Dose Reduction Protocol Research Articles

Outcomes of Radiation Dose Reduction Protocol in Electrophysiologic and Cardiac Device Procedures

Background: Exposure to radiation has been demonstrated to be associated with adverse short- and long-term health outcomes. Objective: To presented outcomes before and after the implementation of a radiation dose reduction protocol in electrophysiologic (EP) and cardiac device procedures. Materials and Methods: The present study was a retrospective comparative study, conducted at Chiang Mai University Hospital in Thailand using 2017 and 2019 data, including all patients who underwent EP and cardiac implantable electronic device (CIED) procedures. Exclusion criteria involved patients with incomplete radiation dose records. The authors compared fluoroscopic time, radiation exposure, and complication rates before and after the protocol. Results: Among the 458 cases, with 214 Eps and 244 devices, the mean age was 58 years. For device implantation procedures, there was no significant change in fluoroscopic time as median (P₂₅, P₇₅) before and after protocol implementation were 3.1 (0.4, 5.8) versus 4.4 (1.2,7.6) minutes, respectively (p=0.117). However, there was a decreasing trend in dose area product (DAP) at 242.0 (119.2, 766.0) versus 197.9 (71.5, 494.5) cGy.cm² (p=0.073). The reduction in DAP was more pronounced in cardiac resynchronization therapy (CRT) implantation when comparing 2017 to 2019 were 1,933.6 (1,039.4, 7,683.8) versus 1,074.6 (427.2, 2,890.7) cGy.cm² (p=0.020). In EP procedures, fluoroscopic time significantly decreased from 8.1 (3.0, 14.3) minutes in 2017 to 1.0 (0.0, 3.6) minute in 2019 (p<0.001), accompanied by a significant reduction in exposure dose of 45.0 (10.8, 153.3) versus 1.7 (0.0, 31.6) mGy (p<0.001) and DAP of 1,022.9 (247.2, 2,660.3) versus 38.5 (0.0, 566.9) cGy.cm² (p<0.001). There was no difference in the complication rate between the two periods. Conclusion: The implementation of the radiation dose reduction protocol resulted in a significant decrease in radiation exposure during EP procedures and showed a trend towards reduction in CIED procedures.

Advances and Applications of Three-Dimensional-Printed Patient-Specific Chest Phantoms in Radiology: A Systematic Review

Lung cancer screening would benefit from low-dose CT protocols optimized by means of a highly accurate three-dimensional radiation-equivalent thoracic phantom. However, whether three-dimensional (3D)-printed chest phantoms have been used for this purpose is unclear, as is their current scope of application. This systematic review aims to explore the range of applications of 3D-printed thoracic phantoms, along with the techniques, materials, and anatomical structures they replicate. Relevant articles were identified using a systematic search strategy across PubMed and Scopus databases, based on pre-determined selection criteria. In total, 20 articles were eligible and critically analysed, all consisting of phantom experiments. Findings reveal that a diverse range of thoracic organs have been 3D-printed, predominantly via fused-deposition modelling incorporating polylactic acid, however, often representing discreet or limited structures. A comprehensive radiation-equivalent chest phantom that mimics the full gamut of thoracic structures is warranted. Most studies are still in their preliminary testing stages, primarily assessing the feasibility of creating morphologically accurate thoracic structures with radiation equivalence. Few studies have progressed to explore their applications. Notably, most investigations into applications have concentrated on dose reduction and CT protocol optimisation for cardiac purposes, rather than pulmonary applications, despite the inclusion of lung cancer nodules in some phantoms.

Insights about cervical lymph nodes: Evaluating deep learning–based reconstruction for head and neck computed tomography scan

PurposeThis study aimed to investigate differences in cervical lymph node image quality on dual-energy computed tomography (CT) scan with datasets reconstructed using filter back projection (FBP), hybrid iterative reconstruction (IR), and deep learning–based image reconstruction (DLIR) in patients with head and neck cancer. MethodSeventy patients with head and neck cancer underwent follow-up contrast-enhanced dual-energy CT examinations. All datasets were reconstructed using FBP, hybrid IR with 30 % adaptive statistical IR (ASiR-V), and DLIR with three selectable levels (low, medium, and high) at 2.5- and 0.625-mm slice thicknesses. Herein, signal, image noise, signal-to-noise ratio, and contrast-to-noise ratio of lymph nodes and overall image quality, artifact, and noise of selected regions of interest were evaluated by two radiologists. Next, cervical lymph node sharpness was evaluated using full width at half maximum. ResultsDLIR exhibited significantly reduced noise, ranging from 3.8 % to 35.9 % with improved signal-to-noise ratio (11.5–105.6 %) and contrast-to-noise ratio (10.5–107.5 %) compared with FBP and ASiR-V, for cervical lymph nodes (p < 0.001). Further, 0.625-mm-thick images reconstructed using DLIR-medium and DLIR-high had a lower noise than 2.5-mm-thick images reconstructed using FBP and ASiR-V. The lymph node margins and vessels on DLIR-medium and DLIR-high were sharper than those on FBP and ASiR-V (p < 0.05). Both readers agreed that DLIR had a better image quality than the conventional reconstruction algorithms. ConclusionDLIR-medium and -high provided superior cervical lymph node image quality in head and neck CT. Improved image quality affords thin-slice DLIR images for dose-reduction protocols in the future.

Impact of a selective lens dose reduction protocol in 3D rotational angiography on radiation exposure to the eye lens during cerebral angiography: a randomized controlled trial

BackgroundWe aimed to investigate the radiation dose to the eye lens (lens dose) during cerebral angiography and to evaluate the effectiveness of the lens dose reduction protocol for 3-dimensional rotational...

TCTAP A-081 Reducing Radiation Dose in Coronary Angiography and Angioplasty Using Dose Reduction Protocol

TCTAP A-081 Reducing Radiation Dose in Coronary Angiography and Angioplasty Using Dose Reduction Protocol

Steps towards implementation of protocolized dose reduction of adalimumab, etanercept and ustekinumab for psoriasis in daily practice

BackgroundDose reduction (DR) of adalimumab, etanercept and ustekinumab has proven to be (cost-)effective in psoriasis patients with low disease activity. Further implementation is needed to establish application of DR for eligible patients.ObjectivesTo evaluate the implementation of protocolized biologic DR in daily practice.MethodsA pilot implementation study was performed in 3 hospitals during 6 months. By combining education and protocol development, involved healthcare providers (HCPs) were directed toward the adoption of protocolized DR. DR of adalimumab, etanercept, and ustekinumab was achieved by stepwise injection interval prolongation. Implementation outcomes (fidelity, feasibility) were assessed. Factors for optimizing implementation were explored in interviews with HCPs. Uptake was measured in patients by chart review.ResultsThe implementation strategy was executed as planned. Implementation fidelity was less than 100% as not all provided tools were used across study sites. HCPs indicated the feasibility of implementing protocolized DR, although time investment was needed. Identified additional factors for successful implementation included support for patients, uptake of DR into guidelines, and supportive electronic health record systems. During the 6 months intervention period, 52 patients were eligible for DR of whom 26 (50%) started DR. The proposed DR protocol was followed in 22/26 patients (85%) on DR.ConclusionAdditional staff for support, extra time during consultations, education on DR for HCPs and patients, and effective tools such as a feasible protocol can lead to more patients on biologic DR.

Reduced Dose Methotrexate and Mycophenolate Mofetil in Noninfectious Uveitis: A Sub-Analysis from the First-Line Antimetabolites as Steroid Sparing Therapy (FAST) Trial

ABSTRACT Purpose Some patients taking methotrexate (MTX) or mycophenolate mofetil (MMF) experience intolerable side effects at full doses. We evaluated whether dose reduction affected treatment outcomes in uveitis patients. Methods Subanalysis of the First-line Antimetabolites as Steroid-sparing Treatment (FAST) uveitis trial. Patients were randomized to receive MTX (25 mg weekly) or MMF (3 g daily). A pre-specified dose reduction protocol could be employed for intolerable side effects. Primary analysis was performed at 6 months. Results 43/194 patients (22%) required dose reduction. 88/151 patients (58%) on maximum doses and 32/43 patients (74%) on reduced doses were deemed treatment successes at 6 months. The odds ratio point estimate (1.60, 95% CI 0.72–3.74) favored dose-reduction but this was not significant. Following reduction, adverse events improved at the subsequent study visit (79 events reduced to 63 events). Conclusion Dose reduction of antimetabolites was not associated with worse outcomes in this subanalysis of a uveitis trial.

Reduction of Radiation Dose to Eye Lens in Cerebral 3D Rotational Angiography Using Head Off-Centering by Table Height Adjustment: A Prospective Study.

Three-dimensional rotational angiography (3D-RA) is increasingly used for the evaluation of intracranial aneurysms (IAs); however, radiation exposure to the lens is a concern. We investigated the effect of head off-centering by adjusting table height on the lens dose during 3D-RA and its feasibility in patient examination. The effect of head off-centering during 3D-RA on the lens radiation dose at various table heights was investigated using a RANDO head phantom (Alderson Research Labs). We prospectively enrolled 20 patients (58.0 ± 9.4 years) with IAs who were scheduled to undergo bilateral 3D-RA. In all patients' 3D-RA, the lens dose-reduction protocol involving elevation of the examination table was applied to one internal carotid artery, and the conventional protocol was applied to the other. The lens dose was measured using photoluminescent glass dosimeters (GD-352M, AGC Techno Glass Co., LTD), and radiation dose metrics were compared between the two protocols. Image quality was quantitatively analyzed using source images for image noise, signal-to-noise ratio, and contrast-to-noise ratio. Additionally, three reviewers qualitatively assessed the image quality using a five-point Likert scale. The phantom study showed that the lens dose was reduced by an average of 38% per 1 cm increase in table height. In the patient study, the dose-reduction protocol (elevating the table height by an average of 2.3 cm) led to an 83% reduction in the median dose from 4.65 mGy to 0.79 mGy (P < 0.001). There were no significant differences between dose-reduction and conventional protocols in the kerma area product (7.34 vs. 7.40 Gy·cm², P = 0.892), air kerma (75.7 vs. 75.1 mGy, P = 0.872), and image quality. The lens radiation dose was significantly affected by table height adjustment during 3D-RA. Intentional head off-centering by elevation of the table is a simple and effective way to reduce the lens dose in clinical practice.

Is the efficacy of cone beam computed tomography in the diagnosis of tooth ankylosis influenced by dose reduction protocols?

To evaluate the diagnostic efficacy of cone beam computed tomography (CBCT) examinations acquired with varying dose protocols in the diagnosis of simulated tooth ankylosis (TA). Tooth ankylosis was simulated in 15 of 30 teeth, and CBCT examinations were acquired at 3 mA levels (8, 6.3, and 5) and 3 voxel sizes (0.08, 0.125, and 0.2 mm). Four radiologists independently assessed the presence of TA using a 5-point scale. Sensitivity, specificity, and area under the curve (AUC) obtained through receiver operating characteristic analysis were compared among mA levels and voxel sizes using two-way analysis of variance (α=0.05). Intra- and interexaminer reliability levels were assessed with the weighted kappa examination. Sensitivity was low (0.32-0.49), and specificity was reasonably high (0.71-0.83). Mean values of AUC were low, ranging between 0.54 and 0.67, which reveals poor overall discrimination between health and disease. The detection of TA was not significantly influenced by mA level or voxel size (P > .05). Intra- and interexaminer agreements ranged from slight to moderate (0.160-0.535) and from fair to substantial (0.236-0.697), respectively. Despite the limited efficacy of CBCT for TA detection, when indicated as a complementary examination, mA reduction should be considered for dose optimization purposes.

Radiation Dose Reduction in Congenital Heart Disease Patients During Cardiac Catheterization by a Novel Protocol.

Objective:Cardiac catheterization remains a major source of radiation exposure for patients with congenital heart disease. This study reports the magnitude of radiation with a 3.75 frame per second (fps) pulse fluoroscopy rate and compares the reduction with the previous 15 fps protocol during cardiac catheterization for pediatric and adult congenital heart disease.Material and Methods:All diagnostic and interventional cardiac catheterization procedures from a single tertiary center were analyzed from January 1, 2014 to December 31, 2015, one year before and after implementing lower starting pulse fluoroscopy rates. The radiation dose was quantified as air kerma dose (mGy) and dose-area product (DAP; µGy/m2). Radiation exposure was analyzed for diagnostic and interventional procedures; the diagnostic group was subdivided into cyanotic and acyanotic patients, whereas the interventional group was subdivided according to the most common indications.Results:A total of 786 procedures were analyzed. The median fluoroscopy times and contrast amounts did not show a statistically significant difference between both periods (487 vs. 456 seconds and 42.5 vs. 45.3 cm3). The median air kerma for all procedures showed an 88% reduction after implementing lower pulse fluoroscopy rates (340-41 mGy). The doses were reduced significantly for diagnostic and interventional angiograms from 470 mGy and 162 mGy to 40 mGy and154 mGy. Among all patient groups, the most striking decrease was observed in the diagnostic procedures we use, of which fluoroscopy is more prominent than cine angiography.Conclusion:We claim that novel radiation dose reduction protocols could be easily applied without increasing fluoroscopy time or losing image quality.

Computed tomography versus fluoroscopic guided-sacroiliac joint injection: a prospective comparative study

BackgroundThere are limited data discussing long-term pain relief and comparability of different image-guided sacroiliac joint (SIJ) injection. This study compared CT and fluoroscopic-guided SIJ injections regarding statistically and clinically significant differences in numeric pain reduction, radiation doses, and patient’s satisfaction.MethodsA prospective study conducted on 52 patients who met specific inclusion criteria of SIJ pain. A mixture of 1 ml of 40 mg methylprednisolone acetate diluted in 2 ml of lidocaine 2% was injected under either CT or fluoroscopic guidance. Numeric rating score (NRS) and Oswestry disability index (ODI) were assessed and recorded for each patient before procedure and one-week, and one-, three-, six-, and 12-months after procedure. The results were compared between both groups.ResultsAnalysis of NRS one-month post-procedure showed a significant decrease from baseline in both groups: 12.5% in CT group (p = 0.002) and 9.5% in fluoroscopic group (p = 0.006). No significant difference in NRS between two groups at one- and three-months post-procedure (p = 0.11 and 0.1, respectively). There was a significant difference in NRS between two groups at six- and 12-months post-procedure (p = 0.001 and < 0.0001, respectively). Comparison of ODI at six-month post-procedure revealed that both groups had a statistically significant improvement (p < 0.0001). There was a significant difference in ODI between two groups at six-months post-procedure (p = 0.01).ConclusionsCT-guided SIJ injection compares favorably with fluoroscopic guidance and offers statistically and clinically significant long-term pain relief. The use of dose reduction protocol in CT is important for decreasing the radiation dose.

Individualized Bone-Protective Management in Long-Term Cancer Survivors With Bone Metastases.

Antiresorptive therapy is an important component of a multimodal approach to treating patients with advanced malignancies and metastatic bone disease. Over the past decade, overall survival of affected patients has improved in most cancer entities, and long-term disease control is a realistic goal in many cases. There are emerging clinical studies showing the benefits of an initial antiresorptive therapy using bisphosphonates or denosumab. However, some adverse events of these therapies, such as osteonecrosis of the jaw, correlate with the cumulative doses given, and there is an increasing clinical need for new antiresorptive concepts to treat long-term survivors. This review summarizes the clinical evidence of antiresorptive therapies across different cancers with bone involvement and presents concepts of dose-reduction protocols for long-term survivors with established metastatic bone disease. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Dual-Energy CT for Urinary Stone Evaluation.

Conventional CT imaging is an excellent tool for the diagnosis of nephrolithiasis however is limited in its ability to detect stone composition. Dual-energy CT (DECT) scans have demonstrated promise in overcoming this limitation. We review the current utility of DECT in nephrolithiasis. DECT is superior to conventional CT in differentiating uric acid stones from non-uric acid stones, with numerous studies reporting sensitivities and specificities approaching > 95%. Dose reduction protocols incorporating low-dose CT scans are commonly used, providing significantly lower effective radiation doses compared to conventional CT. DECT remains an effective diagnostic tool in patients with large body habitus. DECT can accurately detect uric acid stones, which can help guide which stones may be suitable to medical dissolution. Further studies evaluating the effectiveness of DECT in guiding management of patients with nephrolithiasis can help to promote its widespread use.

Deprescribing Opioids in Chronic Non-cancer Pain: Systematic Review of Randomised Trials.

Deprescribing, the process of reducing or discontinuing unnecessary or harmful medicines is an essential part of clinical practice. To evaluate the efficacy of interventions designed to deprescribe opioid analgesics for pain relief in patients with chronic non-cancer pain. We searched electronic databases, including clinical trial registries, from database inception to 13th January 2020 without restrictions, and conducted citation tracking. Our systematic review included randomised controlled trials (RCTs) evaluating interventions reducing the prescription, or use of opioid analgesics in patients with chronic pain versus control. Inventions could be aimed at the patient, clinician, or both. We excluded trials enrolling patients with cancer or illicit drug use. Two authors independently screened and extracted data. Outcome follow-up timepoints were short (≤ 3months), intermediate (> 3 but < 12months) or long (≥ 12months) term. Primary outcome was the reduction in opioid dose [morphine milligram equivalent (MME) mg/day]. Methodological quality was assessed using the Cochrane Risk of Bias Tool. We included ten patient-focused RCT interventions (n = 835; median 37 participants) and 2 testing clinician-focused interventions (n = 291 clinicians); none at low risk of bias. Patient-focused interventions did not reduce opioid dose in the intermediate term [e.g. dose reduction protocol, mean difference (MD) - 19.9 MME, 95% CI - 107.5 to 67.7], nor did they increase the number of participants who ceased their dose, or increase the risk of serious adverse events or adverse events. One clinician intervention of education plus decision tools versus decision tools alone reduced the number of opioid prescriptions (risk difference (RD) - 0.1, 95% CI - 0.2 to - 0.1), dose (MD - 5.3 MME, 95% CI - 6.2 to - 4.5) and use (RD - 0.1, 95% CI - 0.1 to - 0.0) in the long term. Study heterogeneity prevented meta-analysis. The small number of studies and heterogeneity prevented firm conclusions to recommend any one opioid-analgesic-deprescribing strategy in patients with chronic pain. PROSPERO CRD42017068422.

EP27 The Exeter Biologics Management Plan

Abstract Background The introduction of biologic drugs has been life-changing for our patients, but these drugs are very expensive. Moreover, they are immunosuppressive and are associated with an increased infection risk. Conventional practice is to maintain the same dose long term. An internal audit identified significant drug wastage; £40,000 drug 'wasted' per year by repeat prescription requests, hoarding of supplies and missed doses. Dose reduction could result in cost savings and reduced complications, but this strategy also risks loss of disease control &amp; requires enhanced monitoring. Methods We set up a new 'Biologics Managment Plan' Service (BMP) with the following aims: 1. Reduce costs from wastage, 2. Enable patients to confidently reduce dose by introducing a part time nurse and biologics administrator, 3. Assess efficacy, 4. Receive patient feedback. We formulated criteria to ensure eligibility for dose reduction and a dose reduction protocol for each biologic drug. We organised an intensification of follow up, monitoring and support. We maintained close liaison with pharmacy regarding prescription management and vial sharing on Day Case Unit. We fully counselled our BMP patients and subsequently obtained detailed patient feedback using a patient experience measure (PREM), plus free text comments. We examined clinical outcomes including disease activity assessments, occurrence of flares and, where possible, radiological outcomes, in patients with inflammatory arthritis undergoing biologic dose reduction. Results 82 patients entered our BMP, 48 with rheumatoid arthritis (RA). 70% were able to dose reduce successfully. Mean dose reduction was 43%. For the 48 patients with RA, disease duration, presence of erosive disease nor serological status determined dose reduction outcome. 13 patients lost control of disease with dose reduction, but regained control rapidly with intervention. 2 patients switched biologic drug after a period of poor disease control. There was no progression of erosive disease in 31 RA patients who had follow up X-rays, within 18/12 of dose reduction. Similar outcomes were seen in ankylosing spondylitis (15), psoriatic arthritis (19) and JIA (2) with ∼70% success rate. Our PREM revealed &amp;gt;95% felt involved, had sufficient information, &amp; felt that drug reduction had not caused interference with daily life. All would recommend our project to others. We calculated this project was able to save £269,278.58 in the first 12 months. Conclusion It is possible to reduce the dose of biologic drugs in selected patients with inflammatory arthritis in remission. Patients were keen to reduce their drug doses and engaged enthusiastically in the process. Enhanced follow-up and support ensured that patients felt 'looked after' and rapid intervention can manage any loss of control of disease promptly. Significant cost savings can be made. We have begun to determine whether therapeutic drug monitoring can complement this process. Disclosures R. Haigh: Honoraria; speaker fees Pfizer. Grants/research support; conference attendance Pfizer, UCB. D. Murphy: None. J. Moran: None.

Radiation dose reduction and improvement of image quality in digital chest radiography by new spatial noise reduction algorithm.

PurposeTo evaluate the image quality of low-dose chest digital radiographic images obtained with a new spatial noise reduction algorithm, compared to a conventional de-noising technique.Materials and methodsIn 69 patients, the dose reduction protocol was divided into A, B, and C test groups– 60% (n = 22), 50% (n = 23), and 40% (n = 24) of the baseline dose. In each patient, baseline dose radiographs were obtained with conventional image processing while low-dose images were acquired with new image processing. A set of baseline and low-dose radiographic images per patient was evaluated and scored on a 5-point scale over seven anatomical landmarks (radiolucency of unobscured lung, pulmonary vascularity, trachea, edge of rib, heart border, intervertebral disc space, and pulmonary vessels in the retrocardiac area) and three representative abnormal findings (nodule, consolidation, and interstitial marking) by two thoracic radiologists. A comparison of paired baseline and low-dose images was statistically analyzed using a non-inferiority test based on the paired t-test or the Wilcoxon signed-rank test.ResultsIn A, B, and C test groups, the mean dose reduction rate of the baseline radiation dose was 63.4%, 53.9%, and 47.8%, respectively. In all test groups, the upper limit of the 95% confidence interval was less than the non-inferiority margin of 0.5 every seven anatomical landmarks and three representative abnormal findings, which suggested that the image quality of the low-dose image was not inferior to that of the baseline dose image even if the maximum average dose reduction rate was reduced to 47.8% of the baseline dose.ConclusionIn our study, an image processing technique integrating a new noise reduction algorithm achieved dose reductions of approximately half without compromising image quality for abnormal lung findings and anatomical landmarks seen on chest radiographs. This feature-preserving, noise reduction algorithm adopted in the proposed engine enables a lower radiation dose boundary for the sake of patient’s and radiography technologist’s radiation safety in routine clinical practice, in compliance with regulatory guidelines.

Update on radiation exposure in catheter ablation of atrial fibrillation

The rising number of catheter ablations of atrial fibrillation increases radiation exposure for both patients and surgeons. Fortunately, this trend is counteracted by the development of measures to reduce total fluoroscopy time using non-fluoroscopic catheter visualization. Since even low-dose radiation can cause serious injury, all options to reduce radiation burden must be utilized (ALARA, "as low as reasonably achievable"). Dose reduction protocols with low-dose settings, which include reduced framerates, pulse duration, detector entrance dose and increased beam hardening, play adecisive role in this regard. This review provides astate-of-the-art summary of non-fluoroscopic catheter visualization and dose reduction protocols for catheter ablation of atrial fibrillation.

Computed Tomography-Colonography With Intravenous Contrast Medium and Urographic Phase for the Evaluation of Pelvic Deep Infiltrating Endometriosis of Intestinal and Urinary Tract.

The aim of this study was to evaluate the diagnostic accuracy of a specific protocol of computed tomography-colonography with intravenous contrast medium and urographic phase, which combined simultaneously the study of the intestinal and urinary tract, in the preoperative evaluation of women with deep infiltrating endometriosis (DIE) of anterior and posterior pelvic compartments. We retrospectively analyzed 73 women who underwent 74 computed tomography-colonography with intravenous contrast medium and urographic phase examinations for strong clinical suspicion of DIE. All the women had surgical confirmation. Computed tomography-colonography with intravenous contrast medium and urographic phase in detecting DIE rectosigmoid involvement had a sensitivity of 82.3% and a specificity of 66.7%, while in detecting DIE urinary tract involvement had a sensitivity of 45.9% and a specificity of 78.4%. Computed tomography-colonography with intravenous contrast medium and urographic phase is a useful technique for the preoperative planning of selected women with DIE, in particular, for the detection of sigmoid colon and bladder lesions especially when performed with a dose reduction protocol.

QIM19-130: Quality Improvement Project to Standardize a Prehabilitation Pathway for Patients With Esophageal Cancer Receiving Neoadjuvant Chemoradiation

Background: At our institution, the standard treatment recommendation for esophageal cancer patients with stage IB–IIIB disease is for neoadjuvant chemoradiation per the CROSS regimen prior to surgery. This regimen can be difficult for patients to tolerate, and they may be unable to receive full dose therapy without treatment dose reductions and delays. Methods: We conducted a quality improvement (QI) project, STRENGTH (Seeking to Reactivate Esophageal and Gastric Treatment Health), to implement supportive care interventions in the prehabilitation phase of neoadjuvant treatment. Our QI program included a standardized chemotherapy order template with supportive care interventions implemented at specific time points. Following implementation of the STRENGTH pathway, a retrospective QI analysis assessed an equal number of patients in the pre-STRENGTH and STRENGTH group for chemotherapy and radiation therapy dose intensities, as well as treatment outcomes. Results: During the pre-STRENGTH period, patients received an average of 5 chemotherapy treatments (range, 2–6), with an average relative dose intensity of 91.8% for carboplatin and 86.7% for paclitaxel. During the STRENGTH period, patients received an average of 6 (range, 5–8) chemotherapy treatments, with an average relative dose intensity of 111.4% for carboplatin and 112.9% for paclitaxel. In the pre-STRENGTH group, one patient did not complete their planned radiation dose due to nausea, vomiting, and dehydration. All patients in the STRENGTH group received their planned radiation dose. In the STRENGTH group, there is a trend of improved pathologic response, longer progression-free survival, and shortened time to surgery. Conclusion: Implementation of the STRENGTH pathway improved chemotherapy dose intensity, with potentially improved oncologic outcomes in the STRENGTH group. We plan to further optimize the STRENGTH program with implementation of standardized dose reduction and delay protocols for both chemotherapy and radiation, and assess the effects of STRENGTH interventions on patient quality of life.

Dose Reduction Protocol for Full Spine X-ray Examination Using Copper Filters in Patients With Adolescent Idiopathic Scoliosis.

A prospective case series. The aim of this study was to assess a new protocol for full spine X-ray using copper (Cu) filters to reduce radiation exposure in patients with adolescent idiopathic scoliosis (AIS). Radiation exposure is associated with an increased risk of cancer development in children. To reduce the radiation exposure without compromising the image quality using existing radiographic equipment, a new computed radiography protocol was optimized using a variety of heavy metal filters. Study 1: Whole spine radiographs were obtained using a human body phantom, and radiation doses without and with 0.1, 0.2, and 0.3 mm thick Cu filters were compared. Study 2: Patients with AIS who underwent posterior fusion were radiographically evaluated at follow-ups; the X-ray protocols with or without the use of 0.2-mm Cu filters were alternated between consecutive follow-ups. The image quality was independently evaluated using six points in the anterior-posterior (AP) view and seven in the lateral [left-right (LR)] view by three spine surgeons using a three-point grading system. Study 1: The surface doses while obtaining nonfiltered X-rays in AP and LR views were 0.31 and 0.93 mGy, respectively, whereas those with 0.1-, 0.2-, and 0.3-mm Cu filters were 0.16 and 0.52, 0.11 and 0.36, and 0.08 and 0.27 mGy, respectively.Study 2: In patients with AIS, the percentage of grade 3 scores (both endplates were identifiable) on AP-view images was 85% with nonfiltered X-rays and 75% with the filtered X-rays. However, there were no significant differences between the two protocols. On LR images, the frequency of grade 3 scores was significantly lower at Th2 and Th12 on filtered images than on nonfiltered ones. Whole spine radiographs using 0.2-mm Cu filters in patients with AIS could reduce radiation exposure more than 60% while preserving the image quality. 4.