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Targeted temperature management (TTM) directly impacts energy expenditure via temperature modulation and shivering associated with temperature modulating devices. We hypothesized that resting energy expenditure (REE) can be accurately estimated utilizing data obtained from a surface gel pad temperature modulating device (TMD) and demographic factors. Baseline demographic data, along with concurrent temperature, sedation, and shivering data, and indirect calorimetry (IDC) were collected from patients undergoing TTM. The data from the IDC and temperature modulation device (TMD) were synchronized and averaged over 60-second intervals to provide simultaneous comparisons. Heat transfer (calories) was calculated from the TMD by an equation that assessed water temperature from the TMD to the patient, water temperature returning to the TMD, water flow rates, and device mode. A linear regression model was used to determine factors associated with REE as measured by IDC. A difference in the mean between REE and estimated REE was used to assess accuracy. There were 48 assessments conducted in 40 subjects [mean (standard deviation)] age: 58 (14) years, 60% female, body surface area (BSA): 2.0 ± 0.3 who underwent simultaneous assessments. Target temperature was 36-37°C in 75%, with a median Bedside Shivering Assessment Score of 0 (range 0-2). Factors associated with REE on multivariable linear regression included older age (

Introduction Extravasation or partial extravasation of the positron emission tomography (PET) tracer negatively effects image quality in PET and the accuracy of the standard uptake value (SUV). A commercially available topical sensor has been validated using a number of metrics to characterise injection quality. This evaluation explores contributing factors for extravasation and refines metrics to predict extravasation based on the time-activity-curves (TAC) of the topical sensor device. Methods A multi-site, multi-national pooling of 18F FDG PET/CT data was undertaken with 863 patients from 6 sites in the USA and 2 sites in Australia. A number of dose migration metrics determined with topical application of Lara sensors were retrospectively analysed using conventional statistical analysis. Deeper insights into the complex relationship between variables was further explored using an artificial neural network. Results Extravasation was independently predicted by the time taken for the injection sensor counts to reach double the counts of the reference sensor (tc50), the normalised difference between injection and reference sensors counts at 4 min post injection (ndAvgN), or the ratio of injection sensor counts to reference sensor counts at the end of data collection (CEnd ratio). The algorithm developed using the artificial neural network produced 100% sensitivity and 100% specificity against grounded truth for detecting extravasation by weighting and scaling these 3 key metrics; CEnd ratio, ndAvgN and tc50. Conclusion Partial extravasation of a PET dose is readily detected and differentiated using TAC metrics and these metrics could provide deeper insight into the impact of partial extravasation on image quality or quantitation. Further validation of key metrics developed in this study are recommended in a larger and more diverse cohort. Implications for practice Partial extravasation undermines image quality and accuracy of quantitation, impacting efficacy of outcomes for patients. Characterisation of extravasation informs decision making to optimise protocol and procedure, enhancing patient outcomes. Awareness provides the opportunity for education and training to minimise impact. The information can be used to drive policy and regulations to support improved techniques in practice.

Inducing normothermia with surface cooling temperature modulating devices (TMDs) is cumbersome and often associated with significant shivering. We tested the safety and feasibility of a novel transnasal evaporative cooling device to induce and maintain normothermia in febrile patients following ischemic and hemorrhagic stroke. A single-center study utilizing the CoolStat® transnasal cooling device was used to achieve core temperature reduction in mechanically ventilated stroke patients with fever (T ≥ 38.3 C) refractory to acetaminophen by inducing an evaporative cooling energy exchange in the nasal turbinates thru a high flow of dehumidified air into the nasal cavity and out through the mouth. Continuous temperature measurements were obtained from tympanic and core (esophageal or bladder) temperature monitors. Safety assessments included continuous monitoring for hypertension, tachycardia, and raised intracranial pressure (when monitored). Otolaryngology (ENT) evaluations were monitored for any device-related nasal mucosal injury with a pre- and post-visual examination. Shivering was assessed every 30 min using the Bedside Shivering Assessment Scale (BSAS). Duration of device use was limited to 8 h, at which time patients were transitioned to routine care for temperature management. Ten subjects (median age: 54 years, BMI: 32.5 kg/m2, 60% men) were enrolled with normothermia achieved in 90% of subjects. One subject did not achieve normothermia and was later refractory to other TMDs. Median baseline temperature was 38.5 ± 0.1 C, with a reduction noted by 4 h (38.5 ± 0.1 vs 37.3 ± 0.8, P

INTRODUCTION: Aneurysmal subarachnoid hemorrhage(SAH) survivors live with long term residual physical and cognitive disability. We studied whether neuromuscular electrical stimulation(NMES) and high protein supplementation(HPRO) in the first two weeks after SAH could preserve neuromotor and cognitive function as compared to standard of care(SOC) for nutrition and mobilization. METHODS: SAH subjects with a Hunt Hess(HH) grade>1, modified Fisher score>1 and BMI3). Median duration of interventions was 12 days(range 9 – 14) with completion of 98% of NMES sessions and 83% of goal HPRO, and no reported serious adverse events. There was no difference in caloric intake between groups, but HPRO+NMES group received more protein(1.5+/−0.5 g/kg/d v 0.9+/−0.4 g/kg/d, P

Background: Primary resistance to immunotherapy can be observed in approximately 40&ndash, 65% of the stage IV melanoma patients treated with immune checkpoint inhibitors. A minority of the patients receive a second-line therapy, and the clinical benefit is small. Patients and methods: Stage IV melanoma patients treated with first-line PD-1-based immunotherapy between January 2015 and December 2018 were investigated. Primary resistance was defined as progressive disease (PD) at the time of the first tumor assessment after starting immunotherapy. Patients with complete response, partial response, and stable disease were classified as having disease control (DC). Overall survival (OS) and progression-free survival (PFS) were evaluated by Kaplan&ndash, Meier estimator. Univariate and multivariate logistic regression analyses were performed to determine prognostic factors associated with OS. Results: Three hundred and nineteen patients were included, and 40% had primary resistance to immunotherapy. The median follow-up time was 22 months. Patients with primary resistance had 1-, 2-, and 3-year OS rates of 41%, 15%, and 10%, respectively, compared to 91%, 81%, and 65% for the patients who achieved DC. The following independently significant prognostic factors for OS were identified: protein S100B level and primary tumor localization. There was a statistically significant difference for OS (p &lt, 0.0001) but not for PFS (p = 0.230) when analyzing risk groups formed with a combination of these two variables (low-, intermediate-, and high-risk subgroups). Conclusions: Melanoma patients with primary resistance to immunotherapy have a dismal prognosis. Response at the first tumor assessment after starting immunotherapy is a stronger prognostic factor for the further course of the disease than pretreatment risk factors.

Introduction: Extravasation or partial extravasation of the radiopharmaceutical dose quality in positron emission tomography (PET) can undermine standard uptake value (SUV) and image quality. A topical sensor (Lara) has been validated using a number of metrics to characterise injection quality following manual injection. An assessment of the performance of these metrics for autoinjector administration has been undertaken. Methods: A single site, single PET/CT scanner was used to characterise injections using a KARL100 autoinjector with standardised apparatus, flush volume and infusion rate using Rad-inject pump (1 min infusion followed by 2 syringe flushes) for 18F-FDG, 68Ga-PSMA and 68Ga-DOTATATE. 296 patients with topical application of Lara sensors were retrospectively analysed using conventional statistical analysis and an artificial neural network. Results: Partial extravasation was noted in 1.1% of studies with 9.1% (inclusive of partial extravasation) identified to have an injection anomaly (eg. venous retention). Extravasation was independently predicted by the time elapsed as the counts recorded by the injection sensor fall from the maximum value to within 200% of the reference sensor counts (tc50) greater than 1200 seconds, the difference in counts for injection and reference sensors, normalized by dose, from 4 minutes post injection (ndAvgN) greater than 25, and the ratio of the average counts per second recorded by the injection sensor at the end of a monitoring period to those of the reference sensor (CEnd ratio) greater than 2. Conclusion: Extravasation and partial extravasation of PET doses are readily detected and differentiated using TAC metrics. The metrics can provide the insights that could inform image quality or SUV accuracy issues. Further validation of key metrics are recommended in a larger and more diverse cohort.

PET and SUV depend on reliable pharmacokinetic modeling, part of which is predictable dose delivery. Partial extravasation of the intravenous dose administered undermines the predictability of dose delivery and, potentially, the accuracy of the SUV calculation. Use of the Lara device with topical sensors is a simple, noninvasive way to determine partial dose extravasation. As part of routine monitoring of 18F-FDG PET administrations, an interesting case was identified that mimicked extravasation but represented dose leakage during infusion via an automatic injector. The Lara device provided a useful tool for more timely critical evaluation and problem solving, extending advantages to the patient and practice.

Calculation of the standard uptake value (SUV) and image quality in positron emission tomography (PET) hinges on accurate dose delivery. Extravasation or partial extravasation of the radiopharmaceutical dose can undermine SUV and image quality, and contribute to unnecessary imaging (time and CT dose). Topical sensor characterisation of injections has been reported, with extravasation rates ranging from 9% to 23% for 18F-FDG after manual injection.A single site, single PET/CT scanner was used to characterise injections using an autoinjector with standardised apparatus, flush volume and infusion rate using 18F-FDG, 68Ga-PSMA and 68Ga-DOTATATE; more reflective of Australian PET facilities. 296 patients with topical application of LARA sensors were retrospectively analysed.Only 1.1% of studies showed evidence of partial dose extravasation. In total, 9.1% were identified to have an injection anomaly (including venous retention). No statistically significant differences were noted across the radiopharmaceuticals for demographic data. Although not demonstrating a statistically significant correlation, there was more extravasated doses associated with female patients (P = .334), right side (P = .372), and hand injections (P = .539). Extravasation was independent of dose administered (P = .495), the radiopharmaceutical (P = .887), who injected the dose (P = .343), height (P = .438), weight (P = .607) or age (P = .716). Extravasation was associated with higher glucose levels (P.001), higher t-half (P = .019) and higher aUCR10, tc50, aUCR1 and c1 (all P.001).Topical monitoring and characterisation of PET dose administration is possible and practical with the LARA device. Extravasation and partial extravasation of PET doses are not only readily detected but they are also preventable. The LARA device can provide the insights into variables that could eliminate extravasation as a cause of image quality or SUV accuracy issues.

Background This study focuses on the implementation of CYP2D6 genetic test profiling and the challenges associated with using standard pharmacogenetics panels in a diverse South Florida population. Methods A total of 413 participants were recruited to participate in this study through Nicklaus Children's Hospital. Buccal swabs were collected and tested using an extended CYP2D6 panel including 22 alleles. Phenotype, genotype, and allelic frequencies were compared among different racial and ethnic groups. Results The majority of participants (75.0%) self‐identified as Hispanics. Four alleles, CYP2D6*4, *17, *41, and *2A, showed a statistically significant difference between White Hispanics and Black Non‐Hispanics. Aggregate frequency of all alleles with decreased function varied between 2.8% and 50.0% in different racial and ethnic groups. Additionally, rare allele combinations were observed in this South Florida cohort. Conclusions The heterogeneity among Hispanic groups demonstrated in previous literature and by this study reflects the complexity of ethnicity and suggests that a more granular categorization is needed, one based on ancestry and migration history rather than primary language. Overall, we have determined that there are statistically significant differences in CYP2D6 allele frequencies in the distinct racial and ethnic populations of South Florida, demonstrating a unique genetic makeup within South Florida. However, overall, the frequencies of Poor Metabolizer, Normal Metabolizer, Intermediate Metabolizer, and Ultrarapid Metabolizer did not differ between racial and ethnic groups at a statistically significant level.

State health departments commonly use quality improvement coaching as an implementation strategy for improving low human papillomavirus (HPV) vaccination coverage, but such coaching can be resource intensive. To explore opportunities for improving efficiency, we compared in-person and webinar delivery of coaching sessions on implementation outcomes, including reach, acceptability, and delivery cost. In 2015, we randomly assigned 148 high-volume primary care clinics in Illinois, Michigan, and Washington State to receive either in-person or webinar coaching. Coaching sessions lasted about 1 hr and used our Immunization Report Card to facilitate assessment and feedback. Clinics served over 213,000 patients ages 11-17. We used provider surveys and delivery cost assessment to collect implementation data. This report is focused exclusively on the implementation aspects of the intervention. More providers attended in-person than webinar coaching sessions (mean 9 vs. 5 providers per clinic, respectively, p = .004). More providers shared the Immunization Report Card at clinic staff meetings in the in-person than webinar arm (49% vs. 20%; p = .029). In both arms, providers' belief that their clinics' HPV vaccination coverage was too low increased, as did their self-efficacy to help their clinics improve (p < .05). Providers rated coaching sessions in the two arms equally highly on acceptability. Delivery cost per clinic was $733 for in-person coaching versus $461 for webinar coaching. In-person and webinar coaching were well received and yielded improvements in provider beliefs and self-efficacy regarding HPV vaccine quality improvement. In summary, in-person coaching cost more than webinar coaching per clinic reached, but reached more providers. Further implementation research is needed to understand how and for whom webinar coaching may be appropriate.