Search

We investigate uncertainty guidance mechanisms to support proton therapy (PT) planning visualization. Uncertainties in the PT workflow pose significant challenges for navigating treatment plan data and selecting the most optimal plan among alternatives. Although guidance techniques have not yet been applied to PT planning scenarios, they have successfully supported sense- and decision-making processes in other contexts. We hypothesize that augmenting PT uncertainty visualization with guidance may influence the intended users’ perceived confidence and provide new insights. To this end, we follow an iterative co-design process with domain experts to develop a visualization dashboard enhanced with distinct level-of-detail uncertainty guidance mechanisms. Our approach classifies uncertainty guidance into two dimensions: degree of intrusiveness and detail-orientation. Our dashboard supports the comparison of multiple treatment plans (i.e., nominal plans with their translational variations) while accounting for multiple uncertainty factors. We subsequently evaluate the designed and developed strategies by assessing perceived confidence and effectiveness during a sense- and decision-making process. Our findings indicate that uncertainty guidance in PT planning visualization does not necessarily impact the perceived confidence of the users in the process. Nonetheless, it provides new insights and raises uncertainty awareness during treatment plan selection. This observation was particularly evident for users with longer experience in PT planning.

This paper presents an insight into the critical discussions and the current strategies of the Nordic countries for handling the variable proton relative biological effectiveness (RBE) as presented at The Nordic Collaborative Workshop for Particle Therapy that took place at the Skandion Clinic on 14th and 15th of November 2019.In the current clinical practice at the two proton centres in operation at the date, Skandion Clinic, and the Danish Centre for Particle Therapy, a constant proton RBE of 1.1 is applied. The potentially increased effectiveness at the end of the particle range is however considered at the stage of treatment planning at both places based on empirical observations and knowledge. More elaborated strategies to evaluate the plans and mitigate the problem are intensely investigated internationally as well at the two centres. They involve the calculation of the dose-averaged linear energy transfer (LETMethods and tools for LETThe need for collaboration between the clinical proton centres in establishing common platforms and perspectives for treatment planning evaluation and optimisation is highlighted as well as the need of close interaction with the research academic groups that could offer a complementary perspective and actively help developing methods and tools for clinical implementation of the more complex metrics for considering the variable effectiveness of the proton beams.

The public circulation of images, speeches and written documents for the purpose of moral education dates as far back as these modes of communication themselves. Religious imagery and scripture are obvious cases in point. The practice of analyzing such texts as cultural traces of particular historical manifestations of morality has an equally long history, building on the legacy of theology and literary analysis in which, for centuries, scholars have sought to make sense of morality. Today, the deep analytical engagement with individual pieces of text as a method in the social sciences is both enormously popular and, at the same time, criticized with respect to the scientific status of such methods and what kinds of conclusions they can legitimately support. The overall objective of this chapter is to explicate the epistemological assumptions of text-based qualitative research, addressing some of its critics’ concerns, and to offer an overview of the uses of textual analysis in humanitarian communication by focusing on empirical work driven by visual and subsequently verbal/multimodal text analysis. I conclude by proposing directions for future textual approaches to humanitarian communication.

Background: Clinical data suggest that the relative biological effectiveness (RBE) in proton therapy (PT) varies with linear energy transfer (LET). However, LET calculations are neither standardized nor available in clinical routine. Here, the status of LET calculations among European PT institutions and their comparability are assessed. Materials and methods: Eight European PT institutions used suitable treatment planning systems with their center-specific beam model to create treatment plans in a water phantom covering different field arrangements and fulfilling commonly agreed dose objectives. They employed their locally established LET simulation environments and procedures to determine the corresponding LET distributions. Dose distributions D 1.1 and D RBE assuming constant and variable RBE, respectively, and LET were compared among the institutions. Inter-center variability was assessed based on dose- and LET-volume-histogram parameters. Results: Treatment plans from six institutions fulfilled all clinical goals and were eligible for common analysis. D 1.1 distributions in the target volume were comparable among PT institutions. However, corresponding LET values varied substantially between institutions for all field arrangements, primarily due to differences in LET averaging technique and considered secondary particle spectra. Consequently, D RBE using non-harmonized LET calculations increased inter-center dose variations substantially compared to D 1.1 and significantly in mean dose to the target volume of perpendicular and opposing field arrangements (p < 0.05). Harmonizing LET reporting (dose-averaging, all protons, LET to water or to unit density tissue) reduced the inter-center variability in LET to the order of 10–15% within and outside the target volume for all beam arrangements. Consequentially, inter-institutional variability in D RBE decreased to that observed for D 1.1. Conclusion: Harmonizing the reported LET among PT centers is feasible and allows for consistent multi-centric analysis and reporting of tumor control and toxicity in view of a variable RBE. It may serve as basis for harmonized variable RBE dose prescription in PT.

ObjectivesTo investigate illness trajectories as reflected by healthcare utilisation, including hospital and intensive care unit admissions, consultations in general practice and home care provision, before death comparing people dying from chronic obstructive pulmonary disease (COPD), heart failure and cancer.DesignNationwide register-based cohort study.SettingData on all hospital admissions, including intensive care unit admissions, consultations in general practice and home care provision were obtained from nationwide Danish registries.ParticipantsAll adult decedents in Denmark dying from COPD, heart failure or cancer between 2006 and 2016.Outcome measuresFor each day within 5 years before death, we computed a daily prevalence proportion (PP) of being admitted to hospital or consulting a general practitioner. For each day within 6 months before death, we computed PPs of being admitted to intensive care or receiving home care. The PPs were plotted and compared by regression analyses adjusting for age, gender, comorbidity level, marital/cohabitation status, municipality and income level.ResultsAmong 1 74 086 patients dying from COPD (n=22 648), heart failure (n=11 498) or cancer (n=139 940), the PPs of being admitted to hospital or consulting a general practitioner showed similar steady progression and steep increase in the last year of life for all patient populations. The PP of being admitted to intensive care showed modest increase during the last 6 months of life, accelerating in the last month, for all patient populations. For patients with COPD and heart failure, the PP of receiving home care remained stable during the last 6 months of life but increased steadily for patients with cancer.ConclusionWe found limited differences in healthcare resource utilisation at the end of life for people with COPD, heart failure or cancer, indicating comparable illness trajectories.This supports the need to reconsider efforts in achieving equal access to palliative care interventions, which is still mainly offered to patients with cancer.

Over the past two decades, research as well as practice have praised the promise of cross-sector partnerships as the new transnational governance mechanism for reaching international development goals. Although there is general consensus that partnerships have the potential to contribute to development in the Global South, there is, however, increasing suspicion that in practice, they often do not. On the basis of an empirical analysis of a North-South Business-NGO partnership for poverty alleviation in Ghana, we show that existing assessment frameworks in the management literature are useful but insufficient for assessing partnerships in a development context. Through an integration of theoretical and empirical insights, we propose a novel framework, Partnerships for Development, which puts forward organizational preconditions for cross-sector partnerships to produce societal impact in the Global South, giving way to an assessment system for cross-sector partnerships in terms of their impact potential.

Background: Several brain substructures associated with cognition (BSCs) are located close to typical pediatric brain tumors. Pediatric patients therefore have considerable risks of neurocognitive impairment after brain radiotherapy. In this study, we investigated the radiation doses received by BSCs for three common locations of pediatric brain tumor entities. Material and methods: For ten patients in each group [posterior fossa ependymoma (PFE), craniopharyngioma (CP), and hemispheric ependymoma (HE)], the cumulative fraction of BSCs volumes receiving various dose levels were analyzed. We subsequently explored the differences in dose pattern between the three groups and used available dose response models from the literature to estimate treatment-induced intelligence quotient (IQ) decline. Results: Doses to BSCs were found to differ considerably between the groups, depending on their position relative to the tumor. Large inter-patient variations were observed in the ipsilateral structures of the HE groups, and at low doses for all three groups. IQ decline estimates differed depending on the model applied, presenting larger variations in the HE group. Conclusion: While there were notable differences in the dose patterns between the groups, the extent of estimated IQ decline depended more on the model applied. This inter-model variability should be considered in dose–effect assessments on cognitive outcomes of pediatric patients.

Cross-sector partnerships are currently praised as capitalism’s key governance instrument to address development challenges. Although some concern has been raised about the effectiveness of such partnerships, little is known about their actual impact. Often it is assumed that partnership outputs transform straightforwardly into societal impact such as poverty alleviation. This article problematizes this assumption. Employing a critical micro-level study, which draws on a qualitative case study of a nongovernmental organization (NGO)–business partnership in Ghana, we examine how outputs provided by a partnership are put to use and perceived as beneficial from the point of view of its beneficiaries. The findings show that the partnership results in what we term “competences without agency” since it provides new resources and knowledge to the beneficiaries but fails to generate the conditions for these to be transformed into significant changes in their lives. Drawing on the concept of empowerment, we propose a new framework, which conceptualizes “impact as empowerment” and highlights currently unrecognized dynamics, which contribute to shaping the ability of a partnership to serve as a development agent.

This article proposes a communicative approach to business and human rights research, the key objective of which is to understand business responsibility for human rights as discursively constituted. We show that a communicative approach makes it possible to examine how the nature and bounds of business responsibility come about as a negotiation between a range of societal actors that contribute to public discourse on human rights. Given that such an approach is novel in the context of human rights research, the article provides an introduction to the methodological foundations of a communicative framework, maps out the range of applicable methods within the framework, and reviews existing studies. To illustrate, the article presents a study which exemplifies a communicative approach to business and human rights. This study investigates the development over the past 20 years of public discourse on business responsibility for human rights. The article concludes by pointing to gaps in knowledge and potential issues for further research drawing on a communicative approach to business and human rights.

Social media platforms have been vested with hope for their potential to enable ‘ordinary citizens’ to make their judgments public and contribute to pluralized discussions about organizations and their perceived legitimacy (Etter et al. in Bus Soc 57(1):60–97, 2018). This raises questions about how ordinary citizens make judgements and voice them in online spaces. This paper addresses these questions by examining how Western citizens ascribe responsibility and action in relation to corporate misconduct. Empirically, it focuses on modern slavery and analyses online debates in Denmark on child slavery in the cocoa industry. Conceptually, it introduces the notion of cosmopolitanism as a general disposition of care and responsibility towards distant others, conceived as a prerequisite for the critical evaluation of corporate (ir)responsibility in the Global South. The analysis of online debates shows that citizens debate child slavery in terms of individual consumer responsibility rather than corporate responsibility. Corporations are not considered potential agents of change. As a consequence, online citizen debates did not reflect a legitimacy crisis for the cocoa industry, as debates over responsibility were overwhelmingly concerned with the agency of the Western individual, the individual agency of the speakers themselves. Participants in debates understood their agency strictly as consumer agency.

Organic plastic scintillation detectors (PSDs) are known to produce less light per absorbed dose in highly dense radiations in comparison with e.g. 60Co gamma beams. This so-called ionization density quenching can be experimentally determined by comparison of the scintillator output with the absorbed dose established with a reference detector. The hypothesis of this work was that a newly developed small-core graphite calorimeter (core size: ø5mm × 7mm) can be used as reference for such measurements. The potential benefit of a calorimetric reference would be to have a robust and accurate reference with well-understood dosimetry properties even in high-intensity FLASH beams. As a first step, the hypothesis was tested by comparing previously established quenching parameter estimates for the BCF-60 scintillating material with data obtained with the new instrument at different depths along the central axis of a 170 MeV scanned proton beam. After the calorimetric measurements, scintillator measurements were acquired under equivalent conditions by positioning the PSD in a replica graphite core nominally identical to the core used for calorimetry. To experimentally document details of the irradiations, the spot width was mapped along the central beam axis using a new technique based on a PSD and a time-to-distance conversion procedure. Analysing the proton data in the framework of Birks model, the graphite calorimeter gave a kB = (11.2±0.4) mg MeV-1 cm2 quenching parameter for BCF-60 in agreement with literature values. The consistency between the calorimetric results and the other sources of information supports the validity of the new method, and we therefore aim to apply it for characterization of other detectors in more intense beams where ionometry cannot serve as reference.

Purpose An independent dosimetry audit based on end-to-end testing of the entire chain of radiation therapy delivery is highly recommended to ensure consistent treatments among proton therapy centers. This study presents an auditing methodology developed by the MedAustron Ion Beam Therapy Center (Austria) in collaboration with the National Physical Laboratory (UK) and audit results for five scanned proton beam therapy facilities in Europe. Methods The audit procedure used a homogeneous and an anthropomorphic head phantom. The phantoms were loaded either with an ionization chamber or with alanine pellets and radiochromic films. Homogeneously planned doses of 10 Gy were delivered to a box-like target volume in the homogeneous phantom and to two clinical scenarios with increasing complexity in the head phantom. Results For all tests the mean of the local differences of the absolute dose to water determined with the alanine pellets compared to the predicted dose from the treatment planning system installed at the audited institution was determined. The mean value taken over all tests performed was −0.1 ± 1.0%. The measurements carried out with the ionization chamber were consistent with the dose determined by the alanine pellets with a mean deviation of −0.5 ± 0.6%. Conclusion The developed dosimetry audit method was successfully applied at five proton centers including various “turn-key” Cyclotron solutions by IBA, Varian and Mevion. This independent audit with extension to other tumour sites and use of the correspondent anthropomorphic phantoms may be proposed as part of a credentialing procedure for future clinical trials in proton beam therapy.

INTRODUCTION: Inequalities in life expectancy and mortality by social deprivation in the general population of the United Kingdom are widening. For people with dementia, data on potential gradients in life expectancy and mortality by social deprivation are sparse. This study aimed to explore potential differentials in life expectancy and mortality in people with dementia according to social deprivation.METHODS: Using The Health Improvement Network (THIN) primary care database, we included people with a diagnosis of dementia in the United Kingdom in 2000 to 2016 and obtained data on age at death and mortality. Comparisons were made according to social deprivation quintiles adjusting for age at diagnosis.RESULTS: Among 166,268 people with dementia there were no differences in life expectancy and mortality in the most deprived compared with the least deprived. This pattern has been stable during the study period, as no increasing inequalities in life expectancy and mortality according to social deprivation were found.DISCUSSION: Contrary to the general population, there were limited inequalities in life expectancy and mortality according to social deprivation for people with dementia.

ObjectivesEnd-of-life hospitalisations may not be associated with improved quality of life. Studies indicate differences in end-of-life care for cancer and non-cancer patients; however, data on hospital utilisation are sparse. This study aimed to compare end-of-life hospitalisation and place of death among patients dying from cancer, heart failure or chronic obstructive pulmonary disease (COPD).DesignA nationwide register-based cohort study.SettingData on all in-hospital admissions obtained from nationwide Danish medical registries.ParticipantsAll decedents dying from cancer, heart failure or COPD disease in Denmark between 2006 and 2015.Outcome measuresData on all in-hospital admissions within 6 months and 30 days before death as well as place of death. Comparisons were made according to cause of death while adjusting for age, sex, comorbidity, partner status and residential region.ResultsAmong 154 235 decedents, the median total bed days in hospital within 6 months before death was 19 days for cancer patients, 10 days for patients with heart failure and 11 days for patients with COPD. Within 30 days before death, this was 9 days for cancer patients, and 6 days for patients with heart failure and COPD. Compared with cancer patients, the adjusted relative bed day use was 0.65 (95% CI, 0.63 to 0.68) for heart failure patients and 0.68 (95% CI, 0.66 to 0.69) for patients with COPD within 6 months before death. Correspondingly, this was 0.65 (95% CI, 0.63 to 0.68) and 0.70 (95% CI, 0.68 to 0.71) within 30 days before death.Patients had almost the same risk of dying in hospital independently of death cause (46.2% to 56.0%).ConclusionPatients with cancer, heart failure and COPD all spent considerable part of their end of life in hospital. Hospital use was highest among cancer patients; however, absolute differences were small.

The ion recombination is examined in parallel-plate ionization chambers in scanning proton beams at the Danish Centre for Particle Therapy and the Skandion Clinic. The recombination correction factor k s is investigated for clinically relevant energies between 70 MeV and 244 MeV for dose rates below 400 Gy min-1 in air. The Boutillon formalism is used to separate the initial and general recombination. The general recombination is compared to predictions from the numerical recombination code IonTracks and the initial recombination to the Jaffé theory. k s is furthermore calculated with the two-voltage method (TVM) and extrapolation approaches, in particular the recently proposed three-voltage (3VL) method. The TVM is in agreement with the Boutillon method and IonTracks for dose rates above 100 Gy min-1. However, the TVM calculated k s is closer related to the Jaffé theory for initial recombination for lower dose rate, indicating a limited application in scanning light ion beams. The 3VL is in turn found to generally be in agreement with Boutillon's method. The recombination is mapped as a function of the dose rate and proton energy at the two centres using the Boutillon formalism: The initial recombination parameter was found to be A = (0.10 0.01) V at DCPT and A = (0.22 ± 0.13) V at Skandion, which is in better agreement with the Jaffé theory for initial recombination than previously reported values. The general recombination parameter was estimated to. Furthermore, the numerical algorithm IonTracks is demonstrated to correctly predict the initial recombination at low dose rates and the general recombination at high dose rates.

Background In Denmark, a tax-based universal healthcare setting, drug reimbursement for terminal illness (DRTI) should be equally accessible for all terminally ill patients. Examining DRTI status by regions provides new knowledge on inequality in palliative care provision and associated factors. This study aims to investigate geographical variation in DRTI among terminally ill cancer patients. Methods We linked socioeconomic and medical data from 135 819 Danish cancer decedents in the period 2007–15 to regional healthcare characteristics. We analyzed associations between region of residence and DRTI. Prevalence ratios (PR) for DRTI were estimated using generalized linear models adjusted for patient factors (age, gender, comorbidity and socioeconomic profile) and multilevel models adjusted for both patient factors and regional healthcare capacity (patients per general practitioner, numbers of hospital and hospice beds). Results DRTI allocation differed substantially across Danish regions. Healthcare capacity was associated with DRTI with a higher probability of DRTI among patients living in regions with high compared with low hospice bed supply (PR 1.13, 95% CI 1.10–1.17). Also, the fully adjusted PR of DRTI was 0.94 (95% CI 0.91–0.96) when comparing high with low number of hospital beds. When controlled for both patient and regional healthcare characteristics, the PR for DRTI was 1.17 (95% CI 1.14–1.21) for patients living in the Central Denmark Region compared with the Capital Region. Conclusion DRTI status varied across regions in Denmark. The variation was associated with the distribution of healthcare resources. These findings highlight difficulties in ensuring equal access to palliative care even in a universal healthcare system.

Background: Proton arc therapy may improve physical dose conformity and reduce concerns of elevated linear energy transfer (LET) and relative biological effectiveness (RBE) at the end of the proton range, while offering more degrees of freedom for normal tissue sparing. To explore the potential of proton arc therapy, we studied the effect of increasing the number of beams on physical and biologically equivalent dose conformity in the setting of pediatric brain tumors. Material and methods: A cylindrical phantom (Ø = 150 mm) with central cylindrical targets (Ø = 25 and 30 mm) was planned with increasing number of equiangular coplanar proton beams (from 3 to 36). For four anonymized pediatric brain tumor patients, two ‘surrogate’ proton arc plans (18 equiangular coplanar or sagittal beams) and a reference plan with 3 non-coplanar beams were constructed. Biologically equivalent doses were calculated using two RBE scenarios: RBE1.1; and RBELET, the physical dose weighted by the LET. For both RBE scenarios, dose gradients were assessed, and doses to cognitive brain structures were reported. Results: Increasing the number of beams resulted in an improved dose gradient and reduced volume exposed to intermediate LET levels, at the expense of increased low-dose and low-LET volumes. Most of the differences between the two RBE scenarios were seen around the prescription dose level, where the isodose volumes increased with the RBELET plans, e.g. up to 63% in the 3-beam plan for the smallest phantom target. Overall, the temporal lobes were better spared with the sagittal proton arc surrogate plans, e.g. a mean dose of 3.9 Gy compared to 6 Gy in the reference 3-beam plan (median value, RBE1.1). Conclusion: Proton arc therapy has the potential to improve dose gradients to better spare cognitive brain structures. However, this is at the expense of increased low-dose/low-LET volumes, with possible implications for secondary cancer risks.

Ionization quenching in ion beam dosimetry is often related to the fluence- or dose-averaged linear energy transfer (LET). Both quantities are however averaged over a wide LET range and a mixed field of primary and secondary ions. We propose a novel method to correct the quenched luminescence in scintillators exposed to ion beams. The method uses the energy spectrum of the primaries and accounts for the varying quenched luminescence in heavy, secondary ion tracks through amorphous track structure theory. The new method is assessed against more traditional approaches by correcting the quenched luminescence response from the BCF-12, BCF-60, and 81-0084 plastic scintillators exposed to a 100 MeV pristine proton beam in order to compare the effects of the averaged LET quantities and the secondary ions. Calculations and measurements show that primary protons constitute more than 92 % of the energy deposition but account for more than 95 % of the luminescence signal in the scintilllators. The quenching corrected luminescence signal is in better agreement with the dose measurement when the secondary particles are taken into account. The Birks model provided the overall best quenching corrections, when the quenching corrected signal is adjusted for the number of free model parameters. The quenching parameter kB for the BCF-12 and BCF-60 scintillators is in agreement with literature values and was found to be kB = (10.6±0.1) × 10-2 µm/keV-1 for the 81-0084 scintillator. Finally, a fluence threshold for the 100 MeV proton beam was calculated to be of the order of 1010 cm-2, corresponding to 110 Gy, above which the quenching increases non-linearly and the Birks model no longer is applicable.

The aim of this study was to investigate if teaching patients about positioning before radiotherapy treatment would (a) reduce the residual rotational set-up errors, (b) reduce the number of repositionings and (c) improve patients’ sense of control by increasing self-efficacy and reducing distress. Patients were randomized to either standard care (control group) or standard care and a teaching session combining visual aids and practical exercises (intervention group). Daily images from the treatment sessions were evaluated off-line. Both groups filled in a questionnaire before and at the end of the treatment course on various aspects of cooperation with the staff regarding positioning. Comparisons of residual rotational set-up errors showed an improvement in the intervention group compared to the control group. No significant differences were found in number of repositionings, self-efficacy or distress. Results show that it is possible to teach patients about positioning and thereby improve precision in positioning. Teaching patients about positioning did not seem to affect self-efficacy or distress scores at baseline and at the end of the treatment course.

In this work, a calorimetric system based on two graphite cores for absorbed dose measurements is described. The calorimeter also serves to correct the non-proportional (quenched) response in densely ionizing beams observed in scintillators. The system is designed for high-intensity scanning proton beams, where the deposition of each spot can be monitored by a fibre-coupled plastic scintillation detector (PSD). The graphite core can be replaced by a hollow replica of the core accommodating the PSD, in principle allowing the quenched PSD response to be corrected relative to the small graphite core under nominally identical radiation conditions. This work focuses on the design of the calorimetric system to minimize the heat losses during irradiations. The operation of two graphite cores is demonstrated to be reproducible within 1 % . Hence, the scintillator-calorimeter system is applicable for experimental scintillator quenching corrections in high-intensity ion beams where detectors as ionization chambers are insufficient.

Genetisk udredning benyttes i stigende grad af raske mennesker, som er i risiko for at udvikle alvorlige eller livstruende sygdomme. Nogle tilfaelde af brystkraeft og kraeft i aeggestokke og aeggeledere skyldes en mutation i et af de to BRCA-gener, som kan forarsage tidlig sygdom og dod. Gennem interviews med kvinder, der er testet positive for en BRCA-mutation, og med en genetisk radgiver udforsker artiklen, hvilken rolle den affektive cirkulation af risiko, ansvar og kon har i den genetiske radgivningsproces og for valg af testning og profylaktisk kirurgi. Analysen viser, at frygt er en gennemgaende folelse for kvinderne og deres familiemedlemmer bade for, under og efter testning. For kvinder, og saerligt modre, accelererer folelsen af frygt med deres egen og andres forventninger om, at de som kvinder skal vaere omsorgsfulde og beskyttende overfor deres familie. For at handtere frygten hersker der konsensus om at gore brug af de tilbud, som stilles til radighed i den medicinsk genetiske kontekst. Der er en udbredt kulturel forestilling, om at man kan opna viden om sine gener og traeffe beslutninger pa den baggrund, og en tendens til at opfatte genetisk testning og profylaktisk kirurgi som den ansvarlige made for kvinder at handtere risiko. Konnede forestillinger om kvinders og modres udvidede ansvar, lagt oveni den medicinske genetiks muligheder, virker gennem frygten disciplinerende pa kvindernes valg af testning og profylaktisk kirurgi, ogsa selvom det har omfattende negative konsekvenser for deres egne kroppe og liv. Det stiller saerlige krav til genetiske radgivere og sundhedsvaesnets tilbud pa omradet. ”For my children’s sake”: affective circulation of risk, responsibility and gender in BRCA genetic counseling Genetic testing is increasingly used by healthy people who are at risk for developing serious or life threatening diseases. Some instances of breast and ovarian cancer are caused by a mutation in one of the two BRCA-genes and may cause early onset of disease and premature death. Based on interviews of women who have tested positive for a BRCA mutation, and a genetic counselor this article explores the role of affective circulation of risk, responsibility and gender in the processes and choices around genetic counseling, testing and prophylaxis. The analysis shows that for women and their relatives fear is integral to the entire process of genetic testing. For women, and particularly mothers, fear is exacerbated by the widespread culteral expectation that women ought to care for and protect family members. One way to handle that fear and to meet expectations in the context of medical genetics is making use of the available measures. The notion that you can know your genes and act upon genetic knowledge is a cultural given and works as a driver for perceiving genetic counseling, testing and prophylactic surgery as the more responsible way for women and mothers to manage risk. The gendered conception of extended responsibilities of women and mothers, coupled with the promises of medical genetics, may discipline women to undergo genetic testing and surgery for the sake of family members, particularly children, regardless of any adverse consequences for their own bodies and lives.

The images connected to geographies of taxation matter as they can become aligned to wider political projects, programs and technologies aimed at shaping and anticipating the future of tax governance. Shaped by the classifications of their designers, such lists operate as technologies of knowledge condensation, comparison, organization and coordination. The metaphor of 'Tax Haven' has dominated the way of representing the problems of tax avoidance and tax evasion since World War II, conveying the well-known image in public blacklisting of small tropical island jurisdictions being the main actors to blame. The extent of willingness to cooperate with the organisation for economic co-operation and development (OECD) to end harmful tax practices led to the adoption of a process by which tax haven jurisdictions were invited to make commitments to eliminate harmful tax practices. The scrutiny and classification of the activities of the listed entities on the basis of preestablished criteria created the organisation for economic co-operation and development lists.

Purpose: Conventional techniques (3D-CRT) for craniospinal irradiation (CSI) are still widely used. Modern techniques (IMRT, VMAT, TomoTherapy®, proton pencil beam scanning [PBS]) are applied in a limited number of centers. For a 14-year-old patient, we aimed to compare dose distributions of five CSI techniques applied across Europe and generated according to the participating institute protocols, therefore representing daily practice. Material and methods: A multicenter (n = 15) dosimetric analysis of five different techniques for CSI (3D-CRT, IMRT, VMAT, TomoTherapy®, PBS; 3 centers per technique) was performed using the same patient data, set of delineations and dose prescription (36.0/1.8 Gy). Different treatment plans were optimized based on the same planning target volume margin. All participating institutes returned their best treatment plan applicable in clinic. Results: The modern radiotherapy techniques investigated resulted in superior conformity/homogeneity-indices (CI/HI), particularly in the spinal part of the target (CI: 3D-CRT:0.3 vs. modern:0.6; HI: 3D-CRT:0.2 vs. modern:0.1), and demonstrated a decreased dose to the thyroid, heart, esophagus and pancreas. Dose reductions of >10.0 Gy were observed with PBS compared to modern photon techniques for parotid glands, thyroid and pancreas. Following this technique, a wide range in dosimetry among centers using the same technique was observed (e.g., thyroid mean dose: VMAT: 5.6–24.6 Gy; PBS: 0.3–10.1 Gy). Conclusions: The investigated modern radiotherapy techniques demonstrate superior dosimetric results compared to 3D-CRT. The lowest mean dose for organs at risk is obtained with proton therapy. However, for a large number of organs ranges in mean doses were wide and overlapping between techniques making it difficult to recommend one radiotherapy technique over another.

The article investigates the implications of mediatization for the legitimation strategies of humanitarian organizations. Based on a (full population) corpus of ~400 pages of brochure material from 1970 to 2007, the micro-textual processes involved in humanitarian organizations’ efforts to legitimate themselves and their moral claim were examined. A time trend analysis of the prioritization of actors in the material indicates that marked shifts in legitimation loci have taken place during the past 40 years. A discourse analysis unfolds the three dominant discourses behind these shifts, namely legitimation by accountancy, legitimation by institutionalization, and legitimation by compensation. The analysis relates these changes to a problem of trust associated with mediatization through processes of mediation.

Purpose To evaluate an image-guided and adaptive EBRT workflow in locally advanced cervical cancer (LACC) patients treated according to EMBRACE II guidelines in terms of individualized ITV margins and new criteria for dose coverage. Interfractional target-(cervix/uterus) and organ filling was monitored on a daily basis and investigated along with the impact of patient feedback on organ fillings. Methods Patients treated with definitive radiochemotherapy were included. Pretreatment MRI- and (PET)-CT scans with full and empty bladders were performed and a bladder-filling protocol applied. Contouring was according to EMBRACE II guidelines with individualized ITV margin and 5 mm PTV margin. VMAT plans were used to deliver 45Gy/25 fractions with daily onboard cone beam CT (CBCT) scans. Trained RTTs monitored the interfractional target motion and organ fillings, and provided patients with daily feedback on organ-filling. A clinical workflow including thresholds for re-planning if target was not inside PTV was designed and followed. CBCTs were retrospectively reviewed, and the accuracy of the RTT scorings analyzed. Minimum doses to CTV-T HR(aim 42,75 Gy) and CTV-T LR(aim 40 Gy) were retrospectively estimated for replanned patients. Results Twenty-three patients were evaluated. RTT scoring of target coverage was correct in 90% of the CBCTs (505/563), incorrect in Conclusions The study proposes a practical adaptive approach for EBRT in LACC patients with daily IGRT monitoring supporting the EMBRACE II guidelines. The strategy allowed safe treatment with relatively tight ITV margins. In patients with unpredictable interfractional target- and organ motion, the compromised coverage benefitted from re-planning. The approach has limited workload and can be performed with high accuracy by RTTs.

Purpose Patients with urinary bladder cancer are obvious candidates for adaptive radiotherapy (ART) due to large inter-fractional variation in bladder volumes. In this study we have compared the normal tissue sparing potential of two ART strategies: daily plan selection (PlanSelect) and daily plan re-optimisation (ReOpt). Materials and methods Seven patients with bladder cancer were included in the study. For the PlanSelect strategy, a patient-specific library of three plans was generated, and the most suitable plan based on the pre-treatment cone beam CT (CBCT) was selected. For the daily ReOpt strategy, plans were re-optimised based on the CBCT from each daily fraction. Bladder contours were propagated to the CBCT scan using deformable image registration (DIR). Accumulated dose distributions for the ART strategies as well as the non-adaptive RT were calculated. Results A considerable sparing of normal tissue was achieved with both ART approaches, with ReOpt being the superior technique. Compared to non-adaptive RT, the volume receiving more than 57 Gy (corresponding to 95% of the prescribed dose) was reduced to 66% (range 48–100%) for PlanSelect and to 41% (range 33–50%) for ReOpt. Conclusion This study demonstrated a considerable normal tissue sparing potential of ART for bladder irradiation, with clearly superior results by daily adaptive re-optimisation.