The introduction of a fetal ultrasound telemedicine service: quality outcomes and family costs

Introduction: The complexity of fetal medicine (FM) referrals that can be managed in a district general hospital (DGH) is dependent on the availability of specialist ultrasound expertise. Telemedicine can effectively transfer real-time ultrasound images via video-conferencing. We report the successful introduction of a fetal ultrasound telemedicine service. Methods: All women referred for FM consultation from the linked DGH were seen via a weekly telemedicine service, excluding cases where invasive testing was anticipated. Image and audio quality were rated (using a 5 point scale) following each consultation. Women referred for their first appointment were asked to complete a questionnaire following the consultation. Figures presented are median [range]. Results: 80 women had a telemedicine consultation between October 2015 and September 2016. 37 cases were new referrals because of fetal anomaly (n = 17), exclusion of abnormal placental invasion (n = 11), small-for-gestational-age (n = 7) and prior history of fetal anomaly (n = 2) and 43 cases were follow-up consultations. Median gestation was 29 [13–36] weeks. Image quality was of sufficient quality to achieve the aims of the consultation in 79 cases with an image score of 4 [3–5] and audio score of 5 [3–5]. Journey to the telemedicine consultation was 20 [4–150] minutes in comparison to an estimated journey time of 238 [120–450] minutes to the FM centre. Estimated family costs for attendance at the FM centre were £95 [20–555]. Conclusion: We have demonstrated that a fetal ultrasound telemedicine service can be successfully introduced and used to provide high quality consultations

Fetal telemedicine: a mixed methods evaluation

Introduction: The complexity of fetal medicine (FM) referrals that can be managed in a district general hospital (DGH) is dependent on the availability of specialist ultrasound expertise. Telemedicine can effectively transfer real-time ultrasound images via video-conferencing. Aims and objectives: Our objective was to establish a fetal telemedicine service between the obstetric ultrasound unit of a DGH and a specialist FM unit. In evaluating the service we aimed to: (i) determine the technical success of fetal telemedicine; (ii) test the utility of telemedicine technology for training sonographers (iii) assess women’s experiences and acceptance of tele-ultrasound, including a consideration of family costs; (iv) understand the barriers and enablers of technology adoption from the perspectives of clinical stakeholders. Methods: Women referred for FM consultation from the DGH were seen via a weekly telemedicine service, excluding cases where invasive testing was anticipated. Image and audio quality were rated (using a 5 point scale) following each consultation. The service evaluation employed mixed methods. Referred women were asked to complete a questionnaire following their first consultation, 31 did so and follow-up telephone interviews were undertaken with 16 of them. Semi-structured qualitative interviews were also undertaken with six key clinical stakeholders, two commissioners and two service managers. Results: 80 women received a telemedicine consultation between October 2015 and September 2016. Of these, 37 cases were new referrals because of fetal anomaly (n=17), including exclusion of abnormal placental invasion (n=11), small-for-gestational age (n=7) and prior history of fetal anomaly (n=2); 43 cases were follow-up consultations. Median gestation was 29 [13-36] weeks. Image quality was of sufficient quality to achieve the aims of the consultation in 79 cases with an image score of 4 [3-5] and audio score of 5 [3-5]. The majority of referred women responded positively to fetal telemedicine; identified benefits included cost savings and less inconvenience from being seen locally. Average journey time to the telemedicine consultation was 20 [4-150] minutes in comparison to an estimated journey time of 238 [120-450] minutes to the FM centre. Estimated family costs for attendance at the FM centre were £95 [20-555]. A range of tangible benefits to DGH staff were identified in interviews with clinicians. Sonographers were upskilled; more involved in women’s pregnancies; and had better access to specialist support. Consultants felt better supported and less isolated professionally, resulting in improved management of high risk pregnancies. Potential barriers included: engagement of DGH executive/management; establishing the video-link; interruption of routine practise. Most challenges were overcome within the pilot. Conclusions: We have demonstrated that a fetal telemedicine service, that is acceptable to both patients and staff, can be successfully established and used to provide high quality consultations. The service has reduced travel costs and inconvenience for women and has enhanced maternity provision at the DGH

In-vivo EPID dosimetry for IMRT and VMAT based on through-air predicted portal dose algorithm.

We have adapted the methodology of Berry et al. (2012) for Intensity Modulated Radiotherapy (IMRT) and Volumetric Modulated Arc Therapy (VMAT) treatments at a fixed source to imager distance (SID) based on the manufacturer's through-air portal dose image prediction algorithm. In order to fix the SID a correction factor was introduced to account for the change in air gap between patient and imager. Commissioning data, collected with multiple field sizes, solid water thicknesses and air gaps, were acquired at 150 cm SID on the Varian aS1200 EPID. The method was verified using six IMRT and seven VMAT plans on up to three different phantoms. The method's sensitivity and accuracy were investigated by introducing errors. A global 3%/3 mm gamma was used to assess the differences between the predicted and measured portal dose images. The effect of a varying air gap on EPID signal was found to be significant - varying by up to 30% with field size, phantom thickness, and air gap. All IMRT plans passed the 3%/3 mm gamma criteria by more than 95% on the three phantoms. 23 of 24 arcs from the VMAT plans passed the 3%/3 mm gamma criteria by more than 95%. This method was found to be sensitive to a range of potential errors. The presented approach provides fast and accurate in-vivo EPID dosimetry for IMRT and VMAT treatments and can potentially replace many pre-treatment verifications

Implementation of a fetal ultrasound telemedicine service: women’s views and family costs

Background The complexity of fetal medicine (FM) referrals that can be managed within obstetric units is dependent on the availability of specialist ultrasound expertise. Telemedicine can effectively transfer real-time ultrasound images via video-conferencing. We report the successful introduction of a fetal ultrasound telemedicine service linking a specialist fetal medicine (FM) centre and a remote obstetric unit. Methods Over a four-year period from October 2015, all women referred for FM consultation from the obstetric unit were seen via telemedicine, excluding cases where invasive testing, intrauterine therapy or cardiac anomalies were anticipated. The outcomes measured included the indication for FM referral; scan duration and image and sound quality during the consultation. Women’s perceptions of the telemedicine consultation and estimated costs to attend the FM centre were measured by a structured questionnaire completed following the first telemedicine appointment during the Phase 1 of the project. Results Overall, 297 women had a telemedicine consultation during Phase 1 (pilot and evaluation) and Phase 2 (embedding and adoption) of the project, which covered a 4 year period 34 women completed questionnaires during the Phase 1 of the study. Travel to the telemedicine consultation took a median (range) time of 20 min (4150), in comparison to an estimated journey of 230 min (120,450) to the FM centre. On average, women would have spent approximately £28 to travel to the FM centre per visit. The overall costs for the woman and her partner/ friend to attend the FM centre was estimated to be £439. Women were generally satisfied with the service and valued the opportunity to have a FM consultation locally. Conclusions We have demonstrated that a fetal ultrasound telemedicine service can be successfully introduced to provide FM ultrasound of sufficient quality to allow fetal diagnosis and specialist consultation with parents. Furthermore, the service is acceptable to parents, has shown a reduction in family costs and journey times

Conventional versus hypofractionated high-dose intensity-modulated radiotherapy for prostate cancer: 5-year outcomes of the randomised, non-inferiority, phase 3 CHHiP trial

SummaryBackgroundProstate cancer might have high radiation-fraction sensitivity that would give a therapeutic advantage to hypofractionated treatment. We present a pre-planned analysis of the efficacy and side-effects of a randomised trial comparing conventional and hypofractionated radiotherapy after 5 years follow-up.MethodsCHHiP is a randomised, phase 3, non-inferiority trial that recruited men with localised prostate cancer (pT1b–T3aN0M0). Patients were randomly assigned (1:1:1) to conventional (74 Gy delivered in 37 fractions over 7·4 weeks) or one of two hypofractionated schedules (60 Gy in 20 fractions over 4 weeks or 57 Gy in 19 fractions over 3·8 weeks) all delivered with intensity-modulated techniques. Most patients were given radiotherapy with 3–6 months of neoadjuvant and concurrent androgen suppression. Randomisation was by computer-generated random permuted blocks, stratified by National Comprehensive Cancer Network (NCCN) risk group and radiotherapy treatment centre, and treatment allocation was not masked. The primary endpoint was time to biochemical or clinical failure; the critical hazard ratio (HR) for non-inferiority was 1·208. Analysis was by intention to treat. Long-term follow-up continues. The CHHiP trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN97182923.FindingsBetween Oct 18, 2002, and June 17, 2011, 3216 men were enrolled from 71 centres and randomly assigned (74 Gy group, 1065 patients; 60 Gy group, 1074 patients; 57 Gy group, 1077 patients). Median follow-up was 62·4 months (IQR 53·9–77·0). The proportion of patients who were biochemical or clinical failure free at 5 years was 88·3% (95% CI 86·0–90·2) in the 74 Gy group, 90·6% (88·5–92·3) in the 60 Gy group, and 85·9% (83·4–88·0) in the 57 Gy group. 60 Gy was non-inferior to 74 Gy (HR 0·84 [90% CI 0·68–1·03], pNI=0·0018) but non-inferiority could not be claimed for 57 Gy compared with 74 Gy (HR 1·20 [0·99–1·46], pNI=0·48). Long-term side-effects were similar in the hypofractionated groups compared with the conventional group. There were no significant differences in either the proportion or cumulative incidence of side-effects 5 years after treatment using three clinician-reported as well as patient-reported outcome measures. The estimated cumulative 5 year incidence of Radiation Therapy Oncology Group (RTOG) grade 2 or worse bowel and bladder adverse events was 13·7% (111 events) and 9·1% (66 events) in the 74 Gy group, 11·9% (105 events) and 11·7% (88 events) in the 60 Gy group, 11·3% (95 events) and 6·6% (57 events) in the 57 Gy group, respectively. No treatment-related deaths were reported.InterpretationHypofractionated radiotherapy using 60 Gy in 20 fractions is non-inferior to conventional fractionation using 74 Gy in 37 fractions and is recommended as a new standard of care for external-beam radiotherapy of localised prostate cancer.FundingCancer Research UK, Department of Health, and the National Institute for Health Research Cancer Research Network

A systematic review of the effectiveness of universal Health Visitor led Child Health Clinics

This paper presents the findings of a systematic review undertaken to assess how effectively health visitor led child health clinics (‘baby clinics’) contribute to the promotion of pre-school child health and the reduction of health inequalities.Despite the widespread presence of baby clinics across the UK, there is little published research about the service model, its purpose or effectiveness. The initial search produced 559 articles, after removing duplicates, 175 abstracts were assessed against the inclusion criteria and 24 qualitative studies were identified as relevant to the review. No studies were excluded based on quality issues, however the quality of studies was variable. Thematic analysis was used to organise and interpret the data. Although the review presents a synthesis of research over the last 30 years, there is a lack of evaluative research about the structure, process and outcomes of baby clinics, which makes it impossible to draw any conclusions about the effectiveness of the service offer. Findings suggest research on the value and purpose of baby clinics is now needed and whilst good evaluation studies with clear outcome measures are sought, it is clear that the theoretical processes through which positive outcomes are promoted need to be established first

Radiotherapy Quality Assurance for the CHHiP Trial: Conventional Versus Hypofractionated High-Dose Intensity-Modulated Radiotherapy in Prostate Cancer.

Aims The CHHiP trial investigated the use of moderate hypofractionation for the treatment of localised prostate cancer using intensity-modulated radiotherapy (IMRT). A radiotherapy quality assurance programme was developed to assess compliance with treatment protocol and to audit treatment planning and dosimetry of IMRT. This paper considers the outcome and effectiveness of the programme.Materials and methods Quality assurance exercises included a pre-trial process document and planning benchmark cases, prospective case reviews and a dosimetry site visit on-trial and a post-trial feedback questionnaire.Results In total, 41 centres completed the quality assurance programme (37 UK, four international) between 2005 and 2010. Centres used either forward-planned (field-in-field single phase) or inverse-planned IMRT (25 versus 17). For pre-trial quality assurance exercises, 7/41 (17%) centres had minor deviations in their radiotherapy processes; 45/82 (55%) benchmark plans had minor variations and 17/82 (21%) had major variations. One hundred prospective case reviews were completed for 38 centres. Seventy-one per cent required changes to clinical outlining pre-treatment (primarily prostate apex and base, seminal vesicles and penile bulb). Errors in treatment planning were reduced relative to pre-trial quality assurance results (49% minor and 6% major variations). Dosimetry audits were conducted for 32 centres. Ion chamber dose point measurements were within ±2.5% in the planning target volume and ±8% in the rectum. 28/36 films for combined fields passed gamma criterion 3%/3 mm and 11/15 of IMRT fluence film sets passed gamma criterion 4%/4 mm using a 98% tolerance. Post-trial feedback showed that trial participation was beneficial in evolving clinical practice and that the quality assurance programme helped some centres to implement and audit prostate IMRT.Conclusion Overall, quality assurance results were satisfactory and the CHHiP quality assurance programme contributed to the success of the trial by auditing radiotherapy treatment planning and protocol compliance. Quality assurance supported the introduction of IMRT in UK centres, giving additional confidence and external review of IMRT where it was a newly adopted technique

Quantitative historical analysis uncovers a single dimension of complexity that structures global variation in human social organization

Do human societies from around the world exhibit similarities in the way that they are structured, and show commonalities in the ways that they have evolved? These are long-standing questions that have proven difficult to answer. To test between competing hypotheses, we constructed a massive repository of historical and archaeological information known as "Seshat: Global History Databank." We systematically coded data on 414 societies from 30 regions around the world spanning the last 10,000 years. We were able to capture information on 51 variables reflecting nine characteristics of human societies, such as social scale, economy, features of governance, and information systems. Our analyses revealed that these different characteristics show strong relationships with each other and that a single principal component captures around three-quarters of the observed variation. Furthermore, we found that different characteristics of social complexity are highly predictable across different world regions. These results suggest that key aspects of social organization are functionally related and do indeed coevolve in predictable ways. Our findings highlight the power of the sciences and humanities working together to rigorously test hypotheses about general rules that may have shaped human history