Literature review on advance care planning of nursing home residents

Aim: Conduct a search and analytic review of literature regarding attributes of Advance Care Planning (ACP) and Advance Directive in order to identify the experiences and the best care strategies for older adults resident in nursing homes or long term institutions. Methodology: An extensive electronic search was undertaken in the following databases: Pubmed (via Ovid search), Cumulative Index of Nursing and Allied Health (CINAHL, via EBHOST), psychINFO and Cochrane. After analyzing and eliminating duplicates and professional's point of view (19), 144 titles were considered relevant: 28 opinion papers, 94 descriptive/qualitative studies or predictive studies, 17 experimental and five systematic reviews. Most of them were produced in North America and only 10 were in French. Results: With regard to European experiences, studies are scarce and further research could benefit from North American evidence. Contrary to Europe, nurses in North America play a major role in the process of care planning. The major findings were related to the poor efficacy of the completion of Advance Directives, even in presence of a substantial variety of implementation strategies. The evidence supports interventions that conceptualize ACP as a process, with an emphasis on the ascertainment of patients' values and beliefs and the necessity to include the family or loved ones from the beginning of the process in order to favor the expression and sharing of one's life perspectives and priorities in care. The most relevant findings were associated with the conceptualization of the ACP as a change in health behaviors which needs an involvement in different stages to overcome a variety of barriers. Conclusion: Rigorous research in ACP for the older adults in Swiss nursing homes that promote respect and dignity in this frail population is needed. How to best achieve patients and families goals should be the focus of nursing intervention and research in this domain.

The use of 3D planning in facial surgery: Preliminary observations.

Three-dimensional (3D) planning is becoming a more commonly used tool in maxillofacial surgery. At first used only virtually, 3D planning now also enables the creation of useful intraoperative aids such as cutting guides, which decrease the operative difficulty. In our center, we have used 3D planning in various domains of facial surgery and have investigated the advantages of this technique. We have also addressed the difficulties associated with its use. 3D planning increases the accuracy of reconstructive surgery, decreases operating time, whilst maintaining excellent esthetic results. However, its use is restricted to osseous reconstruction at this stage and once planning has been undertaken, it cannot be reversed or altered intraoperatively. Despite the attractive nature of this new tool, its uses and practicalities must be further evaluated. In particular, cost-effectiveness, hospital stay, and patient perceived benefits must be assessed.

Spatial planning to the test of property rights in Switzerland : an innovative land management approach to coordinate spatial planning goals with property rights interests

In Switzerland, the land management regime is characterized by a liberal attitude towards the institution of property rights, which is guaranteed by the Constitution. Under the present Swiss constitutional arrangement, authorities (municipalities) are required to take into account landowners' interests when implementing their spatial planning policy. In other words, the institution of property rights cannot be restricted easily in order to implement zoning plans and planning projects. This situation causes many problems. One of them is the gap between the way land is really used by the landowners and the way land should be used based on zoning plans. In fact, zoning plans only describe how landowners should use their property. There is no sufficient provision for handling cases where the use is not in accordance with zoning plans. In particular, landowners may not be expropriated for a non-conforming use of the land. This situation often leads to the opening of new building areas in greenfields and urban sprawl, which is in contradiction with the goals set into the Federal Law on Spatial Planning. In order to identify legal strategies of intervention to solve the problem, our paper is structured into three main parts. Firstly, we make a short description of the Swiss land management regime. Then, we focus on an innovative land management approach designed to implement zoning plans in accordance with property rights. Finally, we present a case study that shows the usefulness of the presented land management approach in practice. We develop three main results. Firstly, the land management approach brings a mechanism to involve landowners in planning projects. Coordination principle between spatial planning goals and landowners' interests is the cornerstone of all the process. Secondly, the land use is improved both in terms of space and time. Finally, the institution of property rights is not challenged, since there is no expropriation and the market stays free.

Three-dimensional radiobiological dosimetry of kidneys for treatment planning in peptide receptor radionuclide therapy.

PURPOSE: Peptide receptor radionuclide therapy (PRRT) delivers high absorbed doses to kidneys and may lead to permanent nephropathy. Reliable dosimetry of kidneys is thus critical for safe and effective PRRT. The aim of this work was to assess the feasibility of planning PRRT based on 3D radiobiological dosimetry (3D-RD) in order to optimize both the amount of activity to administer and the fractionation scheme, while limiting the absorbed dose and the biological effective dose (BED) to the renal cortex. METHODS: Planar and SPECT data were available for a patient examined with (111)In-DTPA-octreotide at 0.5 (planar only), 4, 24, and 48 h post-injection. Absorbed dose and BED distributions were calculated for common therapeutic radionuclides, i.e., (111)In, (90)Y and (177)Lu, using the 3D-RD methodology. Dose-volume histograms were computed and mean absorbed doses to kidneys, renal cortices, and medullae were compared with results obtained using the MIRD schema (S-values) with the multiregion kidney dosimetry model. Two different treatment planning approaches based on (1) the fixed absorbed dose to the cortex and (2) the fixed BED to the cortex were then considered to optimize the activity to administer by varying the number of fractions. RESULTS: Mean absorbed doses calculated with 3D-RD were in good agreement with those obtained with S-value-based SPECT dosimetry for (90)Y and (177)Lu. Nevertheless, for (111)In, differences of 14% and 22% were found for the whole kidneys and the cortex, respectively. Moreover, the authors found that planar-based dosimetry systematically underestimates the absorbed dose in comparison with SPECT-based methods, up to 32%. Regarding the 3D-RD-based treatment planning using a fixed BED constraint to the renal cortex, the optimal number of fractions was found to be 3 or 4, depending on the radionuclide administered and the value of the fixed BED. Cumulative activities obtained using the proposed simulated treatment planning are compatible with real activities administered to patients in PRRT. CONCLUSIONS: The 3D-RD treatment planning approach based on the fixed BED was found to be the method of choice for clinical implementation in PRRT by providing realistic activity to administer and number of cycles. While dividing the activity in several cycles is important to reduce renal toxicity, the clinical outcome of fractionated PRRT should be investigated in the future.

Segmentation of Head and Neck Lymph Node Regions for Radiotherapy Planning Using Active Contour-Based Atlas Registration

In this paper, we present the segmentation of the headand neck lymph node regions using a new active contourbased atlas registration model. We propose to segment thelymph node regions without directly including them in theatlas registration process; instead, they are segmentedusing the dense deformation field computed from theregistration of the atlas structures with distinctboundaries. This approach results in robust and accuratesegmentation of the lymph node regions even in thepresence of significant anatomical variations between theatlas-image and the patient's image to be segmented. Wealso present a quantitative evaluation of lymph noderegions segmentation using various statistical as well asgeometrical metrics: sensitivity, specificity, dicesimilarity coefficient and Hausdorff distance. Acomparison of the proposed method with two other state ofthe art methods is presented. The robustness of theproposed method to the atlas selection, in segmenting thelymph node regions, is also evaluated.

Model-based Segmentation and Image Fusion of 3D Computed Tomography and 3D Ultrasound of the Eye for Radiotherapy Planning

For radiotherapy treatment planning of retinoblastoma inchildhood, Computed Tomography (CT) represents thestandard method for tumor volume delineation, despitesome inherent limitations. CT scan is very useful inproviding information on physical density for dosecalculation and morphological volumetric information butpresents a low sensitivity in assessing the tumorviability. On the other hand, 3D ultrasound (US) allows ahigh accurate definition of the tumor volume thanks toits high spatial resolution but it is not currentlyintegrated in the treatment planning but used only fordiagnosis and follow-up. Our ultimate goal is anautomatic segmentation of gross tumor volume (GTV) in the3D US, the segmentation of the organs at risk (OAR) inthe CT and the registration of both. In this paper, wepresent some preliminary results in this direction. Wepresent 3D active contour-based segmentation of the eyeball and the lens in CT images; the presented approachincorporates the prior knowledge of the anatomy by usinga 3D geometrical eye model. The automated segmentationresults are validated by comparing with manualsegmentations. Then, for the fusion of 3D CT and USimages, we present two approaches: (i) landmark-basedtransformation, and (ii) object-based transformation thatmakes use of eye ball contour information on CT and USimages.

Accuracy of out-of-field dose calculation of tomotherapy and cyberknife treatment planning systems: A dosimetric study.

PURPOSE: Late toxicities such as second cancer induction become more important as treatment outcome improves. Often the dose distribution calculated with a commercial treatment planning system (TPS) is used to estimate radiation carcinogenesis for the radiotherapy patient. However, for locations beyond the treatment field borders, the accuracy is not well known. The aim of this study was to perform detailed out-of-field-measurements for a typical radiotherapy treatment plan administered with a Cyberknife and a Tomotherapy machine and to compare the measurements to the predictions of the TPS. MATERIALS AND METHODS: Individually calibrated thermoluminescent dosimeters were used to measure absorbed dose in an anthropomorphic phantom at 184 locations. The measured dose distributions from 6 MV intensity-modulated treatment beams for CyberKnife and TomoTherapy machines were compared to the dose calculations from the TPS. RESULTS: The TPS are underestimating the dose far away from the target volume. Quantitatively the Cyberknife underestimates the dose at 40cm from the PTV border by a factor of 60, the Tomotherapy TPS by a factor of two. If a 50% dose uncertainty is accepted, the Cyberknife TPS can predict doses down to approximately 10 mGy/treatment Gy, the Tomotherapy-TPS down to 0.75 mGy/treatment Gy. The Cyberknife TPS can then be used up to 10cm from the PTV border the Tomotherapy up to 35cm. CONCLUSIONS: We determined that the Cyberknife and Tomotherapy TPS underestimate substantially the doses far away from the treated volume. It is recommended not to use out-of-field doses from the Cyberknife TPS for applications like modeling of second cancer induction. The Tomotherapy TPS can be used up to 35cm from the PTV border (for a 390 cm(3) large PTV).

Comparisons of Preoperative Three-Dimensional Planning and Surgical Reconstruction in Primary Cementless Total Hip Arthroplasty

La planification scanographique (3D) a démontré son utilité pour une reconstruction anatomique plus précise de la hanche (longueur du fémur, centre de rotation, offset, antéversion et rétroversion). Des études ont montré que lors de la planification 2D 50% seulement correspondaient à l'implant définitif du fémur alors que dans une autre étude ce taux s'élevait à 94% pour une planification 3D. Les erreurs étaient liées à l'agrandissement des radiographies. L'erreur sur la taille de la tige est liée à l'estimation inadéquate de la morphologie osseuse ainsi qu'à la densité osseuse. L'erreur de l'antéversion, augmentée par l'inclinaison du bassin, a pu être éliminée par la planification 3D et l'offset restauré dans 98%. Cette étude est basée sur une nouvelle technique de planification scanographique en trois dimensions pour une meilleure précision de la reconstruction de la hanche. Le but de cette étude est de comparer l'anatomie post-opératoire à celle préopératoire en comparant les tailles d'implant prévu lors de la planification 3D à celle réellement utilisée lors de l'opération afin de déterminer l'exactitude de la restauration anatomique avec étude des différents paramètres (centre de rotation, densité osseuse, L'offset fémoral, rotations des implants, longueur du membre) à l'aide du Logiciel HIP-PLAN (Symbios) avec évaluation de la reproductibilité de notre planification 3D dans une série prospective de 50 patients subissant une prothèse totale de hanche non cimentée primaire par voie antérieure. La planification pré-opératoire a été comparée à un CTscan postopératoire par fusion d'images. CONCLUSION ET PRESPECTIVE Les résultats obtenus sont les suivants : La taille de l'implant a été prédit correctement dans 100% des tiges, 94% des cupules et 88% des têtes (longueur). La différence entre le prévu et la longueur de la jambe postopératoire était de 0,3+2,3 mm. Les valeurs de décalage global, antéversion fémorale, inclinaison et antéversion de la cupule étaient 1,4 mm ± 3,1, 0,6 ± 3,3 0 -0,4 0 ± 5 et 6,9 ° ± 11,4, respectivement. Cette planification permet de prévoir la taille de l'implant précis. Position de la tige et de l'inclinaison de la cupule sont exactement reproductible. La planification scanographique préopératoire 3D permet une évaluation précise de l'anatomie individuelle des patients subissant une prothèse totale de hanche. La prédiction de la taille de l'implant est fiable et la précision du positionnement de la tige est excellente. Toutefois, aucun avantage n'est observée en termes d'orientation de la cupule par rapport aux études impliquant une planification 2D ou la navigation. De plus amples recherches comparant les différentes techniques de planification pré-opératoire à la navigation sont nécessaire.