: The use of intensity modulated radiation therapy (IMRT) is becoming more commonplace in the treatment of central nervous system (CNS) malignancies. However, the determination of beam arrangements is still an empirical process, and optimization of any given plan may take hours on the part of the dosimetrist and the physician to achieve optimal conformity and normal tissue doses. Regional CNS class solutions (CS) for IMRT planning with the Philips Pinnacle treatment planning system (version 8.0; ADAC Laboratories, Milpitas, CA) have been in partial implementation at our institution since 2009. The purpose of this present work was to investigate their validity in clinical practice.Materials and Methods: The plans of 55 patients treated for high-grade gliomas since 2009 were analyzed retrospectively. Thirty plans were categorized as having been planned with class solutions and 25 plans with user-defined optimization. Each plan was evaluated based on the following: (1) mean dose to the brain; (2) brain V30; and (3) Radiation Therapy Oncology Group (RTOG) conformity index (CIRTOG). These data were then compared with 140 historical benchmark plans that were generated using user-defined optimization prior to 2009.Results: The CS plans for gliomas in frontal, parietal-occipital, and temporal regions typically resulted in superior mean brain dose, brain V30, and conformity index when compared with user-defined plans. The CS plans for brainstem gliomas exhibited improved CIRTOG, but not brain V30 and brain mean dose. In trials of planning efficiency, the CS technique reduced treatment planning time by more than 2 times, independent of prior planning experience.Conclusions: We have developed a CS protocol for IMRT planning of gliomas that has dramatically simplified this complex planning process, allowing dosimetrists of all levels of experience to produce highly conformal plans in a time efficient manner.

Abstract 4060: Use of small animal MRI and cone-beam CT for image-guided radiotherapy of orthotopic tumors in mice

Abstract Introduction: Recent developments in image-guided radiation therapy (IGRT) of small animals aim to adapt the radiation planning and delivery protocols employed in the clinical setting to preclinical investigations. Accurate and targeted delivery of radiation to the disease volume of interest is necessary for evaluation of new treatment strategies and their timely translation to the clinic. This abstract reports the feasibility of employing a 1T small animal MR scanner and a cone-beam CT (CBCT)-equipped small animal irradiator to effectively visualize and delineate orthotopically implanted tumors on the treatment bed prior to targeted radiotherapy. Methods: Male nude mice bearing orthotopically implanted prostate tumor (DU145 and 22Rv1) and female SCID mice bearing orthotopically implanted cervical tumor (ME-180) were positioned on a transportable multimodality imaging and treatment bed (Minerve System, Bioscan) and scanned using a 1T MR scanner (M2, Aspect Imaging) and a small animal irradiator equipped with CBCT (X-rad 255Cx, Precision X-ray). The MR images were acquired using a fast spin echo sequence (TE/TR = 80/4800, NEX of 4 or 6, voxel size of 0.2 x 0.2 x 1.0 mm, 22 to 24 slices and imaging time of 6 to 8 minutes). The CBCT images were acquired at 80 and 100 kVp (for reduced streaking at the bone/soft tissue interface) and 0.5 mA (60 seconds acquisition) and reconstructed at 0.1 x 0.1 x 0.1 mm voxel size. Image analysis was conducted using Microview (GE Healthcare) by manually contouring of the tumor in selected slices and then linearly extrapolating across non-contoured slices. Results: The overall soft tissue contrast in the lower abdominal cavity was poor in the CBCT data set. There are cases where there is sufficient contrast between the bladder and the tumor, and between the tumor and selected segments of the intestinal tract. Nonetheless, it was challenging in most cases to confidently delineate the tumor margins using the CBCT images alone. Side-by-side consultation with the MR images during contouring allowed for the tumors to be more confidently delineated on the CBCT images (without co-registration with the MR data set) with a volumetric accuracy of 92.4 ± 12.3% (7 distinct tumors with volumes ranging from 181 to 1399 mm3) relative to the volumes contoured using the MR data set alone. Conclusion: Precise and accurate delivery of radiation to preclinical animal models must be supplemented by imaging techniques that allow for visualization and delineation of the disease volume in the treatment position. MR images acquired with the animal on a transportable multimodality imaging and treatment bed facilitated the delineation of volumetrically accurate treatment regions using a CBCT-equipped small animal irradiator. Acknowledgements: The authors would like to thank Coackley C, Zafarana G and Bristow RG for providing the prostate mouse models, and Chaudary N and McKee T for providing the cervical mouse model. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 4060. doi:1538-7445.AM2012-4060

Computer-assisted orthognathic surgery: feasibility study using multiple CAD/CAM surgical splints

We present a virtual planning protocol incorporating a patented 3-surgical splint technique for orthognathic surgery. The purpose of this investigation was to demonstrate the feasibility and validity of the method in vivo. The protocol consisted of (1) computed tomography (CT) or cone-beam computed tomography (CBCT) maxillofacial imaging, optical scan of articulated dental study models, segmentation, and fusion; (2) diagnosis and virtual treatment planning; (3) computed-assisted design and manufacture (CAD/CAM) of the surgical splints; and (4) intraoperative surgical transfer. Validation of the accuracy of the technique was investigated by applying the protocol to 8 adult class III patients treated with bimaxillary osteotomies. The virtual plan was compared with the postoperative surgical result using image fusion of CT/CBCT dataset by analysis of measurements between hard and soft tissue landmarks relative to reference planes. The virtual planning approach showed clinically acceptable precision for the position of the maxilla (<0.23 mm) and condyle (<0.19 mm), marginal precision for the mandible (<0.33 mm), and low precision for the soft tissue (<2.52 mm). Virtual diagnosis, planning, and use of a patented CAD/CAM surgical splint technique provides a reliable method that may offer an alternate approach to the use of arbitrary splints and 2-dimensional planning.

Predictors of caregiver distress among palliative home care clients in Ontario: Evidence based on the interRAI Palliative Care

This study examines predictors of caregiver distress among community-based palliative care clients. Analyses are based upon interRAI Palliative Care (interRAI PC) assessment data from palliative home care programs in three regions in Ontario, Canada. The study sample involved all community-based palliative care clients in Ontario who were assessed with the interRAI PC as part of normal clinical practice during pilot implementation of the instrument between 2007 and 2009 (N = 3,929). The assessments were performed by trained case managers and were used as the basis for determining service needs to be addressed through services contracted from provider agencies. The main study outcome of interest was the presence of one or more indicators of caregiver distress: helper(s) unable to continue caring activities; primary informal helper expresses feelings of distress, anger, or depression; family or close friends report feeling overwhelmed by person's illness. Caregiver distress was evident among about 22% of palliative home care clients. Multivariate analyses identified included clinical instability (Changes in Health, End Stage disease, Signs and Symptoms [CHESS] scale), depressive symptoms, cognitive impairment, and positive outlook as significant client-level predictors. Significant caregiver characteristics included hours of informal care. Three service use/provider variables were significant predictors of caregiver distress: the specific home care agency, hospitalizations in the last 90 days, and nursing visits. Caregiver distress affects approximately one in five palliative care clients in the community. This may lead to a number of adverse outcomes for the caregiver and client. The experience of distress is affected by client, caregiver, and agency characteristics that are readily identified by the interRAI PC assessment instrument. The present results point to the need for a care planning protocol that may be used on a targeted basis for clients experiencing or at elevated risk of caregiver distress.

Multi Parametric Voice Assessment: Sri Ramachandra University Protocol

Emergence of "Voice specialty clinics" in ENT and Speech Language Pathologist (SLP) practice in India necessitates development of standard protocols for assessment and management of voice disorders. Based on recommendations from European Laryngological Society in Dejonckere (Eur Arch Otorhinolaryngol 258:77-82, 2001), a comprehensive voice assessment protocol was adapted for Indian population. This study aimed at verifying the face validity and feasibility of using the developed voice assessment protocol in a multi specialty tertiary care hospital. It included: history, clinical examination, visual analysis, perceptual analysis, aerodynamic measures, acoustic analysis and patients' self assessment of voice. The developed protocol was administered on 200 patients with voice concerns and problems. Correlation of self assessment with the assessment by the professionals was done using Kendaul tau_b correlation test. The scores of self assessment did not correlate significantly with acoustic measures. Differences in lab findings and self percept of voice indicated that these two were complementary measures in the protocol. Further, diagnosis and management decisions were arrived through a consensus discussion involving the ENT surgeon, SLP and the patient. Vocal hygiene and voice conservation were advised to all patients. Recommendations for voice therapy and/or surgery were provided based on findings from the protocol. The study demonstrated feasibility of using a comprehensive protocol for effective documentation, comparisons, review, training and treatment planning.

Urban mass transit, gender planning protocols and social sustainability – The case of Jakarta

The discussion within a number of Global South cities is increasingly focused on the planning and implementation of large-scale urban mass transport systems. There is, however, a significant challenge of delivering such large investments in a manner to produce equity in the benefits across different urban spaces and across different social groupings. The transaction costs of urban survival and its associated urban mobility and their differences across gender and other social groups may work against the hypothesised distribution of benefits predicted from traditional individualistic, utility-maximising rational choice planning models. This may affect the social sustainability of such large-scale investments. There is a need for new methods and protocols in transport planning and management to ensure that such transport systems promote social sustainability. The mainstreaming of gender into the planning, financing, implementation, operation and management of such large-scale urban transport systems is a fundamental component for tackling the challenges facing the delivery of social sustainability. This paper will look at a case study of the Jabotabek Suburban Rail and Bus Rapid Transit systems in Jakarta as examples of large-scale mass transit investment. It will draw on survey research that highlights the gender differences in the use of this large urban transport system, gender differences in how the system interacts with geographies of opportunities and daily travel patterns, gender differences in the impact of the systems operation on passenger safety and security. It will highlight the need for new gender and user group protocols in the planning, implementation and management of urban mass-transit systems. It will provide some concrete examples of what measures would arise from such new planning protocols.

Current clinical coverage of Radiation Therapy Oncology Group-defined target volumes for postmastectomy radiation therapy

PurposeThe Radiation Therapy Oncology Group (RTOG) has published consensus guidelines for contouring relevant anatomy for postmastectomy radiation therapy (RT). How these contours relate to current treatment practices is unknown. We analyzed the dose-volume histograms (DVHs) for these contours using current clinical practice at University of Texas MD Anderson Cancer Center and compared them with the proposed treatment plans to treat RTOG-defined targets to full dose. Methods and MaterialsWe retrospectively analyzed treatment plans for 20 consecutive women treated with postmastectomy RT for which the treatment targets were the chest wall (CW), level III axilla (Ax3), supraclavicular (SCV), and internal mammary (IM) nodes. The RTOG consensus definitions were used to contour the following anatomic structures: CW; level I, II, and III axillary nodes (Ax1, Ax2, Ax3); SCV; IM; and heart (H). DVHs for these contours and the ipsilateral lung were generated from clinically designed treatment that had actually been delivered to each patient. For comparison regarding dose to normal tissue, new treatment plans were generated with the goal of covering 95% of the anatomic contours to 45 Gy. ResultsThe prescribed dose was 50 Gy in each case. The mean percent of volumes that received 45 Gy (V45) for the RTOG guideline-based contours were CW 74%, Ax1 84%, Ax2 88%, Ax3 96%, SCV 84%, and IM 80%. Mean heart V10 values were 11% for treatment of left-sided tumors and 6% for right-sided tumors. Mean ipsilateral lung V20 values were 28% for left-sided tumors and 34% for right-sided tumors. For the contour-based plans, mean V45 values were CW 94%, Ax1 95%, Ax2 97%, Ax3 98%, SCV 98%, and IM 85%. Mean heart V10 values were 14% for treatment of left-sided tumors and 12% for right-sided tumors. Mean ipsilateral lung V20 values were 32% for left-sided tumors and 45% for right-sided tumors. ConclusionsClinically derived treatment plans, which have proven efficacy and are the current standard, cover 74% to 96% of the anatomy-based RTOG consensus volumes to the prescription dose. This discrepancy should be considered if treatment planning protocol guidelines are designed to incorporate these new definitions.

Detailed dosimetric evaluation of intensity-modulated radiation therapy plans created for stage C prostate cancer based on a planning protocol

Intensity-modulated radiation therapy (IMRT) has been employed as a precision radiation therapy with higher conformity to the target. Although clinical outcomes have been reported for many investigations, detailed treatment planning results have not been mentioned to date. The aim of this study was to evaluate the dose specifications of our IMRT treatment plans for locally advanced prostate cancer. Seventy-seven clinically applied IMRT plans treated between September 2003 and December 2005, in which patients were irradiated with 78 Gy in the prone position, were retrospectively analyzed. Dosimetric data output from dose volume histograms were evaluated in detail. The mean dose ± standard deviation, homogeneity index, and conformity index to the planning target volume (PTV) were 78.3 ± 0.7 Gy (100.4 ± 0.9%), 13.7 ± 3.0, and 0.83 ± 0.04, respectively. For the clinical target volume, the mean dose was 80.3 ± 0.7 Gy (102.9 ± 0.9%).The V40, V60, and V70 Gy of the rectal wall were 58.3 ± 2.8, 29.6 ± 2.7, and 15.2 ± 3.0%, respectively. Planning difficulties were encountered in patients whose bowels were displaced downward, as constraints imposed by the bowel position altered the dose index of the PTV. In many cases, additional bowel optimization parameters were required to satisfy constraints for organs at risk. However, major deviation could be avoided by inverse planning with computer optimization. IMRT allowed the creation of acceptable and practical treatment plans for locally advanced prostate cancer. Reports regarding detailed dosimetric evaluations are mandatory for interpreting clinical outcomes in the future.

Evaluation of flexible and rigid (class solution) radiation therapy conformal prostate planning protocols

Protocols commonly implemented in radiotherapy work areas may be classified as being either rigid (class solution) or flexible. Because formal evaluation of these protocol types has not occurred within the literature, we evaluated the efficiency of a rigid compared with flexible prostate planning protocol by assessing a series of completed 3D conformal prostate plans. Twenty prostate cancer patients with an average age of 70 years (range, 52–77) and sizes comprising 8 small, 10 medium, and 2 large were planned on the Phillips Pinnacle treatment planning system 6 times by radiation therapists with <2 years, 2–5 years, and >5 years of experience using a rigid and flexible protocol. Plans were critiqued using critical organ doses, confirmation numbers, and conformity index. Plans were then classified as being acceptable or not. Plans produced with the flexible protocol were 53% less likely to require modification (OR 0.47, 95% CI: 0.26, 0.84, p = 0.01). Planners with >5 years of experience were 78% more likely to produce plans requiring modification (OR 1.78, 95% CI: 1.12, 2.83, P = 0.02). Plans according to the flexible protocol took longer (112 min) compared with the time taken using a rigid protocol (68 min) (p < 0.001). The results suggest that further studies are needed; however, we propose that all radiation therapy planners should start with the same limitations, and if an acceptable plan is not reached, then flexibility should be given to improve the plan to meet the desired results.

Integrating conservation, restoration and land-use planning in islands—An illustrative case study in Réunion Island (Western Indian Ocean)

This paper describes an operational protocol for integrating conservation and restoration with land-use planning in islands. Conservation challenges are intensified in insular systems due to higher ecosystem vulnerability, limited spatial options, low data availability, rapid land-use change and, globally, short-term vision planning. Our operational planning protocol integrates ecological and socio-economic factors to identify the best spatial options for conserving and restoring biodiversity, inside and outside extant reserves, while minimising future land-use conflicts. Conservation and restoration targets are formulated for species, habitats and ecological processes that support biodiversity. An optimal network of priority sites is selected to achieve those targets across the landscape. The prioritisation process integrates a Conservation Costs Index to optimise conservation and restoration investments. We discuss the outcomes of the planning protocol in terms of site prioritisation, stakeholders’ participation and general implications for spatial planning in insular systems. As with many islands, the study area of Réunion Island has experienced rapid urban and agricultural expansion, which threatens its unique biodiversity. Forty three per cent of the island is currently protected in a National Park but only half of this reserve network contributes to the achievement of targets. An additional 21% of land should be conserved mainly to ensure the persistence of ecological connections between the marine, terrestrial and freshwater realms. Finally we emphasize that our method doesn’t substitute the land-use planning debate but is aimed to better prepare the conservation sector for negotiating future land-use allocation with other socio-economic sectors in islands.

Avaliação de risco dos organismos geneticamente modificados

Since the commercial approve in 1996, the global area of transgenic crops has raised more than 50 times. In the last two decades, governments have been planning strategies and protocols for safety assessment of food and feed genetically modified (GM). Evaluation of food safety should be taken on a case-by-case analysis depending on the specific traits of the modified crops and the changes introduced by the genetic modification, using for this the concept of substantial equivalence. This work presents approaches for the risk assessment of GM food, as well as some problems related with the genetic construction or even with the expression of the inserted gene.

Preoperative Medical and Surgical Planning for Early Onset Scoliosis

A review of current medical and surgical preoperative planning knowledge and protocols for children with early-onset scoliosis (EOS; onset less than 5 years of age). To describe the preoperative planning process to undertake safe and effective treatment for the EOS patient. Children with EOS present with a myriad of medical and orthopedic conditions associated with their specific diagnosis, and frequently require intensive preoperative evaluation and nutritional, pulmonary, and other support to prepare them for safe and effective treatment of the spinal/chest wall deformity. Such patients are among the most difficult and complex to treat effectively. A literature review of known conditions associated with EOS, and a summary of current surgical techniques to maintain deformity control while promoting spine and thoracic growth, was undertaken. Current recommendations for preoperative support and postoperative management of these complex patients are summarized, drawn from the experiences of the author and members of study groups focusing on EOS. Preoperative assessment of respiratory function, potential for respiratory failure, and determination of objective criteria to indicate surgical management (deformity progression, lack of growth of spine and/or thoracic volume, lack of weight gain) are weighed against the potential for development of thoracic insufficiency syndrome. Magnetic resonance imaging evaluation for neuraxis abnormalities is considered on the basis of diagnosis. Nutritional status, osteopenia, and airway management are evaluated to minimize postoperative complications. Current general recommendations for implants and constructs for specific deformities are reviewed. Thorough preoperative evaluation of EOS patients provides the surgeon with the knowledge to produce a sound surgical plan for this difficult and complex to treat patient population.

Successful Implementation of Image-Guided Radiation Therapy Quality Assurance in the Trans Tasman Radiation Oncology Group 08.01 PROFIT Study

The quality assurance (QA) of image-guided radiation therapy (IGRT) within clinical trials is in its infancy, but its importance will continue to grow as IGRT becomes the standard of care. The purpose of this study was to demonstrate the feasibility of IGRT QA as part of the credentialing process for a clinical trial. As part of the accreditation process for a randomized trial in prostate cancer hypofraction, IGRT benchmarking across multiple sites was incorporated. Each participating site underwent IGRT credentialing via a site visit. In all centers, intraprostatic fiducials were used. A real-time assessment of analysis of IGRT was performed using Varian's Offline Review image analysis package. Two-dimensional (2D) kV and MV electronic portal imaging prostate patient datasets were used, consisting of 39 treatment verification images for 2D/2D comparison with the digitally reconstructed radiograph derived from the planning scan. The influence of differing sites, image modality, and observer experience on IGRT was then assessed. Statistical analysis of the mean mismatch errors showed that IGRT analysis was performed uniformly regardless of institution, therapist seniority, or imaging modality across the three orthogonal planes. The IGRT component of clinical trials that include sophisticated planning and treatment protocols must undergo stringent QA. The IGRT technique of intraprostatic fiducials has been shown in the context of this trial to be undertaken in a uniform manner across Australia. Extending this concept to many sites with different equipment and IGRT experience will require a robust remote credentialing process.

A simple method for dose fusion from multimodality treatment of prostate cancer: Brachytherapy to external beam therapy

Purpose Suboptimal dosage evaluated from postimplant dosimetry of prostate brachytherapy creates conundrum that needs resolution. This pilot study was undertaken to explore the feasibility of summing and visualizing radiation dosage from multimodality treatment. Methods and Materials Four weeks after 125I permanent prostate seed implant, CT scans were performed on the whole pelvis of patients using our standard protocol for prostate planning. The acquired CT data sets were reconstructed using different sizes of field of view (FOV). The images with limited FOV focusing on prostate were imported into Variseed (Varian Medical Systems, Inc., Palo Alto, CA) for postimplant evaluation, whereas images with full FOV were imported to Eclipse (Varian Medical Systems, Inc., Palo Alto, CA) treatment planning system (TPS) for future managements, that is, for external beam salvage. Results The dose matrix resulted from the postimplant dosimetry was exported from Variseed in standard DICOM format and imported into Eclipse TPS. The brachytherapy dose matrix was registered with the patient images with full FOV in Eclipse TPS. Targets for dose boost were defined based on the isodose curves generated from brachytherapy. An external photon beam plan was successfully generated to deliver dose for selected underdose regions. Conclusion Accurate external beam radiation treatment planning can be accomplished using our planning protocols when inadequate brachytherapy dose delivery occurs. The proposed technique can be used to safely deliver additional external radiation dose using intensity-modulated radiation therapy technique after suboptimal brachytherapy procedure.

Acurácia na reprodutibilidade do posicionamento diário de pacientes submetidos a radioterapia conformada (RT3D) para câncer de próstata

OBJETIVO: Avaliar a reprodutibilidade do posicionamento de pacientes com diagnóstico de câncer de próstata submetidos a radioterapia conformada. MATERIAIS E MÉTODOS: Foram avaliados 960 (posições anterior e lateral) filmes radiológicos, de um total de 120 pacientes que receberam radioterapia conformada na próstata com técnica isocêntrica. As imagens foram obtidas em acelerador linear de partículas 6 MV. Aplicou-se protocolo específico para planejamento e tratamento da próstata, com o paciente em posição supina, mãos colocadas sobre o tórax, pés apoiados em suporte apropriado. Diariamente, os pacientes foram posicionados conforme demarcações na pele, coincidentes com os lasers da sala. Os filmes radiológicos foram comparados com as radiografias reconstruídas digitalmente (digitally reconstructed radiography - DRR) em sistema de planejamento computadorizado Eclipse, a partir das tomografias. As radiografias de posicionamento foram realizadas no primeiro dia e após, semanalmente, até o término do tratamento. RESULTADOS: As médias dos deslocamentos observados foram de 1,99 ± 1,25 mm no sentido crânio-caudal, 1,37 ± 0,84 mm no látero-lateral e 1,94 ± 1,10 mm no ântero-posterior. CONCLUSÃO: O uso de protocolos específicos para posicionamento dos pacientes é possível na prática clínica, possibilita reprodutibilidade adequada e rápida correção dos possíveis erros.