Radiochromic film dosimetry in radiotherapy: a survey of current practice in the United Kingdom.

OBJECTIVES: To establish the variation in film dosimetry usage in radiotherapy centres across the United Kingdom. To identify consensus and highlight areas of potential improvement to enhance radiotherapy dosimetry verification with film. METHODS: A survey questionnaire was designed by members of the Institute of Physics and Engineering in Medicine Interdepartmental Dosimetry Audit Group via Microsoft Forms and distributed to all Heads of Radiotherapy Physics in the United Kingdom. The survey was open from June 19, 2023, to July 31, 2023. RESULTS: Forty responses were received from the 62 radiotherapy centres in the United Kingdom, of which 58% were currently using film dosimetry and a further 7 were keen to commence use. Many reported film use had decreased in recent years but was still valuable particularly for commissioning and implementing new techniques. The variation and consensus of methods for film dosimetry calibration, measurement, and application was established. A review of barriers to implementation and methods to reduce uncertainty were included in the assessment. CONCLUSIONS: A comprehensive assessment of film dosimetry usage in radiotherapy in the United Kingdom has been collated, which demonstrates a wide variation in methods, across typical clinical users, but maintains film as a valuable dosimetry option. ADVANCES IN KNOWLEDGE: This research provides a snapshot of current film dosimetry use across the United Kingdom. It examines the variation and consensus of practice to which individual users can compare their systems, and identifies opportunities to improvement in the accuracy of film dosimetry.

The current use of tissue expanders in breast reconstruction: device design, features, and technical considerations.

INTRODUCTION: The use of tissue expanders (TE) in post-mastectomy breast reconstruction is a widely accepted practice, especially in patients desiring implant-based breast reconstruction. It has become the standard of care to perform a two-staged breast reconstruction using tissue expanders for the past 50 years due to its reliability, safety, cost-effectiveness, and versatility. Due to its popularity, there are numerous types and features of breast tissue expanders and various surgical approaches available for plastic surgeons. AREAS COVERED: In this article, we will review the role of tissue expanders in breast reconstruction, the types and features of breast tissue expanders, and technical considerations. EXPERT OPINION: The use of tissue expanders in breast reconstruction offers significant advantages of preserving the breast skin envelope and reestablishing the breast mound. With evolving approaches to breast reconstruction, tissue expander design, and application underwent several refinements and modifications. Due to these advances, studies on its long-term efficacy and safety profile typically fall behind and more studies with higher levels of evidence are needed to better evaluate the efficacy and safety profile of tissue expanders. With increased understanding, reconstructive surgeons can minimize complications and maximize reconstructive, aesthetic outcomes with high patient satisfaction.

Evaluation of a new radiochromic film dosimeter, Gafchomic EBT4, for VMAT, SABR and HDR treatment delivery verification.

Objective.To evaluate a new film for radiotherapy dosimetry, Gafchromic EBT4, compared to the current EBT3. To evaluate dose-response and verify test cases in MV external beam and HDR brachytherapy.Approach. Three lots (batches) of EBT4 and three lots of EBT3 films were calibrated at 6 MV over 0-1200 cGy range, using FilmQAPro software. Signal-to-noise of pixel value, reported dose (RD), and factors affecting dosimetry accuracy were evaluated (rotation of the film at scanning, energy response and post-exposure darkening). Both films were exposed to clinical treatment plans (VMAT prostate, SABR lung, single HDR source dwell, and 'pseudo' 3-channel HDR cervix brachytherapy). Film-RD was compared to TPS-calculated dose.Main results.EBT4 calibration curves had characteristics more favourable than EBT3 for radiation dosimetry, with improved signal to noise in film-RD of EBT4 compared to EBT3 (increase of average 46% in red and green channels at 500 cGy). Film rotation at scanning and post-exposure darkening was similar for the two films. The energy response of EBT4 is similar to EBT3. For all clinical case studies, EBT4 provided better agreement with the TPS-planned doses than EBT3. VMAT prostate gamma 3%/3 mm passing rate, EBT4 100.0% compared to EBT3 97.9%; SABR lung gamma 2%/2 mm, EBT4 99.6% and EBT3 97.9%; HDR cervix gamma 3%/2 mm, EBT4 97.7% and EBT3 95.0%.Significance.These results show EBT4 is superior to EBT3 for radiotherapy dosimetry validation of TPS plan delivery. Fundamental improvements in noise profile and calibration curve are reported for EBT4. All clinical test cases showed EBT4 provided equivalent or smaller difference in measured dose to TPS calculated dose than EBT3. Baseline data is presented on the achievable accuracy of film dosimetry in radiotherapy using the new Gafchromic EBT4 film.

Physician Burnout and Medical Errors: Exploring the Relationship, Cost, and Solutions.

Physician burnout has demonstrated risks to providers and patients through medical errors. This review aims to synthesize current data surrounding burnout and its impacts on quality to inform targeted interventions that benefit providers and patients. Preferred Reporting Items for Systematic Reviews and Meta-Analyses scoping review methodology was utilized to identify studies of quantitative metrics for burnout and medical errors. Three independent reviewers conducted screening, study selection, and data extraction. Of 1096 identified articles, 21 were analyzed. Overall, 80.9% used the Maslach Burnout Inventory to evaluate for burnout. Moreover, 71.4% used self-reported medical errors as their primary outcome measure. Other outcome measures included observed/identified clinical practice errors and medication errors. Ultimately, 14 of 21 studies found links between burnout and clinically significant errors. Significant associations exist between burnout and medical errors. Physician demographics, including psychological factors, well-being, and training level, modulate this relationship. Better metrics are necessary to quantify errors and their impacts on outcomes. These findings may inform novel interventions that target burnout and improve experiences.

Prevalence, Prevention, and Treatment of Work-Related Musculoskeletal Disorders Among Microsurgeons.

BACKGROUND: While work related musculoskeletal disorders have been well recognized among all surgeons, and microsurgeons in particular; their prevention and treatment are presently unknown. Our study aims to define the impact of musculoskeletal ailments on microsurgeons and investigate trends in microsurgeon musculoskeletal injury treatment. METHODS: An electronic survey was sent to all members of the American Society of Reconstructive Microsurgery. The survey solicited surgeon demographics, microsurgical volume, equipment usage, history of musculoskeletal injury, impact of injury, and interventions / treatment modalities used to address / prevent these issues. RESULTS: Of the 883 microsurgeons surveyed, 203 responded (23% response rate). The average age was 45 years (IQR 39-52 years). Most microsurgeons were male (80.8%). Musculoskeletal injury or symptoms related to microsurgery were reported by 137 respondents (67.0%). Fifty surgeons (37.9%) reported that their musculoskeletal injury had adversely affected their practice. Formal medical intervention was sought by 53 respondents (26.1%), with 17 surgeons (8.4%) undergoing surgical intervention. Self-treated was used by 127 microsurgeons (62.6%) for musculoskeletal ailments. Preventative treatments such as strength training, stretching, yoga, massages, and diet were the most beneficial, each with utilization scores of 4 out of 5. CONCLUSION: A majority of microsurgeons experience musculoskeletal injury, and some even require surgery to treat their musculoskeletal pathology. Prophylactic practices such as strength training, stretching, yoga, massages, and diet maintenance, are the superior treatment for musculoskeletal injury. Microsurgeons should incorporate training routines in their lives as injury prophylaxis to improve their career longevity and patient care.

Improving the quality of head and neck radiotherapy CT images using a second image reconstruction set.

PURPOSE: To improve the quality of radiotherapy head and neck CT images through use of an additional image set reconstructed from the raw data of the primary scan, thus allowing parameters such as reconstruction field-of-view (FOV) and kernel to be optimised without impacting on the images used for treatment planning dose calculations. METHODS: Using a Catphan image quality phantom and a Toshiba Aquilion LB CT scanner, qualitative and quantitative measurements were made for different reconstruction kernels and FOV diameters. The preferred FOV diameter and kernels were selected. Clinical images from six patients were reconstructed using those kernels (FC13, FC41, FC44, FC64) and the chosen FOV, 200 mm. The images were ranked to choose the kernel which gave best image quality for organ delineation. The scanner workflow was adjusted to produce for every scan a second image set using the chosen kernel and FOV. Finally, for 10 patient scans, image quality was compared for the two reconstructed images. RESULTS: The second image set was produced using kernel FC44 and 200 mm FOV. The primary image set using 550 mm FOV and FC13 was unchanged and contours from the second image set merged onto the first. Oncologists reported increased confidence in contouring in all cases using the new procedure. CONCLUSION: Production of a second image set, using a reduced reconstruction FOV and a kernel which optimises contrast and sharpness, significantly improves the quality of head and neck CT images for contouring, and avoids any dose increase.

Suitability of propagated contours for adaptive replanning for head and neck radiotherapy.

PURPOSE: Adaptive radiotherapy relies on rapid recontouring for replanning. Contour propagation offers workflow efficiencies, but the impact of using unedited propagated OAR contours directly during re-optimisation is unclear. METHODS: Plans for ten head and neck patients were created on the planning CT scan. OAR contours for the spinal cord, brainstem, parotids and larynx were then propagated to five shading-corrected CBCTs equally spaced throughout treatment using five commercial packages. Two reference contours were created on the CBCTs by (1) a clinician and (2) a geometric consensus from the propagated contours. Treatment plans were re-optimised on each CBCT for each set of contours, and the DVH statistic differences to the reference contours were calculated. The spread of DVH statistic differences between the 5th and 95th percentiles was quantified. RESULTS: The spread of DVH statistic differences was 3.7 Gy compared to the clinician contour and 3.3 Gy compared to the consensus contour for the brainstem (and PRV) and 2.4 Gy and 2 Gy for the spinal cord (and PRV), across all 5 auto-contouring solutions. The parotids and larynx showed differences of 3.7 Gy compared to the clinician and 0.9 Gy to the consensus contour, with the larger difference for the clinician possibly caused by uncertainty in the clinician standard due to poor image quality on the CBCTs. CONCLUSIONS: Propagated OAR contours can be used safely for adaptive radiotherapy replanning, however, where organ doses are close to clinical tolerance then the contours should be reviewed for accuracy regardless of the propagation software used.

The geometric and dosimetric effect of algorithm choice on propagated contours from CT to cone beam CTs.

PURPOSE: Adaptive radiotherapy relies of rapid re-contouring, online more so than offline. Intra-patient contour propagation via non-rigid registration offers a solution but can be of limited accuracy. However, the dosimetric significance of the inaccuracies is unknown. Here we evaluate the dosimetric reliability of contours generated by different commercially-available software packages. METHOD: Planning CT contours for ten head and neck cancer patients were propagated via five commercial packages to five CBCT scans acquired throughout treatment. The treatment plan was recalculated on each of the CBCTs for each set of propagated contours, and DVH parameters extracted for the spinal cord, brainstem, parotids and larynx. The propagated contours were compared to two gold standard contours: contours manually outlined and a consensus STAPLE contours generated from the propagated contours. Geometrical similarity was evaluated using mean distance to agreement (mDTA), Hausdorff distance, centroid agreement and Dice similarity coefficient. Dosimetric reliability was assessed against clinical constraints and comparing via the intraclass correlation coefficient (ICC). RESULTS: All propagated contours were similar to the STAPLE (mDTA < 1.0 mm) whilst larger differences were seen for the manual contours (mDTA < 3.0 mm). The dosimetric comparison showed that the propagated contours gave excellent dose estimates for most organs. The spinal cord reliability was moderate (ICC > 0.66). CONCLUSIONS: Large differences in geometric metrics rarely had a statistically significant impact on DVH parameters for the OARs studied. For that reason, propagated contours on treatment CBCT images are suitable for estimating dose to the OARs.

Building Your Peripheral Artery Disease Toolkit: Medical Management of Peripheral Artery Disease in 2022.

Peripheral artery disease (PAD) is associated with substantial morbidity, including a high risk of cardiovascular and limb events and death. A growing body of evidence has demonstrated the benefits of antithrombotic therapy, lipid lowering, blood pressure control, diabetes management, smoking cessation, and exercise programs on improving symptoms and reducing these complications. Guidelines make specific recommendations on how to use these strategies to prevent adverse cardiovascular and limb outcomes in patients with PAD. Unfortunately, antithrombotic therapies, statins, optimal antihypertensives, smoking cessation counselling and therapies, and exercise programs have all been consistently shown to be underutilised in PAD patients both in Canada and globally. A variety of barriers to optimal utilisation of evidence-based medical therapies have been described at the patient, health care provider, and system levels. These include lack of knowledge among patients and health care providers, and lack of access to secondary prevention programs. We review the evidence for preventive therapies in PAD, evidence for underutilisation of these therapies, and barriers to their use. Core elements of PAD secondary prevention clinics are proposed, and a summary of optimal medical therapies and relevant tools is provided. This review may help clinicians who treat patients with PAD to develop a toolkit to overcome these barriers in order to improve utilisation of medical therapies, with the ultimate goal of improving outcomes for PAD patients.

Social Deprivation and Peripheral Artery Disease.

The link between peripheral artery disease and socioeconomic status is complex. The objective of this narrative review is to explore that relationship in detail, including how social factors affect the development, management, and outcomes of peripheral artery disease. Although the current literature on this topic is limited, some patterns do emerge. Populations of low socioeconomic status appear to be at increased risk for the development of peripheral artery disease, owing to factors such as increased prevalence of cardiovascular risk factors (eg, cigarette smoking) and decreased access to care. However, variables that are more difficult to quantify, such as chronic stress and health literacy, also likely play a significant role. Among those who are living with peripheral artery disease, socioeconomic status can affect disease management as well. Secondary prevention strategies, such as medication use, smoking cessation, and exercise therapy, are underutilised in socially deprived populations. This underutilisation of evidence-based management leads to adverse outcomes in these groups, including increased rates of amputation and decreased postoperative survival. The recognition of the importance of social factors in prognosis is an important first step toward addressing this health disparity. Moving forward, interventions that help to identify those who are at high risk and improve access to care in populations of low socioeconomic status will be critical to improving outcomes.

Estimation of Hemi-Abdominal-Based Free Flap Weight Using Two Computed Tomography-Derived Measurements.

BACKGROUND: Accurate flap weight estimation is crucial for preoperative planning in microsurgical breast reconstruction; however, current flap weight estimation methods are time consuming. It was our objective to develop a parsimonious and accurate formula for the estimation of abdominal-based free flap weight. METHODS: Patients who underwent hemi-abdominal-based free tissue transfer for breast reconstruction at a single institution were retrospectively reviewed. Subcutaneous tissue thicknesses were measured on axial computed tomography angiograms at several predetermined points. Multivariable linear regression was used to generate the parsimonious flap weight estimation model. Split-sample validation was used to for internal validation. RESULTS: A total of 132 patients (196 flaps) were analyzed, with a mean body mass index of 31.2 ± 4.0 kg/m2 (range: 22.6-40.7). The mean intraoperative flap weight was 990 ± 344 g (range: 368-2,808). The full predictive model (R 2 = 0.68) estimated flap weight using the Eq. 91.3x + 36.4y + 6.2z - 1030.0, where x is subcutaneous tissue thickness (cm) 5 cm lateral to midline at the level of the anterior superior iliac spine (ASIS), y is distance (cm) between the skin overlying each ASIS, and z is patient weight (kg). Two-thirds split-sample validation was performed using 131 flaps to build a model and the remaining 65 flaps for validation. Upon validation, we observed a median percent error of 10.2% (interquartile range [IQR]: 4.5-18.5) and a median absolute error of 108.6 g (IQR: 45.9-170.7). CONCLUSION: We developed and internally validated a simple and accurate formula for the preoperative estimation of hemi-abdominal-based free flap weight for breast reconstruction.

Ergonomics Among Craniofacial Surgeons: A Survey of Work-Related Musculoskeletal Discomfort and Injury.

INTRODUCTION: Surgical procedures with loupe magnification, headlights, and microscopes expose craniofacial surgeons to mechanical stress that can increase risk of long-term musculoskeletal pain and injury. Identifying the prevalence and cause of work-related musculoskeletal discomfort may guide preventative strategies to prolong well-being, job satisfaction, and greater duration of surgical careers. METHODS: A 29-question online survey was distributed to the surgeon members of the American Cleft Palate-Craniofacial Association. Eight hundred seventy-three surveys were distributed, and the anonymous responses were recorded using Google forms. RESULTS: One hundred ninety-six unique responses were recorded (22.5% response rate). A total of 64.2% reported experiencing musculoskeletal symptoms during their career, with neck, lower back, and shoulders being the most common problem areas. Multivariate analysis demonstrated surgical loupes (odds ratio 2.36, P = 0.03) and length of surgical practice >15 years (odds ratio 1.95, P = 0.04) were independently associated with greater odds of developing symptoms. Headlights (median pain = 3, P < 0.001), loupes (median pain = 3.5, P < 0.001), and operative microscope use (median pain = 2, P = 0.02) were all associated with higher pain while operating. A total of 52.5% respondents sought medical treatments, 50.5% were concerned musculoskeletal discomfort would affect their careers, 56.6% reported a colleague that required an operation, and 30.2% reported a colleague on temporary or permanent disability. CONCLUSIONS: Craniofacial surgery often involves long procedures, use of surgical adjuncts, and ergonomically straining postures, which can lead to musculoskeletal discomfort and injury. This under-reported and important phenomenon merits candid conversation and active preventative strategies to prolong surgical careers, improve professional satisfaction, and maximize patient safety.

Augmented Lateral Rectus Recession for Consecutive Exotropia.

Purpose: To evaluate the efficacy of augmented bilateral lateral rectus recession in the treatment of consecutive exotropia.Methods: We retrospectively reviewed records of nine patients who underwent augmented bilateral lateral rectus recession for consecutive exotropia with minimal adduction deficits. Our normal surgical dosing tables for bilateral lateral rectus recession were augmented by adding 1.5-2 mm. All patients had been measured preoperatively using prism and alternate cover testing (PACT), except for one patient in whom Krimsky measurements were performed because of amblyopia. Surgery was deemed successful if postoperative alignment fell within a potential monofixation range of ±10 prism diopters (PD) by PACT at the final postoperative examination.Results: Eight out of nine patients (89%) had a successful outcome. One patient was surgically undercorrected. Despite successful realignment to a state of monofixation syndrome in most patients, there was no significant restoration of stereopsis following strabismus surgery.Conclusions: Surgical augmentation of bilateral lateral rectus recession standard dosing by 1.5-2 mm is efficacious for restoring binocular alignment for both distance and near fixation. This surgical approach may be preferable to bimedial advancements in patients with minimal preoperative adduction deficits who show no significant increase in exotropia during near fixation.

The Effect of Vibration on Pain During Intravenous Injection of Propofol: A Randomized Controlled Trial.

PURPOSE: Pain is a common side effect of intravenous injection of propofol. We conducted a randomized, prospective, single-blinded controlled trial to assess the efficacy of vibration analgesia on pain during propofol infusion in ambulatory surgery. METHODS: After institutional review board approval, 100 patients undergoing elective ambulatory surgery with general anesthesia were randomized into 2 groups. A control group (n = 50) consisted of patients who received infusion of propofol without vibration analgesia. A treatment group (n = 50) consisted of patients who received infusion of propofol with vibration analgesia using the Buzzy device. Pain was assessed using a 4-point pain manifestation scale scored by 2 independent, blinded observers. RESULTS: Participants in the treatment group with vibration analgesia were 0.47 times less likely (95% confidence interval, 0.24-0.94; P = 0.03) to experience any pain than the control group. The median summative pain score in the treatment group was significantly less than that of the control group [1 (interquartile range, 1-2) vs 2 (interquartile range, 2-4); P < 0.01] among participants who experienced any pain. Agreement between the 2 blinded observers regarding pain scores was excellent with κw = 0.82 (P < 0.001). Age, sex, body mass index, needle location or size, and medication doses did not differ significantly between the 2 groups. CONCLUSION: Vibration analgesia is an effective, low-risk modality that reduces the pain of intravenous propofol injection in general anesthesia.

An Update to "Understanding Ambulatory Care Practices in the Context of Patient Safety and Quality Improvement".

The aim of this article is to summarize and interpret the current literature on patient quality and safety measures in the ambulatory setting. The authors reviewed the MEDLINE database from 2016 to the present for articles on patient quality and safety measures in the ambulatory setting. The search was guided by the use of specific keywords and medical subject heading terms, including patient safety, ambulatory care, quality, measurements, medical errors, medication safety and electronic prescribing, safety culture, diagnostic error, team training, continuity, care coordination, simulation exercises, and patient-centered. Studying ambulatory quality and safety remains challenging because of the heterogeneity and complexity of the outpatient environment. This review shows that since 2016, very modest progress has been made in this critical area. Effective change in ambulatory quality and safety will require a prioritization and redoubling of efforts.

Ipsilateral gaze deviation as a risk factor for surgical overcorrection in two-muscle surgery for unilateral superior oblique palsy.

PURPOSE: To investigate the angle of deviation in various gaze positions as a risk factor for overcorrection of moderate-angle unilateral trochlear nerve palsies treated with two-muscle surgery. METHODS: The medical records of consecutive patients with presumed unilateral moderate-angle trochlear nerve palsy who underwent two-muscle surgery were retrospectively reviewed. Patients with overcorrection, defined as reversal of hyperdeviation by prism alternate cover testing at distance (straight ahead) or near measured at 6 weeks, were compared to non-overcorrected patients for their preoperative torsion and ocular alignment at near and distance. RESULTS: A total of 45 patients (age range, 12-77 years; 24 [53%] males) with deviation ranging from 14Δ to 25Δ in primary position underwent two-muscle surgery, of whom 8 (18%) experienced surgical overcorrection by 6 weeks' follow-up. The preoperative angle of deviation was similar between overcorrected and non-overcorrected patients for eight of nine cardinal distance positions and near gaze; however, patients with smaller deviations in ipsilateral gaze were more likely to be overcorrected with two-muscle surgery (8.5 vs 16.0 [P = 0.029]). Cut point analysis determined that an ipsilateral gaze of ≤9Δ was significantly associated with overcorrection. Greater lateral incomitance also trended toward overcorrection (15.0 vs 9.0 [P = 0.059]). Torsion was not a clinically significant indicator of overcorrection (3.5 vs 6 [P = 0.083]). CONCLUSIONS: A preoperative ipsilateral angle of ≤9Δ was associated with overcorrection in patients undergoing two-muscle surgery for moderate angle unilateral trochlear nerve palsies.

Estimation of Profunda Artery Perforator Flap Weight Using Preoperative Computed Tomography Angiography.

BACKGROUND: Given the relatively small size of thigh-based flaps and the possible necessity for a multiflap reconstruction, it is imperative to arrive at an accurate estimation of flap weight during preoperative planning. It was our objective to develop a novel technique for the preoperative estimation of profunda artery perforator (PAP) flap weight. METHODS: All patients that underwent transverse PAP flap breast reconstruction at two institutions were retrospectively reviewed. Subcutaneous tissue thicknesses were measured on axial computed tomography angiography scans at several predetermined points. The distance from the inferior gluteal crease to the PAP was also recorded. Linear regression was used to estimate flap weight. RESULTS: A total of 18 patients (32 flaps) were analyzed. The median intraoperative flap weight was 299 g (interquartile range [IQR]: 235-408). The parsimonious model (R 2 = 0.80) estimated flap weight using the Eq. 77.9x + 33.8y + 43.4z - 254.3, where x is subcutaneous tissue thickness (cm) at the lateral border of long head of the biceps femoris at a level 4.5 cm caudal to the inferior gluteal fold, y is distance (cm) from the inferior gluteal fold to the dominant PAP, and z has a value of 1 if the patient was scanned in the supine position or 0 if prone. The aforementioned formula yielded a median estimated flap weight of 305 g (IQR: 234-402) and a median percent error of 10.5% (IQR: 6.1-16.2). CONCLUSION: The authors demonstrate a simple and accurate formula for the preoperative estimation of transverse PAP flap weight for breast reconstruction.