Understanding the Benefit of Magnetic Resonance-guided Adaptive Radiotherapy in Rectal Cancer Patients: a Single-centre Study.

AIMS: Neoadjuvant chemoradiotherapy followed by surgery is the mainstay of treatment for patients with rectal cancer. Standard clinical target volume (CTV) to planning target volume (PTV) margins of 10 mm are used to accommodate inter- and intrafraction motion of target. Treating on magnetic resonance-integrated linear accelerators (MR-linacs) allows for online manual recontouring and adaptation (MRgART) enabling the reduction of PTV margins. The aim of this study was to investigate motion of the primary CTV (CTVA; gross tumour volume and macroscopic nodes with 10 mm expansion to cover microscopic disease) in order to develop a simultaneous integrated boost protocol for use on MR-linacs. MATERIALS AND METHODS: Patients suitable for neoadjuvant chemoradiotherapy were recruited for treatment on MR-linac using a two-phase technique; only the five phase 1 fractions on MR-linac were used for analysis. Intrafraction motion of CTVA was measured between pre-treatment and post-treatment MRI scans. In MRgART, isotropically expanded pre-treatment PTV margins from 1 to 10 mm were rigidly propagated to post-treatment MRI to determine overlap with 95% of CTVA. The PTV margin was considered acceptable if overlap was >95% in 90% of fractions. To understand the benefit of MRgART, the same methodology was repeated using a reference computed tomography planning scan for pre-treatment imaging. RESULTS: In total, nine patients were recruited between January 2018 and December 2020 with T3a-T4, N0-N2, M0 disease. Forty-five fractions were analysed in total. The median motion across all planes was 0 mm, demonstrating minimal intrafraction motion. A PTV margin of 3 and 5mm was found to be acceptable in 96 and 98% of fractions, respectively. When comparing to the computed tomography reference scan, the analysis found that PTV margins to 5 and 10 mm only acceptably covered 51 and 76% of fractions, respectively. CONCLUSION: PTV margins can be reduced to 3-5 mm in MRgART for rectal cancer treatment on MR-linac within an simultaneous integrated boost protocol.

Feasibility of tumour-focused adaptive radiotherapy for bladder cancer on the MR-linac.

Bladder tumour-focused magnetic resonance image-guided adaptive radiotherapy using a 1.5 Tesla MR-linac is feasible. A full online workflow adapting to anatomy at each fraction is achievable in approximately 30 min. Intra-fraction bladder filling did not compromise target coverage with the class solution employed.

The Association Between Social Network and Fear of COVID-19 Among Older Adults.

The COVID-19 pandemic and associated restrictions pose a significant health threat to older adults. Fear of COVID-19 is associated with increased disease transmission and numerous psychosocial health challenges. While social support has been studied extensively in gerontological literature, there is a gap in understanding how social networks influence fear of COVID-19. This study drew from a convenience sample of 239 adults 60+ years of age in the United States who completed a 20-min survey. Regression results indicate that higher social network was significantly associated with decreased fear of COVID-19. Identifying as female and as an ethnic minority were associated with increased fear of COVID-19. These findings document the need for social workers to promote enhanced social networks in reducing fear of COVID-19 among older adults and attend to disparate levels of fear among older women and people of color.

Decision Support Needs for Patients with Severe Symptomatic Aortic Stenosis.

Social workers in healthcare settings often support patient decision-making processes for complex medical decisions. The objective of this study was to examine decision support needs for patients considering aortic valve replacement (AVR) for aortic stenosis. Seventeen qualitative interviews were conducted to explore treatment decision experiences of patients who accepted AVR. Analysis was conducted using a mixed inductive-deductive approach. Fear was a prevalent response for most participants in the face of AVR. Two general paths of decision making emerged: an "active" information seeking approach, or a "passive" simplicity seeking approach. Patients with unique clinical presentations felt alienated by the decision-making process. Acknowledging fear while understanding different decision-making styles provide opportunities for social workers and other members of multidisciplinary teams to support complex patient decisions.

Patient Portals to Support Palliative and End-of-Life Care: Scoping Review.

BACKGROUND: Although patient portals are widely used for health promotion, little is known about the use of palliative care and end-of-life (PCEOL) portal tools available for patients and caregivers. OBJECTIVE: This study aims to identify and assess the user perspectives of PCEOL portal tools available to patients and caregivers described and evaluated in the literature. METHODS: We performed a scoping review of the academic literature directed by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) extension for Scoping Review and searched three databases. Sources were included if they reported the development or testing of a feature, resource, tool, or intervention; focused on at least one PCEOL domain defined by the National Coalition for Hospice and Palliative Care; targeted adults with serious illness or caregivers; and were offered via a patient portal tethered to an electronic medical record. We independently screened the titles and abstracts (n=796) for eligibility. Full-text (84/796, 10.6%) sources were reviewed. We abstracted descriptions of the portal tool name, content, targeted population, and reported user acceptability for each tool from included sources (n=19). RESULTS: In total, 19 articles describing 12 tools were included, addressing the following PCEOL domains: ethical or legal (n=5), physical (n=5), and psychological or psychiatric (n=2). No tools for bereavement or hospice care were identified. Studies have reported high acceptability of tools among users; however, few sources commented on usability among older adults. CONCLUSIONS: PCEOL patient portal tools are understudied. As medical care increasingly moves toward virtual platforms, future research should investigate the usability and acceptability of PCEOL patient portal resources and evaluate their impact on health outcomes.

Patient Perspectives on the Benefits and Risks of Percutaneous Coronary Interventions: A Qualitative Study.

BACKGROUND: Growing evidence for coronary stents in patients with stable coronary artery disease (CAD) suggests that the benefits of stents are uncertain. The goal of this study was to assess patients' informational needs and how patients react to information about the uncertain benefit of stents to CAD patients. METHODS: Semi-structured qualitative interviews (N=20) were conducted with patients with stable CAD who received a recent stent. Data were coded and analyzed using a mixed inductive-deductive approach. RESULTS: Some patients mistakenly believed that the purpose of their stent was to prevent a future heart attack, and few were previously aware of the uncertain benefit. Nearly all patients perceived positive outcomes from their procedure, even if their symptoms persisted. Some patients had difficulty accepting evidence that stents may not reduce the risk of heart attack or reliably improve symptoms. Nonetheless, patients still expressed a desire to receive new information about the uncertain benefits of stents and wanted to have received this information early in their care. CONCLUSION: Many patients with stable CAD do not understand the intended benefit of coronary stents and want to be informed of the evidence of uncertain benefit of coronary stents, even if this would not change their decision. Improved communication and patient education tools are needed to better inform patients. An intervention providing patients with this information early has the potential to solve these problems.

Development of a Decision Aid for Patients and Families Considering Hospice.

Background: Hospice is underutilized. Miscommunication, decisional complexity, and misunderstanding around engaging hospice may contribute. Shared decision making (SDM), aided by patient decision aids (PtDAs), can improve knowledge and decision quality. Currently, there are no freely available hospice-specific PtDA to facilitate conversions between patients and providers about hospice care. Objective: To develop a theory-based and unbiased hospice specific PtDA. Design: Guided by the Ottawa Decision Support Framework and International Patient Decision Aid Standards, we used a theory-driven, eight-step, iterative, user-centered approach with multistakeholder input to develop a hospice-specific PtDA for anyone facing end-of-life decisions. Subjects: Feedback was obtained from a 10-member Patient Advisory Panel composed of lay patient advisors; focus groups of hospice providers, family caregivers, and patients; and the Palliative Care Research Group at University of Colorado Hospital consisting of palliative care physicians, midlevel providers, nurses, social workers, chaplains, and researchers. Results: There are many challenges in developing an unbiased hospice decision aid, including (1) balancing the provision of education (eligibility, payment) with decisional support, (2) clarifying values and incorporating emotion, (3) ideally representing the potential downsides of hospice, and (4) adequately capturing and describing care alternatives to hospice. Within this context, we developed a 12-page article and 17-minute video PtDAs. The PtDA openly acknowledges the emotional complexity of the decision and incorporates values clarification techniques to help decision makers reflect and evaluate their goals and preferences for end-of-life care. Conclusions: Hospice decision making is complex and emotional, demanding high-quality SDM aided by a formal PtDA. This work resulted in a freely available article and video PtDA for patients considering hospice. The effectiveness and implementation of these tools will be studied in future research. Clinical Trials Registration (NCT03794700 & NCT04458090).

Current Status of Anatomical Magnetic Resonance Imaging in Brachytherapy and External Beam Radiotherapy Planning and Delivery.

Radiotherapy planning and delivery have dramatically improved in recent times. Imaging is key to a successful three-dimensional and increasingly four-dimensional based pathway with computed tomography embedded as the backbone modality. Computed tomography has significant limitations for many tumour sites where soft-tissue discrimination is suboptimal, and where magnetic resonance imaging (MRI) has largely superseded in the diagnostic arena. MRI is increasingly used together with computed tomography in the radiotherapy planning pathway and is now established as a prerequisite for several tumours. With the advent of combined MRI and linear accelerator (MR-linac) systems, a transition to MRI-based radiotherapy planning is becoming reality, with increasing experience and research involving these new platforms. In this overview, we aim to highlight how magnetic resonance-guided imaging has improved radiotherapy, using gynaecological malignancies to illustrate, in both external beam radiotherapy and image-guided brachytherapy, and will assess the early evidence for magnetic resonance-guided radiotherapy using combined MR-linac systems.

Dissemination and stakeholder engagement practices among dissemination & implementation scientists: Results from an online survey.

INTRODUCTION: There has been an increasing focus on disseminating research findings, but less about practices specific to disseminating and engaging non-researchers. The present project sought to describe dissemination practices and engagement of stakeholders among dissemination & implementation (D&I) scientists. METHODS: Methods to disseminate to and engage non-research stakeholders were assessed using an online survey sent to a broad, diverse sample of D&I scientists. RESULTS: Surveys were received from 210 participants. The majority of respondents were from university or research settings in the United States. (69%) or Canada (13%), representing a mix of clinical (28%) and community settings (34%). 26% had received formal training in D&I. Respondents indicated routinely engaging in a variety of dissemination-related activities, with academic journal publications (88%), conference presentations (86%), and reports to funders (74%) being the most frequent. Journal publication was identified as the most impactful on respondents' careers (94%), but face-to-face meetings with stakeholders were rated as most impactful on practice or policy (40%). Stakeholder involvement in research was common, with clinical and community-based researchers engaging stakeholder groups in broadly similar ways, but with critical differences noted between researchers with greater seniority, those with more D&I training, those based in the United States vs. Canada, and those in community vs. clinical research settings. CONCLUSIONS: There have been increases in stakeholder engagement, but few other practices since the 2012 survey, and some differences across subgroups. Methods to engage different stakeholders deserve more in-depth investigation. D&I researchers report substantial misalignment of incentives and behaviors related to dissemination to non-research audiences.

Quality of Medical Advice Provided Between Members of a Web-Based Message Board for Patients With Implantable Defibrillators: Mixed-Methods Study.

BACKGROUND: Patients use Web-based medical information to understand medical conditions and treatments. A number of efforts have been made to understand the quality of professionally created content; however, none have described the quality of advice being provided between anonymous members of Web-based message boards. OBJECTIVE: The objective of this study was to characterize the quality of medical information provided between members of an anonymous internet message board addressing treatment with an implantable cardioverter-defibrillator (ICD). METHODS: We quantitatively analyzed 2 years of discussions using a mixed inductive-deductive framework, first, for instances in which members provided medical advice and, then, for the quality of the advice. RESULTS: We identified 82 instances of medical advice within 127 discussions. Advice covered 6 topical areas: (1) Device information, (2) Programming, (3) Cardiovascular disease, (4) Lead management, (5) Activity restriction, and (6) Management of other conditions. Across all advice, 50% (41/82) was deemed generally appropriate, 24% (20/82) inappropriate for most patients, 6% (5/82) controversial, and 20% (16/82) without sufficient context. Proportions of quality categories varied between topical areas. We have included representative examples. CONCLUSIONS: The quality of advice shared between anonymous members of a message board regarding ICDs varied considerably according to topical area and the specificity of advice. This report provides a model to describe the quality of the available Web-based patient-generated material.

Sebaceous adenoma in the region of the medial canthus causing proptosis.

A case of sebaceous adenoma in the region of the medial canthus causing proptosis is presented along with a review of the medical literature. The clinicopathological aspects of the tumour are discussed. The mode of treatment was surgical excision. A six month follow-up showed a reduction in the proptosis with no recurrence.

Fourth branchial arch fistula: a case report.

Fourth branchial arch fistula is a rare anomaly. This report describes in detail the presentation and management of a fourth arch fistula.

Rhinocerebral mucormycosis: an unusual case presentation.

Rhinocerebral mucormycosis is a rapidly fatal fungal disease which involves the nose, paranasal sinuses, orbit and central nervous system. The fungal infection is usually secondary to immunosuppression, diabetic acidosis, or antibiotic, steroid or cytotoxic therapy. It can also occur in patients suffering from burns, malignancy and haematological disorders. Current treatment consists of correction of the underlying disorder, repeated debridement of the wound in combination with intravenous amphotericin B. This paper describes our experience with a case of rhinocerebral mucormycosis. This is an unusual case in which mucormycosis was seen in a young female where no underlying cause was found. She responded to surgical debridement in combination with intravenous amphotericin B.

Transethmoid decompression of the optic nerve in head injuries: an update.

Sixty-three patients with loss of vision following head injury were subjected to decompression of the optic nerve by the transethmoid route. This paper discusses the criteria for selection of patients for surgery, the results of the operation and the prognostic factors determining the results.

Fracture line in post head injury optic nerve damage.

Diminution of vision following head injuries involving the optic canal is not uncommon. In order to find out how a blunt trauma to the frontotemporal region produced damage to the optic nerve in its canalicular portion, this study was conducted on cadaveric skulls and its results are described.

Functional endoscopic sinus surgery--I (Anatomy, diagnosis, evaluation and technique).

It has been proved beyond doubt that the causation and perpetuation of disease in the dependent sinuses (maxillary and frontal sinuses) is secondary to disease of the ostiomeatal complex, the primary focus of which is the anterior ethmoid. Based on this concept, functional endoscopic sinus surgery (FESS) aims at correcting the underlying pathology in the ethmoids and helps to re-establish normal ventilation and mucociliary clearance of the dependent sinuses.

Functional endoscopic sinus surgery--II (A preliminary study).

Seventy-eight patients of chronic sinusitis were subjected to functional endoscopic sinus surgery by the technique described in the previous paper. The clinical features, findings at surgery and the results of this technique are described here.

Focus on sustainability.

PIP: In recent years, sustainability has become one of the most critical concepts in international development and is having a dramatic impact on the way development is conceptualized and carried out. The US Agency for International Development (USAID) is incorporating this concept into its programs and projects. Factors encouraging sustainability of projects and programs include host government policies that support or constrain program objectives, national and/or local commitment to project goals, managerial leadership that helps shape improved policies, collaboration at all staff levels in program management, financial resources that cover program operational costs, appropriate program technology, integration of the program with the social and cultural setting of the country, community involvement in the program, sound environmental management, technical assistance oriented to transferring skills and increasing institutional capacity, perception by the host country that the project is "effective," training provided by the project to transfer skill needed for capacity-building, integration of the program into existing institutional framework, and external political, economic and environmental factors. Impediments to sustainability are often inherent in the donor agency's programming process. This includes the implicit assumption that program objectives can be accomplished in a relatively short time frame, when in fact capacity-building requires a lengthy commitment. USAID professionals are pressured to show near-term results which emphasize outputs rather than purpose and goal-level accomplishments achievable only after extensive effort. The emphasis on obligating money and on the project paper as a sales document leads project designers to talk with a great deal more certainty about project results than is warranted by the complex development situation. Uncertainty and flexibility should be designed into projects so activities and objects can change as more information and on-site experience is gained. Instead of outputs, success should be measured in processes that will continue to produce long-term results. Emphasis should be placed on establishing policymaking processes and decision making procedures in the recipient country that will lead to sound economic policymaking on a continuing basis. Sustainable efforts in agriculture, health, rural development and their evaluation are examined for several USAID projects.^ieng