Magnetic resonance linear accelerator technology and adaptive radiation therapy: An overview for clinicians.

Radiation therapy (RT) continues to play an important role in the treatment of cancer. Adaptive RT (ART) is a novel method through which RT treatments are evolving. With the ART approach, computed tomography or magnetic resonance (MR) images are obtained as part of the treatment delivery process. This enables the adaptation of the irradiated volume to account for changes in organ and/or tumor position, movement, size, or shape that may occur over the course of treatment. The advantages and challenges of ART maybe somewhat abstract to oncologists and clinicians outside of the specialty of radiation oncology. ART is positioned to affect many different types of cancer. There is a wide spectrum of hypothesized benefits, from small toxicity improvements to meaningful gains in overall survival. The use and application of this novel technology should be understood by the oncologic community at large, such that it can be appropriately contextualized within the landscape of cancer therapies. Likewise, the need to test these advances is pressing. MR-guided ART (MRgART) is an emerging, extended modality of ART that expands upon and further advances the capabilities of ART. MRgART presents unique opportunities to iteratively improve adaptive image guidance. However, although the MRgART adaptive process advances ART to previously unattained levels, it can be more expensive, time-consuming, and complex. In this review, the authors present an overview for clinicians describing the process of ART and specifically MRgART.

Promises, Pitfalls, and Clinical Applications of Artificial Intelligence in Pediatrics.

Artificial intelligence (AI) broadly describes a branch of computer science focused on developing machines capable of performing tasks typically associated with human intelligence. Those who connect AI with the world of science fiction may meet its growing rise with hesitancy or outright skepticism. However, AI is becoming increasingly pervasive in our society, from algorithms helping to sift through airline fares to substituting words in emails and SMS text messages based on user choices. Data collection is ongoing and is being leveraged by software platforms to analyze patterns and make predictions across multiple industries. Health care is gradually becoming part of this technological transformation, as advancements in computational power and storage converge with the rapid expansion of digitized medical information. Given the growing and inevitable integration of AI into health care systems, it is our viewpoint that pediatricians urgently require training and orientation to the uses, promises, and pitfalls of AI in medicine. AI is unlikely to solve the full array of complex challenges confronting pediatricians today; however, if used responsibly, it holds great potential to improve many aspects of care for providers, children, and families. Our aim in this viewpoint is to provide clinicians with a targeted introduction to the field of AI in pediatrics, including key promises, pitfalls, and clinical applications, so they can play a more active role in shaping the future impact of AI in medicine.

Investigating the weekend effect in decompressive thoracolumbar hemilaminectomy for acute intervertebral disc extrusion: An observational cohort study of 460 cases (2018-2023).

OBJECTIVE: To investigate if weekend surgery is associated with poorer outcomes in dogs with acute thoracolumbar intervertebral disc extrusion (IVDE) undergoing decompressive thoracolumbar hemilaminectomy. STUDY DESIGN: Retrospective observational cohort study. SAMPLE POPULATION: A total of 460 consecutive cases were reviewed, with 401 dogs undergoing weekday surgery (Cohort WD), and 59 dogs undergoing weekend surgery (Cohort WE). METHODS: Medical records of a surgical referral center in the UK were reviewed. Preoperative patient demographic and clinical data, and postoperative outcome data were collected with a minimum 28-day follow-up period. Multivariable logistic regression analysis was used to model the odds of a negative outcome. RESULTS: Cohort WE had a higher preoperative proportion of nonambulatory dogs (p = .0115) but there were no significant differences between the nonambulatory (p = .3762) and deep-pain negative subgroups (p = .6199). Cohort WE had a higher risk of not recovering ambulation compared to Cohort WD [79.2% vs. 91.6% recovery; adjusted OR 3.010 (95% CI: 1.259-7.190); p = .0132] and had a higher risk of postoperative morbidity [32.2% vs. 17.2%; adjusted OR 2.015 (95% CI: 1.089-3.729); p = .0257]. There were no significant differences in other outcome measures between cohorts. CONCLUSION: Weekend surgery in canine decompressive thoracolumbar hemilaminectomy may be associated with poorer patient outcomes, specifically higher postoperative morbidity and a poorer rate of recovery of ambulation. CLINICAL SIGNIFICANCE: This study demonstrates a weekend effect in veterinary surgery, which may be important in surgical decision-making in acute thoracolumbar IVDE. Further scrutiny of the patient's journey through the veterinary healthcare system is warranted.

The addition of androgen deprivation therapy and pelvic lymph node treatment to prostate bed salvage radiotherapy (NRG Oncology/RTOG 0534 SPPORT): an international, multicentre, randomised phase 3 trial.

BACKGROUND: In men with a detectable prostate-specific antigen (PSA) level after prostatectomy for prostate cancer, salvage prostate bed radiotherapy (PBRT) results in about 70% of patients being free of progression at 5 years. A three-group randomised trial was designed to determine whether incremental gains in patient outcomes can be achieved by adding either 4-6 months of short-term androgen deprivation therapy (ADT) to PBRT, or both short-term ADT and pelvic lymph node radiotherapy (PLNRT) to PBRT. METHODS: The international, multicentre, randomised, controlled SPPORT trial was done at 283 radiation oncology cancer treatment centres in the USA, Canada, and Israel. Eligible patients (aged ≥18 years) were those who after prostatectomy for adenocarcinoma of the prostate had a persistently detectable or an initially undetectable and rising PSA of between 0·1 and 2·0 ng/mL. Patients with and without lymphadenectomy (N0/Nx) were eligible if there was no clinical or pathological evidence of lymph node involvement. Other eligibility criteria included pT2 or pT3 disease, prostatectomy Gleason score of 9 or less, and a Zubrod performance status of 0-1. Eligible patients were randomly assigned to receive PBRT alone at a dose of 64·8-70·2 Gy at 1·8 Gy per fraction daily (group 1), PBRT plus short-term ADT (group 2), or PLNRT (45 Gy at 1·8 Gy per fraction, and then a volume reduction made to the planning target volume for the remaining 19·8-25 ·2 Gy) plus PBRT plus short-term ADT (group 3). The primary endpoint was freedom from progression, in which progression was defined as biochemical failure according to the Phoenix definition (PSA ≥2 ng/mL over the nadir PSA), clinical failure (local, regional, or distant), or death from any cause. A planned interim analysis of 1191 patents with minimum potential follow-up time of 5 years applied a Haybittle-Peto boundary of p<0·001 (one sided) for comparison of 5-year freedom from progression rates between the treatment groups. This trial is registered with ClinicalTrials.gov, NCT00567580. The primary objectives of the trial have been completed, although long-term follow-up is continuing. FINDINGS: Between March 31, 2008, and March 30, 2015, 1792 eligible patients were enrolled and randomly assigned to the three treatment groups (592 to group 1 [PBRT alone], 602 to group 2 [PBRT plus short-term ADT], and 598 to group 3 [PLNRT plus PBRT plus short-term ADT]). 76 patients subsequently found to be ineligible were excluded from the analyses; thus, the evaluable patient population comprised 1716 patients. At the interim analysis (n=1191 patients; data cutoff May 23, 2018), the Haybittle-Peto boundary for 5-year freedom from progression was exceeded when group 1 was compared with group 3 (difference 17·9%, SE 2·9%; p<0·0001). The difference between groups 2 and 3 did not exceed the boundary (p=0·0063). With additional follow-up beyond the interim analysis (the final planned analysis; data cutoff May 26, 2021), at a median follow-up among survivors of 8·2 years (IQR 6·6-9·4), the 5-year freedom from progression rates in all 1716 eligible patients were 70·9% (95% CI 67·0-74·9) in group 1, 81·3% (78·0-84·6) in group 2, and 87·4% (84·7-90·2) in group 3. Per protocol criteria, freedom from progression in group 3 was superior to groups 1 and 2. Acute (≤3 months after radiotherapy) grade 2 or worse adverse events were significantly more common in group 3 (246 [44%] of 563 patients) than in group 2 (201 [36%] of 563; p=0·0034), which, in turn, were more common than in group 1 (98 [18%] of 547; p<0·0001). Similar findings were observed for grade 3 or worse adverse events. However, late toxicity (>3 months after radiotherapy) did not differ significantly between the groups, apart from more late grade 2 or worse blood or bone marrow events in group 3 versus group 2 (one-sided p=0·0060) attributable to the addition of PLNRT in this group. INTERPRETATION: The results of this randomised trial establish the benefit of adding short-term ADT to PBRT to prevent progression in prostate cancer. To our knowledge, these are the first such findings to show that extending salvage radiotherapy to treat the pelvic lymph nodes when combined with short-term ADT results in meaningful reductions in progression after prostatectomy in patients with prostate cancer. FUNDING: National Cancer Institute.

Project SPRUCE: Saving Our Planet by Reducing Carbon Emissions, a Pediatric Anesthesia Sustainability Quality Improvement Initiative.

BACKGROUND: Children are particularly vulnerable to adverse health outcomes related to climate change. Inhalational anesthetics are potent greenhouse gasses (GHGs) and contribute significantly to health care-generated emissions. Desflurane and nitrous oxide have very high global warming potentials. Eliminating their use, as well as lowering fresh gas flows (FGFs), will lead to reduced emissions. METHODS: Using published calculations for converting volatile anesthetic concentrations to carbon dioxide equivalents (CO 2 e), we derived the average kilograms (kg) CO 2 e/min for every anesthetic administered in the operating rooms at our pediatric hospital and ambulatory surgical center between October 2017 and October 2022. We leveraged real-world data captured from our electronic medical record systems and used AdaptX to extract and present those data as statistical process control (SPC) charts. We implemented recommended strategies aimed at reducing emissions from inhalational anesthetics, including removing desflurane vaporizers, unplugging nitrous oxide hoses, decreasing the default anesthesia machine FGF, clinical decision support tools, and educational initiatives. Our primary outcome measure was average kg CO 2 e/min. RESULTS: A combination of educational initiatives, practice constraints, protocol changes, and access to real-world data were associated with an 87% reduction in measured GHG emissions from inhaled anesthesia agents used in the operating rooms over a 5-year period. Shorter cases (<30 minutes duration) had 3 times higher average CO 2 e, likely due to higher FGF and nitrous oxide use associated with inhalational inductions, and higher proportion of mask-only anesthetics. Removing desflurane vaporizers corresponded with a >50% reduction of CO 2 e. A subsequent decrease in anesthesia machine default FGF was associated with a similarly robust emissions reduction. Another significant decrease in emissions was noted with educational efforts, clinical decision support alerts, and feedback from real-time data. CONCLUSIONS: Providing environmentally responsible anesthesia in a pediatric setting is a challenging but achievable goal, and it is imperative to help mitigate the impact of climate change. Large systems changes, such as eliminating desflurane, limiting access to nitrous oxide, and changing default anesthesia machine FGF rates, were associated with rapid and lasting emissions reduction. Measuring and reporting GHG emissions from volatile anesthetics allows practitioners to explore and implement methods of decreasing the environmental impact of their individual anesthesia delivery practices.

Outcomes for 41 260 pediatric surgical patients with opioid-free anesthesia: One center's experience.

BACKGROUND: Opioid use is common and associated with side effects and risks. Consequently, analgesic strategies to reduce opioid utilization have been developed. Regional anesthesia and multimodal strategies are central tenets of enhanced recovery pathways and facilitate reduced perioperative opioid use. Opioid-free anesthesia (OFA) protocols eliminate all intraoperative opioids, reserving opioids for postoperative rescue treatment. Systematic reviews show variable results for OFA. METHODS: In a series of Quality Improvement (QI) projects, multidisciplinary teams developed interventions to test and spread OFA first in our ambulatory surgery center (ASC) and then in our hospital. Outcome measures were tracked using statistical process control charts to increase the adoption of OFA. RESULTS: Between January 1, 2016, and September 30, 2022, 19 872 of 28 574 ASC patients received OFA, increasing from 30% to 98%. Post Anesthesia Care Unit (PACU) maximum pain score, opioid-rescue rate, and postoperative nausea and vomiting (PONV) treatment all decreased concomitantly. The use of OFA now represents our ambulatory standard practice. Over the same timeframe, the spread of this practice to our hospital led to 21 388 of 64 859 patients undergoing select procedures with OFA, increasing from 15% to 60%. Opioid rescue rate and PONV treatment in PACU decreased while hospital maximum pain scores and length of stay were stable. Two procedural examples with OFA benefits were identified. The use of OFA allowed relaxation of adenotonsillectomy admission criteria, resulting in 52 hospital patient days saved. Transition to OFA for laparoscopic appendectomy occurred concomitantly with a decrease in the mean hospital length of stay from 2.9 to 1.4 days, representing a savings of >500 hospital patient days/year. CONCLUSIONS: These QI projects demonstrated that most pediatric ambulatory and select inpatient surgeries are amenable to OFA techniques which may reduce PONV without worsening pain.

Deep neural networks reveal topic-level representations of sentences in medial prefrontal cortex, lateral anterior temporal lobe, precuneus, and angular gyrus.

When reading a sentence, individual words can be combined to create more complex meaning. In this study, we sought to uncover brain regions that reflect the representation of the meaning of sentences at the topic level, as opposed to the meaning of their individual constituent words when considered irrespective of their context. Using fMRI, we recorded the neural activity of participants while reading sentences. We constructed a topic-level sentence representations using the final layer of a convolutional neural network (CNN) trained to classify Wikipedia sentences into broad semantic categories. This model was contrasted with word-level sentence representations constructed using the average of the word embeddings constituting the sentence. Using representational similarity analysis, we found that the medial prefrontal cortex, lateral anterior temporal lobe, precuneus, and angular gyrus more strongly represent sentence topic-level, compared to word-level, meaning, uncovering the important role of these semantic system regions in the representation of topic-level meaning. Results were comparable when sentence meaning was modelled with a multilayer perceptron that was not sensitive to word order within a sentence, suggesting that the learning objective, in the terms of the topic being modelled, is the critical factor in capturing these neural representational spaces.

A systematic review with meta-analysis of the StartReact effect on motor responses in stroke survivors and healthy individuals.

Control of limb movements may be impaired after stroke due to the loss of connectivity between the cerebral cortex and spinal cord. A notion to improve motor function in stroke survivors is to use alternate motor fibers, such as the reticulospinal tract (RST), which originate from the brainstem and terminate at different levels of spinal cord. One way of targeting the RST is to use a "StartReact" protocol to foster premature release of a preplanned movement in response to a startling stimulus. Our aim was to find support for the preservation of such StartReact effect in stroke survivors. We conducted a systematic review with meta-analysis of literature published in English up to September 2020, to explore differences in motor responses to startling stimuli in StartReact effects. Protocol of the study was registered (PROSPERO Registration No. CRD42020191581). PubMed, Google Scholar, Web of Science, PsycINFO, and Science Direct were searched for relevant literature. The meta-analysis contained six studies involving a total of 151 stroke and healthy participants. Muscle onset latency data were extracted from the qualifying studies and compared using RevMan. StartReact effect was present in both stroke and healthy groups, represented by shortened muscle onset latency when startling stimulus was present. There was considerable heterogeneity of the outcome measures, which was attributed to the range of motor impairments among stroke survivors and methodologies used. Our findings support the notion of preservation of preprogramming ability and suitability of RST and StartReact effect for motor rehabilitation following stroke.

The minimal important change for measures of balance and postural control in older adults: a systematic review.

The minimal important change and analogous terms (MIC) can provide a measure of change in health outcome variables that is associated with a level of importance for participant/patient. This review explores the availability of the MIC for different balance measures used with older adults in research and clinical settings. PubMed, ProQuest and Web of Science search engines were used and based on the inclusion and exclusion criteria, 11 studies were deemed suitable for data extraction and analysis. The results demonstrated that MIC is available for the following balance-associated tests: Berg Balance Scale, Timed Up and Go, Short Physical Performance Battery, BESTest and the Tinetti test. A range of MIC values were shown, reflective of different older adult health conditions, calculation methods and anchors used. It was also evident that the responsiveness of the test was not always available or appropriately determined, questioning the validity of the MIC value published. Greater research is needed to establish MIC for balance measurements for use with older adults with different health conditions, preferably using objective measures such as falls. The calculation of such statistics will improve the evaluation of intervention effectiveness.

Completion of an Enhanced Recovery Program in a Pediatric Ambulatory Surgery Center: A Quality Improvement Initiative.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) was first established in 2001 focusing on recovery from complex surgical procedures in adults and recently expanded to ambulatory surgery. The evidence for ERAS in children is limited. In 2018, recognized experts began developing needed pediatric evidence. Center-wide efforts involving all ambulatory surgical patients and procedures have not previously been described. METHODS: A comprehensive assessment and gap analysis of ERAS elements in our ambulatory center identified 11 of 19 existing elements. The leadership committed to implementing an Enhanced Recovery Program (ERP) to improve existing elements and close as many remaining gaps as possible. A quality improvement (QI) team was launched to improve 5 existing ERP elements and to introduce 6 new elements (target 17/19 ERP elements). The project plan was broken into 1 preparation phase to collect baseline data and 3 implementation phases to enhance existing and implement new elements. Statistical process control methodology was used. Team countermeasures were based on available evidence. A consensus process was used to resolve disagreement. Monthly meetings were held to share real-time data, gather new feedback, and modify countermeasure plans as needed. The primary outcome measure selected was mean postanesthesia care unit (PACU) length of stay (LOS). Secondary outcomes measures were mean maximum pain score in PACU and patient/family satisfaction scores. RESULTS: The team had expanded the pool of active ERP elements from 11 to 16 of 19. The mean PACU LOS demonstrated significant reduction (early in phase 1 and again in phase 3). No change was seen for the mean maximum pain score in PACU or surgical complication rates. Patient/family satisfaction scores were high and sustained throughout the period of study (91.1% ± 5.7%). Patient/family and provider engagement/compliance were high. CONCLUSIONS: This QI project demonstrated the feasibility of pediatric ERP in an ambulatory surgical setting. Furthermore, a center-wide approach was shown to be possible. Additional studies are needed to determine the relevance of this project to other institutions.

The effect of walking and stationary work on the acute back pain, muscle activation, posture and postural control of older women.

Back pain is associated with activity such as walking or assembly line work that involves upper-body movement. However, no single study has explored the effect of these tasks on back pain, spinal angles and balance in an older adult female population. This study investigated changes in back pain, postural sway, upper-, lower- and full-spine angle and EMG activation of trunk muscles following 30 minutes of walking and a modified quiet standing task. Fourteen older adult females (62 ± 11yrs) with low to moderate chronic back pain were recruited as participants. Findings demonstrated that following these activities, increased acute back pain and upper-spine flexion occur although acute back pain was not clinically significant; postural control and muscle activation remained unchanged. This suggests that walking and modified quiet standing can lead to subtle acute back pain in older females that could be due to an increased upper spinal flexion rather than muscle fatigue. Practitioner summary: Back pain and postural problems are common in older adults. Older adult female participants experienced increased back pain and greater upper-spine flexion following 30-minute walking and standing with trunk rotation, but the practical importance was less clear. However, balance was unaffected, suggesting no increase in fall risk. Abbreviations: CBP: chronic back pain; MQS: modified quiet standing; QS: quiet standing; RPE: rating of perceived exertion; TD: trapezius descendens; TT: trapezius transversalis; TA: trapezius ascendens; ESL: erector spinae longissimus; C7: seventh cervical vertebrae; T7: seventh thoracic vertebrae; T10: tenth thoracic vertebrae; T12: twelfth thoracic vertebrae; L2: second lumbar vertebrae; S2: second sacral vertebrae; AP: anterior-posterior; ML: medial-lateral; SWAYtot: total postural sway; M: mean.

Magnetic resonance imaging-guided stereotactic body radiotherapy for prostate cancer (mirage): a phase iii randomized trial.

BACKGROUND: Stereotactic body radiotherapy (SBRT) is becoming increasingly used in treating localized prostate cancer (PCa), with evidence showing similar toxicity and efficacy profiles when compared with longer courses of definitive radiation. Magnetic resonance imaging (MRI)-guided radiotherapy has multiple potential advantages over standard computed tomography (CT)-guided radiotherapy, including enhanced prostate visualization (abrogating the need for fiducials and MRI fusion), enhanced identification of the urethra, the ability to track the prostate in real-time, and the capacity to perform online adaptive planning. However, it is unknown whether these potential advantages translate into improved outcomes. This phase III randomized superiority trial is designed to prospectively evaluate whether toxicity is lower after MRI-guided versus CT-guided SBRT. METHODS: Three hundred men with localized PCa will be randomized in a 1:1 ratio to SBRT using CT or MRI guidance. Randomization will be stratified by baseline International Prostate Symptom Score (IPSS) (≤15 or > 15) and prostate gland volume (≤50 cc or > 50 cc). Five fractions of 8 Gy will be delivered to the prostate over the course of fourteen days, with or without hormonal therapy and elective nodal radiotherapy (to a dose of 5 Gy per fraction) as per the investigator's discretion. The primary endpoint is the incidence of physician-reported acute grade ≥ 2 genitourinary (GU) toxicity (during the first 90 days after SBRT), as assessed by the CTCAE version 4.03 scale. Secondary clinical endpoints include incidence of acute grade ≥ 2 gastrointestinal (GI) toxicity, 5-year cumulative incidences of physician-reported late grade ≥ 2 GU and GI toxicity, temporal changes in patient-reported quality of life (QOL) outcomes, 5-year biochemical recurrence-free survival and the proportion of fractions of MRI-guided SBRT in which online adaptive radiotherapy is used. DISCUSSION: The MIRAGE trial is the first randomized trial comparing MRI-guided with standard CT-guided SBRT for localized PCa. The primary hypothesis is that MRI-guided SBRT will lead to an improvement in the cumulative incidence of acute grade ≥ 2 GU toxicity when compared to CT-guided SBRT. The pragmatic superiority design focused on an acute toxicity endpoint will allow an early comparison of the two technologies. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT04384770. Date of registration: May 12, 2020. https://clinicaltrials.gov/ct2/show/NCT04384770 PROTOCOL VERSION: Version 2.1, Aug 28, 2020.

In Pursuit of an Opioid-Free Pediatric Ambulatory Surgery Center: A Quality Improvement Initiative.

BACKGROUND: Opioids have been a central component of routine adult and pediatric anesthesia for decades. However, the long-term effects of perioperative opioids are concerning. Recent studies show a 4.8%-6.5% incidence of persistent opioid use after surgery in older children and adults. This means that >2 million of the 50 million patients undergoing elective surgeries in the United States each year are likely to develop persistent opioid use. With this in mind, anesthesiologists at Bellevue Clinic and Surgery Center assembled an interdisciplinary quality improvement team focused on 2 goals: (1) develop effective anesthesia protocols that minimize perioperative opioids and (2) add value to clinical services by maintaining or improving perioperative outcomes while reducing costs. This article describes our project and findings but does not attempt to make inferences or generalizations about populations outside our facility. METHODS: We performed a large-scale implementation of opioid-sparing protocols at our standalone pediatric clinic and ambulatory surgery facility, based in part on the prior success of our previously published tonsillectomy and adenoidectomy protocol. Multiple Plan-Do-Study-Act cycles were performed using data captured from the electronic medical record. The percentage of surgical patients receiving intraoperative opioids and postoperative morphine preintervention and postintervention were compared. The following measures were evaluated using statistical process control charts: maximum postoperative pain score, postoperative morphine rescue rate, total postanesthesia care unit minutes, total anesthesia minutes, and postoperative nausea and vomiting rescue rate. Intraoperative analgesic costs were calculated. RESULTS: Between January 2017 and June 2019, 10,948 surgeries were performed at Bellevue, with 10,733 cases included in the analyses. Between December 2017 and June 2019, intraoperative opioid administration at our institution decreased from 84% to 8%, and postoperative morphine administration declined from 11% to 6% using analgesics such as dexmedetomidine, nonsteroidal anti-inflammatory drugs, and regional anesthesia. Postoperative nausea and vomiting rescue rate decreased, while maximum postoperative pain scores, total anesthesia minutes, and total postanesthesia care unit minutes remained stable per control chart analyses. Costs improved. CONCLUSIONS: By utilizing dexmedetomidine, nonsteroidal anti-inflammatory drugs, and regional anesthesia for pediatric ambulatory surgeries at our facility, perioperative opioids were minimized without compromising patient outcomes or value.

How I Do It: The pudendal nerve block for pediatric ambulatory urologic surgery.

Regional analgesia is an important adjunct for perioperative pain management in the setting of pediatric penile surgeries. Caudal epidural analgesia (CEA) is the most common analgesic technique performed, but it has limitations and associated morbidity. The pudendal nerve block (PNB) is an effective alternative to CEA with a lower risk profile; in prior examination of the approach, PNB has been demonstrated to have similar postoperative pain control outcomes. We describe our technique and highlight observations made as we have transitioned from CEA to PNB for many patients.

Anesthesia management for ENT surgery in a child with X-linked pyruvate kinase deficiency.

Pyruvate dehydrogenase complex deficiency (PDCD) is a rare X-linked disorder that affects glucose metabolism. There are several case reports describing the anesthetic management of patients with PDCD. This is the first case report to describe the anesthetic management of a PDCD patient requiring spontaneous ventilation using dexmedetomidine and ketamine.

Clinical assessment of geometric distortion for a 0.35T MR-guided radiotherapy system.

PURPOSE: To estimate the overall spatial distortion on clinical patient images for a 0.35 T MR-guided radiotherapy system. METHODS: Ten patients with head-and-neck cancer underwent CT and MR simulations with identical immobilization. The MR images underwent the standard systematic distortion correction post-processing. The images were rigidly registered and landmark-based analysis was performed by an anatomical expert. Distortion was quantified using Euclidean distance between each landmark pair and tagged by tissue interface: bone-tissue, soft tissue, or air-tissue. For baseline comparisons, an anthropomorphic phantom was imaged and analyzed. RESULTS: The average spatial discrepancy between CT and MR landmarks was 1.15 ± 1.14 mm for the phantom and 1.46 ± 1.78 mm for patients. The error histogram peaked at 0-1 mm. 66% of the discrepancies were <2 mm and 51% <1 mm. In the patient data, statistically significant differences (p-values < 0.0001) were found between the different tissue interfaces with averages of 0.88 ± 1.24 mm, 2.01 ± 2.20 mm, and 1.41 ± 1.56 mm for the air/tissue, bone/tissue, and soft tissue, respectively. The distortion generally correlated with the in-plane radial distance from the image center along the longitudinal axis of the MR. CONCLUSION: Spatial distortion remains in the MR images after systematic distortion corrections. Although the average errors were relatively small, large distortions observed at bone/tissue interfaces emphasize the need for quantitative methods for assessing and correcting patient-specific spatial distortions.

Natural Language Processing Reveals Vulnerable Mental Health Support Groups and Heightened Health Anxiety on Reddit During COVID-19: Observational Study.

BACKGROUND: The COVID-19 pandemic is impacting mental health, but it is not clear how people with different types of mental health problems were differentially impacted as the initial wave of cases hit. OBJECTIVE: The aim of this study is to leverage natural language processing (NLP) with the goal of characterizing changes in 15 of the world's largest mental health support groups (eg, r/schizophrenia, r/SuicideWatch, r/Depression) found on the website Reddit, along with 11 non-mental health groups (eg, r/PersonalFinance, r/conspiracy) during the initial stage of the pandemic. METHODS: We created and released the Reddit Mental Health Dataset including posts from 826,961 unique users from 2018 to 2020. Using regression, we analyzed trends from 90 text-derived features such as sentiment analysis, personal pronouns, and semantic categories. Using supervised machine learning, we classified posts into their respective support groups and interpreted important features to understand how different problems manifest in language. We applied unsupervised methods such as topic modeling and unsupervised clustering to uncover concerns throughout Reddit before and during the pandemic. RESULTS: We found that the r/HealthAnxiety forum showed spikes in posts about COVID-19 early on in January, approximately 2 months before other support groups started posting about the pandemic. There were many features that significantly increased during COVID-19 for specific groups including the categories "economic stress," "isolation," and "home," while others such as "motion" significantly decreased. We found that support groups related to attention-deficit/hyperactivity disorder, eating disorders, and anxiety showed the most negative semantic change during the pandemic out of all mental health groups. Health anxiety emerged as a general theme across Reddit through independent supervised and unsupervised machine learning analyses. For instance, we provide evidence that the concerns of a diverse set of individuals are converging in this unique moment of history; we discovered that the more users posted about COVID-19, the more linguistically similar (less distant) the mental health support groups became to r/HealthAnxiety (ρ=-0.96, P<.001). Using unsupervised clustering, we found the suicidality and loneliness clusters more than doubled in the number of posts during the pandemic. Specifically, the support groups for borderline personality disorder and posttraumatic stress disorder became significantly associated with the suicidality cluster. Furthermore, clusters surrounding self-harm and entertainment emerged. CONCLUSIONS: By using a broad set of NLP techniques and analyzing a baseline of prepandemic posts, we uncovered patterns of how specific mental health problems manifest in language, identified at-risk users, and revealed the distribution of concerns across Reddit, which could help provide better resources to its millions of users. We then demonstrated that textual analysis is sensitive to uncover mental health complaints as they appear in real time, identifying vulnerable groups and alarming themes during COVID-19, and thus may have utility during the ongoing pandemic and other world-changing events such as elections and protests.

Stable and Unstable Load Carriage Effects on the Postural Control of Older Adults.

The aim of this study was to investigate the effects of backpack load carriage on quiet standing postural control and limits of stability (LOS) of older adults. Fourteen older adults (65 [6] y) performed quiet standing and a forward, right, and left LOS test in 3 conditions, unloaded, stable, and unstable backpack loads while activity of 4 leg muscles was recorded. Stable and unstable loads decreased postural sway (main effect ηp2=.84, stable P < .001, unstable P < .001), mediolateral (main effect ηp2=.49, stable P = .002, unstable P = .018) and anterior-posterior (main effect ηp2=.64, stable P < .001, unstable P = .001) fractal dimension, and LOS distance (main effect ηp2=.18, stable P = .011, unstable P = .046) compared with unloaded. Rectus femoris (main effect ηp2=.39, stable P = .001, unstable P = .010) and gastrocnemius (main effect ηp2=.30, unstable P = .027) activity increased in loaded conditions during LOS and quiet standing. Gastrocnemius-tibialis anterior coactivation was greater in unstable load than stable loaded quiet standing (main effect ηp2=.24, P = .040). These findings suggest older adults adopt conservative postural control strategies minimizing the need for postural corrections in loaded conditions. Reduced LOS may also increase fall risk when carrying a load. However, there was no difference between unstable and stable loads for postural control variables.

The development of an opioid sparing anesthesia protocol for pediatric ambulatory tonsillectomy and adenotonsillectomy surgery-A quality improvement project.

Pain management following pediatric tonsillectomy and adenotonsillectomy surgery is challenging and traditionally involves perioperative opioids. However, the recent national opioid shortage compelled anesthesiologists at Bellevue Surgery Center to identify an alternative perioperative analgesic regimen that minimizes opioids yet provides effective pain relief. We assembled an interdisciplinary quality improvement team to trial a series of analgesic protocols using the Plan-Do-Study-Act cycle. Initially, we replaced intraoperative morphine and acetaminophen (M/A protocol) with intraoperative dexmedetomidine and preoperative ibuprofen (D/I protocol). However, when results were not favorable, we rapidly transitioned to intraoperative ketorolac and dexmedetomidine (D/K protocol). The following measures were evaluated using statistical process control chart methodology and interpreted using Shewhart's theory of variation: maximum pain score in the postanesthesia care unit, postoperative morphine rescue rate, postanesthesia care unit length of stay, total anesthesia time, postoperative nausea and vomiting rescue rate, and reoperation rate within 30 days of surgery. There were 333 patients in the M/A protocol, 211 patients in the D/I protocol, and 196 patients in the D/K protocol. With the D/I protocol, there were small increases in maximum pain score and postanesthesia care unit length of stay, but no difference in morphine rescue rate or total anesthesia time compared to the M/A protocol. With the D/K protocol, postoperative pain control and postanesthesia care unit length of stay were similar compared to the M/A protocol. Both the D/I and D/K protocols had reduced nausea and vomiting rescue rates. Reoperation rates were similar between groups. In summary, we identified an intraoperative anesthesia protocol for pediatric tonsillectomy and adenotonsillectomy surgery utilizing dexmedetomidine and ketorolac that provides effective analgesia without increasing recovery times or reoperation rates.