Response of the ArcCHECK® device at 6 MV and 15 MV for VMAT and IMRT quality control.

PURPOSE: To study the response of the ArcCHECK® device as VMAT and IMRT verification system. METHODS: Various tests analyzing the linearity, the repeatability and the angular dependence of the device response, its dependence with the pulse repetition rate and the leakage losses were performed. The long-term response in dose measurements and the uniformity of the detectors conforming the system were controlled using a statistical process control program. The Elekta Infinity™ 6 and 15MV photon beams were used. RESULTS: The device showed excellent repeatability and linearity. The differences between the responses obtained for any pair of angular incidences were less than 2%. The absorbed dose increased by 3% when the pulse repetition rate varied from 50 to 600MU/min. Results are in overall agreement with those found in previous works for the ArcCHECK®, in which a reduced number of the device diodes were analyzed, and for the MapCheck®, an older 2D device that used the same diodes. Charge losses were found to be negligible except for some of the diodes of the device. The statistical process control program is a very useful tool to control the correct functioning of the device in the long term. CONCLUSIONS: The results of the analysis carried out indicate that the working and stability conditions of the ArcCHECK® device are adequate for its purpose. The dependence with the pulse repetition rate should be considered when VMAT or similar treatments are evaluated. A control program for the statistical monitoring of the device would be desirable and useful.

Identification of factors associated with diagnostic error in primary care.

BACKGROUND: Missed, delayed or incorrect diagnoses are considered to be diagnostic errors. The aim of this paper is to describe the methodology of a study to analyse cognitive aspects of the process by which primary care (PC) physicians diagnose dyspnoea. It examines the possible links between the use of heuristics, suboptimal cognitive acts and diagnostic errors, using Reason's taxonomy of human error (slips, lapses, mistakes and violations). The influence of situational factors (professional experience, perceived overwork and fatigue) is also analysed. METHODS: Cohort study of new episodes of dyspnoea in patients receiving care from family physicians and residents at PC centres in Granada (Spain). With an initial expected diagnostic error rate of 20%, and a sampling error of 3%, 384 episodes of dyspnoea are calculated to be required. In addition to filling out the electronic medical record of the patients attended, each physician fills out 2 specially designed questionnaires about the diagnostic process performed in each case of dyspnoea. The first questionnaire includes questions on the physician's initial diagnostic impression, the 3 most likely diagnoses (in order of likelihood), and the diagnosis reached after the initial medical history and physical examination. It also includes items on the physicians' perceived overwork and fatigue during patient care. The second questionnaire records the confirmed diagnosis once it is reached. The complete diagnostic process is peer-reviewed to identify and classify the diagnostic errors. The possible use of heuristics of representativeness, availability, and anchoring and adjustment in each diagnostic process is also analysed. Each audit is reviewed with the physician responsible for the diagnostic process. Finally, logistic regression models are used to determine if there are differences in the diagnostic error variables based on the heuristics identified. DISCUSSION: This work sets out a new approach to studying the diagnostic decision-making process in PC, taking advantage of new technologies which allow immediate recording of the decision-making process.

Violencia de género. Hacer visible la vergüenza / Violence against women. Make the shame visible

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