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To maximize procedure volume and minimize workflow inefficiency in our urological procedure clinic, we hypothesized that for staff (nurses/medical assistants) and patient teams, team workflow duration (TWD) (the time required to complete team duties for a single appointment) could be reduced by 50% with a targeted workflow intervention developed using the Model for Improvement and Plan-Do-Study-Act cycles. Workflow inefficiency leads to wasted time and workplace dissatisfaction, resulting in lost revenue due to low procedure volume and high staff turnover. A baseline time study was performed to measure TWD for clinical teams, including the front desk, physician, staff, and patient teams. Implementation of previously identified interventions was also recorded. A workflow intervention was developed in which staff duties were split among two roles: staffer and triager. TWD and intervention implementation were remeasured over six Plan-Do-Study-Act cycles. Semistructured interviews were conducted as a balance measure to assess impact on staff workflow and wellness. Our workflow intervention resulted in a 44% and 42% reduction in staff and patient TWD, saving nearly 17 minutes per appointment on average. Thematic analysis revealed that time saved could be best used to protect lunch breaks and allow time to complete nonclinical duties such as patient calls, which had previously been performed after-hours. Introduction of staffer and triager roles to staff workflow increased clinic efficiency by reducing workflow and procedure appointment duration. Time saved was used to increase procedure volume while also supporting staff wellness. [ABSTRACT FROM AUTHOR]

We report an interesting case of a child with new-onset malignant hypertension (HTN) associated with facial paralysis. A review of the medical literature on this association and discussion of diagnostic and management aspects are included. [ABSTRACT FROM AUTHOR]

Purpose: To measure the internal lung motion due to respiration using magnetic resonance images (MRIs); to evaluate the correlation between lung motion and skin surface motion and the reliability of tracking lung motion with external fiducials.Methods and materials: An MRI protocol using fast gradient-echo sequences was developed to acquire dynamic cine images of the thoracoabdominal region along the axial, sagittal, and coronal planes. The subjects (3 healthy volunteers and 4 lung cancer patients) were instructed to perform normal or altered breathing during MRI. Lung vessels identified on MRI were used as anatomic landmarks for internal lung structures. From sagittal cine MRI scans, the positions of the lung vessels and skin surface were tracked and their movements measured. Correlation between the movements of the external markers and internal structures was then calculated and analyzed.Results: Lung vessel motion in the superior–inferior (SI) direction correlated best with mid-upper abdominal skin surface movement (correlation coefficient, 0.89 ± 0.09 and 0.87 ± 0.23 for volunteers and patients, respectively). The anterior-posterior (AP) vessel motion generally correlated poorly with the skin surface movement, with marker placement on the upper chest yielding the strongest results (correlation coefficient, 0.72 ± 0.23 and 0.44 ± 0.27 for volunteers and patients, respectively). The strength of the correlation depended on the locations of the tracked vessels, locations of the skin surface, and subjects'' breathing patterns. The best correlation was seen between the motion of an abdominal fiducial and SI lung motion. Significant intersubject variability was also observed.Conclusion: Movement of an external fiducial may not correlate fully with, or predict, internal lung motion. Effective monitoring of respiration may have to rely on a combination of multiple fiducials and other physiologic parameters, such as lung volume and/or air flow. [Copyright &y& Elsevier]

Purpose: To analyze the relationship between lung motion and skin surface motion during respiration, determine the uncertainties and variability of such a relationship, and assess the potential of reducing internal target margin for gated radiotherapy.Methods and materials: Three healthy volunteers and four lung cancer patients were recruited in a prospective imaging study using MRI to track the internal lung and external skin motion during breathing. The relationship between the lung and skin motion was modeled using linear regression analysis. The slope of the linear fit and its confidence interval were analyzed for different lung locations, skin surface locations, and breathing patterns from separate imaging sessions. The margins of the internal target volume were calculated based on the residual lung motion during gating and its uncertainties from multiple treatment fractions for the gated treatment.Results: The slope and confidence interval of the linear regression from the motion analysis were uniquely defined by the locations of the lung, skin surface, and breathing patterns. Statistically significant differences were observed among individuals and between different times of measurement. The normal free-breathing motion averaged from all volunteer and patient data was 13.4 ± 7.4 mm along the superior–inferior (SI) direction and 6.9 ± 2.6 mm along the anterior-posterior (AP) direction. With simulated respiratory gating, the average margin reduction was 5.5 ± 4.8 mm and 1.6 ± 1.0 mm, respectively, along the SI and AP directions (or 36% ± 15% and 25% ± 14%, respectively, relative to free-breathing motion).Conclusion: Because respiratory movement is rather complex, the relationship between the lung and skin surface motion is affected by many anatomic and physiologic factors. The reduction of internal target margin and efficacy of the free-breathing gating technique should be assessed for individual cases. [Copyright &y& Elsevier]

Two chemotherapeutic agents used in blood and marrow transplant (BMT) conditioning regimens, melphalan and busulfan, are known for their high rates of oral mucositis (OM). While there is extensive literature on the effects of oral cryotherapy (OC) with melphalan, there is limited literature on its effects with busulfan. The aim of this study was to determine if OC decreases busulfan-associated OM. The secondary aim of this study was to look at the effects OC with busulfan had on length of stay (LOS), intensive care unit (ICU) transfer for airway protection, total parenteral nutrition (TPN) use, and opioid use for OM. Our center began using OC with busulfan infusions in January 2017. OC consists of patients continuously swirling ice chips and/or popsicles in their mouth, as well as swallowing ice cold water every 10-20 minutes, for two hours during busulfan infusions. This descriptive study utilized a retrospective/prospective electronic medical record review of patients receiving busulfan. Patients conditioned for allogeneic transplant using fludarabine along with either two or four days of busulfan were included in this purposive sample. This study compared outcomes among patient groups for two years before (N = 89) and two years after (N = 88) implementing OC. OM severity was measured using the World Health Organization (WHO) OM scale. Between pre- and post-OC, this study found a decrease in WHO scores of 3 (severe) (37 vs 27) and 4 (life-threatening) (17 vs 5) along with an increase in scores of 0 (8 vs 16), 1 (mild) (17 vs 22), and 2 (moderate) (10 vs 18) (p <.001). Mean LOS decreased from 29.2 ± 10.5 to 24.3 ± 4.2 (p <.001). Pre-OC, 5 patients transferred to the ICU for airway protection and post-OC, there were no ICU transfers (p = 0.059). Pre-OC 27 patients required TPN and post-OC 13 patients required TPN (p = 0.013). Pre-OC 69 patients required opioids for OM pain control and post-OC 45 patients required opioids (p <.001). These findings suggest that OC with busulfan is effective in reducing the severity of OM. OC is a low cost, nursing driven, easily implemented intervention which shows benefit in decreasing OM severity, LOS, ICU transfers for airway protection, TPN use, and opioid use for OM. These decreases translate into cost savings for both patients and organizations. [ABSTRACT FROM AUTHOR]

Abstract: Monte Carlo simulations are increasingly used for dose calculations in proton therapy due to its inherent accuracy. However, dosimetric deviations have been found using Monte Carlo code when high density materials are present in the proton beamline. The purpose of this work was to quantify the magnitude of dose perturbation caused by metal objects. We did this by comparing measurements and Monte Carlo predictions of dose perturbations caused by the presence of small metal spheres in several clinical proton therapy beams as functions of proton beam range and drift space. Monte Carlo codes MCNPX, GEANT4 and Fast Dose Calculator (FDC) were used. Generally good agreement was found between measurements and Monte Carlo predictions, with the average difference within 5% and maximum difference within 17%. The modification of multiple Coulomb scattering model in MCNPX code yielded improvement in accuracy and provided the best overall agreement with measurements. Our results confirmed that Monte Carlo codes are well suited for predicting multiple Coulomb scattering in proton therapy beams when short drift spaces are involved. [Copyright &y& Elsevier]