RESUMO
PURPOSE: Since the 2001 IOM Report Crossing the Quality Chasm: A New Health System for the 21st Century, the need to provide quality metrics in health care has increased. Quality metrics have yet to be defined for the field of radiation oncology. This study represents one institutes initial efforts defining and measuring quality metrics using our electronic medical record and verify system(EMR) as a primary data collection tool. This effort began by selecting meaningful quality metrics rooted in the IOM definition of quality (safe, timely, efficient, effective, equitable and patient-centered care) that were also measurable targets based on current data input and workflow. METHODS: Elekta MOSAIQ 2.30.04D1 was used to generate reports on the number of Special Physics Consults(SPC) charged as a surrogate for treatment complexity, daily patient time in department(DTP) as a measure of efficiency and timeliness, and time from CT-simulation to first LINAC appointment(STL). The number of IMRT QAs delivered in the department was also analyzed to assess complexity. RESULTS: Although initial MOSAIQ reports were easily generated, the data needed to be assessed and adjusted for outliers. Patients with delays outside of radiation oncology such as chemotherapy or surgery were excluded from STL data. We found an average STL of six days for all CT-simulated patients and an average DTP of 52 minutes total time, with 23 minutes in the LINAC vault. Annually, 7.3% of all patient require additional physics support indicated by SPC. CONCLUSIONS: Utilizing our EMR, an entire year's worth of useful data characterizing our clinical experience was analyzed in less than one day. Having baseline quality metrics is necessary to improve patient care. Future plans include dissecting this data into more specific categories such as IMRT DTP, workflow timing following CT-simulation, beam-on hours, chart review outcomes, and dosimetric quality indicators.
RESUMO
PURPOSE: Four-dimensional cone-beam CT (4D-CBCT) is a novel imaging technique used to guide treatment setup for patients with pulmonary lesions by providing additional information about tumor motion at the time of treatment. This study aimed to evaluate the efficacy of the 4D-CBCT capability in ensuring accurate patient setup during SBRT. METHODS: Twelve patients with pulmonary lesions were imaged pre-treatment with Elekta XVI4.5 using the Symmetry protocol resulting in a respiratory correlated 4D-CBCT. Reconstruction produced 10 phased-based and one average 3DCT image set. Patient shifts were derived from contour-based(mask) registration driven by the weighted average of shifts from each phased CT(4D shifts). Physicians reviewed registration and manually adjusted shifts based on visual registration. We exported the average 3DCT to MIM Vista Software 5.1.1 in reference volume coordinates and manually fused to the reference CT. All manual fusions were contour-based registrations performed by a single observer. No rotations were permitted in manual fusion to mimic clinical procedure. Translational 3D shifts from manual fusion were compared to 4D(automatic registration) shifts and final physician-corrected shifts. RESULTS: Mean differences between 4D and 3D shifts in lateral, longitudinal, and vertical directions were 1.07mm, 5.92mm, and 1.43mm, respectively. Mean differences between physician-corrected and 3D shifts were 1.41mm, 4.83mm, and 1.61mm. Differences between 4D shifts and 3D shifts increased with increasing tumor motion. One patient had consistently large longitudinal differences between 4D and 3D shifts (mean=3.0cm). Further review revealed poor 4D registration(via mask and clipbox) on the XVI system which was corrected by physician adjustment prior to treatment. CONCLUSIONS: 4D-CBCT is a valuable imaging tool in patient setup. Physician review of contour-based registration is imperative in preventing a geometrical miss. Caution must be employed in tumors that exhibit a large degree of motion. Further research is necessary in determining functional limits of the 4D-CBCT system.
Assuntos
Corticosteroides/efeitos adversos , Corticosteroides/uso terapêutico , Doenças do Prematuro/prevenção & controle , Pneumopatias/prevenção & controle , Doença Crônica , Idade Gestacional , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Metanálise como Assunto , Fatores de Risco , Análise de SobrevidaRESUMO
Survival and neurodevelopmental outcome to 2 years were determined for two cohorts of infants weighing 500 to 999 gm at birth, born in a tertiary maternity hospital. Live births increased over time from an annual average of 48.7 in the first era (January 1977 to March 1982) to 64.6 in the second era (January 1985 to December 1987), largely from referrals of additional mothers with pregnancy complications. In the first era, 33.6% (86/256) of infants survived to 2 years; the survival rate improved significantly to 45.9% (89/194) in era 2. After adjustment for birth weight, the odds ratio for survival in era 2 versus era 1 was 1.39 (95% confidence interval = 1.12, 1.73; p less than 0.01). One known survivor in each era was not seen at 2 years of age. In the first era, 59.3% (51/86) of 2-year-old children were free of disability compared with 68.5% (61/89) in era 2 (NS), but the Mental Development Index of the Bayley Scales improved significantly, from 90.0 in era 1 to 98.0 in era 2. For infants weighing less than 800 gm at birth, not only did the 2-year survival rate improve, adjusted for birth weight (odds ratio = 1.53; 95% confidence interval = 1.06, 2.20; p less than 0.05), but there was also a significant reduction in neurologic disabilities in survivors (p = 0.03). For infants weighing 800 to 999 gm at birth, there was a significant improvement in the survival rate, adjusted for birth weight (odds ratio = 1.37; 95% confidence interval = 1.04, 1.79; p less than 0.05), but the rate of neurologic disabilities was unchanged. Increased survival in our tertiary maternity center was achieved without increasing the annual number of severely disabled 2-year-old survivors.
Assuntos
Mortalidade Infantil , Recém-Nascido de Baixo Peso , Pré-Escolar , Estudos de Coortes , Pessoas com Deficiência/estatística & dados numéricos , Feminino , Seguimentos , Humanos , Recém-Nascido , Masculino , Taxa de Sobrevida , Vitória/epidemiologiaRESUMO
A cohort of 678 consecutive very low birth weight infants, liveborn in one tertiary institution during a 63-month period, was studied to investigate whether antenatal steroid therapy had any beneficial or harmful effects on mortality or morbidity over the first 2 years of life. Comparing the 244 babies who received treatment with the 434 controls, 195 (79.9%) and 265 (61.1%), respectively, were discharged home (P less than 0.001). Mortality in the treated group remained substantially lower and was almost halved after adjustment for birth weight, extreme immaturity, lethal malformations, and confounding obstetric variables (P = 0.001). Fatal cases of respiratory distress syndrome were less common in the treated group (P = 0.044). Of in-hospital survivors, those in the treated group required less positive pressure respiratory support (P = 0.003) and fewer days in oxygen (P = 0.018), and the incidences of bronchopulmonary dysplasia (P = 0.003) and patent ductus arteriosus (P = 0.002) were lower. Two-year survivors who had received treatment were heavier (P = 0.016) and had larger head circumferences (P = 0.029). These beneficial associations in the treated group were not at the expense of increased rates of infection or adverse neurologic outcome. We did not detect any adverse effects of antenatal steroid therapy on any relevant aspect of mortality or morbidity in infancy under circumstances in which the chances of finding substantial differences were high.
Assuntos
Betametasona/uso terapêutico , Recém-Nascido de Baixo Peso , Síndrome do Desconforto Respiratório do Recém-Nascido/prevenção & controle , Displasia Broncopulmonar/prevenção & controle , Doenças do Sistema Nervoso Central/epidemiologia , Pré-Escolar , Ensaios Clínicos como Assunto , Deficiências do Desenvolvimento/epidemiologia , Permeabilidade do Canal Arterial/prevenção & controle , Feminino , Maturidade dos Órgãos Fetais , Seguimentos , Humanos , Lactente , Recém-Nascido , Pulmão/embriologia , Masculino , Gravidez , Síndrome do Desconforto Respiratório do Recém-Nascido/mortalidade , Fatores de TempoRESUMO
Large numbers of black metallic spherules ranging in diameter from a few micrometers to over 800 micrometers are raining into the eastern Gulf of Mexico and adjacent areas of western Florida. The composition of the flux, its association with glass spherules and coky particles, and its magnitude point to industrial pollution, probably coal- and coke-burning facilities around the perimeter of the gulf, as the source. Since metallic particles represent only a small fraction of most fly ash, such an influx of large numbers of black magnetic spherules must be symptomatic of a much higher rate of sedimentation of fly ash. The internal microstructures and the general appearance of spherules derived from industrial processes are similar to those of particles derived from cosmic sources. Because of the high potential for contamination in micrometeorite studies, a complete compositional verification of each "cosmic" particle may be necessary.