Dosimetric evaluation of incorporating the revised V4.0 calibration protocol for breast intraoperative radiotherapy with the INTRABEAM system.

In breast-targeted intraoperative radiotherapy (TARGIT) clinical trials (TARGIT-B, TARGIT-E, TARGIT-US), a single fraction of radiation is delivered to the tumor bed during surgery with 1.5- to 5.0-cm diameter spherical applicators and an INTRABEAM x-ray source (XRS). This factory-calibrated XRS is characterized by two depth-dose curves (DDCs) named "TARGIT" and "V4.0." Presently, the TARGIT DDC is used to treat patients enrolled in clinical trials; however, the V4.0 DDC is shown to better represent the delivered dose. Therefore, we reevaluate the delivered prescriptions under the TARGIT protocols using the V4.0 DDC. A 20-Gy dose was prescribed to the surface of the spherical applicator, and the TARGIT DDC was used to calculate the treatment time. For a constant treatment time, the V4.0 DDC was used to recalculate the dosimetry to evaluate differences in dose rate, dose, and equivalent dose in 2-Gy fractions (EQD2) for an α/ß = 3.5 Gy (endpoint of locoregional relapse). At the surface of the tumor bed (i.e., spherical applicator surface), the calculations using the V4.0 DDC predicted increased values for dose rate (43-16%), dose (28.6-23.2 Gy), and EQD2 (95-31%) for the 1.5- to 5.0-cm diameter spherical applicator sizes, respectively. In general, dosimetric differences are greatest for the 1.5-cm diameter spherical applicator. The results from this study can be interpreted as a reevaluation of dosimetry or the dangers of underdosage, which can occur if the V4.0 DDC is inadvertently used for TARGIT clinical trial patients. Because the INTRABEAM system is used in TARGIT clinical trials, accurate knowledge about absorbed dose is essential for making meaningful comparisons between radiation treatment modalities, and reproducible treatment delivery is imperative. The results of this study shed light on these concerns.

Above, Beyond, and Over the Side rails: Evaluating the New Memorial Emergency Department Fall-Risk-Assessment Tool.

INTRODUCTION: Patient falls are a significant issue in hospitalized patients and financially costly to hospitals. The Joint Commission requires that patients be assessed for fall risk and interventions in place to mitigate the risk of falls. It is imperative to have a patient population/setting specific fall risk assessment tool to identify patients at risk for falling. The purpose of this study was to evaluate the reliability and validity of the 2013 Memorial ED Fall Risk Assessment tool (MEDFRAT) specifically designed for the ED population. METHOD: A two-phase prospective design was used for this study. Phase one determined the interrater reliability of the MEDFRAT. Phase two assessed the validity of the MEDFRAT in an emergency department (ED) within a 600-bed academic/teaching institution; Level II Trauma Center with >100,000 annual patient visits. RESULTS: The Memorial ED Fall Risk Assessment Tool was validated in this ED setting. The tool demonstrated positive interrater reliability (k=0.701) and when implemented with a falls prevention strategy and staff education demonstrated a 48% decrease in ED fall rate (0.57 falls/1000 patient visits) post implementation during the study period. DISCUSSION: The MEDFRAT, an evidenced based ED-specific fall risk tool was implemented on the basis of the risk factors consistently identified in the literature: prior fall history, impaired mobility, altered mental status, altered elimination, and the use of sedative medication. The Memorial ED Fall Risk Assessment Tool demonstrated to be a valid tool for this hospital system.

Reducing indwelling urinary catheter use in the emergency department: a successful quality-improvement initiative.

INTRODUCTION: This quality-improvement project aimed to evaluate the effectiveness of implementing multidisciplinary education and deploying utilization tools aimed at reducing the inappropriate insertion of indwelling urinary catheters (IUCs) in the emergency department. Literature supports the use of decision support tools and education as proven techniques to reduce IUC use. Few studies have implemented a multidisciplinary approach involving the use of focus groups to understand the thought processes behind deciding to place an IUC. METHODS: Focus groups were used to understand the current practice for inserting an IUC in the emergency department. These data were then used to create a nursing-based IUC decision support tool and educational presentation regarding appropriate uses for IUCs. Live, in-person education sessions were given to emergency nurses, emergency medical technicians, physicians, and residents; in addition, electronic education was assigned to all emergency nurses and technicians. Seventy-eight percent of ED staff received some form of education regarding appropriate IUC insertion criteria. Physicians and residents also received an in-person presentation on the topic. A survey was sent to all emergency nurses and emergency medical technicians to assess actual practice changes. In addition, an IUC utilization and appropriateness audit was completed before and immediately after the interventions. RESULTS: The project resulted in a 25% decrease in the proportion of patients admitted to inpatient status with IUCs placed in the emergency department and a 9% decrease in the inappropriate use of IUCs. Staff surveys after education showed that staff members were more likely to document the reason for placing an IUC and to use alternatives to IUCs. CONCLUSIONS: The potential risks associated with IUCs often go overlooked by direct-care staff members. Educating staff and creating new standards and utilization tools have often been used to decrease the initial insertion of IUCs and to improve recognition of appropriate removal of IUCs. Using direct feedback from staff to develop the interventions led to a reduction in IUC insertions in the emergency department in the short-term, but long-term changes were not seen. The project results suggest that incorporating staff into the decision making and implementation will lead to long-term acquisition of knowledge and longer-term results. Ongoing regularly scheduled education refreshers need to be assessed for their potential to affect long-term change.

PI-RADS v2.1: What has changed and how to report.

Multiparametric magnetic resonance imaging (MRI) of the prostate has become a vital imaging tool in daily radiological practice for the stratification of the risk of prostate cancer. There has been a recent update to the Prostate Imaging-Reporting and Data System (PI-RADS). The updated changes in PI-RADS, which is version 2.1, have been described with information pertaining to the recommended imaging protocols, the techniques on how to perform prostate MRI and a simplified approach to interpreting and reporting MRI of the prostate. Explanatory tables, schematic diagrams and key representative images have been used to provide the reader with a useful approach to interpreting and then stratifying lesions in the four anatomical zones of the prostate gland. The intention of this article is to address challenges of interpretation and reporting of prostate lesions in daily practice.

Genetic Polymorphisms Associated with Idiopathic Short Stature and First-Year Response to Growth Hormone Treatment.

BACKGROUND/AIMS: The term idiopathic short stature (ISS) describes short stature of unknown, but likely polygenic, etiology. This study aimed to identify genetic polymorphisms associated with the ISS phenotype, and with growth response to supplemental GH. METHODS: Using a case-control analysis we compared the prevalence of "tall" versus "short" alleles at 52 polymorphic loci (17 in growth-related candidate genes, 35 identified in prior genome-wide association studies of adult height) in 94 children with ISS followed in the Genetics and Neuroendocrinology of Short Stature International Study, versus 143 controls from the Fels Longitudinal Study. RESULTS: Four variants were nominally associated with ISS using a genotypic model, confirmed by a simultaneous confident inference approach: compared with controls children with ISS had lower odds of "tall" alleles (odds ratio, 95% CI) for GHR (0.52, 0.29-0.96); rs2234693/ESR1 (0.50, 0.25-0.98); rs967417/BMP2 (0.39, 0.17-0.93), and rs4743034/ZNF462 (0.40, 0.18-0.89). Children with ISS also had lower odds of the "tall" allele (A) at the IGFBP3 -202 promoter polymorphism (rs2855744; 0.40, 0.20-0.80) in the simultaneous confident inference analysis. A significant association with 1st-year height SD score increase during GH treatment was observed with rs11205277, located near 4 known genes: MTMR11, SV2A, HIST2H2AA3, and SF3B4; the latter, in which heterozygous mutations occur in Nager acrofacial dysostosis, appears the most relevant gene. CONCLUSIONS: In children with ISS we identified associations with "short" alleles at a number of height-related loci. In addition, a polymorphic variant located near SF3B4 was associated with the GH treatment response in our cohort. The findings in our small study warrant further investigation.

Intravenous Push Cephalosporin Antibiotics in the Emergency Department: A Practice Improvement Project.

Delays in administration of appropriate antibiotics to patients with septic shock are associated with increased mortality. To improve the care of patients with sepsis within our 73-bed emergency department (ED), a "first-dose" intravenous push (IVP) cephalosporin antibiotic protocol was initiated. This project was aimed at improving the time from provider order of antibiotic to administration, which follows the Sepsis Core Measure of timely antibiotic administration.This was a single-center, retrospective analysis of a practice improvement study. Time from provider order of an IV cephalosporin antibiotic to administration was compared between postprotocol dates of March to May 2016 (n = 1110) and preprotocol dates of November 2015 to January 2016 (n = 1146). The cost of supplies for IVP was compared with traditional infusion. Prior to implementation of the IVP protocol, ED nursing staff completed a survey of administration preferences and then received one-on-one instruction about the protocol from the clinical nurse specialist and clinical nurse educator. In addition, a tip sheet was developed and IVP kits complete with all needed supplies were made available in the automated medication dispensing system.Median time from IV cephalosporin antibiotic order to administration significantly decreased by 8, 12, 14, and 13 min for ceftriaxone, ceftazidime, cefepime, and cefazolin, respectively (p < 0.007 for all). This was true for all indications of antibiotic use. Nursing staff favored IVP administration over traditional IV infusion (87%). Supply cost to administer IVP antibiotics was $0.83 compared with $9.53 for traditional IV infusion.A "first-dose IVP" protocol decreased time to administration by eliminating the need for procurement of an infusion pump, setup, and documentation of a secondary infusion. It was also preferred by ED nursing staff and associated with cost savings.

Therapeutic communication and relationships in chronic and complex care.

As the population ages and the incidence of chronic diseases and lifestyle-related conditions rises, nurses are increasingly required to provide care for people with a range of chronic (long-term) conditions. The healthcare needs of patients are often complicated by comorbid conditions. Nurses deliver healthcare in the context of the patient's medical conditions, treatment regimens, the healthcare system, and the individual's socioeconomic, personal and family factors, which may include the challenges of social isolation and geographic distance. In such complex circumstances, patients may be perceived as 'difficult' or 'challenging', however, the challenge is not the patient themselves, but the relationship between the nurse and the patient. Communication difficulties can occur between nurses and patients, which may affect the therapeutic relationship and the quality of care provided. This article discusses the communication skills that nurses require to interact effectively with patients who have complex and chronic comorbid conditions. It focuses on therapeutic communication strategies and the nurse-patient relationship, while emphasising the need for nurses to be self-aware when caring for patients with complex healthcare needs.

Medical device research.

This perspective provides a commentary on the quality of life improvements made available from advances in medical device technology. An opinion of the elements necessary to bring innovation into medical device research is offered. In order to enhance the output of medical device research, strong interactive links are needed between clinicians and researchers to ensure research activities are focused on the needs of patients. Alliances with industry umbrella groups can support these links and facilitate the commercialization of new ideas generated from the research. Several forecasts for the medical device market obtained from other sources are also presented.

An overview of craniospinal axis fields and field matching.

Many methods are implemented for craniospinal axis (CSA) radiation treatment (RT). This paper's goal is to define correctly matched CSA RT fields. Overlap or a space between matched RT fields can create variances of dose and the possibility of negative side effects or disease recurrence, respectively. An accurate CSA RT match procedure is created with localization markers, immobilization devices, equations, feathered matches, safety gap, and portal imaging. A CS match angle is predetermined to optimize patient position before immobilization device fabrication. Various central axis (CA) placements within the brain and spine fields that effect gantry, table, and collimator rotation are described. An overview of the methods used to create CSA RT fields and matches is presented for optimal CSA RT implementation. In addition, to the author's knowledge, this is the first time that a prone CSA RT with anesthesia has been described.

Prevalence and incidence of diabetes mellitus in GH-treated children and adolescents: analysis from the GeNeSIS observational research program.

BACKGROUND: GH has an insulin antagonist effect, and GH treatment has therefore been suggested to impair glucose metabolism and increase risk of diabetes mellitus. SETTING: Data from 11,686 GH-treated patients in the Genetics and Neuroendocrinology of Short Stature International Study (GeNeSIS), a multinational observational study of children with growth disorders, were analyzed for diabetes incidence. Baseline diabetes prevalence was determined from a GH-naive subgroup. METHODS: Prevalence and incidence (by standardized incidence ratio) were compared with results from patients aged less than 20 yr in the U.S. SEARCH for Diabetes in Youth study. RESULTS: Baseline type 1 diabetes prevalence per 1000 persons was 4.92 (95% confidence interval = 1.91-12.58) in GeNeSIS and 1.03 (0.97-1.10) in SEARCH for 0- to 9-yr-olds, and 7.33 (4.20-12.77) and 2.99 (2.78-2.98), respectively, for 10- to 19-yr-olds; there were no GeNeSIS cases of type 2 diabetes before GH initiation. During a median 1.8 yr of GH treatment, diabetes standardized incidence ratios for U.S. patients were 1.4 (0.5-3.1) for type 1 and 8.5 (2.8-19.5) for type 2, and for all patients was 1.4 (0.7-2.4) for type 1 and 6.5 (3.3-11.7) for type 2. Among the 11 patients with incident type 2 diabetes, risk factors for diabetes were identified in 10 patients. Glucose concentrations normalized for seven of nine patients for whom glycemic status could be determined (three of whom continued GH therapy and four who discontinued). CONCLUSION: The incidence of type 2 diabetes was higher in GH-treated children than the general population. Monitoring of glucose, before and periodically during GH treatment, is recommended for those with preexisting type 2 diabetes risk factors.

Biotransformation of substituted pyridines with dioxygenase-containing microorganisms.

A series of 2-, 3- and 4-substituted pyridines was metabolised using the mutant soil bacterium Pseudomonas putida UV4 which contains a toluene dioxygenase (TDO) enzyme. The regioselectivity of the biotransformation in each case was determined by the position of the substituent. 4-Alkylpyridines were hydroxylated exclusively on the ring to give the corresponding 4-substituted 3-hydroxypyridines, while 3-alkylpyridines were hydroxylated stereoselectively on C-1 of the alkyl group with no evidence of ring hydroxylation. 2-Alkylpyridines gave both ring and side-chain hydroxylation products. Choro- and bromo-substituted pyridines, and pyridine itself, while being poor substrates for P. putida UV4, were converted to some extent to the corresponding 3-hydroxypyridines. These unoptimised biotransformations are rare examples of the direct enzyme-catalysed oxidation of pyridine rings and provide a novel synthetic method for the preparation of substituted pyridinols. Evidence for the involvement of the same TDO enzyme in both ring and side-chain hydroxylation pathways was obtained using a recombinant strain of Escherichia coli (pKST11) containing a cloned gene for TDO. The observed stereoselectivity of the side-chain hydroxylation process in P. putida UV4 was complicated by the action of an alcohol dehydrogenase enzyme in the organism which slowly leads to epimerisation of the initial (R)-alcohol bioproducts by dehydrogenation to the corresponding ketones followed by stereoselective reduction to the (S)-alcohols.

Exploring a chemical encoding strategy for combinatorial synthesis using Friedel-Crafts alkylation.

The use of scandium(III) triflate and ytterbium(III) triflate-catalysed Friedel-Crafts alkylation to insert a set of hydroxymethyl pyrrole amide tags (1b-i) on to polystyrene resins under mild conditions and the encoding of a split and mix peptide library is demonstrated.