Dosimetric Benefits and Practical Pitfalls of Daily Online Adaptive MRI-Guided Stereotactic Radiation Therapy for Pancreatic Cancer.

PURPOSE: Magnetic resonance imaging guided (MRI-g) radiation therapy provides visualization of the target and organs at risk (OARs), allowing for daily online adaptive radiation therapy (OART). We hypothesized that MRI-g OART would improve OAR sparing and target coverage in patients with pancreatic cancer treated with stereotactic body radiation therapy (SBRT). METHODS AND MATERIALS: Ten patients received pancreas SBRT to a dose of 33 to 40 Gy in 5 fractions. The dose was prescribed to 90% coverage of the planning target volume at 100% isodose (PTV100). After each fraction's setup magnetic resonance imaging scan, the target position was aligned by 3-dimensional shifts, the normal anatomy was recontoured, and the original radiation therapy plan was recalculated to create a nonadaptive plan. A reoptimized (adaptive) plan was then generated for each fraction and renormalized to 90% coverage of PTV100. Target and OAR doses between nonadaptive and adaptive plans were compared to assess the dosimetric impact of daily adaptation. RESULTS: The PTV100 mean for adaptive and nonadaptive techniques was 90% and 80.4% (range, 46%-97%), respectively (P = .0008). Point maximum (Dmax) 38 Gy duodenum objectives were met in 43 adaptive fractions compared with 32 nonadaptive fractions (P = .022). Both PTV100 ≥90% and all OAR objectives were achieved in 28 adaptive fractions compared with only 3 nonadaptive fractions. For nonadaptive plans, interfraction increases in stomach volume correlated with higher stomach V33 (P = .004), stomach Dmax (P = .009), duodenum V33 (P = .021), and duodenum Dmax (P = .105). No correlation was observed between stomach volume and OAR doses for adaptive plans. OART plans with Dmax violations of the spinal cord (20 Gy) in 4 fractions and large bowel (38 Gy) in 5 fractions were identified (although not delivered). CONCLUSIONS: MRI-g OART improves target coverage and OAR sparing for pancreas SBRT. This benefit partially results from mitigation of interfraction variability in stomach volume. Caution must be exercised to evaluate all OARs near the treatment area.

Leadership Development Through Peer-Facilitated Simulation in Nursing Education.

BACKGROUND: Baccalaureate nursing graduates must possess leadership skills, yet few opportunities exist to cultivate leadership abilities in a clinical environment. Peer-facilitated learning may increase the leadership skills of competence, self-confidence, self-reflection, and role modeling. Facilitating human patient simulation provides opportunities to develop leadership skills. METHOD: With faculty supervision, senior baccalaureate students led small-group simulation experiences with sophomore and junior peers and then conducted subsequent debriefings. Quantitative and qualitative descriptive data allowed evaluation of students' satisfaction with this teaching innovation and whether the experience affected students' desire to take on leadership roles. RESULTS: Students expressed satisfaction with the peer-facilitated simulation experience and confidence in mastering the content while developing necessary skills for practice. CONCLUSION: Peer-facilitated simulation provides an opportunity for leadership development and learning. Study results can inform the development of nursing curricula to best develop the leadership skills of nursing students. [J Nurs Educ. 2018;57(1):53-57.].

Teaching caring and competence: Student transformation during an older adult focused service-learning course.

Innovative teaching strategies develop nurses' knowledge, skills, and attitudes while simultaneously integrating the art of caring and transforming attitudes toward adults over age 65. The study's purpose was to explore students' experiences and attitudes toward older adults with cognitive and/or physical limitations as well as the effects on students' knowledge and skills during a baccalaureate nursing, course which included a service-learning experience. Service-learning synthesizes meaningful community service, academic instruction, and reflection. Participants included baccalaureate students enrolled in a service-learning nursing course focused on older adults. This retrospective, qualitative, phenomenological study used reflective journals and an online survey to explore baccalaureate nursing students' experiences toward older adults with cognitive and/or physical limitations. Themes included initial attitudes of anticipation, apprehension, anxiety, and ageist stereotypes. Final attitudes included a "completely changed perspective" of caring, compassion, and respect indicative of a rewarding, "life-changing" experience. Participants cited enhanced learning, especially in the areas of patient-centered care, collaboration, communication, advocacy, empathy, assessment skills, and evidence-based practice. This innovative teaching strategy led to transformed attitudes toward older adults, reduced fear of older adult populations, an increased desire to work with older adults, and the ability to form a transpersonal, caring relationship while enhancing nursing knowledge and skills.

Concentric and eccentric exercise, glycemic responses to a postexercise meal, and inflammation in women with high versus low waist circumference.

Carbohydrate ingestion and level of concentric versus eccentric muscle activity may alter exercise-induced health benefits for individuals who have high waist circumference as a metabolic risk factor. The purpose of this study was to determine whether metabolic and inflammation responses to an exercise recovery meal differ between women with lower (Lo-WC, <80 cm) compared with higher (Hi-WC) waist circumference when the exercise is primarily concentric (uphill walking; UPHILL) versus primarily eccentric (downhill walking; DOWNHILL). Recreationally active women (age, 18-39 years; body mass index, 19-35.4 m·kg-2; Lo-WC, n = 13; Hi-WC, n = 10) completed UPHILL, DOWNHILL, and resting (CONTROL) conditions followed 30 min later by a mixed meal tolerance test (MMTT) with carbohydrates to protein ratio of 4:1, and blood glucose, insulin, and inflammation markers were compared across conditions. Compared with Lo-WC, the Hi-WC group had higher (p < 0.05) (i) insulin during the MMTT in CONTROL (mean ± SE; 48.5 ± 8.2 vs 22.9 ± 2.8 pmol·L-1), (ii) baseline (0.7 ± 0.4 vs 2.0 ± 1.7 pg·mL-1) interleukin-6 (IL-6), and (iii) IL-6 responses 8 h after UPHILL and CONTROL. Both groups had (i) increases in IL-6 at 0 h after UPHILL and at 8 h after DOWNHILL, and (ii) lower glycemic responses in UPHILL. Women with Hi-WC had higher IL-6 at rest and delayed increases in IL-6 after a high-carbohydrate meal in all conditions. This is consistent with an inflammation response to the meal and or uphill walking exercise. However, both concentrically and eccentrically biased exercises offered benefits to insulin responses to a high carbohydrate meal for Hi-WC.

Asymptomatic Congenital Intrahepatic Portosystemic Shunt.

Congenital (spontaneous) intrahepatic portosystemic shunt is rare in the English literature. Most cases of portosystemic shunt occur after trauma, surgery, liver biopsy or as a result of chronic portal hypertension. Chronic shunting may result in encephalopathy, bleeding or hyperinsulinism. We report a case of an asymptomatic adult female with a presumed congenital intrahepatic portosystemic shunt and discuss the pertinent imaging findings and important key concepts related to this condition.

Foliar absorption of intercepted rainfall improves woody plant water status most during drought.

A large proportion of rainfall in dryland ecosystems is intercepted by plant foliage and is generally assumed to evaporate to the atmosphere or drip onto the soil surface without being absorbed. We demonstrate foliar absorption of intercepted rainfall in a widely distributed, continental dryland, woody-plant genus: Juniperus. We observed substantial improvement in plant water status, exceeding 1.0 MPa water potential for drought-stressed plants, following precipitation on an experimental plot that excluded soil water infiltration. Experiments that wetted shoots with unlabeled and with isotopically labeled water confirmed that water potential responded substantially to foliar wetting, that these responses were not attributable to re-equilibration with other portions of the xylem, and that magnitude of response increased with water stress. Foliar absorption is not included in most ecological, hydrological, and atmospheric models; has implications for interpreting plant isotopic signatures; and not only supplements water acquisition associated with increases in soil moisture that follow large or repeated precipitation events, but also enables plants to bypass soil water uptake and benefit from the majority of precipitation events, which wet foliage but do not increase soil moisture substantially. Foliar absorption of intercepted water could be more important than previously appreciated, especially during drought when water stress is greatest.

Radiographic predictors of outcome after long fusion to L5 in adult scoliosis.

Radiographic factors that correlate with outcome following long posterior fusion to L5 for adult scoliosis were investigated. Measurement of thoracic, lumbar, and fractional lumbosacral curves, L5 obliquity, lumbar and L5-S1 lordosis, coronal balance, sagittal balance, and L5-S1 disc height were performed on preoperative, postoperative, and follow-up 36-in posteroanterior/lateral radiographs. Of 16 patients, 14 were female (88%) and 2 male (12%). Average follow-up was 32 months (8-78 months). Scoliotic curves demonstrated stable corrections; however, lumbar and L5-S1 lordosis decreased and sagittal decompensation worsened. Ten patients (62%) had no evidence of transitional degeneration. Six patients (38%) had radiographic evidence of L5-S1 degeneration, and three (19%) underwent revision. Patients with good preoperative sagittal balance, preserved lumbar lordosis, good postoperative fractional curve correction, and L5-S1 disc height preservation are most likely to benefit from posterior fusion to L5, avoiding sacral fusion, for adult scoliosis.

Effect of COX-2-specific inhibition on fracture-healing in the rat femur.

BACKGROUND: Nonsteroidal anti-inflammatory medications have been shown to delay fracture-healing. COX-2-specific inhibitors such as celecoxib have recently been approved for human use. Our goal was to determine, mechanically, histologically, morphologically, and radiographically, whether COX-2-specific inhibition affects bone-healing. METHODS: A nondisplaced unilateral fracture was created in the right femur of fifty-seven adult male rats. Rats were given no drug, indomethacin (1 mg/kg/day), or celecoxib (3 mg/kg/day) daily, starting on postoperative day 1. Fractures were analyzed at four, eight, and twelve weeks after creation of the fracture. Callus and bridging bone formation was assessed radiographically. The amounts of fibrous tissue, cartilage, woven bone, and mature bone formation were determined histologically. Morphological changes were assessed to determine fibrous healing, callus formation, and bone-remodeling. Callus strength and stiffness were assessed biomechanically with three-point bending tests. RESULTS: At four weeks, only the indomethacin group showed biomechanical and radiographic evidence of delayed healing. Although femora from rats treated with celecoxib appeared to have more fibrous tissue than those from untreated rats at four and eight weeks, radiographic signs of callus formation, mechanical strength, and stiffness did not differ significantly between the groups. By twelve weeks, there were no significant differences among the three groups. CONCLUSIONS: Postoperative administration of celecoxib, a COX-2-specific inhibitor, did not delay healing as seen at twelve weeks following fracture in adult rat femora. At four and eight weeks, fibrous healing predominated in the celecoxib group as compared with the findings in the untreated group; however, mechanical strength and radiographic signs of healing were not significantly inhibited. CLINICAL RELEVANCE: Many orthopaedists rely on narcotic analgesia for postfracture and postoperative pain, despite deleterious side effects and morbidity. Traditional nonsteroidal anti-inflammatory medications have been shown to delay fracture union. This effect may be smaller with COX-2-specific inhibitors.

Chocolate, an effective means of oral drug delivery in rats.

Oral gavage is an important procedure for drug discovery and efficacy studies using rodents. However, there are welfare issues related to the use of the method by inexperienced persons or for long-term studies. The authors describe an effective method of administering drugs to rats by mixing the drug with chocolate to provide a consistent and reliable method of oral drug delivery to large groups of rats for a long period of time.