Robustness analysis of surface-guided DIBH left breast radiotherapy: personalized dosimetric effect of real intrafractional motion within the beam gating thresholds.

PURPOSE: The robustness of surface-guided (SG) deep-inspiration breath-hold (DIBH) radiotherapy (RT) for left breast cancer was evaluated by investigating any potential dosimetric effects due to the residual intrafractional motion allowed by the selected beam gating thresholds. The potential reduction of DIBH benefits in terms of organs at risk (OARs) sparing and target coverage was evaluated for conformational (3DCRT) and intensity-modulated radiation therapy (IMRT) techniques. METHODS: A total of 192 fractions of SGRT DIBH left breast 3DCRT treatment for 12 patients were analyzed. For each fraction, the average of the real-time displacement between the isocenter on the daily reference surface and on the live surface ("SGRT shift") during beam-on was evaluated and applied to the original plan isocenter. The dose distribution for the treatment beams with the new isocenter point was then calculated and the total plan dose distribution was obtained by summing the estimated perturbed dose for each fraction. Then, for each patient, the original plan and the perturbed one were compared by means of Wilcoxon test for target coverage and OAR dose-volume histogram (DVH) metrics. A global plan quality score was calculated to assess the overall plan robustness against intrafractional motion of both 3DCRT and IMRT techniques. RESULTS: Target coverage and OAR DVH metrics did not show significant variations between the original and the perturbed plan for the IMRT techniques. 3DCRT plans showed significant variations for the left descending coronary artery (LAD) and the humerus only. However, none of the dose metrics exceeded the mandatory dose constraints for any of the analyzed plans. The global plan quality analysis indicated that both 3DCRT and IMRT techniques were affected by the isocenter shifts in the same way and, generally, the residual isocenter shifts more likely tend to worsen the plan in all cases. CONCLUSION: The DIBH technique proved to be robust against residual intrafractional isocenter shifts allowed by the selected SGRT beam-hold thresholds. Small-volume OARs located near high dose gradients showed significant marginal deteriorations in the perturbed plans with the 3DCRT technique only. Global plan quality was mainly influenced by patient anatomy and treatment beam geometry rather than the technique adopted.

Surface-guided DIBH radiotherapy for left breast cancer: impact of different thresholds on intrafractional motion monitoring and DIBH stability.

PURPOSE: To compare two left breast cancer patient cohorts (tangential vs. locoregional deep-inspiration breath-hold - DIBH treatment) with different predefined beam gating thresholds and to evaluate their impact on motion management and DIBH stability. METHODS: An SGRT-based clinical workflow was adopted for the DIBH treatment. Intrafractional monitoring was performed by tracking both the respiratory signal and the real-time displacement between the isocenter on the daily reference surface and on the live surface ("SGRT shift"). Beam gating tolerances were 5 mm/4 mm for the SGRT shifts and 5 mm/3 mm for the gating window amplitude for breast tangential and breast + lymph nodes locoregional treatments, respectively. A total of 24 patients, 12 treated with a tangential technique and 12 with a locoregional technique, were evaluated for a total number of 684 fractions. Statistical distributions of SGRT shift and respiratory signal for each treatment fraction, for each patient treatment, and for the two population samples were generated. RESULTS: Lateral cumulative distributions of SGRT shifts for both locoregional and tangential samples were consistent with a null shift, whereas longitudinal and vertical ones were slightly negative (mean values < 1 mm). The distribution of the percentage of beam on time with SGRT shift > 3 mm, > 4 mm, or > 5 mm was extended toward higher values for the tangential sample than for the locoregional sample. The variability in the DIBH respiration signal was significantly greater for the tangential sample. CONCLUSION: Different beam gating thresholds for surface-guided DIBH treatment of left breast cancer can impact motion management and DIBH stability by reducing the frequency of the maximum SGRT shift and increasing respiration signal stability when tighter thresholds are adopted.

Bone cement implantation syndrome: a thromboelastographic study of the effect of bone cement on coagulation.

Bone cement implantation syndrome (BCIS) is a rare form of intraoperative pulmonary embolism (EP) that occurs during cementation. It can be explained by two main theories: the monomer mediated model and the mechanic model. Our goal is to evaluate thromboelastographic changes in patients undergoing surgery for femoral neck fractures. We recruited 32 patients with a femoral neck fracture. The average age was 81.91 years (range 62-95). The patients were divided in two different groups: cemented hip arthroplasty (CC, 13 patients) and other surgical non-cemented techniques (SC, non-cemented hip arthroplasty, osteosynthesis). The coagulation was evaluated by TEG in the early pre-operatory (time A) and post-operatory (time B), both on native blood and on blood added with Heparinase. We used the t-test to compare the differences between the two groups. The coagulation index CI was modified on hypercoagulability by surgery in both groups, but without statistical significance between the two groups (p>0.05). R parameter decreases between time A and time B in the same way in both groups (p>0.05). Parameter MA had no major variations between time A and B, without statistical significance (p>0.05). From our study it is evident that although the surgery would result in a change in the layout of the TEG toward hypercoagulability, this is similar both in cemented and non-cemented surgical interventions for femoral neck fractures in elderly patients. An altered coagulation does not appear to be the cause or a factor in determining the BCIS.

A Structured Intervention to Support Early Palliative Care Conversations for Oncology Patients - A Qualitative Feasibility Study.

AIMS: For patients with advanced cancer, early access to palliative care can have numerous psychosocial and disease management benefits. However, it can be difficult for clinicians to initiate these initial conversations about palliative care. The aim of the present study was to beta test an intervention to facilitate timely conversations about palliative care between patients and clinicians. MATERIALS AND METHODS: The study reported forms one stage of a complex intervention development study following Medical Research Council guidance for developing complex interventions. Feasibility was explored from patient and clinician perspectives in an oncology outpatient setting. RESULTS: Sixteen patients and 18 clinicians participated. Three phases of the intervention were assessed through patient and clinician interviews. The analysis produced three themes in each phase: (i) Preparation (patient preparedness; healthcare professionals' perspectives on palliative care; administration, data and communication); (ii) STEP consultation (defining perspectives on palliative care; how palliative care fits with the current treatment plan; permission to explore future care); (iii) Outcomes (changes in perspective and approaches to coping; opening the door to future conversations; referrals and involvement of palliative services). CONCLUSIONS: The STEP intervention generated important early conversations about end-of-life care that may otherwise not have occurred. No patients regretted having the STEP consultation, which resulted in palliative care referrals for some. Others felt better informed about the support services available and better able to have further conversations. Participating clinicians found the structured conversation guide useful, as it acted as a prompt for areas to cover, as well as providing an explicit way to open discussion about difficult topics.

Oxidative stress and viral Infections: rationale, experiences, and perspectives on N-acetylcysteine.

This article explores current evidence on the role of oxidative stress in viral infections, and on the use of antioxidant drugs as adjunctive treatment. MEDLINE/PubMed was searched for appropriate keywords, and preclinical and clinical studies with reviews were retrieved and examined by authors. Old and current evidence shows that GSH content reduction is the main mechanism of redox imbalance in viral-infected cells. Clinical studies found that GSH levels are depleted in patients with viral infections such as HIV and SARS-CoV. Viral infections activate inflammation through different pathways, and several of these mechanisms are related to oxidative stress. NAC is a precursor of GSH, and many of its intracellular effects are mediated by GSH replenishment, but it also activates some anti-inflammatory mechanisms. NAC has an excellent safety profile and better oral and topical bioavailability than GSH. These characteristics make NAC a suitable option as a repurposed drug. Adjunctive antioxidant treatment may improve the outcomes of antiviral therapies. Current evidence supports the rationale for this practice and some clinical experience showed encouraging results.

Prospective study on the FDG-PET/CT predictive and prognostic values in patients treated with neoadjuvant chemoradiation therapy and radical surgery for locally advanced rectal cancer.

BACKGROUND: 2-[fluorine-18]fluoro-2-deoxy-D-glucose-positron emission tomography/computed tomography (FDG-PET/CT) was carried out before and after neoadjuvant chemoradiotherapy (NCRT) followed by radical surgery for locally advanced rectal cancer (LARC). The aim of this study was to define its predictive and prognostic values. PATIENTS AND METHODS: Patients with cT3-T4 N-/+ carcinoma of medium/low rectum received daily 5-fluorouracil-based chemotherapy infusion and radiation therapy on 6-week period followed by surgery 7-8 weeks later. Tumour metabolic activity, expressed as maximum standardised uptake value (SUV-1 = at baseline and SUV-2 = pre-surgery), was calculated in the most active tumour site. Predictive and prognostic values of SUV-1, SUV-2 and Δ-SUV (percentage change of SUV-1 - SUV-2) were analysed towards pathological response (pR) in the surgical specimen and disease recurrence, respectively. RESULTS: Eighty consecutive patients entered the study. SUV-1, SUV-2 and Δ-SUV appeared singly correlated with pR, but not one of them resulted an independent predictive factor at multivariate analysis. After a median follow-up of 44 months, 13 patients (16.2%) presented local and/or distant recurrence. SUV-2 ≤5 was associated with lower incidence of disease recurrence and resulted prognostic factor at multivariate analysis. CONCLUSIONS: Dual-time FDG-PET/CT in patients with LARC treated with NCRT and radical surgery supplies limited predictive information. However, an optimal metabolic response appears associated with a favourable patient outcome.

Phase II study of panitumumab, oxaliplatin, 5-fluorouracil, and concurrent radiotherapy as preoperative treatment in high-risk locally advanced rectal cancer patients (StarPan/STAR-02 Study).

BACKGROUND: The aim of this phase II study was to assess the activity of panitumumab in combination with oxaliplatin, 5-fluorouracil, and external radiotherapy (RT) as preoperative treatment in locally advanced rectal cancer patients. PATIENTS AND METHODS: Patients had rectal adenocarcinoma, cT3N+ or cT4N-/+ stage, located <12 cm from the anal margin. Panitumumab was administered before the start of chemo-RT, and every 2 weeks in combination with 5-fluorouracil-oxaliplatin with concurrent RT. Rectal surgery was carried out 7-8 weeks after the end of neoadjuvant treatment. The primary end point was a pathological complete response rate of 25%. RESULTS: Sixty patients were enrolled from February 2007 to October 2009. Fifty-five (91.7%) patients underwent surgery. Rate of pathological complete response was 21.1% (95% confidence interval 10.4% to 31.6%). Pathological downstaging occurred in 33 of 57 (57.9%) patients. Grade 3-4 toxicity during neoadjuvant treatment was diarrhea (38.9%), cutaneous reactions (18.6%), nausea (5.1%), asthenia (3.4%), anorexia (3.4%), and neutropenia (1.7%). One toxic death was observed for diarrhea. CONCLUSIONS: In our study, the primary end point is not reached and panitumumab combination treatment was associated with high incidence of grade 3-4 diarrhea. The higher pathological complete response rate in comparison with the results of previous neoadjuvant rectal cancer trials with anti-epidermal growth factor receptor monoclonal antibodies supports further studies necessary to understand the possibility of optimal regimens and sequences with chemo-RT.

Frequency and clinical correlates of adult separation anxiety in a sample of 508 outpatients with mood and anxiety disorders.

OBJECTIVE: To evaluate the frequency and clinical correlates of adult separation anxiety disorder in a large cohort of patients with mood and anxiety disorders. METHOD: Overall, 508 outpatients with anxiety and mood disorders were assessed by the structured clinical interview for diagnostic and statistical manual (IV edition) axis I disorders for principal diagnosis and comorbidity and by other appropriate instruments for separation anxiety into adulthood or childhood. RESULTS: Overall, 105 subjects (20.7%) were assessed as having adult separation anxiety disorder without a history of childhood separation anxiety and 110 (21.7%) had adult separation anxiety disorder with a history of childhood separation anxiety. Adult separation anxiety was associated with severe role impairment in work and social relationships after controlling for potential confounding effect of anxiety comorbidity. CONCLUSION: Adult separation anxiety disorder is likely to be much more common in adults than previously recognized. Research is needed to better understand the relationships of this condition with other co-occurring affective disorders.

Influenza A triggered status asthmaticus requiring emergency ECMO.

We describe a case of acute respiratory failure due to severe pneumonia triggered by the influenza A virus, rapidly evolving into a refractory status asthmaticus requiring emergent ECMO assistance, in order to facilitate the clinical management of patients suffering from this rare but life-threatening condition. This case report demonstrates that infection with influenza A virus can present with severe pneumonia and status asthmaticus refractory to medical and ventilatory treatment. When medical treatment and mechanical ventilation fail, extracorporeal membrane oxygenation therapy should not be delayed as it will avoid injury resulting from inadequate mechanical ventilation and lung hyperinflation.

The structure of lifetime panic-agoraphobic spectrum.

The heterogeneity of the clinical presentation of panic disorder (PD) has prompted researchers to describe different subtypes of PD, on the basis of the observed predominant symptoms constellation. Starting from a dimensional approach to panic disorder, an instrument to assess lifetime panic-agoraphobic spectrum (PAS) available in interview or self-report form (SCI-PAS, PAS-SR) was developed which proved to have sound psychometric properties and the ability to predict delayed response to treatment in patients with mood disorders. However, the structure of the instrument was defined a priori and an examination of its empirical structure is still lacking. Aim of the present report is to analyse the factor structure of the PAS taking advantage of a large database of subjects with panic disorders (N=630) assessed in the framework of different studies. Using a classical exploratory factor analysis based on a tetrachoric correlation matrix and oblique rotation, 10 factors were extracted, accounting overall for 66.3% of the variance of the questionnaire: panic symptoms, agoraphobia, claustrophobia, separation anxiety, fear of losing control, drug sensitivity and phobia, medical reassurance, rescue object, loss sensitivity, reassurance from family members. The first two factors comprise the DSM-IV criteria for panic disorder and agoraphobia. The other factors had received limited empirical support to date. We submit that these symptoms profiles might be clinically relevant for tailoring drug treatments or psychotherapeutic approaches to specific needs. Future perspectives might include the use of these factors to select homogeneous subgroups of patients for brain-imaging studies and to contribute to elucidating the causes and pathophysiology of panic disorder at molecular level.

How the detector resolution affects the clinical significance of SBRT pre-treatment quality assurance results.

PURPOSE: Aim of this work was to study how the detector resolution can affect the clinical significance of SBRT pre-treatment volumetric modulated arc therapy (VMAT) verification results. METHODS: Three detectors (PTW OCTAVIUS 4D 729, 1500 and 100 SRS) used in five configurations with different resolution were compared: 729, 729 merged, 1500, 1500 merged and 1000 SRS. Absolute local gamma passing rates of 3D pre-treatment quality assurance (QA) were evaluated for 150 dose distributions in 30 plans. Five different kinds of error were introduced in order to establish the detection sensitivity of the three devices. Percentage dosimetric differences were evaluated between planned dosevolume histogram (DVH) and patients' predicted DVH calculated by PTW DVH 4D® software. RESULTS: The mean gamma passing rates and the standard deviations were 92.4% ±â€¯3.7%, 94.6% ±â€¯1.8%, 95.3% ±â€¯4.2%, 97.4% ±â€¯2.5% and 97.6% ±â€¯1.4 respectively for 729, 729 merged, 1500, 1500 merged and 1000 SRS with 2% local dose/2mm criterion. The same trend was found on the sensitivity analysis: using a tight gamma analysis criterion (2%L/1mm) only the 1000 SRS detected every kind of error, while 729 and 1500 merged detected three and four kinds of error respectively. Regarding dose metrics extracted from DVH curves, D50% was within the tolerance level in more than 90% of cases only for the 1000 SRS. CONCLUSIONS: The detector resolution can significantly affect the clinical significance of SBRT pre-treatment verification results. The choice of a detector with resolution suitable to the investigated field size is of main importance to avoid getting false positive.

Sorption kinetics and chemical forms of Cd(II) sorbed by thiol-functionalized 2:1 clay minerals.

The interaction between Cd(II) in aqueous solution and two 2:1 expandable clay minerals (i.e., montmorillonite and vermiculite), showing different layer charge, was addressed via batch sorption experiments on powdered clay minerals both untreated and amino acid (cysteine) treated. Reaction products were characterized via X-ray powder diffraction (XRDP), chemical analysis (elemental analysis and atomic absorption spectrophotometry), thermal analysis combined with evolved gases mass spectrometry (TGA-MSEGA) and synchrotron-based X-ray absorption spectroscopy via extended X-ray absorption fine structure (EXAFS) characterization. Sorption isotherms for Cd(II) in presence of different substrates, shows that Cd(II) uptake depends both on Cd(II) starting concentration and the nature of the substrate. Thermal decomposition of Cd-cysteine treated clay minerals evidences the evolution of H(2)O, H(2)S, NO(2), SO(2), and N(2)O(3). These results are well consistent with XRDP data collected both at room and at increasing temperature and further stress the influence of the substrate, in particular cysteine, on the interlayer. EXAFS studies suggest that Cd(II) coordinates with oxygen atoms, to give monomer complexes or CdO molecules, either on the mineral surface and/or in the interlayer. For Cd-cysteine complexes EXAFS data agree with the existence of Cd-S clusters, thus suggesting a predominant role of the thiol group in the bonding of Cd with the amino acid.

Unaltered Oxytocin and Vasopressin Plasma Levels in Patients with Schizophrenia After 4 Months of Daily Treatment with Intranasal Oxytocin.

The neuropeptide oxytocin (OXT) has been proposed as a treatment for a number of neuropsychiatric disorders characterised by impaired social behaviour, including schizophrenia. Although several studies have reported the chronic administration of OXT to be safe and tolerable, its effects on circulating levels of OXT, as well as the related neuropeptide arginine vasopressin (AVP), have not been assessed. In the present study, in a within-subjects cross-over, double-blind, randomised controlled trial, we assayed the plasma levels of OXT and AVP in 31 patients with schizophrenia who were treated daily for 4 months with 40 IU of intranasal OXT or placebo. Our data indicate a mean ± SD baseline OXT concentration of 1.62 ± 0.68 pg/ml, as determined by radioimmunoassay, which did not display any significant variation after chronic treatment with OXT or placebo. Similarly, the mean ± SD baseline AVP value of 2.40 ± 1.26 pg/ml remained unchanged. The present study also assessed cardiovascular and body fluid indicators (osmolality, plasma sodium concentration and systolic blood pressure), as well as a parameter for food intake (body mass index), with all observed to remain stable. By reporting that daily treatment with 40 IU of intranasal OXT or placebo for 4 months does not impact on OXT and AVP plasma levels, nor on cardiovascular, body fluids and food intake parameters, the present study represents an important step towards developing OXT as a safe treatment.

Multiple anxiety disorder comorbidity in patients with mood spectrum disorders with psychotic features.

OBJECTIVE: The authors investigated frequencies and clinical correlates of multiple associations of panic disorder, obsessive-compulsive disorder (OCD), and social phobia in patients with severe mood disorders. METHOD: Subjects were 77 consecutively hospitalized adults with psychotic symptoms and with a diagnosis of bipolar I disorder, major depression, or schizoaffective disorder, bipolar type. Principal diagnosis and comorbidity were assessed by the Structured Clinical Interview for DSM-III-R-Patient Version. RESULTS: Of the entire cohort, 33.8% had a single anxiety disorder and 14.3% had two or three comorbid diagnoses. Patients with multiple comorbidity had significantly higher scores on the Brief Psychiatric Rating Scale and SCL-90 and abused stimulants more frequently than did those without anxiety disorders. CONCLUSIONS: Multiple associations of panic disorder, OCD, and social phobia are not rare among patients with affective psychoses and are likely to be associated with more severe psychopathology than is found in patients without anxiety disorders.

Insight into illness in schizophrenia, schizoaffective disorder, and mood disorders with psychotic features.

OBJECTIVE: Deficits in insight have been found in one study to be more common and severe in patients with schizophrenia than in patients with schizoaffective and major depression with and without psychosis but not more severe than they are in patients with bipolar disorder. The goals of this study were to replicate this finding independently and to clarify whether patients with schizophrenia differ from patients with bipolar disorder in a larger study group. METHOD: Using the Scale to Assess Unawareness of Mental Disorder, the authors evaluated 29 inpatients with schizophrenia, 24 with schizoaffective disorder, and 183 with mood disorders with psychotic features (153 with bipolar disorder and 30 with unipolar depression). RESULTS: Patients with schizophrenia had poorer insight than patients with schizoaffective disorder and patients with psychotic unipolar depression but did not differ from patients with bipolar disorder. CONCLUSIONS: The lack of significant differences between patients with schizophrenia and patients with bipolar disorder was not a result of low statistical power. This replication and more detailed examination of diagnostic group differences in insight have clinical, theoretical, and nosological implications.

Awareness of illness and subjective experience of cognitive complaints in patients with bipolar I and bipolar II disorder.

OBJECTIVE: The authors' goal was to investigate the awareness of illness and subjective cognitive complaints of patients with either bipolar I disorder or bipolar II disorder during a phase of clinical stabilization. METHOD: They used a structured clinical interview, the Frankfurt Complaints Questionnaire, to determine subjective cognitive complaints, and the Scale of Unawareness of Mental Disorder to assess 57 consecutively enrolled patients with bipolar I or bipolar II disorder. RESULTS: Patients with bipolar II disorder had significantly less insight and a higher level of subjective complaints of stimulus overload than patients with bipolar I disorder. CONCLUSIONS: These results suggest that a severe deficit in self-awareness may constitute a distinguishing psychopathological characteristic of patients with bipolar II disorder. Further studies are required to determine if there are associated neuropsychological dysfunctions.

Clozapine for treatment-refractory schizophrenia, schizoaffective disorder, and psychotic bipolar disorder: a 24-month naturalistic study.

BACKGROUND: The aim of this study was to evaluate the 24-month response to clozapine in patients with schizophrenia, schizoaffective disorder, or psychotic bipolar disorder. METHOD: Ninety-one psychotic patients with a principal DSM-III-R diagnosis of schizophrenia (N = 31), schizoaffective disorder (N = 26), or bipolar disorder with psychotic features (N = 34) were treated naturalistically with clozapine at flexible dosages over a 24-month period. Improvement was assessed by the 18-item Brief Psychiatric Rating Scale and the Clinical Global Impressions-Severity of Illness scale. RESULTS: All patients showed significant improvement 24 months from intake (p < .001). Such an improvement was significantly greater among patients with schizoaffective disorder or bipolar disorder than in patients with schizophrenia (p < .05). The presence of suicidal ideation at intake predicted greater improvement at endpoint. CONCLUSION: Clozapine appears to be effective and relatively well tolerated in acute and long-term treatment of patients with psychotic bipolar disorder or schizoaffective disorder who have not responded to conventional pharmacotherapies.

Occurrence and clinical correlates of psychiatric comorbidity in patients with psychotic disorders.

BACKGROUND: The aim of this study was to explore patterns and clinical correlates of psychiatric comorbidity in patients with schizophrenia spectrum disorders and mood spectrum disorders with psychotic features. METHOD: Ninety-six consecutively hospitalized patients with current psychotic symptoms were recruited and included in this study. Index episode psychotic diagnosis and psychiatric comorbidity were assessed using the Structured Clinical Interview for DSM-III-R-Patient Version (SCID-P). Psychopathology was assessed by the SCID-P, Brief Psychiatric Rating Scale, Scale for the Assessment of Negative Symptoms, and Hopkins Symptom Checklist. Awareness of illness was assessed with the Scale to Assess Unawareness of Mental Disorders. RESULTS: The total lifetime prevalence of psychiatric comorbidity in the entire cohort was 57.3% (58.1% in schizophrenia spectrum disorders and 56.9% in mood spectrum psychoses). Overall, panic disorder (24%), obsessive-compulsive disorder (24%), social phobia (17.7%), substance abuse (11.5%), alcohol abuse (10.4%), and simple phobia (7.3%) were the most frequent comorbidities. Within the group of mood spectrum disorders, negative symptoms were found to be more frequent among patients with psychiatric comorbidity than among those without comorbidity, while such a difference was not detected within the group of schizophrenia spectrum disorders. Social phobia, substance abuse disorder, and panic disorder comorbidity showed the greatest association with psychotic features. An association between earlier age at first hospitalization and comorbidity was found only in patients with unipolar psychotic depression. Patient self-reported psychopathology was more severe in schizophrenia spectrum patients with comorbidity than in those without, while such a difference was less pronounced in mood spectrum psychoses. CONCLUSION: These findings suggest that psychiatric comorbidity is a relevant phenomenon in psychoses and is likely to negatively affect the phenomenology of psychotic illness. Further studies in larger psychotic populations are needed to gain more insight into the clinical and therapeutic implications of psychiatric comorbidity in psychoses.

Electroconvulsive therapy in medication-nonresponsive patients with mixed mania and bipolar depression.

BACKGROUND: The aim of this study was to investigate the effectiveness of electroconvulsive therapy (ECT) in medication-nonresponsive patients with mixed mania and bipolar depression. METHOD: Forty-one patients with mixed mania (DSM-IV diagnosis of bipolar I disorder, most recent episode mixed) and 23 patients with bipolar depression (DSM-IV diagnosis of bipolar I disorder, most recent episode depressed) consecutively assigned to ECT treatment were included in this study. Subjects were evaluated using the Montgomery-Asberg Depression Rating Scale (MADRS), the Brief Psychiatric Rating Scale (BPRS), and the Clinical Global Impressions-Severity of Illness scale (CGI-S). Assessments were carried out the day before starting ECT, 48 hours after completion of the third session (T1), and a week after the last session of ECT (T2). RESULTS: Both groups received an equal number of ECT sessions (mean +/- SD = 7.2 +/- 1.7 vs. 7.3 +/- 1.6). In both groups, within-group comparisons showed that there was a significant reduction in CGI-S score (mixed mania, p <.0001 at T1 and T2; bipolar depression, p < .01 at T1, p < .0001 at T2), MADRS total score (both groups, p < .0001 at T1 and T2), BPRS total score (mixed mania, p < .0001 at T1 and T2; bipolar depression, p < .001 at T1, p < .0001 at T2), and BPRS activation factor score (mixed mania, p < .0001 at T1 and T2; bipolar depression, NS at T1, p < .01 at T2). Between-group comparisons revealed that patients with mixed mania showed significantly greater decrease in MADRS score (p < .001) and a greater proportion of responders (CGI-S) than patients with bipolar depression at endpoint (56% [N = 23] vs. 26% [N = 6], p = .02). Patients with mixed mania showed a greater reduction in suicidality, as measured by MADRS score, than patients with bipolar depression (p < .02). CONCLUSION: In our study, ECT was associated with a substantial reduction in symptomatology, in both patients with mixed mania and those with bipolar depression. However, the mixed mania group exhibited a more rapid and marked response as well as a greater reduction in suicidal ideation. Response to ECT was not influenced by the presence of delusions.

Dosimetric characterization of a bi-directional micromultileaf collimator for stereotactic applications.

A 6 MV photon beam from Linac SL75-5 has been collimated with a new micromultileaf device that is able to shape the field in the two orthogonal directions with four banks of leaves. This is the first clinical installation of the collimator and in this paper the dosimetric characterization of the system is reported. The dosimetric parameters required by the treatment planning system used for the dose calculation in the patient are: tissue maximum ratios, output factors, transmission and leakage of the leaves, penumbra values. Ionization chambers, silicon diode, radiographic films, and LiF thermoluminescent dosimeters have been employed for measurements of absolute dose and beam dosimetric data. Measurements with different dosimeters supply results in reasonable agreement among them and consistent with data available in literature for other models of micromultileaf collimator; that permits the use of the measured parameters for clinical applications. The discrepancies between results obtained with the different detectors (around 2%) for the analyzed parameters can be considered an indication of the accuracy that can be reached by current stereotactic dosimetry.