| 61. |
- Edvardsson, Maria, 1972-
(author)
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Circulating levels and assessment of clinical laboratory analytes, in >80-year-old, apparently healthy, moderately healthy, and frail individuals
- 2019
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Doctoral thesis (other academic/artistic)abstract
- Blood samples are often used to investigate the possible presence of disease and to make treatment decisions. In the interpretation of the results, comparison either with previous values from the same individual or with a set of appropriate group-based reference intervals are used. Current reference intervals for common laboratory analytes are often based on measurements from apparently healthy persons aged 18–65 years. Age is accompanied by a general decline in organ functions and it is difficult to determine whether a change in levels of laboratory analytes in an elderly individual can be attributed to age alone, independent of environmental or disease processes. Frailty can be seen as a consequence of age-related multifactorial deterioration – physical, cognitive and sensory – resulting in vulnerability and lack of adaptability to internal stressors such as infection or new medication and/or external stressors such as fall at home. Consensus about the definition of “frail” and “frailty” is missing, both nationally and internationally, the question arises whether different definitions of “frailty” affect the interpretation of analytes when comparing different groups of elderly.The overarching aim of the thesis was to interpret and assess circulating levels of some clinical laboratory analytes in relation to conventional reference values in ≥80-year-old, “apparently healthy”, “moderately healthy”, and “frail” individuals. Data originated from other studies, in which blood samples were collected from individuals ≥80-year-old. Comparisons in Paper I of levels of some laboratory analytes, from 138 nursing home residents (NHRs), was made with blood from reference populations, both blood donor and the NORIP study. The results indicated differences for some immunological (complement factor 3 and 4, immunoglobulin G and M) and chemical analytes (alanine aminotransferase (ALT), phosphate, albumin, sodium, creatinine and urea), but no differences in levels occurred for aspartate aminotransferase (AST), gamma-glutamyltransferase (γ-GT) or lactate dehydrogenase (LDH). It was unclear whether the differences were due to differences in age between the elderly and the reference populations or whether the elderly individuals had chronic diseases and were on medication. In Paper II, 569 individuals elderly individuals ≥80 years old were classified as “healthy”, “moderately healthy”, and “frail”, based on diseases, medications and physical and cognitive abilities. Statistical differences between the groups were found for the investigated analytes; albumin, ALT, AST, creatinine and γ-GT. In Paper IV, individuals from Paper II (n=569) were divided into two groups and thereafter divided into “apparently healthy”, “moderately healthy”, and “frail”. One group was subdivided into “apparently healthy”, “moderately healthy” and “frail” based on physical and cognitive abilities and the other group was divided based on the frailty index (FI). There was no statistical difference found between “apparently healthy” and “moderately healthy" groups, regardless of classification model used. Among “frail” individuals, differences in levels occurred for three out of the five investigated analytes: ALT, creatinine and g-GT, with lower levels occurring when the FI classification model was used. No differences in levels occurred for albumin or AST in “frail” individuals, regardless of classification model used. The aim of Paper III was to study whether 1-year changes in complete blood count (CBC) (including haemoglobin (Hb), red blood cell (RBC), erythrocyte volume fraction (EVF), mean corpuscular volume (MCV), mean corpuscular Hb concentration (MCHC), white blood cell (WBC) and platelet count (PLT)), C-reactive protein (CRP) and interleukin (IL)-1β, IL-1RA, IL-6, IL-8 and IL-10 are associated with survival in elderly NHRs aged >80 years. Elevated levels of CRP and IL-8 during 1-year follow-up were associated with reduced length of survival in elderly NHRs. Based on the present thesis it is clear that there is need for reference intervals that consider both age and health status in elderly individuals. A reasonable conclusion when interpreting levels of analytes in elderly individuals with disease or frailty is that individual evaluation based on the individual’s previous levels, is recommended.
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| 62. |
- Ellegård, Rada, 1985-
(author)
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Effects of Complement Opsonization of HIV on Dendritic Cells : and Implications for the Immune Response
- 2018
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Doctoral thesis (other academic/artistic)abstract
- Dendritic cells are key players during HIV pathogenesis, and shape both the immediate immune response at the site of infection as well as directing the adaptive immune response against the virus. HIV has developed a plethora of immune evasion mechanisms that hijack dendritic cell functions, suppressing their ability to mount an accurate immune response and exploiting them for efficient viral transfer to target T cells.To achieve successful replication within dendritic cells without triggering danger signaling, HIV accomplishes a delicate balance where only a low level of transcription can be sustained without triggering antiviral responses that would harm the virus. Here, we describe how the presence of HSV2 coinfection, which is very common in geographic areas with a high HIV prevalence and almost triples the risk of HIV acquisition, alters dendritic cell state to support much higher levels of HIV infection. We found this effect to be mediated by the STING pathway, which is involved in the sensing of DNA in the cell cytosol. STING activation led to an upregulation of factors such as IRF3 and NFkB that can be used for HIV transcription and a degradation of factors that restrict HIV replication.In addition, we describe how HIV exploits the human complement system, a group of proteins that usually help the human body to identify dangerous pathogens while avoiding reaction towards self. HIV can coat itself, i.e. become opsonized, in complement fragments that are typically only present on the body’s own cells, allowing it to activate signaling pathways that are associated with tolerance. Dendritic cells that come into contact with complement opsonized HIV do not mount danger responses, despite the fact that HIV-derived single stranded RNA triggers the pathogen recognition receptor TLR8. The suppression of danger responses is mediated by activation of complement receptor 3, and leads to an increased infection of the dendritic cell and affects its interactions with other immune cells. There is a lack of recruitment of NK cells to the site of infection, and an inhibition of NK cell killing, which plays an important role in the destruction of HIV-infected cells in vivo. T cells primed by dendritic cells exposed to complement opsonized HIV have a lower ability to develop towards effector phenotype, and have an increased expression of the markers PD1, TIM3 and LAG3 which are associated with T cell dysfunction and exhaustion. In addition, T cells primed by these dendritic cells in the presence of NK cells upregulate markers CD38, CXCR3 and CCR4, which have been linked to an increased susceptibility to HIV infection.In summary, we add to the current knowledge on HIV immune evasion mechanisms that allow the virus to establish infection, as well as describing mechanisms that govern whether dendritic cells mount danger signaling and an immune response or not.
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| 63. |
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| 64. |
- Engerström, Lars
(author)
-
The significance of risk adjustment for the assessment of results in intensive care. : An analysis of risk adjustment models used in Swedish intensive care.
- 2018
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Doctoral thesis (other academic/artistic)abstract
- To study the development of mortality in intensive care over time or compare different departments, you need some kind of risk adjustment to make analysis meaningful since patient survival varies with severity of the disease. With the aid of a risk adjustment model, expected mortality can be calculated. The actual mortality rate observed can then be compared to the expected mortality rate, giving a risk-adjusted mortality.In-hospital mortality is commonly used when calculating riskadjusted mortality following intensive care, but in-hospital mortality is affected by the duration of care and transfer between units. Time-fixed measurements such as 30-day mortality are less affected by this and are a more objective measure, but the intensive care models that are available are not adapted for this measure. Furthermore, how length of follow-up affects risk adjusted mortality has not been studied. The degree and pattern of loss of physiological data that exists and how this affects performance of the model has not been properly studied. General intensive care models perform poorly for cardiothoracic intensive care where admission is often planned, where cardiovascular physiology is more affected by extra corporeal circulation and where the reasons for admission are usually not the same.The model used in Sweden for adult general intensive care patients is the Simplified Acute Physiology Score 3 (SAPS3). SAPS3 recalibrations were made for in-hospital mortality and 30-, 90- and 180-day mortality. Missing data were simulated, and the resulting performance compared to performance in datasets with originally missing data.We conclude that SAPS3 works equally well using 30-day mortality as in-hospital mortality.The performance with both 90- and 180-day mortality as outcome was also good. It was found that the model was stable when validated in other patients than it was recalibrated with.We conclude that the amount of data missing in the SIR has a limited effect on model performance, probably because of active data selection based on the patient's status and reason for admission.A model for cardiothoracic intensive care based on variables available on arrival at Swedish cardiothoracic intensive care units was developed and found to perform well.
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| 65. |
- Engstrand, Christina
(author)
-
Hand function in patients with Dupuytren’s disease : Assessment, results & patients’ perspectives
- 2016
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Doctoral thesis (other academic/artistic)abstract
- Background: Dupuytren’s Disease (DD) is a soft tissue disorder that leads to finger joint contractures affecting hand function. DD can be treated with surgery or injection and hand therapy to improve finger joint extension and thereby improve hand function. However, this does not cure the disease and recurrence is common. Previous research on DD has shown improvement in finger joint extension and in self-reported disability of the upper extremity after surgery and hand therapy for DD. However, this provides only a limited perspective on hand function, and multiple dimensions of changes in hand function (i.e. physical, psychosocial aspects and including the patients’ views of results) have not been reported as a whole.Aim: The overall aim of the thesis was to explore hand function before and after surgery and hand therapy in patients with DD, including assessment, results and patients’ perspectives.Methods: The thesis comprises three studies: Study A was a methodological study of interrater reliability in goniometry of the finger joints. Study B was a prospective cohort study with a repeated measures design. Study C was a qualitative interview study, using the model of Patient Evaluation Process and content analysis.Results: Interrater reliability was high or very high for goniometer measurement of finger joint range of motion (ROM) in patients with DD when experienced raters follow our standardized guidelines developed for the study. Changes in hand function consisted of improvement of finger joint extension while active finger flexion was significantly impaired during the first year after surgery and hand therapy. No patient reached a normal ROM, but the majority reached a functional ROM. Sensibility remained unaffected. Patients with surgery on multiple fingers had worse scar pliability than patients with surgery on a single finger. Most patients had their expectations met and were pleased or delighted with their hand function at 12 months after surgery and hand therapy. Safety issues of hand function were of greater concern than social issues. Patients reported less disability and improved health-related quality of life after surgery and hand therapy. The three variables “need to take special precautions”, “avoid using the hand in social context”, and health-related quality of life had significant importance for patients’ rating of functional recovery. Together, these variables explained 62% of the variance in functional recovery. Patients’ perspectives of undergoing a surgical intervention process were described through five categories. Previous experiences of care influenced participants’ expectations of results and the care they were about to receive. Previous experiences and expectations were used as references for appraisal of results, which concerned perceived changes in hand function, the care process, competency, and organization. Appraisal of results could also vary in relation to patient character. Appraisal of results of the intervention process influenced participants’ expectations of future hand function, health and care.Conclusions: Surgery and hand therapy for DD improve hand function and patients regain a functional ROM needed for performance of common daily activities. Despite the negative effect on finger flexion present during the first year after surgery, patients’ regards their hand function as recovered six to eight months after surgery and hand therapy. Measuring digital ROM in the finger joints with a goniometer is a reliable assessment method. However, from the patient’s perspective, it is not enough to evaluate results only in terms of digital extension or ROM. From their view, results of treatment concern consequences on daily use of the hand, what happens during the care process in terms of interaction between patient and health care provider, as well as their view of the competence and logistics of the organization providing the care.
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| 66. |
- Eriksson, Heléne, 1964-
(author)
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End of Life Stroke Care : perspectives of health-care professionals and family members
- 2019
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Doctoral thesis (other academic/artistic)abstract
- IntroductionEven though medical improvements have reduced the mortality rates for patients afflicted by stroke, mortality during the first few days at hospital is significant. Today, there is an increasing recognition that the principles of palliative and supportive care are important components of meeting the needs of patients severely afflicted by stroke even in acute settings. However, there is limited knowledge about which factors have an impact on the end-of-life care (EoLC) for these patients or about how these last days of life are experienced from the family members’ perspective.AimThe overall aim of this thesis was to describe the EoLC of patients severely afflicted by stroke and to identify factors impacting upon EoLC for the patients and their family members in Sweden out of various contexts and methods.Design and MethodsThis thesis is based upon four papers employing qualitative, quantitative and mixed-method designs.Paper I is a qualitative study based on focus-group interviews with 41 health-care professionals (HCPs) in different professions related to stroke care at three stroke units. The aim was to study ethical dilemmas, different approaches and what consequences they had among health HCPs; the data was analysed using content analysis. The result inspired the design and conduct of the following studies.Paper II is a quantitative comparative study based on a retrospectively registered questionnaire from the Swedish Registry of Palliative Care (SRPC). Patients dying of stroke (n =1626) were compared with patients dying from cancer (n=1626), according to symptoms, symptom management and communication with the patient and family members during the last week of life. Data was statistically calculated using OR.Paper III is a mixed-method study employing a sequential explanatory design. In the first, quantitative, part, 995 stroke patients who died in hospital were compared with 631 stroke patients who died at nursing homes, according to symptoms, symptom management and communication with the patient and family members during the last week of life. The quantitative data was statistically calculated using OR and the qualitative data was analysed using content analysis. Nine significant differences drawn from the quantitative results regarding care were chosen to be discussed by twelve nurses working in stroke units.Paper IV is a qualitative interview study with the aim to study the family member descriptions of the trajectory from admission to the hospital until their loved one died. A semi-structured interview guide was used, and data was analysed using thematic analyses.ResultsFactors that had an impact on EoLC were consequences related to the difficulties around decision-making about withholding or withdrawing life-sustaining treatment. Non-decisions or not holding to the decision generated communication barriers causing obstacles in inter-professional collaboration and ethical dilemmas within the team (Study I). The absence of a mutual approach to care resulted in underprovided palliation, undignified medical treatment and ambiguity in care, generating feelings of distrust among the family members. The results described in Study I of underprovided palliation were further investigated in Study II. The differences in knowledge about whether symptoms were present or not in patients afflicted by stroke compared to patients with cancer were significant. For example, the HCPs in the stroke group did not know if pain was present nine times more frequently than in the cancer group. These differences in knowledge about whether symptoms were present of not were also identified in Study III. Here, HCPs at the nursing home more often had knowledge about whether a symptom was present in patients dying of stroke or not, compared to HCPs at hospitals. This study also identifies differences in the presence of the symptoms being compared and whether the patient’s suffering was fully relieved. The nurses working at stroke units explained that these differences were a consequence of the stroke unit’s aim (saving lives), no previous relationship to the patient and ambiguity in the evaluation of symptoms. The patient’s altered levels of consciousness increased the difficulties in evaluation. In addition, the hospital setting’s aim increased the risk of prolonged treatment, for example nutrition supplied during the last day of life, and underprovided palliation of for example, pain compared to nursing homes. In Study IV, family members were seeking trust through mutual collaboration and creating relationships with the HCPs. If the family did not feel that their search for trust was taken care of, it generated feelings of distrust allied with anxiety and memories of failing to do the best for their loved one at in the end of life. During the trajectory at the hospital, family members were “seeking trust in chaos”, “seeking clarity when deciding about living or dying” and finally they were “seeking trust in care as a final act of love”.Conclusions:The results of this thesis suggest that the absence of a coherent approach contributes to developing ethical dilemmas within the HCPs. The ambiguity in care had an impact on the quality on EoLC, with an increased risk of unnecessary suffering and questionable symptom management. The prevailing culture at acute-care hospitals affected the HCPs’ attitudes towards EoLC, with attention being predominantly on life-sustaining treatments. There is an increasing recognition of the need for improvement in the PC approach at acute-care hospitals in order to create equal quality of care during end of life, irrespective of the place of death for patients dying of stroke. Furthermore, family members need to feel trust, which is achieved through relationships and collaboration with HCPs. In the striving to accomplish a wholly compensatory care of quality during the trajectory, this thesis can be a source of knowledge and guidance for nurses and for teams at the stroke unit.
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| 67. |
- Ertzgaard, Per, 1958-
(author)
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Studies on Spasticity from an Interventional Perspective
- 2018
-
Doctoral thesis (other academic/artistic)abstract
- This thesis focuses on interventional aspects of spasticity, but has a very holistic approach, grounded in the specialty of Rehabilitation medicine. This means capturing the effects of spasticity, on such a complex biological system as the human being, living in a psychosocial context affecting the situation. When evaluating spasticity there are a number of levels of evidence. The first of course, understanding what we mean with spasticity, where there unfortunately is no consensus. The second level is to study if our treatments affect spasticity in a positive direction. The third is to grasp if a decrease in spasticity improve or normalize patient’s movement patterns. The fourth level investigates if improvement in movement patterns improve patient’s ability to perform activities; and the fifth level, comprising whether this intervention improves life satisfaction. Finally, on a societal level, we wish to investigate whether the improvement in life satisfaction or health related quality of life would motivate society to fund the intervention.Paper I on Goal Attainment Scaling pointed out necessary aspects to consider when using this instrument. This relates, among other things, to the need of learning (“the art of”) goal setting and deciding the purpose of the measurements. Research and clinical use puts different demands on the instrument, for the latter time-efficiency and simplicity to use being most important. For research, it is important to be able to register deterioration, and this can be achieved using the 6-step version.In paper II, concerning validation of the portable motion system, we showed this system to be valid for short-term measurements and that the use of Exposure Variation Analysis (EVA) seems to be a valuable tool for graphically elucidating different movements. The equipment needs further development in handling long-term measurements (which is effectuated), and norms for normal movements in different activities has to be produced. The discriminative value of EVA needs confirmation in coming studies. For the future, there is the intriguing possibility of long-term measurements in patients’ every-day life, thereby getting objective measures on how our patients use their abilities, thus capturing the difference between what you can do and what you actually do.The results from paper III demonstrated a large inequality in Sweden regarding the accessibility of BoNT-A treatment for spasticity. We could also show that treatment with BoNT-A is sound from a health-economic perspective, accounting for the uncertainty of data via the sensitivity analysis. For the future, we need to explore if this inequality also exists for other modes of spasticity treatments, e.g. multidisciplinary spasticity treatment and ITB pumps, and in other countries.In paper IV evaluating multifocal TES, the results could not confirm efficacy with the treatment according to the protocol of the manufacturer. The results have to be interpreted with care, as low compliance and frequent adverse events made deduction not captured in the RCT study. Further studies are needed in a number of areas, e.g. what is the optimal stimulation frequency, what patients can gain from the treatment and how should adjunct treatment be organized.In this thesis, I have had the privilege to explore different methods of evaluating spasticity interventions from a multimodal perspective as a starting point in an effort to understand more of this intriguing phenomenon. Some of the research questions above are already in the “pipeline” for coming studies; others are to be planned by our research group and others.
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| 68. |
- Fagerlind Ståhl, Anna-Carin, 1982-
(author)
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Live long and prosper : Health-promoting conditions at work
- 2015
-
Doctoral thesis (other academic/artistic)abstract
- The aim of this thesis is to contribute with knowledge concerning health-promoting conditions at work, and to investigate how individual, workplace and organisational conditions are interrelated. In the thesis, work-related flow, i.e. an experience of motivation, absorption and work enjoyment, is used as a holistic notion of occupational health. In Paper I, work-related flow is investigated in relation to decision latitude, social capital and an innovative learning climate at work. Paper II investigates whether the use of tools inspired by lean production, such as standardisation and value stream mapping, is positively associated with conditions for innovative learning in organisations. The aim of Paper III is to identify conditions for health and performance in organisation and at work; further, to investigate the association between work-related flow and performance. Paper IV reports on a longitudinal investigation of workrelated flow in relation to lean tool use and conditions at the workplace. The empirical material is based on data from 10 organisations, including 4442 employees. Papers I-III are cross-sectional, whereas Paper IV is longitudinal. Papers II-IV utilise multilevel analyses.The results show that decision latitude, social capital and an innovative learning climate are associated with an increase in work-related flow (Papers I, III & IV), and with performance (Paper III). Individuals’ decision latitude enables an increased benefit from the social capital and innovative learning climate at work (Paper I). The effect of tools inspired by lean production on work-related flow (Papers III & IV), and on conditions for innovative learning (Paper II) differs, depending on which tools are used, and on workplace conditions. These tools enable innovative learning mainly where decision latitude is low (Paper II), and it is primarily the lean tool value stream mapping which has the potential to create an arena for innovative learning (Paper II) and work-related flow (Paper IV).It is concluded that the individual is embedded in a social work context that has the potential to strengthen the ability to act with motivation, absorption and enjoyment. In order to utilise collective healthpromoting conditions at work, individuals need to have authority to make their own decisions and use their skills. The effect of tools inspired by lean production depends on the specific tools that are used, and on individuals’ decision latitude at work. Their potential to enable innovative learning is most evident for employees who have few opportunities for autonomous decision-making and skill use in their work. For those with a high degree of decision latitude, the use of lean tools has a smaller effect. Work-related flow may in itself serve as a resource that improves performance and increases engagement in health-promoting work conditions. In order to promote health as well as performance, work needsto be organised so that employees have opportunities to decide over their own work, and utilise their skills, individually and collectively within the workgroup.
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| 69. |
- Falkeborn, Tina, 1981-
(author)
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Nasal vaccination using novel mucosal adjuvants : with main focus on influenza A virus
- 2015
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Doctoral thesis (other academic/artistic)abstract
- Influenza viruses have sporadically caused pandemics during the last century, with the most severe occurring in 1918 when the “Spanish flu”, an A/H1N1 influenza virus, passed around the globe killing about 20-100 million people. Today 250 000-500 000 deaths occur annually due to influenza virus or secondary infection after influenza, e.g. pneumonia. Influenza viruses cause severe infections in susceptible age groups like children and elderly and in individuals with impaired immune response due to other medical conditions. The best way to prevent an influenza epidemic is by vaccination. Since the 1950´s we have vaccines against seasonal flu, but vaccine efficacy is not 100 % and there is a need to develop better and more effective vaccines, especially for the risk groups. Since the virus enters the host through the nasal cavity, nasal vaccination is a good approach. By stimulating a mucosal immune response already in the nasal cavity, the goal with nasal vaccination is to stop the virus before it enters the host. Nasal vaccination also reduces the risk of transmission of blood-borne diseases, and is less painful and easier to administer, compared to injectable vaccines.In order to be able to use less immunogenic antigens, like split and subunit antigens, as nasal vaccine components, an adjuvant is needed to enhance the immune response. At the moment there is no licensed mucosal adjuvant for human use. Several studies are ongoing, but it is a complicated and long way to reach the market. In this thesis nasal vaccination with influenza antigen together with the mucosal adjuvant Endocine™ and other mucosal adjuvants has been evaluated. The Endocine™ adjuvant has been shown to be safe and well tolerated in clinical trials. Depending on the pathogen of interest, different approaches are necessary. For HIV, DNA-vaccination has been evaluated together with a plasmid encoding Salmonella typhimurium flagellin C and the mucosal adjuvant N3. The results found in paper I-IV show that by adding adjuvant to the antigen enhances the protective immune response towards the antigen. Enhanced systemic, mucosal and cell-mediated immunity were observed. Hopefully in the future these adjuvants evaluated in this thesis, will be used in vaccines for humans.
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| 70. |
- Flejmer, Anna M.
(author)
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Radiation burden from modern radiation therapy techniques including proton therapy for breast cancer treatment - clinical implications
- 2016
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Doctoral thesis (other academic/artistic)abstract
- The purpose of this thesis was to study the clinical implications of modern radiotherapy techniques for breast cancer treatment. This was investigated in several individual studies.Study I investigated the implications of using the analytical anisotropic algorithm (AAA) from the perspective of clinical recommendations for breast cancer radiotherapy. Pencil beam convolution plans of 40 breast cancer patients were recalculated with AAA. The latter plans had a significantly worse coverage of the planning target volume (PTV) with the 93% isodose, higher maximum dose in hotspots, higher volumes of the ipsilateral lung receiving doses below 25 Gy and smaller volumes with doses above 25 Gy. AAA also predicted lower doses to the heart.Study II investigated the implications of using the irregular surface compensator (ISC), an electronic compensation algorithm, in comparison to three‐dimensional conformal radiotherapy (3D‐CRT) for breast cancer treatment. Ten breast cancer patients were planned with both techniques. The ISC technique led to better coverage of the clinical target volume of the tumour bed (CTV‐T) and PTV in almost all patients with significant improvement in homogeneity.Study III investigated the feasibility of using scanning pencil beam proton therapy for regional and loco‐regional breast cancer with comparison of ISC photon planning. Ten patients were included in the study, all with dose heterogeneity in the target and/or hotspots in the normal tissues outside the PTV. The proton plans showed comparable or better CTV‐T and PTV coverage, with large reductions in the mean doses to the heart and the ipsilateral lung.Study IV investigated the added value of enhanced inspiration gating (EIG) for proton therapy. Twenty patients were planned on CT datasets acquired during EIG and freebreathing (FB) using photon 3D‐CRT and scanning proton therapy. Proton spot scanning has a high potential to reduce the irradiation of organs‐at‐risk for most patients, beyond what could be achieved with EIG and photon therapy, especially in terms of mean doses to the heart and the left anterior descending artery.Study V investigated the impact of physiological breathing motion during proton radiotherapy for breast cancer. Twelve thoracic patients were planned on CT datasets during breath‐hold at inhalation phase and breath‐hold at exhalation phase. Between inhalation and exhalation phase there were very small differences in dose delivered to the target and cardiovascular structures, with very small clinical implication.The results of these studies showed the potential of various radiotherapy techniques to improve the quality of life for breast cancer patients by limiting the dose burden for normal tissues.
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