The identifying assumption for those instruments to be valid are the following. Firstly, the instruments must be a relevant factor in determining the decision to attend a high-quality school. Here the argument is that transportation costs will have an effect. Parents (and teachers who make the recommendations) tend to favor local schooling and children in towns with a local high-quality school are more likely to attend those institutions. The relevance of our instruments can be tested in the first stage of the 2SLS estimation. The second assumption is that the instruments are exogenous to unobservable character- istics in the outcome equation. In our case, we would be particularly concerned if parents strategically locate with regard to the supply of such high-quality schools. For the US, we know that location decisions are strongly affected by the local qualityof the school (see Black (1999), Bayer, Ferreira, and McMillan (2007)). However, in the context of Germany, we are, ex ante, less worried that choice of location is endogenous. Other than in the US, school finances and school quality are not depended on housing values. Thus, the wealthi- ness of the area that a family lives in does not determine the availability of a high-quality school.
as a performance indicator in routine outcome monitoring . This approach encompasses two steps: first, identifying the subsample of patients that reached a reliable change and then determining which among them moved outside the range of the dysfunctional population. This method presup- poses a valid and consistent distinction between functionality and dysfunctionality already at the onset of the treatment. Therefore, the percentage of cases that can be adequately categorized depends on the sensitivity of the instrument. For self-report questionnaires measuring important mental health problems, the expected sensitivity is of at least 80% [50, 51]. Our results reveal a heterogeneous picture in this regard. For inpatients with an F3, F4, or F6 diagnosis the sensitivity to psychopathology of both instruments exceeds 80%. However, the questionnaires exhibited low values with inpatients with a principal diagnosis of substance abuse or schizophrenia. Especially within the latter group, which represents an important diagnosis group in an inpatient setting, about 25% of the respondents were misclassified as nonclinical subjects according to the GSI score. The patients with schizophrenia analyzed in this study had a mean GAF score of 32 points at admission and were hospitalized on average 36 days in a primary care hospital. Thus, the substan- tial misclassification cannot be explained by a lack of mental illness but instead by limitations, either of the measures used in assessing psychopathology or of the methodology used in assessing caseness. Analyses based on outpatients have reported sensitivity of above 90% for the OQ total scale  as well as the GSI scale . Sensitivity values of at least 80% based on inpatient data were reported by Moessner et al.  for both global scales using data from inpatients with an F3, F4, F5, or F6 diagnosis and by Timman et al.  for the OQ Total Score using an inpatient sample with personality disorders. Nevertheless, our analyses do not support a generalization of this high accuracy in detecting caseness among inpatients with an F1 or F2 diagnosis. A lack of research on the generalizability of the OQ-45 was confirmed by Lambert and Hawkins , who admitted that much of the research “demonstrating the use of the OQ-45 has been conducted with young, educated patients” (p. 496). Concerning the limitations of our methodology in assess- ing clinical significance, we see the following possibilities for
A successful psychotherapy continues to show positive outcomes after most of the therapy sessions and also between sessions. Over time, patients begin to form mental representations of their psychotherapy that can be activated between therapy sessions. Following this assumption, Orlinsky et al [ 7 ] were the first to propose the “representations of a patient’s psychotherapy between two sessions” as a focus for psychotherapy research, building the foundation of what later became the concept of the intersession process. The intersession process encompasses thoughts, feelings, and behaviors concerning a patient’s current psychotherapy, including the therapist. They occur between two therapy sessions; can be of varying emotional quality, intensity, and frequency; and include memories of words and feelings toward the dyadic partner, applying techniques learned in the psychotherapy or doing therapeutic homework. The intersession process has been operationalized and can be measured for a specific period of time between two sessions using the Intersession Experience Questionnaire (IEQ) [ 8 ]. The positive intersession experience of patients has been positively linked to therapy outcome variables in various studies [ 9 ], and it has been found to be predictive of therapy outcome using weekly retrospective measures [ 10 - 12 ].
induces DNA damage in spermatozoa and in generated preimplantation embryos. Also, nicotine at a concenteration of 10mM for 24 hours resulted in the formation of definite fragmentation which could be seen via electrophoresis as a characteristic ladder pattern and 5mM nicotine treatment for 24 hours showed week intensity of DNA laddering (Khae-hawn et al., 2005). Moreover, Cigarette smoking is significantly correlated with increased levels of seminal oxidative stress, as evidenced by a significant reduction in Reactive Oxygen Species-Total Antioxidant Capacity score (ROS-TAC). To strengthen the above hypothesis, it should be emphasized that cigarette smoke has been associated with increased frequency of aneuploidy in sperm (Twigg et al., 1998a;b), lower seminal plasma antioxidant levels and increased oxidative damage to DNA (Fraga et al., 1996; Shen et al., 1997). It is concluded that certain life style factors, such as tobacco smoking, may reduce the antioxidant capacity of seminal plasma and impair the secretion of accessory sex glands (Depuydt et al., 1996; Klinefelterand Hess, 1998). The seminal plasma protects spermatozoa from excessive ROS by means of small molecular weight free radical scavengers, such as Ascorbate and Tocopheral, Uric acid and ROS-metabolizing enzymes, such as superoxide dismutase, catalase, and glutathione peroxidase (Alvarez and Storey, 1989). ROS-TAC scores decrease as a result of an imbalance between levels of ROS and antioxidants in semen (Sharma et al., 1999).
32 * Adjusted mean estimates (least square means) with respective 95% confidence intervals are derived from logistic regression analysis (for outcomes use of CGMS, use of rapid-acting insulin analogs, use of long-acting insulin analogs, participation in diabetes education program, prevalence of obesity), linear regression analysis (for outcomes SMBG, BMI SDS), or Poisson regression analysis considering overdispersion (for outcomes rate of severe hypoglycemia with coma, rate of severe DKA (pH <7.1), number of hospital days). All regression models were performed with GIMD 2010 quintiles as the categorical independent variable and adjusting for sex, age group, migration background, and diabetes duration.
Review of relevant literature
Healthcare service quality
Donabedian  defined healthcare service quality as “the application of medical science and technology in a manner that maximizes its benefit to health without correspondingly increasing the risk. ” While this study reflected a definition that empha- sizes the evaluation of benefit to risk, Leebov et al.  highlighted the assessment of progressive and preventative measures: “doing the right thing and making continuous improvements, obtaining the best possible clinical outcome, satisfying all customers, retaining talented staff and maintain sound financial performance. ” These definitions emphasize that healthcare service quality is delivered to satisfy customer expectations and patient needs, as well as to improve care by skilled professional providers. How- ever, healthcare service quality is difficult to define and measure depending on the type oftreatment, perception of patients, and interactions between patients and providers including characteristics of care service and ethical culture of the hospital.
Results: The majority of patients (61.1%) were referred for rehabilitation after cardiac surgery, 38.9% after conservative or interventional treatment for an acute coronary syndrome. Functionally relevant comorbidities were seen in 49.2% (diabetes mellitus, stroke, peripheral artery disease, chronic obstructive lung disease). In three key areas 13 parameters were identified as being sensitive to change and subject to modification by rehabilitation: cardiovascular risk factors (blood pressure, low-density lipoprotein cholesterol, triglycerides), exercise capacity (resting heart rate, maximal exer- cise capacity, maximal walking distance, heart failure, angina pectoris) and subjective health (IRES-24 (indicators of rehabilitation status): pain, somatic health, psychological well-being and depression as well as anxiety on the Hospital Anxiety and Depression Scale).
30 ]. The prolonged surgical time, the proximity of the tumor to the rectum and genitourinary tract, together with a large dead space filled with a large amount of foreign material are all argu- ments for the high risk of infection, particularly after pelvic reconstruction [ 30 ]. Earlier, we were able to show that almost 50% of patients died within 15 months after surgery or were alive with disease and as a consequence, resection should be followed by pelvic reconstruction meth- ods that warrant the lowest complication rate and the earliest possible rehabilitation [ 15 ]. Con- sequently, a cautious and restrictive decision-making process is necessary when indicating pelvic reconstruction, which may be tailored to a large number of serious complications and in succession, would impede the patient’s qualityof life, considering the probability of a poor life expectancy.
individuals who have difficulty accessing psychological treatment or do not want to utilize face-to-face treatment (Barak & Grohol, 2011; Johansson & Andersson, 2012; Moritz,
Schröder, Meyer & Hauschildt, 2013; Ryan, Shochet, & Stallman, 2010; Titov, 2011). Several studies suggest that some forms of Web-based interventions may be as effective as face-to- face therapy (Andrews, Cuijpers, Craske, McEvoy & Titov, 2010), although various methodological limitations of this body of research have also been noted (Arnberg et al., 2014). One limitation of Web interventions is that they are not accepted by all patients and some drop out early or do not adhere to the treatment protocol (Gilbody et al., 2015). Especially in unguided Web interventions, the risk of dropout is high (Melville, Casey, & Kavanagh, 2010; Richards & Richardson, 2012) and results of studies on prereatment predictors ofoutcome in Web interventions remain inconsistent (Andersson & Hedman, 2013). Additionally, not all Web interventions are equal with regard to their quality or evidence base (Renton et al., 2014). So far, investigations of Web interventions have mainly focused on treatment efficacy and short-term symptom change in comparison with treatment- as-usual control groups, in which participants were only able to access the Web intervention after a delay of several weeks or months (Leykin, Muñoz, Contreras, & Latham, 2014; Richards et al., 2014).
All patients who match the inclusion criteria and who are not dismissed by exclusion criteria are included in the study cohort. The parameters as listed in tables 22.214.171.124. and 126.96.36.199 are obtained from the patient data in AKIM and RDA by the thesis student and the diploma thesis adviser. The collected data is documented in the inflammatory bowel disease database (IBDIS). The database IBDIS (Unidata, Geodesign, Vienna, Austria) was designed prior to this study by A.o. Prof. Dr. Walter Reinisch at the Department of Gastroenterology and Hepatology at the III. Department of Internal Medicine at the AKH in cooperation with the ÖGGH. Patients with IBD were recruited from the outpatient clinic of the above mentioned department in the period from 2010 to 2016. Patients who were included were extensively informed about the data base and have provided their written consent.
Some of our variables – stadium attendance of both the home team and away team in the previous season, team quality and cumulative surprise measured over the previous 34 matches – use values from the previous season. Since each season contains at least one, but potentially two or three promoted teams, we must decide how to deal with this. One solution would be to use values from previous season, when the club played on the second level of professional football. However, this approach seems suboptimal for at least the following two reasons. First, related to attendance numbers, we can be sure that these are lower if a club plays on the second level. However, the accuracy of the available data is doubtful, especially for the earlier seasons in our sample. Second, and related to both attendance numbers and (expected) results, the second level is substantially different from the highest level in Dutch football. For example, the majority of matches are played on Friday evenings, with rather limited media coverage. Also, the structure of the division is different and has certain special regulations with regard to the qualification for end-of-season play- off matches for promotion. This may provide clubs with unclear incentives (i.e. if a club already qualified for the play-offs in October, it might not feel the urgency to perform in the rest of the season. Therefore, as an easy and practical solution, we use the values of the relegated teams as if they were related to the promoted teams. The promoted teams are generally quite comparable to the relegated teams, for example in terms of budget, stadium and fan base. Thus, this approach seems applicable. Furthermore, we also include a dummy variable for promoted teams that will account for potential biases of this practical approach.
These main findings have important implications for clinical care. CBT for PD/AG is sometimes assumed to be effective primarily for monosymptomatic patients with mild illness severity. Our findings provide evidence that overall CBT for PD/AG is effective irrespective of comor- bid depression or severity of depressive symptomatology. In clinical routine, many clinicians tend to modify their therapeutic strategy by addressing depressive symptoms when deemed necessary. Practitioners thereby deviate from established state-of-the-art manuals for PD/AG. Al- though it remains an empirical question as to whether these findings could have otherwise been further bol- stered, our results strongly suggest that retaining a con- sistent focus on the primary anxiety diagnosis does not negatively affect the short- and long-term anxiety out- comes and also reduces depressive symptomatology. CBT is a first-line treatment for PD/AG, can be administered alone, and needs to be further investigated given the un- clear role of psychopharmacotherapy [58, 59] .
The presented planning study (author’s contribution A) provides the first study to dis- tinguish the influence of the delivery technique and the MLC by largely eliminating the influence of the optimization and dose calculation algorithms. By using constraint opti- mization and tightly restricting the dose to organs at risk during the optimization, the effects oftreatment delivery technique (sIMRT, dMLC, VMAT) and different MLC de- signs on tumor dose and treatment time were studied. It was found that the delivery of VMAT is fastest without sacrificing dose to the tumor or OAR constraints. In conjunction with small and fast driving leaves, the delivery is not only accelerated, but also improved with respect to PTV dose. As intended by the use of constraint optimization, dose to OARs was the same for all generated treatments plans for each patient, while mean dose and dose homogeneity as well as treatment time improved with more complex techniques (sIMRT<dMLC<VMAT). However, the influence of the MLC design is smaller than the influence of the delivery technique. While interdigitation does not add much to the plan quality in terms of the dose distribution, it may reduce treatment time for some (complex) cases and thereby enhances delivery efficiency. Smaller leaf width, on the other hand, im- proves dose homogeneity to the tumor as well as PTV mean dose, if small structures in the vicinity of the PTV have to be spared. Especially faster leaf speed accelerates the treat- ment time, which largely improves patient comfort and minimizes organ motion during treatment.
Later in the Groundwork, Kant repeated this claim that “the will is in all its actions a law to itself” (GMS 4:447; Kant, 1998, p. 53). What is suggestive of this proposition or principle is the fact that Kant places a high demand on universalising our maxims as a universal moral principle. In fact, Kant introduces the idea of autonomy specifically to provide an explanation for the unconditionality of the moral law. As I understand Kant, if the autonomous will is regarded as “the sovereignty of the will over itself (that has both forms of freedom), then the law that the will is to itself is the Categorical Imperative” (Reath, 2006, 2013, p. 32). Therefore, “a free will and a will under moral laws are one and the same” (GMS 4:447; Kant, 1998, p. 53). This apparent paradoxical claim is what Kant himself calls a circularity (Br 11:155; Kant, 1999a, p. 343) and is now known as the reciprocity thesis. The problem associated with circularity concerns a hidden circle of thought in which freedom is presupposed solely in the negative sense rather than the positive sense. If freedom of the will is mainly presupposed in the positive sense and not merely as an independence from all matter of the law, we can infer without much ado that the moral law is the grounds of freedom (in the same way that the law of nature is the grounds of all appearances) (GMS 4:453; Kant, 1998, p. 57). This is because Kant holds that freedom is embedded in the categorical imperative of duty itself (NF 27:1326; Kant, 2003, p. 10). He believes that the moral law necessitates through itself, and for that reason, it necessitates from the idea of respect for the law. In so doing, the human being can put his incentive for inclination aside and posit an absolute value in his actions because “respect is the esteem of a value that restricts all inclinations” (NF 27:1326; Kant, 2003, p. 10).
below the 70% target, a sign of the seriousness of the MDR-TB epidemic in the EU/EEA. It is well documented that treatment failure and mortality are higher among MDR-TB cases than among susceptible cases [30,31]. Although we found only a slight difference in treat- ment success rate in native and foreign cases, being of foreign origin was a significant risk factor for unsuc- cessful TO in our analysis. Markedly, a high proportion of cases of foreign origin had unknown outcome. It is unclear to which extent this might be due to migration for medical reasons. Overall, this result suggests that programmatic issues may play a role including access to healthcare in the context of mobility e.g. patients returning to their country of origin before the treatment is completed, as was observed in a study from London , and challenges in cross-border collaboration. Thus, the 61st World Health Assembly in 2008 called on countries to address migrant health issues in a more integrated, harmonised approach . Foreign origin may be a proxy for other unmeasured indicators related to migration. In the EU, migrants have been reported to be at risk of not receiving the same level of healthcare in the preventive, diagnostic and treatment services as the native communities . This might be due to a combination of factors including legal and working sta- tus, social exclusion, substandard economic condition and barriers in accessing healthcare services .
evidence-based self-help programs as a first step within the treatment course. Self-help programmes may improve outcomes and be sufficient for a subset of patients. If not sufficient, as step 2 cognitive behaviour therapy for BN should be applied as single or group therapy in 16-20 sessions over a period of 4-5 months. With this type of therapy, reported remission rates range from 30-40% (P. J. Hay & Bacaltchuk, 2008; Mitchell, Agras, & Wonderlich, 2007) to 40-60% at the end oftreatment and at follow-up (Williams, 2003). If CBT does not lead to positive outcome, if CBT is not available, or if patients don’t want to work with this kind of therapeutic intervention, other forms of therapy can be taken into consideration. Interpersonal therapy has been proven to be effective in patients with BN, but duration oftreatment has been shown to be longer (8- 12 months) to get comparable results as with CBT. An enhanced form CBT including interpersonal factors, emotional tolerance, perfectionism and self-esteem did not improve outcome (C. G. Fairburn et al., 2009). Psychoanalysis is also mentioned as alternative psychotherapeutic treatment with a longer treatment period.
EPID-based in-vivo dosimetry has proliferated in the past few years. The final aim is to provide an accurate and independent dose verification of the treatment delivery. In addition to sensitivity to errors in dose calculation, data transfer, and dose delivery as in pre-treatment QA, in-vivo dosimetry would enable the identification of errors gener- ated by patient setup and changes in patient anatomy. However, current applications of EPID-based dosimetry are focused on pre-treatment dose verification and applications for in-vivo dosimetry are still limited. In brief, the proposed concept for EPID-based in-vivo dosimetry relies on either predicting images at the EPID level through patient anatomy extracted from the treatment planning CT or estimating fluences from the EPID image to forward calculate the dose as imparted in the patient CT. The ability of both approaches to detect errors undetectable by a solely pre-treatment QA has been demonstrated by different groups   . All these methods were very sensitive to anatomi- cal changes. Although this is one of the main advantages of in-vivo over pre-treatment dosimetry, the interpretation of observed differences between measured and predicted 3D dose distributions is complicated. Since the in-vivo methods rely on the treatment plan- ning patient CT, the generated dose distribution is valid for dose verification only and is not representative of the ”true” dose delivered to the patient. Consequently, when a deviation is detected, the decision making for re-planning or other adaptive strategies is performed qualitatively by visual inspection of the CBCT acquired prior to treatment . Indeed, implementing the in-vivo dosimetry provides a better safety net for the treatment delivery in comparison to full dependence on pre-treatment QA. However, it is still a dosimetric verification tool rather than independent dosimetry, and its accuracy is associated with good modeling of the linac components and modulation (e.g. MLC move- ment) and patient anatomy. As an alternative approach to EPID-based in-vivo dosimetry, the proposed comprehensive patient-specific QA, including the plan-specific QA object of this thesis work, is planned to be implemented in our clinic.
guided by the online acquired respiratory signal. Additionally, if projection data is miss- ing, a rapid breathing record analysis will allow to trigger potential local re-scannings. Unfortunately, these methods were clinically not available when the patient image data sets employed in this thesis were acquired. The other typical 4D CT artifact type, i. e. dou- ble structure artifacts, is in general more challenging regarding its complete prevention, but in novel CT reconstruction techniques the usage of advanced protocols can to some extent reduce their occurrence . The impact of this artifact type on proposed pipeline, however, tends to be much smaller, as illustrated in Fig. 3 [SPIE 2018]. Nevertheless, obtained results showed that a consideration of artifacts is not only mandatory for treat- ment planning but also for the proposed 4D dose simulation scheme. Furthermore, in the specific task of 4D CT motion extraction using DIR, image quality and imaged anatomy (e. g. thoracic/abdominal with high/low image contrast, respectively) highly influence the registration result. Following this argumentation, and the fact that DIR is the basis of the proposed dose simulation scheme, directly motivated to develop a registration approach that allows estimating registration uncertainty maps. Inspired by the approach of Yang et al. , a probabilistic registration framework based on a CNN with integrated dropout layers was developed for registration of 4D CT image data. Training the network with an in-house acquired 4D CT data base, with corresponding pseudo ground truth vector fields estimated by standard DIR algorithms, allowed to analyze the DIR accuracy by means of additional external data bases. That is, no bias towards the external image data regarding the scanner type, reconstruction method or image dimensionality was introduced during training. Strikingly, the registration accuracy of proposed model variants (depending on the DIR algorithm used for ground truth generation) were similar or even higher compared to standard DIR accuracy. Further, a 60-fold run time reduction was achieved. However, extending the deterministic network to be probabilistic using dropouts, and in consequence allowing for an uncertainty estimation, was only partly successful. More specifically, computation of registration uncertainty maps was possible, yet, the applicability of such information for e. g. radiotherapy treatment planning and estimation of uncertainties therein, as proposed by Amir-Khalili et al. , remains unclear. Nevertheless, a consideration of predicted uncertainties in the proposed dose simulation pipeline was investigated. Beforehand, however, the general accuracy of the dose simulation scheme was metrologically determined to identify influencing parameters and potential improvements.
Precision mental health has only recently received considerable attention. For example, a new method has been introduced, which aims at treatment selection based on empirical data, namely the Personalized Advantage Index (PAI; [3, 4]). Using multiple regression methods that weigh the predictive value of different pa- tient intake characteristics, the PAI is a measure of the potential advantage of a Treatment A over a Treatment B. The use of the PAI has been shown in two applica- tions: In the first demonstration, DeRubeis et al. used the PAI to predict which patients would profit more from CBT than an antidepressive medication (ADM) and vice versa . In the second study, Huibers et al. demonstrated the PAI’s potential for the selection be- tween cognitive therapy (CT) and IPT . Another methodology was adapted for the prediction of treat- ment response by Lutz et al. in a sample of 618 psycho- therapy outpatients . In accordance with avalanche prediction models (e.g. ), the response curves of the most similar patients who had already been treated were