Rare case of pediatric trauma with hepatic injury managed using gel-foam embolization: a case report.

Nonoperative management for hepatic injuries requires observation and supportive care in the case of hemodynamically stable patients. If there is active bleeding on presentation, hepatic artery embolization is an option to achieve hemostasis in the acute setting. Although interventional radiology procedures are well documented in adults, there is limited literature regarding these procedures in the pediatric population. In this report, we present a case of a pediatric patient who sustained blunt abdominal trauma, resulting in a grade IV liver injury. Treatment involved fluoroscopically guided right hepatic segmental arterial gel-foam embolization.

Evaluating the utility of knowledge-based planning for clinical trials using the TROG 08.03 post prostatectomy radiation therapy planning data.

Background and purpose: Poor quality radiotherapy can detrimentally affect outcomes in clinical trials. Our purpose was to explore the potential of knowledge-based planning (KBP) for quality assurance (QA) in clinical trials. Materials and methods: Using 30 in-house post-prostatectomy radiation treatment (PPRT) plans, an iterative KBP model was created according to the multicentre clinical trial protocol, delivering 64 Gy in 32 fractions. KBP was used to replan 137 plans. The KB (knowledge based) plans were evaluated for their ability to fulfil the trial constraints and were compared against their corresponding original treatment plans (OTP). A second analysis between only the 72 inversely planned OTPs (IP-OTPs) and their corresponding KB plans was performed. Results: All dose constraints were met in 100% of KB plans versus 69% of OTPs. KB plans demonstrated significantly less variation in PTV coverage (Mean dose range: KB plans 64.1 Gy-65.1 Gy vs OTP 63.1 Gy-67.3 Gy, p < 0.01). KBP resulted in significantly lower doses to OARs. Rectal V60Gy and V40Gy were 17.7% vs 27.7% (p < 0.01) and 40.5% vs 53.9% (p < 0.01) for KB plans and OTP respectively. Left femoral head (FH) V45Gy and V35Gy were 0.4% vs 7.4% (p < 0.01) and 7.9% vs 34.9% (p < 0.01) respectively. In the second analysis plan improvements were maintained. Conclusions: KBP created high quality PPRT plans using the data from a multicentre clinical trial in a single optimisation. It is a powerful tool for utilisation in clinical trials for patient specific QA, to reduce dose to surrounding OARs and variations in plan quality which could impact on clinical trial outcomes.

Improving efficiency in the radiation management of multiple brain metastases using a knowledge-based planning solution for single-isocentre volumetric modulated arc therapy (VMAT) technique.

INTRODUCTION: This study aimed to develop a single-isocentre volumetric modulated arc therapy (si-VMAT) technique for multiple brain metastases using knowledge-based planning software, comparing it with a multiple-isocentre stereotactic radiosurgery (mi-SRS) planning approach. METHODS: Twenty-six si-VMAT plans were created and uploaded into RapidPlanTM (RP) to create a si-VMAT model. Ten patients, with 2 to 6 metastases (mets), were planned with a si-VMAT technique utilising RP, and a mi-SRS technique on Brainlab iPlan. Paddick Conformity Index (PCI) was used to compare conformity. The volumes of the brain receiving 15Gy, 12Gy, 10Gy, 7.5Gy and 3Gy were also compared. Retrospective treatment times from the last eight patients treated were averaged for pre-imaging and beam on time to calculate treatment times for both techniques. RESULTS: There was a significant difference in the PCI scores for the mi-SRS plans (M = 0.667, SD = 0.114) and si-VMAT plans (M = 0.728, SD = 0.088), with PCI values suggesting better prescription dose conformity with the si-VMAT technique (P = 0.014). Percentage of total brain volume receiving low-dose wash at four of the five different dose levels was significantly less (P < 0.05) with mi-SRS. Average time to treat a single met with current mi-SRS technique is 25.7 min, with each additional met requiring this same amount of time. The average time to treat 2-3 mets using si-VMAT would be 25.3 min and 4+ metastases 33.5 min. CONCLUSION: A knowledge-based si-VMAT approach was efficient in planning and treating multi metastases while achieving clinically acceptable dosimetry with respect to dose conformity and low-dose fall off.

Rolling out RapidPlan: What we've learnt.

INTRODUCTION: RapidPlan (RP), a knowledge-based planning system, aims to consistently improve plan quality and efficiency in radiotherapy. During the early stages of implementation, some of the challenges include knowing how to optimally train a model and how to integrate RP into a department. We discuss our experience with the implementation of RP into our institution. METHODS: We reviewed all patients planned using RP over a 7-month period following inception in our department. Our primary outcome was clinically acceptable plans (used for treatment) with secondary outcomes including model performance and a comparison of efficiency and plan quality between RP and manual planning (MP). RESULTS: Between November 2017 and May 2018, 496 patients were simulated, of which 217 (43.8%) had an available model. RP successfully created a clinically acceptable plan in 87.2% of eligible patients. The individual success of the 24 models ranged from 50% to 100%, with more than 90% success in 15 (62.5%) of the models. In 40% of plans, success was achieved on the 1st optimisation. The overall planning time with RP was reduced by up to 95% compared with MP times. The quality of the RP plans was at least equivalent to historical MP plans in terms of target coverage and organ at risk constraints. CONCLUSION: While initially time-consuming and resource-intensive to implement, plans optimised with RP demonstrate clinically acceptable plan quality, while significantly improving the efficiency of a department, suggesting RP and its application is a highly effective tool in clinical practice.

Parotid sparing in RapidPlan Oropharynx models: To split or not to split.

INTRODUCTION: Differences in knowledge and experience, patient anatomy and tumour location and manipulation of inverse planning objectives and priorities will lead to a variability in the quality of radiation planning. The aim of this study was to investigate whether parotid glands should be treated as separate or combined structures when using knowledge-based planning (KBP) to create oropharyngeal plans, based on the dose they receive. METHOD: Two separate RapidPlan (RP) models were created using the same 70 radical oropharyngeal patients. The 'separated model' divided the parotids into ipsilateral and contralateral structures. The 'combined model' did not separate the parotids. The models were independently validated using 20 patients not included in the models. The same dose constraints and priorities were applied to planning target volumes (PTVs) and organs at risk (OARs) for all plans. An auto-generated line objective and priority was applied in both models, with parotid mean dose and V50 doses evaluated and compared. RESULTS: Plans optimised using the combined model resulted in lower ipsilateral mean doses and lower V50 doses in 80% and 75% of cases, respectively. Fifty-five per cent of plans produced lower mean doses for the contralateral parotid when optimised using the combined model, while lower V50 doses were evenly split between the models. CONCLUSION: Combining the data for both parotids into one RP model resulted in better ipsilateral parotid sparing. Results also suggest that a combined parotid model will spare dose to the contralateral parotid; however, further investigation is required to confirm these results.

An assessment of the performance of municipal constructed wetlands in Ireland.

While performance assessments of constructed wetlands sites around the world have appraised their capacity for effective removal of organics, a large variance remains in these sites' reported ability to retain nutrients, which appears to depend on differences in design, operation and climate factors. Nutrient retention is a very important objective for constructed wetlands, to avoid eutrophication of aquatic environments receiving their effluents. This study assessed the performance of constructed wetlands in terms of nutrient retention and associated parameters under the humid conditions of Ireland's temperate maritime climate. A review of the performance of 52 constructed wetland sites from 17 local authorities aimed to identify the best performing types of constructed wetlands and the treatment factors determining successful compliance with environmental standards. Data analysis compared effluent results from constructed wetlands with secondary free surface flow or tertiary horizontal subsurface flow, hybrid systems and integrated constructed wetlands with those from small-scale mechanical wastewater treatment plants of the same size class. Nutrient concentrations in effluents of constructed wetlands were negatively correlated (p < .01) with specific area, i.e. the ratio of surface area and population equivalents. The latest generation of integrated constructed wetlands, which had applied design guidelines issued by the Department of the Environment, performed best. Storm management design features improved treatment performance of constructed wetlands significantly (p < .05) for total suspended solids concentrations and exceedance frequency of limit values for total nitrogen. Mechanical wastewater treatment plants, secondary free surface water and tertiary horizontal subsurface flow wetlands showed a very large variance in effluent concentrations for organic and nutrient parameters. E. coli numbers in effluents were lowest for integrated constructed wetlands with an arithmetic mean of 89 MPN/100 ml. Despite Ireland's humid climate, some constructed wetland sites achieved long or frequent periods of zero effluent discharge and thus did not transfer any waterborne pollution to their receptors during these periods.

Weight loss in videoconference and in-person iDiet weight loss programs in worksites and community groups.

OBJECTIVE: To examine the association of program delivery factors with weight loss (WL) in enrollees in iDiet® , a commercial WL program. METHODS: Data were from 644 adults enrolling in an 11-week group WL program and 461 who reported weight to 11 weeks (complete reporters). Predictors of %WL were analyzed using ANCOVA, including meeting type (in-person vs. videoconference), participant type (worksite employees vs. community members), age, gender, BMI, and payment structure. RESULTS: Mean starting BMI was 32.4 ± 7.1 (mean ± SD); WL was 6.1 ± 3.9% in all enrollees in an intention-to-treat analysis and 7.4 ± 3.4% in complete reporters. Videoconference participants, older adults, and enrollees in incentivized programs were more likely to be complete reporters (P < 0.004). %WL at 11 weeks was not associated with gender, starting BMI, or videoconference versus in-person groups. Worksite participants had greater %WL than community participants (+1.2%, P < 0.001), and there was no significant difference in %WL between programs paid by the employee or employer. Greater %WL was achieved by individuals ≥30 versus < 30 years (+2.2%, P < 0.001) and by those enrolling in January-March versus April-June (+1.4%, P = 0.02). CONCLUSIONS: iDiet participants had clinically impactful mean WL. The observed high mean WL in worksites and videoconference-delivered programs broadens options for scalable WL program implementation.

A double-blind controlled trial of polyglytone 6211 versus poliglecaprone 25 for use in body contouring.

The use of absorbable sutures to obtain secure dermal closure in surgeries such as body contouring is common. The risk of complications based on the absorption rate of these materials is unknown. This study attempts to determine whether a faster absorbing suture material such as polyglytone 6211 will lead to fewer complications such as extrusion and granuloma formation as compared with less rapidly absorbing materials such as poliglecaprone 25. Concomitantly, this study also attempts to explore the possible negative outcomes that may be due to faster loss of strength, such as dehiscence and poor scar aesthetics. We found that extrusion occurs less frequently with the rapidly absorbed polyglytone 6211 suture material, without increase in granuloma formation, infection, dehiscence, cellulitis, necrosis, seroma formation, and hematoma formation. We also observed no clinical difference in the cosmetic appearance of scars at the 12-week postoperative follow-up visit.

What's needed next: a culture of candor.

If there's one thing that the past decade's business disasters should teach us, it's that we need to stop evaluating corporate leaders simply on the basis of how much wealth they create for investors. A healthier yardstick would be this: the extent to which leaders create firms that are economically, ethically, and socially sustainable. The first step toward accomplishing that task is to create a culture of candor. Companies can't innovate, respond to stakeholder needs, or run efficiently unless the people inside them have access to timely, relevant information, point out professors O'Toole, of the University of Denver's Daniels College of Business, and Bennis, of the University of Southern California. Increasing transparency can be an uphill battle against human nature, however. The obstacles are numerous: macho executives who don't listen to their subordinates or punish them for bringing bad news; leaders who believe that information is power and hoard it; groupthink among team members who don't know how to disagree; boards that fail to question charismatic CEOs. Nevertheless, leaders can take steps to nurture transparency. By being open and candid, admitting their errors, encouraging employees to speak truth to power, and rewarding contrarians, executives can model the kind of conduct they want to see. Training employees to handle unpleasant conversations with grace also will break down barriers to honest communication. To avoid being blinded by biases, leaders can diversify their sources of information--an obvious measure that's rarely taken. Perhaps the biggest lever for cultural change is the executive selection process--choosing leaders for their transparent behavior, not just their ability to compete. And a few companies have even gone so far as to share all relevant information with every employee.

How business schools lost their way.

Business schools are facing intense criticism for failing to impart useful skills, failing to prepare leaders, failing to instill norms of ethical behavior--and even failing to lead graduates to good corporate jobs. These criticisms come not just from students, employers, and the media but also from deans of some of America's most prestigious B schools. The root cause oftoday's crisis in management education, assert Warren G. Bennis and James O'Toole, is that business schools have adopted an inappropriate--and ultimately self-defeating--model of academic excellence. Instead of measuring themselves in terms of the competence of their graduates, or by how well their faculty members understand important drivers of business performance, they assess themselves almost solely by the rigor of their scientific research. This scientific model is predicated on the faulty assumption that business is an academic discipline like chemistry or geology when, in fact, business is a profession and business schools are professional schools--or should be. Business school deans may claim that their schools remain focused on practice, but they nevertheless hire and promote research-oriented professors who haven't spent time working in companies and are more comfortable teaching methodology than messy, multidisciplinary issues--the very stuff of management. The authors don't advocate a return to the days when business schools were glorified trade schools. But to regain relevancy, they say, business schools must rediscover the practice of business and find a way to balance the dual mission of educating practitioners and creating knowledge through research.