A Mathematical Method to Adjust MLC Leaf End Position for Accurate Dose Calculation in Carbon Ion Beam Radiation Therapy Treatment Planning System.

INTRODUCTION: We present a mathematical method to adjust the leaf end position for dose calculation correction in the carbon ion radiation therapy treatment planning system. METHODS AND MATERIALS: A straggling range algorism of 400 MeV/n carbon ion beam in nine different multileaf collimator (MLC) materials was conducted to calculate the dose 50% point to derive the offset corrections in the carbon ion treatment planning system (ciPlan). The visualized light field edge position in the treatment planning system is denoted as X tang.p, and MLC position (X mlc.p) is defined as the source to leaf end midpoint projection on axis for monitor unit calculation. The virtual source position of energy at 400 MeV/n and straggling range in MLC at different field sizes were used to calculate the dose 50% position on axis. On-axis MLC offset (correction) could then be obtained from the position corresponding to 50% of the central axis dose minus the X mlc.p. RESULTS: The exact MLC position in the carbon ion treatment planning system can be used as an offset to do the correction. The offset correction of pure tungsten is the smallest among the others due to its shortest straggling range of carbon ion beam in MLC. The positions of 50% dose of all MLC materials are always located in between X tang.p and X mlc.p under the largest field of 12 cm by 12 cm. CONCLUSIONS: MLC offset should be adjusted carefully at different field sizes in the treatment planning systems especially of its small penumbra characteristic in the carbon ion beam. It is necessary to find out the dose 50% position for adjusting MLC leaf edge on-axis location in the treatment planning system to reduce dose calculation error.

Towards Goals to Refine Prophylactic and Therapeutic Strategies Against COVID-19 Linked to Aging and Metabolic Syndrome.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) gave rise to the coronavirus disease 2019 (COVID-19) pandemic. A strong correlation has been demonstrated between worse COVID-19 outcomes, aging, and metabolic syndrome (MetS), which is primarily derived from obesity-induced systemic chronic low-grade inflammation with numerous complications, including type 2 diabetes mellitus (T2DM). The majority of COVID-19 deaths occurs in people over the age of 65. Individuals with MetS are inclined to manifest adverse disease consequences and mortality from COVID-19. In this review, we examine the prevalence and molecular mechanisms underlying enhanced risk of COVID-19 in elderly people and individuals with MetS. Subsequently, we discuss current progresses in treating COVID-19, including the development of new COVID-19 vaccines and antivirals, towards goals to elaborate prophylactic and therapeutic treatment options in this vulnerable population.

Efficacy of an Online Curriculum for Perioperative Goals of Care and Code Status Discussions: A Randomized Controlled Trial.

BACKGROUND: Preoperative goals of care (GOC) and code status (CS) discussions are important in achieving an in-depth understanding of the patient's care goals in the setting of a serious illness, enabling the clinician to ensure patient autonomy and shared decision making. Past studies have shown that anesthesiologists are not formally trained in leading these discussions and may lack the necessary skill set. We created an innovative online video curriculum designed to teach these skills. This curriculum was compared to a traditional method of learning from reading the medical literature. METHODS: In this bi-institutional randomized controlled trial at 2 major academic medical centers, 60 anesthesiology trainees were randomized to receive the educational content in 1 of 2 formats: (1) the novel video curriculum (video group) or (2) journal articles (reading group). Thirty residents were assigned to the experimental video curriculum group, and 30 were assigned to the reading group. The content incorporated into the 2 formats focused on general preoperative evaluation of patients and communication strategies pertaining to GOC and CS discussions. Residents in both groups underwent a pre- and postintervention objective structured clinical examination (OSCE) with standardized patients. Both OSCEs were scored using the same 24-point rubric. Score changes between the 2 OSCEs were examined using linear regression, and interrater reliability was assessed using weighted Cohen's kappa. RESULTS: Residents receiving the video curriculum performed significantly better overall on the OSCE encounter, with a mean score of 4.19 compared to 3.79 in the reading group. The video curriculum group also demonstrated statistically significant increased scores on 8 of 24 rubric categories when compared to the reading group. CONCLUSIONS: Our novel video curriculum led to significant increases in resident performance during simulated GOC discussions and modest increases during CS discussions. Further development and refinement of this curriculum are warranted.

Hydroxyethyl starch for perioperative goal-directed fluid therapy in 2020: a narrative review.

BACKGROUND: Perioperative fluid management - including the type, dose, and timing of administration -directly affects patient outcome after major surgery. The objective of fluid administration is to optimize intravascular fluid status to maintain adequate tissue perfusion. There is continuing controversy around the perioperative use of crystalloid versus colloid fluids. Unfortunately, the importance of fluid volume, which significantly influences the benefit-to-risk ratio of each chosen solution, has often been overlooked in this debate. MAIN TEXT: The volume of fluid administered during the perioperative period can influence the incidence and severity of postoperative complications. Regrettably, there is still huge variability in fluid administration practices, both intra-and inter-individual, among clinicians. Goal-directed fluid therapy (GDFT), aimed at optimizing flow-related variables, has been demonstrated to have some clinical benefit and has been recommended by multiple professional societies. However, this approach has failed to achieve widespread adoption. A closed-loop fluid administration system designed to assist anesthesia providers in consistently applying GDFT strategies has recently been developed and tested. Such an approach may change the crystalloid versus colloid debate. Because colloid solutions have a more profound effect on intravascular volume and longer plasma persistence, their use in this more "controlled" context could be associated with a lower fluid balance, and potentially improved patient outcome. Additionally, most studies that have assessed the impact of a GDFT strategy on the outcome of high-risk surgical patients have used hydroxyethyl starch (HES) solutions in their protocols. Some of these studies have demonstrated beneficial effects, while none of them has reported severe complications. CONCLUSIONS: The type and volume of fluid used for perioperative management need to be individualized according to the patient's hemodynamic status and clinical condition. The amount of fluid given should be guided by well-defined physiologic targets. Compliance with a predefined hemodynamic protocol may be optimized by using a computerized system. The type of fluid should also be individualized, as should any drug therapy, with careful consideration of timing and dose. It is our perspective that HES solutions remain a valid option for fluid therapy in the perioperative context because of their effects on blood volume and their reasonable benefit/risk profile.

Coming together to improve access to medicines: The genesis of the East African Community's Medicines Regulatory Harmonization initiative.

Hiiti Sillo and colleagues reveal how the East African Community's Medicines Regulatory Harmonization initiative improves access to important medicines in Africa.

Impact of Goal-Directed Therapy on Delayed Ischemia After Aneurysmal Subarachnoid Hemorrhage: Randomized Controlled Trial.

BACKGROUND AND PURPOSE: Delayed cerebral ischemia (DCI) is the most important cause for a poor clinical outcome after a subarachnoid hemorrhage. The aim of this study was to assess whether goal-directed hemodynamic therapy (GDHT), as compared to standard clinical care, reduces the rate of DCI after subarachnoid hemorrhage. METHODS: We conducted a prospective randomized controlled trial. Patients >18 years of age with an aneurysmal subarachnoid hemorrhage were enrolled and randomly assigned to standard therapy or GDHT. Advanced hemodynamic monitoring and predefined GDHT algorithms were applied in the GDHT group. The primary end point was the occurrence of DCI. Functional outcome was assessed using the Glasgow Outcome Scale (GOS) 3 months after discharge. RESULTS: In total, 108 patients were randomized to the control (n=54) or GDHT group (n=54). The primary outcome (DCI) occurred in 13% of the GDHT group and in 32% of the control group patients (odds ratio, 0.324 [95% CI, 0.11-0.86]; P=0.021). Even after adjustment for confounding parameters, GDHT was found to be superior to standard therapy (hazard ratio, 2.84 [95% CI, 1.18-6.86]; P=0.02). The GOS was assessed 3 months after discharge in 107 patients; it showed more patients with a low disability (GOS 5, minor or no deficits) than patients with higher deficits (GOS 1-4) in the GDHT group compared with the control group (GOS 5, 66% versus 44%; GOS 1-4, 34% versus 56%; P=0.025). There was no significant difference in mortality between the groups. CONCLUSIONS: GDHT reduced the rate of DCI after subarachnoid hemorrhage with a better functional outcome (GOS=5) 3 months after discharge. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01832389.

Bringing asthma care into the twenty-first century.

Despite access to diagnostic tests and effective therapies, asthma often remains misdiagnosed and/or poorly controlled or uncontrolled. In this review, we address the key issues of asthma diagnosis and management, recent evidence for levels of asthma control, the consequences of poor control and, in line with that, explore the potential reasons for poor asthma control and acute exacerbations. Based on recent evidence and current guidelines, we also aim to provide practical answers to the key questions of how to improve asthma management, with the best possible prevention of exacerbations, addressing the basics-adherence, inhaler misuse, obesity and smoking-and how to facilitate a new era of asthma care in the twenty-first century. We hope this review will be useful to busy primary care clinicians in their future interactions with their patients with both suspected and proven asthma.

[Patient safety: current problems and challenges]. / Patientensicherheit ­ aktuelle Probleme und Herausforderungen.

Two decades after "To Err Is Human", the groundbreaking report published by the Institute of Medicine in the US, the German Patient Safety Alliance (Aktionsbündnis Patientensicherheit, APS) has published the "White Paper on Patient Safety". Based on the throughput model of health services research, the paper proposes a revised concept and definition of patient safety that focuses not only on the presence of adverse events (AE), but also on the ability of organizations and systems to adequately prioritize patient safety and implement this sustainably with improvement processes. Accordingly, a concept for measuring patient safety will be developed that no longer only quantitatively records AE, but also focuses on patient safety indicators that describe innovation competence. The epidemiological data will be updated; the rates of approximately 2-4% avoidable AE and 0.1% avoidable deaths among hospital patients appear to be highly conservative estimates. Data from non-representative sources, such as on legal procedures, underestimate frequencies by a factor of 30 ("litigation gap"). The most important obstacles to improving the situation are analyzed and give rise to the recommendation that, instead of one-point interventions (e.g., of a technical nature, such as IT-supported procedures), complex multicomponent interventions should increasingly be used in Germany, combining interventions with different approaches. Interventions at team level and with regard to management structures are focused on here.

Management of Urgent Medical Conditions at the End of Life.

Medical emergencies at the end of life require recognition of patients at risk, so that a comprehensive assessment and plan of care can be put in place. Frequently, the interventions depend on the patient's underlying prognosis, location of care, and goals of care. The mere presence of a medical emergency often rapidly changes an estimated prognosis. Education of the patient and family may help empower them to adequately handle many situations when clinicians are not available.

New insights to guide patient care: the bidirectional relationship between male infertility and male health.

Male reproduction is a complex process, and numerous medical conditions have the potential to alter spermatogenesis. In addition, male factor infertility may be a biomarker for future health. In the present review, we discuss the current literature regarding the association between systemic diseases and fertility, which may impact clinical outcomes or semen parameters. A number of conditions that have systemic consequences were identified, including genetic (e.g., cystic fibrosis, DNA mismatch repair alterations), obesity, psychological stress, exogenous testosterone, and a variety of common medications. As such, the infertility evaluation may offer an opportunity for health counseling beyond the discussion of reproductive goals. Moreover, male infertility has been suggested as a marker of future health, given that poor semen parameters and a diagnosis of male infertility are associated with an increased risk of hypogonadism, cardiometabolic disease, cancer, and even mortality. Therefore, male fertility requires multidisciplinary expertise for evaluation, treatment, and counseling.

Forecasting Content and Stage in a Nursing Home Information Technology Maturity Instrument Using a Delphi Method.

Health information technology capabilities in some healthcare sectors, such as nursing homes, are not well understood because measures for information technology uptake have not been fully developed, tested, validated, or measured consistently. The paper provides a report of the development and testing of a new instrument measuring nursing home information technology maturity and stage of maturity. Methods incorporated a four round Delphi panel composed of 31 nursing home experts from across the nation who reported the highest levels of information technology sophistication in a separate national survey. Experts recommended 183 content items for 27 different content areas specifying the measure of information technology maturity. Additionally, experts ranked each of the 183 content items using an IT maturity instrument containing seven stages (stages 0-6) of information technology maturity. The majority of content items (40% (n = 74)) were associated with information technology maturity stage 4, corresponding to facilities with external connectivity capability. Over 11% of the content items were at the highest maturity stage (Stage 5 and 6). Content areas with content items at the highest stage of maturity are reflected in nursing homes that have technology available for residents or their representatives and used extensively in resident care. An instrument to assess nursing home IT maturity and stage of maturity has important implications for understanding health service delivery systems, regulatory efforts, patient safety and quality of care.

Las desigualdades en salud como prioridad política en Barcelona / Health inequalities as a political priority in Barcelona

Existe abundante información e investigaciones sobre las desigualdades en salud en Barcelona, pero este tema no estuvo claramente priorizado en la agenda política. Con la llegada al gobierno de un partido de la nueva izquierda (Barcelona en Comú) en 2015 hubo un impulso importante de la agenda política para reducir las desigualdades, también las de salud. El objetivo de esta revisión es describir el avance realizado respecto a las desigualdades en salud en estos 4 años, sobre todo en los ámbitos donde ha participado la salud pública. Respecto a la evidencia y la comunicación sobre las desigualdades en salud, se presentan los avances en el Informe Anual de Salud de Barcelona y la creación del Observatorio de Salud, Desigualdades e Impactos de las Políticas Municipales. Las políticas que se presentan se refieren a diferentes estrategias municipales, el Plan de Salud, el impulso del programa Barcelona Salud en los Barrios y el Plan para el Abordaje de las Desigualdades en la Agència de Salut Pública de Barcelona. La conjunción de la voluntad política, la capacidad técnica y el impulso de la ciudadanía han facilitado un avance en la ciudad de Barcelona en las políticas para reducir las desigualdades sociales en salud

There is a wealth of information and research on health inequalities in Barcelona, but this issue has not been clearly prioritised on the political agenda. The arrival in government of a new left-wing party (Barcelona en Comú) in 2015, gave an important boost to the political agenda to reduce inequalities and health inequalities. The aim of this review is to describe the progress made in relation to health inequalities in these four years and especially in the areas involving public health. With respect to evidence and communication on health inequalities, the progress made is presented in the Barcelona annual health report and the creation of the Observatory on Health, Inequalities and Impacts of Municipal Policies. The policies presented refer to different municipal strategies, the Health Plan, the promotion of the Barcelona Health in the Neighbourhoods programme and the Plan for Tackling Inequalities in the Barcelona Public Health Agency. The combination of political will, technical capacity and the drive of citizens have facilitated progress in the city of Barcelona in policies to reduce social inequalities in health

Perioperative goal-directed therapy - What is the evidence?

Perioperative goal-directed therapy aims at optimizing global hemodynamics during the perioperative period by titrating fluids, vasopressors, and/or inotropes to predefined hemodynamic goals. There is evidence on the benefit of perioperative goal-directed therapy, but its adoption into clinical practice is slow and incomprehensive. Current evidence indicates that treating patients according to perioperative goal-directed therapy protocols reduces morbidity and mortality, particularly in patients having high-risk surgery. Perioperative goal-directed therapy protocols need to be started early, should include vasoactive agents in addition to fluids, and should target blood flow related variables. Future promising developments in the field of perioperative goal-directed therapy include personalized hemodynamic management and closed-loop system management.

A Survey of Colorectal Cancer Surveillance Practices In Ireland, And Implementation of A Survivorship Care Plan Pilot Programme

Aims The number of colorectal cancer (CRC) survivors in Ireland is rising. We aimed to survey current surveillance practices and pilot the use of survivorship care plans (SCPs) in the clinic. Methods An online survey was issued to medical oncologists (MOs) in designated cancer centres (DCC) and satellite centres. The SCP was piloted in CRC patients and a follow-up questionnaire assessing their views was issued. Results Responses from 8 DCC and satellite centres were obtained (n=13). Routine surveillance is practiced by 77% (n=10) and 69% (n=9) believe that the MO clinic is inappropriate for follow-up. Most think that the SCP is useful and that ANP-led surveillance clinics should be introduced. Of 16 patients who replied to the survey, most felt that the SCP was bene􀂡cial. Sixty-two percent (n=10) were agreeable to GP follow-up using the SCP. Conclusion Surveillance practices in Ireland are heterogeneous. The SCP may be useful for streamlining follow-up practices nationally.