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Complexity may also increase the opportunities for accidental exposures repaglinide 1 mg free shipping, and ‘common sense’ and intuition may no longer be as effective a mechanism to perceive ‘when something may be wrong’ as it is with conventional radiation therapy  cheap 1 mg repaglinide with visa. The challenge is 0.5 mg repaglinide otc, therefore discount 0.5 mg repaglinide visa, to implement new technologies in conjunction with the appropriate means to ensure that they can and will be used safely  order 0.5mg repaglinide mastercard. A wealth of standards, guidance and information have been developed over the years that can be used to ensure quality and safety in external beam radiotherapy. Standards and protocols for a programme of quality and safety The first element is the design of a programme of quality and safety. Protocols, usually prepared within national and international organizations and professional bodies, can be adopted or adapted in individual radiotherapy departments [8–10]. Some of the accidental exposures have occurred even in countries with a tradition in quality assurance, when some of the procedures or verifications were omitted. Thus, there is a need for continuous supervision to ensure that the programme remains effective over time and during any evolutionary change in the department. Lessons from accidental exposures and near misses Available lessons from accidental exposures with conventional technologies and techniques [4, 11–16] can be directly used to check whether the quality and safety programme is robust enough to withstand situations such as those found in reported accidental exposures and to find vulnerable areas needing attention. In addition, information on events that occurred with new technologies and techniques is also available . Teaching case histories and their lessons to radiotherapy staff as part of their training is an effective tool to maintain awareness. Not only can lessons from major past events be used, but also ‘near misses’ that happened to have no consequences, but may have severe consequences next time in another place can also be shared. Sharing near misses helps to address these types of error and to perform regular reviews, and, thus, is a tool for continuous improvement. Methods based on sharing information on past events are sometimes referred to as ‘retrospective approaches’. Anticipative methods While the use of retrospective approaches is an important step, it has the limitation of being confined to reported events. These risks will remain unaddressed unless a proactive search is performed to reveal them in a systematic, anticipative manner. They all have in common that the analysis is performed by a multidisciplinary group of radiotherapy staff and safety specialists. The first step consists of describing the radiotherapy process and breaking down the process into steps in a flow diagram. Once potential events have been identified, the task becomes that of analysing the likelihood of an unacceptable event occurring, assessing the severity or consequences of the event should it occur, and assessing the likelihood that the event will not be detected during quality control checks and will, hence, have a negative impact on the patient’s treatment. The risk matrix approach is relatively straightforward and provides an opportunity for self-evaluation in individual hospitals. A rational strategy to preventing accidental exposure consists of three steps: (a) Establishing a programme of safety and quality in compliance with safety standards and quality protocols; (b) Obtaining confidence that this programme is robust enough to withstand situations such as those found in reported accidental exposures; (c) Anticipating the unknown or unreported, screening the potential events by combining likelihood of occurrence with severity of outcome to sort the events in the order of level of risk and focusing on the most important ones. Modern radiotherapy permits precise irradiation of tumours with minimum side effects. However, the methods are often associated with complex procedures with many steps, requiring careful adjustment and parameter setting in each individual patient. Rapid expansion of these new technologies in clinical practice may introduce increased risk of accidental exposure. Education and training for the personnel involved in the treatment procedure are essential for patient protection. These new technologies have successfully improved the dose distribution, resulting in a significant reduction of undesirable radiation to the outside target volume. However, the area which receives relatively low dose radiation may be increased, which might increase the risk of secondary cancer. Health care professionals should also be aware of the possible risk and consider the necessary procedures for patient protection when new technologies are introduced in clinical practice. In particular, high precision photon beam radiotherapy, such as intensity modulated radiotherapy and stereotactic radiotherapy, has been used effectively in clinical practice. The use of ion beams, such as proton and carbon, has also been rapidly advancing in recent years. Introduction of these new technologies in radiotherapy has successfully contributed to conquering cancer in many patients. The advancement of modern radiotherapy is associated with complicated procedures, which require many experts with different professional skills. Thus, special arrangements are required for the construction of the facility, the management of the procedures and patients, and for education and training of the staff. The ability of precisely irradiating the target tumour region permits effective treatment with minimum biological effects in surrounding tissues . The impact of new treatment technology in radiotherapy is discussed from the viewpoint of patient protection. Various new approaches have been proposed and some of them have demonstrated excellent outcomes in the treatment of cancer patients.
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A utility of 1 is assigned to a perfect outcome buy repaglinide 2 mg mastercard, usually meaning a complete cure or perfect health order repaglinide 2 mg with mastercard. A utility of 0 is usually thought of as a totally unacceptable outcome cheap 1 mg repaglinide with visa, usually reserved for death purchase repaglinide 0.5 mg. The quality of life resulting from each intermediate outcome will be less than expected with a total cure but more than death cheap repaglinide 2 mg fast delivery. This outcome state may be wholly or partially unbearable due to treatment side effects or adverse effects of the illness. As research into the development of patient values has continued, it is clear that there are many outcomes that are valued as less than zero. A recent example was a study that requested patients to determine their values in stroke care. A decision tree illustrating treatment options can then be constructed, as seen from the following clinical example. Consider a patient who is a 60-year-old man with sudden onset of weakness of the right arm and leg associated with inability to speak. A stroke is suspected and the physician wants to try this new form of treatment to dissolve the suspected clot in the artery supplying the left parietal area of the brain. For purposes of the exercise we will greatly simplify this process and assume that there are only three possible outcomes. Thrombolytic therapy can result in one of two out- comes, either a cure with complete resolution of the symptoms or death from intracranial hemorrhage, bleeding into the substance of the brain. Traditional medical therapy will result in some improvement in the clinical symptoms in all patients but leave all of them with some residual deﬁcit. Outcome probabilities are obtained from studies of populations of patients with similarities for both the stroke and risk factors for bleeding. The probability of death from thrombolyic therapy is Pd, for complete cure it is Pc, which is equal to 1 – Pd, and for partial improvement with medical therapy in this example only, the probability is 1. The utility of com- plete cure is 1, death is 0, and the unknown residual chronic disability is Ux. These values are obtained from studies of patient attitudes toward each of the outcomes in question and will be discussed in more detail shortly. Mechanics of constructing a decision tree There are three components to any decision tree. A decision node is the point where the clinician or patient must choose between two or more possible options. A probability node is the point where one of two or more possible outcomes can occur by chance. A stationary node is the point where the patient starts, their initial presentation, or ﬁnishes, their ultimate outcome. In this sim- pliﬁed decision tree for stroke, one arm represents thrombolytic therapy and the other represents standard medical therapy. The thrombolytic therapy arm has a probability node and then two other arms come from that. In the simpliﬁed stroke-therapy example calculate the expected values in each arm of the tree by multiplying the utility and probability and summing their val- ues around each node. Therefore, for thrombolytic therapy the expected value E will equal 1(1 – Pd) + 0(Pd). For standard medical therapy, since the utility of chronic residual disability is Ux and since all patients have this intermediate outcome, the expected value E is Ux. The patient should always prefer the strat- egy that leads to the highest expected value. In this example, the patient would always choose standard medical treatment for stroke if the expected value for this arm is 100%, which will occur if Ux = 1 and if there is a measurable death rate for treating with thrombolytic therapy, making the expected value of the throm- bolytic arm 100% – Pd. Final Utility Outcome E = Expected value for each arm of the tree Probabilities E (thrombolytics) = (1 − Pd) × 1+ (Pd × 0) E (medicine) = 1 × Ux Fig. However, the value of a lifetime of chronic neurological disability is not 100%, and lets assume for this example that it is 0. This means that living with chronic neurological disability is somehow equated with living 90% of a normal life. Recalculating the expected value of each arm will determine what probability of death from thrombolytics would result in wanting to choose thrombolytics over medical therapy. For example, if the experience of getting thrombolytics were unpleasant, that may lead to a utility reduction of 0. For the thrombolytic-therapy arm, the clot can be dissolved successfully, there can be residual deﬁcit, or the patient may have an intracranial bleed resulting in death, or have partial improvement but be left with a residual deﬁcit. The degree of deﬁcit can also be divided into different categories, for example using the Modi- ﬁed Rankin Scale to create six criteria for outcomes. Resolution U = 1 (cure) Pc Standard medical therapy Death U = 0 Pdm Residual damage U = Ux 1 − Pc − Pdm E = Pc(1) + (1 − Pc − Pdm) Ux + Pdm × 0 Fig. The probability of death due to hem- orrhage is Pdt and for residual damage due to hemorrhage is 1 – Pdt.