How we adapt treatment algorithms to complex, clinically untested, difficult-to-engage patient groups without losing evidence base in everyday practice is a clinical challenge. Here we describe ...process and reasoning for fast, pragmatic, context-relevant and service-based adaptations of a group intervention for unaccompanied minor asylum seekers (UASC) arriving in Europe. We employed a distillation-matching model and deployment-focused process in a mixed-method, top-down (theory-driven) and bottom-up (participant-informed) approach. Prevalence of mental disorders amongst UASC is extremely high. They also represent a marginalised and hard-to-engage group with limited evidence for effective treatments.
Content and process adaptations followed four steps: (1) descriptive local group characterisation and theoretical formulation of problems; (2) initial adaptation of evidenced treatment, based on problem-to-component grid; (3) iterative adaptation using triangulated feedback; and (4) small-scale pilot evaluation.
Based on evidence and participant feedback, adaptations included minimising verbal demands, facilitating in-session inductive learning, fostering social connectedness via games, enhancing problem-solving skills, accounting for multi-traumatisation, uncertainty and deportation. Quantitative evaluation suggested improved feasibility, with increased attendance, low drop-out and symptom improvement on depression and trauma scores.
By describing the principles under-pinning development of a group intervention for severely traumatised UASC, we contribute to the literature supporting dynamic adaptations of psychological interventions, without losing reference to evidence base. Complex and difficult-to-reach clinical groups are often those in most need of care, yet least researched and most affected by inequality of care. Pragmatic adaptations of proven programs are often necessary to increase feasibility.
Although transient neglect of contralesional space occurs following damage to either hemisphere, persistent forms are overwhelmingly associated with right hemisphere lesions. This has led to the ...suggestion that impairments in other right hemisphere systems—in particular those that mediate alertness—may undermine recovery. Reductions in neglect severity with stimulation, exacerbation with sedatives and the poor performance of chronic neglect patients on sustained attention tasks are consistent with this view. However, the question of whether changes in alertness exert a specific influence over spatial attention—or simply improve performance across many domains—is difficult to address using only patient studies. Here, we examine this question with individuals from the healthy adult population. On certain spatial tasks, adults show a modest but reliable leftward attentional bias. On the basis of the neglect studies, we hypothesised that this bias would diminish—or even reverse—as alertness levels declined. In the first study, participants were asked to judge the relative lengths of the left and right sections of a line when sleep deprived and when well rested. A significant rightward shift in attention was associated with sleep deprivation. A rightward shift was also observed over the course of the session. The second study replicated this time-on-task effect. The results suggest that a diminution in alertness may be
sufficient to induce a rightward shift in visual attention in the healthy brain. Implications for the persistence of neglect in patients, for spatial biases in children and for normal free viewing asymmetries are discussed.
Although childhood adversity (CA) increases risk for subsequent mental illnesses, developmental mechanisms underpinning this association remain unclear. The hypothalamic-pituitary-adrenal axis (HPAA) ...is one candidate system potentially linking CA with psychopathology. However, determining developmental effects of CA on HPAA output and differentiating these from effects of current illness has proven difficult. Different aspects of HPAA output are governed by differentiable physiological mechanisms. Disaggregating HPAA output according to its biological components (baseline tonic cortisol, background diurnal variation, phasic stress response) may improve precision of associations with CA and/or psychopathology. In a novel proof-of-principle investigation we test whether different predictors, CA (distal risk factor) and current depressive symptoms, show distinct associations with dissociable HPAA components. A clinical group (aged 16–25) at high-risk for developing severe psychopathology (n = 20) were compared to age and sex matched healthy controls (n = 21). Cortisol was measured at waking (x4), following stress induction (x8), and during a time-environment-matched non-stress condition. Using piecewise multilevel modeling, stress responses were disaggregated into increase and decrease, while controlling for waking cortisol, background diurnal output and confounding variables. Elevated waking cortisol was specifically associated with higher CA scores. Higher non-stress cortisol was specifically associated with higher depressive scores. Following stress induction, depressive symptoms attenuated cortisol increase, whilst CA attenuated cortisol decrease. The results support a differential HPAA dysregulation hypothesis where physiologically dissociable components of HPAA output are differentially associated with distal (CA) or proximal (depressive symptoms) predictors. This proof-of-principle study demonstrates that future cortisol analyses need to disaggregate biologically independent mechanisms of HPAA output.
•Update of cortisol analysis.•Disaggregation of biological components of HPA axis output.•Associations of early adversity and/or illness are tested for each component.•Early adversity relates to high waking cortisol and attenuated post-stress recovery.•Current symptoms relate to high daytime cortisol and less adaptive cortisol release.
Background: There is growing literature suggesting that some children diagnosed with attention deficit hyperactivity disorder (ADHD) can show a significant bias in attention away from left space. ...Here we examine mechanisms that may underpin these effects in both clinical and non‐clinical child populations. Unilateral spatial inattention (unilateral neglect) is a commonly reported consequence of stroke in adults. Although for most patients the problem is relatively transient, persistent forms of neglect are almost exclusively associated with right hemisphere lesions. It has been suggested that this chronicity may result from co‐existing disruption to right hemisphere dominant systems that mediate alertness. Here we present two studies examining the relationship between sustained attention and left spatial awareness in childhood.
Method: In the first, normal children without the ADHD diagnosis were administered a non‐spatial test of sustained attention/alertness. Children who performed poorly at this task, relative to their more attentive peers, showed a modest but reliable delay in awareness of left‐sided visual information. Furthermore, attention towards the left declined for both groups as a function of time‐on‐task, suggesting a significant within‐subject modulatory effect of alertness on spatial awareness. The second study examines this relationship in children referred to clinical services for attention problems. Irrespective of their final diagnosis, children were divided into two groups according to their performance in sustained attention/alertness tasks.
Results: The results suggest that, regardless of the children's clinical diagnosis, diminished sustained attention/alertness levels formed the strongest predictor of relatively delayed awareness of information presented within left visual space. Two children within this group exhibited signs of hitherto undetected spatial neglect as severe as that observed in some brain‐injured adults.
Conclusions: Clinical and theoretical implications are discussed. Keywords: Sustained attention, visuo‐spatial attention, normal 6–7‐year‐old children.
IMRT for breast. A planning study Fogliata, A.; Nicolini, G.; Alber, M. ...
Radiotherapy and oncology,
September 2005, 2005-Sep, 2005-9-00, Letnik:
76, Številka:
3
Journal Article
Recenzirano
To evaluate the performance of ten different treatment-planning systems when intensity modulated (IMRT) plans are designed for breast treatments that include the irradiation of the internal mammary ...chain.
A dataset of five patients (CT images and volumes of interest) was distributed to design IMRT plans on the ten systems. To minimise biases, the same geometry and clinical planning aims were imposed on the individual plans. Results were analysed in terms of dose distributions and dose volume histograms.
For target coverage, the volume receiving more than 95% of the prescribed dose ranged from 77% (OTP) to 91% (Eclipse and Pinnacle), the volume receiving more than 107% ranged from 3.3% (Hyperion) to 23.2% (OTP). The mean dose to ipsilateral lung ranged from 13Gy (Eclipse) to 18Gy (OTP). The volume of the contralateral breast receiving more than 10Gy ranged from 3% (Pinnacle) to 26% (Precise). The volume of heart receiving more than 20Gy ranged from 7% (Eclipse) to 47% (Precise), the maximum significant dose to heart ranged from ∼27Gy (XiO) to ∼49Gy (Precise). The maximum significant dose to healthy tissue ranged from ∼51Gy (Eclipse) to ∼62Gy (OTP). It was also possible to show that the treatment geometry proposed here enables to minimise contralateral breast irradiation while keeping minimal ipsilateral lung (or heart) involvement and satisfactory target coverage.
Purpose:
The authors present a stochastic framework for radiotherapy patient positioning directly utilizing radiographic projections. This framework is developed to be robust against anatomical ...nonrigid deformations and to cope with challenging imaging scenarios, involving only a few cone beam CT projections from short arcs.
Methods:
Specifically, a Bayesian estimator (BE) is explicitly derived for the given scanning geometry. This estimator is compared to reference methods such as chamfer matching (CM) and the minimization of the median absolute error adapted as tools of robust image processing and statistics. In order to show the performance of the stochastic short-arc patient positioning method, a CIRS IMRT thorax phantom study is presented with movable markers and the utilization of an Elekta Synergy® XVI system. Furthermore, a clinical prostate CBCT scan of a Varian® On-Board Imager® system is utilized to investigate the robustness of the method for large variations of image quality (anterior-posterior vs lateral views).
Results:
The results show that the BE shifts reduce the initial setup error of up to 3 cm down to 3 mm at maximum for an imaging arc as short as 10° while CM achieves residual errors of 7 mm at maximum only for arcs longer than 40°. Furthermore, the BE can compensate robustly for low image qualities using several low quality projections simultaneously.
Conclusions:
In conclusion, an estimation method for marker-based patient positioning for short imaging arcs is presented and shown to be robust and accurate for deformable anatomies.
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