Specific Treatment Plan Research Articles

Integrating the fourth dimension into orthodontic administration

Dear Dr Jerrold: When is the proper time to review and sign the informed consent form? In my practice, we use the form that came with our practice management software. This is then supplemented by an additional informed consent form that addresses specific concerns once we have reviewed the diagnostic records and arrived at a specific treatment plan. We do this at the separation visit, which is about a week before our appliance insertion visit. I have received legal advice to have the patients sign the informed consent form at the first visit before doing anything, including taking records. This seems a bit premature because the particulars of the case have not been determined. What is your opinion on this? Thanks. J. G. The short answer to our reader’s question is that an informed consent document should be signed at any time before the treatment plan is actually decided upon and certainly before any treatment is rendered. But what is treatment? Let’s step back a moment and look at this from the beginning. The patient’s mother, Ms Iwork Allday calls to make an initial screening appointment for her daughter, Needsome Retraction Allday. She is given an appointment, but, alas, it is during her hours of employment, so grandma, Ms Bornwith Straightteeth, brings our little model-to-be in for the examination. You perform an initial screening that consists of whatever you want it to consist of in terms of records and determine whatever it is you determine regarding starting now or waiting and, if applicable, the appliance du jour that you are recommending. Bornwith says that she will discuss what you told her with Iwork, and one of them will get back to you. Relative to informed consent, the first thing one must realize is that there is a difference between consent and informed consent. To put it into simple terms, consent is a threshold issue; before you can obtain a patient’s informed consent to render any form

A cluster analysis of people on Community Treatment Orders in Victoria, Australia

This paper explores the clinical, social and demographic characteristics of 164 people on Community Treatment Orders (CTOs) in one area mental health service in Victoria, Australia. The results of an exploratory cluster analysis are presented to address the question of whether people on Community Treatment Orders can be categorised into statistically reliable, qualitatively distinct groupings. The data are presented in the context of key stakeholder perspectives on the current use and purpose of CTOs. Three stable clusters emerged and each potentially reflects how social dimensions, as well as clinical issues, influence decision making regarding the implementation of CTOs. These findings are important in the context of policy and practice in Victoria, where the use of CTOs is common practice, and orders are generally made for a 12 month period. The potential for improved targeting of CTOs and more specific treatment planning is identified.

Medical audit on asthma in an emergency department

Background To determine the management of acute bronchial asthma in an adult emergency department. Methods A retrospective medical audit of 46 consecutive adult patients with acute asthma exacerbations was performed. We collected information from 48 episodes of acute asthma over a 5-month period. Using classical audit methodology, four indicators were examined: severity evaluation, diagnostic tests, specific treatment, and discharge treatment plans. Results The least recorded severity indicators were respiratory rate (27 %), heart rate (50 %) and peak expiratory flow (20 %). Heart and respiratory auscultation were recorded in all patients and oxygen saturation was recorded in 93 %. Laboratory blood test and chest radiograph were performed in all patients. Arterial blood gas was tested in 57 %, electrocardiography in 17 %, and coagulation in 39%. No treatment was provided in 12% of patients. Bronchodilator medications were administered in all treated patients and oxygen was prescribed in 60 %. Systemic corticosteroids (methylprednisolone or hydrocortisone) were administered in 80 % of treated patients. Seventeen percent of patients were discharged from hospital with no change to their usual treatment. Conclusions The following weak points were identified: 1) Severity assessment is inadequate, 2) use of diagnostic tests is excessive, 3) patients discharged to home with no treatment plan. Opportunities for improvement consisted of: 1) greater availability of peak expiratory flow meters, 2) individualized use of diagnostic tests, and 3) management protocols.

Quality assurance for radiotherapy in prostate cancer: Point dose measurements in intensity modulated fields with large dose gradients

Purpose: We aimed to evaluate an optimization algorithm designed to find the most favorable points to position an ionization chamber (IC) for quality assurance dose measurements of patients treated for prostate cancer with intensity-modulated radiotherapy (IMRT) and fields up to 10 cm × 10 cm. Methods and Materials: Three cylindrical ICs (PTW, Freiburg, Germany) were used with volumes of 0.6 cc, 0.125 cc, and 0.015 cc. Dose measurements were made in a plastic phantom (PMMA) at 287 optimized points. An algorithm was designed to search for points with the lowest dose gradient. Measurements were made also at 39 nonoptimized points. Results were normalized to a reference homogeneous field introducing a dose ratio factor, which allowed us to compare measured vs. calculated values as percentile dose ratio factor deviations ΔF (%). A tolerance range of ΔF (%) of ±3% was considered. Results: Half of the ΔF (%) values obtained at nonoptimized points were outside the acceptable range. Values at optimized points were widely spread for the largest IC (i.e., 60% of the results outside the tolerance range), whereas for the two small-volume ICs, only 14.6% of the results were outside the tolerance interval. No differences were observed when comparing the two small ICs. Conclusions: The presented optimization algorithm is a useful tool to determine the best IC in-field position for optimal dose measurement conditions. A good agreement between calculated and measured doses can be obtained by positioning small volume chambers at carefully selected points in the field. Large chambers may be unreliable even in optimized points for IMRT fields ≤10 cm × 10 cm.

A paradigm for the systemic treatment of plaque psoriasis

AbstractClinical guidelines are prominent in the medical practice. Many practice guidelines have recently been published for the treatment of plaque psoriasis. Although they provide useful information on how the different treatments should be applied, unfortunately, most of them do not give instructions on the sequence in which these treatments should be prescribed. In the light of recent publications proposing algorithms and the clinician's paradigm in the treatment of psoriasis, three key questions are discussed in this paper: How do we evaluate the severity of psoriasis? Which treatment should be given in order of preference? And how do we make the therapeutic decision? It is generally agreed that each patient requires an individualized treatment plan and that the decision to undertake systemic treatment and the choice of the specific treatment plan must ultimately and mutually be made by both the patient and the physician.

TH‐B‐224A‐01: QA for Linacs and MLC Used for IMRT

Intensity‐modulated radiotherapy (IMRT) has become a part of our routine treatment for external beam radiotherapy. Most quality assurance procedures set for linear accelerators and multi‐leaf collimators (MLC) have been designed for conventional external beam radiotherapy. With IMRT, radiation portals are often irregular, small, off‐center, and abutting in the middle of the target volumes, which require specific IMRT QA for the linear accelerators and MLCs. Some of the QA issues are related to the specific IMRT delivery method, and the specific treatment planning system. This review course will discuss (1) the characteristics of three major MLC collimators and the specific QA related to the unique MLC design; (2) additional QA for linear accelerators pertinent to the small MU and small field sizes used in IMRT; (3) tools often used to perform these QA tasks; (4) specific QA issues for different IMRT delivery methods, step and shoot vs sliding window.Educational Objectives:1. Understand the characteristics of three major MLC systems.2. Understand different IMRT delivery methods and their specific QA issues.3. Understand effect of QA on the IMRT delivery accuracy.

TH‐E‐224C‐04: MMCTP, a Radiotherapy Research Environment for Monte Carlo and Patient‐Specific Treatment Planning

Purpose: To develop a flexible software package, on low cost hardware with the aim of integrating new patient specific treatment planning with Monte Carlo dose calculation suitable for large‐scale prospective and retrospective treatment planning studies.Programming Philosophy: The McGill Monte Carlo Treatment Planning system (MMCTP) is designed as a software environment for the research development of patient specific treatment planning. The design includes a workstation GUI for treatment planning tools, and anonymous access to standard low cost hardware for MC dose calculation. Results: Before using MMCTP, treatment plans are converted into the so‐called McGill RT format. This new file structure was designed for saving patient plans on the workstation. The current MMCTP features are: (a) DICOM and RTOG imports; (b) transverse/sagittal/coronal slice viewing for contours, CT scans, dose distributions; (c) contouring tools; (d) colour‐wash and isodose line display; (e) DVH analysis, and dose matrix comparison tools; (f) external beam editing; (g) thumbnail CT navigation tool; (h) EGS/Beam calculation and XVMC patient transport for photon and electron beams. MMCTP uses a two‐step process to generate MC dose distributions. The MC module controls egs/Beam and XVMC calculations. Input files, prepared from the beam geometry, are uploaded and run on the cluster using shell commands. Upon completion of XVMC, the GUI downloads individual dose files. Conclusion: The MMCTP GUI provides a flexible research platform for the development of patient specific MC treatment planning for photon and electron external beam radiation therapy. MMCTP uses an internal storage format that is flexible in that it allows for multi‐instance multi‐modality image information useful in the planning process. The visualization, dose matrix operation and DVH tools offer extensive possibility for plan analysis and comparison to plans imported from commercial treatment planning systems through well‐documented image storage protocols such as DICOM.

Clinicopathologic Comparison of Siewert Type II and III Adenocarcinomas of the Gastroesophageal Junction

Since Misumi et al. and Siewert proposed a new classification for carcinoma of the gastroesophageal junction (GEJ), few surgical studies using these criteria have been reported from Eastern countries. Siewert type II adenocarcinomas are managed using general rules for either gastric or esophageal cancer. We set out to determine whether type II adenocarcinoma is a distinct clinical entity requiring a more specific treatment plan. Among 125 Japanese patients who underwent resection of adenocarcinoma of the GEJ (type I, 2; type II, 44; type III, 79), 101 who underwent R0 resections (type II, 40; type III, 61) were analyzed to evaluate surgical results and compare clinicopathologic factors. Barrett's epithelium was recognized in two patients with type II adenocarcinoma. Type II differed significantly from type III in higher prevalence of Borrmann macroscopic type 2, more frequent lymph node metastasis (58% vs. 34%), higher metastatic rate to lower mediastinal lymph nodes (13%), increased risk of hepatic recurrence, and lower 5-year survival after R0 resection (67.4% vs. 87.1%). Clinicopathologic differences were evident between type II and III adenocarcinomas. Siewert type II adenocarcinoma differs sufficiently to be considered a clinical entity distinct and independent from type III.

Protracted remission of metastatic epithelioid angiosarcoma with weekly infusion of doxorubicin, paclitaxel, and cisplatin

Poorly differentiated neoplasms present diagnostic challenges to the pathologist, the classification of which might have substantial effect on treatment choice and patient outcome. For the patient we present here, a decision to obtain additional tissue for assessment led to a new perspective in the differential diagnosis and a specific treatment plan associated with protracted complete remission.

Integrative Review of Research Related to Meditation, Spirituality, and the Elderly

Recently, increased attention has been given to meditation-relaxation strategies to improve physical health, reduce pain, enhance immune response, improve emotional well-being, and foster spiritual growth. This article reviews research conducted in the last 25 years about meditation and spirituality, in particular as it relates to the health of the elderly. This review supports the hypothesis that meditation can be taught to the elderly, even those with dementia. The results also support the hypothesis that meditation and spiritual practices could promote significant social and emotional benefits for those in social isolation. Specific treatment plan interventions for nursing homes are discussed. Future research should investigate the effectiveness of various types of meditative and spiritual practices to nursing home residents.

Ann

Aaron Beck’s cognitive therapy model has been used repeatedly to treat depression and anxiety. The case presented here is a 34-year-old female law student with an adjustment disorder with mixed anxiety and depressed mood. It is presented to illustrate a successful treatment outcome using cognitive interventions. Sessions by session summaries are offered to further demonstrate the specific treatment plan implemented and to serve as a learning tool for clinicians and students.

A Review of Myofascial Pain and Fibromyalgia – Factors that Promote Their Persistence

Chronic muscle pain (myalgia) is a common problem throughout the world. Seemingly simple, it is actually a difficult problem for the clinician interested in determining the aetiology of the pain, as well as in managing the pain. The two common muscle pain conditions are fibromyalgia and myofascial pain syndrome. Fibromyalgia is a chronic, widespread muscle tenderness syndrome, associated with central sensitisation. It is often accompanied by chronic sleep disturbance and fatigue, visceral pain syndromes like irritable bowel syndrome and interstitial cystitis. Myofascial pain syndrome is an overuse or muscle stress syndrome characterised by the presence of trigger points in muscle. The problem these syndromes pose lies not in making the diagnosis of muscle pain. Rather, it is the need to identify the underlying cause(s) of persistent or chronic muscle pain in order to develop a specific treatment plan. Chronic myalgia may not improve until the underlying precipitating or perpetuating factor(s) are themselves managed. Precipitating or perpetuating causes of chronic myalgia include structural or mechanical causes like scoliosis, localised joint hypomobility, or generalised or local joint laxity; and metabolic factors like depleted tissue iron stores, hypothyroidism or Vitamin D deficiency. Sometimes, correction of an underlying cause of myalgia is all that is needed to resolve the condition.

Kardiologische Notfälle im Kindesalter

There are relatively few situations where cardiac emergencies can occur in a child. A special focus is directed to the cyanotic newborn. In these cases a very specific treatment plan is necessary which is limited to a few dedicated centres. The importance lies in the timely diagnosis of a cyanotic heart defect and the rapid and safe transport from the referring hospital. An outline is given on the causes and treatment of congestive heart failure in infancy. Management guidelines are given for the most frequent types of cardiac arrhythmias and the few occasions, where an arrhythmia can lead to a real emergency, mostly in infants. To complete the list of the most frequent cardiac emergencies in pediatrics, pericardial effusion/tamponade is mentioned as well as the occurrence of cyanotic spells typically in the baby with Fallot's tetralogy.

Addiction Counseling Self-Efficacy Scale (ACSES): development and initial validation

This article reports on the development of the Addiction Counseling Self-Efficacy Scale (ACSES) through two studies. Exploratory factor analysis yielded a five-factor solution that accounted for 65% of the variance. The five factors obtained assess various aspects of addiction counselors' perceived self-efficacy for working with clients in the areas of (a) specific addiction counseling skills, (b) assessment, treatment planning, and referral skills, (c) co-occurring disorders skills, (c) group counseling skills, and (d) basic counseling skills. Reliability estimates suggest that the ACSES is internally reliable. Initial criterion validity is supported through comparisons of certified/licensed and noncertified/licensed addiction counselors on ACSES scores and among level of expertise in the addiction field, specific work activities, and ACSES scores. Preliminary evidence indicates that the ACSES is a reliable and valid instrument to use when assessing addiction counselors' self-efficacy for working with clients. The next steps in the development of ACSES are also discussed.

Gene expression signatures of conventional prognostic factors in multiple myeloma

6606 Background: Recent advances in Multiple Myeloma have led to identification of novel therapeutic targets and new agents highlighting the need for patient specific treatment plans. We have initiated molecular studies of MM plasma cells (PC) to correlate conventional prognostic factors with the genomic signature of MM PCs. Factors with high discriminatory value will allow clinicians to tailor therapy to the patient, decreasing toxicity and improving outcome. Methods: Gene expression profiling was performed on CD138 sorted PCs from 14 pts with newly diagnosed MM using the Affymetrix U133A platform. The data was analyzed using dChip software (V1.3). Results: We have identified differentially expressed genes with biological relevance that correlates with the important prognostic factors; plasma cell labeling index (PCLI), circulating PCs, LDH and β2 microglobulin. High PCLI was associated with upregulation of growth and proliferation related genes (IGFBP-7, WHSC1 [mapped to 4p16 and correlated with t(4;14)], TIMP1 [related with STAT3 phosphorylation] and down regulation of wnt5a, CD79a (MB1, member of Ig superfamily gene), NEDD9 (associated with β1 integrin signaling), BCR1 (B cell receptor signaling) and Lysosomal associated multispanning membrane protein 5 (described in MM progression). Increased number of circulating PCs was associated with modulation of adhesion-related and migration associated genes such as CD86, metastasis associated protein S100A4, galectin-1 (associated with β1 integrin), hsp27, glucosamine-6-sulfatase, NCAM1, and cyclin D1, among others. Similar analyses performed grouping patients according to LDH, β2 microglobulin also revealed differentially expressed genes that may have correlative significance.Conclusions: Identification of differentially expressed genes that correlates with MM-related prognostic factors can help understand the biological basis for these factors. Additionally, identification of non-overlapping discriminatory genes for individual prognostic factors can lead to development of focused arrays that can be used clinically for prognostication. Ongoing studies with additional patients as well as in vitro studies are underway to validate these results. No significant financial relationships to disclose.

SU-FF-T-401: Development of Specific Treatment Plan Based On Physical Lattice Structure for Stereotactic Radiosurgery

Purpose: The stereotactic radiosurgery (SRS) describes a method of delivering a high dose of radiation to a small target volume in the brain, generally in a single fraction, while the dose delivered to the surrounding normal tissue should be minimized. To perform automatic plan of the SRS, a new method of multi-isocenter/shot linear accelerator (linac) and gamma knife (GK) radiosurgery treatment plan was developed, based on a physical lattice structure in target. Method and Materials: The optimal radiosurgical plan had constructed by many beam parameters in a linear accelerator or gamma knife-based radiation therapy. In this work, one isocenter/shot was modeled as a sphere, which is equal to the circular collimator/helmet hole size because the dimension of the 50% isodose level in the dose profile is similar to its size. In computer-aided system, it accomplished first an automatic arrangement of multi-isocenter/shot considering two parameters such as positions and collimator/helmet sizes for each isocenter/shot. Simultaneously, an irregularly shaped target was approximated by cubic structures through computation of voxel units. The treatment planning method by the technique was evaluated as a dose distribution by dose volume histograms (DVHs), dose conformity, and dose homogeneity to targets. Results: For irregularly shaped targets, the new method performed the optimal multi-isocenter packing, and it only took a few seconds in computer-aided system. The targets were included in a more than 50% isodose curve. The dose conformity was ordinarily acceptable levels and the dose homogeneity was always less than 2.0, satisfying for various targets referred to Radiation Therapy Oncology Group (RTOG) SRS criteria. Conclusion: This approach using new method could be an efficient radiosurgical plan used two beam parameters both the irregularly shaped targets and different modality techniques such as linac and GK for SRS.

Wolf–Hirschhorn syndrome – two case‐study reports focusing particularly on long‐term survival

The clinical features of this rare chromosomal syndrome are described in two individuals. Our limited knowledge of the natural history of this disorder has made it difficult to counsel parents as well as outline specific treatment and management plans. Interviews were undertaken with subjects, carers and next of kin, and the literature was searched. Pertinent features of the syndrome are reported. These two cases highlight that long-term survival may occur and that accurate diagnosis is paramount so that healthcare professionals are able to provide accurate information.

Irradiation with standard tangential breast fields in patients treated with conservative surgery and sentinel node biopsy: using a three-dimensional tool to evaluate the first level coverage of the axillary nodes

Recent data show that axillary coverage can be obtained, but only through a selective CT-based treatment planning, as standard tangential fields are inadequate to deliver therapeutic doses. Currently, the replacement of axillary dissection with new techniques, such as sentinel node (SN) biopsy, makes it necessary to re-address the question about the real role of axillary irradiation, complicated by the differences in the anatomy of dissected and undissected axillary regions. The purpose of this paper is the dosimetric analysis of first axillary level coverage in standard irradiation of 15 breast-cancer patients treated with quadrantectomy and SN biopsy (negative finding). During surgery a clip on the site of the SN was positioned, marking the caudal margin of first axillary level. After the breast treatment plan was completed, the first axillary level was contoured on CT scans, from the site of the surgical clip up to the sternal manubrium, for coverage analysis with dose-volume histograms (DVHs) and three-dimensional isodose visualization. The maximum dose mean ranged from 5% to 80% of the prescribed dose (mean value 48.7%). The mean total dose received by the volume of interest was lower than 40 Gy in all but one patient. No patient had total irradiation of first nodal level; only one patient had 35% of the volume enclosed in the 100% isodose. Our analysis lead to the conclusion that therapeutic doses are not really delivered to first level axillary level nodes by a standard tangential field technique, and that specific treatment planning and beam arrangement are required when adequate coverage is necessary.

Bioinformatic tools for cancer geneticists

Early detection is essential for the control and prevention of many diseases, particularly cancer, which is the reason why the need for new disease markers with improved sensitivity and specificity continues to grow. Utilization of sophisticated bioinformatic tools enables the increased specificity and a relatively large quantity of high quality assays for any gene of interest. Understanding the molecular characteristics of diseases, such as cancer and the detection of mutations or changes in gene expression patterns that occur as a result of the disease, will bring researchers one step closer to achieving the predictive power needed for the development of new therapies, the design of clinical trials, and specific patient treatment planning. Genetic screening is one of the fastest moving areas of medical science, particularly in oncology, and as more genes are cloned, and more disease-associated mutations discovered, the workload is set to increase considerably with the utilization of bioinformatics tools used in integration and analysis of genomic, proteomic and metabolomic profiles of cancer. .

Anaphylactoid reactions to radiocontrast media

Adverse reactions to contrast material are a concern because iodinated contrast materials are commonly used drugs. The risk for adverse reaction is 4% to 12% with ionic contrast materials and 1% to 3% with nonionic contrast materials. The risk for severe adverse reaction is 0.16% with ionic contrast materials and 0.03% with nonionic contrast materials. The death rate, one to three per 100,000 contrast administrations, is similar for both ionic and nonionic agents. More than 90% of adverse reactions with nonionic contrast materials are anaphylactoid. The types of severe reactions seen with nonionic contrast administration were initially predominantly anaphylactoid. With the advent of helical CT angiography, the reactions are now predominantly attributable to cardiopulmonary decompensation. With the widespread use of nonionic contrast materials, adverse reactions are now seen less frequently. Skills involved in evaluating and treating adverse reactions are not as frequently used. Periodic reviews and updates of specific treatment plans for various reactions with the physicians and staff who use contrast material are very important to ensure optimal preparedness. The key to successful treatment is preparation and early intervention.