Simulation de radiographies à partir d'images tomodensitométriques pour l'enseignement de l'anatomie radiographique en médecine vétérinaire

L'un des principaux défis de l'interprétation radiographique réside dans la compréhension de l’anatomie radiographique, laquelle est intrinsèquement liée à la disposition tridimensionnelle des structures anatomiques et à l’impact du positionnement du tube radiogène vis-à-vis de ces structures lors de l'acquisition de l'image. Traditionnellement, des radiographies obtenues selon des projections standard sont employées pour enseigner l'anatomie radiographique en médecine vétérinaire. La tomodensitométrie − ou communément appelée CT (Computed Tomography) − partage plusieurs des caractéristiques de la radiographie en ce qui a trait à la génération des images. À l’aide d'un plug-in spécialement développé (ORS Visual ©), la matrice contenant les images CT est déformée pour reproduire les effets géométriques propres au positionnement du tube et du détecteur vis-à-vis du patient radiographié, tout particulièrement les effets de magnification et de distorsion. Afin d'évaluer le rendu des images simulées, différentes régions corporelles ont été imagées au CT chez deux chiens, un chat et un cheval, avant d'être radiographiées suivant des protocoles d'examens standards. Pour valider le potentiel éducatif des simulations, dix radiologistes certifiés ont comparé à l'aveugle neuf séries d'images radiographiques simulées aux séries radiographiques standard. Plusieurs critères ont été évalués, soient le grade de visualisation des marqueurs anatomiques, le réalisme et la qualité radiographique des images, le positionnement du patient et le potentiel éducatif de celles-ci pour différents niveaux de formation vétérinaire. Les résultats généraux indiquent que les images radiographiques simulées à partir de ce modèle sont suffisamment représentatives de la réalité pour être employées dans l’enseignement de l’anatomie radiographique en médecine vétérinaire.

Estudo comparativo para avaliação das falhas técnicas em radiografias convencionais de tórax

OBJETIVO: Especificar e quantificar as principais falhas técnicas, sejam elas eletrônicas ou mecânicas, presentes em radiografias convencionais de tórax, com o intuito de melhorar a sua qualidade e reduzir a necessidade da repetição dos exames e, consequentemente, a dose recebida pelo paciente. MATERIAIS E MÉTODOS: Foram selecionadas e avaliadas por um pneumologista 897 radiografias convencionais realizadas ou em projeção posteroanterior ou lateral em cinco instituições de saúde da cidade de São Paulo. em cada uma delas foram feitas análises das falhas técnicas presentes, as quais foram classificadas de acordo com o erro técnico radiográfico pré-definido e que levou à repetição do exame. RESULTADOS: Os resultados obtidos mostraram que o posicionamento incorreto do paciente (27%), a subexposição (23%) e a superexposição (15%) foram as principais falhas que contribuíram para a repetição dos exames e que apresentaram, na matriz de coeficiente de correlação Pearson, um erro acima de 0,7%, ocasionando aumento da dose recebida pelos pacientes. CONCLUSÃO: Os resultados observados indicaram a necessidade da realização de controle de qualidade dos aparelhos de raios X, a atenção do operador do equipamento, bem como outras abordagens para esclarecer o impacto da necessidade de repetição do exame.

Efeito da posição do prematuro no desmame da ventilação mecânica

Objective: the purpose of this study was to determine the effects of prone positioning on cardiorespiratory stability and weaning outcome of preterm infants during weaning from mechanical ventilation. Methods: from January to December 1999, a sample of 42 preterm infants, with birthweight < 2,000 g, mechanically ventilated in the first week of life, were randomly divided, in the beginning of the weaning process, in two groups according to the position: supine position (n = 21) or prone position (n = 21). Heart rate, respiratory rate, transcutaneous oxygen saturation and ventilatory parameters were recorded every one hour. Length of the weaning process and complications were also assessed. Results: in both groups the mean gestational age was 29 weeks, most of the patients presented very low birthweight and respiratory distress syndrome. The mean length of the weaning process was 2 days. There were no differences between the groups regarding respiratory rate, heart rate and transcutaneous oxygen saturation, however, oxygen desaturation episodes were more frequent in supine position (p = 0.009). Ventilatory parameters decreased faster and reintubation was less frequent in the prone group (4% versus 33%). No adverse effects of prone positioning were observed. Conclusion: these results suggest that prone position is a safe and beneficial procedure during the weaning from mechanical ventilation and may contribute to weaning success in preterm infants.

Aplicação de princípios de ergonomia no atendimento odontológico

The dentist has been suggested as a professional vulnerable to labor risks mainly related to working posture. This study examined the application of ergonomics principles during the dental attendances made by university student of the last period of the Araçatuba Dental University. Twenty-four attendants were photographed and the images were digitally analyzed for the verification of 10 requirements that determine a healthy labor posture, defined by the project ISO Standard / TC 106/SC 6 N 411. It was observed that 50% of items from the check list obtained higher percentages of negative replies. The students had greater difficulties as to the correct position of the angle between the upper and lower leg when sitting, the ideal adjustment of the light focus reflector in the field of work and the patient positioning. It was concluded that the dental attendances were held without compliance with the ergonomic requirements. The greatest difficulties regarding the work posture were the sitting posture, the light beam and the patient positioning. Students need better guidance about ergonomic principles and requirements, which should occur at any time of life, but earliest they are installed, greater the benefits, assimilation and incorporation of adequate working postures will be. We need a reform that addresses all sectors of the dental system, so that learning and application of ergonomics in dentistry become effective, efficient and effective.

Vergleich der Elastographie-gesteuerten Biopsie mit der Systembiopsie bei der Detektion von Prostatakarzinomen

Hintergrund: Die Systembiopsie gilt als Goldstandard zum Nachweis eines Prostatakarzinoms, obwohl ein relevanter Anteil an Prostatakarzinomen nicht diagnostiziert wird. Wir wollten mit unserer Arbeit die Frage beantworten, ob mittels elastographisch gezielter Biopsien die Prostatakarzinom-Detektion im Vergleich zur Goldstandard-Systembiopsie verbessert werden kann. Material und Methode: 152 Patienten wurden in einer prospektiven Studie einer 12-fachen Prostata-Systembiopsie unterzogen. In Linksseitenlagerung wurde dabei aus jedem der vordefinierten 6 Prostatasegmente je 1 laterale und 1 mediale Stanze entnommen. Elastographisch suspekte Areale wurden zusätzlich gezielt biopsiert. Als statistisch signifikant wurde p<0,05 angenommen. Ergebnisse: Bei 62 der 152 Patienten (40,8%) wurde ein Prostatakarzinom diagnostiziert. Die Detektionsrate der Systembiopsie betrug 39,5% (60/152), die Detektionsrate der Elastographie 29,6% (45/152). Somit war die Systembiopsie der elastographisch gezielten Biopsie signifikant überlegen (p=0,039).Jedoch war die Wahrscheinlichkeit mit einer Prostatastanze ein Karzinomherd zu entdecken, für die elastographischen Biopsien 3,7-fach höher als für die Systembiopsien. Die Sensitivität der Elastographie betrug 72,6% und die Spezifität 66,6%. Der positive Vorhersagewert für die Elastographie war 60%, der negative Vorhersagewert 78%. Die Kombination von Systembiopsie und elastographisch gezielten Biopsien bot die höchste Detektionsrate. In der rechten Prostatahälfte (48%) verzeichneten wir doppelt so viele elastographisch falsch-positive Befunde wie in der linken Prostatahälfte (25%). Desweiteren fanden sich am häufigsten falsch-positive Befunde im Prostata-Apex (46%) und am seltensten in der Prostata-Basis (29%). Schlussfolgerung: In unserer Studie war die elastographisch gezielte Biopsie der Systembiopsie signifikant unterlegen (p=0,039). Die Kombination von Systembiopsie mit elastographisch gezielten Biopsien bot die höchste Detektionsrate und kann daher empfohlen werden. Die Auffälligkeiten in der Segment-bezogenen Auswertung und ein möglicher Einfluss der Patienten-Lagerung müssen durch weitere Studien überprüft werden.rn

Safety, effectiveness and predictors for early reoperation in therapeutic and prophylactic vertebroplasty: short-term results of a prospective case series of patients with osteoporotic vertebral fractures

Abstract Introduction Vertebroplasty (VP) is a cost-efficient alternative to kyphoplasty; however, regarding safety and vertebral body (VB) height restoration, it is considered inferior. We assessed the safety and efficacy of VP in alleviating pain, improving quality of life (QoL) and restoring alignment. Methods In a prospective monocenter case series from May 2007 until July 2008, there were 1,408 vertebroplasties performed during 319 interventions in 306 patients with traumatic, lytic and osteoporotic fractures. The 249 interventions in 233 patients performed because of osteoporotic vertebral fractures were analyzed regarding demographics, treatment and radiographic details, pain alleviation (VAS), QoL improvement (NASS and EQ-5D), complications and predictors for new fractures requiring a reoperation. Results The osteoporotic patient sample consisted of 76.7% (179) females with a median age of 80 years. A total of 54 males had a median age of 77 years. On average, there were 1.8 VBs fractured and 5 VBs treated. The preoperative pain was assessed by the visual analog scale (VAS) and decreased from 54.9 to 40.4 pts after 2 months and 31.2 pts after 6 months. Accordingly, the QoL on the EQ-5D measure (−0.6 to 1) improved from 0.35 pts before surgery to 0.56 pts after 2 and to 0.68 pts after 6 months. The preoperative Beck Index (anterior height/posterior height) improved from a mean of 0.64 preoperative to 0.76 postoperative, remained stable at 2 months and slightly deteriorated to 0.72 at 6 months postoperatively. There were cement leakages in 26% of the fractured VBs and in 1.4% of the prophylactically cemented VBs; there were symptoms in 4.3%, and most of them were temporary hypotension and one pulmonary cement embolism that remained asymptomatic. The univariate regression model revealed a tendency for a reduced risk for new or refractures on radiographs (OR = 2.61, 95% CI 0.92–7.38, p = 0.12) and reoperations (OR = 2.9, 95% CI 0.94–8.949, p = 0.1) when prophylactic augmentation was performed. The final multivariate regression model revealed male patients to have an about three times higher refracture risk (radiographic) (OR = 2.78, p = 0.02) at 6 months after surgery. Patients with a lumbar index fracture had an about three to five times higher refracture/reoperation risk than patients with a thoracic (OR = 0.33/0.35, p = 0.009/0.01) or thoracolumbar (OR = 0.32/0.22, p = 0.099/0.01) index fracture. Conclusion If routinely used, VP is a safe and efficacious treatment option for osteoporotic vertebral fractures with regard to pain relief and improvement of the QoL. Even segmental realignment can be partially achieved with proper patient positioning. Certain patient or fracture characteristics increase the risk for early radiographic refractures or new fractures, or a reoperation; a consequent prophylactic augmentation showed protective tendencies, but the study was underpowered for a final conclusion.

Calibration of a portal imaging device for high-precision dosimetry: a Monte Carlo study

Today electronic portal imaging devices (EPID's) are used primarily to verify patient positioning. They have, however, also the potential as 2D-dosimeters and could be used as such for transit dosimetry or dose reconstruction. It has been proven that such devices, especially liquid filled ionization chambers, have a stable dose response relationship which can be described in terms of the physical properties of the EPID and the pulsed linac radiation. For absolute dosimetry however, an accurate method of calibration to an absolute dose is needed. In this work, we concentrate on calibration against dose in a homogeneous water phantom. Using a Monte Carlo model of the detector we calculated dose spread kernels in units of absolute dose per incident energy fluence and compared them to calculated dose spread kernels in water at different depths. The energy of the incident pencil beams varied between 0.5 and 18 MeV. At the depth of dose maximum in water for a 6 MV beam (1.5 cm) and for a 18 MV beam (3.0 cm) we observed large absolute differences between water and detector dose above an incident energy of 4 MeV but only small relative differences in the most frequent energy range of the beam energy spectra. It is shown that for a 6 MV beam the absolute reference dose measured at 1.5 cm water depth differs from the absolute detector dose by 3.8%. At depth 1.2 cm in water, however, the relative dose differences are almost constant between 2 and 6 MeV. The effects of changes in the energy spectrum of the beam on the dose responses in water and in the detector are also investigated. We show that differences larger than 2% can occur for different beam qualities of the incident photon beam behind water slabs of different thicknesses. It is therefore concluded that for high-precision dosimetry such effects have to be taken into account. Nevertheless, the precise information about the dose response of the detector provided in this Monte Carlo study forms the basis of extracting directly the basic radiometric quantities photon fluence and photon energy fluence from the detector's signal using a deconvolution algorithm. The results are therefore promising for future application in absolute transit dosimetry and absolute dose reconstruction.

The silent loss of neuronavigation accuracy: a systematic retrospective analysis of factors influencing the mismatch of frameless stereotactic systems in cranial neurosurgery

BACKGROUND Neuronavigation has become an intrinsic part of preoperative surgical planning and surgical procedures. However, many surgeons have the impression that accuracy decreases during surgery. OBJECTIVE To quantify the decrease of neuronavigation accuracy and identify possible origins, we performed a retrospective quality-control study. METHODS Between April and July 2011, a neuronavigation system was used in conjunction with a specially prepared head holder in 55 consecutive patients. Two different neuronavigation systems were investigated separately. Coregistration was performed with laser-surface matching, paired-point matching using skin fiducials, anatomic landmarks, or bone screws. The initial target registration error (TRE1) was measured using the nasion as the anatomic landmark. Then, after draping and during surgery, the accuracy was checked at predefined procedural landmark steps (Mayfield measurement point and bone measurement point), and deviations were recorded. RESULTS After initial coregistration, the mean (SD) TRE1 was 2.9 (3.3) mm. The TRE1 was significantly dependent on patient positioning, lesion localization, type of neuroimaging, and coregistration method. The following procedures decreased neuronavigation accuracy: attachment of surgical drapes (DTRE2 = 2.7 [1.7] mm), skin retractor attachment (DTRE3 = 1.2 [1.0] mm), craniotomy (DTRE3 = 1.0 [1.4] mm), and Halo ring installation (DTRE3 = 0.5 [0.5] mm). Surgery duration was a significant factor also; the overall DTRE was 1.3 [1.5] mm after 30 minutes and increased to 4.4 [1.8] mm after 5.5 hours of surgery. CONCLUSION After registration, there is an ongoing loss of neuronavigation accuracy. The major factors were draping, attachment of skin retractors, and duration of surgery. Surgeons should be aware of this silent loss of accuracy when using neuronavigation.

The Role of Cell Sterilization in Population Based Studies of Radiogenic Second Cancers Following Radiation Therapy

Advances in radiotherapy have generated increased interest in comparative studies of treatment techniques and their effectiveness. In this respect, pediatric patients are of specific interest because of their sensitivity to radiation induced second cancers. However, due to the rarity of childhood cancers and the long latency of second cancers, large sample sizes are unavailable for the epidemiological study of contemporary radiotherapy treatments. Additionally, when specific treatments are considered, such as proton therapy, sample sizes are further reduced due to the rareness of such treatments. We propose a method to improve statistical power in micro clinical trials. Specifically, we use a more biologically relevant quantity, cancer equivalent dose (DCE), to estimate risk instead of mean absorbed dose (DMA). Our objective was to demonstrate that when DCE is used fewer subjects are needed for clinical trials. Thus, we compared the impact of DCE vs. DMA on sample size in a virtual clinical trial that estimated risk for second cancer (SC) in the thyroid following craniospinal irradiation (CSI) of pediatric patients using protons vs. photons. Dose reconstruction, risk models, and statistical analysis were used to evaluate SC risk from therapeutic and stray radiation from CSI for 18 patients. Absorbed dose was calculated in two ways: with (1) traditional DMA and (2) with DCE. DCE and DMA values were used to estimate relative risk of SC incidence (RRCE and RRMA, respectively) after proton vs. photon CSI. Ratios of RR for proton vs. photon CSI (RRRCE and RRRMA) were then used in comparative estimations of sample size to determine the minimal number of patients needed to maintain 80% statistical power when using DCE vs. DMA. For all patients, we found that protons substantially reduced the risk of developing a second thyroid cancer when compared to photon therapy. Mean RRR values were 0.052±0.014 and 0.087±0.021 for RRRMA and RRRCE, respectively. However, we did not find that use of DCE reduced the number of patents needed for acceptable statistical power (i.e, 80%). In fact, when considerations were made for RRR values that met equipoise requirements and the need for descriptive statistics, the minimum number of patients needed for a micro-clinical trial increased from 17 using DMA to 37 using DCE. Subsequent analyses revealed that for our sample, the most influential factor in determining variations in sample size was the experimental standard deviation of estimates for RRR across the patient sample. Additionally, because the relative uncertainty in dose from proton CSI was so much larger (on the order of 2000 times larger) than the other uncertainty terms, it dominated the uncertainty in RRR. Thus, we found that use of corrections for cell sterilization, in the form of DCE, may be an important and underappreciated consideration in the design of clinical trials and radio-epidemiological studies. In addition, the accurate application of cell sterilization to thyroid dose was sensitive to variations in absorbed dose, especially for proton CSI, which may stem from errors in patient positioning, range calculation, and other aspects of treatment planning and delivery.

Rigid and Non-rigid Point-based Medical Image Registration

The primary goal of this dissertation is to develop point-based rigid and non-rigid image registration methods that have better accuracy than existing methods. We first present point-based PoIRe, which provides the framework for point-based global rigid registrations. It allows a choice of different search strategies including (a) branch-and-bound, (b) probabilistic hill-climbing, and (c) a novel hybrid method that takes advantage of the best characteristics of the other two methods. We use a robust similarity measure that is insensitive to noise, which is often introduced during feature extraction. We show the robustness of PoIRe using it to register images obtained with an electronic portal imaging device (EPID), which have large amounts of scatter and low contrast. To evaluate PoIRe we used (a) simulated images and (b) images with fiducial markers; PoIRe was extensively tested with 2D EPID images and images generated by 3D Computer Tomography (CT) and Magnetic Resonance (MR) images. PoIRe was also evaluated using benchmark data sets from the blind retrospective evaluation project (RIRE). We show that PoIRe is better than existing methods such as Iterative Closest Point (ICP) and methods based on mutual information. We also present a novel point-based local non-rigid shape registration algorithm. We extend the robust similarity measure used in PoIRe to non-rigid registrations adapting it to a free form deformation (FFD) model and making it robust to local minima, which is a drawback common to existing non-rigid point-based methods. For non-rigid registrations we show that it performs better than existing methods and that is less sensitive to starting conditions. We test our non-rigid registration method using available benchmark data sets for shape registration. Finally, we also explore the extraction of features invariant to changes in perspective and illumination, and explore how they can help improve the accuracy of multi-modal registration. For multimodal registration of EPID-DRR images we present a method based on a local descriptor defined by a vector of complex responses to a circular Gabor filter.

Applications of advanced and dual energy computed tomography in proton therapy

This thesis focuses on advanced reconstruction methods and Dual Energy (DE) Computed Tomography (CT) applications for proton therapy, aiming at improving patient positioning and investigating approaches to deal with metal artifacts. To tackle the first goal, an algorithm for post-processing input DE images has been developed. The outputs are tumor- and bone-canceled images, which help in recognising structures in patient body. We proved that positioning error is substantially reduced using contrast enhanced images, thus suggesting the potential of such application. If positioning plays a key role in the delivery, even more important is the quality of planning CT. For that, modern CT scanners offer possibility to tackle challenging cases, like treatment of tumors close to metal implants. Possible approaches for dealing with artifacts introduced by such rods have been investigated experimentally at Paul Scherrer Institut (Switzerland), simulating several treatment plans on an anthropomorphic phantom. In particular, we examined the cases in which none, manual or Iterative Metal Artifact Reduction (iMAR) algorithm were used to correct the artifacts, using both Filtered Back Projection and Sinogram Affirmed Iterative Reconstruction as image reconstruction techniques. Moreover, direct stopping power calculation from DE images with iMAR has also been considered as alternative approach. Delivered dose measured with Gafchromic EBT3 films was compared with the one calculated in Treatment Planning System. Residual positioning errors, daily machine dependent uncertainties and film quenching have been taken into account in the analyses. Although plans with multiple fields seemed more robust than single field, results showed in general better agreement between prescribed and delivered dose when using iMAR, especially if combined with DE approach. Thus, we proved the potential of these advanced algorithms in improving dosimetry for plans in presence of metal implants.

Verification of patient position and delivery of IMRT by electronic Portal Imaging

We have taken a new method of calibrating portal images of IMRT beams and used this to measure patient set-up accuracy and delivery errors, such as leaf errors and segment intensity errors during treatment. A calibration technique was used to remove the intensity modulations from the images leaving equivalent open field images that show patient anatomy that can be used for verification of the patient position. The images of the treatment beam can also be used to verify the delivery of the beam in terms of multileaf collimator leaf position and dosimetric errors. A series of controlled experiments delivering an IMRT anterior beam to the head and neck of a humanoid phantom were undertaken. A 2mm translation in the position of the phantom could be detected. With intentional introduction of delivery errors into the beam this method allowed us to detect leaf positioning errors of 2mm and variation in monitor units of 1%. The method was then applied to the case of a patient who received IMRT treatment to the larynx and cervical nodes. The anterior IMRT beam was imaged during four fractions and the images calibrated and investigated for the characteristic signs of patient position error and delivery error that were shown in the control experiments. No significant errors were seen. The method of imaging the IMRT beam and calibrating the images to remove the intensity modulations can be a useful tool in verifying both the patient position and the delivery of the beam.

Positioning the nursing librarian on the wards: nursing grand rounds with a difference

The concept nursing grand rounds (NGR) has been reported in the nursing literature since the 1960s. Many of the reported initiatives are based on a presentation forum in the manner of medical grand rounds, as an approach to undergraduate education, or as a means to monitor patients. Among the points of difference in the design of the pilot project undertaken in a busy surgical ward to investigate the effectiveness of NGR in increasing nurses work satisfaction was the inclusion of the nursing librarian as an integral part of the NGR team and processes which previously has not reported in the literature. The nursing librarian’s role was to search the literature and find the best evidence on the predetermined patient topic prior to the NGR to enable the nurse presenting to integrate the research findings into the presentation of the patient. The nursing librarian attended each NGR and commented where appropriate on the level of evidence. Nurses discussed current practice and the impact the retrieved literature would have on patient care comparing best practice with current practice. Outcomes of this project include in some cases change in practice, change in culture where NGRs are now embedded into ward culture, NGR extended to other wards, enthusiasm for EBP, the initiation of a “super searcher” model where the nursing librarian is more of a consultant and develops the searching skills of nominated nurses who become the resource on the ward.

Cloud based global positioning system as a safety monitor for dementia patients

The aim of using GPS for Alzheimer's Patients is to give carers and families of those affected by Alzheimer's Disease, as well as all the other dementia related conditions, a service that can, via SMS text message, notify them should their loved one leave their home. Through a custom website, it enables the carer to remotely manage a contour boundary that is specifically assigned to the patient as well as the telephone numbers of the carers. The technique makes liberal use of such as Google Maps.