Optical Fibre Based Real-Time Measurements During an LDR Prostate Brachytherapy Implant Simulation: Using a 3D printed anthropomorphic phantom

An optical fbre sensor based on radioluminescence, using the scintillation material terbium doped gadolinium oxysulphide (Gd2O2S:Tb) is evaluated, using a 3D printed anthropomorphic phantom for applications in low dose-rate (LDR) prostate brachytherapy. The scintillation material is embedded in a 700 µm diameter cavity within a 1 mm plastic optical fbre that is fxed within a brachytherapy needle. The high spatial resolution dosimeter is used to measure the dose contribution from Iodine-125 (I-125) seeds. Initially, the efects of sterilisation on the sensors (1) repeatability, (2) response as a function of angle, and (3) response as a function of distance, are evaluated in a custom polymethyl methacrylate phantom. Results obtained in this study demonstrate that the output response of the sensor, pre- and post-sterilisation are within the acceptable measurement uncertainty ranging from a maximum standard deviation of 4.7% pre and 5.5% post respectively, indicating that the low temperature sterilisation process does not damage the sensor or reduce performance. Subsequently, an LDR brachytherapy plan reconstructed using the VariSeed treatment planning system, in an anthropomorphic 3D printed training phantom, was used to assess the suitability of the sensor for applications in LDR brachytherapy. This phantom was printed based on patient anatomy, with the volume and dimensions of the prostate designed to represent that of the patient. I-125 brachytherapy seeds, with an average activity of 0.410 mCi, were implanted into the prostate phantom under transrectal ultrasound guidance; following the same techniques as employed in clinical practice by an experienced radiation oncologist. This work has demonstrated that this sensor is capable of accurately identifying when radioactive I-125 sources are introduced into the prostate via a brachytherapy needle

The frequency and outcome of lupus nephritis: results from an international inception cohort study

OBJECTIVE: To determine nephritis outcomes in a prospective multi-ethnic/racial SLE inception cohort. METHODS: Patients in the Systemic Lupus International Collaborating Clinics inception cohort

Orientation to time as a guide to the presence and severity of cognitive impairment in older hospital patients

Background Testing of orientation to time is an important part of mental status examination. The validity of errors in different aspects of temporal orientation was examined in older hospital patients as a guide to the presence of dementia or delirium and as a measure of the severity of dementia, as defined by the Global Deterioration Scale. Methods Inpatients and outpatients attending an acute hospital underwent independent assessments by two doctors on the same day to determine orientation to time and cognitive status. Optimum cut-offs for error scores on the different aspects of temporal orientation were calculated to maximise the sum of sensitivity and specificity for detection of dementia or delirium. Results Of the 262 patients assessed, 62 (23.7%) had dementia or delirium. The best cut-offs for detection of these disorders were: any error in identifying the year, month, day of the month or day of the week; and an error of more than 1 h in identifying the time of day. Failure to identify the year correctly was the most valuable single sign of dementia or delirium (sensitivity 86% and specificity 94%); failure to identify either year or month correctly was 95% sensitive and 86.5% specific for the detection of cognitive impairment. Severity of temporal disorientation, measured using a number of approaches, was strongly associated with severity of dementia. Conclusion Disorientation to time is a useful guide to the presence and severity of dementia or delirium in older hospital patients. Failure to identify the year or month correctly is a sufficiently sensitive and specific indicator of dementia or delirium to warrant more detailed cognitive assessment in this population

Development and implementation of resuscitation guidelines: a personal experience

Objectives: to develop and implement guidelines on the appropriate use of cardiopulmonary resuscitation, which would ensure patient involvement in decision-making about cardiopulmonary resuscitation whenever possible but without offering illusory choices where resuscitation was unlikely to succeed. Design: quantitative guidelines were developed after a review of the Literature on survival after cardiopulmonary resuscitation. Patients were classified according to their estimated likelihood of survival to discharge after resuscitation: <1%, group A; 1-10%, group B; and >10%, group C. Qualitative guidelines were developed after consideration of the legal and ethical principles of cardiopulmonary resuscitation. It was decided to inform competent patients in group A that cardiopulmonary resuscitation would be inappropriate, and to seek the preferences of competent patients in group B. The operation of the guidelines was examined in patients aged 65 years or more admitted under a single consultant in an acute community hospital. Results: 147 patients were studied: 39 in group A, 26 in group B and 82 in group C. Of 36 patients in groups A and B judged competent, cardiopulmonary resuscitation discussions were only undertaken in 17, usually because acute distress or anxiety precluded effective communication. Of the 23 patients or family members from whom cardiopulmonary resuscitation preferences were sought, four opted for full cardiopulmonary resuscitation and six for limited cardiopulmonary resuscitation (usually witnessed-arrest only and no ventilation). Conclusion: it is difficult to involve acutely ill elderly patients in cardiopulmonary resuscitation decision-making. Limited cardiopulmonary resuscitation is a useful option for patients, relatives and doctors

A cross-sectional study of doctors\u27, managers\u27 and public representatives\u27 views regarding acceptable level of risk in discharges from the emergency department

Background: Discharging a patient from the emergency department (ED) always involves some risk of a poor outcome. Aim: This study examined the hypothesis that there would be an increasing gradient of risk aversion from physicians through clinicians in management and managers to public representatives regarding an acceptable level of risk when considering discharging a patient from the ED. Methods: An internet survey was conducted among 180 consultant physicians, 47 clinicians involved in management, 143 senior healthcare managers and 418 public representatives in Ireland. Subjects asked to assess three clinical vignettes for the level of risk for death within the next week that could have been prevented by admission at which discharge from the ED would be acceptable. Choices ranged from 1/100 risk of death to \u27no risk of death is acceptable\u27. The median of each subject\u27s responses was the primary outcome measure. Results: The response rates were 64% for consultant physicians, 57% for clinicians in management, 53% for managers and 29% for public representatives. The median risk choice (interquartile range) was 1/1000 (1/500-1/5000), 1/1000 (1/500-1/10 000), 1/5000 (1/1000-1/10 000) and 1/10 000 (1/1000-0) in the respective groups (Jonckheere-Terpstra test P < 0.0001). All pairwise comparisons between doctors and managers or public representatives were significant. Older clinicians were significantly more risk tolerant than younger clinicians. Conclusions: There are significant differences in risk tolerance when considering discharge from the ED between different groups with doctors being most risk tolerant and politicians most risk averse

Prevalence and predictors of bedrail use in an acute hospital

Objective: to determine the prevalence and predictors of bedrail use in an acute hospital. Design and setting: overnight survey in a University teaching hospital. Subjects: Three-hundred and twenty-seven beds and patients in 14 wards. Methods: data were collected on bedrail use and on the bed system, ward and patient characteristics. Medical, nursing and physical therapy notes were examined and the night and day nurses and, if necessary, the doctors and therapists caring for the patient interviewed to determine patients\u27 diagnoses, functional and cognitive status. Results: there were 133 (40.7%) beds with one or more raised rails. Independent predictors of bedrail use were use of electric profiling beds, confusion, reduced alertness and any difficulty with transferring from bed. The most common reported indication for bedrail use was \u27to prevent rolling out of bed\u27 (59%); \u27to prevent getting out of bed\u27 was recorded in 11% of cases. Use of bedrails was judged inappropriate in 27/133 (20.3%) patients and in 14/43 (32.6%) patients with abnormal mental status; misuse was particularly common in those with confusion or agitation [13/34 (38.2%)]. Failure to use bedrails was potentially inappropriate in 32/194 (16.5%) of those without bedrails. Conclusion: this study using individual patient data shows that the use of electric profiling beds, abnormal mental states and difficulty transferring from bed are the main predictors of bedrail use in acute hospitals. Inappropriate use of bedrails is common in those with cognitive impairment or with agitation

Variable Sensitivity Online Optical Fibre Radiation Dosimeter

The use of Poly Methyl MethAcrylate (PMMA) optical fibres for monitoring a wide range of radiation doses, for a multi-functional dosimeter, is being investigated. The sensitivity of the fibre to ionising radiation is shown to be dependant on wavelength, with the sensitivity increasing with decreasing wavelength. The fibres exhibit high sensitivity, as high as 0.6dBm -1/kGy, and are capable of monitoring dose ranges between 30Gy and 45kGy. This exceeds the sensing range of all currently commercially available PMMA slab sensors. By carefully selecting the monitoring wavelength, the exact sensitivity and dose range can be achieved, thereby allowing the dosimeter to be suitable for a wide range of applications. ©2009 IEEE

High frequency of potential entrapment gaps in beds in an acute hospital

Objective: dimensional guidelines for bedrails have been developed to minimise the risk of patient entrapment within the bed. We examined whether bedrails in a large Irish teaching hospital complied with these standards. Design and setting: survey of 60 accessible beds in six hospital wards. Methods: a specialised cone and cylinder tool that mimics the size and weight of a small adult neck and head was used to determine gaps in the four zones most associated with entrapment. Results: the number of failures for each zone was 15 beds for zone 1 (any space between the perimeters of the rail); 42 beds for zone 2 (the space under the rail); 41 beds for zone 3 (the space between the inside surface of the bedrail and the mattress) and 13 beds for zone 4 (the space between the mattress and rail at the end of the rail). Failures were more common with hydraulic adjusted than with electric profiling beds. Mattresses that were the wrong size (usually too narrow) or too soft and bedrails that were loose or were poorly maintained accounted for many failures. Conclusion: many beds used in our hospital did not comply with dimensional standards to minimise entrapment risks. This emphasises the need for careful selection of patients for whom bedrails are to be used as well as the need for monitoring and maintenance of bed systems

Low Dose Plastic Optical Fibre Radiation Dosimeter For Clinical Dosimetry Applications

PMMA optical fibres offer the opportunity to monitor ionising radiation doses online and in real-time. The work presented here investigates the use of these fibres in clinical dosimetry applications. Tests to determine the sensitivity of the PMMA optical fibres at low radiation doses were carried out at the MD Anderson Cancer Center Orlando, Florida. The results demonstrate that PMMA optical fibres exhibit a quantifiable response to low doses (up to 12Gy) of radiation, similar to that received during radiation treatment. ©2009 IEEE

Randomised controlled trial of the effect of standard and detailed risk disclosure prior to bronchoscopy on peri-procedure anxiety and satisfaction

Background: Deciding what risks to disclose before a procedure is often challenging for clinicians. Consecutive patients undergoing elective fibreoptic bronchoscopy were randomised to receive simple or more detailed written information about the risks of the procedure and the effects on anxiety and satisfaction levels were compared. Methods: A 100 mm anxiety visual analogue scale (VAS) and a modified Amsterdam preoperative anxiety (scored 4 -20) scale (APAIS) were completed before and after reading the designated information leaflet. Following bronchoscopy, subjects completed a satisfaction questionnaire. Results: Of 142 consecutive patients, 122 (86%) (mean age 57.8 years, 53% male) completed the study. Baseline demographic, clinical and anxiety measures were similar in the two groups. Those who received more detailed risk information had significantly greater increase in anxiety levels than those who received simple information on both the VAS (mean 14.0 (95% CI 10.1 to 17.9) vs 2.5 (95% CI -1.4 to 6.4), p < 0.001) and the APAIS (1.73 (95% CI 1.19 to 2.26) vs 0.57 (95% CI 0.05 to 1.10), p< 0.001). Almost twice as many of those receiving detailed risk information reported that they felt they had received too much information about complications or that the information they had received about bronchoscopy had been worrying. Conclusions: Provision of more detailed risk information before bronchoscopy may come at the cost of a small but significant increase in anxiety