COVID-19 disruption to family medicine residency curriculum: results from a 2020 US programme directors survey.

OBJECTIVE: This research project examined the effects of the COVID-19 pandemic on the required curriculum in graduate medical education for family medicine residencies. DESIGN: Our questions were part of a larger omnibus survey conducted by the Council of Academic Family Medicine Educational Research Alliance. Data were collected from 23 September to 16 October 2020. SETTING: This study was set in the USA. PARTICIPANTS: Emails were sent to 664 family medicine programme directors in the USA. Of the 312 surveys returned, 35 did not answer our questions and were excluded, a total of 277 responses (44%) were analysed. RESULTS: The level of disruption varied by discipline and region. Geriatrics had the highest reported disruption (median=4 on a 5-point scale) and intensive care unit had the lowest (median=1 on a 5-point scale). There were no significant differences for disruption by type of programme or community size. CONCLUSION: Programme directors reported moderate disruption in family medicine resident education in geriatrics, gynaecology, surgery, musculoskeletal medicine, paediatrics and family medicine site during the pandemic. We are limited in generalisations about how region, type of programme, community size or number of residents influenced the level of disruption, as less than 50% of programme directors completed the survey.

Fascitis plantar. Criterios y experiencias sobre la infiltración con anestésicos locales y corticoesteroides / Plantar fasciitis Criteria and experiences on infiltration with local anesthetics and corticosteroids

Introducción: Dentro del grupo de las enfermedades del sistema osteomioarticular la fascitis plantar (FP) es una de las causas más frecuente de dolor crónico del pie. Objetivo: aportar criterios sobre el empleo de la infiltración de anestésicos locales y corticoesteroides para el tratamiento de la fascitis plantar. Desarrollo: se seleccionaron las infiltraciones de corticoesteroides y de anestésicos locales que se realizan con mayor frecuencia en la práctica clínica, se analizó su efectividad según la evidencia en la literatura internacional y a partir de ahí se contrastaron los resultados encontrados con los criterios y experiencias de los autores de este trabajo. Conclusiones: Las consideraciones realizadas en este estudio apuntan a que el uso de los corticoides mediante infiltraciones en patologías ortopédicas es un medio valioso para mejorar la inflamación de los tejidos y para el alivio de los dolores, tanto cuando se emplea en las articulaciones como en las partes blandas(AU)

Introduction: within the group of diseases of the osteomioarticular system, plantar fasciitis (FP) is one of the most frequent causes of chronic foot pain. Objective: to provide criteria on the use of infiltration of local anesthetics and corticosteroids for the treatment of plantar fasciitis. Development: the infiltrations of corticosteroids and local anesthetics that are performed more frequently in clinical practice were selected, their effectiveness was analyzed according to the evidence in the international literature and from there the results were contrasted with the criteria and experiences of the patients authors of this work. Conclusions: the considerations made in this study suggest that the use of corticosteroids through infiltrations in orthopedic pathologies is a valuable means to improve inflammation of the tissues and for the relief of pain, both when used in the joints and in the joints and soft parts(AU)

Semiconductor real-time quality assurance dosimetry in brachytherapy.

With the increase in complexity of brachytherapy treatments, there has been a demand for the development of sophisticated devices for delivery verification. The Centre for Medical Radiation Physics (CMRP), University of Wollongong, has demonstrated the applicability of semiconductor devices to provide cost-effective real-time quality assurance for a wide range of brachytherapy treatment modalities. Semiconductor devices have shown great promise to the future of pretreatment and in vivo quality assurance in a wide range of brachytherapy treatments, from high-dose-rate (HDR) prostate procedures to eye plaque treatments. The aim of this article is to give an insight into several semiconductor-based dosimetry instruments developed by the CMRP. Applications of these instruments are provided for breast and rectal wall in vivo dosimetry in HDR brachytherapy, urethral in vivo dosimetry in prostate low-dose-rate (LDR) brachytherapy, quality assurance of HDR brachytherapy afterloaders, HDR pretreatment plan verification, and real-time verification of LDR and HDR source dwell positions.

Development of a silicon diode detector for skin dosimetry in radiotherapy.

PURPOSE: The aim of in vivo skin dosimetry was to measure the absorbed dose to the skin during radiotherapy, when treatment planning calculations cannot be relied on. It is of particularly importance in hypo-fractionated stereotactic modalities, where excessive dose can lead to severe skin toxicity. Currently, commercial diodes for such applications are with water equivalent depths ranging from 0.5 to 0.8 mm. In this study, we investigate a new detector for skin dosimetry based on a silicon epitaxial diode, referred to as the skin diode. METHOD: The skin diode is manufactured on a thin epitaxial layer and packaged using the "drop-in" technology. It was characterized in terms of percentage depth dose, dose linearity, and dose rate dependence, and benchmarked against the Attix ionization chamber. The response of the skin diode in the build-up region of the percentage depth dose (PDD) curve of a 6 MV clinical photon beam was investigated. Geant4 radiation transport simulations were used to model the PDD in order to estimate the water equivalent measurement depth (WED) of the skin diode. Measured output factors using the skin diode were compared with the MOSkin detector and EBT3 film at 10 cm depth and at surface at isocenter of a water equivalent phantom. The intrinsic angular response of the skin diode was also quantified in charge particle equilibrium conditions (CPE) and at the surface of a solid water phantom. Finally, the radiation hardness of the skin diode up to an accumulated dose of 80 kGy using photons from a Co-60 gamma source was evaluated. RESULTS: The PDD curve measured with the skin diode was within 0.5% agreement of the equivalent Geant4 simulated curve. When placed at the phantom surface, the WED of the skin diode was estimated to be 0.075 ± 0.005 mm from Geant4 simulations and was confirmed using the response of a corrected Attix ionization chamber placed at water equivalent depth of 0.075 mm, with the measurement agreement to within 0.3%. The output factor measurements at 10 cm depth were within 2% of those measured with film and the MOSkin detector down to a field size of 2 × 2 cm2 . The dose-response for all detector samples was linear and with a repeatability within 0.2%. The skin diode intrinsic angular response showed a maximum deviation of 8% at 90 degrees and from 0 to 60 degree is less than 5%. The radiation sensitivity reduced by 25% after an accumulated dose of 20 kGy but after was found to stabilize. At 60 kGy total accumulated dose the response was within 2% of that measured at 20 kGy total accumulated dose. CONCLUSIONS: This work characterizes an innovative detector for in vivo and real-time skin dose measurements that is based on an epitaxial silicon diode combined with the Centre for Medical Radiation Physics (CMRP) "drop-in" packaging technology. The skin diode proved to have a water equivalent depth of measurement of 0.075 ± 0.005 mm and the ability to measure doses accurately relative to reference detectors.

A 2D silicon detector array for quality assurance in small field dosimetry: DUO.

PURPOSE: Nowadays, there are many different applications that use small fields in radiotherapy treatments. The dosimetry of small radiation fields is not trivial due to the problems associated with lateral disequilibrium and source occlusion and requires reliable quality assurance (QA). Ideally such a QA tool should provide high spatial resolution, minimal beam perturbation and real time fast measurements. Many different types of silicon diode arrays are used for QA in radiotherapy; however, their application in small filed dosimetry is limited, in part, due to a lack of spatial resolution. The Center of Medical Radiation Physics (CMRP) has developed a new generation of a monolithic silicon diode array detector that will be useful for small field dosimetry in SRS/SRT. The objective of this study is to characterize a monolithic silicon diode array designed for dosimetry QA in SRS/SRT named DUO that is arranged as two orthogonal 1D arrays with 0.2 mm pitch. METHODS: DUO is two orthogonal 1D silicon detector arrays in a monolithic crystal. Each orthogonal array contains 253 small pixels with size 0.04 × 0.8 mm2 and three central pixels are with a size of 0.18 × 0.18 mm2 each. The detector pitch is 0.2 mm and total active area is 52 × 52 mm2 . The response of the DUO silicon detector was characterized in terms of dose per pulse, percentage depth dose, and spatial resolution in a radiation field incorporating high gradients. Beam profile of small fields and output factors measured on a Varian 2100EX LINAC in a 6 MV radiation fields of square dimensions and sized from 0.5 × 0.5 cm2 to 5 × 5 cm2 . The DUO response was compared under the same conditions with EBT3 films and an ionization chamber. RESULTS: The DUO detector shows a dose per pulse dependence of 5% for a range of dose rates from 2.7 × 10-4 to 1.2 × 10-4 Gy/pulse and 23% when the rate is further reduced to 2.8 × 10-5 Gy/pulse. The percentage depth dose measured to 25 cm depth in solid water phantom beyond the surface and for a field size of 10 × 10 cm2 agrees with that measured using a Markus IC within 1.5%. The beam profiles in both X and Y orthogonal directions showed a good match with EBT3 film, where the FWHM agreed within 1% and penumbra widths within 0.5 mm. The effect of an air gap above the DUO detector has also been studied. The output factor for field sizes ranging from 0.5 × 0.5 cm2 to 5 × 5 cm2 measured by the DUO detector with a 0.5 mm air gap above silicon surface agrees with EBT3 film and MOSkin detectors within 1.8%. CONCLUSIONS: The CMRP's monolithic silicon detector array, DUO, is suitable for SRS/SRT dosimetry and QA because of its very high spatial resolution (0.2 mm) and real time operation.

Initial experiments with gel-water: towards MRI-linac dosimetry and imaging.

Tracking the position of a moving radiation detector in time and space during data acquisition can replicate 4D image-guided radiotherapy (4DIGRT). Magnetic resonance imaging (MRI)-linacs need MRI-visible detectors to achieve this, however, imaging solid phantoms is an issue. Hence, gel-water, a material that provides signal for MRI-visibility, and which will in future work, replace solid water for an MRI-linac 4DIGRT quality assurance tool, is discussed. MR and CT images of gel-water were acquired for visualisation and electron density verification. Characterisation of gel-water at 0 T was compared to Gammex-RMI solid water, using MagicPlate-512 (M512) and RMI Attix chamber; this included percentage depth dose, tissue-phantom ratio (TPR20/10), tissue-maximum ratio (TMR), profiles, output factors, and a gamma analysis to investigate field penumbral differences. MR images of a non-powered detector in gel-water demonstrated detector visualisation. The CT-determined gel-water electron density agreed with the calculated value of 1.01. Gel-water depth dose data demonstrated a maximum deviation of 0.7% from solid water for M512 and 2.4% for the Attix chamber, and by 2.1% for TPR20/10 and 1.0% for TMR. FWHM and output factor differences between materials were ≤0.3 and ≤1.4%. M512 data passed gamma analysis with 100% within 2%, 2 mm tolerance for multileaf collimator defined fields. Gel-water was shown to be tissue-equivalent for dosimetry and a feasible option to replace solid water.