A Letter to Your Care Providers: Implementation and Analysis of a Letter-based Advance Care Planning Initiative for Gynecologic Oncology Patients.

To determine the impact of a letter-based advance care planning (ACP) healthcare improvement (HI) initiative on rates of ACP conversations and documentation among gynecologic oncology (GO) inpatients. An HI initiative was implemented from January to December 2020 to improve ACP documentation among GO inpatients. Patients admitted to the GO service were given ACP packets with a letter-based ACP worksheet. GO inpatients who were interested in learning more about ACP were visited by medical students trained to lead ACP conversations. ACP documentation rates in the EMR (electronic medical record) pre- and post-intervention were evaluated. Descriptive statistics were calculated. Associations between sociodemographic characteristics and ACP documentation were analyzed using logistic regression. There were 172 patients admitted in 2019 (pre-implementation cohort). Of these, 45/172 patients (26%) had an advance directive (AD) documented in their electronic medical record (EMR). Following the implementation of the ACP HI in 2020, 55/168 patients (33%) had an AD documented in their EMR. This was a 7% absolute increase and 27% relative increase from pre-intervention AD documentation rates. Increasing age was associated with an increased likelihood of having an AD in the chart (p = 0.004). Married women were less likely to have an AD in their chart (p = 0.05). An HI utilizing a letter-based ACP packet given to GO inpatients improved AD documentation in the EMR. This HI offers a unique method for introducing ACP to patients. More work is needed to improve the occurrence and documentation of ACP conversations.

Dosimetric assessment of patient-specific breath-hold reproducibility on liver motion for SBRT planning.

PURPOSE: To investigate the impact of breath-hold reproducibility on liver motion using a respiratory motion management device. METHODS: Forty-four patients with hepatic tumors, treated with SBRT with breath-hold, were randomly selected for this study. All patients underwent three consecutive computed tomography (CT) scans using active breath-hold coordinator (ABC) with three repeated single breath-hold during simulation. The three CT scans were labeled as ABC1-CT, ABC2-CT, and ABC3-CT. Displacements of centroids of the entire livers among the three ABC-CTs were measured as a surrogate for intrafractional motion. For each patient, two different treatment plans were prepared: (a) a clinical plan using a 5-mm expansion of an ITV that encompassed all three GTVs from each of the three ABC-CTs, and (b) a research plan using a 5-mm expansion of the GTV from only ABC1-CT to create PTV. The clinical plan acceptance criteria were that 95% of the PTV and 99% of the GTV received 100% of the prescription dose. Dosimetric endpoints were analyzed and compared for the two plans. RESULTS: All shifts in the medial-lateral direction (range: -3.9 to 2.0 mm) were within 5 mm while 7% of shifts in the anterior-posterior direction (range: -10.5 to 16.7 mm) and 11% of shifts in the superior-inferior direction (range: -17.0 to 8.7 mm) exceeded 5 mm. Six patients (14%) had an intrafraction motion greater than 5 mm in any direction. For these six patients, if a plan was created based on a PTV from a single CT (ex. ABC1-CT), 5 of 12 GTVs captured from other ABC-CTs would fail to meet the clinical acceptance criteria due to poor breath-hold reproducibility. CONCLUSIONS: Non-negligible intrafractional motion occurs in patients with poor breath-hold reproducibility. To identify this subgroup of patients, acquiring three CTs with active breath-hold during simulation is a feasible practical method.

Impact of exposure to counterstereotypic causality of obesity on beliefs about weight controllability and obesity bias.

Individuals with obesity often report experiencing prejudice and discrimination due to their weight. Past research on obesity bias reduction strategies have yielded mixed results. The present study investigated the effectiveness of manipulating information about weight controllability in reducing obesity bias. Participants (N = 350) were randomly assigned into one of three conditions: counterstereotypic, stereotypic, or control. Each condition consisted of four short vignettes. The counterstereotypic condition provided an uncontrollable explanation of obesity (e.g., genetics) in each vignette describing a person with obesity, while the stereotypic condition emphasized lifestyle choices as the main cause of obesity. The control condition included a vignette in which weight was not addressed. Participants completed questionnaires about weight controllability and obesity bias pre- and post-exposure. There was a significant interaction between time and condition on beliefs about weight controllability and obesity bias. Participants in the counterstereotypic condition increased in belief about the uncontrollability of weight and decreased in obesity bias, while participants in the stereotypic condition decreased in belief about the uncontrollability of weight and increased in obesity bias. Obesity bias reduction strategies that utilize information about weight controllability can be effective. However, perpetuating stereotypic causes of obesity can worsen the problem.

Initial treatment of uninsured patients with ST-elevation myocardial infarction by facility percutaneous coronary intervention capabilities.

BACKGROUND: Timely reperfusion is necessary to reduce morbidity and mortality in patients with ST-elevation myocardial infarction (STEMI). Initial care by facilities with percutaneous coronary intervention (PCI) capabilities reduces time to reperfusion. We sought to examine whether insurance status was associated with initial care at emergency departments (EDs) with PCI capabilities among adult patients with STEMI. METHODS: We conducted a retrospective cross-sectional study using Department of Healthcare Access and Information, a nonpublic statewide database reporting ED visits and hospitalizations in California. We included adults initially arriving at EDs with STEMI by diagnostic code (International Classification of Diseases Ninth Revision or 10th Revision) from 2011 to 2019. Multivariable logistic regression modeling included initial care by PCI capable facility as the primary outcome and insurance status (none vs. any) as the primary exposure. Covariates included patient, facility, and temporal factors and we conducted multiple robustness checks. RESULTS: We analyzed 135,358 eligible visits with STEMI included. In our multivariable model, the odds of uninsured patients being initially treated at a PCI-capable facility were significantly lower than those of insured patients (adjusted odds ratio 0.62, 95% CI 0.54-0.72, p < 0.001) and was unchanged in sensitivity analyses. CONCLUSIONS: Uninsured patients with STEMI had significantly lower odds of first receiving care at facilities with PCI capabilities. Our results suggest potential disparities in accessing high-quality and time-sensitive treatment for uninsured patients with STEMI.

Automatic dose prediction using deep learning and plan optimization with finite-element control for intensity modulated radiation therapy.

BACKGROUND: Automatic solutions for generating radiotherapy treatment plans using deep learning (DL) have been investigated by mimicking the voxel's dose. However, plan optimization using voxel-dose features has not been extensively studied. PURPOSE: This study aims to investigate the efficiency of a direct optimization strategy with finite elements (FEs) after DL dose prediction for automatic intensity-modulated radiation therapy (IMRT) treatment planning. METHODS: A double-UNet DL model was adapted for 220 cervical cancer patients (200 for training and 20 for testing), who underwent IMRT between 2016 and 2020 at our clinic. The model inputs were computed tomography (CT) slices, organs at risk (OARs), and planning target volumes (PTVs), and the outputs were dose distributions of uniformly generated high-dose region-controlled plans. The FEs were discretized into equal intervals of the dose prediction value within the [OARs avoid PTV(O-P)] and [body avoids OARs & PTV(B-OP)] regions in the test cohort and used to define the objectives for IMRT plan optimization. The plans were optimized using a two-step process. In the beginning, the plans of two extra cases with and without low-dose region control were compared to pursue robust and optimal dose adjustment degree pattern of FEs. In the first step, the mean dose of O-P FEs were constrained to differing degrees according to the pattern. The further the FEs from the PTV, the tighter the constraints. In the second step, the mean dose of O-P FEs from first step were constrained again but weakly and the dose of the B-OP FEs from dose prediction and PTV were tightly regulated. The dosimetric parameters of the OARs and PTV were evaluated and compared using an interstep approach. In another 10 cases, the plans optimized via the aforementioned steps (method 1) were compared with those directly generated by the double-UNet dose prediction model trained by low and high region-controlled plans (method 2). RESULTS: The mean differences in dose metrics between the UNet-predicted dose and the clinical plans were: 0.47 Gy for bladder D50% ; 0.62 Gy for rectum D50% ; 0% for small intestine V30Gy ; 1% for small intestine V40Gy ; 4% for left femoral head V30Gy ; and 6% for right femoral head V30Gy . The reductions in mean dose (p < 0.001) after FE-based optimization were: 4.0, 1.9, 2.8, 5.9, and 5.7 Gy for the bladder, rectum, small intestine, left femoral head, and right femoral head, respectively, with flat PTV homogeneity and conformity. Method 1 plans produced lower mean doses than those of method 2 for the bladder (0.7 Gy), rectum (1.0 Gy), and small intestine (0.6 Gy), while maintaining  PTV homogeneity and conformity. CONCLUSION: FE-based direct optimization produced lower OAR doses and adequate PTV doses after DL prediction. This solution offers rapid and automatic plan optimization without manual adjustment, particularly in low-dose regions.

A census of the lung: CellCards from LungMAP.

The human lung plays vital roles in respiration, host defense, and basic physiology. Recent technological advancements such as single-cell RNA sequencing and genetic lineage tracing have revealed novel cell types and enriched functional properties of existing cell types in lung. The time has come to take a new census. Initiated by members of the NHLBI-funded LungMAP Consortium and aided by experts in the lung biology community, we synthesized current data into a comprehensive and practical cellular census of the lung. Identities of cell types in the normal lung are captured in individual cell cards with delineation of function, markers, developmental lineages, heterogeneity, regenerative potential, disease links, and key experimental tools. This publication will serve as the starting point of a live, up-to-date guide for lung research at https://www.lungmap.net/cell-cards/. We hope that Lung CellCards will promote the community-wide effort to establish, maintain, and restore respiratory health.

Anaerobic-aerobic biofilm-based digestion of chemical contaminants of emerging concern (CEC) and pathogen indicator organisms in synthetic wastewater.

The efficacy of biofilm based anaerobic-aerobic treatment to reduce caffeine, carbamazepine, and three estrogens (Estrone (E1), 17ß-estradiol (E2), and 17α-ethynylestradiol (EE2)), as well as E. coli (CN-13) and F+ specific coliphage (MS2), from synthetic wastewater was investigated. Results showed no observable reduction of carbamazepine by either anaerobic or aerobic biofilms over a dosing period of 51-days followed by an additional 23 days of observation. Caffeine, by contrast, was reduced by 11.09% in the upflow anaerobic packed bed biofilm reactor (UAnPBBR) and by 91.90% in the aerobic trickling filter biofilm reactor (TF). Estrone (E1) and 17ß-estradiol (E2) showed minimal reduction in the UAnPBBR but 99.67% reduction in the TF, while EE2 was reduced 1.62% in the AnPBBR and 20.36% in the TF. On average, a 3-log reduction of E. coli (CN-13) and a 1-log reduction of F+ specific coliphage (MS2) concentration was observed across the overall reactor system.

A Treatment Planning Study of Stereotactic Body Radiotherapy for Atrial Fibrillation.

PURPOSE:  To explore the feasibility of using stereotactic body radiotherapy (SBRT) to irradiate the antra of the four pulmonary veins while protecting nearby critical organs, such as the esophagus. MATERIALS AND METHODS:  Twenty patients who underwent radiofrequency catheter ablation for atrial fibrillation were selected. For each patient, the antra of the four pulmonary veins were identified as the target volumes on a pre-catheterization contrast or non-contrast CT scan. On each CT scan, the esophagus, trachea, heart, and total lung were delineated and the esophagus was identified as the critical organ. For each patient, three treatment plans were designed with 0, 2, and 5 mm planning margins around the targets while avoiding overlap with a planning organ at risk volume (PRV) generated by a 2 mm expansion of the esophagus. Using three non-coplanar volumetric modulated arcs (VMAT), 60 plans were created to deliver a prescription dose of 50 Gy in five fractions, following the SBRT dose regimen for central lung tumors. With greater than 97% of the planning target volumes (PTV) receiving the prescription doses, we examined dosimetry to 0.03 cc and 5 cc of the esophagus PRV volume as well as other contoured structures. RESULTS: The average PTV-0 mm, PTV-2 mm, and PTV-5 mm volumes were 3.05 ± 1.90 cc, 14.70 ± 5.00 cc, and 40.85 ± 10.20 cc, respectively. With three non-coplanar VMAT arcs, the average conformality indices (ratio of prescription isodose volume to the PTV volume) for the PTV-0 mm, PTV-2 mm and PTV-5 mm were 4.81 ± 2.0, 1.71 ± 0.19, and 1.23 ± 0.08, respectively. Assuming patients were treated under breath-hold with 2 mm planning margins to account for cardiac motion, all plans met esophageal PRV maximum dose limits < 50 Gy to 0.03 cc and 16 plans (80%) met < 27.5 Gy to 5 cc of the esophageal PRVs. For PTV-5 mm plans, 18 plans met the maximum dose limit < 50 Gy to 0.03 cc and only two plans met the maximum dose limit < 27.5 Gy to 5 cc of the esophageal PRV. CONCLUSIONS: The anatomical relationship between the antra of the four pulmonary veins and the esophagus varies from patient to patient. Adding 2 mm planning margins and a 2 mm PRV to the esophagus can meet the dose constraints developed for SBRT central lung tumors. Future studies are needed to validate the safety and efficacy of the planning dose, tolerance dose to normal cardiac tissue, and adequate planning margins.

Identification of threshold concepts for biochemistry.

Threshold concepts (TCs) are concepts that, when mastered, represent a transformed understanding of a discipline without which the learner cannot progress. We have undertaken a process involving more than 75 faculty members and 50 undergraduate students to identify a working list of TCs for biochemistry. The process of identifying TCs for biochemistry was modeled on extensive work related to TCs across a range of disciplines and included faculty workshops and student interviews. Using an iterative process, we prioritized five concepts on which to focus future development of instructional materials. Broadly defined, the concepts are steady state, biochemical pathway dynamics and regulation, the physical basis of interactions, thermodynamics of macromolecular structure formation, and free energy. The working list presented here is not intended to be exhaustive, but rather is meant to identify a subset of TCs for biochemistry for which instructional and assessment tools for undergraduate biochemistry will be developed.