Treatment with Soteria-elements in acute psychiatry-Effectiveness for acutely ill and voluntarily treated patients.

Objective: This article aims at evaluating the treatment outcomes of acute psychiatric patients before and after the implementation of Soteria-elements in an acute psychiatric ward. The implementation process resulted in an interconnected small locked and much larger open area, enabling continuous milieu therapeutic treatment by the same staff in both areas. This approach enabled the comparison of structural and conceptual reconstruction regarding treatment outcomes of all voluntarily treated acutely ill patients before (2016) and after (2019). A subgroup analysis focused on patients suffering from schizophrenia. Methods: Using a pre-post design, the following parameters were examined: total treatment time, time in locked ward, time in open ward, antipsychotic discharge medication, re-admissions, discharge circumstances, and treatment continuation in day care clinic. Results: Compared to 2016, there was no significant difference in the total time of stay in the hospital. However, data show a significant decrease of days spent in locked ward, a significant increase of days in open ward, a significant increase of treatment discontinuation but without an increase of re-admissions, and a significant interaction of diagnosis and year regarding the medication dosage, resulting altogether in a reduction of antipsychotic medication for patients suffering from schizophrenia spectrum disorder. Conclusion: The implementation of Soteria-elements in an acute ward facilitates less potentially harmful treatments of psychotic patients, likewise enabling lower dosages of medication.

From Wish to Reality: Soteria in Regular Care-Proof of Effectiveness of the Implementation of Soteria Elements in Acute Psychiatry.

Objective: This article examines the influence of the implementation of Soteria elements on coercive measures in an acute psychiatric ward after reconstruction in 2017, thereby comparing the year 2016 to the year 2019. The special feature is that this is the only acute psychiatric ward in Hennigsdorf Hospital, connected now both spatially and therapeutically to an open ward and focusing on the treatment of patients suffering from schizophrenia and schizophrenia spectrum disorders. Methods: The following parameters were examined: aggressive assaults, use of coercion (mechanical restraints), duration of treatment in open or locked ward, type of discharge, coercive medication, and dosage of applied antipsychotics. For this purpose, the data of all legally accommodated patients in the year 2016 (before the reconstruction) and 2019 (after the reconstruction) were statistically analyzed in a pre-post mirror quasi-experimental design. Results: In 2019, the criteria of the Soteria Fidelity Scale for a ward with Soteria elements were reached. In comparison to 2016 with a comparable care situation and a comparable patient clientele, there was now a significant decrease in aggressive behavior toward staff and fellow patients, a significantly reduced number of fixations, a significantly reduced overall duration of inpatient stay, and a significant increase in treatment time in the open area of our acute ward. Conclusion: The establishment of Soteria elements in the acute psychiatric ward leads to a verifiable less violent environment of care for severely ill patients and to a drastic reduction in coercive measures.

Measurement-guided volumetric dose reconstruction for helical tomotherapy.

It was previously demonstrated that dose delivered by a conventional linear accelerator using IMRT or VMAT can be reconstructed - on patient or phantom datasets - using helical diode array measurements and a technique called planned dose perturbation (PDP). This allows meaningful and intuitive analysis of the agreement between the planned and delivered dose, including direct comparison of the dose-volume histograms. While conceptually similar to modulated arc techniques, helical tomotherapy introduces significant challenges to the PDP formalism, arising primarily from TomoTherapy delivery dynamics. The temporal characteristics of the delivery are of the same order or shorter than the dosimeter's update interval (50 ms). Additionally, the prevalence of often small and complex segments, particularly with the 1 cm Y jaw setting, lead to challenges related to detector spacing. Here, we present and test a novel method of tomotherapy-PDP (TPDP) designed to meet these challenges. One of the novel techniques introduced for TPDP is organization of the subbeams into larger subunits called sectors, which assures more robust synchronization of the measurement and delivery dynamics. Another important change is the optional application of a correction based on ion chamber (IC) measurements in the phantom. The TPDP method was validated by direct comparisons to the IC and an independent, biplanar diode array dosimeter previously evaluated for tomotherapy delivery quality assurance. Nineteen plans with varying complexity were analyzed for the 2.5 cm tomotherapy jaw setting and 18 for the 1 cm opening. The dose differences between the TPDP and IC were 1.0% ± 1.1% and 1.1% ± 1.1%, for 2.5 and 1.0 cm jaw plans, respectively. Gamma analysis agreement rates between TPDP and the independent array were: 99.1%± 1.8% (using 3% global normalization/3 mm criteria) and 93.4% ± 7.1% (using 2% global/2 mm) for the 2.5 cm jaw plans; for 1 cm plans, they were 95.2% ± 6.7% (3% G/3) and 83.8% ± 12% (2% G/2). We conclude that TPDP is capable of volumetric dose reconstruction with acceptable accuracy. However, the challenges of fast tomotherapy delivery dynamics make TPDP less precise than the IMRT/VMAT PDP version, particularly for the 1 cm jaw setting.

Motion as a perturbation: measurement-guided dose estimates to moving patient voxels during modulated arc deliveries.

PURPOSE: To present a framework for measurement-guided VMAT dose reconstruction to moving patient voxels from a known motion kernel and the static phantom data, and to validate this perturbation-based approach with the proof-of-principle experiments. METHODS: As described previously, the VMAT 3D dose to a static patient can be estimated by applying a phantom measurement-guided perturbation to the treatment planning system (TPS)-calculated dose grid. The fraction dose to any voxel in the presence of motion, assuming the motion kernel is known, can be derived in a similar fashion by applying a measurement-guided motion perturbation. The dose to the diodes in a helical phantom is recorded at 50 ms intervals and is transformed into a series of time-resolved high-density volumetric dose grids. A moving voxel is propagated through this 4D dose space and the fraction dose to that voxel in the phantom is accumulated. The ratio of this motion-perturbed, reconstructed dose to the TPS dose in the phantom serves as a perturbation factor, applied to the TPS fraction dose to the similarly situated voxel in the patient. This approach was validated by the ion chamber and film measurements on four phantoms of different shape and structure: homogeneous and inhomogeneous cylinders, a homogeneous cube, and an anthropomorphic thoracic phantom. A 2D motion stage was used to simulate the motion. The stage position was synchronized with the beam start time with the respiratory gating simulator. The motion patterns were designed such that the motion speed was in the upper range of the expected tumor motion (1-1.4 cm∕s) and the range exceeded the normally observed limits (up to 5.7 cm). The conformal arc plans for X or Y motion (in the IEC 61217 coordinate system) consisted of manually created narrow (3 cm) rectangular strips moving in-phase (tracking) or phase-shifted by 90° (crossing) with respect to the phantom motion. The XY motion was tested with the computer-derived VMAT MLC sequences. For all phantoms and plans, time-resolved (10 Hz) ion chamber dose was collected. In addition, coronal (XY) films were exposed in the cube phantom to a VMAT beam with two different starting phases, and compared to the reconstructed motion-perturbed dose planes. RESULTS: For the X or Y motions with the moving strip and geometrical phantoms, the maximum difference between perturbation-reconstructed and ion chamber doses did not exceed 1.9%, and the average for any motion pattern∕starting phase did not exceed 1.3%. For the VMAT plans on the cubic and thoracic phantoms, one point exhibited a 3.5% error, while the remaining five were all within 1.1%. Across all the measurements (N = 22), the average disagreement was 0.5 ± 1.3% (1 SD). The films exhibited γ(3%∕3 mm) passing rates ≥90%. CONCLUSIONS: The dose to an arbitrary moving voxel in a patient can be estimated with acceptable accuracy for a VMAT delivery, by performing a single QA measurement with a cylindrical phantom and applying two consecutive perturbations to the TPS-calculated patient dose. The first one accounts for the differences between the planned and delivered static doses, while the second one corrects for the motion.

VMAT QA: measurement-guided 4D dose reconstruction on a patient.

PURPOSE: To develop and validate a volume-modulated arc therapy (VMAT) quality assurance (QA) tool that takes as input a time-resolved, low-density (∼10 mm) cylindrical surface dose map from a commercial helical diode array, and outputs a high density, volumetric, time-resolved dose matrix on an arbitrary patient dataset. This first validation study is limited to a homogeneous "patient." METHODS: A VMAT treatment is delivered to a diode array phantom (ARCCHECK, Sun Nuclear Corp., Melbourne, FL). 3DVH software (Sun Nuclear) derives the high-density volumetric dose using measurement-guided dose reconstruction (MGDR). MGDR cylindrical phantom results are then used to perturb the three-dimensional (3D) treatment planning dose on the patient dataset, producing a semiempirical volumetric dose grid. Four-dimensional (4D) dose reconstruction on the patient is also possible by morphing individual sub-beam doses instead of the composite. For conventional (3D) dose comparison two methods were developed, using the four plans (Multi-Target, C-shape, Mock Prostate, and Head and Neck), including their structures and objectives, from the AAPM TG-119 report. First, 3DVH and treatment planning system (TPS) cumulative point doses were compared to ion chamber in a cube water-equivalent phantom ("patient"). The shape of the phantom is different from the ARCCHECK and furthermore the targets were placed asymmetrically. Second, coronal and sagittal absolute film dose distributions in the cube were compared with 3DVH and TPS. For time-resolved (4D) comparisons, three tests were performed. First, volumetric dose differences were calculated between the 3D MGDR and cumulative time-resolved patient (4D MGDR) dose at the end of delivery, where they ideally should be identical. Second, time-resolved (10 Hz sampling rate) ion chamber doses were compared to cumulative point dose vs time curves from 4D MGDR. Finally, accelerator output was varied to assess the linearity of the 4D MGDR with global fluence change. RESULTS: Across four TG-119 plans, the average PTV point dose difference in the cube between 3DVH and ion chamber is 0.1 ± 1.0%. Average film vs TPS γ-analysis passing rates are 83.0%, 91.1%, and 98.4% for 1%∕2 mm, 2%∕2 mm, and 3%∕3 mm threshold combinations, respectively, while average film vs 3DVH γ-analysis passing rates are 88.6%, 96.1%, and 99.5% for the same respective criteria. 4D MGDR was also sufficiently accurate. First, for 99.5% voxels in each case, the doses from 3D and 4D MGDR at the end of delivery agree within 0.5% local dose-error∕1 mm distance. Moreover, all failing voxels are confined to the edge of the cylindrical reconstruction volume. Second, dose vs time curves track between the ion chamber and 4D MGDR within 1%. Finally, 4D MGDR dose changes linearly with the accelerator output: the difference between cumulative ion chamber and MGDR dose changed by no more than 1% (randomly) with the output variation range of 10%. CONCLUSIONS: Even for a well-commissioned TPS, comparison metrics show better agreement on average to MGDR than to TPS on the arbitrary-shaped measurable "patient." The method requires no more accelerator time than standard QA, while producing more clinically relevant information. Validation in a heterogeneous thoracic phantom is under way, as is the ultimate application of 4D MGDR to virtual motion studies.

Clinical validation of atlas-based auto-segmentation of multiple target volumes and normal tissue (swallowing/mastication) structures in the head and neck.

PURPOSE: To validate and clinically evaluate autocontouring using atlas-based autosegmentation (ABAS) of computed tomography images. METHODS AND MATERIALS: The data from 10 head-and-neck patients were selected as input for ABAS, and neck levels I-V and 20 organs at risk were manually contoured according to published guidelines. The total contouring times were recorded. Two different ABAS strategies, multiple and single subject, were evaluated, and the similarity of the autocontours with the atlas contours was assessed using Dice coefficients and the mean distances, using the leave-one-out method. For 12 clinically treated patients, 5 experienced observers edited the autosegmented contours. The editing times were recorded. The Dice coefficients and mean distances were calculated among the clinically used contours, autocontours, and edited autocontours. Finally, an expert panel scored all autocontours and the edited autocontours regarding their adequacy relative to the published atlas. RESULTS: The time to autosegment all the structures using ABAS was 7 min/patient. No significant differences were observed in the autosegmentation accuracy for stage N0 and N+ patients. The multisubject atlas performed best, with a Dice coefficient and mean distance of 0.74 and 2 mm, 0.67 and 3 mm, 0.71 and 2 mm, 0.50 and 2 mm, and 0.78 and 2 mm for the salivary glands, neck levels, chewing muscles, swallowing muscles, and spinal cord-brainstem, respectively. The mean Dice coefficient and mean distance of the autocontours vs. the clinical contours was 0.8 and 2.4 mm for the neck levels and salivary glands, respectively. For the autocontours vs. the edited autocontours, the mean Dice coefficient and mean distance was 0.9 and 1.6 mm, respectively. The expert panel scored 100% of the autocontours as a "minor deviation, editable" or better. The expert panel scored 88% of the edited contours as good compared with 83% of the clinical contours. The total editing time was 66 min. CONCLUSION: Multiple-subject ABAS of computed tomography images proved to be a useful novel tool in the rapid delineation of target and normal tissues. Although editing of the autocontours is inevitable, a substantial time reduction was achieved using editing, instead of manual contouring (180 vs. 66 min).

Sleep and health consequences of shift work in women.

Women constitute about half the work force, and women shift workers warrant special attention given the different physiological needs of women, their reproductive status, and the added burden of family responsibilities. There is increasing evidence that women have greater difficulty adjusting to shift work compared to their male counterparts and that sleep problems may in large part account for this difficulty. The purpose of this article is to review the existing literature to highlight the differential negative impact of shift work on sleep and other health issues in women and as part of a needs assessment to promote research in female shift workers by developing and prioritizing research questions in this field. The literature suggests that women shift workers report poor sleep quality and experience reproductive disturbances, an increased risk of breast cancer, and a greater risk of metabolic and cardiovascular disorders.

Atlas-based auto-segmentation of head and neck CT images.

Treatment planning for high precision radiotherapy of head and neck (H&N) cancer patients requires accurate delineation of many structures and lymph node regions. Manual contouring is tedious and suffers from large inter- and intra-rater variability. To reduce manual labor, we have developed a fully automated, atlas-based method for H&N CT image segmentation that employs a novel hierarchical atlas registration approach. This registration strategy makes use of object shape information in the atlas to help improve the registration efficiency and robustness while still being able to account for large inter-subject shape differences. Validation results showed that our method provides accurate segmentation for many structures despite difficulties presented by real clinical data. Comparison of two different atlas selection strategies is also reported.

Cannabis induces different cognitive changes in schizophrenic patients and in healthy controls.

It is known that 60 to 80% of schizophrenic patients show deficits in cognition. There may be an increase in these deficits as a result of additional regular use of cannabis. The aim of the study was to evaluate the effect of chronic cannabis consumption on the cognitive functions of schizophrenic patients and healthy control subjects after a minimum abstinence time of 28 days. The study sample consisted of 39 schizophrenics (19 cannabis-abusers and 20 non-abusers) and 39 healthy controls (18 cannabis-abusers, 21 non-abusers). In a 2x2-factorial design (Diagnostic Groups [healthy controls, schizophrenic patients]xCannabis abuse [without, with]) with diagnostic group and cannabis consumption considered between-subject factors) we tested the hypothesis that dually diagnosed patients (i.e. suffering both from schizophrenia and cannabis abuse) perform worse in neuropsychological tests than schizophrenic patients without cannabis abuse. On the whole, schizophrenic patients performed worse than healthy control subjects. Surprisingly, rather than deteriorating neuropsychological performance, regular cannabis abuse prior to the first psychotic episode improved cognition in some tests. This was even more pronounced when regular consumption started before the age of 17. On the other hand, cannabis use deteriorated test performance in healthy controls, especially in cases when regular consumption started before the age of 17. To sum up, regular cannabis abuse has a different effect on cognitive function in schizophrenic patients and healthy controls.