MR imaging (MRI) plays an increasing role at different stages in the radiation oncology workflow, including tumor detection and delineation, the prediction of margins, fiducial marker detection, the estimation of organ and tumor motion, biofunctional avoidance and treatment response assessment using quantitative imaging biomarkers. Where conventional anatomical contrast-weighted MRI scans are a first-line strategy used for tumor detection and delineation, quantitative biofunctional MRI can provide predictors of tumor response or regional information on functional organs at risk. Unfortunately, the implementation of advanced quantitative MRI in radiation oncology may be prone to bias and uncertainties as a result of an over-reliance on vendor provided pulse sequences, image processing and analysis methods that have not been designed in the light of robust imaging biomarkers for radiotherapy guidance. Bias in quantitative MRI (qMRI) measurements can originate from the implementation of oversimplified physical models, unrecognized image artifacts and poor parametric fitting methods. Moreover, inconsistency in the use of imaging parameters and image post-processing methods across different centers results in a large variability in reported quantitative parameters. Much bias slips under the radar of both the medical physicist and MRI technologists because of the intrinsic variability between different human subjects which may remain undetected even when the imaging protocol is optimized with commercial quality assurance (QA) phantoms. Adequate pulse sequence optimization, harmonization of protocols and QA is essential to safeguard the reliability and robustness of the MRI protocols and can provide objective measures of uncertainty in quantitative parametric MRI maps. The increasing introduction of compressed sensing and data driven approaches in MRI image reconstruction demands for a different approach in imaging QA. In this first part, in-house fabricated phantoms are discussed that have proven useful in the optimization and QA of MRI sequences, protocols and post-processing methods. Sources of measurement bias and uncertainties in quantitative MRI, including diffusion mapping,T1andT2mapping will be discussed in parts 2 and 3. Novel imaging QA methods using anthropomorphic phantoms are introduced and the discrepancy between conventional inline approaches and in-house developed offline processing is discussed.
One of the most used bio-functional MRI techniques deployed in radiation therapy is diffusion-weighted MRI (DWI) for both the delineation of the gross target volume and for treatment response assessment. While the diffusion mechanism is in principle inherently independent of the magnetic field strength and scanner type, there exist significant discrepancies in quantitative apparent diffusion coefficient (ADC) maps between published studies, which can be largely attributed to the use of sub-optimal scanning and oversimplified diffusion models, including inline vendor-implemented ADC map reconstructions. Robust quality assurance (QA) and the use of adequate fitting models are essential to guarantee the accuracy of quantitative DWI. Different QA methods are proposed and common pitfalls in clinical DWI studies are discussed. While standard commercial QA phantoms provide a first and necessary step in QA of clinical trials, it is shown that some methodological errors may remain undetected. Significant deviations from the mono-exponential diffusion model, a dependence on the diffusion time and directional dependence are illustrated in different human tissues. Different diffusion models are discussed. It is also illustrated how organ motion can severely compromise the accuracy of quantitative parametric diffusion maps and is not always recognized as obvious imaging artifacts.
OBJECTIVES:To evaluate the implementation of the Australian Hip Fracture Clinical Care Standard for patients with low-trauma hip fracture. This study aimed to (1) document facility-level adoption, (2) explore healthcare providers' perspectives on Standard delivery and (3) describe patient engagement with post-acute discharge care recommendations, including outcomes for culturally and linguistically diverse (CALD) and limited English proficiency subgroups. METHODS:A mixed-methods approach was undertaken. Community-dwelling adults who underwent surgical treatment for low-trauma hip fractures at a tertiary hospital over 1 year were included. Facility-level adoption was determined by auditing medical records against the Clinical Care Standard. Patient engagement with post-discharge recommendations was assessed by structured telephone follow-up at 16 weeks and English proficiency. An electronic survey explored healthcare providers' perspectives of Standard implementation. RESULTS:Of 189 patients admitted, 136 (72%) were eligible; 127 completed follow-up assessment. The cohort was predominantly female (66%), with a mean age of 79 years and 80% migrants. Most components of the Care Standard were implemented with high fidelity (> 90% for four of seven indicators). Acute care data indicated effective implementation of most components of the Care Standard, supported by responses from 28 healthcare providers (28% response rate). However, healthcare providers highlighted the need for enhanced interprofessional training and resourcing for refracture prevention. Patient engagement with refracture prevention recommendations was low (44% participated in strength exercises, 26% in balance, 11% sought dietary advice and 44% consumed calcium supplementation), with no significant differences by CALD status or English proficiency. CONCLUSIONS:Despite high facility-level implementation of the Care Standard, patient adoption of post-discharge refracture prevention strategies remains suboptimal. Bridging this gap requires multi-faceted, consumer-centred solutions and improved interdisciplinary training to enhance outcomes and reduce refracture risk, particularly in diverse and multicultural populations.
BACKGROUND:Women at a high risk of developing preeclampsia are recommended to have additional blood pressure surveillance, but frequent outpatient attendances are demanding for patients and the healthcare system. It is unclear whether remote blood pressure monitoring can replace conventional office-based monitoring and improve healthcare utilization without increasing the signal for harm. OBJECTIVE:To evaluate the effects of substituting clinic blood pressure monitoring with remote blood pressure monitoring on fetal and maternal outcomes, and healthcare utilization, in pregnant women at a high risk of developing preeclampsia. STUDY DESIGN:Unblinded, noninferiority, multicenter randomized controlled trial, with recruitment between July 2022 and February 2024 from 3 metropolitan hospitals in Australia. Participants were pregnant women at a high risk of developing preeclampsia based on clinical risk factors or combined first-trimester screening tests, who are routinely referred to a specialist hypertension service for extra blood pressure surveillance, in addition to standard antenatal care. Women randomized to usual care attended these specialist hypertension clinics in-person, with frequency of appointments dictated by clinical need. Women randomized to remote blood pressure monitoring, in addition to receiving routine antenatal care, measured their own blood pressure using an automated blood pressure machine with data transmitted via a smartphone application for specialist review. The primary outcome was a perinatal composite of adverse events of at least one of perinatal loss, high-level neonatal care for more than 48 hours, or a small-for-gestational age baby (<10th centile for fetal weight). The primary outcome was assessed in the intention-to-treat population. The trial was prospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12620001049965p). RESULTS:270 women were included in the final analysis (intervention n=132, usual care n=138; mean age 34 years, 60.4% from a self-reported non-Caucasian ethnic group). There was no difference in the primary outcome (hazard ratio, 1.0; 95% confidence interval, 0.57-1.76; P=.99). There was also no difference in secondary fetal and maternal outcomes. The intervention group had less total antenatal attendances (median [interquartile range], 14 [10-17]) compared to usual care (16 [13-20]; P<.01) and less planned outpatient appointments (median [interquartile range], 10 [8-12] vs 13 [10-16]; P<.01), without an associated increase in unscheduled hospital presentations. Women undertaking remote blood pressure monitoring were less likely to be admitted to hospital for any cause (hazard ratio, 0.54; 95% confidence interval, 0.30-0.97; P=.04) and specifically for hypertension (hazard ratio, 0.41; 95% confidence interval, 0.19-0.88; P=.02). More antihypertensive prescriptions filled per patient in the intervention arm compared to usual care (median [interquartile range], 5 [3-9] vs 3 [2-5]; P<.01). CONCLUSION:Compared to usual care, remote blood pressure monitoring reduced antenatal outpatient appointments and the likelihood of inpatient admissions, without increasing adverse fetal and maternal outcomes. Women undertaking remote monitoring were also more likely to fill antihypertensive medication scripts.
While there are numerous social skills interventions (SSI) designed for pre-schoolers, the evidence supporting their effectiveness for adolescents and young adults remains limited. This study conducted a systematic review and meta-analysis to examine the available evidence on the efficacy of SSIs on core autistic traits among youth diagnosed with autism spectrum disorder aged 12–25 years. Several electronic databases such as APA PsychINFO, Academic Search Complete, CINAHL, Education Source, Psychology and Behavioural Sciences Collection, Education Resources Information Center (ERIC), Pubmed, Ovid MEDLINE, Educational Administration Abstracts and SocINDEX with Full Text, were systematically searched for randomised controlled trials (RCTs) and quasi-controlled studies, with either a waitlist or active control group. The review included 15 (14 RCTs and one quasi-control study) studies (N = 1244). Meta-analysis revealed that participants receiving SSIs resulted in improvements in social skills, based on observation (standardised mean difference (SMD) = 0.49, 95
