Geometrical imaging accuracy, image quality and plan quality for prostate cancer treatments on a 1.5 T MRLinac in patients with a unilateral hip implant.

Purpose.To assess the feasibility of prostate cancer radiotherapy for patients with a hip implant on an 1.5 T MRI-Linac (MRL) in terms of geometrical image accuracy, image quality, and plan quality.Methods.Pretreatment MRI images on a 1.5 T MRL and 3 T MRI consisting of a T2-weighted 3D delineation scan and main magnetic field homogeneity (B0) scan were performed in six patients with a unilateral hip implant. System specific geometrical errors due to gradient nonlinearity were determined for the MRL. Within the prostate and skin contour,B0inhomogeneity, gradient nonlinearity error and the total geometrical error (vector summation of the prior two) was determined. Image quality was determined by visually scoring the extent of implant-born image artifacts. A treatment planning study was performed on five patients to quantify the impact of the implant on plan quality, in which conventional MRL IMRT plans were created, as well as plans which avoid radiation through the left or right femur.Results.The total maximum geometrical error in the prostate was <1 mm and the skin contour <1.7 mm; in all cases the machine-specific gradient error was most dominant. TheB0error for the MRlinac MRI could partly be predicted based on the pre-treatment 3 T scan. Image quality for all patients was sufficient at 1.5 T MRL. Plan comparison showed that, even with avoidance of the hips, in all cases sufficient target coverage could be obtained with similar D1cc and D5cc to rectum and bladder, while V28Gy was slightly poorer in only the rectum for femur avoidance.Conclusion.We showed that geometrical accuracy, image quality and plan quality for six prostate patients with a hip implant or hip fixation treated on a 1.5 T MRL did not show relevant deterioration for the used image settings, which allowed safe treatment.

Sparing the surgical area with stereotactic body radiotherapy for combined treatment of spinal metastases: a treatment planning study.

INTRODUCTION: Decreasing the radiation dose in the surgical area is important to lower the risk of wound complications when surgery and radiotherapy are combined for the treatment of spinal metastases. The purpose of this study was to compare the radiation dose in the surgical area for spinal metastases between single fraction external beam radiotherapy (EBRT), single fraction stereotactic body radiotherapy (SBRT) and single fraction SBRT with active sparing (SBRT-AS) of the posterior surgical area. METHODS: Radiotherapy treatment plans for EBRT, SBRT and SBRT-AS of the posterior surgical area were created for 13 patients with spinal metastases. A single fraction of 8Gy was prescribed to the spinal metastasis in the EBRT plan. For the SBRT treatment plans, a single fraction of 18Gy was prescribed to the metastasis and 8Gy to the rest of the vertebral body. For the SBRT plan with active sparing the dose in the designated surgical area was minimized without compromising the dose to the organs at risk. RESULTS: The median dose in the surgical area was 2.6Gy (1.6-5.3Gy) in the SBRT plan with active sparing of the surgical area compared to a median dose of 3.7Gy (1.6-6.3Gy) in the SBRT plan without sparing and 6.5Gy (3.5-9.1Gy) in the EBRT plans (p < .001). The radiation doses to the spinal metastases and organs at risk were not significantly different between the SBRT plan with and without sparing the surgical area. CONCLUSIONS: The radiation dose to the surgical area is significantly decreased with the use of SBRT compared to EBRT. Active sparing of the surgical area further decreased the mean radiation dose in the surgical area without compromising the dose to the spinal metastasis and the organs at risk.

Development and clinical introduction of automated radiotherapy treatment planning for prostate cancer.

To develop an automated radiotherapy treatment planning and optimization workflow to efficiently create patient specifically optimized clinical grade treatment plans for prostate cancer and to implement it in clinical practice. A two-phased planning and optimization workflow was developed to automatically generate 77Gy 5-field simultaneously integrated boost intensity modulated radiation therapy (SIB-IMRT) plans for prostate cancer treatment. A retrospective planning study (n = 100) was performed in which automatically and manually generated treatment plans were compared. A clinical pilot (n = 21) was performed to investigate the usability of our method. Operator time for the planning process was reduced to <5 min. The retrospective planning study showed that 98 plans met all clinical constraints. Significant improvements were made in the volume receiving 72Gy (V72Gy) for the bladder and rectum and the mean dose of the bladder and the body. A reduced plan variance was observed. During the clinical pilot 20 automatically generated plans met all constraints and 17 plans were selected for treatment. The automated radiotherapy treatment planning and optimization workflow is capable of efficiently generating patient specifically optimized and improved clinical grade plans. It has now been adopted as the current standard workflow in our clinic to generate treatment plans for prostate cancer.

Length of hospitalization and disposition of elderly vs younger delirium patients in psychiatric hospitals.

Although it is commonly accepted that delirium patients require the full facilities of general hospitals, practical experience has shown that delirium patients of all ages continue to be admitted to psychiatric institutions. The present study was designed to detect any differences in the length of hospitalization and disposition (discharge back to the community, transfer to a general hospital, death during the index hospitalization, transfer to another psychiatric hospital) between elderly (> 65 years) and younger delirium patients admitted to psychiatric hospitalization. Our hypothesis was that the prognosis (represented in this study by the above-mentioned measures) of elderly delirium patients in a psychiatric hospital would be poorer compared with younger delirium patients. We studied psychiatric case register data of 805 patients with delirium admitted to psychiatric hospitals during the period 1984-1993. Our sample was divided into four ICD-9-CM categories: delirium in dementia, delirium tremens (DT), drug-induced delirium, and acute and subacute delirium. No significant differences in the length of hospitalization were found between < 65- and > 65-year-old patients in the categories studied. There were disposal differences between the two age groups in the acute and subacute delirium parameters, but findings in the other categories were similar. Practical implementation of the results in terms of appropriate place of management of delirium patients in a psychiatric hospital is discussed.

Diagnosis of dementia by different specialties.

The present study was undertaken to describe, explore and compare the specific methods and services provided by physicians of different specialties (general practitioners, geriatricians, neurologists, psychiatrists and geriatric psychiatrists) in the evaluation process of patients with suspected dementia in Israel. A self-administered questionnaire--mailed to 203 physicians (response rate 37%)--included items covering medical and specialty training, numbers of patients examined, evaluation approaches, use of formal diagnostic criteria, use of mini-mental tests, use of dementia severity rating scales, use of psychiatric and behavioral rating scales, and the use of laboratory examinations. Results indicate that the majority of physicians in all specialties either provided history taking, physical and neurological examination, or referred for it elsewhere. Deficiencies were noted regarding the use of psychiatric examination by the nonpsychiatric specialties, and provision of ADL evaluation by all specialties (except geriatricians). All specialties made a minimal use of neuropsychological tests. DSM-3/DSM-3R criteria for dementia were widely used by all specialties (except general practitioners). MMSE was the most widely used brief cognitive screening test. However, only a minority of general practitioners and psychiatrists made use of it. Laboratory tests in dementia evaluation were widely used by most physicians, irrespective of specialty. Further research is needed in order to define in more specific terms the advantages contributed by each specialty separately and in collaboration to the diagnostic process of dementia.

Psychiatric hospitalization of dementia patients by commitment order in Israel.

Commitment order by a district psychiatrist is one of several modes of involuntary admission into a psychiatric hospital. Data regarding all the commitment orders by district psychiatrists in 1990 for elderly patients age 65 years or more were obtained from the national psychiatric case register. Demographic and clinical characteristics of patients diagnosed as ICD-9 senile organic psychotic conditions have been compared with the same characteristics of patients suffering from ICD-9 affective psychoses, schizophrenic disorders, paranoid states and transient organic psychotic conditions. The conclusions are: (a) Dementia patients are underrepresented in this sample of commitment orders; (b) from a demographic point of view dementia patients are no different from other psychiatric patients, age being the sole exception; and (c) from a clinical point of view dementia patients differ from other committed psychiatric patients in three ways: (i) their commitment is usually their first hospitalization; (ii) they are discharged from hospital within a two-month period; and (iii) they are referred for continuation of treatment in a non-psychiatric system. We conclude that psychiatric admissions under commitment order constitute a temporary solution for a very small group of dementia patients.

Influence of age on the management of blow-out fractures of the orbital floor.

This study concerns 50 patients with blow-out fractures of the orbital floor, including 15 children, and was designed to evaluate the influence of age on clinical presentation and postoperative results. Fourteen of the 15 children were found to have a trap-door fracture. This type of fracture was not found in adults, who usually present with a large "open-door" fracture. In trap-door fractures, orbital tissues are liable to become trapped and even strangulated. It is therefore suggested that young patients with severely restricted eyeball motility, an unequivocal positive forced duction test, and findings indicating blow-out fracture of the orbital floor on CT, should undergo operative treatment as soon as possible after injury. A "wait and see" policy, keeping the patient under observation, seems to be appropriate for blow-out fractures in adults. Surgical treatment is recommended only in those adult patients who demonstrate impairment of vertical eyeball motility within the mainfield of view after the haemorrhage and oedema have resolved and in whom change in motility is no longer seen and Hertel measurements have stabilized.

Adverse cutaneous reactions to psychotropic drugs.

This article reviews the adverse cutaneous reactions due to psychotropic medications. The prevalence of skin reactions to these agents is about 5%.

Use of blocks of hydroxylapatite for secondary reconstruction of the orbital floor.

Malposition of the globe and failure to fuse images may be the result of orbital trauma. Five patients are reviewed in whom secondary correction of enophthalmos, sunken globe and diplopia was performed by implantation of blocks of dense hydroxylapatite.

Staff attitudes toward violence in the general hospital. A comparison between Amsterdam and Tel Aviv.

This study reports the results of a cross-cultural comparative investigation of violent behavior of patients, relatives, and visitors toward the medical staff in two general hospitals. The situation in an Israeli community general hospital in Tel Aviv was compared to that of a Dutch university hospital. General impressions existed that violence appeared to be a serious problem in the hospital in Tel Aviv, whereas there are scarcely any reports of violence in general hospitals in the Netherlands. Semistructured interviews with members of the medical and nursing staff confirmed these impressions. In Israel, the "aggressor" would be described as a young male without any specific traits, whereas in the Netherlands, he would be associated with alcohol abuse, drug addiction, and would possibly belong to street gangs or be a member of a minority group. Circumstances that may lead to violence are mentioned and situational, and social and cultural influences are discussed.

Bimaxillary hyperplasia: the facial expression of homozygous beta-thalassemia.

A boy born in Curaçoa, who was 6 years old at his initial visit and known to have homozygous beta-thalassemia, is described. Emphasis is directed to the typical facial expression. The possibility of surgical treatment of the maxillary hypertrophy is discussed. However, in view of the limited life expectancy of these patients, correction should not be performed before adolescence.

Roulette of the road: a new kind of suicide attempt? A preliminary report.

The author reports on children aged 7-14 who throw an object onto the highway shortly before a car comes and run to fetch it in front of the approaching automobile. He discusses the problems linked with that roulette-style play with death.

Carotid-cavernous sinus fistula following maxillofacial trauma and orthognathic surgery.

The presence of a carotid-cavernous sinus fistula after maxillofacial trauma or orthognathic surgery is uncommon. 2 patients are described who developed a carotid-cavernous sinus fistula. Early diagnosis is important, since delay in treatment may cause irreversible neurological and/or ophthalmological damage. The etiology of the carotid-cavernous sinus fistulas is discussed, in the cases described.

Sudden open bite resulting from hemarthrosis: report of a case.

In contrast to chronic inability to open the mouth, inadequate closure of the jaws seldom occurs. The present case describes a young women with hereditary hyperlipoproteinism on an anticoagulant who suddenly developed an unilateral open bite due to a hemarthrosis of the left TMJ. After aspiration of the accumulated blood in the temporomandibular joint, the open bite disappeared and the occlusion became normal.

Gingival hyperplasia induced by nifedipine, an arterial vasodilating drug.

In a 32-year-old patient a relationship was suggested between the development of gingival hyperplasia and the vasodilating drug nifedipine (Adalat). The hyperplasia was clinically and histologically similar to the gingival hyperplasia previously noticed with diphenylhydantoin. The nifedipine-induced gingival hyperplasia may be caused by alterations in calcium metabolism.