Psychospiritual care for parents during the COVID-19 pandemic.

In a recent article, energy poverty increases the likelihood of depression in parents. The authors responded that this situation must be given attention because parental well-being can influence child development and outcomes. With this, we propose, in this paper, that an avenue that can be done is by providing a psychospiritual care for parents especially during the COVID-19 pandemic in which anxieties among family members arise.

Ipsilateral Vocal Cord Monitoring for Carotid Endarterectomy and Concurrent Contralateral Vocal Cord Paralysis: A Case Report.

Vagus nerve injury may complicate carotid endarterectomy (CEA). The recurrent laryngeal nerve (RLN) branches from the vagus nerve, innervating the ipsilateral vocal cord. Vagus nerve injury can cause vocal cord dysfunction. Intraoperative vocal cord monitoring can detect vagus nerve injury during CEA. A patient with distorted neck anatomy from radiotherapy to treat oropharyngeal cancer and resultant right vocal cord paralysis required left CEA. Anticipating difficult neck dissection risking vagus nerve damage with associate RLN malfunction, we added vocal cord electromyography (EMG) to routine CEA electroencephalography (EEG). We recommend vocal cord EMG in anatomically complex CEA to avoid vagus nerve injury.

Dynamic mapping of the corticospinal tract in open cordotomy and myelomeningocele surgery.

OBJECT: Spinal cord surgeries carry a high risk for significant neurological impairments. The initial techniques for spinal cord mapping emerged as an aid to identify the dorsal columns and helped select a safe myelotomy site in intramedullary tumor resection. Advancements in motor mapping of the cord have also been made recently, but exclusively with tumor surgery. We hereby present our experiences with dynamic mapping of the corticospinal tract (CST) in other types of spinal cord procedures that carry an increased risk of postoperative motor deficit, and thus could directly benefit from this technique. CASE REPORTS: Two patients with intractable unilateral lower extremity pain due to metastatic disease of the sacrum and a thoraco-lumbar chordoma, respectively underwent thoracic cordotomy to interrupt the nociceptive pathways. A third patient with progressive leg weakness underwent cord untethering and surgical repair of a large thoracic myelomeningocele. In all three cases, multimodality intraoperative neurophysiologic testing included somatosensory and motor evoked potentials monitoring as well as dynamic mapping of the CST. CONCLUSION: CST mapping allowed safe advancement of the cordotomy probe and exploration of the meningocele sac with untethering of the anterior-lateral aspect of the cord respectively, resulting in postoperative preservation or improvement of motor strength from the pre-operative baseline. Stimulus thresholds varied likely with the distance between the stimulating probe and the CST as well as with the baseline motor strength in the mapped myotomes.

Factors that modify the risk of intraoperative seizures triggered by electrical stimulation during supratentorial functional mapping.

OBJECTIVE: Intraoperative mapping via electrical stimulation is the gold standard technique for surgeries close to the eloquent cortex. However, it can trigger seizures which immediately impact patient's safety. We studied whether administration of antiepileptic drugs (AED) prior to and/or at the beginning of the surgery decreases the probability of triggering seizures, while adjusting for other risk factors. METHODS: 544 consecutive intraoperative mapping cases performed at a tertiary care center for epilepsy and brain tumor surgery were included in the study. Using a multivariate logistic regression analysis, we analyzed the independent impacts of AED loading at time of surgery, preoperative AED maintenance, history of seizures, type of stimulation paradigm, lobar location of stimulation, age, opioid administration and pathology on the probability of triggering seizures. RESULTS: Seizures were identified in 135 patients. Intravenous loading with AED decreased the odds of triggering seizures by 45% (OR = 0.55, p = 0.01), Penfield (versus multipulse train) stimulation and diffuse (versus well circumscribed) pathology increased it twice (OR = 1.97, p = 0.01) and 2.4 times (OR = 2.42, p = 0.003) respectively. No other factors had a significant impact. CONCLUSIONS: Seizures triggered during mapping occur frequently and are multifactorial. SIGNIFICANCE: Loading with AED independently reduces the risk of their occurrence.

Receptor tyrosine kinase gene amplification is predictive of intraoperative seizures during glioma resection with functional mapping.

OBJECTIVE: Intraoperative seizures during craniotomy with functional mapping is a common complication that impedes optimal tumor resection and results in significant morbidity. The relationship between genetic mutations in gliomas and the incidence of intraoperative seizures has not been well characterized. Here, the authors performed a retrospective study of patients treated at their institution over the last 12 years to determine whether molecular data can be used to predict the incidence of this complication. METHODS: The authors queried their institutional database for patients with brain tumors who underwent resection with intraoperative functional mapping between 2005 and 2017. Basic clinicopathological characteristics, including the status of the following genes, were recorded: IDH1/2, PIK3CA, BRAF, KRAS, AKT1, EGFR, PDGFRA, MET, MGMT, and 1p/19q. Relationships between gene alterations and intraoperative seizures were evaluated using chi-square and two-sample t-test univariate analysis. When considering multiple predictive factors, a logistic multivariate approach was taken. RESULTS: Overall, 416 patients met criteria for inclusion; of these patients, 98 (24%) experienced an intraoperative seizure. Patients with a history of preoperative seizure and those treated with antiepileptic drugs prior to surgery were less likely to have intraoperative seizures (history: OR 0.61 [95% CI 0.38-0.96], chi-square = 4.65, p = 0.03; AED load: OR 0.46 [95% CI 0.26-0.80], chi-square = 7.64, p = 0.01). In a univariate analysis of genetic markers, amplification of genes encoding receptor tyrosine kinases (RTKs) was specifically identified as a positive predictor of seizures (OR 5.47 [95% CI 1.22-24.47], chi-square = 5.98, p = 0.01). In multivariate analyses considering RTK status, AED use, and either 2007 WHO tumor grade or modern 2016 WHO tumor groups, the authors found that amplification of the RTK proto-oncogene, MET, was most predictive of intraoperative seizure (p < 0.05). CONCLUSIONS: This study describes a previously unreported association between genetic alterations in RTKs and the occurrence of intraoperative seizures during glioma resection with functional mapping. Future models estimating intraoperative seizure risk may be enhanced by inclusion of genetic criteria.

Induction of smell through transethmoid electrical stimulation of the olfactory bulb.

BACKGROUND: Anosmia has an estimated prevalence of 5% of the general population. Outside of inflammatory causes, therapeutic options are limited despite research advances. Bypassing peripheral neuronal damage through central stimulation is a potential therapeutic option that has shown success in other sensory systems, most notably with hearing. We performed a pilot study to determine the feasibility of inducing smell through artificial electrical stimulation of the olfactory bulbs in humans. METHODS: Subjects with a history of sinus surgery, including total ethmoidectomy, with intact ability to smell were enrolled. The ability to smell was confirmed with a 40-item smell identification test. Awake subjects underwent nasal endoscopy and either a monopolar or bipolar electrode was positioned at 3 areas along the lateral lamella of the cribriform plate within the ethmoid sinus cavity. A graded stimulation current of 1-20 mA at 3.17 Hz was administered while cortical evoked potential (CEP) recordings were collected. Subjective responses of perceived smell along with reports of discomfort were recorded. Subjects with artificially induced smell underwent repeat stimulation after medically induced anosmia. RESULTS: Five subjects (age, 43-72 years) were enrolled. Three subjects reported smell perception smell with electrical stimulation. This was reproducible after inducing anosmia, but CEP recordings could not provide objective support. All subjects tolerated the study with minimal discomfort. CONCLUSION: This is the first report of induced smell through transethmoid electrical stimulation of the olfactory bulb. These results provide a proof of concept for efforts in development of an olfactory implant system.

Extended Motor Evoked Potentials Monitoring Helps Prevent Delayed Paraplegia After Aortic Surgery.

OBJECTIVE: Motor evoked potentials (MEPs) monitoring can promptly detect spinal cord ischemia (SCI) from aortic clamping during open thoracoabdominal aneurysm repair (OTAAR) with distal aortic perfusion (DAP) and thus help decrease the risk of immediate postoperative SCI (IP-SCI). However, neither stable MEPs during aortic clamp interval (ACI) nor absence of IP-SCI eliminate the possibility of delayed postoperative SCI (DP-SCI). We hypothesized that extension of MEPs monitoring beyond ACI can also help decrease the risk of DP-SCI. METHODS: We identified 150 consecutive patients at our institution between April 2005 and October 2014 who underwent OTAAR with DAP and MEPs monitoring and had no IP-SCI. Using logistic regression analysis, we studied the independent effect of extended MEPs monitoring on the risk of developing DP-SCI. We used a propensity score analysis to adjust for potential confounders, such as poorly controlled hypertension, previous aneurysm surgery, splenectomy, acute aortic dissection, aneurysm type, older age, and history of diabetes and smoking. RESULTS: From the 150 patients, 129 (86%) remained neurologically intact whereas 21 (14%) developed DP-SCI. Nineteen of these twenty-one patients (90%) had no extended monitoring. Fifty-seven of fifty-nine (97%) patients who benefited from extended monitoring had no DP-SCI (p = 0.003). Extended MEPs monitoring was independently associated with decreased risk of DP-SCI (odds ratio = 0.14; 95% confidence interval: 0.03, 0.65; p = 0.01). INTERPRETATION: MEPs detect the lowest systemic blood pressure that ensures appropriate spinal cord perfusion in the postoperative period. Thus, they inform the hemodynamic management of patients post-OTAAR, particularly in the absence of a reliable neurological exam.

A method for scoring treatment time efficiency of Gamma Knife radiosurgical treatment plans for brain metastases.

PURPOSE: In Gamma Knife radiosurgery, an efficient plan is one that achieves dosimetric quality while minimizing treatment time. Although minimization of treatment time to improve throughput and benefit patient comfort is a common and important goal of radiosurgery planning, to date no studies have attempted to specifically quantify efficiency. The aim of this study was to define simple index to score efficiency, and by quantifying time savings achieved by replanning those cases identified as least efficient, so demonstrate the efficacy of the index. METHODS: To quantify efficiency, it is necessary to determine treatment times expected for specified lesions. However, because of numerous case-specifics, efficiency cannot be quantified in terms of treatment times alone. This study defines a new quantity, the attenuation-corrected normalized treatment time-dose rate product, nTRP(corr), to account for differing dose rates, prescriptions, and attenuation. A plan efficiency index (PEI) is then defined for lesions of similar volume and shape in terms of expected and planned nTRP(corr). nTRP(corr) was retrospectively calculated for metastatic lesions of comparable shape. A curve fitted to data describing how nTRP(corr) typically varied with volume for these lesions was then used to determine expected nTRP(corr). For each lesion, PEI was calculated as the ratio of expected-to-planned nTRP(corr). Plans with the lowest PEI were replanned, with the aim of maintaining dosimetric quality while minimizing treatment time. Dosimetric quality was defined in terms of coverage, conformity, and gradient index. Statistical significance of differences between original and replans was quantified via paired t-tests. RESULTS: The mean(standard deviation) PEI of all reviewed lesions was 1.08(0.28). The 14 least efficient plans across the range of investigated volumes (45-19 800 mm(3)) had a mean PEI of 0.64, versus 1.18 when replanned (p < 0.0001). This corresponded to a mean(range) time saving of 42%(19%-62%), [29(8-52) min at date of treatment] with no statistically significant (p > 0.05) change in dosimetric quality. CONCLUSIONS: The PEI is a viable metric for identifying those plans that benefit from a more efficient planning strategy.

A comparison of four skull models for independent dose calculations for Gamma Knife PERFEXION.

PURPOSE: It is recommended to have a method for independently verifying planned doses in stereotactic radiosurgery. The problem is one of how to model the geometry of a skull sampled by a limited number of points and how to subsequently calculate numerous attenuation pathlengths through the modeled skull. While methods of verification have been previously published for model B and C Gamma Knife units, the aims of the current work were to apply the principles of these previously published techniques for the verification of plans for Gamma Knife PERFEXIONTM, to present a new method of verification, and to compare all methods in terms of their agreement with GammaPlan. METHODS: Four algorithms were implemented: the previously published spherical approximation method (SAM) and bubble helmet skull (BHS), plus a modified BHS named interpolated BHS (IBHS) and a newly developed variable radius SAM (VRSAM). Reference point doses calculated by the four algorithms were compared to those reported by GammaPlan for 54 simple test plans and for 35 targets in 20 recent patient plans. RESULTS: For test plans, the mean (standard deviation) discrepancies against GammaPlan-reported doses were 0.3 (1.3)%, 0.3 (1.3)%, -1.6 (3.4)%, and -0.4 (1.0)% for SAM, VRSAM, BHS, and IBHS, respectively. For patient plans both the VRSAM and IBHS showed insignificant (p=0.22 and p = 0.50) discrepancies against GammaPlan of 0.38 (1.86)% and -0.11 (1.86)%, respectively. More significant discrepancies against GammaPlan (p < 0.0001) of 2.64 (2.98)% and -4.43 (3.39)% were observed for the SAM and BHS. CONCLUSIONS: The SAM can lead to large discrepancies against GammaPlan when a sphere is a poor approximation of the true skull surface, and in peripheral locations can lead to nonreal solutions to the attenuation pathlength calculations. While the BHS does not suffer the same geometric assumptions of the SAM, it can underestimate dose for peripherally located shots. The IBHS exhibits better agreement with GammaPlan than does the BHS, but requires two-dimensional interpolation that was found to be impractical to implement in the Excel-based software used in the current work. Combining aspects of both the previously published SAM and BHS algorithms, the newly presented VRSAM exhibits comparable results to the IBHS but without the need for interpolation and is therefore considered the preferred technique of the four implemented.

The Swiss IMRT dosimetry intercomparison using a thorax phantom.

PURPOSE: In 2008, a national intensity modulated radiation therapy (IMRT) dosimetry intercomparison was carried out for all 23 radiation oncology institutions in Switzerland. It was the aim to check the treatment chain focused on the planning, dose calculation, and irradiation process. METHODS: A thorax phantom with inhomogeneities was used, in which thermoluminescence dosimeter (TLD) and ionization chamber measurements were performed. Additionally, absolute dosimetry of the applied beams has been checked. Altogether, 30 plan-measurement combinations have been used in the comparison study. The results have been grouped according to dose calculation algorithms, classified as "type a" or "type b," as proposed by Kntis et al. ["Comparison of dose calculation algorithms for treatment planning in external photon beam therapy for clinical situations," Phys. Med. Biol. 51, 5785-5807 (2006)]. RESULTS: Absolute dosimetry check under standard conditions: The mean ratio between the dose derived from the single field measurement and the stated dose, calculated with the treatment planning system, was 1.007 +/- 0.010 for the ionization chamber and 1.002 +/- 0.014 (mean+/- standard deviation) for the TLD measurements. IMRT Plan Check: In the lung tissue of the planning target volume, a significantly better agreement between measurements (TLD, ionization chamber) and calculations is shown for type b algorithms than for type a (p <0.001). In regions outside the lungs, the absolute differences between TLD measured and stated dose values, relative to the prescribed dose, [(Dm-Ds)/Dprescribed], are 1.9 +/- 0.4% and 1.4 +/- 0.3%, respectively. These data show the same degree of accuracy between the two algorithm types if low-density medium is not present. CONCLUSIONS: The results demonstrate that the performed intercomparison is feasible and confirm the calculation accuracies of type a and type b algorithms in a water equivalent and low-density environment. It is now planned to offer the intercomparison on a regular basis to all Swiss institutions using IMRT techniques.

Pattern of developing the performance template.

BACKGROUND: The pattern of energy expenditure during sustained high-intensity exercise is influenced by several variables. Data from athletic populations suggest that a pre-exercise conceptual model, or template, is a central variable relative to controlling energy expenditure. AIMS: The aim of this study was to make systematic observations regarding how the performance template develops in fit individuals who have limited specific experience with sustained high-intensity exercise (eg, time trials). METHODS: The study was conducted in four parts and involved measuring performance (time and power output) during: (A) six 3 km cycle time trials, (B) three 2 km rowing time trials, (C) four 2 km rowing time trials with a training period between trials 2 and 3, and (D) three 10 km cycle time trials. All time trials were self-paced with feedback to the subjects regarding previous performances and momentary pace. RESULTS: In all four series of time trials there was a progressive pattern of improved performance averaging 6% over the first three trials and 10% over six trials. In all studies improvement was associated with increased power output during the early and middle portions of the time trial and a progressively greater terminal rating of perceived exertion. Despite the change in the pattern of energy expenditure, the subjects did not achieve the pattern usually displayed by athletes during comparable events. CONCLUSIONS: This study concludes that the pattern of learning the performance template is primarily related to increased confidence that the trial can be completed without unreasonable levels of exertion or injury, but that the process takes more than six trials to be complete.

Platelet adhesion onto immobilized fibrinogen under arterial and venous in-vitro flow conditions does not significantly differ between men and women.

BACKGROUND: Gender-related differences in incidence of arterial thrombosis have been a focus of interest for years. The platelet integrin alphaIIbbeta3 is primarily responsible for the interaction between platelets and fibrinogen and consecutive thrombus growth. In this study, we evaluated platelet adhesion onto immobilized fibrinogen under venous and arterial flow conditions in men and women. METHODS: Platelets in whole anticoagulated blood were labelled with the fluorescence dye Mepacrine and perfused through the rectangular flow chamber over glass cover slips coated with fibrinogen (shear rates of 50 s-1, 500 s-1 and 1500 s-1). A fluorescence laser-scan microscope was used for visualisation and quantification of platelet adhesion at 15 seconds, 1 and 5 minutes after the start of perfusion. RESULTS: During perfusion, the platelet adhesion linearly increased in regard to exposition time and shear rate. After five minutes of perfusion the platelet adhesion onto immobilized fibrinogen showed no significant gender related difference, neither at 50 s-1 nor at 500 s-1 and 1500 s-1 (p > 0.05), respectively. No significant difference in platelet adhesion onto immobilized fibrinogen, in regard to the menopausal status, was either observed (p > 0.05). CONCLUSION: In our in vitro experimental system, hormonal differences between men and women did not influence platelet adhesion onto immobilized fibrinogen, neither under venous nor under arterial rheological conditions.

Canine borreliosis: a laboratory diagnostic trial.

The aim of this study was to investigate samples from dogs suggestive of active canine borreliosis (group A) by culture and PCR and the detection of antibodies against Borrelia burgdorferi sensu lato in order to confirm a presumptive clinical diagnosis of canine borreliosis by laboratory results. Criteria for such a diagnosis were: history of tick exposure, lameness, neurological signs, nephropathy, lethargy, anorexia, and fever. A total of 302 samples comprising EDTA blood, urine, synovial fluid, cerebrospinal fluid, and tissue (skin, synovial membrane, kidney) from 98 dogs (26 with arthritis, 46 with neurological signs, 21 with nephropathy, 5 with non-specific symptoms) were collected and examined. Moreover, 55 healthy dogs (group B) and 236 dogs with symptoms or injuries unlikely to be associated with borreliosis (group C) were included in this study. Blood serum samples collected from all individuals (n=389) were analysed by ELISA. Twenty-one (21%) out of 98 dogs from group A, 4 (7%) out of 55 from group B and 15 (6%) out of 236 dogs from group C were positive for antibodies against B. burgdorferi sensu lato. The seroprevalences between groups A, B and C differed significantly. None of the corresponding samples investigated by PCR and culture were positive for spirochetal DNA or viable spirochetes. Borrelia afzelii was grown from one EDTA-blood sample but the corresponding blood serum sample remained antibody-negative. Consequently, the etiologic role of B. afzelii in this case is unclear. In approximately 40% of the presumptive canine borreliosis cases, other lesions have been found to be responsible for clinical signs. This study affirms that a definitive diagnosis of canine borreliosis cannot be made by clinical symptoms and serology based on a single consultation. Moreover, this study clearly revealed that the diagnostic sensitivity is enhanced by a thorough consideration and exclusion of other diseases.

The screening power of methylenetetrahydrofolate reductase C677T polymorphism versus plasma homocysteine concentration in patients with stenosis of the internal carotid artery.

BACKGROUND: Hyperhomocysteinemia is an important and independent risk factor for vascular disease. About 35% of patients with stroke and 47% of patients with peripheral arterial disease have elevated plasma homocysteine (HCY) concentrations. The relationship between plasma HCY and the methylentetrahydrofolate reductase (MTHFR) C677T polymorphism is still unclear, especially in regard to screening/diagnostic power. METHODS: This case-control study was performed on 96 patients, who underwent surgery due to asymptomatic or symptomatic high grade stenosis of the internal carotid artery (ICA), and 96 healthy age and sex-matched, controls. Plasma HCY concentration was determined using a commercial kit for fully automated analysis (AxSYM, Abbott). The C677T polymorphism of the MTHFR-gene was assessed by PCR. RESULTS: The mean plasma HCY concentration was significantly higher in the group with stenosis of ICA compared to the controls, 12.43 +/- 6.96 microM and 10.16 +/- 3.16 microM, respectively, (p < 0.05). An HCY plasma concentration of 1.5 SD above the mean value of the control group, was defined as cut-off for a pathological versus physiological plasma concentration. The sensitivity and specificity of HCY was 0.27 and 0.94, respectively. The positive predictive value was 0.82. There was no significant difference in the frequency of the MTHFR 677 CT and TT genotype between patients and controls (47% vs. 47% and 8.3% vs. 11.4%, respectively). Carriers of the T-allele (CT and TT genotypes) have significantly higher plasma HCY concentrations than CC patients, 14.1 +/- 7.6 microM and 10.29 +/- 5.2 microM, respectively, p < 0.05. Sensitivity and specificity of the MTHFR C677T polymorphism (T-allele) were 0.56 and 0.40, respectively. The positive predictive value was 0.48. There was no significant difference in plasma HCY or genotype frequency of the MTHFR C677T polymorphism between asymptomatic and symptomatic patients. CONCLUSION: Our study shows that in a population with a given pretest disease probability of 50%, the determination of plasma HCY concentration, with a positive predictive value of 0.82, is more suitable for screening of patients at risk than analysis of the MTHFR C677T polymorphism.

A novel technique using customised templates for the application of fractionated interstitial HDR brachytherapy to the tumour bed in soft-tissue sarcomas located in the extremities.

AIMS: Postoperative interstitial brachytherapy of limbs is challenging, because it is difficult to deliver a conformal dose to the tumour bed. We developed and assessed a new surgical fixation system for positioning guiding tubes in interstitial brachytherapy in order to achieve favourable geometry. MATERIALS AND METHODS: A 28-year-old patient was treated with postoperative interstitial brachytherapy boost followed by external radiotherapy after the 11th recurrence of a desmoid tumour in the forearm. On the basis of preoperative imaging data, customised resorbable templates made of polydioxanone (PDS) were cut to fit in the space left by the resected tumour. These were strategically positioned in the tumour bed during surgery. In order to hold the brachytherapy-guiding tubes parallel for the duration of treatment, they were passed through a series of holes bored into the templates. RESULTS: Fixing the guiding tubes with PDS templates resulted in a fixed geometry, and thus in an optimal dose distribution with only little additional dose optimisation needed by the brachytherapy treatment planning system. An optimised dose to the tumour bed, and a reduction of dose to critical normal tissues, is achievable with this template system for sarcomas located between osseous structures. CONCLUSION: The PDS templates offer a more rigid fixation of the guiding tubes in relation to the surrounding anatomy even after the operation cavity has been closed. A tailored dose distribution can be achieved, thus reducing possible side-effects. Additionally, because of the self-resorbable nature of the material, a re-operation for template removal is not necessary. The potential advantages of this method are being further investigated.

Time course of serum cytokines in patients receiving proton or combined photon/proton beam radiation for resectable but medically inoperable non-small-cell lung cancer.

PURPOSE: We prospectively measured the levels of basic fibroblast growth factor (bFGF), tumor necrosis factor-alpha (TNF-alpha), interleukin (IL)-1beta, IL-6, IL-10, and procollagen III peptide (P III P) in serum from non-small-cell lung cancer patients treated with photons combined with protons or protons alone. These factors were quantified because they may be extremely important in the development of side effects, and the treated volume integral dose may be crucial in inducing them. METHODS: Of the 12 participating patients, 6 with squamous cell carcinoma (SCC) and 3 with adenocarcinoma received combined photon/proton beam radiation, whereas 2 with SCC and 1 with large-cell carcinoma (LCC) received only proton radiation. Mean age was 73.6 years. There were 4 male and 8 female patients with a mean smoking history of 87.0 packyears. Nine patients had Stage I, 2 had Stage II, and 1 had stage IIIA lung cancer. Serum samples were obtained at baseline and on Days 15, 30, 45, 60, 90, 120, 150, 180, and 210 after initiation of radiation therapy. Injury scores for pneumonitis and fibrosis based on computed tomography (CT) scans were assigned. RESULTS: The percentage of lung volume irradiated was significantly less for patients treated with protons alone compared with those receiving photon plus proton therapy (p < 0.001). Injury scores were also lower for proton only treatment (p = 0.039). When evaluated collectively, bFGF, TNF-alpha, and IL-6 concentrations were significantly higher in the photon/proton group (p < 0.05 or less); radiation regimen, but not time after treatment initiation, was a significant factor in their levels. P III P level was also higher in the photon/proton patients (p < 0.001) and both radiation regimen (p = 0.027) and time after treatment (p = 0.019) had an impact. CONCLUSIONS: Although significant changes occurred in some of the measured cytokines and P III P, it was the difference in the volume integral dose that occurred when protons were used alone vs. mixed photon/proton therapy that correlated with the incidence of pneumonitis and/or fibrosis. However, it cannot be ruled out that differences in cytokine levels before radiotherapy initiation may have contributed to the outcome.

Electronic teaching files: seven-year experience using a commercial picture archiving and communication system.

With the advent of electronic imaging and the internet, the ability to create, search, access, and archive digital imaging teaching files has dramatically improved. Despite the fact that a picture archival and communication system (PACS) has the potential to greatly simplify the creation of, archival, and access to a department or multifacility teaching file, this potential has not yet been satisfactorily realized in our own and most other PACS installations. Several limitations of the teaching file tools within our PACS have become apparent over time. These have, at our facility, resulted in a substantially reduced role of the teaching file tools for conferences, daily teaching, and research purposes. With the PACS at our institution, academic folders can only be created by the systems engineer, which often serves as an impediment to the teaching process. Once these folders are created, multiple steps are required to identify the appropriate folders, and subsequently save images. Difficulties exist for those attempting to search for the teaching file images. Without pre-existing knowledge of the folder name and contents, it is difficult to query the system for specific images. This is due to the fact that there is currently no fully satisfactory mechanism for categorizing, indexing, and searching cases using the PACS. There is currently no easy mechanism to save teaching, research, or clinical files onto a CD or other removable media or to automatically strip demographic or other patient information from the images. PACS vendors should provide much more sophisticated tools to create and annotate teaching file images in an easy to use but standard format (possibly Radiological Society of North America's Medical Image Resource Center [MIRC] format) that could be exchanged with other sites and other vendors' PAC systems. The privilege to create teaching or conference files should be given to the individual radiologists, technologists, and other users, and an audit should be kept of who has created these files, as well as keep track of who has accessed the files. Vendors should maintain a local PACS library of image quality phantoms, normal variants, and interesting cases and should have the capability of accessing central image repositories such as the RSNA's MIRC images. Commercial PAC systems should utilize a standard lexicon to facilitate the creation and categorization of images, as well as to facilitate sharing of images and related text with other sites. This should be combined with a very easy to use mechanism to write images and related text when appropriate onto removable media (while maintaining a high level of security and confidentiality) to make it easier to share images for teaching, research, or clinical purposes.

The Radiological Society of North America's Medical Image Resource Center: an update.

The Radiological Society of North America (RSNA) has initiated a long-term project called the Medical Image Resource Center (MIRC). The overall goal of the effort is to create an on-line library of medical images and related information and to maintain and index a number of other medical image resources. The rationale for the project, a summary of the overall requirements and objectives, and a finally a brief description of the future plans for MIRC are presented.

Application service providers: an alternative approach to PACS implementation.

Several impediments have delayed the adoption of filmless imaging by the majority of radiology practitioners. These factors include concerns for technology obsolescence, limited available capital, and lack of existing information technology (IT) infrastructure and experienced personnel. Application service providers (ASPs) have begun to emerge as an alternative approach to the more traditional acquisition of picture archiving and communication (PAC) systems. This approach offers the prospective PACS customer the opportunity to outsource hardware, software, and IT services to a vendor on a fee-per-use basis. The ideal candidates for such an approach would be small to medium-sized hospitals with limited existing IT infrastructure. Using the ASP model, prospective PACS customers can purchase services unique to their needs and upgrade or expand these as needed. As ASP vendors increase their customer base, there is the potential for customers to achieve unique economies of scale not available through traditional financing means. This report discusses the economic and operational issues associated with ASPs, as well as potential limitations and future implications of this phenomenon.