Outcomes of a Virtual 10-Week COVID-19 and Psychosis Program in an HMO: A Mixed Methods Quality Improvement Project.

Virtual clinical services became the primary treatment modality in a large U.S. HMO psychiatry department during the COVID-19 pandemic. A mixed methods quality improvement project was developed to address psychosis, severe anxiety, and stressors unique to COVID-19 and sheltering in place. The purpose was to determine if a virtual 10-week pilot program combining psychoeducation, skills-based training, experiential exercises using third-wave CBT, and process questions would decrease symptoms and hospitalization rates and improve quality of life. Pre- and postmeasure scores on pandemic-related stress (the PRSF), perceived stress (PSS), and general patient health (PHQ-9) were gathered from five patients in the Department of Psychiatry at Kaiser Permanente in Oakland, California. Qualitative interviews explored patients' perceptions of program benefits. Mean, median, and range on the pre- and postprogram assessments and paired samples t tests for means were calculated. Quantitative results were not statistically significant: p = 0.32 (Revised PRSF), p = 0.34 (PSS), p = 0.94 (PHQ-9). In interviews, most participants reported a decrease in pandemic-related stress. Half reported a decrease in general perceived stress. Half reported no change. Self-assessment reflected perceptions of benefits from this 10-week program, using words such as useful and important. The virtual program helped relieve pandemic-related stress and improved overall quality of life. The results show promise for expanding the program to other hospitals providing services for this diagnostic population.

ARFID Parent Training Protocol ("ARFID-PTP"): Results of a Randomized Pilot Trial Evaluating a Brief, Parent-Training Program for Avoidant/Restrictive Food Intake Disorder.

OBJECTIVE: Accessible treatment options for avoidant/restrictive food intake disorder (ARFID) in children are limited. The current study sought to assess acceptability, feasibility, and preliminary efficacy of a brief, virtual intervention for ARFID in children ("ARFID-PTP"). METHOD: Families of children ages 5-12 with ARFID (n = 30) were randomized to immediate or waitlist treatment groups, with both groups ultimately receiving ARFID-PTP. ARFID-PTP consists of two, 2-h individual treatment sessions with an optional booster session at 4-week follow-up. Families completed acceptability and feasibility measures at end-of-treatment, as well as preliminary efficacy measures at 4-week, 3-month, and 6-month follow-up. RESULTS: Of 30 families who completed an intake session, 27 (90%) completed treatment. Families rated acceptability as high (MCEQ-C = 7.75). Treatment was feasible by participant retention. Exposure adherence was lower than expected, and booster session requests were higher than expected, indicating that achieving feasibility across measures may require treatment modifications. Regarding preliminary efficacy, children in the immediate treatment group had a decrease in ARFID symptoms compared to those on the waitlist. Overall, at 6-month follow-up linear mixed models showed participants had significantly reduced ARFID symptoms by presentation (p < 0.05) and in follow-up completers, children incorporated eight new foods on average. DISCUSSION: ARFID-PTP is acceptable and preliminarily efficacious. The protocol may benefit from modifications to increase feasibility; however, booster session content and treatment outcomes suggest a priori feasibility markers may not accurately capture the utility of ARFID-PTP. Further work should continue to examine the efficacy ARFID-PTP, particularly in diverse samples where treatment accessibility is urgently needed. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04913194.

Outcomes of a Virtual Day Treatment Program for Adults With Eating Disorders-Comparison With In-Person Day Treatment.

OBJECTIVE: Previous studies have indicated that virtual treatments for eating disorders (EDs) are roughly as effective as are in-person treatments; the present nonrandomized study aimed to expand on the current body of evidence by comparing outcomes from a virtual day treatment program with those of an in-person program in an adult ED sample. METHOD: Participants were 109 patients who completed at least 60% of day treatment sessions (n = 55 in-person and n = 54 virtual). Outcome measures included ED and comorbid symptoms, and motivation. RESULTS: Linear mixed models showed that global EDE-Q scores decreased during treatment (AIC = 376.396, F = 10.94, p = 0.002), irrespective of treatment modality (p = 0.186). BMI significantly increased over time (AIC = 389.029, F = 27.97, p < 0.001), with no effect of treatment modality (p = 0.779). DISCUSSION: Our findings suggest that the virtual delivery of day treatments produces comparable outcomes to those obtained using in-person formats, and that virtual formats may represent a pragmatic treatment option, especially in situations in which access to in-person care is limited.

The development and evaluation of a virtual, asynchronous, trauma-focused treatment program for adult survivors of childhood interpersonal trauma.

BACKGROUND: The long-term mental and physical health implications of childhood interpersonal trauma on adult survivors is immense, however, there is a lack of available trauma-focused treatment services that are widely accessible. This study, utilizing a user-centered design process, sought feedback on the initial design and development of a novel, self-paced psychoeducation and skills-based treatment intervention for this population. AIMS: To explore the views and perspectives of adult survivors of childhood interpersonal trauma on the first two modules of an asynchronous trauma-focused treatment program. METHODS: Fourteen participants from our outpatient hospital service who completed the modules consented to provide feedback on their user experience. A thematic analysis of the three focus groups was conducted. RESULTS: Four major themes emerged from the focus groups: (1) technology utilization, (2) module content, (3) asynchronous delivery, and (4) opportunity for interactivity. Participants noted the convenience of the platform and the use of multimedia content to increase engagement and did not find the modules to be emotionally overwhelming. CONCLUSIONS: Our research findings suggest that an asynchronous virtual intervention for childhood interpersonal trauma survivors may be a safe and acceptable way to provide a stabilization-focused intervention on a wider scale.

Virtual and analytical self-expandable braided stent treatment models.

The Flow Diverter is a self-expandable braided stent that has helped improve the effectiveness of cerebral aneurysm treatment during the last decade. The Flow Diverter's efficiency heavily relies on proper decision-making during the pre-operative phase, which is currently based on static measurements that fail to account for vessel or tissue deformation. In the context of providing realistic measurements, a biomechanical computational method is designed to aid physicians in predicting patient-specific treatment outcomes. The method integrates virtual and analytical treatment models, validated against experimental mechanical tests, and two patient treatment outcomes. In the case of both patients, deployed stent length was one of the validated result parameters, which displayed an error inferior to 1.5% for the virtual and analytical models. These results indicated both models' accuracy. However, the analytical model provided more accurate results with a 0.3% error while requiring a lower computational cost for length prediction. This computational method can offer designing and testing platforms for predicting possible intervention-related complications, patient-specific medical device designs, and pre-operative planning to automate interventional procedures.

Association Between Clinician-Level Factors and Patient Outcomes in Virtual and In-Person Outpatient Treatment for Substance Use Disorders: Multilevel Analysis.

BACKGROUND: The use of virtual treatment services increased dramatically during the COVID-19 pandemic. Unfortunately, large-scale research on virtual treatment for substance use disorder (SUD), including factors that may influence outcomes, has not advanced with the rapidly changing landscape. OBJECTIVE: This study aims to evaluate the link between clinician-level factors and patient outcomes in populations receiving virtual and in-person intensive outpatient services. METHODS: Data came from patients (n=1410) treated in a virtual intensive outpatient program (VIOP) and an in-person intensive outpatient program (IOP), who were discharged between January 2020 and March 2021 from a national treatment organization. Patient data were nested by treatment providers (n=58) examining associations with no-shows and discharge with staff approval. Empathy, comfort with technology, perceived stress, resistance to change, and demographic covariates were examined at the clinician level. RESULTS: The VIOP (ß=-5.71; P=.03) and the personal distress subscale measure (ß=-6.31; P=.003) were negatively associated with the percentage of no-shows. The VIOP was positively associated with discharges with staff approval (odds ratio [OR] 2.38, 95% CI 1.50-3.76). Clinician scores on perspective taking (ß=-9.22; P=.02), personal distress (ß=-9.44; P=.02), and male clinician gender (ß=-6.43; P=.04) were negatively associated with in-person no-shows. Patient load was positively associated with discharge with staff approval (OR 1.04, 95% CI 1.02-1.06). CONCLUSIONS: Overall, patients in the VIOP had fewer no-shows and a higher rate of successful discharge. Few clinician-level characteristics were significantly associated with patient outcomes. Further research is necessary to understand the relationships among factors such as clinician gender, patient load, personal distress, and patient retention.

Baseline symptomatology and treatment outcomes of young adults in a virtual versus in-person partial hospitalization and intensive outpatient program for eating disorders.

OBJECTIVE: The COVID-19 pandemic resulted in a shift from traditional, in-person treatment to virtual treatment for eating disorders (EDs), with little knowledge about the relative efficacy of virtual formats. METHOD: In the current study, we examined baseline symptomatology and treatment outcomes of young adults in our virtual partial hospitalization and intensive outpatient program (PHP/IOP) for EDs, implemented shortly after the onset of the COVID-19 pandemic. We investigated outcomes on body mass index, ED symptoms, anxiety, ED-related clinical impairment, and emotion regulation. RESULTS: We found significant differences in ED symptomatology, ED-related clinical impairment, and difficulties with emotion regulation at admission between participants in the virtual and in-person versions of our PHP/IOP. Despite these differences, the results demonstrated that the degree of change from admission to discharge on these measures was comparable for both conditions. DISCUSSION: These findings suggest that PHPs and IOPs are relatively effective in a virtual format. Providing effective virtual options across various levels of care will improve access to specialized treatment for EDs. PUBLIC SIGNIFICANCE: (i) Participants in the virtual program reported less severe symptomatology at baseline, (ii) Participants in the virtual and in-person programs experienced similar improvements, (iii) Virtual programs may be an effective option for young adults with eating disorders.

Culturally Centered Implementation of Video Telehealth for Rural Native Veterans.

Introduction: Native American Veterans are the most rural and experience heightened risk for mental health (MH) challenges while facing significant health care inequities and access barriers. Rural Native Veterans (RNVs) have experienced historical loss and racial discrimination, contributing to mistrust of Veterans Health Administration (VHA) and other Federal systems. Telemedicine, including video telehealth (VTH), can improve access to MH care for RNVs by addressing barriers. Understanding the cultural context and existing community resources can improve engagement and implementation efforts with RNVs. Objective: This article describes a model of culturally centered MH care and a flexible implementation approach, Personalized Implementation of Virtual Treatments for Rural Native Veterans (PIVOT-RNV), used to disseminate the model. Methods: Participants included four VHA sites serving large RNV populations where PIVOT-RNV was applied to expand the availability of virtual solutions, including VTH, for RNVs. A mixed methods formative evaluation tracked VTH utilization and used provider and RNV feedback to inform iterative process improvements. Results: Where PIVOT-RNV was used, number of providers using VTH with RNVs, number of unique RNVs receiving MH care through VTH, and number of VTH encounters with RNVs grew annually. Provider and RNV feedback highlighted the importance of addressing the unique barriers and cultural context of RNVs. Conclusions: PIVOT-RNV demonstrates promise for improving implementation of virtual treatments and access to MH care for RNVs. The integration of implementation science within a cultural safety framework helps address specific barriers to adoption of virtual treatments for RNVs. Next steps include expanding PIVOT-RNV efforts at additional sites.

Digitally Delivered Dietary Interventions for Patients with Eating Disorders Undergoing Family-Based Treatment: Protocol for a Randomized Feasibility Trial.

BACKGROUND: Eating disorders (EDs) affect 9% of the United States population, and anorexia nervosa (AN), specifically, has the second highest mortality rate of all psychiatric disorders. Yet, only 20% are able to access treatment. Access to care issues include long waitlists, lack of trained specialists, financial, and geographic barriers, all of which highlight the need for effective telehealth interventions. Family-based therapy (FBT) is a first-line treatment for adolescents and young adults with EDs, and weight gain early in treatment is considered a primary predictor of success with FBT. However, nutrition requirements for patients with EDs are uniquely complex. A variety of dietary interventions for guiding the renourishment process are used in practice, but empirical data on the effectiveness and acceptability of the various interventions are sparse. The significance of nutritional restoration and issues with access to first-line treatments underscore the need for further research exploring virtually delivered dietary interventions. OBJECTIVE: Our objective is to compare the effectiveness and acceptability of 2 digitally delivered dietary interventions frequently used in eating disorder treatment settings: (1) calorie-based meal plans and (2) the Plate-by-Plate approach. Specifically, we will explore any potential differences in weight restoration achieved over 8 weeks of treatment as a primary measure of effectiveness, as well as additional treatment outcomes (ED symptoms, anxiety, depression, caregiver burden, and perceived effectiveness and acceptability for both caregivers and clinicians). METHODS: Patients (N=100) with either AN or avoidant restrictive food intake disorders (ARFID) aged 6-24 years seeking treatment at a nationwide virtual eating disorder treatment program, were enrolled between May and August 2022. Upon admission, patients were randomly assigned to receive either the calorie-based intervention or Plate-by-Plate approach from their registered dietitian, all of whom have received training as study interventionists. While we were primarily interested in responses during the first 8 weeks of treatment, patients will be followed for up to 12 months. Descriptive statistics were used to describe patient characteristics and demographics. Weight changes and other treatment outcomes between groups will be compared using generalized linear models. Semistructured caregiver and clinician interview transcripts will undergo qualitative analysis. RESULTS: Enrollment ran from March to August 2022, and we anticipate completion of data collection by November 2022. Analyses will be completed in January 2023. CONCLUSIONS: This study contributes to existing FBT literature by thoroughly exploring the acceptability of dietary interventions and their influence on weight restoration, an area in which research is sparse. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/41837.

The accuracy of soft tissue movement using virtual planning for non-syndromic facial asymmetry cases-a systematic review.

The 3D prediction of post-operative changes is an inevitable tool for the surgical correction of facial asymmetry. The objective is to execute an evidence-based review answering the following question. Does the 3D virtual prediction planning draw reliable and accurate results in the surgical outcome related to the soft tissues of the face in facial asymmetry? This systematic review of the literature is based on the 3D soft tissue prediction planning of facial asymmetry correction to draw conclusions on the reliability and accuracy of these methods in the surgical outcome related to the soft tissues of the face. PubMed, Web of Science, Cochrane, and Ovid databases were adopted for the literature search. Studies published between years 2000 and 2020, aimed at the assessment of soft tissue predictions using software prediction packages for facial asymmetry, were selected. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) was applied. Quadas-2 tool was used for the qualitative evaluation of selected studies. Initial search yielded 248 articles. Twenty articles fulfilled the inclusion and exclusion criteria and selected for qualitative analysis. Finally, 12 articles were selected for quantitative analysis. The results indicate 3D imaging prediction methods provided more accurate information with less distortion for soft tissue prediction regardless of various softwares currently available. The prediction of soft tissue accuracy in facial asymmetry was less accurate in lower face regardless of the type of surgery for facial asymmetry. The mean prediction error was less than 2 mm.

Comparison of hemodynamics in biological surgical aortic valve replacement and transcatheter aortic valve implantation: An in-silico study.

OBJECTIVES: In aortic valve replacement (AVR), the treatment strategy as well as the model and size of the implanted prosthesis have a major impact on the postoperative hemodynamics and thus on the clinical outcome. Preinterventional prediction of the hemodynamics could support the treatment decision. Therefore, we performed paired virtual treatment with transcatheter AVR (TAVI) and biological surgical AVR (SAVR) and compared hemodynamic outcomes using numerical simulations. METHODS: 10 patients with severe aortic stenosis (AS) undergoing TAVI were virtually treated with both biological SAVR and TAVI to compare post-interventional hemodynamics using numerical simulations of peak-systolic flow. Virtual treatment procedure was done using an in-house developed tool based on position-based dynamics methodology, which was applied to the patient's anatomy including LVOT, aortic root and aorta. Geometries were automatically segmented from dynamic CT-scans and patient-specific flow rates were calculated by volumetric analysis of the left ventricle. Hemodynamics were assessed using the STAR CCM+ software by solving the RANS equations. RESULTS: Virtual treatment with TAVI resulted in realistic hemodynamics comparable to echocardiographic measurements (median difference in transvalvular pressure gradient [TPG]: -0.33 mm Hg). Virtual TAVI and SAVR showed similar hemodynamic functions with a mean TPG with standard deviation of 8.45 ± 4.60 mm Hg in TAVI and 6.66 ± 3.79 mm Hg in SAVR (p = 0.03) while max. Wall shear stress being 12.6 ± 4.59 vs. 10.2 ± 4.42 Pa (p = 0.001). CONCLUSIONS: Using the presented method for virtual treatment of AS, we were able to reliably predict post-interventional hemodynamics. TAVI and SAVR show similar hemodynamics in a pairwise comparison.

Virtual and Augmented Surgical Skills in Total Hip Arthroplasty.

A surgical treatment called arthroplasty can be used to rehabilitate the function of joints. Hip arthroplasty is the surgical replacement of a hip joint. It is the procedure in which the joint surface can be replaced, retreated, or readjusted. It is useful when medical treatment cannot overcome long-lasting joint pain. Arthroplasty in patients significantly increases quality of life, activity level, and joint pain. The most commonly performed arthroplasty is of hip and knee joints. During any surgical treatment, complications occur. Some common complications during arthroplasty are hemorrhage, septicemia, mass in the legs and lungs, and loosening of prosthetic parts. This method's proponents point out that quicker recovery periods, decreased pain levels, higher patient satisfaction, and immediate return to function are the highlighted indicators. Many techniques have been created and used for preoperative planning for a hip replacement with varying degrees of effectiveness. It mainly includes digital templating, which has allegedly improved the accuracy of prosthetic implant size prediction and increased the efficacy of total hip arthroplasty (THA). Surgical training for hip replacement includes teaching, practice, treatment, and techniques performed during arthroplasty. Preoperative education also plays a vital role in surgical training as it is a major surgical procedure that is physically and mentally stressful for the patient. The resources in surgical training of hip arthroplasty contribute to rapid progress in surgical training worldwide with increasing occurrence of THA. This article's focus is to draw outcomes from the surgical treatment of hip arthroplasty by comparing and concluding about virtual and surgical treatment.

Immediate Implant Placement in the Maxillary Aesthetic Zone: A Cone Beam Computed Tomography Study.

This study aimed to investigate the factors that could be associated with the risk of labial cortical bone wall perforation with immediate implant placement (IIP) in the maxillary aesthetic zone, in a cone-beam computed tomography (CBCT) virtual study. CBCT exams from 126 qualified subjects (756 teeth) were included. Implants were virtually positioned in two different positions: in the long axis of the tooth (prosthetically-driven position) and in an ideal position in relation to adjacent anatomical structures (bone-driven position). Two different implant diameters were planned for each tooth position, namely, 3.75 and 4.3 mm for central incisors and canines, and 3.0 and 3.3 mm for lateral incisors. The incidence of perforation was nearly 80% and 5% for prosthetically- and bone-driven position, respectively. Factors associated with a higher risk of cortical bone wall perforation (bone-driven position), according to logistic regression analysis, were women, wider implants, Sagittal Root Position class IV, and decrease of the labial concavity angle. Perforation of the labial cortical bone wall can be greatly minimized when the implant is placed in a bone-driven position compared to a prosthetically-driven position. It is important to preoperatively evaluate the morphological features of the implant site for risk assessment and to individualize the treatment plan.

Pilot outcomes from a multidisciplinary telehealth versus in-person intensive outpatient program for eating disorders during versus before the Covid-19 pandemic.

INTRODUCTION: Eating disorders (EDs) are serious mental illnesses with high rates of mortality, morbidity, and personal and societal costs. Onset of the Covid-19 pandemic led to increased ED diagnoses in the general public, as well as worsening of ED symptoms in those with an existing ED diagnosis. Heightened prevalence and severity of EDs during the pandemic is complicated by the fact that traditional modes of ED care (specialty intensive treatment provided by a multidisciplinary team) have been difficult to access during the pandemic. METHODS: The current between-groups study (N = 93 ED) tested a multidisciplinary intensive outpatient program (IOP) delivered via in-person (pre-pandemic; n = 60) and virtually via telehealth (during the pandemic; n = 33). RESULTS: We found no differences in outcomes via delivery mode, such that regardless of in-person versus telehealth programming, ED symptoms, depression, and perfectionism significantly decreased and body mass index significantly increased. CONCLUSIONS: Our findings suggest that a multi-disciplinary telehealth ED IOP program is feasible and has comparable outcomes to in-person IOP treatment. These findings have implications for treatment beyond the pandemic, suggesting that adoption of telehealth IOPs is warranted. Such delivery modes of intensive treatments for EDs could be expanded to reach underserved populations, especially in rural areas where treatment is often difficult to access.

Continuation of an eating disorders day programme during the COVID-19 pandemic.

The current paper describes an adaptation of a daypatient programme for adults with anorexia nervosa in the UK in response to the COVID-19 pandemic and consequent government guidelines. The paper details how the programme, which is normally delivered face-to-face, became a 'virtual' clinic, providing support to a group of patients via the Internet and conducting its core activities almost exclusively via videoconferencing. Anxiety around the pandemic influenced patients' feelings about recovery, and there were concerns about the programme moving online, which necessitated careful management. It has been possible to continue an intensive level of care given wider organisational backing and the support of the patients involved. Some of the patients' reflections on the experience are included in the article. As well as the adaptations, the article also discusses some of the challenges and opportunities encountered, in the hope of guiding similar services.

A Virtual, Randomized, Control Trial of a Digital Therapeutic for Speech, Language, and Cognitive Intervention in Post-stroke Persons With Aphasia.

Background: Post-stroke aphasia is a chronic condition that impacts people's daily functioning and communication for many years after a stroke. Even though these individuals require sustained rehabilitation, they face extra burdens to access care due to shortages in qualified clinicians, insurance limitations and geographic access. There is a need to research alternative means to access intervention remotely, such as in the case of this study using a digital therapeutic. Objective: To assess the feasibility and clinical efficacy of a virtual speech, language, and cognitive digital therapeutic for individuals with post-stroke aphasia relative to standard of care. Methods: Thirty two participants completed the study (experimental: average age 59.8 years, 7 female, 10 male, average education: 15.8 years, time post-stroke: 53 months, 15 right handed, 2 left handed; control: average age 64.2 years, 7 female, 8 male, average education: 15.3 years, time post-stroke: 36.1 months, 14 right handed, 1 left handed). Patients in the experimental group received 10 weeks of treatment using a digital therapeutic, Constant Therapy-Research (CT-R), for speech, language, and cognitive therapy, which provides evidence-based, targeted therapy with immediate feedback for users that adjusts therapy difficulty based on their performance. Patients in the control group completed standard of care (SOC) speech-language pathology workbook pages. Results: This study provides Class II evidence that with the starting baseline WAB-AQ score, adjusted by -0.69 for every year of age, and by 0.122 for every month since stroke, participants in the CT-R group had WAB-AQ scores 6.43 higher than the workbook group at the end of treatment. Additionally, secondary outcome measures included the WAB-Language Quotient, WAB-Cognitive Quotient, Brief Test of Adult Cognition by Telephone (BTACT), and Stroke and Aphasia Quality of Life Scale 39 (SAQOL-39), with significant changes in BTACT verbal fluency subtest and the SAQOL-39 communication and energy scores for both groups. Conclusions: Overall, this study demonstrates the feasibility of a fully virtual trial for patients with post-stroke aphasia, especially given the ongoing COVID19 pandemic, as well as a safe, tolerable, and efficacious digital therapeutic for language/cognitive rehabilitation. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT04488029.

Operating a treatment planning system using a deep-reinforcement learning-based virtual treatment planner for prostate cancer intensity-modulated radiation therapy treatment planning.

PURPOSE: In the treatment planning process of intensity-modulated radiation therapy (IMRT), a human planner operates the treatment planning system (TPS) to adjust treatment planning parameters, for example, dose volume histogram (DVH) constraints' locations and weights, to achieve a satisfactory plan for each patient. This process is usually time-consuming, and the plan quality depends on planer's experience and available planning time. In this study, we proposed to model the behaviors of human planners in treatment planning by a deep reinforcement learning (DRL)-based virtual treatment planner network (VTPN), such that it can operate the TPS in a human-like manner for treatment planning. METHODS AND MATERIALS: Using prostate cancer IMRT as an example, we established the VTPN using a deep neural network developed. We considered an in-house optimization engine with a weighted quadratic objective function. Virtual treatment planner network was designed to observe an intermediate plan DVHs and decide the action to improve the plan by changing weights and threshold dose in the objective function. We trained the VTPN in an end-to-end DRL process in 10 patient cases. A plan score was used to measure plan quality. We demonstrated the feasibility and effectiveness of the trained VTPN in another 64 patient cases. RESULTS: Virtual treatment planner network was trained to spontaneously learn how to adjust treatment planning parameters to generate high-quality treatment plans. In the 64 testing cases, with initialized parameters, quality score was 4.97 (±2.02), with 9.0 being the highest possible score. Using VTPN to perform treatment planning improved quality score to 8.44 (±0.48). CONCLUSIONS: To our knowledge, this was the first time that intelligent treatment planning behaviors of human planner in external beam IMRT are autonomously encoded in an artificial intelligence system. The trained VTPN is capable of behaving in a human-like way to produce high-quality plans.

User-dependent variability in mitral valve segmentation and its impact on CFD-computed hemodynamic parameters.

PURPOSE: While novel tools for segmentation of the mitral valve are often based on automatic image processing, they mostly require manual interaction by a proficient user. Those segmentations are essential for numerical support of mitral valve treatment using computational fluid dynamics, where the reconstructed geometry is incorporated into a simulation domain. To quantify the uncertainty and reliability of hemodynamic simulations, it is crucial to examine the influence of user-dependent variability in valve segmentation. METHODS: Previously, the inter-user variability of landmarks in mitral valve segmentation was investigated. Here, the inter-user variability of geometric parameters of the mitral valve, projected orifice area (OA) and projected annulus area (AA), is investigated for 10 mitral valve geometries, each segmented by three users. Furthermore, the propagation of those variations into numerically calculated hemodynamics, i.e., the blood flow velocity, was investigated. RESULTS: Among the three geometric valve parameters, AA was least user-dependent. Almost all deviations to the mean were below 10%. Larger variations were observed for OA. Variations observed for the numerically calculated hemodynamics were in the same order of magnitude as those of geometric parameters. No correlation between variation of geometric parameters and variation of calculated hemodynamic parameters was found. CONCLUSION: Errors introduced due to the user-dependency were of the same size as the variations of calculated hemodynamics. The variation was thereby of the same scale as deviations in clinical measurements of blood flow velocity using Doppler echocardiography. Since no correlation between geometric and hemodynamic uncertainty was found, further investigation of the complex relationship between anatomy, leaflet shape and flow is necessary.

Two auricular epithesis surgical cases retained by a custom titanium implant: result at four years.

INTRODUCTION: This article aims at describing the four-year outcome of a surgical procedure implanting a patient specific epithesis system in two patients. TECHNICAL NOTE: After virtual 3D reconstruction of the anatomy and mirroring of the healthy ear, the position of the three Locator® attachments were optimized in the software to embed them as accurately as possible in the planned episthesis antihelix. The personalized plate bearing the three Locator® implants was then manufactured. Ten osteosynthesis screws were placed around the abutments to ensure bone anchorage. Post-operative antibiotic therapy was prescribed for the duration of ten days. The episthesis was placed two months post-operatively. The follow-up for each patient was 65 and 57 months respectively with no complications to report. CONCLUSION: 3D planning assists the surgeon and eliminates several constraints related to the placement of bone implants. It assists the surgical procedure and improves both the aesthetics and functional result of the surgery.