Sweeping-beam technique with electrons for large treatment areas as total skin irradiation : Dosimetric and technical aspects of a modified Stanford technique.

PURPOSE: Total skin electron beam therapy (TSEBT) is still a technical and therapeutic challenge today. Thus, we developed TSEBT using a sweeping-beam technique. METHODS: For treatment delivery, a linear accelerator Versa HD (ELEKTA, Stockholm, Sweden) with high-dose-rate electrons (HDRE) was used with a dose rate of 9000 MU/min. Dosimetry quality assurance was performed by multiple measurements with film dosimetry, 2D array, and Roos chamber. RESULTS: Clinical experience shows that treatment durations of 75 to 90 min are usual for the Stanford technique without using HDRE. With this new sweeping-beam irradiation technique, the total treatment time of a daily fraction could be reduced to 20 min while keeping over- and underdosing low. The treatment area is about 60 cmâ€¯× 200 cm and the dose distribution is uniform within 2% and 5% in vertical and horizontal directions, respectively. Initially, the electron energy of 6 MeV is reduced to 3.2 MeV by 1­cm polymethylmethacrylat (PMMA) scatter and the irradiation conditions of a source-surface distance (SSD) of 350 cm. The photon contamination drops to under 1%. CONCLUSION: These results show that the mean dose to total skin varies between 1.3 and 1.8 Gy. The sweeping-beam technique with electrons has a homogeneous dose distribution in connection with a short treatment time.

Timing of delivery with coronavirus disease 2019 pneumonia requiring intensive care unit admission.

Approximately 4% of pregnant patients with coronavirus disease 2019 require intensive care unit admission. Given the practical implications of advanced ventilatory and circulatory support techniques, urgent or emergent delivery for nonreassuring fetal status frequently presents a logistical impossibility. This article proposes a protocol for obstetrical management of patients in these situations, emphasizing coordinated preparation among obstetrical, anesthesiology, and intensivist teams for planned preterm delivery at gestational ages when neonatal outcomes are likely to be favorable.

Association of Maternal Buprenorphine or Methadone Dose with Fetal Growth Indices and Neonatal Abstinence Syndrome.

OBJECTIVE: Our objective was to compare fetal growth and incidence of neonatal abstinence syndrome requiring treatment across pregnant women with opioid use disorders on two types and two dose categories of medication-assisted treatment. STUDY DESIGN: A retrospective cohort study was conducted in a comprehensive, perinatal program in western North Carolina comparing growth percentiles on third-trimester ultrasound and at birth, and diagnosis of neonatal abstinence syndrome requiring treatment. Singletons were exposed in utero to low- to moderate-dose buprenorphine (≤16 mg/day; n = 70), high-dose buprenorphine (≥17 mg/day; n = 36), low- to moderate-dose methadone (≤89 mg/day; n = 41), or high-dose methadone (≥90 mg/day; n = 74). Multivariate analysis of variance with posthoc Bonferroni comparisons (p ≤ 0.01) and multinomial logistic regressions (adjusted odds ratio, 99% confidence interval) were conducted. RESULTS: Differences in neonatal outcomes reached statistical significance for larger head circumference for buprenorphine doses (p = 0.01) and for longer length (p < 0.01) and lower odds of neonatal abstinence syndrome requiring treatment (p < 0.01) with low- to moderate-dose buprenorphine versus high-dose methadone. CONCLUSION: Among pregnant women using medication-assisted treatment for opioid use disorders, low- to moderate-dose buprenorphine (≤16 mg/day) was associated with the most favorable neonatal outcomes. However, more rigorous control of confounders with a larger sample is necessary to determine if low- to moderate-dose buprenorphine is the better treatment choice.

Exploration of the Effects of Rural Obstetric Unit Closures on Birth Outcomes in North Carolina.

PURPOSE: Closures of rural labor and delivery (L/D) units have prompted national and state-based efforts to assess the impact on birth outcomes. This study explores local effects of L/D closures in rural areas of North Carolina (NC). METHODS: This is a retrospective cohort study of birth outcomes of 4,065 women in 5 rural areas of NC with L/D unit closures between 2013 and 2017. Outcomes were abstracted from birth certificate data from the NC Vital Statistics Reporting System. Localized outcomes 1 year prior to L/D unit closure were compared with outcomes 1 and 2 years post closure, including: (1) birth location and demographics, (2) change in travel patterns for birth, and (3) birth outcomes, including rates of labor induction, cesarean deliveries, maternal morbidity, and neonatal outcomes. FINDINGS: Before closures, 25%-56% of deliveries occurred outside county of residence. Commercially insured and college-educated women were more likely to deliver out-of-area. Closures increased travel distance to delivery hospital an average of 7-27 miles. In 2 areas, cesarean delivery rates decreased despite an increase in labor inductions. There was also variability between areas in prenatal care adequacy and breastfeeding. CONCLUSIONS: We found that L/D unit closures in rural NC disproportionately affected women on Medicaid. The impact showed area-specific variability, highlighting effects potentially masked by statewide or national analyses. Implications for future L/D closures would be eased by regional coordination and planning to mitigate negative effects, and state and national policies should address the excess burden placed on vulnerable populations.

Buprenorphine and Naloxone Versus Buprenorphine for Opioid Use Disorder in Pregnancy: A Cohort Study.

OBJECTIVE: To compare maternal and fetal outcomes among dyads prescribed buprenorphine and naloxone or buprenorphine during pregnancy. METHODS: Retrospective cohort study of patients with opioid use disorder obtaining care in a comprehensive, perinatal program. Patients utilized medication for opioid use disorder: a buprenorphine and naloxone combination product or buprenorphine monotherapy. The primary outcome was neonatal abstinence syndrome requiring treatment. Maternal secondary outcomes included: negative urine drug screen at delivery, obstetrical care attendance, primary cesarean delivery, and preterm delivery. Neonatal secondary outcomes included neonatal biometry, admission to neonatal intensive care, appropriate findings on cord toxicology, and length of stay. Univariate analyses included Chi square, Fisher exact, t-, or Mann-Whitney tests, as appropriate. Multivariate binary logistic regressions examined the association of type of buprenorphine product with diagnosis of neonatal abstinence syndrome requiring treatment and adjusted for variables significantly different in between-group comparisons and correlates of treatments and the primary outcome. RESULTS: The rate of neonatal abstinence syndrome was significantly higher (P = 0.007) among infants exposed in utero to buprenorphine versus buprenorphine and naloxone: 59/108 (54.6%) versus 30/85 (35.3%), respectively. The combined product, relative to the monoproduct, was associated with lower odds of neonatal abstinence syndrome: odds ratio (OR) = 0.453 (95% confidence interval [CI] 0.253-0.813; P = 0.008). Adjusting for dose of buprenorphine product at delivery, year of expected delivery, type of prescriber, diagnosis of hepatitis C, and preterm delivery negated these results: adjusted OR = 0.627 (95% CI 0.309-1.275). Secondary outcomes were similar. CONCLUSION: Compared with buprenorphine monotherapy, the combined buprenorphine and naloxone product was an acceptable alternative pharmacologic treatment for opioid use disorder during pregnancy.

Financial remuneration is positively correlated with the number of clinical activities: an example from diabetes management in Alberta community pharmacies.

OBJECTIVE: To determine whether use of a compensation plan to remunerate pharmacists for clinical pharmacy services was associated with the number of diabetes management activities provided. METHODS: Alberta pharmacists were asked about compensation plan use and frequency they provide a list of 80 diabetes management activities. KEY FINDINGS: A total of 168 community pharmacists responded to the survey. When compensation plan use, diabetes-specific training, practice characteristics and additional authorizations were incorporated into a factorial ANOVA, pharmacists who used the compensation plan reported a mean of 42.9 (95% CI 39.4 to 46.4) diabetes management activities, while those who did not reported a mean of 29.9 (95% CI 21.4 to 38.4) activities (P = 0.016). CONCLUSIONS: After considering other important influencing factors, use of the compensation plan is positively correlated with the number of diabetes management activities pharmacists provided.

Patient-related quality assurance with different combinations of treatment planning systems, techniques, and machines : A multi-institutional survey.

PURPOSE: This project compares the different patient-related quality assurance systems for intensity-modulated radiation therapy (IMRT) and volumetric-modulated arc therapy (VMAT) techniques currently used in the central Germany area with an independent measuring system. MATERIALS AND METHODS: The participating institutions generated 21 treatment plans with different combinations of treatment planning systems (TPS) and linear accelerators (LINAC) for the QUASIMODO (Quality ASsurance of Intensity MODulated radiation Oncology) patient model. The plans were exposed to the ArcCHECK measuring system (Sun Nuclear Corporation, Melbourne, FL, USA). The dose distributions were analyzed using the corresponding software and a point dose measured at the isocenter with an ionization chamber. RESULTS: According to the generally used criteria of a 10 % threshold, 3 % difference, and 3 mm distance, the majority of plans investigated showed a gamma index exceeding 95 %. Only one plan did not fulfill the criteria and three of the plans did not comply with the commonly accepted tolerance level of ±3 % in point dose measurement. CONCLUSION: Using only one of the two examined methods for patient-related quality assurance is not sufficiently significant in all cases.

Factors Affecting Number of Diabetes Management Activities Provided by Pharmacists.

BACKGROUND: Legislative changes since 2007 have given Alberta pharmacists additional authorizations and new practice settings, which should enhance provision of clinical services to patients. This study examined whether these changes are related to the number of diabetes management activities provided by pharmacists. METHODS: Cross-sectional surveys of Alberta pharmacists were conducted in 2006 and 2015. Both questionnaires contained 63 diabetes management activities, with response options to indicate how frequently the activity was provided. Respondents were grouped by survey year, practice setting, diabetes-specific training and additional authorizations. The number of diabetes management activities provided often or always were compared among groups by using analysis of variance. RESULTS: Data from 128 pharmacists participating in the 2006 survey were compared with 256 pharmacists participating in the 2015 survey; overall mean age was 41.6 (±10.9) years, 245 (64%) were women, mean duration of practice was 16.1 (±11.8) years, 280 (73%) were community pharmacists, 75 (20%) were certified diabetes educators (CDEs), and 100 (26%) had additional prescribing authorization (APA). Pharmacists provided a mean of 28.7 (95% CI 26.3 to 31.2) diabetes management activities in 2006 and 35.2 (95% CI 33.4-37.0) activities in 2015 (p<0.001). Pharmacists who were CDEs provided significantly more activities compared to other pharmacists (p<0.001). In 2015, working in a primary care network and having APA were also associated with provision of more activities (p<0.05 for both comparisons). CONCLUSIONS: Pharmacists provided more diabetes management activities in 2015 than in 2006. The number of diabetes management activities was also associated with being a CDE, working in a primary care network or having APA.

Moral science: ethical argument and the production of knowledge about place of birth.

Ethical arguments about caregiver responsibility and the limits of client autonomy rely on best evidence about the risks and benefits of medical interventions. But when the evidence is unclear, or when the peer-reviewed literature presents conflicting accounts of the evidence, how are clinicians and their clients to recommend or decide the best course of action? Conflicting evidence about the outcomes of home and hospital birth in the peer-reviewed literature offers an opportunity to explore this question. We present the contrary evidence and describe the social and cultural elements that influence the production of the science of birth, including professional, publication, and critical bias. We then consider how the science of birth has been used an misused in making ethical arguments about preferred place of birth. We conclude with a number of recommendations about the responsible use of the evidence, arguing for an "ethics of information" that can be drawn on to guide caregivers and clients in the use of evidence for clinical decision making.