Background and purpose: Automatic approaches are widely implemented to automate dose optimization in radiotherapy treatment planning. This study systematically investigates how to configure automatic planning in order to create the best possible plans. Materials and methods: Automatic plans were generated using protocol based automatic iterative optimization. Starting from a simple automation protocol which consisted of the constraints for targets and organs at risk (OAR), the performance of the automatic approach was evaluated in terms of target coverage, OAR sparing, conformity, beam complexity, and plan quality. More complex protocols were systematically explored to improve the quality of the automatic plans. The protocols could be improved by adding a dose goal on the outer 2 mm of the PTV, by setting goals on strategically chosen subparts of OARs, by adding goals for conformity, and by limiting the leaf motion. For prostate plans, development of an automated post-optimization procedure was required to achieve precise control over the dose distribution. Automatic and manually optimized plans were compared for 20 head and neck (H&N), 20 prostate, and 20 rectum cancer patients. Results: Based on simple automation protocols, the automatic optimizer was not always able to generate adequate treatment plans. For the improved final configurations for the three sites, the dose was lower in automatic plans compared to the manual plans in 12 out of 13 considered OARs. In blind tests, the automatic plans were preferred in 80% of cases. Conclusions: With adequate, advanced, protocols the automatic planning approach is able to create high-quality treatment plans.
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This article presents a variety of treatment approaches based on an understanding of four components of communication, and describes cluttering intervention focusing on problem identification, speech rate reduction, appropriate pausing, appropriate monitoring, and addressing story narrating skills. Therapeutic considerations, taking into account the specific characteristics of cluttering, will also be presented. Finally, building clients’ confidence, emotional skills, and sense of accomplishment will turn the therapeutic process into awareness of realistic expectations and motivation to pursue challenging goals. Cluttering is a disorder of speech fluency in which people are not capable of adequately adjusting their speech rate to the syntactical or phonological demands of the moment (van Zaalen, 2009). When language production is relatively easy, people with cluttering (PWC) are capable of producing fluent and intelligible speech. When language production demands are more complex, the speech rate should be adjusted to the language complexity. PWC tend to have difficulties doing so. This reduced ability of PWC to control their speech rate results in either a higher than normal frequency of disfluencies or multiple speech errors. This article presents various intervention approaches based on an understanding of four components of communication: cognitive, emotional, verbal-motor, and communicative. The article focuses on problem identification, speech rate reduction, appropriate pausing, and addressing monitoring and story narrating skills. Therapeutic considerations, taking into account the specific characteristics of cluttering, will also be presented.
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Purpose/objective: Stereotactic radiosurgery of brain metastases requires highly conformal dose distributions. Besides beams setup, characteristics of the linear accelerator collimator may also play a role. In this study we compared the impact of leaf width on the dose outside the target for stereotactic radiosurgery of single brain metastases. Results: The mean dose was evaluated in the first 2 rings of 5 mm around the PTV(table 1). The difference in mean dose for the small lesions(Dpres=24 Gy) of the first ring of 5 mm is 1.8 Gy in favor of the Agility and 0.9 Gy for the larger lesions(Dpres=18 Gy)also in favor of the Agility. The difference is smaller for the larger lesions (figure1). Also for the second ring of 5 mm, adjacent to the first ring, the difference is is 1.1 Gy vs 0.8 Gy also in favor of the Agility. Conclusion: For the small lesions with a volume smaller than 4 cm³ the Agility shows a steeper gradient in the two surrounding rings than the MLCi1. Therefore we recommend the use of the Agility for treating the smaller lesions.
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When planning a study measuring the effects of a neurodevelopmental treatment (NDT), we were confronted with the methodological problem that while measuring the effects of NDT, a rival hypothesis is that the decision to implement the NDT might be related to the quality of nursing care. Therefore, we measured the quality of nursing care as a possible confounding variable in relation to this outcome study. The quality of nursing care was measured on 12 wards participating in the experimental and control groups of the outcome study. Data were collected from 125 patients and 71 nurses and patients' records. The findings showed no significant differences in the quality of nursing care between the 2 groups of wards (P = .49). This method may be useful to other researchers conducting outcome research and who are confronted with a similar methodological problem.
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During the past decades deinstitutionalisation policies have led to a transition from inpatient towards community mental health care. Many European countries implement Assertive Community Treatment (ACT) as an alternative for inpatient care for “difficult to reach” children and adolescents with severe mental illness. ACT is a well-organized low-threshold treatment modality; patients are actively approached in their own environment, and efforts are undertaken to strengthen the patient’s motivation for treatment. The assumption is that ACT may help to avoid psychiatric hospital admissions, enhance cost-effectiveness, stimulate social participation and support, and reduce stigma. ACT has been extensively investigated in adults with severe mental illness and various reviews support its effectiveness in this patient group. However, to date there is no review available regarding the effectiveness of youth-ACT. It is unknown whether youth-ACT is as effective as it is in adults. This review aims to assess the effects of youth-ACT on severity of psychiatric symptoms, general functioning, and psychiatric hospital admissions.
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Introduction: Although some adults with autism spectrum disorder (ASD) require intensive and specialized ASD treatment, there is little research on how these adults experience the recovery process. Recovery is defined as the significant improvement in general functioning compared to the situation prior to treatment. Methods: This qualitative study describes the recovery process from the perspective of adults on the autism spectrum during intensive inpatient treatment. Semi-structured interviews (n = 15) were carried out and analyzed according to the principles of grounded theory. Results: Our results indicate that, given the specific characteristics of autism, therapeutic interventions and goal-oriented work cannot be carried out successfully, and the recovery process cannot begin, if no good working relationship has been established, and if care is not organized in ways that a person on the autism spectrum finds clear and predictable.
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Background: Research into termination of long-term psychosocial treatment of mental disorders is scarce. Yearly 25% of people in Dutch mental health services receive long-term treatment. They account for many people, contacts, and costs. Although relevant in different health care systems, (dis)continuation is particularly problematic under universal health care coverage when secondary services lack a fixed (financially determined) endpoint. Substantial, unaccounted, differences in treatment duration exist between services. Understanding of underlying decisional processes may result in improved decision making, efficient allocation of scarce resources, and more personalized treatment.
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Background: Recent theoretical models emphasize the role of impulsive processes in alcohol addiction, which can be retrained with computerized Cognitive Bias Modification (CBM) training. In this study, the focus is on action tendencies that are activated relatively automatically. Objective: The aim of the study is to examine the effectiveness of online CBM Alcohol Avoidance Training using an adapted Approach-Avoidance Task as a supplement to treatment as usual (TAU) in an outpatient treatment setting. Methods: The effectiveness of 8 online sessions of CBM Alcohol Avoidance Training added to TAU is tested in a double-blind, randomized controlled trial with pre- and postassessments, plus follow-up assessments after 3 and 6 months. Participants are adult patients (age 18 years or over) currently following Web-based or face-to-face TAU to reduce or stop drinking. These patients are randomly assigned to a CBM Alcohol Avoidance or a placebo training. The primary outcome measure is a reduction in alcohol consumption. We hypothesize that TAU + CBM will result in up to a 13-percentage point incremental effect in the number of patients reaching the safe drinking guidelines compared to TAU + placebo CBM. Secondary outcome measures include an improvement in health status and a decrease in depression, anxiety, stress, and possible mediation by the change in approach bias. Finally, patients’ adherence, acceptability, and credibility will be examined. Results: The trial was funded in 2014 and is currently in the active participant recruitment phase (since May 2015). Enrolment will be completed in 2019. First results are expected to be submitted for publication in 2020. Conclusions: The main purpose of this study is to increase our knowledge about the added value of online Alcohol Avoidance Training as a supplement to TAU in an outpatient treatment setting. If the added effectiveness of the training is proven, the next step could be to incorporate the intervention into current treatment.
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Purpose/Objective: Most dose-escalation trials in glioblastoma patients integrate the escalated dose throughout the standard course by targeting a specific subvolume. We hypothesize that anatomical changes during irradiation may affect the dose coverage of this subvolume for both proton- and photon-based radiotherapy. Material and Methods: For 24 glioblastoma patients a photon- and proton-based dose escalation treatment plan (of 75 Gy/30 fr) was simulated on the dedicated radiotherapy planning MRI obtained before treatment. The escalated dose was planned to cover the resection cavity and/or contrast enhancing lesion on the T1w post-gadolinium MRI sequence. To analyze the effect of anatomical changes during treatment, we evaluated on an additional MRI that was obtained during treatment the changes of the dose distribution on this specific high dose region. Results: The median time between the planning MRI and additional MRI was 26 days (range 16–37 days). The median time between the planning MRI and start of radiotherapy was relatively short (7 days, range 3–11 days). In 3 patients (12.5%) changes were observed which resulted in a substantial deterioration of both the photon and proton treatment plans. All these patients underwent a subtotal resection, and a decrease in dose coverage of more than 5% and 10% was observed for the photon- and proton-based treatment plans, respectively. Conclusion: Our study showed that only for a limited number of patients anatomical changes during photon or proton based radiotherapy resulted in a potentially clinically relevant underdosage in the subvolume. Therefore, volume changes during treatment are unlikely to be responsible for the negative outcome of dose-escalation studies.
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Introduction: Gastroenteropancreatic neuroendocrine neoplasms (GEPNENs) are often diagnosed in an advanced stage. As the optimal sequence of therapy remains largely unclear, all treatment-related outcomes, including health-related quality of life (HRQoL) prospects, should be assessed according to patients' preferences. Methods: A targeted search was performed in PubMed and EMBASE to identify studies on treatment effect and HRQoL, measured using the EORTC QLQ-C30 tool, in patients with advanced, well-differentiated GEPNENs. Study quality was assessed, and meta-analyses were performed for global health status/QOL and tumour response. Results: The search yielded 1,322 records, and 20 studies were included, examining somatostatin analogues (SSA), peptide receptor radionuclide therapies (PRRT), chemotherapy, SSA-based combination therapies, and targeted therapies. Global HRQoL was stable, and rates for disease stabilisation were moderate to high across all treatments. Meta-analyses for global health status/QOL after SSA treatment were not significant (mean difference: –0.3 [95% CI: −1.3 to 0.7]). The highest pooled overall tumour response rate was 33% (95% CI: 24–45%) for PRRT. The highest pooled clinical benefit rate was 94% (95% CI: 65–99%) for chemotherapy. Conclusion: All treatments appeared beneficial for disease stabilisation while maintaining stable global health status/QOL. High-quality HRQoL reporting was lacking. HRQoL should be a central outcome next to well-established outcomes.
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