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Background: Patient adherence to insulin therapy is one of the major challenges during the treatment of diabetes mellitus. Considering the dearth of investigations, this study aimed to determine the adherence pattern and factors linked with nonadherence among diabetic patients using insulin in Al-Jouf region of Saudi Arabia. Methods: This cross-sectional study included diabetic patients using basal-bolus regimens, whether they had type 1 or type 2 diabetes. This study's objective was determined using a validated data collection form that included sections on demographics, reasons for missed insulin doses, list of barriers to therapy, difficulties during insulin administration, and factors that may improve insulin inaction adherence. Results: Of 415 diabetic patients, 169 (40.7%) were reported to forget doses of insulin every week. The majority of these patients (38.5%) forget one or two doses. Away from home (36,1%), inability to adhere to the diet (24.3%) and embarrassment to administer injections in public (23.7%) were frequently cited as reasons for missing insulin doses. The occurrence of hypoglycemia (31%), weight gain (26%), and needle phobia (22%) were frequently cited as obstacles to insulin injection use. Preparing injections (18.3%), using insulin at bedtime (18.3%), and storing insulin at a cold temperature (18.1%) were the most challenging aspects of insulin use for patients. Reduction in the number of injections (30.8%) and convenient timing for insulin administration (29.6%) were frequently cited as factors that may improve participant adherence. Conclusions: This study revealed that the majority of diabetic patients forget to inject insulin, primarily as a result of travel. By identifying potential obstacles faced by patients, these findings direct health authorities to design and implement initiatives to increase insulin adherence among patients. [ABSTRACT FROM AUTHOR]

Objective(s): The aim of this study was to determine the entrance skin dose distribution for breast cancer patients who undergo radiotherapy in the presence of bolus containing gold and Fe3O4 nanoparticles to evaluate and compare the changes in dose distribution. Materials and Methods: Gold and Fe3O4 nanoparticles can increase the rate of photoelectric, Compton, and pair production absorption of x-ray photons. Nanoparticles were simulated in the bolus, over the skin of a breast phantom, by the exertion of MCNPX Monte Carlo code. The skin dose was also experimentally measured by using a bolus that contained homogeneously distributed Fe3O4 nanoparticles on the surface of a slab phantom and an advanced Markus chamber. Results: A significant skin dose enhancement was obtained for the case that 25 nm gold and Fe3O4 nanoparticles with 3% concentration were uniformly distributed in the bolus. However, increased concentration of nanoparticles in the bolus will increase the skin dose. Conclusion: It is concluded that using nanoparticles in the bolus leads to a significant skin dose enhancement for 6 MV x-ray photons. Furthermore, this study suggested that, less thick blouses may provide the same dose distribution. [ABSTRACT FROM AUTHOR]

Background Acute radiodermatitis is a common side effect during and after radiotherapy course in breast cancer patients treated by radiotherapy. This study explores the frequency of acute radiodermatitis and records the predictive factors for acute radiodermatitis. Methods An observational descriptive study performed at Baghdad, Iraq from August 2020 to September 2021. Seventy females scheduled for radiotherapy sessions enrolled in this study. sociodemographic data were recorded and Skin examination before radiotherapy and weekly till the end of the radiotherapy sessions was done to record the frequency, risk factors, clinical picture and grades of acute radiodermatitis based on The National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE 4). Results Fifty four (77.1%) female developed acute radiodermatitis during their radiotherapy sessions: 38 (70.4%) was Grade I, 12 (22.2%) Grade II and 4 (7.4%) Grade III. Statistically significant more severe radiodermatitis Grade among conventional dose group (54.5%) compared to (23.3%) in hypofractionation group (P=0.043). Acute radiodermatitis rate and grade was statistically significant high in patient using bolus during radiotherapy than in those did not use it (P=0.048, P=0.017) respectively. The Grade of radiodermatitis was statistically significant more severe in breast conservative surgery patients (P=0.046). Skin type I & II patients were more liable to radidermatitis compared with those with skin type III & IV (P=0.035). No significant associations between radiodermatitis and different patients' and tumor characteristics. Conclusion We found that conventional dose, addition of bolus, breast conservative surgery and patients skin type I&II were all significant factors that enhance skin reaction. [ABSTRACT FROM AUTHOR]

Feeding and swallowing difficulties and their consequences on the nutritional status of people with dementia have been the subject of recurrent research, albeit strong evidence is still lacking. When a person no longer swallows safely, it is the caregivers who face difficulties of providing adequate care. Therefore, it is important to understand and analyze their perspectives on the topic. Despite the recent development of theoretical models to manage mealtimes and nutrition intake, the participation of health professionals and caregivers in these types of studies are still limited. The study of van Buuren et al., which this commentary refers to, aimed to identify key factors that contribute to the development of a conceptual model to step up nutritional care in dementia. [ABSTRACT FROM AUTHOR]

This document is a response to a letter regarding an article published in Critical Care Medicine. The authors of the article thank the letter writers for their comments and acknowledge the importance of considering the impact of individual patient illness severity in their analysis. They used the Australian and New Zealand Risk of Death (ANZROD) model and conducted several relevant analyses, which are available in the Online Supplementary Material. The authors confirmed that the ICU's activity index was a significant independent predictor of mortality. [Extracted from the article]

Clinical outcomes, including the primary outcome of day 28 mortality, were not statistically different but there were more deaths by day 90 in patients assigned to conservative oxygen therapy (44/99 I v i 31/102 patients; difference, 14.0 percentage points; 95% CI, 0.7-27.2). Keywords: Intensive care; Resuscitation; Shock; Oxygen delivery; Neurocognitive disorders; Grief EN Intensive care Resuscitation Shock Oxygen delivery Neurocognitive disorders Grief 153 156 4 03/08/23 20230301 NES 230301 Recent advances in critical care relevant to a broad range of clinicians Global interest in the management of critically ill patients has increased significantly with the coronavirus disease 2019 (COVID-19) pandemic. Intensive care, Resuscitation, Shock, Oxygen delivery, Neurocognitive disorders, Grief Evaluation of early administration of simvastatin in the prevention and treatment of delirium in critically ill patients undergoing mechanical ventilation (MODUS): a randomised, double-blind, placebo-controlled trial. [Extracted from the article]

Simple Summary: Horses performing strenuous exercise can experience tissue damage, causing a delayed return to work. L-Carnitine supplements may accelerate the post-exercise recovery period, allowing for an earlier return to work. Adult Thoroughbreds were administered a commercial carnitine-containing recovery aid prior to performing exercise to exhaustion (D1). The activity was repeated after a single day of rest (D2), with physiological and biochemical measures obtained following exercise on both days. The results demonstrate that horses receiving the L-carnitine-containing supplement retained a greater range of motion in their fetlock on D2 than the controls. A normal inflammatory response to exercise was observed for all horses on D1, which was not found on D2; the heart rate recovery on D2 was also slower. These results indicate that a single day between strenuous work is insufficient to allow for tissue recovery. Strenuous exercise can cause tissue damage, leading to an extended recovery period. To counteract delayed post-exercise recovery, a commercial product containing L-carnitine (AID) was tested in adult horses performing consecutive exercise tests to exhaustion. Fit Thoroughbreds were administered an oral bolus of placebo (CON) or AID prior to performing an exercise test to exhaustion (D1). The heart rate (HR) and fetlock kinematics were captured throughout the exercise test. Blood was collected before, 10 min and 1, 4 and 6 h relative to exercise for the quantification of cytokine (IL1β, IL8, IL10, TNFa) gene expression and lactate concentration. Horses performed a second exercise test 48 h later (D2), with all biochemical and physiological measures repeated. The results demonstrate that the horses receiving AID retained a greater (p < 0.05) amount of flexion in the front fetlock on D2 than the horses given CON. The horses presented a reduced (p < 0.05) rate of HR decline on D2 compared to that on D1. The expression of IL1β, IL8 and IL10 increased at 1 h post-exercise on D1 and returned to baseline by 6 h; the cytokine expression pattern was not duplicated on D2. These results provide evidence of disrupted cytokine expression, HR recovery and joint mobility in response to consecutive bouts of exhaustive exercise. Importantly, AID may accelerate recovery through an undetermined mechanism. [ABSTRACT FROM AUTHOR]

Conclusion For a high fat (40 g), high protein (50 g) meal that also contains carbohydrate (30 g), giving 125% of the usual ICR as aspart insulin 30 minutes before the meal improves postprandial glycemia significantly more than giving the usual aspart insulin dose (100Asp). A higher glucose target (temporary target, 8.3 mmol/L) was set 2 hours before exercise for all exercise conditions, and supplemental carbohydrate (15 g), without an insulin bolus, was administered 15 minutes before exercise if the glucose level was <7.0 mmol/L. For all exercise interventions, the temporary glucose target was ceased immediately after exercise with reversion to the usual target of 5.6 mmol/L. The primary outcome was continuous glucose monitoring (CGM) time-in-range (TIR, 3.9-10.0 mmol/L) for 24 hours after exercise. The CGM median TIR 24 hours after exercise was >81%, percent time below range (<3.9 mmol/L) was <4%, and percent time above range (>10.0 mmol/L) was <17% for both exercise conditions (MIE vs HIE) and insulin formations, with no significant differences between insulins ( I P i >.05). HYPOGLYCEMIA PREVENTION STRATEGIES AND INTERACTIONS WITH INSULIN Anticipated Basal Insulin Reduction To Prevent Exercise-Induced Hypoglycemia in Adults and Ad... I Tagougui S SP 1,2,3 sp , Legault L SP 1,4 sp , Heyman E SP 3 sp , Messier V SP 1 sp , Suppere C SP 1 sp , Potter KJ SP 1 sp , Pigny P SP 5 sp , Berthoin S SP 3 sp , Taleb N SP 1,6,7 sp , Rabasa-Lhoret R SP 1,2,7 sp i I SP 1 sp Montreal Clinical Research Institute (IRCM), Montreal, Canada; SP 2 sp Département de nutrition, Université de Montréal, Montreal, Canada; SP 3 sp Univ. Lille, Univ. Artois, Univ. [Extracted from the article]

In radiation therapy (RT) for skin cancer, tissue-equivalent substances called boluses are widely used to ensure the delivery of an adequate dose to the skin surface and to provide a radioprotective effect for normal tissue. The aim of this study was to develop a new type of three-dimensional (3D) bolus for RT involving body parts with irregular geometries and to evaluate its clinical feasibility. Two 3D-printed boluses were designed for two patients with squamous cell carcinoma (SCC) of their distal extremities based on computed tomography (CT) images and printed with polylactic acid (PLA). The clinical feasibility of the boluses was evaluated by measuring the in vivo skin dose at the tumor site with optically stimulated luminescence detectors (OSLDs) and comparing the results with the prescribed and calculated doses from the Eclipse treatment planning system (TPS). The average measured dose distribution for the two patients was 94.75% of the prescribed dose and 98.8% of the calculated dose. In addition, the average measured dose during repeated treatments was 189.5 ± 3.7 cGy, thus demonstrating the excellent reproducibility of the proposed approach. Overall, the customized 3D-printed boluses for the RT of distal extremities accurately delivered doses to skin tumors with improved reproducibility. [ABSTRACT FROM AUTHOR]

The necessity for multiple injections and cold‐chain storage has contributed to suboptimal vaccine utilization, especially in pandemic situations. Thermally‐stable and single‐administration vaccines hold a great potential to revolutionize the global immunization process. Here, a new approach to thermally stabilize protein‐based antigens is presented and a new high‐throughput antigen‐loading process is devised to create a single‐administration, pulsatile‐release microneedle (MN) patch which can deliver a recombinant SARS‐CoV‐2 S1‐RBD protein—a model for the COVID‐19 vaccine. Nearly 100% of the protein antigen could be stabilized at temperatures up to 100 °C for at least 1 h and at an average human body temperature (37 °C) for up to 4 months. Arrays of the stabilized S1‐RBD formulations can be loaded into the MN shells via a single‐alignment assembly step. The fabricated MNs are administered at a single time into the skin of rats and induce antibody response which could neutralize authentic SARS‐CoV‐2 viruses, providing similar immunogenic effect to that induced by multiple bolus injections of the same antigen stored in conventional cold‐chain conditions. The MN system presented herein could offer the key solution to global immunization campaigns by avoiding low patient compliance, the requirement for cold‐chain storage, and the need for multiple booster injections. [ABSTRACT FROM AUTHOR]

Gastrointestinal disorders are among the most common disease processes in captive elephants. Colic is a frequent clinical presentation and may have several infectious and noninfectious causes. Ingestion of sand has been reported in elephants living in enclosures with loose sandy soils. Similar to the situation in horses, sand ingestion can cause intestinal impaction and colic in elephants. Here we describe a case of colonic sand impaction with cecal rupture and peritonitis in an African savanna elephant from a zoologic collection that died after several days of colic. On autopsy, abundant, gritty, sandy material was found within a segment of colon immediately aboral to the cecum. There was a full-thickness tear in the cecal wall, free intestinal contents within the abdominal cavity, and peritonitis. To our knowledge, the postmortem examination of an elephant with sand impaction and cecal rupture has not been reported previously; this condition should be included among the differential diagnoses in elephants with colic. We review the reports of noninfectious causes of gastrointestinal disease in elephants, which include cases of small intestinal and colonic torsion and of intestinal obstruction by fecal boluses. [ABSTRACT FROM AUTHOR]

This single-institution proof of concept and early experience on an innovative workflow for the creation of custom applicators for high dose rate (HDR) skin brachytherapy and skin bolus in low to middle-income countries, where access to CT simulation or dedicated surface scanners is sparse, we utilized geometry mapping technology found in many readily available smartphones as an alternative to other design methods, reducing the number of CT-simulations needed from two to one, improving access to custom applicators for more patients. We now report our skin brachytherapy early experience. In selected consenting patients with indication for skin brachytherapy or EBRT, a smartphone front camera system (e.g. Apple iPhone X or newer with TrueDepth camera) was used to capture the skin surface with capturing software (Apple iOS - Heges 3D Scanner by Marek Simonik), then exported to a computer-aided design software to blueprint the applicator (Meshmixer and Fusion 360 Autodesk on Apple MacOS or Microsoft Windows). The applicator was then 3D printed in-house using a fused deposition modeling printer (Flashforge Adventure 3) with polylactic Acid (PLA) material. The applicator completed a quality assurance examination and then fitted to the patient for a single CT simulation for planning (SagiPlan®), quality assurance and treatment delivery with a Cobalt - 60 after loader (SagiNova®). Follow-up was conducted per standard institutional protocol, and Common Terminology Criteria for Adverse Events Version 5.0 (CTCAE) was used to report toxicities. From July 2023 to January 2024, 05 patients were scanned, 4 patients received a 3D printed custom bolus for EBRT, and 1 patient received a custom HDR skin brachytherapy custom applicator, the one patient treated with HDR brachytherapy is reported, had basal cell carcinoma of the nose, the prescription dose was 40Gy in 10 fractions delivered daily, 100% isodose line encapsulated the PTV, limiting surface dose <150%. Acute grade 1 skin toxicity was observed at the end of treatment, it completely resolved at 3 months. No late toxicity or recurrence was observed at 6 months. This small, early-reported experience with a novel workflow seems faceable and safe, potentially allowing less congestion at the CT Sim, improving access for more patients in low to middle-income countries to custom 3D printed accessories. A larger number of patients and longer follow-ups are needed, report on 3D EBRT bolus results to follow. [ABSTRACT FROM AUTHOR]

Accurate representation of patient anatomy is essential for radiation therapy. Surface changes arising from weight gain/loss or tissue edema occurring during a treatment course can currently only be detected by on-treatment imaging modalities during a clinical visit. However, delayed detection of surface changes may result in postponed treatments due to the need to generate a new treatment plan. We investigate here the feasibility of a new paradigm: patient-driven radiation therapy, in which patients can self-perform 3D surface scans using affordable smartphone photogrammetry. The surface-scanned models can then be compared to reference surfaces obtained from planning images to detect surface changes, triggering the need for an adaptive plan. An initial feasibility study was performed using an anthropomorphic head phantom and two healthy volunteers. The combination of an iPhone 15 Pro Max (Apple Inc., USA) and smartphone application Polycam were used to create 3D surface models using photogrammetry. Ground truth surface contours of the phantom and volunteers were obtained with CT and MRI, respectively. Image processing and analysis was performed in 3D Slicer. The CT and MRI defined surface contours were saved as standard tessellation language (STL) files and registered with smartphone-generated 3D surface models. The accuracy of the smartphone generated models relative to reference models was evaluated using Hausdorff distances. To evaluate the ability of photogrammetry to detect surface changes, smartphone surface models were also measured after placing a 1cm thick 3D printed bolus on the phantom and volunteers. Overall, good agreement was obtained between surface models generated from smartphone photogrammetry and ground truth CT or MRI scans. As shown in Table 1, mean and standard deviation Hausdorff distances were 1.25 ± 0.70mm, 1.04 ± 0.74mm, and 0.64 ± 0.66 mm for the phantom and two human studies, respectively. Smartphone photogrammetry was able to detect the changes in surface anatomy, induced by the 3D printed bolus. The maximum Hausdorff distance in the surface region where 3D printed bolus was placed was 10.9 mm. Accurate 3D surface model generation using smartphone photogrammetry is feasible. The portable and affordable surface scanning with smartphone presents a promising solution for early detection of patient surface changes using home-based monitoring. Early detection can prompt the need for plan adaptation outside the clinic, preventing further treatment delays. [ABSTRACT FROM AUTHOR]

Bolus is an essential tissue-equivalent material that allows 95-100% isodose transfer to the skin and subcutaneous tissue for patients with breast cancer receiving postoperative radiotherapy. However, the bolus with low-temperature (21-25℃) may lead to involuntary body position movement and patient discomfort due to the temperature differences between bolus and body. Therefore, we designed a randomized controlled study to investigate whether preheating bolus with 37℃ could reduce setup errors and improve patients comfortable feeling during breast cancer radiotherapy. Patients with breast cancer received radical resection and postoperative radiotherapy were randomly assigned into preheating group and non-preheating group in a 1:1 ratio from June 2023-February 2024. For preheating group, bolus was preheated in a thermostat for 30min with 37℃ before it was used for patients. For non-preheating group, bolus with room-temperature was used during radiotherapy. All patients received radiotherapy with bolus from first to 15th radiotherapy according to medical prescription. The cone beam computed tomography (CBCT) was used to evaluate setup errors once a week. The setup errors in translational directions ML, SI and AP were recorded based on CBCT image. The study also evaluated the variations in the anteroposterior diameter of the thorax and skin toxicity in the two groups. The comfort satisfaction score which was reported in a previous article was used to evaluate for each patient. The primary endpoint of this study was setup error between two groups. This registration number of this trial was ChiCTR2300072549. A total of 152 patients were enrolled in this study. Patient characteristics were well balanced in both arms. The AP and ML directional setup errors in the preheating group were less than non-preheating group (AP, 0.22 ± 2.41 mm vs -0.54 ± 2.46 mm, P <0.01;ML, -0.04 ± 2.51 mm vs 0.62 ± 2.48 mm, P < 0.01). Patients in preheating group had better comfort scores (33.25 ± 2.62 vs 32.19 ± 2.50, P < 0.01) and temperature satisfaction comfort scores (4.24 ± 0.44 vs 3.71 ± 0.54, P <0.01) than those in non-preheating group. Compared with non-preheating group, preheating bolus had a trend to reduce the AP directional setup error (0.17 ± 0.15 vs. 0.23 ± 0.19cm, P = 0.054). There were no significant differences in incidence of grade 2 radiation-related dermatitis (47.6% vs. 44.3%, P = 0.661) and grade 3 radiation-related dermatitis (2.7% vs. 2.9%, P = 1.000). Preheating bolus reduced setup errors in in the AP and ML directions without increasing skin toxicities in breast cancer patient receiving postoperative radiotherapy. [ABSTRACT FROM AUTHOR]

To evaluate the technology of creating 3D printed boluses without a prior computed tomography scan using widely available, inexpensive mobile LIDAR and 3D sensors. Gel, thermoplastic, or wax boluses, have several shortcomings, including problems with proper bolus fitting to the surface. Some of these problems can be solved by using personalized 3D printed boluses. Currently, most 3D boluses are generated based on the computed tomography (CT) scans used for treatment planning. Such a method has a disadvantage of assuming perfect placement of the "virtual" bolus". The objective of the study is to develop and validate an adaptable technology for 3D printing of boluses for high-conformal radiotherapy using mobile devices equipped with LIDAR and 3D sensors, which will allow to improve dose distribution in anatomically challenging sites without prior CT. We investigated two methods of 3D-printed bolus creation, namely LIDAR available on smartphones and a commercially available mobile smartphone-attachable optical sensor. We used two types of filaments, thermoplastic polyurethane (TPU) and polylactic acid (PLA), as well as a standard 0.5 cm gel bolus. Based on a previous dosimetric study, we found that 0.5 cm TPU with 100% infill and 1 cm PLA with 50% infill present similar dosimetric parameters to 0.5 cm gel bolus. Therefore, we used those thicknesses in 3D-printing. We prepared boluses for three anatomically-challenging sites, namely the face, corner of the eye, and thoracic wall. After scanning, bolus printing, and placement, we performed relevant CT scans. We aimed to calculate the volume of the air gap between the target volume and skin surface made for tumor models with 3D boluses and standard gel boluses performed on an anthropomorphic phantom. For all cases, the airspace volumes were measured using the lung window of Hounsfield units scale with the same threshold parameters. Results are presented in Tab. 1. The lowest volumes of air gaps were achieved by using 3D boluses created by scanning the surface with an optical sensor, whereas the highest volumes were generated by the placement of conventional gel boluses. Table 1. Air gaps volumes using different scanning techniques and materials The investigated method enabled the preparation of fast, cheap, and accurate 3D-printed boluses that are superior to conventional gel boluses used in clinical practice. [ABSTRACT FROM AUTHOR]

The impact of radiation on polymer materials, and consequently on their mechanical and physical properties, is a burgeoning field of research. This research assesses the dosimetric, mechanical, and thermal characteristics of Acrylonitrile Butadiene Styrene (ABS) and Polylactic Acid (PLA) materials developed through plastic injection molding as possible alternatives to commercial bolus used in radiotherapy. The materials were thoroughly compared with the commercial bolus material, EXAFLEX, by various tests such as Hounsfield Unit (HU) Analysis, Radiation Transmittance, Thermogravimetric Analysis (TGA), Thermomechanical Analysis (TMA), and Fourier Transform Infrared Spectroscopy (FTIR). The research indicates that ABS and PLA materials have similar radiological qualities to EXAFLEX, showing constant surface and accumulation area doses. Minor differences are seen deeper inside the phantom, indicating a stable tissue equivalency. ABS demonstrated strong resistance to radiation-induced chemical modifications, but PLA exhibited susceptibility to molecular changes. The TMA findings showed that radiation caused a decrease in softening temperatures and an increase in the coefficient of thermal expansion for both ABS and PLA, indicating changes in their thermal stability and mechanical characteristics after irradiation. The study highlights the potential of ABS and PLA materials made through plastic injection molding as efficient and safety substitutes for commercial bolus materials, particularly for large area irradiation. This requires more research into their clinical uses and consequences. • Assessed ABS and PLA as radiotherapy bolus alternatives, comparing to commercial EXAFLEX. • Employed tests including HU Analysis, Radiation Transmittance, and TGA to compare materials. • Found ABS and PLA show similar radiological qualities to EXAFLEX with stable doses. • ABS resists radiation-induced changes; PLA shows susceptibility to molecular alterations. • Radiation affects thermal stability and mechanical properties of ABS and PLA. [ABSTRACT FROM AUTHOR]

Background: Mycosis fungoides (MF) represents the most common cutaneous T-cell lymphoma and approximately 4% of non- Hodgkin lymphomas. Treatment of skin lesions includes external beam radiation therapy which often provides adequate local control and symptom relief. Case Presentation: A 39-year-old male with the diagnosis of MF presents with infiltrative and pruriginous plaques comprising the plantar, interdigital, lateral, and posterior surfaces of the foot. A protocol using a water tank was used to provide uniform coverage to an irregular target volume. By creating a tissue-equivalent and homogenous bolus material a total dose of 8 Gy in two fractions of photon-beam therapy was prescribed. After 1 month of treatment, there was a partial response with minimal toxicity, achieving a complete response in most lesions after 6 months. Conclusion: Photon-beam therapy for irregular surfaces such as extremities is a valid alternative to conventional electron-beam radiation by attaining uniform coverage while minimizing hotspots. Treatment utilizing a water tank is well-tolerated and has good clinical outcomes even in the presence of extensive skin lesions. [ABSTRACT FROM AUTHOR]

Background: The current classification for acute kidney injury (AKI) according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria integrates both serum creatinine (SCr) and urine output (UO). Most reports on AKI claim to use KDIGO guidelines but fail to include the UO criterion. It has been shown that patients who had intensive UO monitoring, with or without AKI, had significantly less cumulative fluid volume and fluid overload, reduced vasopressor use, and improved 30-day mortality. We examined whether real-time monitoring of this simple, sensitive, and easy-to-use biomarker in the ICU led to more appropriate intervention by healthcare providers and better outcomes. Methods: RenalSense Clarity RMS Consoles were installed in the General ICU at the Hadassah Medical Center, Israel, from December 2019 to November 2020. The Clarity RMS system continuously and electronically monitors UO in real-time. 100 patients were randomly selected from this period as the study group (UOelec) and compared to a matched control group (UOmanual) from the same period two years earlier. To test whether there was an association between oliguric hours and fluid treatment in each group, the correlation was calculated and analyzed for each of the different UO monitoring methods. Results: Therapeutic intervention: The correlation of the sum of all oliguric hours on Day 1 and 2 with the sum of any therapeutic intervention (fluid bolus or furosemide) showed a significant correlation for the study group UOelec (P = 0.017). The matched control group UOmanual showed no such correlation (P = 0.932). Length of Stay (LOS): Median LOS [IQR] in the ICU of UOelec versus UOmanual was 69.46 [44.7, 125.9] hours and 116.5 [62.46, 281.3] hours, respectively (P = 0.0002). Conclusions: The results of our study strongly suggest that ICU patients had more meaningful and better medical intervention, and improved outcomes, with electronic UO monitoring than with manual monitoring. [ABSTRACT FROM AUTHOR]

To assess the planned dose, in vivo dosimetry, acute skin toxicity, pain, and distress using Thermoplastic Elastomer (TPE) bolus for postmastectomy radiotherapy (PMRT). Thirty-two PMRT patients with TPE bolus (17 patients for 25 fractions, 15 patients for the first 20 fractions) were selected for the study. The acute skin toxicity, pain, and psychological distress were assessed from the first treatment week to the fourth week after the end of treatment. At the first treatment, the MOSFET was used in vivo dosimetry measurement. In vivo dosimetry with the bolus, the dose deviation ranged from −6.22% to −1.56% for 5 points. The presence of grade 1 and 2 skin toxicity reached its peak (70.0% and 13.3%) in the sixth week. Two patients (6.6%) with 25 fractions bolus experienced moist desquamation in the fifth and seventh week, with pain score 2 and 3, and interruptions of 3 and 5 days, respectively. The incidence of pain score 1, 2, and 3 peaked in the fifth (33.3%), fourth (33.3%), and seventh (10.0%) week. No patients experienced grade 3 skin toxicity and severe pain. One patient had significant anxiety, and two patients had significant depression. The TPE bolus can accurately fit skin and improve the surface dose to more than 90%. Twenty fractions with TPE bolus had similar skin toxicity and pain to those without bolus and did not increase patients' distress and clinical workload, compared with the literature's data, which is an alternative to the 3D printing bolus for PMRT. • First reported the soft and self-viscosity TPE bolus in PMRT. • Evaluated the planning and in vivo dose in PMRT using TPE bolus. • TPE bolus had similar skin toxicity to those without bolus compared with the literature's data. • Using TPE bolus did not increase patients' psychological distress and clinical workload compared with the literature's data. [ABSTRACT FROM AUTHOR]

Due to COVID-19, all courses at a regional comprehensive university in the southeastern United States transitioned online and were delivered remotely in the latter half of the spring semester of 2020. In this study, students' performance data from four graduate programs in social sciences and two graduate mathematics programs for the spring semesters of 2019, 2020. and 2021 were collected and analyzed. Different e-learning methods were used across the different fields represented in these graduate programs. This study shows that graduate students performed well and synchronous hybrid courses reduced or negated the negative impacts of the pandemic COVID-19 on Mudent learning. The percentage of students receiving a -B-" or better did not change significantly overtime (p = 0.796 toi- social sciences and p = 0.315 for mathematics). total enrollment increased over time (p < 0.001 for both social sciences and mathematics). and graduation rates remained conxtant for social sciences 0, = 0.346) while there was a bolus of graduating students in spring 2020 for mathematic>4 9, < 0.001 ). Based on this study. recommendations were made for teaching and learning in future graduate level courses. [ABSTRACT FROM AUTHOR]

Although videofluorography (VFG) is an effective tool for evaluating swallowing functions, its accurate evaluation requires considerable time and effort. This study aimed to create a deep learning model for automated bolus segmentation on VFG images of patients with healthy swallowing and dysphagia using the artificial intelligence deep learning segmentation method, and to assess the performance of the method. VFG images of 72 swallowing of 12 patients were continuously converted into 15 static images per second. In total, 3910 images were arbitrarily assigned to the training, validation, test 1, and test 2 datasets. In the training and validation datasets, images of colored bolus areas were prepared, along with original images. Using a U-Net neural network, a trained model was created after 500 epochs of training. The test datasets were applied to the trained model, and the performances of automatic segmentation (Jaccard index, Sørensen–Dice coefficient, and sensitivity) were calculated. All performance values for the segmentation of the test 1 and 2 datasets were high, exceeding 0.9. Using an artificial intelligence deep learning segmentation method, we automatically segmented the bolus areas on VFG images; our method exhibited high performance. This model also allowed assessment of aspiration and laryngeal invasion. [ABSTRACT FROM AUTHOR]

Dysphagia care and management may differ between countries and healthcare settings. This study aims to describe the management and care of dysphagia in rehabilitation centres and health houses across Norway. Two national surveys were developed targeting either managers or healthcare professionals. Both surveys focused on staff and client populations; screening and assessment of dysphagia; dysphagia management and interventions; staff training and education; and self-perceived quality of dysphagia care. A total of 71 managers and clinicians from 45 out of 68 identified rehabilitation centres and health houses in Norway completed the surveys. The resulting overall response rate was 72.1%. Significant differences in dysphagia care and management were identified between rehabilitation services across Norway. Rehabilitation centres and health houses often had neither a speech therapist among their staff nor had access to external healthcare professionals. Screening was most frequently performed using non-standardised water swallows and only limited data were available on non-instrumental assessments. None of the respondents reported having access to instrumental assessments. Dysphagia interventions mainly consisted of compensatory strategies, including bolus modification, with very infrequent use of rehabilitative interventions, such as swallow manoeuvres. Although almost half of all respondents perceived the overall quality of care for clients with eating and swallowing problems as good, lack of awareness of dysphagia and its symptoms, consequences and options for treatment may have influenced quality ratings. There is a need to raise awareness of dysphagia and provide training opportunities for healthcare professionals in both screening and assessment, and dysphagia care and management. [ABSTRACT FROM AUTHOR]

Eosinophilic Esophagitis (EoE) is an esophageal allergic inflammatory disorder triggered by food proteins. Symptoms of EoE are variable within and between individuals. Presenting symptoms may include dysphagia, food bolus impaction, dyspepsia, or more subtle symptoms such as feeding disorders, regurgitation sensation, or nausea. The development and validation of a pediatric EoE patient self-reported and parent proxy-reported outcome symptom scoring tool was created by Franciosi et al. published in BMJ 2011, titled the Pediatric Eosinophilic Esophagitis Symptom Score (PEESS™ v2.0). To date, its use is largely for research purposes. We propose to evaluate the implementation of the PEESS™ v2.0 in a prospective interventional controlled clinical practice. The study included 620 patients over an 18-month period. Surveys were delivered and administered digitally every month through the MyGeisinger.org Patient Portal. Our analysis demonstrated symptom severity and symptom frequency scores significantly improved over time. However, counter to our hypothesis, patients who completed the PEESS™v2.0 ultimately had higher EoE-related health care utilization of office visits and endoscopies compared with those who did not complete the PEESS™v2.0. This could be related to greater awareness of disease activity and/or increased willingness to seek care. Our study, in the context of mobile health tool and patient-reported outcome trends, represents an opportunity for improved disease monitoring at-home within the field of eosinophilic gastrointestinal diseases. [ABSTRACT FROM AUTHOR]

Introduction: The prevalence of dysphagia in the general population is 6–16%. The dysphagia team focuses on dia-gnosis and treatment of dysphagia. The dysphagia team consists of a clinical speech therapist, an otorhinolaryngologist and nurse (depending on the workplace). Other specialties such as radiologist, nutritionist and physiotherapist can also be a member of the team. FEES (Flexible Endoscopic Evaluation of Swallowing) and VFSS (Videofluoroscopic Swallow Study) are used as the gold standard for objective examination of the dysphagia. Aim of the work: The aim of the work is to evaluate retrospectively the contribution of the dysphagia team working in the department of otorhinolaryngology in Hospital České Budějovice, in the care of patients after stroke disease indicated for examination from the Complex Cerebrovascular Center (CCC) in 2016–2020. Material and methods: The retrospective study included 33 patients after stroke with clinical suspicion of dysphagia, who were referred from the CCC to the Counseling Center for Swallowing Disorders for objective examination of dysphagia. Results: In 9 patients (27.3%), dysphagia was ruled out during FEES, thus enabling oral intake without restrictions. Dysphagia was confirmed in 24 patients (72.7%). Ten patients (30.3%) had a prolonged pharyngeal swallowing phase without food penetration into the airways. Three patients (9.1%) had a bolus penetration into the airways during the examination, but it remained above the vocal cords and it was completely expelled from the airways (PAS 2). In 11 cases (33.3%) aspiration was found, of which nine cases (27.3% of all patients, 81.8% of patients with aspiration) involved silent aspiration without any attempt to expel bolus from the airways (PAS 8). Conclusion: In 31 patients (94.0%) the benefit of examination by the dysphagia team was noted. In the case of 22 patients (66.7%), it was an adjustment of nutrition and swallowing rehabilitation with confirmed dysphagia. Restrictions were lifted in 9 patients (27.3%) with false-positive screening and clinical examination. We observe a positive effect of long-term swallowing rehabilitation in 61.5% of the monitored patients. [ABSTRACT FROM AUTHOR]

Data sources: A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted. PubMed and Cochrane databases were searched. Study selection: Journal articles published between January 2007 and January 2023 were identified. Studies that assessed malocclusion indices and oral function were included. Non-English articles and irrelevant studies were excluded. A total of 480 articles were identified. Following exclusion, 29 articles were included in the systematic review. Data extraction and synthesis: Data was compiled using Microsoft Excel. Information from each article was extracted including study design, evaluation criteria of malocclusion and oral function, and findings. Studies were assessed using the STROBE GRADE approach. The results were compiled in a brief narrative review investigating the type and strength of the association between malocclusion and ingestion. Results: Malocclusion was recorded using Index of Treatment Need, Dental Aesthetic Index, Goslon Yardstick Index, Index of Complexity Outcomes and Need, Peer Assessment Rating, Angle's classification, Specific Severity Score, dental inter-arch relation and cephalometric analysis. Ingestion was measured by bite force, electromyography, mixing ability index, bolus granulometric analysis, video analysis of kinetic parameters during mastication, and subjective questionnaires. Of the 29 articles identified, 20 demonstrated a negative impact of malocclusion on oral ingestion, highlighting impaired masticatory efficiency, bite force and subjective difficulties. Eight studies found no significant association. One study, which used two questionnaires, found a significant relationship between eating and malocclusion using one questionnaire but not the other. Discussion: Limitations in current research methodologies were identified, particularly the heterogeneity in assessment tools. The indicators used to assess ingestion and malocclusion are flawed, with questionable reliability. No study was able to identify which features or severity of malocclusion impact ingestion. The relationship between ingestion and malocclusion could not be quantified and the need for longitudinal and case report studies was deemed essential to establish causality. Conclusion: This review underscores the importance of considering how malocclusion impacts function in orthodontic treatment planning. Future research should focus on standardised assessment methods for measuring malocclusion and oral ingestion to establish the nature of the relationship between the two. This will ultimately guide orthodontic intervention aiming to enhance oral function. [ABSTRACT FROM AUTHOR]

The article discusses research by Maha Lebbar, Zoé Henry, and Charles Thivolet, reported in the Diabetes Care issue focusing on topics such as the comparison of glucose control and patient-reported outcomes after initiation of advanced hybrid closed-loop (AHCL) insulin delivery systems (Medtronic SmartGuard 780G and Tandem T-Slim Control-IQ), differences in continuous glucose monitoring outcomes between AHCL systems, and the impact of age on glucose efficacy.

Background: This study assessed the effects of esmolol injection in patients with in-hospital cardiac arrest (IHCA) with refractory ventricular fibrillation (VF)/pulseless ventricular tachycardia (pVT). Methods: From January 2018 to December 2021, 29 patients with IHCA with refractory shockable rhythm were retrospectively reviewed. Esmolol was administered after advanced cardiovascular life support (ACLS)-directed procedures, and outcomes were assessed. Results: Among the 29 cases, the rates of sustained return of spontaneous circulation (ROSC), 24-h ROSC, and 72-h ROSC were 79%, 62%, and 59%, respectively. Of those patients, 59% ultimately survived to discharge. Four patients with cardiac insufficiency died. The duration from CA to esmolol infusion was significantly shorter for patients in the survival group (SG) than for patients in the dead group (DG) (12 min, IQR: 8.5-19.5 vs. 23.5 min, IQR: 14.4-27 min; p = 0.013). Of those patients, 76% (22 of 29) started esmolol administration after the second dose of amiodarone. No significant difference was observed in the survival rate between this group and groups administered an esmolol bolus simultaneously or before the second dose of amiodarone (43% vs. 64%, p = 0.403). Of those patients, 31% (9 of 29) were administered an esmolol bolus for defibrillation attempts ≤ 5, while the remaining 69% of patients received an esmolol injection after the fifth defibrillation attempt. No significant differences were observed in the rates of ≥ 24-h ROSC (67% vs. 60%, p = 0.73), ≥ 72-h ROSC (67% vs. 55%, p = 0.56), and survival to hospital discharge (67% vs. 55%, p = 0.56) between the groups administered an esmolol bolus for defibrillation attempts ≤ 5 and defibrillation attempts > 5. Conclusion: IHCA patients with refractory shockable rhythms receiving esmolol bolus exhibited a high chance of sustained ROSC and survival to hospital discharge. Patients with end-stage heart failure tended to have attenuated benefits from beta-blockers. Further large-scale, prospective studies are necessary to determine the effects of esmolol in patients with IHCA with refractory shockable rhythms. [ABSTRACT FROM AUTHOR]

Background: A main factor contributing to insufficient glycemic control, during basal/bolus insulin therapy, is poor self-management bolus. Insulin bolus administration frequency is strongly associated with glycated hemoglobin (A1c) in Type 1 Diabetes (T1D). In the present study, we analyzed the performance of two-bolus calculator's software that could be accessible to T1D patients from a Public Health Service to improve glycemic time in range (TIR) and A1c. Methods: This prospective, controlled, randomized, parallel intervention clinical trial was carried out with 111 T1D participants on basal/bolus therapy [multiple daily insulin injections (MDI) or subcutaneous infusion pump (CSII)] with basal A1c ≥ 8.5% for 24 weeks. Patients were divided into 3 groups: 2 interventions: COMBO® (bolus calculator) and GLIC (mobile application) and 1 control (CSII group). Anthropometrics and metabolic variables were assessed on basal, 3 and 6 months of follow-up. Results: TIR was increased in 9.42% in COMBO group (29 ± 12% to 38.9 ± 12.7%; p < 0.001) in 8.39% in the GLIC® group (28 ± 15% to 36.6 ± 15.1%; p < 0.001) while remained stable in CSII group (40 ± 11% to 39.3 ± 10.3%). A1c decrease in 1.08% (p < 0.001), 0.64% (p < 0.001) and 0.38% (p = 0.01) at 6 months in relation to basal in the COMBO, GLIC and CSII respectively. Daily basal insulin dose was reduced by 8.8% (p = 0.01) in the COMBO group. Conclusion: The COMBO and a mobile applicative (GLIC) bolus calculator had a similar and a good performance to optimize the intensive insulin treatment of T1D in the public health system with increase in the TIR and reduction in A1C without increase hypoglycemia prevalence. [ABSTRACT FROM AUTHOR]

Context: Opioid continuous infusions are commonly used for end-of-life (EOL) symptoms in hospital settings. However, prescribing practices vary, and even the recent literature contains conflicting protocols and guidelines for best practice.Objectives: To determine the prevalence of potentially inappropriate opioid infusion use for EOL comfort care at an academic medical center, and determine if inappropriate use is associated with distress.Methods: Through literature review and iterative interdisciplinary discussion, we defined three criteria for "potentially inappropriate" infusion use. We conducted a retrospective, observational study of inpatients who died over six months, abstracting demographics, opioid use patterns, survival time, palliative care (PC) involvement, and evidence of patient/caregiver/staff distress from the electronic medical record.Results: We identified 193 decedents who received opioid infusions for EOL comfort care. Forty-four percent received opioid infusions that were classified as "potentially inappropriate." Insufficient use of as-needed intravenous opioid boluses and use of opioid infusions in opioid-naïve patients were the most common problems observed. Potentially inappropriate infusions were associated with more frequent patient (24% vs. 2%; P < 0.001) and staff distress (10% vs. 2%; P = 0.02) and were less common when PC provided medication recommendations (20% vs. 50%; P < 0.001).Conclusion: Potentially inappropriate opioid infusions are prevalent at our hospital, an academic medical center with an active PC team and existing contracts for in-hospital hospice care. Furthermore, potentially inappropriate opioid infusions are associated with increased patient and staff distress. We are developing an interdisciplinary intervention to address this safety issue. [ABSTRACT FROM AUTHOR]

Introduction: Polylactic acid (PLA) is a promising material for customised bolus 3D‐printing in radiotherapy, however variations in printing techniques between external manufacturers could increase treatment uncertainties. This study aimed to assess consistency across various 3D‐printed PLA samples from different manufacturers. Methods: Sample prints of dimensions 5 × 5 × 1 cm with 100% infill were acquired from multiple commercial 3D‐printing services. All samples were CT scanned to determine average Hounsfield unit (HU) values and physical densities. The coefficient of equivalent thickness (CET) was obtained for both photons and electrons and dose attenuation compared to TPS calculations in Elekta Monaco v5.11. Results: Some samples showed warped edges up to 1.5 mm and extensive internal radiological defects only detectable with CT scanning. Physical densities ranged from 1.06 to 1.22 g cm−3 and HU values ranged from −5.1 to 221.0 HU. Measured CET values varied from 0.95 to 1.17 and TPS dose calculations were consistent with the variation in CET. Electron R50 and R90 shifted by up to 2 mm for every 1 cm of printed bolus, a clinically significant finding. Photon surface dose varied by up to 3%, while depth doses were within 1%. Conclusions: 3D‐printed PLA can have considerable variability in density, HU and CET values between samples and manufacturers. Centres looking to outsource 3D‐printed bolus would benefit from clear, open communication with manufacturers and undertake stringent QA examination prior to implementation into the clinical environment. [ABSTRACT FROM AUTHOR]

This study aimed to assess the potential impact of implementing an electronic alert system (EAS) for systemic inflammatory syndrome (SIRS) and sepsis in pediatric patients mortality. This retrospective study had a pre and post design. We enrolled patients aged ≤ 14 years who were diagnosed with sepsis/severe sepsis upon admission to the pediatric intensive care unit (PICU) of our tertiary hospital from January 2014 to December 2018. We implemented an EAS for the patients with SIRS/sepsis. The patients who met the inclusion criteria pre-EAS implementation comprised the control group, and the group post-EAS implementation was the experimental group. Mortality was the primary outcome, while length of stay (LOS) and mechanical ventilation in the first hour were the secondary outcomes. Of the 308 enrolled patients, 147 were in the pre-EAS group and 161 in the post-EAS group. In terms of mortality, 44 patients in the pre-EAS group and 28 in the post-EAS group died (p 0.011). The average LOS in the PICU was 7.9 days for the pre-EAS group and 6.8 days for the post-EAS group (p 0.442). Considering the EAS initiation time as the "zero time", early recognition of SIRS and sepsis via the EAS led to faster treatment interventions in post-EAS group, which included fluid boluses with median (25th, 75th percentile) time of 107 (37, 218) min vs. 30 (11,112) min, p < 0.001) and time to initiate antimicrobial therapy median (25th, 75th percentile) of 170.5 (66,320) min vs. 131 (53,279) min, p 0.042). The difference in mechanical ventilation in the first hour of admission was not significant between the groups (25.17% vs. 24.22%, p 0.895). The implementation of the EAS resulted in a statistically significant reduction in the mortality rate among the patients admitted to the PICU in our study. An EAS can play an important role in saving lives and subsequent reduction in healthcare costs. Further enhancement of systematic screening is therefore highly recommended to improve the prognosis of pediatric SIRS and sepsis. The implementation of the EAS, warrants further validation in multicenter or national studies. [ABSTRACT FROM AUTHOR]

Background: Malignancies of the head and neck region, encompassing cutaneous, mucosal, and sarcomatous histologies, are complex entities to manage, comprising of coordination between surgery, radiation therapy, and systemic therapy. Malignancies of the posterior scalp are particular challenging to treat with radiation therapy, given its irregular contours and anatomy as well as the superficial location of the target volume. Bolus material is commonly used in radiation therapy to ensure that the dose to the skin and subcutaneous tissue is appropriate and adequate, accounting for the buildup effect of megavoltage photon treatment. The use of commercially available bolus material on the posterior scalp potentially creates air gaps between the bolus and posterior scalp. Case presentations: In this report, we created and utilized a custom 3D-printed integrated bolus and headrest for 5 patients to irradiate malignancies involving the posterior scalp, including those with cutaneous squamous cell carcinoma, melanoma, malignant peripheral nerve sheath tumor, and dermal sarcoma. Treatment setup was consistently reproducible, and patients tolerated treatment well without any unexpected adverse effects. Conclusions: We found that the use of this custom 3D-printed integrated bolus/headrest allowed for comfortable, consistent, and reproducible treatment set up while minimizing the risk of creating significant air gaps and should be considered in the radiotherapeutic management of patients with posterior scalp malignancies. [ABSTRACT FROM AUTHOR]

Introduction: Tymanoplasty, a middle ear surgery, is done either under Local Anaesthesia (LA), General Anaesthesia (GA) or sedation with local anaesthesia. It is usually performed under Monitored Anesthesia Care (MAC) providing advantages of rapid onset, allowing hearing test intraoperatively and early mobilisation of the patient. Aim: To study the effect of nalbuphine/dexmedetomidine with nalbuphine/propofol on sedation and analgesia in tympanoplasties performed under MAC. Materials and Methods: This randomised, double-blind, clinical study was conducted from June 2020 to June 2021 in the Department of Anaesthesiology at Mahatma Gandhi Memorial Medical College and MY Hospital, Indore, Madhya Pradesh, India. Total 60 adult patients, of American Society of Anesthesiologists (ASA) grade I and II undergoing tympanoplasty under MAC, were randomly allocated into two groups. All patients received injection nalbuphine 50 µg/kg intravenously. Group D received a bolus dose of injection dexmedetomidine 1 µg/kg i.v. over 10 min followed by an infusion at 0.3 µg/kg/h i.v. Group P received a bolus dose of injection propofol 0.75 mg/kg followed by an infusion at 0.025 mg/kg/min i.v. Sedation and analgesia were titrated to Ramsay Sedation Score (RSS) and Visual Analog Scale (VAS) of 3 each. The vital parameters and need for intraoperative rescue sedation/analgesia were recorded and compared. Results: Mean RSS was significantly more in group D (3.11±0.055) than group P (2.80±0.350). Overall, VAS score was significantly less in group D (1.60±0.670) than group P (2.70±0.691). In group D, 2 (6%) patients and in group P, 4 (12%) patients required inj. midazolam. Similarly, the requirement of inj. paracetamol in group D was in 3 (10%) patients, and in Group P it was 10 (33%) patients. Bradycardia (23.3% in group D and 13.3% in group P) and hypotension (20% in group D and 13.3% in group P) were the major side-effects seen in the study. Conclusion: Nalbuphine/dexmedetomidine is superior to nalbuphine/propofol in producing sedation and decreasing VAS in patients undergoing tympanoplasty under MAC. [ABSTRACT FROM AUTHOR]

The article reports on the positive impact of a tubeless automated insulin delivery (AID) system on glycemic control in a diverse group of adults with type 2 diabetes, as revealed during the American Diabetes Association's 84th Scientific Sessions. Topics discussed include the SECURE-T2D clinical trial findings, demographic details of the study participants, and the significant improvements in A1c levels, particularly among individuals with higher baseline A1c.