Experiences of people with non-traumatic spinal cord injuries returning home after inpatient rehabilitation.

PURPOSE: The aim of this study was to explore the experience of people with non-traumatic spinal cord injuries who have recently returned home from inpatient rehabilitation. METHODS: Semi-structured interviews were conducted with seven adults with non-traumatic spinal cord injuries who had been discharged from inpatient rehabilitation from an Australian rehabilitation hospital, within the last two years. RESULTS: Three themes were identified: the practicalities of coming home; adjusting to "my altered home life"; pursuing recovery. When people felt prepared by their rehabilitation service, and had appropriate support from others, they had a more positive adjustment experience, although not one without challenges. Due to less independence and inability to participate in meaningful life roles, participants experienced a sense of lost or changed identity. Maintaining hope for physical recovery was very important and motivated participants to actively engage in rehabilitation efforts. CONCLUSIONS: This study adds to the knowledge regarding the lived experience of people with non-traumatic spinal cord injury transitioning from rehabilitation to home. Facilitators for successful rehabilitation discharge included ensuring community services contacted patients immediately after they left hospital, and providing support for carers. Health care workers can positively influence the adjustment process of people with NTSCI by facilitating re-engagement in meaningful roles.IMPLICATIONS FOR REHABILITATIONThe transition home from inpatient rehabilitation after non-traumatic spinal cord injury (NTSCI) is facilitated by early discharge planning and follow-up from services after discharge.Establishing routines helped participants adjust to their new circumstances.The emotional and practical support of carers is vital for successful adjustment to living in the community with an NTSCI.Health care workers can positively influence the adjustment process of people with NTSCI by facilitating their re-engagement in meaningful roles.

Capacitive monitoring system for real-time respiratory motion monitoring during radiation therapy.

This work introduces a novel capacitive-sensing technology capable of detecting respiratory motion with high temporal frequency (200 Hz). The system does not require contact with the patient and has the capacity to sense motion through clothing or plastic immobilization devices. ABSTRACT: PURPOSE: This work presents and evaluates a novel capacitive monitoring system (CMS) technology for continuous detection of respiratory motion during radiation therapy. This modular system provides real-time motion monitoring without any contact with the patient, ionizing radiation, or surrogates such as reflective markers on the skin. MATERIALS AND METHODS: The novel prototype features an array of capacitive detectors that are sensitive to the position of the body and capable of high temporal frequency readout. Performance of this system was investigated in comparison to the RPM infrared (IR) monitoring system (Varian Medical Systems). The prototype included three (5 cm × 10 cm) capacitive copper sensors in one plane, located at a distance of 8-10 cm from the volunteer. Capacitive measurements were acquired for central and lateral-to-central locations during chest free-breathing and abdominal breathing. The RPM IR data were acquired with the reflector block at corresponding positions simultaneously. The system was also tested during deep inspiration and expiration breath-hold maneuvers. RESULTS: Capacitive monitoring system data demonstrate close agreement with the RPM status quo at all locations examined. Cross-correlation analysis on RPM and CMS data showed an average absolute lag of 0.07 s (range: 0.03-0.23 s) for DIBH and DEBH data and 0.15 s (range: 0-0.43 s) for free-breathing. Amplitude difference between the normalized CMS and RPM signal during chest and abdominal breathing was within 0.15 for 94.3% of the data points after synchronization. CMS performance was not affected when the subject was clothed. CONCLUSION: This novel technology permits sensing of both free-breathing and breath-hold respiratory motion. It provides data comparable to the RPM system but without the need for an IR tracking camera in the treatment room or use of reflective markers on the patient.

Pan-Canadian Survey of Medical Radiation Technologist's Views Toward Evidence-Based Practice, Research, Barriers, and Enablers.

OBJECTIVES: To examine the attitudes, perceptions, enablers/barriers, and level of uptake of evidence-based practice (EBP) and research within the medical radiological technologist (MRT) community in Canada. METHODS: Using the Canadian Association of Medical Radiation Technologists' e-mail distribution list, all members were sent an invitation and link to an online electronic survey. The survey included demographics and questions asking participants about their perceptions of EBP, research, and barriers. Data were analyzed with descriptive statistics and partial proportional odds models. RESULTS: Four hundred and forty-four completed surveys were available for analysis. Respondents showed good distribution among professions and geographical location. Eighty-four percent of respondents indicated having a good grasp of the concept of EBP. A majority of the respondents (>70%) in all the professions strongly agreed/agreed that all MRTs should practice in an evidence-based manner. Eighty percent of respondents strongly agreed/agreed that there is a link between EBP and research. There was a statistically significant association between the current level of knowledge to develop a research project and level of academic research education received, research culture in the department, and the presence of barriers. Partial proportional odds model indicates participants were more likely to have a good grasp of EBP and have strongly agreed/agreed that they should practice in an evidence-based manner if they were a radiation therapist, have medium-high current levels of research knowledge, or were a permanent full-time employee. In addition, radiation therapists were at least 4 times more likely to participate in research as a primary or coinvestigator, compared to other MRT professions. Most frequently identified extrinsic barriers to EBP/research included lack of time, heavy workload, lack of leadership support, and workplace attitudes/culture. Extrinsic success factors included access to a mentor, dedicated time, collaboration, and support from management and peers. Intrinsic success factors were as follows: self-motivation, sense of inquiry/curiosity, and satisfaction with creating patient or workplace change based on research. CONCLUSIONS: This pan-Canadian, interprofessional survey highlights the current landscape with respect to perceptions and uptake of EBP and research among MRTs. Results of this study may offer MRTs, employers, educational facilities, and professional bodies insight into strategies that can be undertaken to improve MRT research participation across professions.

Describing a Process for Creating a Patient Visible Quality Educational Display to Increase Patient Engagement in Radiation Oncology Throughout the Canadian Maritimes Provinces.

Here, we report the process for creating a patient visible quality educational display to highlight the collaborative quality working practices of Radiation Oncology clinicians and staff in the main Radiotherapy Centers throughout three Canadian provinces. These processes are often not visible to patients yet they speak directly to the standards of care delivered at these centers. The Canadian Partnership for Quality Radiotherapy (CPQR) Quality Assurance Guidelines for Canadian Radiation Treatment Programs guided this process. The display slides created were approved by the local Radiation Oncology departmental leadership for each participating medical center as well as patient focus groups and revised with feedback from both perspectives. Of 27 patients/families who evaluated the resulting educational patient display, 70% expressed high engagement in the information presented, and 81% felt the display will be of interest to patients receiving radiotherapy treatment. Patients/families surveyed reported that the displayed content made them feel more informed and more comfortable with their treatments. Survey data from this project indicates that increasing transparency and deepening patient education about the quality working practices behind radiotherapy treatments has the potential to empower patients receiving radiotherapy and increase their confidence in the care they are receiving.

Performance optimization of capacitive motion sensing (CMS) system for intra-fraction motion detection during stereotactic radiosurgery.

The purpose of this investigation is to improve intra-fractional motion detection during cranial stereotactic radiosurgery with a novel capacitive motion sensing (CMS) system. Previous work showed that a capacitive detection system, based on a MPR121 capacitance-to-digital converter, provided a number of advantages over existing patient imaging systems used in the clinic, by uniquely offering ionizing-radiation-free and continuous monitoring without modification to the immobilization mask or treatment room. However, in order to provide submillimeter detection accuracy, the MPR121-based CMS system required relatively large sensors in close proximity to the patient. Therefore, the aim of this investigation was to improve sensitivity of the system, allowing reduction in sensor size and preserving its stable operation in the linear accelerator environment. For this, we developed, characterized and compared motion detection capabilities of four CMS systems based on different capacitance-to-digital converters: MPR121, CPT212B, FDC1004 and FDC2214. Among all candidates, the FDC2214-based system was found to uniquely combine accurate 3D motion detection in real time, with stable performance under ionizing radiation. It exhibited an order of magnitude improvement in sensitivity in comparison with the proof-of-study system, allowing a spatial precision as low as 0.3 mm, and its overall performance was found to satisfy the AAPM practice guidelines of positioning tolerance within 1 mm. Furthermore, the high sensitivity of the system allows both reduction of the sensor area and location more distant from the patient surface, which are key improvements with regard to development of a clinical device.

Intrapatient study comparing 3D printed bolus versus standard vinyl gel sheet bolus for postmastectomy chest wall radiation therapy.

PURPOSE: This patient study evaluated the use of 3-dimensional (3D) printed bolus for chest wall radiation therapy compared with standard sheet bolus with regard to accuracy of fit, surface dose measured in vivo, and efficiency of patient setup. By alternating bolus type over the course of therapy, each patient served as her own control. METHODS AND MATERIALS: For 16 patients undergoing chest wall radiation therapy, a custom 5.0 mm thick bolus was designed based on the treatment planning computed tomography scan and 3D printed using polylactic acid. Cone beam computed tomography scanning was used to image and quantify the accuracy of fit of the 2 bolus types with regard to air gaps between the bolus and skin. As a quality assurance measure for the 3D printed bolus, optically stimulated luminescent dosimetry provided in vivo comparison of surface dose at 7 points on the chest wall. Durations of patient setup and image guidance were recorded and compared. RESULTS: In 13 of 16 patients, the bolus was printed without user intervention, and the median print time was 12.6 hours. The accuracy of fit of the bolus to the chest wall was improved significantly relative to standard sheet bolus, with the frequency of air gaps 5 mm or greater reduced from 30% to 13% (P < .001) and maximum air gap dimension diminished from 0.5 ± 0.3 to 0.3 ± 0.3 mm on average. Surface dose was within 3% for both standard sheet and 3D printed bolus. On average, the use of 3D printed bolus reduced the setup time from 104 to 76 seconds. CONCLUSIONS: This study demonstrates 3D printed bolus in postmastectomy radiation therapy improves fit of the bolus and reduces patient setup time marginally compared with standard vinyl gel sheet bolus. The time savings on patient setup must be weighed against the considerable time needed for the 3D printing process.

Clinical applications of 3-dimensional printing in radiation therapy.

Three-dimensional (3D) printing is suitable for the fabrication of complex radiotherapy bolus. Although investigated from dosimetric and feasibility standpoints, there are few reports to date of its use for actual patient treatment. This study illustrates the versatile applications of 3D printing in clinical radiation oncology through a selection of patient cases, namely, to create bolus for photon and modulated electron radiotherapy (MERT), as well as applicators for surface high-dose rate (HDR) brachytherapy. Photon boluses were 3D-printed to treat a recurrent squamous cell carcinoma (SCC) of the nasal septum and a basal cell carcinoma (BCC) of the posterior pinna. For a patient with a mycosis fungoides involving the upper face, a 3D-printed MERT bolus was used. To treat an SCC of the nose, a 3D-printed applicator for surface brachytherapy was made. The structures' fit to the anatomy and the radiotherapy treatment plans were assessed. Based on the treatment planning computed tomography (CT), the size of the largest air gap at the interface of the 3D-printed structure was 3 mm for the SCC of the nasal septum, 3 mm for the BCC of the pinna, 2 mm for the mycosis fungoides of the face, and 2 mm for the SCC of the nose. Acceptable treatment plans were obtained for the SCC of the nasal septum (95% isodose to 99.8% of planning target volume [PTV]), the BCC of the pinna (95% isodose to 97.7% of PTV), and the mycosis fungoides of the face (90% isodose to 92.5% of PTV). For the latter, compared with a plan with a uniform thickness bolus, the one featuring the MERT bolus achieved relative sparing of all the organs at risk (OARs) distal to the target volume, while maintaining similar target volume coverage. The surface brachytherapy plan for the SCC of the nose had adequate coverage (95% isodose to 95.6% of clinical target volume [CTV]), but a relatively high dose to the left eye, owing to its proximity to the tumor. 3D printing can be implemented effectively in the clinical setting to create highly conformal bolus for photon and MERT, as well as applicators for surface brachytherapy.

The Canadian National System for Incident Reporting in Radiation Treatment (NSIR-RT) Taxonomy.

PURPOSE: Incident investigation, reporting, and learning are core elements of quality improvement in radiation treatment. This report describes the development of a Canadian National System for Incident Reporting in Radiation Treatment (NSIR-RT), focusing especially on the taxonomy. METHODS AND MATERIALS: The NSIR-RT was developed to provide a framework in Canada for reporting and analyzing radiation treatment incidents. A key objective was to assure compatibility with other international reporting systems to facilitate future information exchange. The Canadian community was engaged at every step of the development process through Delphi consensus building and inter-user agreement testing to promote awareness of the system and motivate broad-based utilization across the country. RESULTS: The final taxonomy was comprised of 6 data groups (impact, discovery, patient, details, treatment delivery, and investigation) and 33 data categories with predefined menu options. There was a high level agreement within the Canadian community about the final suite of data categories, and broad alignment of these categories with the World Health Organization and other American and European radiation treatment incident classifications. CONCLUSIONS: The Canadian NSIR-RT taxonomy will be implemented as an online, web-based reporting and analysis system. It is expected that the taxonomy will evolve and mature over time to meet the changing needs of the Canadian radiation treatment community and support radiation treatment incident learning on a global scale.

The Outcome of Using Closed Suction Wound Drains in Patients Undergoing Lumbar Spine Surgery: A Systematic Review.

Study Design Systematic review. Objective Determine whether closed suction wound drains decrease the incidence of postoperative complications compared with no drain use in patients undergoing spine surgery for lumbar degenerative conditions. Methods Electronic databases and reference lists of key articles were searched up through January 22, 2015, to identify studies comparing the use of closed suction wound drains with no drains in spine surgery for lumbar degenerative conditions. Outcomes assessed included the cumulative incidence of epidural hematoma, superficial and deep wound infection, and postoperative blood transfusion. The overall strength of evidence across studies was based on precepts outlined by the Grades of Recommendation Assessment, Development and Evaluation Working Group. Results Five heterogeneous studies, three randomized controlled trials, and two cohort studies form the evidence basis for this report. There was no difference in the incidence of hematoma, superficial wound infection, or deep infection in patients with compared with patients without closed suction wound drains after lumbar surgery. The upper bounds of the 95% confidence interval for hematoma ranged from 1.1 to 16.7%; for superficial infection, 1.0 to 7.3%; and for deep infection, 1.0 to 7.1%. One observational study reported a 3.5-fold increase in the risk of blood transfusion in patients with a drain. The overall strength of evidence for these findings is considered low or insufficient. Conclusions Conclusions from this systematic review are limited by the quality of included studies that assessed the use of closed suction wound drains in lumbar spine surgeries for degenerative conditions. We believe that spine surgeons should not routinely rely on closed suction wound drains in lumbar spine surgery until a higher level of evidence becomes available to support its use.

The Quest for Quality: Principles to Guide Medical Radiation Technology Practice.

Quality is a ubiquitous term in medical radiation technology; technologists, programs, and organizations emphasize the importance of "quality care," yet the concept of what is encompassed by the term, how it is built and measured, and who is the judge of whether it has been achieved, are often left undefined. This article will present theoretical definitions of quality, considering the value of professional, patient, and organization perspectives. Foundational quality principles and frameworks will be explored to highlight tools necessary to engage in "quality-related" activities and research at the individual, institutional, and systems level. Being equipped with an understanding of the work of Deming, the underpinnings of the lean strategy and the idea of continuous quality improvement will support technologists in contributing to evidence-based, high-quality, and safe practice. Building on these basics, concepts of complexity and standardization will be explored as they relate to achieving and maintaining quality given changing practice, focusing on personalized medicine, technological innovation, and best practice guidelines. Means to measure and evaluate quality will be presented, emphasizing the need for a structured approach. Using the work of the Canadian Partnership for Quality Radiotherapy as an example, key quality-related considerations, such as incident reporting, organizational structure, and quality culture will be discussed, with specific attention to roles within the team. When appropriately defined, measured, and evaluated, the quest for quality has the potential to improve safety and mitigate risk. Engaging technologists to assume strong roles in providing the highest quality of care will contribute positively at the level of the individual patient, the organization, and the system.

Design and production of 3D printed bolus for electron radiation therapy.

This is a proof-of-concept study demonstrating the capacity for modulated electron radiation therapy (MERT) dose distributions using 3D printed bolus. Previous reports have involved bolus design using an electron pencil beam model and fabrication using a milling machine. In this study, an in-house algorithm is presented that optimizes the dose distribution with regard to dose coverage, conformity, and homogeneity within the planning target volume (PTV). The algorithm takes advantage of a commercial electron Monte Carlo dose calculation and uses the calculated result as input. Distances along ray lines from the distal side of 90% isodose line to distal surface of the PTV are used to estimate the bolus thickness. Inhomogeneities within the calculation volume are accounted for using the coefficient of equivalent thickness method. Several regional modulation operators are applied to improve the dose coverage and uniformity. The process is iterated (usually twice) until an acceptable MERT plan is realized, and the final bolus is printed using solid polylactic acid. The method is evaluated with regular geometric phantoms, anthropomorphic phantoms, and a clinical rhabdomyosarcoma pediatric case. In all cases the dose conformity are improved compared to that with uniform bolus. For geometric phantoms with air or bone inhomogeneities, the dose homogeneity is markedly improved. The actual printed boluses conform well to the surface of complex anthropomorphic phantoms. The correspondence of the dose distribution between the calculated synthetic bolus and the actual manufactured bolus is shown. For the rhabdomyosarcoma patient, the MERT plan yields a reduction of mean dose by 38.2% in left kidney relative to uniform bolus. MERT using 3D printed bolus appears to be a practical, low-cost approach to generating optimized bolus for electron therapy. The method is effective in improving conformity of the prescription isodose surface and in sparing immediately adjacent normal tissues.

Scientific basis for safely shutting in the Macondo Well after the April 20, 2010 Deepwater Horizon blowout.

As part of the government response to the Deepwater Horizon blowout, a Well Integrity Team evaluated the geologic hazards of shutting in the Macondo Well at the seafloor and determined the conditions under which it could safely be undertaken. Of particular concern was the possibility that, under the anticipated high shut-in pressures, oil could leak out of the well casing below the seafloor. Such a leak could lead to new geologic pathways for hydrocarbon release to the Gulf of Mexico. Evaluating this hazard required analyses of 2D and 3D seismic surveys, seafloor bathymetry, sediment properties, geophysical well logs, and drilling data to assess the geological, hydrological, and geomechanical conditions around the Macondo Well. After the well was successfully capped and shut in on July 15, 2010, a variety of monitoring activities were used to assess subsurface well integrity. These activities included acquisition of wellhead pressure data, marine multichannel seismic profiles, seafloor and water-column sonar surveys, and wellhead visual/acoustic monitoring. These data showed that the Macondo Well was not leaking after shut in, and therefore, it could remain safely shut until reservoir pressures were suppressed (killed) with heavy drilling mud and the well was sealed with cement.

The early Miocene onset of a ventilated circulation regime in the Arctic Ocean.

Deep-water formation in the northern North Atlantic Ocean and the Arctic Ocean is a key driver of the global thermohaline circulation and hence also of global climate. Deciphering the history of the circulation regime in the Arctic Ocean has long been prevented by the lack of data from cores of Cenozoic sediments from the Arctic's deep-sea floor. Similarly, the timing of the opening of a connection between the northern North Atlantic and the Arctic Ocean, permitting deep-water exchange, has been poorly constrained. This situation changed when the first drill cores were recovered from the central Arctic Ocean. Here we use these cores to show that the transition from poorly oxygenated to fully oxygenated ('ventilated') conditions in the Arctic Ocean occurred during the later part of early Miocene times. We attribute this pronounced change in ventilation regime to the opening of the Fram Strait. A palaeo-geographic and palaeo-bathymetric reconstruction of the Arctic Ocean, together with a physical oceanographic analysis of the evolving strait and sill conditions in the Fram Strait, suggests that the Arctic Ocean went from an oxygen-poor 'lake stage', to a transitional 'estuarine sea' phase with variable ventilation, and finally to the fully ventilated 'ocean' phase 17.5 Myr ago. The timing of this palaeo-oceanographic change coincides with the onset of the middle Miocene climatic optimum, although it remains unclear if there is a causal relationship between these two events.

Episodic fresh surface waters in the Eocene Arctic Ocean.

It has been suggested, on the basis of modern hydrology and fully coupled palaeoclimate simulations, that the warm greenhouse conditions that characterized the early Palaeogene period (55-45 Myr ago) probably induced an intensified hydrological cycle with precipitation exceeding evaporation at high latitudes. Little field evidence, however, has been available to constrain oceanic conditions in the Arctic during this period. Here we analyse Palaeogene sediments obtained during the Arctic Coring Expedition, showing that large quantities of the free-floating fern Azolla grew and reproduced in the Arctic Ocean by the onset of the middle Eocene epoch (approximately 50 Myr ago). The Azolla and accompanying abundant freshwater organic and siliceous microfossils indicate an episodic freshening of Arctic surface waters during an approximately 800,000-year interval. The abundant remains of Azolla that characterize basal middle Eocene marine deposits of all Nordic seas probably represent transported assemblages resulting from freshwater spills from the Arctic Ocean that reached as far south as the North Sea. The termination of the Azolla phase in the Arctic coincides with a local sea surface temperature rise from approximately 10 degrees C to 13 degrees C, pointing to simultaneous increases in salt and heat supply owing to the influx of waters from adjacent oceans. We suggest that onset and termination of the Azolla phase depended on the degree of oceanic exchange between Arctic Ocean and adjacent seas.

Subtropical Arctic Ocean temperatures during the Palaeocene/Eocene thermal maximum.

The Palaeocene/Eocene thermal maximum, approximately 55 million years ago, was a brief period of widespread, extreme climatic warming, that was associated with massive atmospheric greenhouse gas input. Although aspects of the resulting environmental changes are well documented at low latitudes, no data were available to quantify simultaneous changes in the Arctic region. Here we identify the Palaeocene/Eocene thermal maximum in a marine sedimentary sequence obtained during the Arctic Coring Expedition. We show that sea surface temperatures near the North Pole increased from 18 degrees C to over 23 degrees C during this event. Such warm values imply the absence of ice and thus exclude the influence of ice-albedo feedbacks on this Arctic warming. At the same time, sea level rose while anoxic and euxinic conditions developed in the ocean's bottom waters and photic zone, respectively. Increasing temperature and sea level match expectations based on palaeoclimate model simulations, but the absolute polar temperatures that we derive before, during and after the event are more than 10 degrees C warmer than those model-predicted. This suggests that higher-than-modern greenhouse gas concentrations must have operated in conjunction with other feedback mechanisms--perhaps polar stratospheric clouds or hurricane-induced ocean mixing--to amplify early Palaeogene polar temperatures.

The Cenozoic palaeoenvironment of the Arctic Ocean.

The history of the Arctic Ocean during the Cenozoic era (0-65 million years ago) is largely unknown from direct evidence. Here we present a Cenozoic palaeoceanographic record constructed from >400 m of sediment core from a recent drilling expedition to the Lomonosov ridge in the Arctic Ocean. Our record shows a palaeoenvironmental transition from a warm 'greenhouse' world, during the late Palaeocene and early Eocene epochs, to a colder 'icehouse' world influenced by sea ice and icebergs from the middle Eocene epoch to the present. For the most recent approximately 14 Myr, we find sedimentation rates of 1-2 cm per thousand years, in stark contrast to the substantially lower rates proposed in earlier studies; this record of the Neogene reveals cooling of the Arctic that was synchronous with the expansion of Greenland ice (approximately 3.2 Myr ago) and East Antarctic ice (approximately 14 Myr ago). We find evidence for the first occurrence of ice-rafted debris in the middle Eocene epoch (approximately 45 Myr ago), some 35 Myr earlier than previously thought; fresh surface waters were present at approximately 49 Myr ago, before the onset of ice-rafted debris. Also, the temperatures of surface waters during the Palaeocene/Eocene thermal maximum (approximately 55 Myr ago) appear to have been substantially warmer than previously estimated. The revised timing of the earliest Arctic cooling events coincides with those from Antarctica, supporting arguments for bipolar symmetry in climate change.