Target volume coverage and dose to organs at risk in prostate cancer patients. Dose calculation on daily cone-beam CT data sets.

PURPOSE: On the basis of correct Hounsfield unit to electron density calibration, cone-beam computed tomography (CBCT) data provide the opportunity for retrospective dose recalculation in the patient. Therefore, the consequences of translational positioning corrections and of morphological changes in the patient anatomy can be quantified for prostate cancer patients. MATERIALS AND METHODS: The organs at risk were newly contoured on the CBCT data sets of 7 patients so as to evaluate the actual applied dose. The daily dose to the planning target volume (PTV) was recalculated with and without the translation data, which result from the real patient repositioning. RESULTS: A CBCT-based dose recalculation with uncertainties less than 3 % is possible. The deviations between the planning CT and the CBCT without the translational positioning correction vector show an average dose difference of - 8 % inside the PTV. An inverse proportional relation between the mean bladder dose and the actual volume of the bladder could be established. The daily applied dose to the rectum is about 1-54 % higher than predicted by the planning CT. CONCLUSION: A dose calculation based on CBCT data is possible. The daily positioning correction of the patient is necessary to avoid an underdosage in the PTV. The new contouring of the organs at risk - the bladder and rectum - allows a better appraisal to be made of the total applied dose to these organs.

Protection of quality and innovation in radiation oncology: the prospective multicenter trial the German Society of Radiation Oncology (DEGRO-QUIRO study). Evaluation of time, attendance of medical staff, and resources during radiotherapy with IMRT.

BACKGROUND: A number of national and international societies published recommendations regarding the required equipment and manpower assumed to be necessary to treat a number of patients with radiotherapy. None of these recommendations were based on actual time measurements needed for specific radiotherapy procedures. The German Society of Radiation Oncology (DEGRO) was interested in substantiating these recommendations by prospective evaluations of all important core procedures of radiotherapy in the most frequent cancers treated by radiotherapy. The results of the examinations of radiotherapy with intensity-modulated radiation therapy (IMRT) in patients with different tumor entities are presented in this manuscript. PATIENTS, MATERIAL, AND METHODS: Four radiation therapy centers [University Hospital of Marburg, University Hospital of Giessen, University Hospital of Berlin (Charité), Klinikum rechts der Isar der Technischen Universität München] participated in this prospective study. The workload of the different occupational groups and room occupancies for the core procedures of radiotherapy were prospectively documented during a 2-month period per center and subsequently statistically analyzed. RESULTS: The time needed per patient varied considerably between individual patients and between centers for all the evaluated procedures. The technical preparation (contouring of target volume and organs at risk, treatment planning, and approval of treatment plan) was the most time-consuming process taking 3 h 54 min on average. The time taken by the medical physicists for this procedure amounted to about 57%. The training part of the preparation time was 87% of the measured time for the senior physician and resident. The total workload for all involved personnel comprised 74.9 min of manpower for the first treatment, 39.7 min for a routine treatment with image guidance, and 22.8 min without image guidance. The mean room occupancy varied between 10.6 min (routine treatment without image guidance) and 23.7 min (first treatment with image guidance). CONCLUSION: The prospective data presented here allow for an estimate of the required machine time and manpower needed for the core procedures of radiotherapy in an average radiation treatment with IMRT. However, one should be aware that a number of necessary and time-consuming activities were not evaluated in the present study.

Investigations on the beam quality correction factor for ionization chambers in high-energy brachytherapy dosimetry.

Objective. To enhance the investigations on MC calculated beam quality correction factors of thimble ionization chambers from high-energy brachytherapy sources and to develop reliable reference conditions in source and detector setups in water.Approach. The response of five different ionization chambers from PTW-Freiburg and Standard Imaging was investigated for irradiation by a high dose rate Ir-192 Flexisource in water. For a setup in a Beamscan water phantom, Monte Carlo simulations were performed to calculate correction factors for the chamber readings. After exact positioning of source and detector the absorbed dose rate at the TG-43 reference point at one centimeter nominal distance from the source was measured using these factors and compared to the specification of the calibration certificate. The Monte Carlo calculations were performed using the restricted cema formalism to gain further insight into the chamber response. Calculations were performed for the sensitive volume of the chambers, determined by the methods currently used in investigations of dosimetry in magnetic fields.Main results. Measured dose rates and values from the calibration certificate agreed within the combined uncertainty (k= 2) for all chambers except for one case in which the full air cavity was simulated. The chambers showed a distinct directional dependence. With the restricted cema formalism calculations it was possible to examine volume averaging and energy dependence of the perturbation factors contributing to the beam quality correction factor also differential in energy.Significance. This work determined beam quality correction factors to measure the absorbed dose rate from a brachytherapy source in terms of absorbed dose to water for a variety of ionization chambers. For the accurate dosimetry of brachytherapy sources with ionization chambers it is advisable to use correction factors based on the sensitive volume of the chambers and to take account for the directional dependence of chamber response.

On the wall perturbation correction for a parallel-plate NACP-02 chamber in clinical electron beams.

PURPOSE: In recent years, several Monte Carlo studies have been published concerning the perturbation corrections of a parallel-plate chamber in clinical electron beams. In these studies, a strong depth dependence of the relevant correction factors (p(wall) and P(cav)) for depth beyond the reference depth is recognized and it has been shown that the variation with depth is sensitive to the choice of the chamber's effective point of measurement. Recommendations concerning the positioning of parallel-plate ionization chambers in clinical electron beams are not the same for all current dosimetry protocols. The IAEA TRS-398 as well as the IPEM protocol and the German protocol DIN 6800-2 interpret the depth of measurement within the phantom as the water equivalent depth, i.e., the nonwater equivalence of the entrance window has to be accounted for by shifting the chamber by an amount deltaz. This positioning should ensure that the primary electrons traveling from the surface of the water phantom through the entrance window to the chamber's reference point sustain the same energy loss as the primary electrons in the undisturbed phantom. The objective of the present study is the determination of the shift deltaz for a NACP-02 chamber and the calculation of the resulting wall perturbation correction as a function of depth. Moreover, the contributions of the different chamber walls to the wall perturbation correction are identified. METHODS: The dose and fluence within the NACP-02 chamber and a wall-less air cavity is calculated using the Monte Carlo code EGSnrc in a water phantom at different depths for different clinical electron beams. In order to determine the necessary shift to account for the nonwater equivalence of the entrance window, the chamber is shifted in steps deltaz around the depth of measurement. The optimal shift deltaz is determined from a comparison of the spectral fluence within the chamber and the bare cavity. The wall perturbation correction is calculated as the ratio between doses for the complete chamber and a wall-less air cavity. RESULTS: The high energy part of the fluence spectra within the chamber strongly varies even with small chamber shifts, allowing the determination of deltaz within micrometers. For the NACP-02 chamber a shift deltaz = -0.058 cm results. This value is independent of the energy of the primary electrons as well as of the depth within the phantom and it is in good agreement with the value recommended in the German dosimetry protocol. Applying this shift, the calculated wall perturbation correction as a function of depth is varying less than 1% from zero up to the half value depth R50 for electron energies in the range of 6-21 MeV. The remaining depth dependence can mainly be attributed to the scatter properties of the entrance window. When neglecting the nonwater equivalence of the entrance window, the variation of p(wall) with depth is up to 10% and more, especially for low electron energies. CONCLUSIONS: The variation of the wall perturbation correction for the NACP-02 chamber in clinical electron beams strongly depends on the positioning of the chamber. Applying a shift deltaz = -0.058 cm toward the focus ensures that the primary electron spectrum within the chamber bears the largest resemblance to the fluence of a wall-less cavity. Hence, the influence of the chamber walls on the perturbation correction can be separated out and the residual variation of p(wall) with depth is minimized.

Dietary consistency and the midline sutures in growing pigs.

OBJECTIVES: The purpose of this study was to investigate the effects of reduced masticatory function on midline suture growth and morphology in growing pigs. SETTING AND SAMPLE POPULATION: The sample was 20 pigs separated into two dietary groups and raised at the Department of Anthropology, Harvard University. Midline suture specimens were analyzed at the Department of Orthodontics, University of Washington. MATERIALS AND METHODS: Ten farm pigs and 10 minipigs, all male, were randomly assigned to hard (n = 9) and soft-diet (n = 11) groups. Fluorochromic mineral labels were administered to document bone apposition, and the animals were killed after 12 weeks. Undecalcified sections of the interfrontal, interparietal, internasal, and intermaxillary sutures were evaluated for bone quantity and sutural thickness, interdigitation ratio and growth rate. RESULTS: Soft-diet pigs were characterized by a slower rate of weight gain and less bone than their hard-diet counterparts. Even after correction for weight gain, soft-diet pigs had reduced suture growth rate and thickness. However, no difference in interdigitation ratio was detected between dietary groups. CONCLUSIONS: Restriction to a soft diet reduces midline suture growth and bone apposition in the growing pig.

Calculated beam quality correction factors for ionization chambers in MV photon beams.

The beam quality correction factor, [Formula: see text], which corrects for the difference in the ionization chamber response between the reference and clinical beam quality, is an integral part of radiation therapy dosimetry. The uncertainty of [Formula: see text] is one of the most significant sources of uncertainty in the dose determination. To improve the accuracy of available [Formula: see text] data, four partners calculated [Formula: see text] factors for 10 ionization chamber models in linear accelerator beams with accelerator voltages ranging from 6 MV to 25 MV, including flattening-filter-free (FFF) beams. The software used in the calculations were EGSnrc and PENELOPE, and the ICRU report 90 cross section data for water and graphite were included in the simulations. Volume averaging correction factors were calculated to correct for the dose averaging in the chamber cavities. A comparison calculation between partners showed a good agreement, as did comparison with literature. The [Formula: see text] values from TRS-398 were higher than our values for each chamber where data was available. The [Formula: see text] values for the FFF beams did not follow the same [Formula: see text], [Formula: see text] relation as beams with flattening filter (values for 10 MV FFF beams were below fits made to other data on average by 0.3%), although our FFF sources were only for Varian linacs.

Determination of consensus k Q values for megavoltage photon beams for the update of IAEA TRS-398.

The IAEA is currently coordinating a multi-year project to update the TRS-398 Code of Practice for the dosimetry of external beam radiotherapy based on standards of absorbed dose to water. One major aspect of the project is the determination of new beam quality correction factors, k Q , for megavoltage photon beams consistent with developments in radiotherapy dosimetry and technology since the publication of TRS-398 in 2000. Specifically, all values must be based on, or consistent with, the key data of ICRU Report 90. Data sets obtained from Monte Carlo (MC) calculations by advanced users and measurements at primary standards laboratories have been compiled for 23 cylindrical ionization chamber types, consisting of 725 MC-calculated and 179 experimental data points. These have been used to derive consensus k Q values as a function of the beam quality index TPR20,10 with a combined standard uncertainty of 0.6%. Mean values of MC-derived chamber-specific [Formula: see text] factors for cylindrical and plane-parallel chamber types in 60Co beams have also been obtained with an estimated uncertainty of 0.4%.

Positioning of a plane-parallel ionization chamber in clinical electron beams and the impact on perturbation factors.

Current dosimetry protocols recommend the use of plane-parallel ionization chambers for the dosimetry of clinical electron beams. The necessary perturbation corrections p(wall) and p(cav) are assumed to be unity, independent of the depth of measurement and the energy of the primary electrons. To verify these assumptions detailed Monte Carlo studies of a Roos chamber in clinical electron beams with energies in the range of 6-21 MeV are performed at different depths in water and analyzed in terms of Spencer-Attix cavity theory. Separate simulations for the perturbation corrections p(wall) and p(cav) indicate quite different properties of both correction factors with depth. Dose as well as fluence calculations show a nearly depth-independent wall correction factor for a shift of the Roos chamber Deltaz = -0.017 cm toward the focus. This value is in good agreement with the positioning recommendation given in all dosimetry protocols. Regarding the fluence perturbation p(cav) the simulation of the electron fluence inside the air cavity in comparison to water unambiguously reveals an in-scattering of low energy electrons, despite the fact, that the cavity is 'well guarded'. For depths beyond the reference depth z(ref) this effect is superimposed by an increased loss of primary electrons from the beam resulting in p(cav) > 1. This effect is largest for low electron energies but present for all electron energies involved in this study. Based on the different depth dependences of p(wall) and p(cav) it is possible to choose a chamber shift Deltaz in a way to minimize the depth dependence of the overall perturbation factor p. For the Roos chamber this shift is Deltaz = -0.04 cm independent of electron energy.

[Preventive measures and organization of a regional shared-care system for foot treatment]. / Präventive Massnahmen und Organisation eines regionalen Shared-care-Systems zur Fussversorgung.

A shared-care system should be established to treat diabetic foot wounds. This means including different professions and institutions to optimize the treatment of these patients in respect of medical, psychological and social aspects. This procedure is very well described in the national guidelines of treatment of type 2 diabetes to prevent and treat diabetic foot complications. In the treatment of the diabetic foot syndrome the establishment of such a shared-care system has to recognize the wound classification and the underlying risk of patients. In this article the stage-adjusted approach and the duties of the different levels of responsibility are described.

Advantage of proton-radiotherapy for pediatric patients and adolescents with Hodgkin's disease.

Radiotherapy is frequently used in the therapy of lymphoma. Since lymphoma, for example Hodgkin's disease, frequently affect rather young patients, the induction of secondary cancer or other long-term adverse effects after irradiation are important issues to deal with. Especially for mediastinal manifestations numerous organs and substructures at risk play a role. The heart, its coronary vessels and cardiac valves, the lungs, the thyroid and, for female patients, the breast tissue are only the most important organs at risk. In this study we investigated if proton-radiotherapy might reduce the dose delivered to the organs at risk and thus minimize the therapy-associated toxicity. METHODS: In this work we compared the dose delivered to the heart, its coronary vessels and valves, the lungs, the thyroid gland and the breast tissue by different volumetric photon plans and a proton plan, all calculated for a dose of 28.8 Gy (EURO-NET-PHL-C2). Target Volumes have been defined by F18-FDG PET-positive areas, following a modified involved node approach. Data from ten young female patients with mediastinal lymphoma have been evaluated. Three different modern volumetric IMRT (VMAT) photon plans have been benchmarked against each other and against proton-irradiation concepts. For plan-evaluation conformity- and homogeneity-indices have been calculated as suggested in ICRU 83. The target volume coverage as well as the dose to important organs at risk as the heart with its substructures, the lungs, the breast tissue, the thyroid and the spinal cord were calculated and compared. For statistical evaluation mean doses to organs at risk were evaluated by non- parametric Kruskal-Wallis calculations with pairwise comparisons. RESULTS: Proton-plans and three different volumetric photon-plans have been calculated. Proton irradiation results in significant lower doses delivered to organ at risk. The median doses and the mean doses could be decreased while PTV coverage is comparable. As well conformity as homogeneity are slightly better for proton plans. For several organs a risk reduction for secondary malignancies has been calculated using literature data as reference. According to the used data derived from literature especially the secondary breast cancer risk, the secondary lung cancer risk and the risk for ischemic cardiac insults can be reduced significantly by using protons for radiotherapy of mediastinal lymphomas. CONCLUSION: Irradiation with protons for mediastinal Hodgkin-lymphoma results in significant lower doses for almost all organs at risk and is suitable to reduce long term side effects for pediatric and adolescent patients.

Efficiency improvements for ion chamber calculations in high energy photon beams.

This article presents the implementation of several variance reduction techniques that dramatically improve the simulation efficiency of ion chamber dose and perturbation factor calculations. The cavity user code for the EGSnrc Monte Carlo code system is extended by photon cross-section enhancement (XCSE), an intermediate phase-space storage (IPSS) technique, and a correlated sampling (CS) scheme. XCSE increases the density of photon interaction sites inside and in the vicinity of the chamber and results-in combination with a Russian Roulette game for electrons that cannot reach the cavity volume-in an increased efficiency of up to a factor of 350 for calculating dose in a Farmer type chamber placed at 10 cm depth in a water phantom. In combination with the IPSS and CS techniques, the efficiency for the calculation of the central electrode perturbation factor Pcel can be increased by up to three orders of magnitude for a single chamber location and by nearly four orders of magnitude when considering the Pcel variation with depth or with distance from the central axis in a large field photon beam. The intermediate storage of the phase-space properties of particles entering a volume that contains many possible chamber locations leads to efficiency improvements by a factor larger than 500 when computing a profile of chamber doses in the field of a linear accelerator photon beam. All techniques are combined in a new EGSnrc user code egs_chamber. Optimum settings for the variance reduction parameters are investigated and are reported for a Farmer type ion chamber. A few example calculations illustrating the capabilities of the egs_chamber code are presented.

Monte Carlo calculations of beam quality correction factors kQ for electron dosimetry with a parallel-plate Roos chamber.

Current dosimetry protocols (AAPM, IAEA, DIN) recommend the use of parallel-plate ionization chambers for the measurement of absorbed dose-to-water in clinical electron beams. For well-guarded plane-parallel chambers, it is assumed that the perturbation correction pQ is unity for all electron energies. In this study, we present detailed Monte Carlo simulations with the EGSnrc code for the widely used Roos parallel-plate chamber which is, besides other plane-parallel chamber types, recommended in all protocols. We have calculated the perturbation corrections pcav and pwall for a wide range of electron energies and for 60Co. While our results confirm the recommended value of unity for the cavity perturbation pcav, the wall-correction factor pwall depends on electron energy and decreases with increasing electron energy. For the lowest electron energies in this study (R50 approximately 2 cm), pwall deviates from unity by up to 1.5%. Using the perturbation factors for the different electron energies and those for the reference beam quality, 60Co, we have calculated the beam quality correction factor kQ. For electron energies E0>9 MeV (R50>4 cm), the calculated values are in good agreement with the data published in the IAEA protocol. Deviations in the range of 0.5-0.8% are found for R50<3 cm.

Monte-Carlo-based perturbation and beam quality correction factors for thimble ionization chambers in high-energy photon beams.

This paper presents a detailed investigation into the calculation of perturbation and beam quality correction factors for ionization chambers in high-energy photon beams with the use of Monte Carlo simulations. For a model of the NE2571 Farmer-type chamber, all separate perturbation factors as found in the current dosimetry protocols were calculated in a fixed order and compared to the currently available data. Furthermore, the NE2571 Farmer-type and a model of the PTW31010 thimble chamber were used to calculate the beam quality correction factor kQ. The calculations of kQ showed good agreement with the published values in the current dosimetry protocols AAPM TG-51 and IAEA TRS-398 and a large set of published measurements. Still, some of the single calculated perturbation factors deviate from the commonly used ones; especially prepl deviates more than 0.5%. The influence of various sources of uncertainties in the simulations is investigated for the NE2571 model. The influence of constructive details of the chamber stem shows a negligible dependence on calculated values. A comparison between a full linear accelerator source and a simple collimated point source with linear accelerator photon spectra yields comparable results. As expected, the calculation of the overall beam quality correction factor is sensitive to the mean ionization energy of graphite used. The measurement setup (source-surface distance versus source-axis distance) had no influence on the calculated values.

Thimble ionization chambers in medium-energy x-ray beams and the role of constructive details of the central electrode: Monte Carlo simulations and measurements.

This paper presents investigations of thimble ionization chamber response in medium-energy kilovoltage x-ray beams (70-280 kVp, 0.09-3.40 mm Cu HVL). Two thimble ionization chambers (PTW30015 and PTW30016) were investigated, regarding the influence of the central electrode dimensions made of aluminum. Measurements were carried out in photon fields of different beam quality. Corresponding Monte Carlo simulations employing the EGSnrc Monte Carlo code system were performed. The simulations included the modelling of the x-ray tube and measurement setup for generation of x-ray spectra. These spectra were subsequently used to calculate the absorbed energy in the air cavity of the two thimble ionization chamber models and the air kerma at the reference point of the chambers. Measurements and simulations revealed an optimal diameter of the central electrode, concerning an almost energy-independent response of the ionizaton chamber. The Monte Carlo simulations are in good agreement with the measured values, expressed in beam quality correction factors k(Q). The agreement was generally within 0.6% but could only be achieved with an accurate model of the central electrode including its exact shape. Otherwise, deviations up to 8.5% resulted, decreasing with higher photon energies, which can be addressed to the high yield of the photoelectric effect in the electrode material aluminum at low photon energies.

Defining stakeholder involvement in participatory design processes.

A participatory approach could be used to implement work place or organizational improvements. However, the question is which participants should be involved and how. In this paper the theoretical involvement in different steps of a linear stepwise approach is described and compared with the latest projects of 300 practitioners. From a theoretical point of view ergonomists and employees play an essential role in the improvement process and are involved in most stages of a change process. Designers play an important role in idea generation and prototyping. Top management and middle management are important in the first step to set goals that are consistent with the strategy of the enterprise. Middle management is also needed in the steps where improvements are selected. This theoretical prediction is affirmed. However, middle management appeared to be also involved in implementation. The role of ergonomists is in practice limited in later stages in implementation, which is not preferred by the ergonomists.

Perturbation correction for alanine dosimeters in different phantom materials in high-energy photon beams.

In modern radiotherapy the verification of complex treatments plans is often performed in inhomogeneous or even anthropomorphic phantoms. For dose verification small detectors are necessary and therefore alanine detectors are most suitable. Though the response of alanine for a wide range of clinical photon energies in water is well know, the knowledge about the influence of the surrounding phantom material on the response of alanine is sparse. Therefore we investigated the influence of twenty different surrounding/phantom materials for alanine dosimeters in clinical photon fields via Monte Carlo simulations. The relative electron density of the used materials was in the range [Formula: see text] up to 1.69, covering almost all materials appearing in inhomogeneous or anthropomorphic phantoms used in radiotherapy. The investigations were performed for three different clinical photon spectra ranging from 6 to 25 MV-X and Co-60 and as a result a perturbation correction [Formula: see text] depending on the environmental material was established. The Monte Carlo simulation show, that there is only a small dependence of [Formula: see text] on the phantom material and the photon energy, which is below ±0.6%. The results confirm the good suitability of alanine detectors for in-vivo dosimetry.

Uncertainties in Monte Carlo-based absorbed dose calculations for an experimental benchmark.

There is a need to verify the accuracy of general purpose Monte Carlo codes like EGSnrc, which are commonly employed for investigations of dosimetric problems in radiation therapy. A number of experimental benchmarks have been published to compare calculated values of absorbed dose to experimentally determined values. However, there is a lack of absolute benchmarks, i.e. benchmarks without involved normalization which may cause some quantities to be cancelled. Therefore, at the Physikalisch-Technische Bundesanstalt a benchmark experiment was performed, which aimed at the absolute verification of radiation transport calculations for dosimetry in radiation therapy. A thimble-type ionization chamber in a solid phantom was irradiated by high-energy bremsstrahlung and the mean absorbed dose in the sensitive volume was measured per incident electron of the target. The characteristics of the accelerator and experimental setup were precisely determined and the results of a corresponding Monte Carlo simulation with EGSnrc are presented within this study. For a meaningful comparison, an analysis of the uncertainty of the Monte Carlo simulation is necessary. In this study uncertainties with regard to the simulation geometry, the radiation source, transport options of the Monte Carlo code and specific interaction cross sections are investigated, applying the general methodology of the Guide to the expression of uncertainty in measurement. Besides studying the general influence of changes in transport options of the EGSnrc code, uncertainties are analyzed by estimating the sensitivity coefficients of various input quantities in a first step. Secondly, standard uncertainties are assigned to each quantity which are known from the experiment, e.g. uncertainties for geometric dimensions. Data for more fundamental quantities such as photon cross sections and the I-value of electron stopping powers are taken from literature. The significant uncertainty contributions are identified as the energy of the radiation source and the underlying photon cross sections as well as the I-value of media involved in the simulation. The combined standard uncertainty of the Monte Carlo calculation yields 0.78% as a conservative estimation. The result of the calculation is close to the experimental result and with each combined standard uncertainty <1%, the accuracy of EGSnrc is confirmed. The setup and methodology of this study can be employed to benchmark other Monte Carlo codes for the calculation of absorbed dose in radiotherapy.

Response of the alanine/ESR dosimeter to radiation from an Ir-192 HDR brachytherapy source.

The response of the alanine dosimeter to radiation from an Ir-192 source with respect to the absorbed dose to water, relative to Co-60 radiation, was determined experimentally as well as by Monte Carlo simulations. The experimental and Monte Carlo results for the response agree well within the limits of uncertainty. The relative response decreases with an increasing distance between the measurement volume and the source from approximately 98% at a 1 cm distance to 96% at 5 cm. The present data are more accurate, but agree well with data published by Schaeken et al (2011 Phys. Med. Biol. 56 6625-34). The decrease of the relative response with an increasing distance that had already been observed by these authors is confirmed. In the appendix, the properties of the alanine dosimeter with respect to volume and sensitivity corrections are investigated. The inhomogeneous distribution of the detection probability that was taken into account for the analysis was determined experimentally.

Safety and quality issues as part of a holistic (i.e., sociotechnological) approach.

In the past, many so-called management concepts were not very successful because of their fragmented approach. This is also true for topics like safety and quality. Here, technical aspects often predominated while disregarding the equally important need for a change of attitude. On the other hand, awareness was created by timely limited programmes. The paper deals with integrating quality and safety in holistic (management) concepts, which are described first before being discussed in detail.