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Limited capacity in the emergency department (ED) secondary to boarding and crowding has resulted in patients receiving care in hallways to provide access to timely evaluation and treatment. However, there are concerns raised by physicians and patients regarding a decrease in patient centered care and quality resulting from hallway care. We sought to explore social risk factors associated with hallway placement and operational outcomes. Observational study between July 2017 and February 2020. Primary outcome was the adjusted odds ratio (aOR) of patient placement in a hallway treatment space adjusting for patient demographics and ED operational factors. Secondary outcomes included left without being seen (LWBS), discharge against medical advice (AMA), elopement, 72-h ED revisit, 10-day ED revisit and escalation of care during boarding. Among 361,377 ED visits, 100,079 (27.7%) visits were assigned to hallway beds. Patient insurance coverage (Medicaid (aOR 1.04, 95% CI 1.01,1.06) and Self-pay/Other (1.08, (1.03, 1.13))) with comparison to private insurance, and patient sex (Male (1.08, (1.06, 1.10))) with comparison to female sex are associated with higher odds of hallway placement but patient age, race, and language were not. These associations are adjusted for ED census, triage assigned severity, ED staffing, boarding level, and time effect, with social factors mutually adjusted. Additionally adjusting for patients' social factors, patients placed in hallways had higher odds of elopement (1.23 (1.07,1.41)), 72-h ED revisit (1.33 (1.08, 1.64)) and 10-day ED revisit (1.23 (1.11, 1.36)) comparing with patients placed in regular ED rooms. We did not find statistically significant associations between hallway placement and LWBS, discharge AMA, or escalation of care. While hallway usage is ad hoc, we find consistent differences in care delivery with those insured by Medicaid and self-pay or male sex being placed in hallway beds. Further work should examine how new front-end processes such as provider in triage or split flow may be associated with inequities in patient access to emergency and hospital care. [ABSTRACT FROM AUTHOR]

Oligometastatic breast cancer is typically defined as the presence of 1-5 metastases and represents an intermediate state between locally advanced and widely metastatic disease. Oligometastatic cancer appears have a molecular signature that is distinct from widely metastatic disease and is associated with a superior prognosis. Due to its more limited capacity for widespread progression, oligometastatic disease could potentially benefit from aggressive ablative therapy to known sites of disease. The phase II SABR-COMET trial enrolled patients with oligometastatic disease of multiple histologies and randomized them to HIGRT vs. standard of care, finding a notable survival advantage in favor of HIGRT. There are many ongoing trials exploring the role of HIGRT for the treatment of oligometastatic breast cancer. Future studies may identify optimal candidates for ablative therapy by molecular signature; current clinically-based selection criteria include longer disease-free interval from diagnosis to metastasis (>2 years), fewer metastases, and fewer involved organs. [ABSTRACT FROM AUTHOR]

Our purpose was to characterize the radiation doses to organs-at-risk (OAR) in the phase I trial (NCT02608385) that established safety/efficacy of stereotactic body radiation therapy (SBRT) using NRG-BR001 dose constraints combined with programmed cell death protein 1 blockade for metastatic disease. Between January 2016 and May 2018, 73 patients with advanced solid tumors were treated with SBRT followed by pembrolizumab. Tumor volumes (gross tumor volume/internal tumor volume) were delineated for each metastasis, with planning target volume contraction to limit OAR dose per protocol (n = 54) or when gross tumor volume/internal tumor volume > 65 cm3 (n = 19). For 20 OAR, doses were compared with NRG-BR001 constraints. Protocol constraints were considered challenged when the minimum of the highest dose received by ≥6 patients without dose-limiting toxicities (DLTs) (D m a x 6 t h) was ≥70% of the protocol constraint. A total of 151 metastases were irradiated including 32 peripheral lung, 23 central lung, 13 mediastinal/cervical, 24 liver, 28 abdominal-pelvic, 16 osseous, and 15 spinal metastases. A median of 2 metastases (range, 2-4) with mean volumes of 33.5 cm3 (range, 0.4-391 cm3) were treated using average planning target volumes of 50.7 cm3 (range, 3.2-161 cm3). At least 1 dose constraint from NRG-BR001 was exceeded in 38 of 73 (52%) patients. OAR constraints were challenged in 10 serial organs (gastrointestinal, cardio-pulmonary, musculoskeletal, and nervous systems) and 1 parallel OAR (lung). Grade 3 DLTs occurred in 6 patients, including pneumonitis (n = 3), colitis (n = 2), and hepatic failure (n = 1). In 4 patients, the toxicity could be directly attributed to the planned dose to OAR (ie, pneumonitis due to high lung dose or colitis due to high bowel dose). Multisite SBRT in combination with programmed cell death protein 1 blockade was safely tolerated when treating critical central, abdominal-pelvic, and peripheral OAR nearing NRG-BR001 constraints with clinically acceptable toxicity in the corresponding organ systems. The observed relationship between dose and DLTs in 4 of 6 patients indicates that NRG-BR001 dose constraints should be respected in subsequent trials to maintain clinical safety. [ABSTRACT FROM AUTHOR]

Forest trees facing climate change may persist in a short term through acclimation within the limits of their phenotypic plasticity. In the longer term, however, evolutionary adaptation would be needed for populations to thrive in the changed climate, or species may migrate to new areas as climate becomes favorable there. European beech is one of the most important tree species in western and central Europe, and projections indicate that it may contract its southern range and migrate towards northern and north-eastern Europe in the future climates. It is therefore important to recognize the level of variation in climatic adaptation and climatic responsiveness of populations which are likely the source of genetic material for expanding the species range. In this study we examined variation in growth and productivity among 39 European beech populations, which represent the north-eastern margin of the species distribution range. We employed the transfer function and the Universal Response Function approaches to analyze populations' performance in response to the climatic transfer across five provenance test sites and in relationship to climate at the populations' origin and planting sites. We found significant but low variation among tested populations in tree diameter (DBH; cm) and Volume index (m3 ha−1) and significant population × site interaction at age 30 years. That variation, however, was only weakly related to gradients of climatic variables represented by the set of sampled populations. The variable performance of populations across planting sites, and the importance of planting sites' climate in explaining traits' variation in this experiment confirm the plastic response of examined populations to climate change. Our findings indicate that beech populations from the analyzed region have a high acclimation potential to the projected changes in climate, although for high-altitude populations (from > 600 m a.s.l) the negative effect of transfers to warmer and drier conditions was observed. Detailed knowledge of the plasticity of response and adaptive potential of marginal beech populations in the longer term would be needed to guide management decisions to help future forests to cope with climate change. • Beech populations at species north-east margin would contribute to range expansion. • Those populations vary in diameter growth and productivity across planting sites. • Variation was related more to the climate of planting site than population origin. • The pattern on variation reflects plastic response to climate change. • Beech populations from analyzed region have overall a high acclimation potential. [ABSTRACT FROM AUTHOR]

The use of a soft tissue laser will not only improve the quality and speed of orthodontic treatment, it can dramatically enhance final esthetic results. To optimize the speed of treatment, esthetic considerations should be considered as part of the initial diagnosis. Using a laser allows cleaner finish lines and reduces damage to the gingival crests, with faster healing and less discomfort when compared to more conventional techniques. Even when dealing with complex altered passive eruption cases, soft-tissue laser procedures can provide significant benefits to patients. [ABSTRACT FROM AUTHOR]

Adding a soft tissue laser to an orthodontist's technology toolbox permits performance of numerous procedures that reduce time in treatment, saves valuable chair time and improves results. It is critical to know both the abilities and limitations of the device in order to maximize benefits to both patient and practice, and realize an acceptable return on investment. Important considerations to understand when treatment planning for a laser procedure include the type of laser to use, levels of keratinized tissue, an understanding of biologic width and measurement of pocket depth. It is also critical to use the proper settings on the laser to reduce tissue charring, which could potentially result in delayed healing and postoperative discomfort. The most critical criterion when purchasing a laser may well be the amount and type of training that comes with the device. Within these parameters, a number of procedures may be safely and easily performed by orthodontists including gingivectomies, tooth exposures, frenotomies (labial and lingual), crestal fiberotomies and treatment of aphthous ulcers. [ABSTRACT FROM AUTHOR]

• A novel yttrium-90 Superficial Brachytherapy source has been characterized. • Yttrium-90 is a highly conforming source, ideal for the treatment of superficial lesions. • The Conformal Superficial Brachytherapy applicator uses multiple brachytherapy sources. • The Conformal Superficial Brachytherapy applicator was designed to treat non-melanoma skin cancers. To characterize the dose distribution in water of a novel beta-emitting brachytherapy source for use in a Conformal Superficial Brachytherapy (CSBT) device. Yttrium-90 (90Y) sources were designed for use with a uniquely designed CSBT device. Depth dose and planar dose measurements were performed for bare sources and sources housed within a 3D printed source holder. Monte Carlo simulated dose rate distributions were compared to film-based measurements. Gamma analysis was performed to compare simulated and measured dose rates from seven 90Y sources placed simultaneously using the CSBT device. The film-based maximum measured surface dose rate for a bare source in contact with the surface was 3.35 × 10–7 cGy s−1 Bq−1. When placed in the source holder, the maximum measured dose rate was 1.41 × 10–7 cGy s−1 Bq−1. The Monte Carlo simulated depth dose rates were within 10% or 0.02 cm of the measured dose rates for each depth of measurement. The maximum film surface dose rate measured using a seven-source configuration within the CSBT device was 1.78 × 10−7 cGy s−1 Bq−1. Measured and simulated dose rate distribution of the seven-source configuration were compared by gamma analysis and yielded a passing rate of 94.08%. The gamma criteria were 3% for dose-difference and 0.07056 cm for distance-to-agreement. The estimated measured dose rate uncertainty was 5.34%. 90Y is a unique source that can be optimally designed for a customized CSBT device. The rapid dose falloff provided a high dose gradient, ideal for treatment of superficial lesions. The dose rate uncertainty of the 90Y-based CSBT device was within acceptable brachytherapy standards and warrants further investigation. [ABSTRACT FROM AUTHOR]