bluuebunny/crossref_metadata_2025 huggingface dataset:
Effects of erythropoietin on erythrocyte deformability in non‐transfused preterm infants
Authors: Klipp Martina , Holzwarth Anne‐Ulrike , Poeschl Johannes M , Nelle Mathias , Linderkamp Otwin
Published: April 2008

Aim: Suppression of erythropoiesis due to low plasma erythropoietin levels is an important factor in the development of anaemia of prematurity. Premature infants may therefore be treated with recombinant human erythropoietin (rhEPO). This prospective, randomised and controlled study was designed to find out whether rhEPO treatment improves erythrocyte deformability in preterm infants.

Methods: Sixteen infants were treated with rhEPO (250 IU/kg three times weekly) a total of 15 times beginning on day of life 5 whereas fifteen infants served as controls. Haemoglobin concentration, haematocrit, reticulocyte count, ferritin level and erythrocyte deformability were measured on days 5, 14, 28, 42 and 63. Erythrocyte elongation was determined as an indicator of erythrocyte deformability using a shear stress diffractometer (Rheodyn SSD) at shear forces of 0.3 to 60 Pa.

Results: Haemoglobin concentration was significantly higher on days 28 and 42 and reticulocyte percentage on day 28 in the rhEPO group compared to the controls. Serum ferritin was lower in the rhEPO group on day 28. Erythrocyte deformability was significantly increased on days 28 and 42 in the infants receiving rhEPO. We found a strong relationship between erythrocyte elongation and reticulocyte count.

Conclusion: RhEPO markedly increases the erythropoiesis in preterm infants in the critical first weeks of life and the anaemia of prematurity is obviously reduced. The erythrocyte deformability improved under rhEPO treatment. Erythrocyte deformability was significantly related to the reticulocyte count indicating that the improvement of erythrocyte deformability was due to the formation of well‐deformable young erythrocytes.
Family and school determinants of overweight in 13‐year‐old Portuguese adolescents
Authors: Ramos Elisabete , Barros Henrique
Published: April 2008

Aims: To identify familial and school determinants of overweight in 13‐year‐old adolescents.

Methods: All 27 public and 19 (79%) private schools allowed to contact age eligible students, 77.5% accepting to participate (1116 girls, 1045 boys). Self‐administered questionnaires were completed and physical examination performed, including weight and height measurements. Overweight (>95th percentile) and at risk of overweight (85th–95th) were defined using CDC standards. Its determinants were identified using logistic regression models, entering parents' education and all variables significantly associated in crude analysis.

Results: Prevalence of overweight (10.2%) and at risk of overweight (16.5%) was not influenced by type of school, vending machines and number of school canteen meals. In girls, the prevalence of body mass index (BMI) >85th percentile increased significantly with decreasing age at menarche (45.7% if menstruating before 11‐year and 13.2% when pre‐menarche), and increasing parental BMI or time spent on sedentary activities. In multivariate analysis, age at menarche and increasing parental BMI remained significant risks in girls. In boys, besides parental BMI, ever smoking, sleeping <9 h and sedentary leisure activities were significant determinants.

Conclusions: Food offered at school had no significant impact on adolescents overweight, which was mainly dependent on parental anthropometrics and leisure time activities.
Child behaviour after anaesthesia: association of socioeconomic factors and child behaviour checklist to the post‐hospital behaviour questionnaire
Authors: Karling M. , Hägglöf B.
Published: April 2008

Aim: In the process of validation of the Swedish translation of the Post‐Hospital Behaviour Questionnaire (PHBQ) to assess its relation to the Child Behaviour Checklist (CBCL) and to describe its relation to sociodemographic factors.

Method: Three hundred and forty children 2–13 years studied in connection with elective procedures which included anaesthesia. Parents completed the CBCL forms before and after hospitalization as well as the PHBQ 2 weeks after hospitalization.

Results: In multivariate analysis of PHBQ total score independent risk factors were: age <5 (OR 2.4; CI 1.4–4.0), living in a one parent family (OR 4.4; CI: 1.6–12.6) and not living in a rural area (OR 1.6; CI: 1.0–2.6). The correlation between the total scores for PHBQ and CBCL for children aged 2–4 was moderate: (r = 0.38; p < 0.005). For children aged 4–7 there were significant correlations between PHBQ sleep anxiety and CBCL Other problems (r = 0.4; p < 0.01), PHBQ eating disturbances and CBCL total score (r = 0.3; p < 0.01), though none of these significant correlations were observed for children above 7 years of age.

Conclusion: There is an association between PHBQ and CBCL which is weaker for older children. The reason for this might be that PHBQ is more sensitive in the younger age group and to minor changes in behaviour. Children younger than 5 years of age or living in a one parent family or not living in rural areas appear to have higher incidence of problematic behaviour in a 2 week follow up after anaesthesia.
Performance of neonatal ventilators in volume targeted ventilation mode
Authors: Sharma Atul , Milner Anthony D. , Greenough Anne
Published: April 2008

Aim: To test the hypothesis that in volume targeted ventilation modes, ventilator performance would vary according to ventilator type.

Methods: Four neonatal ventilators: Draeger Babylog 8000 (Draeger Medical, Germany), SLE 5000 infant ventilator (SLE systems, UK), Stephanie paediatric ventilator (F. Stephan Biomedical, German) and V.I.P. Bird gold (Viasys Healthcare, USA) were assessed using a lung model. Delivered peak pressure, inflation time, mean airway pressure (MAP) and volume were measured.

Results: At the same preset ventilator settings, the Stephanie and V.I.P. Bird ventilators delivered significantly lower peak pressures and tended to deliver lower MAPs than the other two ventilators. At a volume targeted ventilation level of 5 mL, the SLE and the V.I.P. Bird delivered significantly shorter inflation times. The above differences related to differences in the airway pressure waveforms delivered by the four ventilators. The V.I.P. Bird had a less variable volume delivery, but this was always significantly lower than the preset volume guarantee level but higher than the volume displayed by the ventilator.

Conclusion: In volume targeted ventilation modes, performance differs between neonatal ventilator types; these results may have implications for clinical practise.
Women's involvement in household decision‐making and strengthening social capital—crucial factors for child survival in Ethiopia
Authors: Fantahun Mesganaw , Berhane Yemane , Wall Stig , Byass Peter , Högberg Ulf
Published: April 2008

Aims: To assess the influence of household decision making, social capital, socio‐economic factors and health service use on under‐five mortality.

Setting: Butajira Demographic Surveillance Site, Ethiopia.

Methods: A prospective case‐referent design with a total of 209 under‐five year old deaths occurring in an 18‐month period, together with 627 referents matched for age, sex and community of residence were included. Questionnaires were administered to mothers or caretakers. Matched case control analysis investigated the effect of risk factors on mortality and the presence of avoidable factors was assessed for each death.

Results: Lack of immunization was strongly associated with mortality (adjusted OR = 9.8, 95% CI 5.9, 16.1). Low decision making capacity of women (adjusted OR= 3.2 95% CI 2.0, 5.0) and low social capital scores (adjusted OR = 1.9 95% CI 1.1, 3.5) were also related to high under‐five mortality in multivariate analyses. Potentially avoidable household and health facility factors were identified, respectively in 71% and 40% of the deaths.

Conclusion: Combined efforts to improve women's involvement in household decision making, social capital and immunization may decrease the high child mortality in this setting where the level of poverty is high and no appreciable trend in child mortality decline has been noted over the years.
Atopy in childhood idiopathic nephrotic syndrome
Authors: Salsano Maria Esposito , Graziano Luisa , Luongo Ilaria , Pilla Paola , Giordano Mario , Lama Giuliana
Published: April 2008

Aim: Aim of the study was to evaluate the immunoallergic pattern and their modulating serum cytokines in children with primary manifestation of nephrotic syndrome, in order to analyse the correlation with disease activity and the outcome of childhood NS.

Materials and methods: We have evaluated 72 children: 58 steroid‐sensitive and 14 steroid‐resistant; 42 subjects were the healthy controls. In all were measured serum: T cell‐subset, cytokines by Th‐1, Th‐2, total IgE levels and specific IgE antibodies.

Results: Of the 72 children investigated, 35 (48.6%) had either a history of atopy and/or elevated serum IgE; 14 of these children (40%) had clinical sign of an atopic disease (asthma, rhinitis, dermatitis) and 21 (60%) had elevated sIgE. The atopy was more frequent among SS than SRNS patients (52% versus 36%, p < 0.05). The CD19 were significantly increased in nephrotic patients compared with controls. IL‐4 levels were not different from those in normal control both in SS and SRNS patients, either in relapse than in remission. There was no correlation between the sIgE and IL‐4 levels. Therefore, IL‐5 and Il‐13 levels were significantly higher in SSNS compared to controls, in both pre than posttreatment, and higher in atopic patients. Interestingly, IL‐6 and IL‐10 levels were significantly increased in SRNS pretreatment compared to posttreatment and controls and, only for IL‐10, significantly higher in atopic patients.

Conclusion: In our study, only 40% of atopic children had a positive allergic history and 51.4% of the nephrotic children had normal sIgE levels, both pre and posttreatment, indicating different aetiologies, as immune mechanisms, in the pathogenesis of NS. Therefore, specific IgE antibodies were not related to disease activity, suggesting that IgE production might be co‐incident in childhood NS. However, the increased production of IL‐5 and IL‐13 in atopic SSNS may indicate that these cytokines are involved in the enhanced production of sIgE while IL‐4 have a role as controlling cytokine.
Haematological changes and iron status in teenage girls with eating disorders and weight loss—the importance of menstrual status
Authors: Swenne Ingemar
Published: April 2008

Aim: To study haematological changes and iron stores in teenage girls with eating disorders and weight loss.

Methods: Blood haemoglobin concentration, white blood cell and thrombocyte count and serum ferritin concentration were measured at assessments of 446 subjects.

Results: Haemoglobin concentrations, leukocyte and thrombocyte counts were related to weight and rate of weight loss but were largely within reference ranges. Serum ferritin concentrations were high in girls with amenorrhea and related to weight and rate of weight loss. Girls who retained menstruations had low serum ferritin concentrations and 37% had depleted iron stores (serum ferritin <16 μg/L).

Conclusion: Anaemia, leukopenia and thrombocytopenia are uncommon in teenage girls with eating disorders and weight loss. When present, other diseases causing haematological changes should be considered. In amenorrhoic girls muscle catabolism increases serum ferritin concentrations which may give a false impression of an adequate iron status. This is unmasked in girls with retained menstruations who often have depleted iron stores.
Hospital readmissions and morbidity in a fifteen‐year follow‐up of very low birthweight children in Southeast Sweden
Authors: Gäddlin Per‐Olof , Finnström Orvar , Hellgren Kerstin , Leijon Ingemar
Published: April 2008

Aim: To study the effect of very low birthweight on hospital care and morbidity, and their relationship to gender, birthweight and neonatal complications.

Methods: Eighty‐five very low birthweight (VLBW; ≤1500 g) children and term controls born in 1987–1988 in south‐east region of Sweden were checked in registers regarding readmissions and diagnoses, need for habilitation and child psychiatric care up to 15 years of age. Ophthalmological examinations were made at age 4 in 64 of VLBW and 61 of control children, and at age 15 in 59 of VLBW and 55 of control children.

Results: VLBW boys had three times more readmissions compared with normal weight control boys (p = 0.003). Neonatal risk factors for readmissions were gestational age under 30 weeks (OR 3.1), birthweight less than 1000 g (OR 4.6), mechanical ventilation (OR 9.5) and more than 60 days' stay in neonatal ward (OR 5.0).

A minority of VLBW children had an impairment/handicap such as cerebral palsy (CP) in five (5.9%) children, attention deficit hyperactivity disorders (ADHD) in five children, and blindness due to retinopathy of prematurity in one child. One child in the control group had ADHD. At the 15‐year examination median visual acuity in the best eye was better in the control group (1.6) than in the VLBW group (1.3) (p = 0.009). 32% of VLBW children and 11% of controls had latent or manifest strabismus (p = 0.007).

Conclusion: Risk factors for readmissions were gender, low gestational age, birthweight <1000 g or mechanical ventilation. A minority of VLBW children had a handicap that influenced their daily life activities at 15 years of age.
Circulating stem cells in extremely preterm neonates
Authors: Bizzarro Matthew J , Bhandari Vineet , Krause Diane S , Smith Brian R , Gross Ian
Published: April 2008

Aim: To measure circulating CD34+cell levels in premature neonates and to correlate the initial CD34+counts with measures of pulmonary function and neonatal morbidity.

Methods: CD34+cell counts were measured in the peripheral blood of preterm neonates (gestational ages 24–32 weeks) ventilated for respiratory disease at <48 h of life, and at the start of the 2nd, 3rd and 4th weeks of life. Data pertaining to neonatal demographics and short‐term outcomes were collected. Pulmonary function tests were performed to coincide with CD34+sampling.

Results: Thirty preterm neonates with median gestational age of 24 weeks and birth weight of 641 g were analysed. A mean of 99.4 CD34+cells per microliter was observed in the 1st week of life with a decline to 54.4 cells per microliter by the 4th week. An inverse correlation between initial CD34+count and gestational age (p = 0.01) was observed. No significant correlations were observed with measures of pulmonary function or neonatal morbidities.

Conclusions: Extremely premature neonates have remarkably high levels of CD34+cells in their peripheral blood at birth. Umbilical cord blood from this population may potentially provide an abundant source of hematopoietic stem and progenitor cells for therapeutic purposes.
Risk of concurrent bacterial infection in preterm infants hospitalized due to respiratory syncytial virus infection
Authors: Resch Bernhard , Gusenleitner Walter , Mueller Wilhelm D
Published: April 2008

Objective: To evaluate the risk of concurrent bacterial infection in preterm infants hospitalized due to respiratory syncytial virus (RSV) disease.

Patients and methods: Retrospective cohort analysis of all infants hospitalized due to RSV infection between January 1, 2001 and July 31, 2005. Patients were identified by ICD‐10 diagnosis of RSV infection including codes J21.0, J21.9, J12.1, J20.5 and B97.4. Medical charts were reviewed and RSV infection had to be confirmed by positive antigen detection test on nasopharyngeal aspirates.

Results: A total of 464 infants had been hospitalized due to RSV infection and 42 (9.1%) were born <37 weeks of gestational age. Concurrent bacterial infections were diagnosed by either positive blood or urine cultures, stool culture, tracheal aspirates or smears in 4 of 42 preterm (9.5%) compared to 13 of 422 term (3.1%) infants (p = 0.017, RR 3.092, CI 95% 1.251–7.641). Excluding the infants admitted to the intensive care unit (ICU) the total rate of bacterial co‐infection was 1.9%. Ten of 42 preterm (23.8 %) compared to 25 of 422 term (5.2 %) infants were referred to ICU (p < 0.001, RR 3.349, CI 95% 1.882–5.959). All preterm infants had pneumonia, and isolates were Streptococcus pneumoniae, Chlamydia pneumoniae and Streptococcus pneumoniae with Haemophilus influenzae. Mean length of stay in preterm infants with bacterial co‐infection was 22.3 days compared to 10.3 days without bacterial co‐infection (p < 0.006).

Conclusion: The overall low risk of concurrent bacterial infection was significantly increased in preterm infants associated with prolonged hospitalization and ICU admission.
Socio‐demographic and psychopathologic correlates of enuresis in urban Ethiopian children
Authors: Desta Menelik , Hägglöf Bruno , Kebede Derege , Alem Atalay
Published: April 2008

Aim: To examine the association between enuresis and psychopathology in urban Ethiopian children.

Methods: A two‐stage mental health survey of 5000 urban children found enuresis to be by far the most common disorder. Logistic regression modelling was carried out to determine the independent associations of a number of socio‐demographic and psychopathological characteristics with enuresis.

Results: Male sex, younger age and lower achieved educational grade of the child were all independently associated with childhood enuresis. The odds of having enuresis were significantly higher for children in families with significant financial worries and in children from homes where parents were separated. Children with DSMIII‐R anxiety disorders, especially simple phobia, or disruptive behaviour disorders were found to have significantly higher odds of having enuresis.

Conclusion: Psychopathology, both anxiety and behavioural disorders, as well as family stressors in urban Ethiopian children were found to be risk factors for enuresis. Although a cause‐effect relationship could not be ascertained, the findings of higher association of psychopathology with enuresis in this and other studies indicate that there is a need for evaluating children with enuresis for the presence of concurrent psychopathology, especially in traditional societies where undetected psychopathology may be more common.
Beauty Spot, Blind Spot: Romantic Wales
Authors: Constantine Mary‐Ann
Published: April 2008

Romantic‐period Wales was a fascinating place: part literary construct, part tourist destination, it appears in the work of many writers as a locus of alternative possibilities, both political and personal. Welsh landscape, language and literature attracted poets, artists, antiquarians and historians alike, and an energetic literary cultural revival within Wales produced a rich blend of texts, legends and fabrications which would inspire makers of both fiction and history on either side of the border. The questions of national and cultural allegiance at the heart of this revival are of profound importance to current discussions of ‘British’ identity, particularly in the light of so‐called ‘four nations’ criticism. This article argues that the Welsh contribution to British Romanticism has been seriously neglected by Romantic studies in general. It suggests reasons for this neglect, surveys recent work in the field, and points to future possible directions for research.
Combined endo‐laparoscopic approach in managing patients with gallstones and common bile duct stones: An early experience
Authors: Ng Dennis Chung‐Kei , Tsui David Ka‐Kin , Yang George Pei‐Cheung , Ha Joe Ping‐Yiu , Chan Angus Chi‐Wai , Tang Chung‐Ngai , Li Michael Ka‐Wah
Published: April 2008

Gallstones with common bile duct stones is a common condition in Hong Kong. Management still remains a challenge nowadays. Laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiopancreatography (ERCP) is a single‐stage approach which improves patient comfort and is associated with less post‐ERCP pancreatitis. With the new endo‐laparoscopic operating theatre in service, the combined endo‐laparoscopic approach becomes simple and practical. We report here our two early experiences using this approach.
Aneurysmal subarachnoid haemorrhage
Authors: Wong George Kwok‐Chu , Ng Rebecca Yuen‐Ting , Poon Wai‐Sang
Published: April 2008

Spontaneous subarachnoid haemorrhage accounts for only 3–4% of all stroke but the consequences can be devastating. In the present review article, we review the epidemiology, clinical features, investigations and management philosophy in patients with aneurysmal subarachnoid haemorrhage. Oral nimodipine, aneurysmal occlusion and advances in neurointensive care are the keys to improve neurological outcome in patients after aneurysmal subarachnoid haemorrhage. These patients should be managed by a combined team with expertise in microsurgery, endovascular surgery and neurointensive care for optimal management outcome. Early diagnosis and treatment is the key to improve outcome and reduce disability and mortality.
Some Issues in Chinese Philosophy of Religion
Authors: Yang Xiaomei
Published: April 2008

Chinese philosophy of religion is a less discussed and less clearly formed area in the study of Chinese philosophy. It is true that there is virtually no discussion in Chinese philosophy about rationality or justification of religious beliefs comparable to the discussion of the same issues in Western philosophy of religion. The inquiry about rationality and justification of religious beliefs has shaped Western philosophy of religion. However, the scope of philosophy of religion in the Western context has been widened since Hume and Kant. When the West began to be exposed to non‐Western religions, philosophical reflection on non‐Western religions is also brought into the scope of philosophy of Religion. We can expect that the concept of religion will become much broader, the scope of philosophy of religion will expand and new issues, especially, issues concerning specific and non‐Western religions, will be framed. When we look at philosophy of religion in a broad sense, the field of Chinese philosophy of religion begins to emerge. In this survey paper, I will focus on several issues which, in a broad sense of philosophy of religion, can be construed as the issues of Chinese philosophy of religion. One of the issues is about the religiosity of Confucianism. The second issue is about the concept of Tian. The third is the issue regarding the origin and nature of Chinese state religion and its characteristics which also have caught the attention of scholars, especially, in China. Is Confucianism a religion? How should we construe the religiosity of Confucianism if it does have a religious dimension? Is Tian a theological term? How does Tian differ from Western God? Is the sacrifice to Tian religious and a form of monotheism? What is the nature of state religion in traditional China? What is the relation between the state religion and Confucianism in traditional China? The debates on the issues addressing these questions will be introduced and discussed in this paper.
Malignant Gliomas with Primitive Neuroectodermal Tumor‐like Components: A Clinicopathologic and Genetic Study of 53 Cases
Authors: Perry Arie , Miller C. Ryan , Gujrati Meena , Scheithauer Bernd W. , Zambrano Sandro Casavilca , Jost Sarah C. , Raghavan Ravi , Qian Jiang , Cochran Elizabeth J. , Huse Jason T , Holland Eric C. , Burger Peter C. , Rosenblum Marc K.
Published: April 2008

Central nervous system neoplasms with combined features of malignant glioma and primitive neuroectodermal tumor (MG‐PNET) are rare, poorly characterized, and pose diagnostic as well as treatment dilemmas. We studied 53 MG‐PNETs in patients from 12 to 80 years of age (median = 54 years). The PNET‐like component consisted of sharply demarcated hypercellular nodules with evidence of neuronal differentiation. Anaplasia, as seen in medulloblastomas, was noted in 70%. Within the primitive element, N‐myc or c‐myc gene amplifications were seen in 43%. In contrast, glioma‐associated alterations involved both components, 10q loss (50%) being most common. Therapy included radiation (78%), temozolomide (63%) and platinum‐based chemotherapy (31%). Cerebrospinal fluid (CSF) dissemination developed in eight patients, with response to PNET‐like therapy occurring in at least three. At last follow‐up, 27 patients died, their median survival being 9.1 months. We conclude that the primitive component of the MG‐PNET: (i) arises within a pre‐existing MG, most often a secondary glioblastoma; (ii) may represent a metaplastic process or expansion of a tumor stem/progenitor cell clone; (iii) often shows histologic anaplasia and N‐myc (or c‐myc) amplification; (iv) has the capacity to seed the CSF; and (v) may respond to platinum‐based chemotherapy regimens.
Effect of Microbial Transglutaminase on Spaghetti Quality
Authors: Aalami M. , Leelavathi K.
Published: April 2008

ABSTRACT:  To examine the potential application of microbial transglutaminase (MTG) on semolina dough properties and quality of raw and cooked spaghetti, the effects of various MTG addition levels on the solubility of proteins, SDS‐PAGE pattern of semolina dough proteins, and textural and structural properties of raw and cooked spaghetti were investigated using semolina from a high‐protein good variety (MACS 1967) and a low‐protein poor variety (PDW 274) durum wheat. To increase the concentration of lysyl residues and possibly enhance the extent of cross‐linking of protein matrix by MTG, a commercial soy protein isolate (SPI) was added at a level of 3% (w/w) in combination with MTG, and its effect on semolina dough properties and spaghetti quality was investigated. The addition of MTG significantly decreased the solubility of semolina dough proteins. SDS‐PAGE results showed that with increasing levels of MTG, a progressive decrease in the intensity of the bands corresponding to molecular weight of around 66 kDa was observed. Protein cross‐linking reaction catalyzed by MTG resulted in changes in dough properties, dry spaghetti quality, cooking quality characteristics, and microstructure of cooked spaghetti. However, the quality improvements were more evident in spaghetti from the poor variety PDW 274 than from the good variety MACS 1967. The results also showed the ability of MTG in the formation of heterologous polymers between SPI and durum wheat proteins to improve the quality of spaghetti samples.
Effects of static dosimetric leaf gap on MLC‐based small‐beam dose distribution for intensity‐modulated radiosurgery
Authors: Lee Jeong‐Woo , Choi Kyoung‐Sik , Hong Semie , Kim Yon‐Lae , Chung Jin‐Beom , Lee Doo‐Hyun , Choe Bo‐Young , Jang Hong‐Seok , Suh Tae‐Suk
Published: April 2008

The aim of the present study was to evaluate the effect of various specific dosimetric leaf gaps on the multileaf collimator (MLC)–based small‐beam dose distribution. The dosimetric static leaf gap was determined by comparing the profiles of small MLC‐based beams with those of small collimated fields (square fields of 1, 2, 3, and 4cm). The results showed that an approximately 2‐mm gap was optimal with the Millennium 120‐leaf MLC (Varian Medical Systems, Palo Alto, CA) and a Varian 21EX 6‐MV photon beam. We also investigated how much the leaf gap affects the planning results and the actual dose distribution. A doughnut‐shaped planning target volume (PTV, 6.1 cm3) and inner organ at risk (OAR, 0.3 cm3) were delineated for delicate intensity‐modulated radiosurgery test planning. The applied leaf gaps were 0, 1, and 2 mm. The measured dose distributions were compared with the dose distribution in the treatment planning system. The maximum dose differences at inside PTV, outside PTV, and inner OAR were, respectively, 22.3%, 20.2%, and 35.2% for the 0‐mm leaf gap; 17.8%, 22.8%, and 30.8% for the 1‐mm leaf gap; and 5.5%, 8.5%, and 6.3% for the 2‐mm leaf gap. In a human head phantom (model 605: CIRS, Norfolk, VA) study, large dose differences of 1.3% – 12.7% were noted for the measurements made using the MLC files generated by the three different leaf gaps. The planned results were similar, and measurements showed a large dose difference associated with the various leaf gaps. These results strongly suggest that plans generated by a commercial inverse planning system commissioned using general collimated field data will probably demonstrate discrepancies between the planned treatments and the measured results.

PACS number: 87.53.Dq
A device for precision positioning and alignment of room lasers to diminish their contribution to patient setup errors
Authors: Brezovich Ivan A. , Jordan Stephen
Published: April 2008

This report presents an analysis of patient setup errors resulting from inaccurately positioned wall lasers. It suggests that laser beams should agree within 0.2 degree or better with the machine axes that they are delineating. For typical simulator and treatment rooms having wall‐to‐isocenter distances of 3 m, this requirement is satisfied when the beam‐emitting aperture is mounted within about 1.0 cm from the intersection of the respective machine axis with the wall. To achieve the required precision, we developed and clinically tested a simple, inexpensive tool, the Laser Placer (LP). The essential component of the LP is a cube with mirror surfaces that is aligned with the machine axes using built‐in spirit levels and the light field and crosshairs of the collimator. Wall, ceiling, and sagittal lasers are installed and aligned according to reflections of their beams by the cube, and reference lines provided by the LP. Measurements showed that, even in new accelerator installations performed by highly experienced technicians, wall lasers are often mounted off target by more than 1.5 cm. Such inaccuracies can contribute systematic errors of 2 mm or more to the random setup errors attributable to interfraction movement in patient anatomy. To keep setup errors to a minimum, medical physicists should check beam orthogonality in addition to beam congruence at isocenter as recommended by the TG‐40 quality assurance protocol from the American Association of Physicists in Medicine.

PACS number: 87.53.‐j
Measurement of craniocaudal catheter displacement between fractions in computed tomography–based high dose rate brachytherapy of prostate cancer
Authors: Kim Yongbok , Hsu I‐Chow J. , Pouliot Jean
Published: April 2008

The objective of the present work was to measure the craniocaudal displacement of catheters occurring between consecutive fractions of transrectal ultrasound (TRUS)‐guided high dose rate (HDR) prostate brachytherapy. Ten consecutive patients were treated with 2 fractions of 9.5‐Gy TRUS‐guided HDR brachytherapy, with dental putty being used for the fixation of catheters. For each patient, a computed tomography (CT) scan with 3‐mm slice thickness was acquired before each of the 2 fractions. Two different references were used to measure the catheter displacement between fractions: the ischial bone as a bony marker (BM) and the center of two gold markers (COGM) implanted in the prostate. Catheter displacement was calculated by multiplying the thickness of the CT slice by the difference in number of CT slices between the reference slice and the slice containing the tip of a catheter. The average magnitude of caudal catheter displacement was 2.7 mm (range: to 13.5 mm) for the BM method and 5.4 mm (range: to 18.0 mm) for the COGM method. The measurement data obtained from the BM and COGM methods verified that prostate movement and catheter displacement both occurred independently between fractions. The most anterior and medial two catheters (catheter positions 8 and 12) had the greatest tendency to be displaced in the caudal direction because they were located at the most distant position from the fulcrum, making them susceptible to rotation of the dental putty in the lateral plane because of the movement of the patients’ legs between fractions. In conclusion, the combination of the BM and COGM methods can demonstrate prostate and catheter movement relative to the BM between fractions. Our technique found a pattern of catheter displacement. Based on that finding, further improvement of our results may be possible by modification of our current technique.

PACS number: 87.53.Jw
Using an onboard kilovoltage imager to measure setup deviation in intensity‐modulated radiation therapy for head‐and‐neck patients
Authors: Mechalakos James G. , Hunt Margie A. , Lee Nancy Y. , Hong Linda X. , Ling C. Clifton , Amols Howard I.
Published: April 2008

The purpose of the present study was to use a kilovoltage imaging device to measure interfractional and intrafractional setup deviations in patients with head‐and‐neck or brain cancers receiving intensity‐modulated radiotherapy (IMRT) treatment.

Before and after IMRT treatment, approximately 3 times weekly, 7 patients were imaged using the Varian On‐Board Imager (OBI: Varian Medical Systems, Palo Alto, CA), a kilovoltage imaging device permanently mounted on the gantry of a Varian 21EX LINAC (Varian Medical Systems). Because of commissioning of the remote couch correction of the OBI during the study, online setup corrections were performed on 2 patients. For the other 5 patients, weekly corrections were made based on a sliding average of the measured data. From these data, we determined the interfractional setup deviation (defined as the shift from the original setup position suggested by the daily image), the residual error associated with the weekly correction protocol, and the intrafractional setup deviation, defined as the difference between the post‐treatment and pretreatment images. We also used our own image registration software to determine interfractional and intrafractional rotational deviations from the images based on the template‐matching method. In addition, we evaluated the influence of inter‐observer variation on our results, and whether the use of various registration techniques introduced differences. Finally, translational data were compared with rotational data to search for correlations.

Translational setup errors from all data were , , and in the right–left (RL), anterior–posterior (AP), and superior–inferior (SI) directions respectively. Residual error for the 5 patients with a weekly correction protocol was (RL), (AP), and (SI). Intrafractional translation errors were small, amounting to , , and in the RL, AP, and SI directions respectively. In the sagittal and coronal views respectively, interfractional rotational errors were degrees and degrees, and intrafractional rotational errors were degrees and degrees. No significant correlation was seen between translational and rotational data.

The OBI image data were used to study setup error in the head‐and‐neck patients. Nonzero systematic errors were seen in the interfractional translational and rotational data, but not in the intrafractional data, indicating that the mask is better at maintaining head position than at reproducing it.

PACS numbers:87.53.Kn, 87.53.Oq
Development of an optimum photon beam model for head‐and‐neck intensity‐modulated radiotherapy
Authors: Webster Gareth J , Rowbottom Carl G , Mackay Ranald I
Published: April 2008

Intensity‐modulated radiotherapy (IMRT) for complex sites such as tumors of the head and neck requires a level of accuracy in dose calculation beyond that currently used for conformal treatment planning. Recent advances in treatment planning systems have aimed to improve the dose calculation accuracy by improving the modeling of machine characteristics such as interleaf leakage, tongue and groove, and rounded multileaf collimator (MLC) leaf ends. What is uncertain is the extent to which these model parameters improve the agreement between dose calculation and measurements for IMRT treatments.

We used Pinnacle version 7.4f (Philips Medical Systems, Andover, MA) to carry out optimization of additional photon‐beam model parameters for both an Elekta Precise (Elekta, Stockholm, Sweden) and a Varian (Varian Medical Systems, Palo Alto, CA) linear accelerator (LINAC). One additional parameter was added to the beam models in turn, and associated models were commissioned to investigate the dosimetric impact of each model parameter on 5 clinical head‐and‐neck IMRT plans. The magnitude and location of differences between the models was determined from gamma analysis of the calculated planar dose maps. A final model that incorporated all of the changes was then commissioned. For the Elekta Precise, the impact of all the changes was determined using a gamma analysis as compared with measured films.

Cumulative differences of up to more than 3%/3 mm were observed when dose distributions with and without all of the model changes were compared. Individually, for both LINACs, the addition of modeling for the rounded MLC leaf ends caused the most dramatic change to the calculation of the dose distribution, generating a difference of 3%/3 mm in up to 5% of pixels for the 5 patient plans sampled. The effect of tongue‐and‐groove modeling was more significant for the Varian LINAC (at 1%/1 mm, mean of 25% of pixels as compared with 5% of pixels with the Elekta Precise LINAC). The combined changes to the Elekta model were found to improve agreement with measurement.

Current commercially available treatment planning systems offer accuracy sufficient for clinical implementation of head‐and‐neck IMRT. For this treatment site, the ability to accurately model the rounded MLC leaf ends has the greatest affect on the similarity of the calculated dose distribution to measurements. In addition, for the Varian LINAC, modeling of the tongue‐and‐groove effect was also advantageous.

PACS numbers: 87.53.‐j, 87.53.Bn, 87.53.Tf
Learning a way through ethical problems: Swedish nurses’ and doctors’ experiences from one model of ethics rounds
Authors: Svantesson M , Löfmark R , Thorsén H , Kallenberg K , Ahlström G
Published: April 2008

Objective:

To evaluate one ethics rounds model by describing nurses’ and doctors’ experiences of the rounds.

Methods:

Philosopher-ethicist-led interprofessional team ethics rounds concerning dialysis patient care problems were applied at three Swedish hospitals. The philosophers were instructed to promote mutual understanding and stimulate ethical reflection, without giving any recommendations or solutions. Interviews with seven doctors and 11 nurses were conducted regarding their experiences from the rounds, which were then analysed using content analysis.

Findings:

The goal of the rounds was partly fulfilled. Participants described both positive and negative experiences. Good rounds included stimulation to broadened thinking, a sense of connecting, strengthened confidence to act, insight into moral responsibility and emotional relief. Negative experiences were associated with a sense of unconcern and alienation, as well as frustration with the lack of solutions and a sense of resignation that change is not possible. The findings suggest that the ethics rounds above all met the need of a forum for crossing over professional boundaries. The philosophers seemed to play an important role in structuring and stimulating reasoned arguments. The nurses’ expectation that solutions to the ethical problems would be sought despite explicit instructions to the contrary was conspicuous.

Conclusion:

When assisting healthcare professionals to learn a way through ethical problems in patient care, a balance should be found between ethical analyses, conflict resolution and problem solving. A model based on the findings is presented.
An assessment of the process of informed consent at the University Hospital of the West Indies
Authors: Barnett A T , Crandon I , Lindo J F , Gordon-Strachan G , Robinson D , Ranglin D
Published: April 2008

Objective:

To assess the adequacy of the process of informed consent for surgical patients at the University Hospital of the West Indies.

Method:

The study is a prospective, cross-sectional, descriptive study. 210 patients at the University Hospital of the West Indies were interviewed using a standardised investigator-administered questionnaire, developed by the authors, after obtaining witnessed, informed consent for participation in the study. Data were analysed using SPSS V.12 for Windows.

Results:

Of the patients, 39.4% were male. Of the surgical procedures, 68.6% were scheduled, 7.6% urgent and 23.8% emergency, 35.2% were minor and 64.8% major. Information imparted/received was acceptable in 40% of cases, good in 24% and inadequate (unacceptable) in 36% of cases. Almost all (97.6%) patients stated that they understood why an operation was planned and 93.3% thought that they had given informed consent. Most (95.2%) thought that they had free choice and made up their own mind. A quarter (25.2%) of all patients were told that it was mandatory for them to sign the form. There was a discussion of possible side effects and complications in 56.7% of patients.

Conclusions:

This study clearly indicates that surgical patients at the University Hospital of the West Indies feel that they have given informed consent. However, it also suggests that more information should be given to patients for consent to be truly informed.
The practicalities of terminally ill patients signing their own DNR orders—a study in Taiwan
Authors: Huang C-H , Hu W-Y , Chiu T-Y , Chen C-Y
Published: April 2008

Objectives:

To investigate the current situation of completing the informed consent for do-not-resuscitate (DNR) orders among the competent patients with terminal illness and the ethical dilemmas related to it.

Participants:

This study enrolled 152 competent patients with terminal cancer, who were involved in the initial consultations for hospice care.

Analysis:

Comparisons of means, analyses of variance, Student’s t test, χ2test and multiple logistic regression models.

Results:

After the consultations, 117 (77.0%) of the 152 patients provided informed consent for hospice care and DNR orders. These included 21 patients (17.9%) who signed the consent by themselves, and 96 (82.1%) whose consent sheet was signed only by family members. The reasons why patients were not involved in the discussions toward the consent (n = 82) included poor physical or psychological condition (44.9%), concerns of the consultant hospice team (37.2%), and the family’s refusal (28.2%). On a multivariate analysis, patients’ awareness of their poor prognosis (odds ratio = 4.07, 95% confidence interval = 2.05 to 8.07) and their understanding of hospice care (2.27, 1.33 to 3.89) were two independent factors (p<0.01) that influenced their participation in the discussions or their personal signature in the informed consent.

Conclusion:

The family-oriented culture in Asian countries may violate the principles of the Patient Self-Determination Act and the requirements of the Hospice Care Law in Taiwan, which inevitably poses an ethical dilemma. Earlier truth-telling and continuing education of the public by hospice care workers will be helpful in solving such ethical dilemmas.
The potential impact of decision role and patient age on end-of-life treatment decision making
Authors: Zikmund-Fisher B J , Lacey H P , Fagerlin A
Published: April 2008

Background:

Recent research demonstrates that people sometimes make different medical decisions for others than they would make for themselves. This finding is particularly relevant to end-of-life decisions, which are often made by surrogates and require a trade-off between prolonging life and maintaining quality of life. We examine the impact of decision role, patient age, decision maker age and multiple individual differences on these treatment decisions.

Methods:

Participants read a scenario about a terminally ill cancer patient faced with a choice between an aggressive chemotherapy regimen that will extend life by two years and palliative treatments to control discomfort for one remaining month. Participants were randomly assigned to one of three decision roles (patient, physician, or an abstract other) and the scenario randomly varied whether the patient was described as 25 or 65-years old.

Results:

When deciding for a 65-year old patient, approximately 60% of participants selected aggressive chemotherapy regardless of decision role. When deciding for a 25-year old patient, however, participants were more likely to select chemotherapy for a patient (physician role) or another person (abstract other) than for themselves (70%, 67%, and 59%, respectively). In addition, confidence that powerful others (eg, physicians) control one’s health, as well as respondents’ age and race, consistently predicted treatment choices.

Conclusions:

Patient age appears to influence medical decisions made for others but not those that we make for ourselves. These findings may help to explain the discord that often occurs when younger cancer patients refuse life-extending treatments.
The perceived role of Islam in immigrant Muslim medical practice within the USA: an exploratory qualitative study: Table 1
Authors: Padela A I , Shanawani H , Greenlaw J , Hamid H , Aktas M , Chin N
Published: April 2008

Background:

Islam and Muslims are underrepresented in the medical literature and the influence of physician’s cultural beliefs and religious values upon the clinical encounter has been understudied.

Objective:

To elicit the perceived influence of Islam upon the practice patterns of immigrant Muslim physicians in the USA.

Design:

Ten face-to-face, in-depth, semistructured interviews with Muslim physicians from various backgrounds and specialties trained outside the USA and practising within the the country. Data were analysed according to the conventions of qualitative research using a modified grounded-theory approach.

Results:

There were a variety of views on the role of Islam in medical practice. Several themes emerged from our interviews: (1) a trend to view Islam as enhancing virtuous professional behaviour; (2) the perception of Islam as influencing the scope of medical practice through setting boundaries on career choices, defining acceptable medical procedures and shaping social interactions with physician peers; (3) a perceived need for Islamic religious experts within Islamic medical ethical deliberation.

Limitations:

This is a pilot study intended to yield themes and hypotheses for further investigation and is not meant to fully characterise Muslim physicians at large.

Conclusions:

Immigrant Muslim physicians practising within the USA perceive Islam to play a variable role within their clinical practice, from influencing interpersonal relations and character development to affecting specialty choice and procedures performed. Areas of ethical challenges identified include catering to populations with lifestyles at odds with Islamic teachings, end-of-life care and maintaining a faith identity within the culture of medicine. Further study of the interplay between Islam and Muslim medical practice and the manner and degree to which Islamic values and law inform ethical decision-making is needed.