Radiation Oncology Education Collaborative Study Group Annual Spring Symposium: Initial Impact and Feedback.

The Radiation Oncology Education Collaborative Study Group (ROECSG) is an international collaborative network of radiation oncology (RO) professionals with the goal of improving RO education. This report summarizes the first two ROECSG annual symposia including an overview of presentations and analysis of participant feedback. One-day symposia were held in June 2018 and May 2019. Programs included oral and poster presentations, RO education leadership perspectives, and keynote addresses. Post-symposia surveys were collected. Research presentations were recorded and made available online. The 2018 symposium was had 36 attendees from 25 institutions in three countries. The 2019 symposium had 76 individuals from 41 institutions in five countries. Attendees represented diverse backgrounds including attending physicians (46%), residents (13%), medical students (14%), physicists (2%), nurses (1%), and program coordinators (1%). Fifty-five oral presentations were given with 53 released online. Ninety percent of attendees rated the symposium as improving their knowledge of RO educational scholarship, 98% felt the symposium provided the opportunity to receive feedback on RO education scholarship, and 99% felt that the symposium fostered the development of collaborative RO education projects. ROECSG was rated higher than professional organizations in fostering educational scholarship (p<0.001). All attendees felt that the symposium produced new RO education scholarship ideas and provided unique networking opportunities. The first two ROECSG symposia drew a diverse population of attendees and provided unique opportunities for presentation of RO education scholarship. Future ROECSG symposia will be designed to enhance opportunities to present RO education scholarship and to facilitate networking.

The use of complementary and integrative therapies as adjunct interventions during radiotherapy: a systematic review.

PURPOSE: Literature supporting the efficacy of complementary and integrative medicine (CIM) alongside radiotherapy is fragmented with varying outcomes and levels of evidence. This review summarizes the available evidence on CIM used with radiotherapy in order to inform clinicians. METHODS: A systematic literature review identified studies on the use of CIM during radiotherapy. Inclusion required the following criteria: the study was interventional, CIM therapy was for human patients with cancer, and CIM therapy was administered concurrently with radiotherapy. Data points of interest were collected from included studies. A subset was identified as high-quality using the Jadad scale. Fisher's exact test was used to assess the association between study results, outcome measured, and type of CIM. RESULTS: Overall, 163 articles met inclusion. Of these, 68 (41.7%) were considered high-quality trials. Articles published per year increased over time (p < 0.01). Frequently identified therapies were biologically based therapies (47.9%), mind-body therapies (23.3%), and alternative medical systems (13.5%). Within the subset of high-quality trials, 60.0% of studies reported a favorable change with CIM while 40.0% reported no change. No studies reported an unfavorable change. Commonly assessed outcome types were patient-reported (41.1%) and provider-reported (21.5%). Rate of favorable change did not differ based on type of CIM (p = 0.90) or outcome measured (p = 0.24). CONCLUSIONS: Concurrent CIM may reduce radiotherapy-induced toxicities and improve quality of life, suggesting that physicians should discuss CIM with patients receiving radiotherapy. This review provides a broad overview of investigations on CIM use during radiotherapy and can inform how radiation oncologists advise their patients about CIM.

Mentorship Initiatives in Radiation Oncology: A Scoping Review of the Literature.

PURPOSE: Although mentorship is described extensively in academic medical literature, there are few descriptions of mentorship specific to radiation oncology. The goal of the current study was to investigate the state of mentorship in radiation oncology through a scoping review of the literature. METHODS AND MATERIALS: A search protocol was defined according to Preferred Reporting Items for Systematic Reviews and Meta Analyses extension for scoping reviews (PRISMA-ScR) guidelines. Predefined search terms and medical subject headings were used to search PubMed for English language articles published after January 1, 1990, on mentorship in radiation oncology. Additionally, in-press articles from major radiation oncology and medical education journals were searched. Three reviewers determined article eligibility. Included articles were classified based on predefined evaluation criteria. RESULTS: Fourteen publications from 2008 to 2019 met inclusion criteria. The most commonly described form of mentorship was the dyad (64.3%), followed by team (14.3%) and peer (7.1%); 2 articles did not specify mentorship type (14.3%). The most commonly mentored participants were residents (35.7%), followed by medical students (35.7%) and attendings (21.4%); 1 study included participants of all levels (7.1%). Thirteen studies (92.9%) identified an experimental study design, most of which were cross-sectional (42.9%), followed by cohort studies (28.6%) and before/after (21.4%). Median sample size, reported in 12 of 13 experimental studies, was 132 (coefficient of variation, 1.06). Although outcomes varied widely, the majority described successful implementation of mentorship initiatives with high levels of participant satisfaction. CONCLUSIONS: Although few initiatives are currently reported, the present study suggests that these initiatives are successful in promoting career development and increasing professional satisfaction. The interventions overwhelmingly described mentorship dyads; other forms of mentorship are either less common or understudied. Limitations included interventions not being evaluated in a controlled setting, and many were assessed using surveys with low response rates. This review highlights rich opportunities for future scholarship to develop, evaluate, and disseminate radiation oncology mentorship initiatives.

Three-dimensional printing in radiation oncology: A systematic review of the literature.

PURPOSE/OBJECTIVES: Three-dimensional (3D) printing is recognized as an effective clinical and educational tool in procedurally intensive specialties. However, it has a nascent role in radiation oncology. The goal of this investigation is to clarify the extent to which 3D printing applications are currently being used in radiation oncology through a systematic review of the literature. MATERIALS/METHODS: A search protocol was defined according to preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Included articles were evaluated using parameters of interest including: year and country of publication, experimental design, sample size for clinical studies, radiation oncology topic, reported outcomes, and implementation barriers or safety concerns. RESULTS: One hundred and three publications from 2012 to 2019 met inclusion criteria. The most commonly described 3D printing applications included quality assurance phantoms (26%), brachytherapy applicators (20%), bolus (17%), preclinical animal irradiation (10%), compensators (7%), and immobilization devices (5%). Most studies were preclinical feasibility studies (63%), with few clinical investigations such as case reports or series (13%) or cohort studies (11%). The most common applications evaluated within clinical settings included brachytherapy applicators (44%) and bolus (28%). Sample sizes for clinical investigations were small (median 10, range 1-42). A minority of articles described basic or translational research (11%) and workflow or cost evaluation studies (3%). The number of articles increased over time (P < 0.0001). While outcomes were heterogeneous, most studies reported successful implementation of accurate and cost-effective 3D printing methods. CONCLUSIONS: Three-dimensional printing is rapidly growing in radiation oncology and has been implemented effectively in a diverse array of applications. Although the number of 3D printing publications has steadily risen, the majority of current reports are preclinical in nature and the few clinical studies that do exist report on small sample sizes. Further dissemination of ongoing investigations describing the clinical application of developed 3D printing technologies in larger cohorts is warranted.

A Retrospective Comparative Analysis of Titanium Mesh and Custom Implants for Cranioplasty.

BACKGROUND: Autologous bone removed during craniectomy is often the material of choice in cranioplasty procedures. However, when the patient's own bone is not appropriate (infection and resorption), an alloplastic graft must be utilized. Common options include titanium mesh and polyetheretherketone (PEEK)-based custom flaps. Often, neurosurgeons must decide whether to use a titanium or custom implant, with limited direction from the literature. OBJECTIVE: To compare surgical outcomes of synthetic cranioplasties performed with titanium or vs custom implants. METHODS: Ten-year retrospective comparison of patients undergoing synthetic cranioplasty with titanium or custom implants. RESULTS: A total of 82 patients were identified for review, 61 (74.4%) receiving titanium cranioplasty and 21 (25.6%) receiving custom implants. Baseline demographics and comorbidities of the 2 groups did not differ significantly, although multiple surgical characteristics did (size of defect, indication for craniotomy) and were controlled for via a 2:1 mesh-to-custom propensity matching scheme in which 36 titanium cranioplasty patients were compared to 18 custom implant patients. The cranioplasty infection rate of the custom group (27.8%) was significantly greater (P = .005) than that of the titanium group (0.0%). None of the other differences in measured complications reached significance. Discomfort, a common cause of reoperation in the titanium group, did not result in reoperation in any of the patients receiving custom implants. CONCLUSION: Infection rates are higher among patients receiving custom implants compared to those receiving titanium meshes. The latter should be informed of potential postsurgical discomfort, which can be managed nonsurgically and is not associated with return to the operating room.

Treatment of pediatric extra-axial sinogenic infection: case series and literature review.

PURPOSE: Analyze the clinical presentation, microbiology, outcomes, and medical and surgical treatment strategies of intracranial extension of sinogenic infection in pediatric patients. METHODS: A retrospective, single-center study of patients < 18 years of age, presenting with intracranial extension of bacterial sinogenic infections requiring surgical intervention over a 5-year period, was conducted. Electronic medical records were reviewed for age, sex, primary symptoms, duration of symptoms, presence of sinusitis at initial presentation, microorganisms isolated, mode of surgery, timing of surgery, length of stay, and neurologic sequelae. RESULTS: Seventeen patients were identified; mean age was 10 years with 82.3% male predominance. Average duration of illness prior to presentation was 9.8 days, with 64.7% of patients displaying disease progression while on oral antibiotics prior to presentation. Sinusitis and intracranial extension were present in all patients upon admission. Simultaneous endoscopic endonasal drainage and craniotomy were performed on 70.5% of the patients, with the remaining 29.5% undergoing endonasal drainage only. Of the patients who underwent simultaneous endoscopic endonasal drainage and craniotomy, 17.6% required repeat craniotomy and 5.8% required repeat sinus surgery. The most commonly isolated organisms were S. intermedius (52.9%), S. anginosus (23.5%), and S. pyogenes (17.6%). All patients were treated postoperatively antibiotic on average 4-6 weeks. Frequently occurring long-lasting complications included seizures (29.4%) and focal motor deficits (17.6%); learning disability, anxiety disorders, impaired cognition, and sensory deficits occurred less frequently. CONCLUSION: In the case of intracranial extension of bacterial sinogenic infection, early identification and surgical treatment are crucial to avoid neurological sequelae.

Radiation-Induced Sarcoma After Heterotopic Ossification Prophylaxis: A Case Report.

CASE: Heterotopic ossification (HO) is a pathological formation of bone in nonosseous tissue and is a common complication of orthopaedic procedures. Radiotherapy is often used to prevent HO despite the small risk of secondary malignancy. Here, we report a case of a patient who developed a periprosthetic, radiation-induced sarcoma after delivery of a single fraction of 7 Gy for HO prophylaxis. This sarcoma was found to lie entirely within the treatment field and occurred within 5 years of radiation. CONCLUSION: Appropriate counseling regarding radiation-induced sarcoma formation should be provided to patients considering radiotherapy for this HO prophylaxis.

Association of for-profit hospital ownership status with intracranial hemorrhage outcomes and cost of care.

OBJECTIVE: Much of the current discourse surrounding healthcare reform in the United States revolves around the role of the profit motive in medical care. However, there currently exists a paucity of literature evaluating the effect of for-profit hospital ownership status on neurological and neurosurgical care. The purpose of this study was to compare inpatient mortality, operation rates, length of stay, and hospital charges between private nonprofit and for-profit hospitals in the treatment of intracranial hemorrhage. METHODS: This retrospective cohort study utilized data from the National Inpatient Sample (NIS) database. Primary outcomes, including all-cause inpatient mortality, operative status, patient disposition, hospital length of stay, total hospital charges, and per-day hospital charges, were assessed for patients discharged with a primary diagnosis of intracranial (epidural, subdural, subarachnoid, or intraparenchymal) hemorrhage, while controlling for baseline demographics, comorbidities, and interhospital differences via propensity score matching. Subgroup analyses by hemorrhage type were then performed, using the same methodology. RESULTS: Of 155,977 unique hospital discharges included in this study, 133,518 originated from private nonprofit hospitals while the remaining 22,459 were from for-profit hospitals. After propensity score matching, mortality rates were higher in for-profit centers, at 14.50%, compared with 13.31% at nonprofit hospitals (RR 1.09, 95% CI 1.00-1.18; p = 0.040). Surgical operation rates were also similar (25.38% vs 24.42%; RR 0.96, 95% CI 0.91-1.02; p = 0.181). Of note, nonprofit hospitals appeared to be more intensive, with intracranial pressure monitor placement occurring in 2.13% of patients compared with 1.47% in for-profit centers (RR 0.69, 95% CI 0.54-0.88; p < 0.001). Discharge disposition was also similar, except for higher rates of absconding at for-profit hospitals (RR 1.59, 95% CI 1.12-2.27; p = 0.018). Length of stay was greater among for-profit hospitals (mean ± SD: 7.46 ± 11.91 vs 6.50 ± 8.74 days, p < 0.001), as were total hospital charges ($141,141.40 ± $218,364.40 vs $84,863.54 ± $136,874.71 [USD], p < 0.001). These findings remained similar even after segregating patients by subgroup analysis by hemorrhage type. CONCLUSIONS: For-profit hospitals are associated with higher inpatient mortality, lengths of stay, and hospital charges compared with their nonprofit counterparts.

Cranioplasty in Infants Less Than 24 Months of Age: A Retrospective Case Review of Pitfalls, Outcomes, and Complications.

BACKGROUND: Management of pediatric skull defects after decompressive craniectomy (DC) poses unique problems, particularly in children younger than 24 months. These problems include complications such as resorption and infection as well as difficulties with plagiocephaly and reconstruction. The goal of this study was to evaluate bone resorption complications after cranioplasty in patients <24 months. METHODS: A single-center retrospective case study was performed of all patients younger than 24 months who underwent cranioplasty after DC between 2011 and 2018. The following variables were assessed: injury cause, age at craniotomy, time to cranioplasty, craniectomy size, mode of fixation, drain use, shunt use, subdural fluid collection, resorption, need for synthetic graft revision, and plagiocephaly. RESULTS: A total of 10 patients were identified who met inclusion criteria; 3 patients were excluded for insufficient follow-up. Ages ranged from <1 day to 19 months, with a mean of 10.7 months. Overall rate of cranioplasty resorption was 85.7%, 57.1% of which required revision with synthetic graft. There were univariate trends toward more frequent implant resorption with subdural fluid collection (P = 0.1071) and without shunt placement (P = 0.1429). These effects persisted through multivariable analysis and even reached statistical significance in the case of subdural collection when controlling for operative and demographic characteristics (P = 0.01138, P = 0.0694). In addition, univariate analysis showed a trend toward more frequent neurologic complications with greater craniotomy-to-cranioplasty intervals (P = 0.1043), which reached significance on multivariable analysis (P = 0.00518). CONCLUSIONS: In patients younger than 24 months undergoing cranioplasty subdural collection, a lack of shunt placement and increased time to cranioplasty were associated with increased rates of resorption.

Supratentorial and Infratentorial Approaches to Pineal Surgery: A Database Analysis.

Objectives Neoplasms involving the pineal gland are rare. When they do occur, tumor resection is anatomically challenging and is traditionally addressed by either a supratentorial or an infratentorial approach. To date, no large, multicenter studies have been performed that systematically analyze outcomes comparing these two approaches. This study aimed to evaluate outcomes for patients undergoing pineal neoplasm resection, comparing supratentorial and infratentorial approaches. Design Retrospective database review. Setting Multi-institutional database. Participants From 2005 to 2016, 60 patients were identified, with 13 undergoing a supratentorial approach and 47 undergoing an infratentorial approach. Main Outcome Measures Patient demographics, comorbidities, and 30-day postoperative outcomes were investigated using the American College of Surgeons National Surgical Quality Improvement Program database. Demographics, readmission, reoperation, and complication rates were analyzed and compared with previous studies. Results Patient demographics were similar between these two groups. The overall complication rates for the supratentorial and infratentorial approaches were 30.8 and 17%, respectively, and the difference was not statistically significant. The most common medical complications encountered were respiratory and hematological. Conclusion As the first multi-institutional database analysis of approaches to the pineal gland, this study provides an analysis of patient demographics, comorbidities, and postoperative complications. After controlling for preoperative risk factors and demographic characteristics, no statistically significant differences in postoperative outcomes were found between infratentorial and supratentorial approaches. The mean readmission, reoperation, and complication rates were found to be 2.1, 8.3, and 20%, respectively. The lack of significant difference between approaches suggests that clinical decision-making should depend upon anatomical considerations and physician preference, although the complications illustrated here may provide some preoperative guidance.

Autologous Bone Cranioplasty: A Retrospective Comparative Analysis of Frozen and Subcutaneous Bone Flap Storage Methods.

OBJECTIVE: The use of autologous bone for cranioplasty offers superior cosmesis and cost-effectiveness compared with synthetic materials. The choice between 2 common autograft storage mechanisms (subcutaneous vs. frozen) remains controversial and dictated by surgeon preference. We compared surgical outcomes after autologous bone cranioplasty between patients with cryopreserved and subcutaneously stored autografts. METHODS: Ten-year retrospective comparative analysis of patients undergoing cranioplasty with autologous bone stored subcutaneously or frozen at a tertiary academic medical center. RESULTS: Ninety-four patients were studied, with 34 (36.2%) bone flaps stored subcutaneously and 59 (62.8%) frozen. The 2 groups were similar in demographics, comorbidities, and craniectomy indication, with only body mass index and race differing statistically. The mean operation time was greater within the subcutaneous group (P < 0.001), which also had a greater number of ventriculoperitoneal shunt (VPS) placements (P = 0.02). There were no significant differences in complications, readmissions, unplanned reoperations, or length of stay between the 2 groups. VPS placement during cranioplasty increased length of stay (P < 0.001), and placement prior to cranioplasty increased both length of stay (P = 0.009) and incidence of hospital-acquired infection (P = 0.03). CONCLUSIONS: Subcutaneous and frozen storage of autologous bone result in similar surgical risk profiles. Cryopreservation may be preferred because of shorter operation time and avoidance of complications with the abdominal pocket, whereas the portability of subcutaneous storage remains favorable for patients undergoing cranioplasty at a different institution. VPS placement prior to cranioplasty should be avoided, if possible, due to the increased risk of hospital-acquired infection.

Unintentional error in formula preparation and its simulated impact on infant weight and adiposity.

BACKGROUND: Accelerated weight gain in infancy is a public health issue and is likely due to feeding behaviours. OBJECTIVES: To test the accuracy of individuals to dispense infant formula as compared with recommended serving sizes and to estimate the effect of dispensing inaccuracy on infant growth. METHODS: Fifty-three adults dispensed infant formula powder for three servings of 2, 4, 6, and 8 fl oz bottles, in random order. The weight of dispensed infant formula powder was compared with the recommended serving size weight on the nutrition label. A novel mathematical model was used to estimate the impact of formula dispensing on infant weight and adiposity. RESULTS: Nineteen percent of bottles (20 of 636) prepared contained the recommended amount of infant formula powder. Three percent were underdispensed, and 78% of bottles were overdispensed, resulting in 11% additional infant formula powder. Mathematical modelling feeding 11% above energy requirements exclusively for 6 months for male and female infants suggested infants at the 50th percentile for weight at birth would reach the 75th percentile with increased adiposity by 6 months. CONCLUSIONS: Inaccurate measurement of infant formula powder and overdispensing, which is highly prevalent, specifically, may contribute to rapid weight gain and increased adiposity in formula-fed infants.

Laparotomy complications on extracorporeal life support: Surgical site bleeding does not increase mortality.

PURPOSE: The risks of laparotomy during extracorporeal life support (ECLS) are poorly defined. We examined risk factors associated with bleeding and mortality after laparotomy on ECLS. METHODS: The Extracorporeal Life Support Organization (ELSO) database was queried for all pediatric patients [0-17 years] with a procedure code for laparotomy. Outcome data were analyzed to define factors contributing to laparotomy complications and mortality while on ECLS. Univariate and multivariate analyses were applied to determine independent risk factors. RESULTS: 196 patients who met inclusion criteria were identified. The mortality rate in the entire cohort was 67.3%. In both univariate and multivariate analyses, surgical site bleeding did not significantly increase the risk of mortality (OR 0.8; 95% CI 0.4-1.7). Logistic regression analysis revealed that lower gestational age, infectious complications and nonsurgical site hemorrhagic complications were independently increased mortality risk (all p < 0.05). CONCLUSION: Mortality following laparotomy on ECLS is not independently associated with surgical site bleeding, but is associated with lower gestational age, infectious and nonsurgical site hemorrhagic complications. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: Level III.

Neurophysiological analytics for all! Free open-source software tools for documenting, analyzing, visualizing, and sharing using electronic notebooks.

Neurophysiology requires an extensive workflow of information analysis routines, which often includes incompatible proprietary software, introducing limitations based on financial costs, transfer of data between platforms, and the ability to share. An ecosystem of free open-source software exists to fill these gaps, including thousands of analysis and plotting packages written in Python and R, which can be implemented in a sharable and reproducible format, such as the Jupyter electronic notebook. This tool chain can largely replace current routines by importing data, producing analyses, and generating publication-quality graphics. An electronic notebook like Jupyter allows these analyses, along with documentation of procedures, to display locally or remotely in an internet browser, which can be saved as an HTML, PDF, or other file format for sharing with team members and the scientific community. The present report illustrates these methods using data from electrophysiological recordings of the musk shrew vagus-a model system to investigate gut-brain communication, for example, in cancer chemotherapy-induced emesis. We show methods for spike sorting (including statistical validation), spike train analysis, and analysis of compound action potentials in notebooks. Raw data and code are available from notebooks in data supplements or from an executable online version, which replicates all analyses without installing software-an implementation of reproducible research. This demonstrates the promise of combining disparate analyses into one platform, along with the ease of sharing this work. In an age of diverse, high-throughput computational workflows, this methodology can increase efficiency, transparency, and the collaborative potential of neurophysiological research.

Genetic variation and population substructure in outbred CD-1 mice: implications for genome-wide association studies.

Outbred laboratory mouse populations are widely used in biomedical research. Since little is known about the degree of genetic variation present in these populations, they are not widely used for genetic studies. Commercially available outbred CD-1 mice are drawn from an extremely large breeding population that has accumulated many recombination events, which is desirable for genome-wide association studies. We therefore examined the degree of genome-wide variation within CD-1 mice to investigate their suitability for genetic studies. The CD-1 mouse genome displays patterns of linkage disequilibrium and heterogeneity similar to wild-caught mice. Population substructure and phenotypic differences were observed among CD-1 mice obtained from different breeding facilities. Differences in genetic variation among CD-1 mice from distinct facilities were similar to genetic differences detected between closely related human populations, consistent with a founder effect. This first large-scale genetic analysis of the outbred CD-1 mouse strain provides important considerations for the design and analysis of genetic studies in CD-1 mice.

Neuroanatomical specificity of conditioned responses to cocaine versus food in mice.

Neural circuits implicated in drug conditioning, craving and relapse overlap extensively with those involved in natural reward and reinforcement. To determine whether specificity could be detected in conditioned brain responses to drugs versus food, male outbred HSD:ICR mice were conditioned to a common environment using either 20 mg/kg cocaine (ip) or a familiar food (under food restriction). The mice were then re-exposed to the same environment without the reinforcer and patterns of brain activation were compared using immunohistochemical detection of Fos. Conditioned place preference tests were conducted first to establish relative potency of each reward and facilitate analysis of correlations between Fos and motivation. Place preference was stronger for cocaine than food. Food- but not cocaine-paired cues increased Fos in the paraventricular hypothalamic nucleus whereas the opposite occurred for prefrontal, cingulate and piriform cortices. Individual differences in cocaine place preference were negatively correlated with Fos in the prefrontal cortex. One difference between drugs and natural reinforcers may be lack of feedback from the periphery for drugs which may circumvent control from the hypothalamus in the development of reinforcement circuits.