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Carbon-fiber reinforced (CFR) polyetheretherketone hardware is an alternative to traditional metal hardware used for spinal fixation surgeries before postoperative radiation therapy for patients with spinal metastases. CFR hardware's radiolucency decreases metal artifact, improving visualization and accuracy of treatment planning. We present the first clinical use and proof of principle of CFR spinal hardware with tantalum markers used for successful tracking of intrafraction motion (IM) using Varian TrueBeam IMR (Intrafraction Motion Review) software module during postoperative spine stereotactic radiation. A 63-year-old woman with history of endometrial cancer presented with acute back pain. Imaging demonstrated pathologic T12 vertebral fracture with cord compression. She underwent T12 vertebrectomy with circumferential decompression and posterior instrumented T10-L2 fusion at our facility using CFR-polyetheretherketone hardware with tantalum screw markers followed by postoperative stereotactic body radiation therapy to 3000 cGy in 5 fractions delivered to T11-T12. Tantalum screw markers were used for IMR tracking. During irradiation, 260 kV images were acquired, and IMR software was able to identify and track markers. During the entire treatment, the IM motions were less than 3 mm. This is the first presented case of CFR spinal hardware with tantalum markers used for successful IMR tracking of IM during daily spine stereotactic treatment. Future work will be needed to improve workflow and create a spine-specific IMR protocol., Competing Interests: Disclosures JDP reports research and speaking fees from Icotec, outside submitted work: Varian speeking fees, Novocure advisory board, Kroger trial funding, NIH R01CA269948, NIH R702 award, Biocept clinical trial funding, genentech clinical trial funding, (Copyright © 2023 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Mitigation of intrafraction motion (IM) is valuable in stereotactic radiotherapy (SRT) radiotherapy where submillimeter accuracy is desired. The purpose of this study was to investigate the application of triggered kilovoltage (kV) imaging for spine SRT patients with hardware by correlating kV imaging with patient motion and summarizing implications of tolerance for IM based on calculated dose., Materials and Methods: Ten plans (33 fractions) were studied, correlating kV imaging during treatment with pre- and post-treatment cone beam computed tomography (CBCT). Images were taken at 20-degree gantry angle intervals during the arc-based treatment. The contour of the hardware with a 1 mm expansion was displayed at the treatment console to manually pause treatment delivery if the hardware was visually detected outside the contour. The treatment CBCTs were compared using retrospective image registration to assess the validity of contour-based method for pausing treatment. Finally, plans were generated to estimate dose volume objective differences in case of 1 mm deviation., Results: When kV imaging during treatment was used with the 1 mm contour, 100 % of the post-treatment CBCTs reported consistent results. One patient in the cohort exhibited motion greater than 1 mm during treatment which allowed intervention and re-setup during treatment. The average translational motion was 0.35 mm. Treatment plan comparison at 1 mm deviation showed little differences in calculated dose for the target and cord., Conclusions: Utilizing kV imaging during treatment is an effective method of assessing IM for SRT spine patients with hardware without increasing treatment time., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Author.)

Purpose: Radiation therapy (RT) is essential to managing many pediatric malignancies but can provoke anxiety, fear, and discomfort for children owing to prolonged treatment time, extended course, and restrictive immobilization. Patients younger than 10 years frequently require daily general anesthesia (GA), which is resource intensive, expensive, potentially toxic, and anxiety and fear provoking. Audio-Visual Assisted Therapeutic Ambience in Radiation Therapy (AVATAR), a video streaming device, has been proposed as an alternative to anesthesia in patients aged 3 to 10 years. A pilot study evaluating the efficacy of this novel innovation is accruing, but patients younger than 3 years are ineligible., Methods and Materials: We simulated a 2-year-old with stage IV Wilms tumor for bilateral whole-lung and left-flank irradiation without GA. Using AVATAR, we attempted to deliver RT to this patient without sedation. Patient anxiety at the time of simulation and at the beginning, middle, and end of the treatment course was characterized using the validated Modified Yale Preoperative Anxiety Score (mYPAS) measurement tool., Results: Although the patient tolerated computed tomography simulation without GA or AVATAR use, his mYPAS of 14 out of 18 indicated significant anxiety. Using AVATAR, all treatments were delivered without GA; his mYPASs were 5 and 4 (the lowest possible) and 4 at the first, midcourse, and final treatments, indicating no significant anxiety and a decrease from the pre-AVATAR baseline. Without GA, the time to deliver RT decreased by 66% from 90 to 30 minutes., Conclusions: We describe an expanded, previously unreported indication for AVATAR by demonstrating the feasibility of this approach to reduce or omit anesthesia in appropriate younger patients currently excluded from ongoing trials. The financial and quality-of-life benefits (including decreased stress, anxiety, toxic effects, cost, and appointment time) of AVATAR use may be extendable to a younger patient population than previously thought. In older children, prospective validation is ongoing, but additional study in patients younger than 3 years is needed., (Copyright © 2021 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.)

Purpose: To monitor intrafraction motion during spine stereotactic body radiotherapy(SBRT) treatment delivery with readily available technology, we implemented triggered kV imaging using the on-board imager(OBI) of a modern medical linear accelerator with an advanced imaging package. Methods: Triggered kV imaging for intrafraction motion management was tested with an anthropomorphic phantom and simulated spine SBRT treatments to the thoracic and lumbar spine. The vertebral bodies and spinous processes were contoured as the image guided radiotherapy(IGRT) structures specific to this technique. Upon each triggered kV image acquisition, 2D projections of the IGRT structures were automatically calculated and updated at arbitrary angles for display on the kV images. Various shifts/rotations were introduced in x, y, z, pitch, and yaw. Gantry-angle-based triggering was set to acquire kV images every 45°. A group of physicists/physicians(n = 10) participated in a survey to evaluate clinical efficiency and accuracy of clinical decisions on images containing various phantom shifts. This method was implemented clinically for treatment of 42 patients(94 fractions) with 15 second time-based triggering. Result: Phantom images revealed that IGRT structure accuracy and therefore utility of projected contours during triggered imaging improved with smaller CT slice thickness. Contouring vertebra superior and inferior to the treatment site was necessary to detect clinically relevant phantom rotation. From the survey, detectability was proportional to the shift size in all shift directions and inversely related to the CT slice thickness. Clinical implementation helped evaluate robustness of patient immobilization. Based on visual inspection of projected IGRT contours on planar kV images, appreciable intrafraction motion was detected in eleven fractions(11.7%). Discussion: Feasibility of triggered imaging for spine SBRT intrafraction motion management has been demonstrated in phantom experiments and implementation for patient treatments. This technique allows efficient, non-invasive monitoring of patient position using the OBI and patient anatomy as a direct visual guide.

Complexity in MLC-based radiosurgery treatment delivery can be characterized by the efficiency of monitor unit (MU) utilization and the average MLC leaf separation distance for a treatment plan. A reduction in plan complexity may be desirable if plan quality is not impacted. In this study, a number of strategies are explored to determine how plan quality is affected by efforts to reduce plan complexity. Ten radiosurgery cases of varying complexity are retrospectively planned using six optimization strategies: an unconstrained volumetric modulated arc therapy (VMAT) technique, a MU-constrained VMAT technique, three techniques using various strengths of the aperture shape controller (ASC), and a hybrid technique consisting of a final-stage VMAT optimization applied to a dynamic conformal arc leaf sequence (ODCA). The plans are compared in terms of MU efficiency, MLC leaf-separation, conformity index (CI), gradient index (GI), and QA measurement results. The five VMAT techniques exhibited only minor differences in CI and GI values, though the ASC and MU-constrained techniques did require 6-20% fewer MU and had mean field apertures 5-19% larger. On average, the ODCA technique had CI values 3.5% lower and GI values 1.0-2.5% higher than the VMAT techniques, but also had a mean field aperture 24-47% larger and required 16-32% fewer MU. The QA measurement results showed a 0.61% variation in mean per-field 2%/1 mm gamma passing rates across all techniques (range 96.81%-97.42%), with no observed correlation between passing rate and technique. For simple targets, the ODCA technique achieved CI results that were equivalent to the unconstrained VMAT technique with an average 30% reduction in required MU, an average 50% increase in mean leaf separation distance, and brain V12 Gy values within 0.38 cc of the VMAT technique for targets up to approximately 2 cm diameter. For MLC-based single-target radiosurgery, plan complexity can often be significantly reduced without an equivalent reduction in plan quality., (© 2020 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals LLC on behalf of American Association of Physicists in Medicine.)

Introduction: Adult cancer pain is a disease state battled on a global scale. Proper pain management is essential to prevent health complications and promote patient well-being. Due to the opioid misuse crisis in the United States, providers are looking for alternatives to traditional opioids used for adult cancer pain. Buprenorphine has a unique pharmacologic profile, allowing it to be delivered in noninvasive ways; thus, it offers an alternative to traditional options. Randomized controlled trials have shown improved pain scores with transdermal buprenorphine, and they showed reductions in pain scores and increased improvement in quality of life scores versus other opioids. Sublingual buprenorphine has more limited, but promising data for reducing cancer pain., Areas Covered: We provide a narrative review of pathophysiological pathways of pain in cancer, how they are treated, and the unique properties of buprenorphine. Guidelines addressing pain management during cancer treatment are assessed to identify buprenorphine's place in therapy. Recent literature reporting efficacy and safety of buprenorphine use in pain management during cancer treatment will be presented., Expert Opinion: Current literature shows strong data for transdermal buprenorphine and promising data for sublingual buprenorphine. With this evidence, buprenorphine could have a more expanded role in managing adult cancer pain.

Background: Fiducial markers are frequently used before treatment for image-guided patient setup in radiation therapy (RT), but can also be used during treatment for image-guided intrafraction motion detection. This report describes our implementation of automatic marker detection with periodic kV imaging (TrueBeam v2.5) to monitor and correct intrafraction motion during prostate RT., Methods: We evaluated the reproducibility and accuracy of software fiducial detection using a phantom with 3 implanted fiducial markers. Clinical implementation for patients with intraprostatic fiducials receiving volumetric modulated arc therapy (VMAT) utilized periodic on-board kV imaging with 10 s intervals during treatment delivery. For each image, the software automatically identified fiducial locations and determined whether their distance relative to planned locations were within a 3 mm tolerance. Motion was corrected if either ≥2 fiducials in a single image or ≥1 fiducial in sequential images were out of tolerance., Results: Phantom studies demonstrated poorer performance of linear fiducials compared to collapsible fiducials, and wide variability to accurately detect fiducials across eight software settings. For any given setting, results were relatively reproducible and precise to ~0.5 mm. Across 17 patients treated with a median of 20 fractions, the software recommended a shift in 44% of fractions, and a shift was actually implemented after visual confirmation of movement greater than the 3 mm threshold in 20% of fractions. Adjustment of our approach led to improved accuracy for the latter (n = 7) patient subset. On average, table repositioning added 3.0 ± 0.3 min to patient time on table. Periodic kV imaging increased skin dose by an estimated 1 cGy per treatment arc., Conclusions: Periodic kV imaging with automatic detection of motion during VMAT prostate treatments is commercially available, and can be successfully implemented to mitigate effects of intrafraction motion with careful attention to software settings., (© 2020 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals, Inc. on behalf of American Association of Physicists in Medicine.)

Background: Mechanical ventilation after general surgery is associated with worse outcomes, prolonged hospital stay, and increased health care cost. Postoperatively, patients admitted to the intensive care unit (ICU) may be categorized into 1 of 3 groups: extubated patients (EXT), patients with objective medical indications to remain ventilated (MED), and patients not meeting these criteria, called "discretional postoperative mechanical ventilation" (DPMV). The objectives of this study were to determine the incidence of DPMV in general surgery patients and identify the associated operative factors., Methods: At a large, tertiary medical center, we reviewed all surgical cases performed under general anesthesia from April 1, 2008 to February 28, 2015 and admitted to the ICU postoperatively. Patients were categorized into 1 of 3 cohorts: EXT, MED, or DPMV. Operative factors related to the American Society of Anesthesiologists Physical Status (ASA PS), duration of surgery, surgery end time, difficult airway management, intraoperative blood and fluid administration, vasopressor infusions, intraoperative arterial blood gasses, and ventilation data were collected. Additionally, anesthesia records were reviewed for notes indicating a reason or rationale for postoperative ventilation. Categorical variables were compared by χ test, and continuous variables by analysis of variance or Kruskal-Wallis H test. Categorical variables are presented as n (%), and continuous variables as mean ± standard deviation or median (interquartile range) as appropriate. Significance level was set at P≤ .05., Results: Sixteen percent of the 3555 patients were categorized as DPMV and 12.2% as MED. Compared to EXT patients, those classified as DPMV had received significantly less fluid (2757 ± 2728 mL vs 3868 ± 1885 mL; P < .001), lost less blood during surgery (150 [20-625] mL vs 300 [150-600] mL; P< .001), underwent a shorter surgery (199 ± 215 minutes vs 276 ± 143 minutes; P< .001), but received more blood products, 900 (600-1800) mL vs 600 (300-900) mL. The DPMV group had more patients with high ASA PS (ASA III-V) than the EXT group: 508 (90.4%) vs 1934 (75.6%); P< .001. Emergency surgery (ASA E modifier) was more common in the DPMV group than the EXT group: 145 (25.8%) vs 306 (12%), P< .001, respectively. Surgery end after regular working hours was not significantly higher with DPMV status compared to EXT. DPMV cohort had fewer cases with difficult airway when compared to EXT or MED. When compared to MED patients, those classified as DPMV received less fluid (2757 ± 2728 mL vs 4499 ± 2830 mL; P< .001), lost less blood (150 [20-625] mL vs 500 [200-1350] mL; P < .001), but did not differ in blood products transfused or duration of surgery., Conclusions: In our tertiary medical center, patients often admitted to the ICU on mechanical ventilation without an objective medical indication. When compared to patients admitted to the ICU extubated, those mechanically ventilated but without an objective indication had a higher ASA PS class and were more likely to have an ASA E modifier. A surgery end time after regular working hours or difficult airway management was not associated with higher incidence of DPMV.

Background: There has been an increase in health problems among physicians due to low primary care maintenance, noncompliance with recommendations for physical activity and balanced eating practices, high levels of caffeine intake, and reduced amount of sleep. We hypothesize that physical health, specifically blood pressure (BP) control, is suboptimal among anesthesiology residents., Methods: The purpose of this study is to investigate the prevalence of hypertension and stress among an anesthesiology resident population, and attempt to correlate possible hypertension and increased stress among residents with life and work environment factors. All University of Miami anesthesiology residents in the year 2016 were invited to participate. Blood pressures were taken and anonymous surveys, including demographic and lifestyle questions, were administered., Results: Of 85 invited residents, 80 (92%) participated. 18 (22.50%) residents had blood pressures within the normal range. Twenty (25.00%) residents were hypertensive and 42 (52.50%) were pre-hypertensive. Males exhibited higher systolic blood pressures than females (p<0.0001). The mean Perceived Stress Scale (PSS) for all residents was 17.16 ± 7.2. Fifty-four (67.50%) residents scored a PSS above 13, indicating stress levels greater than the national average. Thirty-three (41.25%) residents scored above 20, indicating the presence of severe stress. Females were more likely than males to have stress (p=0.0314). Residents sleeping less than 6 hours per night were more likely to have stress (p=0.0158). Residents reporting more than one overnight call per week were also more likely to have stress (p=0.013)., Conclusions: Our study showed 75% of residents have hypertensive disease and 68% of residents exhibit clinically significant stress. These findings emphasize the need for greater attention to personal health and well-being.

Objective: To compare monitored anesthesia care (MAC) and general anesthesia (GA) for transcatheter aortic valve implantation (TAVI)., Design: Retrospective, case-control study., Setting: A large university-affiliated hospital system., Participants: The study comprised patients who underwent TAVI with the Medtronic CoreValve (Medtronic, Minneapolis, MN) between 2011 and 2015., Interventions: None., Measurements and Main Results: MAC (n = 44) and GA (n = 21) were compared in 65 patients who underwent TAVI. Baseline characteristics/demographics, hospital stay, intraoperative conditions, and intensive care unit (ICU)/hospital stays were compared using the chi-square test, unpaired t-test, or binomial regression where appropriate. There were no significant differences between patient populations with regard to 30-day mortality, ICU/hospital stay, and complication rates. The GA group used more blood product. The rate of ICU readmission was greater in the GA group but did not reach statistical significance., Conclusions: GA provides no significant advantages over MAC during TAVI., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Aim: The aim of this study was to describe our institutional experience, primarily with general anesthesiologists consulting with cardiac anesthesiologists, caring for left ventricular assist device (LVAD) patients undergoing noncardiac surgery., Materials and Methods: This is a retrospective review of the population of patients with LVADs at a single institution undergoing noncardiac procedures between 2009 and 2014. Demographic, perioperative, and procedural data collected included the type of procedure performed, anesthetic technique, vasopressor requirements, invasive monitors used, anesthesia provider type, blood product management, need for postoperative intubation, postoperative disposition and length of stay, and perioperative complications including mortality., Statistical Analysis: Descriptive statistics for categorical variables are presented as frequency distributions and percentages. Continuous variables are expressed as mean ± standard deviation and range when applicable., Results: During the study, 31 patients with LVADs underwent a total of 74 procedures. Each patient underwent an average of 2.4 procedures. Of the total number of procedures, 48 (65%) were upper or lower endoscopies. Considering all procedures, 81% were performed under monitored anesthesia care (MAC). Perioperative care was provided by faculty outside of the division of cardiac anesthesia in 62% of procedures. Invasive blood pressure monitoring was used in 27 (36%) procedures, and a central line, peripherally inserted central catheter or midline was in place preoperatively and used intraoperatively for 38 (51%) procedures. Vasopressors were not required in the majority (65; 88%) of procedures. There was one inhospital mortality secondary to multiorgan failure; 97% of patients survived to discharge after their procedure., Conclusion: At our institution, LVAD patients undergoing noncardiac procedures most frequently require endoscopy. These procedures can frequently be done safely under MAC, with or without consultation by a cardiac anesthesiologist.

Purpose of Review: Pain management is one of the most important fields in the practice of anesthesiology. The concept that genes involved in the absorption, metabolism, and receptor affinity of analgesics are critical to a drug's efficacy is becoming widely accepted. A review of pharmacogenomics and how it affects the response to analgesics, mainly opioids, is presented in this article., Recent Findings: As the field of pharmacogenomics expands, more and more candidate genes are being evaluated. Genes related to the μ-opioid receptor, ATP-binding cassette subfamily B, catechol-O-methyltransferase, and cytochrome 2D6 currently show promise in helping predict the gene phenotype. Recent studies have also focused on the interleukin-1 receptor antagonist and the melanocortin-1 receptor, further adding to the picture., Summary: Through increased knowledge in the area of pharmacogenomics, it is hoped that that treatment of pain will move into the realm of personalized medicine. This should result in greater treatment success and a reduction of significant side-effects.

Amish sisters who shared a terrible disease captured this nurse's heart.

A colorimetric, microplate-based Alamar Blue assay (MABA) method was used to determine the MICs of isoniazid (INH), rifampin, streptomycin (SM), and ethambutol (EMB) for 34 Peruvian Mycobacterium tuberculosis isolates (including both pansensitive and multidrug-resistant strains) and the H37Rv strain by using bacterial suspensions prepared directly from solid media. Results for all isolates were available within 8 days. Discordant results were observed on initial tests for 3 of 16 INH-susceptible isolates, 5 of 31 EMB-susceptible isolates, and 2 of 4 SM-resistant isolates (by the BACTEC 460 system). The overall agreements between the MICs obtained by MABA and the results obtained with the BACTEC 460 system were 87.9% for initial results and 93.6% after retesting 12 of 17 samples with discrepant results. Interpretation of MABA endpoints improved with technical experience. The MABA is a simple, rapid, low-cost, appropriate technology which does not require expensive instrumentation and which makes use of a nontoxic, temperature-stable reagent.

To improve upon the activity and properties of the 3-aryl-7-chloro-3,4- dihydro-1,9(2H,10H)-acridinediones, a variety of 1-[(alkylamino)alkylene]imino derivatives (3) were prepared and shown to be highly active antimalarial agents in both rodents and primates. Among structural modifications prepared, including N10-alkyl and C2-substituted analogs, removal of the C9 oxygen, and introduction of an imino side chain at C9, the imines of the N10-H acridinediones were the most active compounds obtained. The [3-(N,N- dimethylamino)propyl]imino derivative of 7-chloro-3-(2,4-dichlorophenyl)-3,4-dihydro-1,9(2H,10H)- acridinedione (9aa) proved to be highly active in advanced studies in primates.

A family is described in which a reciprocal translocation involving 5p and 21q appeared de novo in the chromosome complement of a woman who then transmitted it in both balanced and unbalanced form to her progeny. The proposita, a child with the cri du chat syndrome, had a deficiency for most of 5p, all of 21p, 21 centromere, and a small proximal segment of 21q. The reported cases of the cri du chat syndrome associated with translocations are reviewed and discussed in relation to this family.

A retrospective analysis of 242 families revealed that the incidence of reflux among siblings of children with reflux was 2.2 per cent. In a prospective study of 24 families, 8 of 50 siblings (16 per cent) had reflux. Although the incidence of reflux in the prospective study is surprisingly high infections was absent in all affected siblings in whom cultures were obtained and in only 2 siblings (4 per cent) was surgical correction necessary.

A variety of analogues of 2,4-diamino-6-[(aryl)thio]quinazolines with known antimalarial properties were prepared wherein the 4-amino group was replaced by hydrazino and hydroxyamino moieties. Such changes were found to reduce markedly the antimalarial and antitumor properties of this series.