Highly efficient and sensitive patient-specific quality assurance for spot-scanned proton therapy.

The purpose of this work was to develop an end-to-end patient-specific quality assurance (QA) technique for spot-scanned proton therapy that is more sensitive and efficient than traditional approaches. The patient-specific methodology relies on independently verifying the accuracy of the delivered proton fluence and the dose calculation in the heterogeneous patient volume. A Monte Carlo dose calculation engine, which was developed in-house, recalculates a planned dose distribution on the patient CT data set to verify the dose distribution represented by the treatment planning system. The plan is then delivered in a pre-treatment setting and logs of spot position and dose monitors, which are integrated into the treatment nozzle, are recorded. A computational routine compares the delivery log to the DICOM spot map used by the Monte Carlo calculation to ensure that the delivered parameters at the machine match the calculated plan. Measurements of dose planes using independent detector arrays, which historically are the standard approach to patient-specific QA, are not performed for every patient. The nozzle-integrated detectors are rigorously validated using independent detectors in regular QA intervals. The measured data are compared to the expected delivery patterns. The dose monitor reading deviations are reported in a histogram, while the spot position discrepancies are plotted vs. spot number to facilitate independent analysis of both random and systematic deviations. Action thresholds are linked to accuracy of the commissioned delivery system. Even when plan delivery is acceptable, the Monte Carlo second check system has identified dose calculation issues which would not have been illuminated using traditional, phantom-based measurement techniques. The efficiency and sensitivity of our patient-specific QA program has been improved by implementing a procedure which independently verifies patient dose calculation accuracy and plan delivery fidelity. Such an approach to QA requires holistic integration and maintenance of patient-specific and patient-independent QA.

Assessment of older urban drivers by nurse practitioners.

Thirty-five older urban adults who had forfeited a driver's license and 25 nurse practitioners (NPs) who provided health care to them participated in a qualitative study to (a) explore the perception of NPs regarding their role in assessing the driving abilities of older adults, (b) describe the ways in which NPs assist their clients to cope with the loss of a driver's license, and (c) delineate the NPs influence on the elders' decision to forfeit their license. Findings suggest that most NPs had concerns about their older clients' driving abilities. However, assessment of parameters related to driving safety was not their primary objective. An NPs recommendation to forfeit a license was important to the older driver's decision to do so. Assisting clients with the consequences of no longer driving was difficult for a variety of reasons.

Product review: lucis image processing software.

Lucis is a software program that allows the manipulation of images through the process of selective contrast pattern emphasis. Using an image-processing algorithm called Differential Hysteresis Processing (DHP), Lucis extracts and highlights patterns based on variations in image intensity (luminance). The result is that details can be seen that would otherwise be hidden in deep shadow or excessive brightness. The software is contained on a single floppy disk, is easy to install on a PC, simple to use, and runs on Windows 95, Windows 98, and Windows NT operating systems. The cost is $8,500 for a license, but is estimated to save a great deal of money in photographic materials, time, and labor that would have otherwise been spent in the darkroom. Superb images are easily obtained from unstained (no lead or uranium) sections, and stored image files sent to laser printers are of publication quality. The software can be used not only for all types of microscopy, including color fluorescence light microscopy, biological and materials science electron microscopy (TEM and SEM), but will be beneficial in medicine, such as X-ray films (pending approval by the FDA), and in the arts.

Bilevel multidisciplinary discharge planning and length of stay.

As health care funding gets more and more tenuous, leaders in all institutions are called upon to find innovative ways to reduce costs while maintaining quality. It is possible to realize undreamed-of savings by reengineering certain processes, but such an undertaking demands that wholesale changes in the corporate culture and substantial effort at all levels. This paper reports a long-term project at a large, urban, tertiary care institution, the redesign of discharge planning to improve patient care and reduce lengths of stay and related expenses.

Nursing assessment of older rural drivers.

Fifty rural nurses and 75 rural elders participated in a study to (a) explore the perceptions of nurses regarding their role in assessing the driving abilities of rural elders and (b) to describe the nurse's influence on rural elders' decision to stop driving. Findings suggest that, although driving safety of rural elders is of concern to nurses, they do not discuss these concerns with their clients, and rural elders do not discuss driving with nurses.

Robotic solid-phase extraction of amphetamines from urine for analysis by gas chromatography-mass spectrometry.

We have evaluated the use of the Hamilton Microlab 2200 robotic pipetting system modified to conduct solid-phase extractions of amphetamines from urine. The Hamilton system is a programmable XYZ robotic sample handling instrument compatible with commercial solid-phase extraction (SPE) columns in the most commonly available sizes. During the extraction and elution steps, the system delivers programmable positive pressure with pressure controlled feedback so as to ensure consistent recovery. The system increases sample throughput while reducing technician hands-on time and improving sample-to-sample and batch-to-batch consistency. In comparison with the manual SPE method, the automated scheme provides similar analyte recovery, accuracy, and precision and a reduced potential for laboratory errors. The method's upper limits of linearity, detection, and lquantitation were, respectively, 10,000, 100, and 100 ng/mL for amphetamine and 25,000, 50, and 50 ng/mL for methamphetamine. Extraction recoveries for the compounds ranged from 88 to 101%. Carryover amounted to less than 0.02% even at 50,000 ng/mL concentrations of analyte. A typical automated run required 20 min of technician time versus 90 min for a corresponding manual SPE procedure. The automated procedure proved to be a reliable and labor-efficient addition to the laboratory.

Patients' health problems: differences in perceptions between home health patients and nurses.

Quality care is consumer-driven care. Yet, much of home healthcare is driven by Medicare regulations and reimbursement rates. This study compared home health patients' perceptions of their health problems with nurses' documentation of the patients' health problems. The results showed that the problems patients report and nurses document are very different. Home health nurses must move beyond a focus on medicare-reimbursable patient problems to documenting and providing consumer-driven patient care.