Stereotactic body radiotherapy for pancreatic cancer - A systematic review of prospective data

Purpose

This systematic review aims to comprehensively summarize the current prospective evidence regarding Stereotactic Body Radiotherapy (SBRT) in various clinical contexts for pancreatic cancer including its use as neoadjuvant therapy for borderline resectable pancreatic cancer (BRPC), induction therapy for locally advanced pancreatic cancer (LAPC), salvage therapy for isolated local recurrence (ILR), adjuvant therapy after radical resection, and as a palliative treatment. Special attention is given to the application of magnetic resonance-guided radiotherapy (MRgRT).

Methods

Following PRISMA guidelines, a systematic review of the Medline database via PubMed was conducted focusing on prospective studies published within the past decade. Data were extracted concerning study characteristics, outcome measures, toxicity profiles, SBRT dosage and fractionation regimens, as well as additional systemic therapies.

Results and conclusion

31 studies with in total 1,571 patients were included in this review encompassing 14 studies for LAPC, 9 for neoadjuvant treatment, 2 for adjuvant treatment, 2 for ILR, with an additional 4 studies evaluating MRgRT. In LAPC, SBRT demonstrates encouraging results, characterized by favorable local control rates. Several studies even report conversion to resectable disease with substantial resection rates reaching 39%. The adoption of MRgRT may provide a solution to the challenge to deliver ablative doses while minimizing severe toxicities. In BRPC, select prospective studies combining preoperative ablative-dose SBRT with modern induction systemic therapies have achieved remarkable resection rates of up to 80%. MRgRT also holds potential in this context. Adjuvant SBRT does not appear to confer relevant advantages over chemotherapy. While prospective data for SBRT in ILR and for palliative pain relief are limited, they corroborate positive findings from retrospective studies.

Principles of oncology taught in a one-week course

BACKGROUND

Growing challenges in oncology require evolving educational methods and content. International efforts to reform oncology education are underway. Hands-on, interdisciplinary, and compact course formats have shown great effectiveness in the education of medical students. Our aim was to establish a new interdisciplinary one-week course on the principles of oncology using state-of-the-art teaching methods.

METHODS

In an initial survey, medical students of LMU Munich were questioned about their current level of knowledge on the principles of oncology. In a second two-stage survey, the increase in knowledge resulting from our recently established interdisciplinary one-week course was determined.

RESULTS

The medical students' knowledge of clinically important oncological topics, such as the diagnostic workup and interdisciplinary treatment options, showed a need for improvement. Knowledge of the major oncological entities was also in an expandable state. By attending the one-week course on the principles of oncology, students improved their expertise in all areas of the clinical workup in oncology and had the opportunity to close previous knowledge gaps. In addition, students were able to gain more in-depth clinical knowledge on the most common oncological entities.

CONCLUSION

The interdisciplinary one-week course on the principles of oncology proved to be an effective teaching method to expand the knowledge of the future physicians to an appropriate level. With its innovative and interdisciplinary approach, the one-week course could be used as a showcase project for the ongoing development of medical education in Germany.

Deep Learning and Registration-Based Mapping for Analyzing the Distribution of Nodal Metastases in Head and Neck Cancer Cohorts: Informing Optimal Radiotherapy Target Volume Design

We introduce a deep-learning- and a registration-based method for automatically analyzing the spatial distribution of nodal metastases (LNs) in head and neck (H/N) cancer cohorts to inform radiotherapy (RT) target volume design. The two methods are evaluated in a cohort of 193 H/N patients/planning CTs with a total of 449 LNs. In the deep learning method, a previously developed nnU-Net 3D/2D ensemble model is used to autosegment 20 H/N levels, with each LN subsequently being algorithmically assigned to the closest-level autosegmentation. In the nonrigid-registration-based mapping method, LNs are mapped into a calculated template CT representing the cohort-average patient anatomy, and kernel density estimation is employed to estimate the underlying average 3D-LN probability distribution allowing for analysis and visualization without prespecified level definitions. Multireader assessment by three radio-oncologists with majority voting was used to evaluate the deep learning method and obtain the ground-truth distribution. For the mapping technique, the proportion of LNs predicted by the 3D probability distribution for each level was calculated and compared to the deep learning and ground-truth distributions. As determined by a multireader review with majority voting, the deep learning method correctly categorized all 449 LNs to their respective levels. Level 2 showed the highest LN involvement (59.0%). The level involvement predicted by the mapping technique was consistent with the ground-truth distribution (p for difference 0.915). Application of the proposed methods to multicenter cohorts with selected H/N tumor subtypes for informing optimal RT target volume design is promising.

Identifying the duration of emotional stimulus presentation for conscious versus subconscious perception via hierarchical drift diffusion models

To investigate subliminal priming effects, different durations for stimulus presentation are applied ranging from 8 to 30 ms. This study aims to select an optimal presentation span whichleads to a subconscious processing. 40 healthy participants rated emotional faces (sad, neutral or happy expression) presented for 8.3 ms, 16.7 ms and 25 ms. Alongside subjective and objectivestimulus awareness, task performance was estimated via hierarchical drift diffusion models. Participants reported stimulus awareness in 65 % of the 25 ms trials,in 36 % of 16.7 ms trials, and in 2.5 % of 8.3 ms trials.Emotion-dependent responses were reflected in decreased performance (drift rates, accuracy)during sad trials. The detection rate (probability of making a correct response) during 8.3 ms was 12.2 % and slightly above chance level (33.333 % for three response options) during 16.7 ms trials (36.8 %). The experiments suggest a presentation time of 16.7 ms as optimal for subconscious priming. An emotion-specific response was detected during 16.7 ms while the performanceindicates a subconscious processing.

Absolute risks of self-harm and interpersonal violence by diagnostic category following first discharge from inpatient psychiatric care

BACKGROUND

Persons discharged from inpatient psychiatric services are at greatly elevated risk of harming themselves or inflicting violence on others, but no studies have reported gender-specific absolute risks for these two outcomes across the spectrum of psychiatric diagnoses. We aimed to estimate absolute risks for self-harm and interpersonal violence post-discharge according to gender and diagnostic category.

METHODS

Danish national registry data were utilized to investigate 62,922 discharged inpatients, born 1967-2000. An age and gender matched cohort study was conducted to examine risks for self-harm and interpersonal violence at 1 year and at 10 years post-discharge. Absolute risks were estimated as cumulative incidence percentage values.

RESULTS

Patients diagnosed with substance misuse disorders were at especially elevated risk, with the absolute risks for either self-harm or interpersonal violence being 15.6% (95% CI 14.9, 16.3%) of males and 16.8% (15.6, 18.1%) of females at 1 year post-discharge, rising to 45.7% (44.5, 46.8%) and 39.0% (37.1, 40.8%), respectively, within 10 years. Diagnoses of personality disorders and early onset behavioral and emotional disorders were also associated with particularly high absolute risks, whilst risks linked with schizophrenia and related disorders, mood disorders, and anxiety/somatoform disorders, were considerably lower.

CONCLUSIONS

Patients diagnosed with substance misuse disorders, personality disorders and early onset behavioral and emotional disorders are at especially high risk for internally and externally directed violence. It is crucial, however, that these already marginalized individuals are not further stigmatized. Enhanced care at discharge and during the challenging transition back to life in the community is needed.

Sensors and Techniques for On-Line Determination of Cell Viability in Bioprocess Monitoring

In recent years, the bioprocessing industry has experienced significant growth and is increasingly emerging as an important economic sector. Here, efficient process management and constant control of cellular growth are essential. Good product quality and yield can only be guaranteed with high cell density and high viability. Whereas the on-line measurement of physical and chemical process parameters has been common practice for many years, the on-line determination of viability remains a challenge and few commercial on-line measurement methods have been developed to date for determining viability in industrial bioprocesses. Thus, numerous studies have recently been conducted to develop sensors for on-line viability estimation, especially in the field of optical spectroscopic sensors, which will be the focus of this review. Spectroscopic sensors are versatile, on-line and mostly non-invasive. Especially in combination with bioinformatic data analysis, they offer great potential for industrial application. Known as soft sensors, they usually enable simultaneous estimation of multiple biological variables besides viability to be obtained from the same set of measurement data. However, the majority of the presented sensors are still in the research stage, and only a few are already commercially available.

BOK controls ER proteostasis and physiological ER stress responses in neurons

The Bcl-2 family proteins BAK and BAX control the crucial step of pore formation in the mitochondrial outer membrane during intrinsic apoptosis. Bcl-2-related ovarian killer (BOK) is a Bcl-2 family protein with a high sequence similarity to BAK and BAX. However, intrinsic apoptosis can proceed in the absence of BOK. Unlike BAK and BAX, BOK is primarily located on the endoplasmic reticulum (ER) and Golgi membranes, suggesting a role for BOK in regulating ER homeostasis. In this study, we report that BOK is required for a full ER stress response. Employing previously characterized fluorescent protein-based ER stress reporter cell systems, we show that BOK-deficient cells have an attenuated response to ER stress in all three signaling branches of the unfolded protein response. Fluo-4-based confocal Ca2+ imaging revealed that disruption of ER proteostasis in BOK-deficient cells was not linked to altered ER Ca2+ levels. Fluorescence recovery after photobleaching (FRAP) experiments using GRP78/BiP-eGFP demonstrated that GRP78 motility was significantly lower in BOK-deficient cells. This implied that less intraluminal GRP78 was freely available and more of the ER chaperone bound to unfolded proteins. Collectively, these experiments suggest a new role for BOK in the protection of ER proteostasis and cellular responses to ER stress.

Deep learning based time-to-event analysis with PET, CT and joint PET/CT for head and neck cancer prognosis

OBJECTIVES

Recent studies have shown that deep learning based on pre-treatment positron emission tomography (PET) or computed tomography (CT) is promising for distant metastasis (DM) and overall survival (OS) prognosis in head and neck cancer (HNC). However, lesion segmentation is typically required, resulting in a predictive power susceptible to variations in primary and lymph node gross tumor volume (GTV) segmentation. This study aimed at achieving prognosis without GTV segmentation, and extending single modality prognosis to joint PET/CT to allow investigating the predictive performance of combined- compared to single-modality inputs.

METHODS

We employed a 3D-Resnet combined with a time-to-event outcome model to incorporate censoring information. We focused on the prognosis of DM and OS for HNC patients. For each clinical endpoint, five models with PET and/or CT images as input were compared: PET-GTV, PET-only, CT-GTV, CT-only, and PET/CT-GTV models, where -GTV indicates that the corresponding images were masked using the GTV contour. Publicly available delineated CT and PET scans from 4 different Canadian hospitals (293) and the MAASTRO clinic (74) were used for training by 3-fold cross-validation (CV). For independent testing, we used 110 patients from a collaborating institution. The predictive performance was evaluated via Harrell's Concordance Index (HCI) and Kaplan-Meier curves.

RESULTS

In a 5-year time-to-event analysis, all models could produce CV HCIs with median values around 0.8 for DM and 0.7 for OS. The best performance was obtained with the PET-only model, achieving a median testing HCI of 0.82 for DM and 0.69 for OS. Compared with the PET/CT-GTV model, the PET-only still had advantages of up to 0.07 in terms of testing HCI. The Kaplan-Meier curves and corresponding log-rank test results also demonstrated significant stratification capability of our models for the testing cohort.

CONCLUSION

Deep learning-based DM and OS time-to-event models showed predictive capability and could provide indications for personalized RT. The best predictive performance achieved by the PET-only model suggested GTV segmentation might be less relevant for PET-based prognosis.

Clinical outcome of combined intracavitary / interstitial brachytherapy using a hybrid applicator in locally advanced cervical cancer

OBJECTIVE

The aim of this study was to evaluate the clinical outcome in locally advanced cervical cancer (LACC) after image-guided adaptive brachytherapy (IGABT) with combined intracavitary and interstitial (IC/IS) techniques using the hybrid Venezia applicator (Elekta AB, Sweden).

METHODS

LACC patients (UICC Stage IIB - IVB) treated with radiochemotherapy followed by IGABT with the hybrid IC/IS Venezia applicator at a single institution were retrospectively analyzed. Treatment comprised EBRT of the pelvis with 45 Gy and concomitant weekly cisplatin chemotherapy (40 mg/m²) followed by MRI-based IGABT. Dosimetry, oncological outcome and toxicity were investigated.

RESULTS

Forty-six patients underwent a total of 184 fractions of IGABT between 2017 and 2020. Median follow-up was 24 months. Combined IC/IS techniques were used in 40 patients (87%). The median HRCTV volume was 31.2 cm³ and the median HRCTV D_90% was 92.3 Gy (EQD2₁₀). The median D_2cm³ was 74.8 Gy for bladder, 57.9 Gy for rectum, 60.0 Gy for sigmoid and 52.2 Gy for bowel (EQD2₃). The 3-yr actuarial rates were 97.6% for local control, 97.6% for pelvic control, 59.9% for distant metastasis-free survival and 81.6% for overall survival. The crude rate for G2 and G3 late toxicity was 21.7% and 4.3%.

CONCLUSIONS

IGABT with the hybrid Venezia applicator and a pronounced use of a combined IC/IS technique achieved high target doses, while maintaining low doses to organs at risk, leading to excellent local control and overall survival rates with acceptable toxicity.

Combining inter-observer variability, range and setup uncertainty in a variance-based sensitivity analysis for proton therapy

Margin concepts in proton therapy aim to ensure full dose coverage of the clinical target volume (CTV) in presence of setup and range uncertainty. Due to inter-observer variability (IOV), the CTV itself is uncertain. We present a framework to evaluate the combined impact of IOV, setup and range uncertainty in a variance-based sensitivity analysis (SA). For ten patients with skull base meningioma, the mean calculation time to perform the SA including 1.6 × 10⁴ dose recalculations was 59 min. For two patients in this dataset, IOV had a relevant impact on the estimated CTV D_95% uncertainty.

Interstitial High-Dose-Rate Brachytherapy of Liver Metastases in Oligometastatic Patients

Simple Summary

Local ablative treatments have emerged as a promising treatment strategy for patients with oligometastatic disease. Interstitial brachytherapy (iBT) is one of the locally ablative treatment options for unresectable liver metastases in oligometastatic disease. We report the feasibility and oncologic outcome of 141 iBT treatments of 244 oligometastatic liver metastases performed in patients with limited tumor burdens in a high-volume center. iBT was feasible, safe and effective in the treatment of oligometastatic liver metastases with good local control rates and low toxicity. Histology and total tumor volume had an impact on local control rates.

Abstract

Local ablative treatments have emerged as a promising treatment strategy for patients with oligometastatic disease. Among others, interstitial brachytherapy (iBT) is an upcoming treatment option for unresectable liver metastases. We report the feasibility and oncologic outcome of iBT of oligometastatic liver metastases performed in patients with limited tumor burdens in a high-volume center. Patients undergoing iBT between August 2017and March 2019 were included. A retrospective analysis of patient outcomes and treatment complications was performed. Patients treated for metastatic colorectal carcinoma (CRC) were compared to other histologies. A total of 141 iBT procedures were performed in 106 patients (male:52; female:54) and 244 liver metastases. Overall, 51% (54/106) of patients had a diagnosis of metastatic CRC. The median follow-up was 9 months, and overall survival (OS) was 92.3% at 6 months and 76.3% at 12 months. Local-relapse-free survival (LRFS) was 88.4% at 6 months and 71.5% at 12 months, with a significant difference between patients with CRC (84.1% and 50.6%) versus other histologies (92.4% and 92.4%, p < 0.001). A sub-group analysis showed a significant advantage in patients with CRC receiving a minimal dose (D100) of 20 Gy to the planning target volume. Treatments of smaller total liver-tumor volumes (<18 ccm) resulted in better LRFS rates. iBT is a safe and effective treatment approach for oligometastatic liver disease. A higher treatment dose is needed for patients with CRC. Moreover, lower metastatic burdens may be favorable for LRFS. Prospective studies are needed to assess the role of iBT in the oligometastatic setting as an alternative to other local ablative treatment approaches in patients with liver metastases.

Kognitive Fähigkeiten von Kindern mit Defiziten in der Sprachentwicklung – Ergebnisse zur WPPSI-IV

In dieser Case-Control-Studie wurden kognitive Leistungen (WPPSI-IV) von Vorschulkindern mit rezeptiven und/oder expressiven Sprachdefiziten mit den Leistungen einer nach Alter, Geschlecht gematchten sprachunauffälligen Kontrollgruppe verglichen (N = 186).

Insbesondere die sprachbezogenen Indizes sowie umgebungsbedingte Faktoren, wie mütterlicher Bildungshintergrund und Mehrsprachigkeit, werden in der Teilstichprobe der sprachbeeinträchtigten Kinder exploriert.

Jeweils die Leistungen der beiden Gruppen im Sprachverständnis, Wortschatzerwerb, Allgemeinen Fähigkeitsindex und Gesamt-IQ unterscheiden sich signifikant mit kleinen bis mittleren Effekten voneinander.

Signifikante Unterschiede der sprachbezogenen Indizes in Abhängigkeit des mütterlichen Bildungsniveaus und der Ein-/Mehrsprachigkeit der Kinder verweisen auf die hohe Bedeutung der häuslichen Umgebung für die Sprachentwicklung. Praktische Implikationen bezüglich des Einsatzes der WPPSI-IV bei sprachbeeinträchtigen Kindern werden erörtert.

HDR Brachytherapy and SBRT as Bridging Therapy to Liver Transplantation in HCC Patients: A Single-Center Experience

Background

In the treatment of patients with HCC awaiting liver transplantation (LT), local ablative treatments (LAT) are available either for downstaging or as bridging treatment. We present our clinical experience with both available radiation-based techniques, brachytherapy (BT), and stereotactic body radiotherapy (SBRT).

Methods

All patients diagnosed with HCC and who were treated with BT or SBRT at our institution between 2011 and 2018 were retrospectively reviewed. The current analysis included all patients who subsequently underwent LT.

Results

A total of 14 patients (male=9; female=5) were evaluated. Seven underwent BT for bridging before LT, and seven were treated with SBRT. BT was performed with a prescribed dose of 1 × 15 Gy, while SBRT was applied with 37 Gy (65%-iso) in three fractions in six patients, and one patient was treated with 54 Gy (100%-iso) in nine fractions. The treatment was generally well tolerated. One case of grade 3 bleeding was reported after BT, and one case of liver failure occurred following SBRT. All patients underwent LT after a median time interval of 152 days (range 47–311) after BT and 202 days (range 44–775) following SBRT. In eight cases, no viable tumor was found in the explanted liver, while four liver specimens showed vital tumor. The median follow-up after SBRT was 41 months and 17 months following BT. Overall, no hepatic HCC recurrence occurred following LT.

Conclusion

Both SBRT and BT are feasible and well tolerated as bridging to LT when applied with caution in patients with impaired liver function. Radiation-based treatments can close the gap for patients not suitable for other locally ablative treatment options.

Risk Stratification Using 18F-FDG PET/CT and Artificial Neural Networks in Head and Neck Cancer Patients Undergoing Radiotherapy

This study retrospectively analyzed the performance of artificial neural networks (ANN) to predict overall survival (OS) or locoregional failure (LRF) in HNSCC patients undergoing radiotherapy, based on 2-[¹⁸F]FDG PET/CT and clinical covariates. We compared predictions relying on three different sets of features, extracted from 230 patients. Specifically, (i) an automated feature selection method independent of expert rating was compared with (ii) clinical variables with proven influence on OS or LRF and (iii) clinical data plus expert-selected SUV metrics. The three sets were given as input to an artificial neural network for outcome prediction, evaluated by Harrell’s concordance index (HCI) and by testing stratification capability. For OS and LRF, the best performance was achieved with expert-based PET-features (0.71 HCI) and clinical variables (0.70 HCI), respectively. For OS stratification, all three feature sets were significant, whereas for LRF only expert-based PET-features successfully classified low vs. high-risk patients. Based on 2-[¹⁸F]FDG PET/CT features, stratification into risk groups using ANN for OS and LRF is possible. Differences in the results for different feature sets confirm the relevance of feature selection, and the key importance of expert knowledge vs. automated selection.

Validation of the collapsed cone algorithm for HDR liver brachytherapy against Monte Carlo simulations

PURPOSE

To validate the collapsed cone (CC) algorithm against Monte Carlo (MC) simulations for model-based dose calculations in high-dose-rate (HDR) liver brachytherapy.

METHODS AND MATERIALS

Doses for liver brachytherapy treatment plans of 10 cases were retrospectively recalculated with a model-based approach using Monte Carlo n-Particle Code (MCNP) 6 (Dm,m-MC) and Oncentra Brachy ACE (Dm,m-ACE). Tissue segmentation consisted of assigning uniform compositions and mass densities to predefined Hounsfield Unit (HU) thresholds. Resulting doses were compared according to dose volume histogram parameters typical for clinical routine. These included the percentage liver volume receiving 5 Gy (V5Gy) or 10 Gy (V10Gy), the maximum dose to one cubic centimeter (D1cc) of organs at risk, the clinical target volume (CTV) fractions receiving 150% (V150), 100% (V100), 95% (V95) and 90% (V90) of the prescribed dose and the absolute doses to 95% (D95) and 90% (D90) of the CTV volumes.

RESULTS

Doses from Oncentra Brachy ACE agreed well with MC simulations. Differences were seen far from the source, in low-density regions and bone structures. Median percentage deviations were 1.1% for the liver V5Gy and 0.4% for the liver V10Gy, with deviations of largest magnitude amounting to 2.2% and 1.0%, respectively. Organs at risk had median deviations ranging from 0.3% to 1.5% for D1cc, with outliers ranging up to 4.6%. CTV volume parameter deviations ranged between -1.5% and 0.5%, dose parameter deviations ranged mostly between -2% and 1%, with two outliers at -4.0% and -3.4% for a small CTV.

Comparison of liver exposure in CT-guided high-dose rate (HDR) interstitial brachytherapy versus SBRT in hepatocellular carcinoma

Background

In unresectable hepatocellular carcinoma several local ablative treatments are available. Among others, radiation based treatments such as stereotactic body radiotherapy (SBRT) and high-dose rate interstitial brachytherapy (HDR BT) have shown good local control rates.

Methods

We conducted a dose comparison between actually performed HDR BT versus virtually planned SBRT to evaluate the respective clinically relevant radiation exposure to uninvolved liver tissue. Moreover, dose coverage and conformity indices were assessed.

Results

Overall, 46 treatment sessions (71 lesions, 38 patients) were evaluated. HDR BT was applied in a single fraction with a dose prescription of 1 × 15 Gy. D98 was 17.9 ± 1.3 Gy, D50 was 41.8 ± 8.1 Gy. The SBRT was planned with a prescribed dose of 3 × 12.5 Gy (65%-Isodose), D98 was 50.7 ± 3.1 Gy, D2 was 57.0 ± 2.3 Gy, and D50 was 55.2 ± 2.3 Gy.

Regarding liver exposure Vliver10Gy_BT was compared to Vliver15.9Gy_SBRT, Vliver16.2Gy_SBRT (EQD2 equivalent doses), and Vliver20Gy_SBRT (clinically relevant dose), all results showed significant differences (p < .001). In a case by case analysis Vliver10Gy_BT was smaller than Vliver20Gy_SBRT in 38/46 cases (83%). Dmean of the liver was significantly smaller in BT compared to SBRT (p < .001).

GTV volume was correlated to the liver exposure and showed an advantage of HDR BT over SBRT in comparison of clinically relevant doses, and for EQD2 equivalent doses. The advantage was more pronounced for greater liver lesions The Conformity Index (CI) was significantly better for BT, while Healthy Tissue Conformity Index (HTCI) and Conformation Number (CN) showed an advantage for SBRT (p < .001).

Conclusion

HDR BT can be advantageous in respect of sparing of normal liver tissue as compared to SBRT, while providing excellent target conformity.

Sex Differences in Intelligence in Children Aged 2:6–7:7: Analysis of the Factor Structure and Measurement Invariance of the German Wechsler Primary and Preschool Scale of Intelligence–Fourth Edition

The present study investigated gender differences in cognitive abilities for children aged 2–7 years on the German Wechsler Primary and Preschool Scale of Intelligence–Fourth Edition (WPPSI-IV). WPPSI-IV data of 1,042 children (517 girls and 525 boys) were selected from the extended dataset of the German WPPSI-IV standardization sample. First of all, confirmatory factor analyses (CFAs) were used to verify the factor structure of the WPPSI-IV, which was proposed by the test developers. Then, multiple-group confirmatory factor models were implemented to explore measurement invariance across gender. Finally, mean differences in the subtests, index scores, as well as full scale IQ (FSIQ) were analyzed. The second-order three-factor model for age group 2:6–3:11 as well as the second-order five-factor model for age group 4:0–7:7 could be verified. For age group 2:6–3:11, full scalar invariance could be accepted, whereas partial scalar invariance could be established by freeing five nonequivalent subtest intercepts for age group 4:0–7:7. These findings support interpretable comparisons of the WPPSI-IV scores between girls and boys. For age group 4:0–7:7, partial invariance should be taken into account in these comparisons. Furthermore, girls aged 4:0–7:7 showed an advantage in processing speed (PS). Mean scores in any of the other cognitive abilities did not differ between girls and boys in both age groups. These results indicated measurement invariance across gender on the WPPSI-IV, so that the tests measure cognitive abilities in the same way for girls and boys. The current findings showed that gender differences in PS may emerge in early childhood, which might lead to gender differences in later educational skills.

Radiotherapy in oncological emergencies: fast-track treatment planning

BACKGROUND AND PURPOSE

To report on our clinical experience with a newly implemented workflow for radiotherapy (RT) emergency treatments, which allows for a fast treatment application outside the regular working-hours, and its clinical applicability.

METHODS

Treatment planning of 18 emergency RT patients was carried out using diagnostic computed tomography (CT) without a dedicated RT simulation CT. The cone-beam CT (CBCT) deviations of the first RT treatment were analyzed regarding setup accuracy. Furthermore, feasibility of the "fast-track" workflow was evaluated with respect to dose deviations caused by different Hounsfield unit (HU) to relative electron density (rED) calibrations and RT treatment couch surface shapes via 3D gamma index analysis of exemplary treatment plans. The dosimetric uncertainty introduced by different CT calibrations was quantified.

RESULTS

Mean patient setup vs. CBCT isocenter deviations were (0.49 ± 0.44) cm (x), (2.68 ± 1.63) cm (y) and (1.80 ± 1.06) cm (z) for lateral, longitudinal and vertical directions, respectively. Three out of four dose comparisons between the emergency RT plan calculated on the diagnostic CT and the same plan calculated on the treatment planning CT showed clinically acceptable gamma passing rates, when correcting for surface artifacts. The maximum difference of rED was 0.054, while most parts of the CT calibration curves coincided well.

CONCLUSION

In an emergency RT setting, the use of diagnostic CT data for treatment planning might be time-saving and was shown to be suitable for many cases, considering reproducibility of patient setup, accuracy of initial patient setup and accuracy of dose-calculation.

[The Influence of a Statement of Truth on the Authenticity of Complaints]

BACKGROUND

Implicit motives have a moderating effect on dishonest answering behaviour during the testing of applicants for disability pensions. Persons would rather act dishonest if they do not have do keep up their positive self-image therefore.

OBJECTIVE

Does a statement of truth at the beginning of a functional capacity evaluation lead to lower dishonest answering behaviour?

METHODS

248 applicants for a disability pension were randomly allocated to giving such a statement either before or after symptom validity tests (SIMS, BEVA).

RESULTS

The statement of truth affected the SIMS but not the BEVA. The effect depended on the education level.

CONCLUSION

Moral and social motives have to be taken into account when assessing malingering during a functional capacity evaluation. Higher educated persons refer to other moral standards or take a more individual and case-by-case approach to morally challenging situations.

Stability and reproducibility of 6013 deep inspiration breath-holds in left-sided breast cancer

Purpose

Patients with left-sided breast cancer frequently receive deep inspiration breath-hold (DIBH) radiotherapy to reduce the risk of cardiac side effects. The aim of the present study was to analyze intra-breath-hold stability and inter-fraction breath-hold reproducibility in clinical practice.

Material and methods

Overall, we analyzed 103 patients receiving left-sided breast cancer radiotherapy using a surface-guided DIBH technique. During each treatment session the vertical motion of the patient was continuously measured by a surface guided radiation therapy (SGRT) system and automated gating control (beam on/off) was performed using an audio-visual patient feedback system. Dose delivery was automatically triggered when the tracking point was within a predefined gating window. Intra-breath-hold stability and inter-fraction reproducibility across all fractions of the entire treatment course were analyzed per patient.

Results

In the present series, 6013 breath-holds during beam-on time were analyzed. The mean amplitude of the gating window from the baseline breathing curve (maximum expiration during free breathing) was 15.8 mm (95%-confidence interval: [8.5–30.6] mm) and had a width of 3.5 mm (95%-CI: [2–4.3] mm). As a measure of intra-breath-hold stability, the median standard deviation of the breath-hold level during DIBH was 0.3 mm (95%-CI: [0.1–0.9] mm). Similarly, the median absolute intra-breath-hold linear amplitude deviation was 0.4 mm (95%-CI: [0.01–2.1] mm). Reproducibility testing showed good inter-fractional reliability, as the maximum difference in the breathing amplitudes in all patients and all fractions were 1.3 mm on average (95%-CI: [0.5–2.6] mm).

Conclusion

The clinical integration of an optical surface scanner enables a stable and reliable DIBH treatment delivery during SGRT for left-sided breast cancer in clinical routine.

Recent advances of PET imaging in clinical radiation oncology

Radiotherapy and radiation oncology play a key role in the clinical management of patients suffering from oncological diseases. In clinical routine, anatomic imaging such as contrast-enhanced CT and MRI are widely available and are usually used to improve the target volume delineation for subsequent radiotherapy. Moreover, these modalities are also used for treatment monitoring after radiotherapy. However, some diagnostic questions cannot be sufficiently addressed by the mere use standard morphological imaging. Therefore, positron emission tomography (PET) imaging gains increasing clinical significance in the management of oncological patients undergoing radiotherapy, as PET allows the visualization and quantification of tumoral features on a molecular level beyond the mere morphological extent shown by conventional imaging, such as tumor metabolism or receptor expression. The tumor metabolism or receptor expression information derived from PET can be used as tool for visualization of tumor extent, for assessing response during and after therapy, for prediction of patterns of failure and for definition of the volume in need of dose-escalation. This review focuses on recent and current advances of PET imaging within the field of clinical radiotherapy / radiation oncology in several oncological entities (neuro-oncology, head & neck cancer, lung cancer, gastrointestinal tumors and prostate cancer) with particular emphasis on radiotherapy planning, response assessment after radiotherapy and prognostication.

The dosimetric impact of replacing the TG-43 algorithm by model based dose calculation for liver brachytherapy

PURPOSE

To compare treatment plans for interstitial high dose rate (HDR) liver brachytherapy with ¹⁹²Ir calculated according to current-standard TG-43U1 protocol with model-based dose calculation following TG-186 protocol.

METHODS

We retrospectively evaluated dose volume histogram (DVH) parameters for liver, organs at risk (OARs) and clinical target volumes (CTVs) of 20 patient cases diagnosed with hepatocellular carcinoma (HCC) or metastatic colorectal cancer (mCRC). Dose calculations on a homogeneous water geometry (TG-43U1 surrogate) and on a computed tomography (CT) based geometry (TG-186) were performed using Monte Carlo (MC) simulations. The CTs were segmented based on a combination of assigning TG-186 recommended tissues to fixed Hounsfield Unit (HU) ranges and using organ contours delineated by physicians. For the liver, V_5Gy and V_10Gy were analysed, and for OARs the dose to 1 cubic centimeter (D_1cc). Target coverage was assessed by calculating V₁₅₀, V₁₀₀, V₉₅ and V₉₀ as well as D₉₅ and D₉₀. For every DVH parameter, median, minimum and maximum values of the deviations of TG-186 from TG-43U1 were analysed.

RESULTS

TG-186-calculated dose was found to be on average lower than dose calculated with TG-43U1. The deviation of highest magnitude for liver parameters was -6.2% of the total liver volume. For OARs, the deviations were all smaller than or equal to -0.5 Gy. Target coverage deviations were as high as -1.5% of the total CTV volume and -3.5% of the prescribed dose.

CONCLUSIONS

In this study we found that TG-43U1 overestimates dose to liver tissue compared to TG-186. This finding may be of clinical importance for cases where dose to the whole liver is the limiting factor.

Novel rotatable tabletop for total-body irradiation using a linac-based VMAT technique

BACKGROUND

Volumetric Modulated Arc Therapy (VMAT) techniques have recently been implemented in clinical practice for total-body irradiation (TBI). To date, most techniques still use special couches, translational tables, or other self-made immobilization devices for dose delivery. Aim of the present study was to report the first results of a newly developed rotatable tabletop designed for VMAT-TBI.

METHODS

The VMAT-TBI technique theoretically allows the use of any standard positioning device at the linear accelerator. Nevertheless, the main problem is that patients taller than 120 cm cannot be treated in one position due to the limited cranial-caudal couch shift capacities of the linac. Therefore, patients are usually turned from a head-first supine position (HFS) to a feet-first supine position (FFS) to overcome this limitation. The newly developed rotatable tabletop consists completely of carbon fiber, including the ball bearing within the base plate of the rotation unit. The patient can be turned 180° from a HFS to a FFS position within a few seconds, without the need of repositioning.

RESULTS

The first 20 patients had a median age of 47 years, and received TBI before bone marrow transplantation for acute myeloid leukemia. Most patients (13/20) received a TBI dose of 4 Gy in 2 fractions, twice daily. The mean number of applied monitor units (MU) was 6476 MU using a multi-arcs and multi-isocenter VMAT-TBI technique. The tabletop has been successfully used in daily clinical practice and helped to keep the treatment times at an acceptable level. During the first treatment fraction, the mean overall treatment time (OTT) was 57 min. Since no additional image guidance was used in fraction 2 of the same day, the OTT was reduced to mean 38 min.

CONCLUSIONS

The easy and reproducible rotation of the patient on the treatment couch using the rotatable tabletop, is time-efficient and overcomes the need of repositioning the patient after turning from a HFS to a FFS position during VMAT TBI. Furthermore, it prevents couch-gantry collisions, incorrect isocenter shifts and beam mix-up due to predicted absolute table coordinates, which are recorded to the R + V system with the corresponding beams.

Comparative analysis between interstitial brachytherapy and stereotactic body irradiation for local ablation in liver malignancies

PURPOSE

Interstitial high-dose-rate brachytherapy (BT) is an alternative treatment option to stereotactic body radiotherapy (SBRT) for the ablative treatment of liver malignancies. The aim of the present comparative planning study was to reveal the possibilities and limitations of both techniques with regard to dosimetric properties.

METHODS AND MATERIALS

Eighty-five consecutive patients with liver malignancy diagnosis were treated with interstitial BT between 12/2008 and 09/2009. The prescription dose of BT varied between 15 and 20 Gy, depending on histology. For dosimetric comparison, virtual SBRT treatment plans were generated using the original BT planning CTs. Additional margins reflecting the respiratory tumor motion were added to the target volumes for SBRT planning.

RESULTS

The mean PTV_BT was 34.7 cm³ (0.5-410.0 cm³) vs. a mean PTV_SBRT of 73.2 cm³ (6.1-593.4 cm³). Regarding the minimum peripheral dose (D_99.9), BT achieved the targeted prescription dose of 15 Gy/20 Gy better without violating organ at risk constraints. The dose exposure of the liver was significantly influenced by treatment modality. The liver exposure to 5 Gy was statistically lower with 611 ± 43 cm³ for BT as compared with 694 ± 37 cm³ for SBRT plans (20-Gy group, p = 0.001), corresponding to 41.8% vs. 45.9% liver volume, respectively.

CONCLUSIONS

To the best of our knowledge, this is the first report on the comparison of clinically treated liver BT treatments with virtually planned SBRT treatments. The planning study showed a superior outcome of BT regarding dose coverage of the target volume and exposed liver volume. Nevertheless, further studies are needed to determine ideal applicability for each treatment approach.

Impact of surface-guided positioning on the use of portal imaging and initial set-up duration in breast cancer patients

OBJECTIVE

The impact of optical surface guidance on the use of portal imaging and the initial set-up duration in patients receiving postoperative radiotherapy of the breast or chest wall was investigated.

MATERIAL AND METHODS

A retrospective analysis was performed including breast cancer patients who received postoperative radiotherapy between January 2016 and December 2016. One group of patients received treatment before the optical surface scanner was installed (no-OSS) and the other group was positioned using the additional information derived by the optical surface scanner (OSS). The duration of the initial set-up was recorded for each patient and a comparison of both groups was performed. Accordingly, the differences between planned and actually acquired portal images during the course of radiotherapy were compared between both groups.

RESULTS

A total of 180 breast cancer patients were included (90 no-OSS, 90 OSS) in this analysis. Of these, 30 patients with left-sided breast cancer received radiotherapy in deep inspiration breath hold (DIBH). The mean set-up time was 10 min and 18 s and no significant difference between the two groups of patients was found (p = 0.931). The mean set-up time in patients treated without DIBH was 9 min and 45 s compared to 13 min with DIBH (p < 0.001), as portal imaging was performed in DIBH. No significant difference was found in the number of acquired to the planned number of portal images during the entire radiotherapy treatment for both groups (p = 0.287).

CONCLUSION

Optical surface imaging is a valuable addition for primary patient set-up. The findings confirm that the addition of surface-based imaging did not prolong the clinical workflow and had no significant impact on the number of portal verification images carried out during the course of radiotherapy.

Mixed copper(ii)–phenanthroline complexes induce cell death of ovarian cancer cells by evoking the unfolded protein response

There is an ongoing need for development of new therapeutics that override acquired resistance to cancer therapy. Targeting endoplasmic reticulum by Cu(ii)–phenanthroline complexes may represent such alternative strategy to current cytotoxic drugs.

ER stress signaling has an activating transcription factor 6α (ATF6)-dependent "off-switch"

In response to an accumulation of unfolded proteins in the endoplasmic reticulum (ER) lumen, three ER transmembrane signaling proteins, inositol-requiring enzyme 1 (IRE1), PRKR-like ER kinase (PERK), and activating transcription factor 6α (ATF6α), are activated. These proteins initiate a signaling and transcriptional network termed the unfolded protein response (UPR), which re-establishes cellular proteostasis. When this restoration fails, however, cells undergo apoptosis. To investigate cross-talk between these different UPR enzymes, here we developed a high-content live cell screening platform to image fluorescent UPR-reporter cell lines derived from human SH-SY5Y neuroblastoma cells in which different ER stress signaling proteins were silenced through lentivirus-delivered shRNA constructs. We observed that loss of ATF6 expression results in uncontrolled IRE1-reporter activity and increases X box-binding protein 1 (XBP1) splicing. Transient increases in both IRE1 mRNA and IRE1 protein levels were observed in response to ER stress, suggesting that IRE1 up-regulation is a general feature of ER stress signaling and was further increased in cells lacking ATF6 expression. Moreover, overexpression of the transcriptionally active N-terminal domain of ATF6 reversed the increases in IRE1 levels. Furthermore, inhibition of IRE1 kinase activity or of downstream JNK activity prevented an increase in IRE1 levels during ER stress, suggesting that IRE1 transcription is regulated through a positive feed-forward loop. Collectively, our results indicate that from the moment of activation, IRE1 signaling during ER stress has an ATF6-dependent "off-switch."

Defining, Measuring and Preventing the Diagnosis of Cancer as an Emergency: A Critical Review of Current Evidence

Background: Many patients with cancer are diagnosed through an emergency presentation, which is associated with inferior clinical and patient-reported outcomes compared with those of patients who are diagnosed electively or through screening. Reducing the proportion of patients with cancer who are diagnosed as emergencies is, therefore, desirable; however, the optimal means of achieving this aim are uncertain owing to the involvement of different tumor, patient and health-care factors, often in combination. Methods: We searched the literature to identify all population-based studies that examined emergency presentation as a diagnosis or independent variable. Results: Most relevant evidence relates to patients with colorectal or lung cancer in a few economically developed countries, and defines emergency presentations contextually (that is, whether patients presented to emergency health-care services and/or received emergency treatment shortly before their diagnosis) as opposed to clinically (whether patients presented with life-threatening manifestations of their cancer). Consistent inequalities in the risk of emergency presentations by patient characteristics and cancer type have been described, but limited evidence is available on whether, and how, such presentations can be prevented. Evidence on patients' symptoms and health-care use before presentation as an emergency is sparse. Conclusion: In this review, we describe the extent, causes and implications of a diagnosis of cancer following an emergency presentation, and provide recommendations for public health and health-care interventions, and research efforts aimed at addressing this underresearched aspect of cancer diagnosis.

Factors Affecting Diagnostic Timeliness and Safety in Symptomatic Patients Subsequently Diagnosed With Bladder and Kidney Cancer: A Systematic Review

Background: Timely diagnosis of cancer is important for good clinical outcomes and patient experience. Bladder and kidney cancer, being two relatively common cancers, can pose diagnostic challenges. Symptoms such as hematuria and urinary tract infections in some patients have a higher than 3% positive predictive value for cancer, a threshold above which English GPs are advised to consider the referral of patients for, under the 2015 NICE guidelines. However, the majority of patients with these symptoms will end up not having cancer. Therefore, the decision to perform further investigations or refer patients with these common urinary symptoms may differ despite the existence of guidelines. Studying in whom, and why, some patients may experience a longer than average time to diagnosis is important to understanding how avoidable diagnostic delay can be reduced, so that targeted interventions to improve early diagnosis can be developed to improve, ultimately, the outcome of these cancers. Aim: A systematic review was therefore performed to identify the factors that affect the diagnostic timeliness and safety of patients with urological symptoms that may be suggestive of kidney and bladder cancer. Methods: We searched Embase and Medline (Ovid) between 2000 and January 2018, for publications on symptoms/conditions including hematuria and urinary tract infection (UTI). We focused on clinical features that are listed in the English 2015 NICE guidelines for suspected cancer to examine the population that are most likely to have cancer, and in whom a timely diagnosis is the most crucial for outcomes. We also included symptoms that might be suggestive of a UTI (including dysuria, urinary frequency, urgency, incontinence and nocturia) to be overinclusive in our search. Results: Our initial search identified 7787 articles. Following title and abstract screening, 37 full texts were assessed for eligibility. A final 23 relevant studies were included. Our preliminary findings include evidence on patient, clinician and system factors contributing to diagnostic timeliness and safety issues (such as completeness of evaluation/investigations and referrals) in patients with possible urological cancer. These include patient sociodemographic factors (age, gender, ethnicity), clinician type (generalist, urologist vs gynecologist) and experience, and system factors such as delay in specialist appointment scheduling and patient no-shows. Conclusion: Our findings will provide a granular understanding of the factors contributing to avoidable diagnostic delay of patients with possible urological cancers globally. This is particularly important so that targeted interventions can be developed to help clinicians and health systems to better identify and manage at-risk patients with symptoms, so as to improve early diagnosis and outcomes of urological cancers.

Variation in 'Fast-Track' Referrals for Suspected Cancer by Patient Characteristic and Cancer Diagnosis: Evidence From 670,000 Patients With Cancers of 35 Different Sites

Background: In England, 'fast-track' (also known as 'two-week wait') general practitioner referrals for suspected cancer in symptomatic patients are used to shorten diagnostic intervals and are supported by clinical guidelines. However, the use of the fast-track pathway may vary for different patient groups. Methods:  We examined data from 669,220 patients with 35 cancers diagnosed 2006-2010 following either fast-track or nonfast track primary-to-secondary care referrals using a bespoke English dataset, the 'Routes to Diagnosis' data. We estimated the proportion of fast-track referrals by sociodemographic characteristics and cancer diagnosis and used logistic regression to estimate respective crude and adjusted odds ratios. We additionally explored whether sociodemographic associations varied by cancer. Results:  There were large variations in the odds of fast-track referral by cancer ( P < 0.001). Patients with testicular and breast cancer were most likely to have been diagnosed after a fast-track referral (adjusted odds ratios 2.73 and 2.35 respectively, using rectal cancer as reference); while patients with brain cancer and leukemias least likely (adjusted odds ratios 0.05 and 0.09 respectively for brain cancer and acute myeloid leukemia). There were sex, age and deprivation differences in the odds of fast-track referral ( P < 0.013), which varied in their size and direction for patients with different cancers ( P < 0.001). For example, fast-track referrals were least likely in younger women with endometrial cancer and in older men with testicular cancer. Conclusion: Fast-track referrals are less likely for cancers characterized by nonspecific presenting symptoms and patients belonging to low incidence demographic strata. Interventions beyond clinical guidelines for “alarm” symptoms are needed to improve diagnostic timeliness.

Zum Zusammenhang von Verhaltensauffälligkeiten in exekutiven Funktionen und Intelligenzleistungen in der WPPSI-IV

Zusammenfassung. Der BRIEF-P basiert auf alltagsnahen kindlichen Verhaltensweisen im Bereich der exekutiven Funktionen, die durch Bezugspersonen beurteilt werden. Allgemein gilt dieses Verfahren als ökonomisch einsetzbares und ökologisch valides Instrument. In der vorliegenden Studie wurde untersucht, ob und welcher Zusammenhang zwischen exekutiven Funktionen (EF) und Intelligenz im Kindergartenalter besteht. Für eine Stichprobe von N = 169 Kindern im Alter von 2;6 bis 6;11 Jahren wurden Daten aus einem Elternfragebogen zum familiären Hintergrund, zu den EF des Kindes (BRIEF-P) und aus der Wechsler Preschool and Primary Scale of Intelligence – Fourth Edition (WPPSI-IV) analysiert. Es wurden Häufigkeitsanalysen zu den Defiziten in den EF, Korrelationen und Regressionsanalysen berechnet. Sowohl die primäre Skala Arbeitsgedächtnis (Updating) als auch der Gesamtwert EF des BRIEF-P tragen zur Vorhersage der Intelligenz (Gesamt-IQ) bei. Die Skala Inhibition und der Gesamtwert EF des BRIEF-P korrelieren signifikant mit drei der fünf primären und allen vier sekundären Indizes der WPPSI-IV. Aus der Perspektive der WPPSI-IV-Indizes sticht der Index Fluides Schlussfolgern hervor, mit dem fast alle erfassten EF-Bereiche des BRIEF-P korrelieren. Die Indizes der WPPSI-IV werden hinsichtlich ihrer Nähe zur fluiden Intelligenz diskutiert. Die EF spielen bereits im Vorschulalter eine wichtige Rolle für die kognitiven Leistungen. Die Ergebnisse werden im Zusammenhang von Sprachauffälligkeiten und ADHS betrachtet. Förder- und Interventionsprogramme sollten bereits in einem frühen Alter etabliert werden, um die Voraussetzungen für schulisches Lernen zu verbessern.

Wie gut stimmen Eltern- und Kinderurteile bei der Einschätzung von Kinderängsten überein?

Zusammenfassung. Im Rahmen der vorliegenden Studie soll die Interrater-Reliabilität des Eltern- und Kinderurteils für alle Skalen des Bereichsspezifischen Angstfragebogens für Kinder und Jugendliche (BAK) und der Einfluss von möglichen Variablen (Alter und Geschlecht des Kindes) auf die Übereinstimmung von Eltern- und Kindurteil ermittelt werden. Es wurden 572 Kinder und Jugendliche (295 Mädchen; 277 Jungen) im Alter von 9 bis 16 Jahren aus der Allgemeinbevölkerung und ihre Eltern anhand des BAK zu den Ängsten befragt. Berechnet wird die Interrater-Reliabilität sowohl für die intervallskalierten Daten (T-Werte) als auch für die daraus resultierenden kategorialen Daten. Es zeigt sich ausschließlich ein Alterseffekt auf die Übereinstimmung in den Punktwerten für die Skala Naturgewalten des BAK. Für alle Skalen des BAK mit Ausnahme der Skalen Medizinischer Bereich und Trennung/Unbekanntes konnte ein Geschlechtseffekt belegt werden. Die Interrater-Reliabilitäten sind als gering bis mittelmäßig einzustufen (ICC = .33 bis .62; Krippendorffs αü = .25 bis .57; Gewichtetes Cohens ϰ = .29 bis .58). Die Beurteiler-Übereinstimmungen fallen über alle Skalen hinweg bei den Mädchen höher aus als bei den Jungen. Die Ergebnisse verdeutlichen, dass es sinnvoll ist, bei der Beurteilung der Angstsymptomatik eines Kindes sowohl das Selbsturteil als auch das Elternurteil einzuholen.

Zum Zusammenhang von motorischer und kognitiver Entwicklung im Vorschulalter

Zusammenfassung. Inwieweit die motorische und kognitive Entwicklung von Kindern miteinander verbunden ist, wird seit langem kontrovers diskutiert. Insbesondere für die frühkindliche Förderung ist es von Bedeutung, das Zusammenspiel beider Entwicklungsbereiche genau zu analysieren, um passgenaue Fördermöglichkeiten zu entwickeln. Ziel dieser Arbeit ist es, den Zusammenhang von motorischen und kognitiven Leistungen zu untersuchen. Es wurden die Testergebnisse von 87 Kindern im Alter von drei bis sechs Jahren im Motoriktest LoMo 3 – 6 mit denen in der WPPSI-IV korreliert. Die Ergebnisse sprechen dafür, dass motorische Leistungen insbesondere mit visuellen Leistungen und der Verarbeitungsgeschwindigkeit assoziiert sind. Ein Subgruppenvergleich zwischen motorisch unterdurchschnittlich, durchschnittlich und überdurchschnittlich entwickelten Kindern zeigt, dass sich diese besonders in den Indizes Visuell-Räumliche Verarbeitung und Verarbeitungsgeschwindigkeit unterscheiden. Programme zur Bewegungsförderung sollten Aspekte der feinmotorischen Koordination, Objektkontrolle sowie der bilateralen Körperkoordination beinhalten, da diese Bereiche motorischer Kompetenz eng mit visuell-räumlichen Funktionen sowie der kognitiven Verarbeitungsgeschwindigkeit in Verbindung gebracht werden.