Interinstitutional Variation Research Articles

Quality assurance of magnetic resonance imaging for a polymer gel dosimeter using a 3D-printed phantom

PurposeQuality assurance (QA) of magnetic resonance imaging (MRI) for gel dosimetry using an in-house phantom was established to ensure consistent dosimetric performance. MethodsA normoxic N-vinylpyrrolidone-based gel dosimeter sensitized with an inorganic salt was used. Each individual gel dosimeter, in addition to a specially designed image QA phantom, was imaged at three institutions with different MRI systems. ResultsBoth the gel dosimeter and QA phantom had linear dose–response curves at all institutions, with correlation coefficients = 1.00 and ≥ 0.99, respectively. Minor inter-institutional variations in the sensitivity (gel dosimeter, 0.096 ± 0.010 s−1Gy−1; QA phantom, 0.140 ± 0.003 s−1Gy−1) and offset value (gel dosimeter, 2.188 ± 0.222 s−1; QA phantom, 3.318 ± 0.081 s−1) were found. Dose uncertainties for the gel dosimeter ranged from 3.2% to 3.5% at 10 Gy and 1.7%–2.1% at 20 Gy, and these were comparable with the corresponding QA phantom uncertainties. Dose resolutions were 0.8–1.2 Gy for the gel dosimeter and 0.6–1.4 Gy for the QA phantom. Uniformity factors were ≥98% at all institutions. Spatial linearity had a geometric distortion ≤1.0%, Gamma passing rates of 95%–100% met recommended QA guidelines; strong correlations between the QA phantom and gel dosimeter were also obtained for each of these measures. ConclusionOur study demonstrates the viability of applying MRI acquisition parameters validated using a QA phantom to polymer gel dosimetry across diverse MRI systems. This approach enables robust QA measures, focusing on effective management of uniformity and dose uncertainty.

Unfolding the empathic insights and tendencies among medical students of two gulf institutions using interpersonal reactivity index

BackgroundEmpathy is an essential core competency for future doctors. Unfortunately, the medical curriculum is infamously known to burn out aspiring doctors, which may potentially lead to a decline in empathy among medical students. This research was planned to understand the evolution of empathic approaches among students across the curriculum using the Interpersonal reactivity index (IRI) as a benchmark at the Royal College of Surgeons in Ireland - Medical University of Bahrain (RCSI-MUB) and University of Sharjah (UoS).MethodsWe adopted a cross-sectional design and administered an online survey to the medical students of RCSI-MUB and UoS using a modified version of the IRI along with its three subscales of empathic concern (EC), perspective taking (PT), and personal distress (PD). To identify intra- and inter-institutional variations in empathy scores, the Analysis of Variance (ANOVA) was performed separately for each institution and with both institutions combined. A two-way ANOVA was conducted for the comparison between years and institutions. For the subscale analysis of EC, PT, and PD, we used one-way ANOVA for significant differences between years at both institutions. For the gender-effect analysis, t-test was performed to examine the differences in total IRI scores at both institutions combined and at each institution separately. Additionally, an Analysis of Covariance (ANCOVA) was done to identify the influence of gender on empathy scores.ResultsA total of 140 students from both institutions participated in this study. We found a fluctuating pattern of empathy scores without a clear trend across the years. The sub-scales of EC, PD, and PT across academic years at both institutions showed significant differences within the EC at RCSI-MUB (p = 0.003). No significant differences were identified across other years from both institutions. There were significant differences between empathy scores from RCSI-MUB and UoS for EC (p = 0.011). Additionally, a pronounced interaction effect between year and institution was observed for PT (p = 0.032). The gender-wise analysis showed that female students had higher empathy scores than males (p = 0.004). The ANCOVA for IRI score results revealed a p-value of 0.023, indicating that gender plays a crucial role in empathy levels among medical students. The ANCOVA results revealed a p-value of 0.022 in the EC subscale.ConclusionOur study unveiled intricate patterns in empathy development among medical students across years and genders at RCSI-MUB and UoS. These congruences and dissimilarities in empathy scores signal a subjective understanding of empathy by medical students. The disparities in understanding may encourage medical educators to embed empathy in standard medical curricula for better healthcare outcomes.

Impact of on-trial IGRT quality assurance in an international adaptive radiotherapy trial for participants with bladder cancer

Background and purposeRadiotherapy trial quality assurance (RT QA) is crucial for ensuring the safe and reliable delivery of radiotherapy trials, and minimizing inter-institutional variations. While previous studies focused on outlining and planning quality assurance (QA), this work explores the process of Image-Guided Radiotherapy (IGRT), and adaptive radiotherapy.This study presents findings from during-accrual QA in the RAIDER trial, evaluating concordance between online and offline plan selections for bladder cancer participants undergoing adaptive radiotherapy. RAIDER had two seamless stages; stage 1 assessed adherence to dose constraints of dose escalated radiotherapy (DART) and stage 2 assessed safety. The RT QA programme was updated from stage 1 to stage 2. Materials and methodsData from all participants in the adaptive arms (standard dose adaptive radiotherapy (SART) and DART) of the trial was requested (33 centres across the UK, Australia and New Zealand). Data collection spanned September 2015 to December 2022 and included the plans selected online, on Cone-Beam Computed Tomography (CBCT) data. Concordance with the plans selected offline by the independent RT QA central reviewer was evaluated. ResultsAnalysable data was received for 72 participants, giving a total of 884 CBCTs. The overall concordance rate was 83% (723/884). From stage 1 to stage 2 the concordance in the plans selected improved from 75% (369/495) to 91% (354/389). ConclusionDuring-accrual IGRT QA positively influenced plan selection concordance, highlighting the need for ongoing support when introducing a new technique. Overall, it contributes to advancing the understanding and implementation of QA measures in adaptive radiotherapy trials.

Anesthesia Techniques for Vitreoretinal Surgery in the United States: A Report from the Multicenter Perioperative Outcomes Group Research Consortium

PurposeTo explore the patterns of anesthesia use and their determinants during vitreoretinal (VR) surgeries in academic and community hospitals across the US, using data from the Multicenter Perioperative Outcomes Group (MPOG). DesignA retrospective, multicenter, cohort study. MethodsWe queried the MPOG database of 107,066 patients undergoing VR surgeries. Patients (≥18 yrs.) undergoing VR surgery with monitored anesthesia care (MAC) or general anesthesia (GA) from January 1, 2015, to December 31, 2021 were included. Patient-level, case-based, and institutional-level covariates were collected. We performed multivariable mixed-effects models to determine predictors of anesthesia type use. The primary outcome was the type of anesthesia (MAC or GA) used during VR surgeries. As a secondary outcome, MAC cases were further classified based on the additional use of sedation into MAC with or without sedation. ResultsWe found that 67.45% of VR surgery cases received MAC, and 73.63% of institutions administered MAC to more than half of cases. Random effect modeling revealed that 47.76% of the variation in MAC use was attributed to institutions. A trend toward increased use of MAC with increasing age was observed. Patients diagnosed with chronic pulmonary disease, liver disease, or a history of drug abuse were less likely to receive MAC. Conversely, we found that patients with reported alcohol abuse disorder, diabetes with complications, and those with American Society of Anesthesiologists (ASA) physical status of 4 (vs. 1, 2, or 3) were more likely to use MAC. Compared to non-complex VR surgeries, there was a notably decreased likelihood of MAC use in complex PPV (P = 0.004), PPV + scleral buckle (SB) for retinal detachment (P < 0.0001), and primary SB surgery (P < 0.0001). ConclusionsApproximately 2/3 of VR anesthesia is under MAC, but GA is still preferred for SBs, complex vitrectomy, and younger patients. We show that large interinstitutional variation for using MAC in practice exists.

The impact of obesity on rates of post-operative CSF leak following endoscopic skull base surgery: results from a prospective international multi-centre cohort study.

Post-operative CSF leak is the major source of morbidity following transsphenoidal approaches (TSA) and expanded endonasal approaches (EEA) to lesions of the sella turcica and the ventral skull base. There are conflicting reports in the literature as to whether obesity (BMI ≥30) is a risk factor for this complication. We aimed to evaluate data collected as part of prospective multi-centre cohort study to address this question. The CRANIAL (CSF Rhinorrhoea After Endonasal Intervention to the Skull Base) study database was reviewed and patients were divided into obese and non-obese cohorts. Data on patient demographics, underlying pathology, intra-operative findings and skull base repair techniques were analysed. TSA were performed on 726 patients, of whom 210 were obese and 516 were non-obese. The rate of post-operative CSF leak in the obese cohort was 11/210 (5%), compared to 17/516 (3%) in the non-obese cohort, which was not statistically significant (χ2 = 1.520, p=0.217). EEA were performed on 140 patients, of whom 28 were obese and 112 were non-obese. The rate of post-operative CSF leak in the obese cohort was 2/28 (7%), which was identical to the rate observed in the non-obese cohort 8/112 (7%) Fisher's Exact Test, p=1.000). These results persisted following adjustment for inter-institutional variation and baseline risk of post-operative CSF leak. CSF leak rates following TSA and EEA, in association with modern skull base repair techniques, were found to be low in both obese and non-obese patients. However, due to the low rate of post-operative CSF leak, we were unable to fully exclude a small contributory effect of obesity to the risk of this complication.

Benchmarks in Liver Resection for Intrahepatic Cholangiocarcinoma

IntroductionBenchmarking in surgery has been proposed as a means to compare results across institutions to establish best practices. We sought to define benchmark values for hepatectomy for intrahepatic cholangiocarcinoma (ICC) across an international population.MethodsPatients who underwent liver resection for ICC between 1990 and 2020 were identified from an international database, including 14 Eastern and Western institutions. Patients operated on at high-volume centers who had no preoperative jaundice, ASA class <3, body mass index <35 km/m2, without need for bile duct or vascular resection were chosen as the benchmark group.ResultsAmong 1193 patients who underwent curative-intent hepatectomy for ICC, 600 (50.3%) were included in the benchmark group. Among benchmark patients, median age was 58.0 years (interquartile range [IQR] 49.0–67.0), only 28 (4.7%) patients received neoadjuvant therapy, and most patients had a minor resection (n = 499, 83.2%). Benchmark values included ≥3 lymph nodes retrieved when lymphadenectomy was performed, blood loss ≤600 mL, perioperative blood transfusion rate ≤42.9%, and operative time ≤339 min. The postoperative benchmark values included TOO achievement ≥59.3%, positive resection margin ≤27.5%, 30-day readmission ≤3.6%, Clavien-Dindo III or more complications ≤14.3%, and 90-day mortality ≤4.8%, as well as hospital stay ≤14 days.ConclusionsBenchmark cutoffs targeting short-term perioperative outcomes can help to facilitate comparisons across hospitals performing liver resection for ICC, assess inter-institutional variation, and identify the highest-performing centers to improve surgical and oncologic outcomes.

Trends and variation in cervical spine imaging utilization across children's hospitals for pediatric trauma.

Cervical spine (c-spine) evaluation is a critical component in trauma evaluation, and although several pediatric c-spine evaluation algorithms have been developed, none have been widely implemented. Here, we assess rates of c-spine imaging use across children's hospitals, specifically temporal trends in imaging use, variation across hospitals in imaging used, and timing of magnetic resonance imaging in admitted patients. Data from the Children's Hospital Associations Pediatric Health Information System were abstracted from 2015 to 2020. Patients younger than 18 years seen in the emergency department with an International Classification of Diseases, Tenth Revision , code indicative of trauma and c-spine plain radiograph or computed tomography (CT) in the emergency department were included. Data visualization and descriptive statistics were used to assess rates of imaging use by age, year, hospital, injury severity, and day of service. Changes in rates of imaging use over time were evaluated via simple linear regression. Across 25,238 patient encounters at 35 children's hospitals, there was an increase in use of c-spine CT from 2015 to 2020 (28.5-36.5%). There was substantial interinstitutional variation in rates of use of plain radiographs versus CT for initial evaluation of the c-spine across all age groups. Magnetic resonance imaging was obtained more than 3 days after admission in 31.5% of intensive care patients who received this imaging. Increasing use of CT, substantial interinstitutional variation in rates of use of plain radiographs versus CT, and heterogenous timing of magnetic resonance imaging for evaluation of the pediatric c-spine demonstrate the growing need for development and implementation of an age-specific c-spine evaluation algorithm to guide judicious use of diagnostic resources. Prognostic and Epidemiological; Level III.

Oncologic Significance of Therapeutic Delays in Patients With Oral Cavity Cancer

Oral cavity cancer often requires multidisciplinary management, subjecting patients to complex therapeutic trajectories. Prolonged treatment intervals in oral cavity cancer have been associated with poor oncological outcomes, but there has yet to be a study investigating treatment times in Canada. To report treatment delays for patients with oral cavity cancer in Canada and evaluate the outcomes of treatment delays on overall survival. This multicenter cohort study was performed at 8 Canadian academic centers from 2005 to 2019. Participants were patients with oral cavity cancer who underwent surgery and adjuvant radiation therapy. Analysis was performed in January 2023. Treatment intervals evaluated were surgery to initiation of postoperative radiation therapy interval (S-PORT) and radiation therapy interval (RTI). The exposure variables were prolonged intervals, respectively defined as index S-PORT greater than 42 days and RTI greater than 46 days. Patient demographics, Charlson Comorbidity Index, smoking status, alcohol status, and cancer staging were also considered. Univariate (log rank and Kaplan-Meier) and multivariate (Cox regression) analyses were performed to determine associations with overall survival (OS). Overall, 1368 patients were included; median (IQR) age at diagnosis was 61 (54-70) years, and 896 (65%) were men. Median (IQR) S-PORT was 56 (46-68) days, with 1093 (80%) patients waiting greater than 42 days, and median (IQR) RTI was 43 (41-47) days, with 353 (26%) patients having treatment time interval greater than 46 days. There were variations in treatment time intervals between institutions for S-PORT (institution with longest vs shortest median S-PORT, 64 days vs 48 days; η2 = 0.023) and RTI (institution with longest vs shortest median RTI, 44 days vs 40 days; η2 = 0.022). Median follow-up was 34 months. The 3-year OS was 68%. In univariate analysis, patients with prolonged S-PORT had worse survival at 3 years (66% vs 77%; odds ratio 1.75; 95% CI, 1.27-2.42), whereas prolonged RTI (67% vs 69%; odds ratio 1.06; 95% CI, 0.81-1.38) was not associated with OS. Other factors associated with OS were age, Charlson Comorbidity Index, alcohol status, T category, N category, and institution. In the multivariate model, prolonged S-PORT remained independently associated with OS (hazard ratio, 1.39; 95% CI, 1.07-1.80). In this multicenter cohort study of patients with oral cavity cancer requiring multimodal therapy, initiation of radiation therapy within 42 days from surgery was associated with improved survival. However, in Canada, only a minority completed S-PORT within the recommended time, whereas most had an appropriate RTI. An interinstitution variation existed in terms of treatment time intervals. Institutions should aim to identify reasons for delays in their respective centers, and efforts and resources should be directed toward achieving timely completion of S-PORT.

Dummy run quality assurance study in the Korean Radiation Oncology Group 19 − 09 multi-institutional prospective cohort study of breast cancer

BackgroundThe Korean Radiation Oncology Group (KROG) 19 − 09 prospective cohort study aims to determine the effect of regional nodal irradiation on regional recurrence rates in ypN0 breast cancer patients. Dosimetric variations between radiotherapy (RT) plans of participating institutions may affect the clinical outcome of the study. We performed this study to assess inter-institutional dosimetric variations by dummy run.MethodsTwelve participating institutions created RT plans for four clinical scenarios using computed tomography images of two dummy cases. Based on a reference structure set, we analyzed dose-volume histograms after collecting the RT plans.ResultsWe found variations in dose distribution between institutions, especially in the regional nodal areas. Whole breast and regional nodal irradiation (WBI + RNI) plans had lower inter-institutional agreement and similarity for 95% isodose lines than WBI plans. Fleiss’s kappa values, which were used to measure inter-institutional agreement for the 95% isodose lines, were 0.830 and 0.767 for the large and medium breast WBI plans, respectively, and 0.731 and 0.679 for the large and medium breast WBI + RNI plans, respectively. There were outliers in minimum dose delivered to 95% of the structure (D95%) of axillary level 1 among WBI plans and in D95% of the interpectoral region and axillary level 4 among WBI + RNI plans.ConclusionWe found inter-institutional and inter-case variations in radiation dose delivered to target volumes and organs at risk. As KROG 19 − 09 is a prospective cohort study, we accepted the dosimetric variation among the different institutions. Actual patient RT plan data should be collected to achieve reliable KROG 19 − 09 study results.

Chinese Neonatal Network: a national protocol for collaborative research and quality improvement in neonatal care

IntroductionThe objective of the Chinese Neonatal Network (CHNN) is to provide a platform for collaborative research, outcomes evaluation and quality improvement for preterm infants with gestational age less than 32...

How do type of preoperative P2Y12 receptor inhibitor and withdrawal time affect bleeding? Protocol of a systematic review and individual patient data meta-analysis

IntroductionIn order to reduce the risk of bleeding in patients on P2Y12 receptor inhibitors presenting for non-emergent coronary artery bypass grafting (CABG), current guidelines recommend a preoperative discontinuation period of...

A bi-institutional multi-disciplinary failure mode and effects analysis (FMEA) for a Co-60 based total body irradiation technique

BackgroundWe aim to assess the risks associated with total body irradiation (TBI) delivered using a commercial dedicated Co-60 irradiator, and to evaluate inter-institutional and inter-professional variations in the estimation of these risks.MethodsA failure mode and effects analysis (FMEA) was generated using guidance from the AAPM TG-100 report for quantitative estimation of prospective risk metrics. Thirteen radiation oncology professionals from two institutions rated possible failure modes (FMs) for occurrence (O), severity (S), and detectability (D) indices to generate a risk priority number (RPN). The FMs were ranked by descending RPN value. Absolute gross differences (AGD) in resulting RPN values and Jaccard Index (JI; for the top 20 FMs) were calculated. The results were compared between professions and institutions.ResultsA total of 87 potential FMs (57, 15, 10, 3, and 2 for treatment, quality assurance, planning, simulation, and logistics respectively) were identified and ranked, with individual RPN ranging between 1–420 and mean RPN values ranging between 6 and 74. The two institutions shared 6 of their respective top 20 FMs. For various institutional and professional comparison pairs, the number of common FMs in the top 20 FMs ranged from 6 to 13, with JI values of 18–48%. For the top 20 FMs, the trend in inter-professional variability was institution-specific. The mean AGD values ranged between 12.5 and 74.5 for various comparison pairs. AGD values differed the most for medical physicists (MPs) in comparison to other specialties i.e. radiation oncologists (ROs) and radiation therapists (RTs) [MPs-vs-ROs: 36.3 (standard deviation SD = 34.1); MPs-vs-RTs: 41.2 (SD = 37.9); ROs-vs-RTs: 12.5 (SD = 10.8)]. Trends in inter-professional AGD values were similar for both institutions.ConclusionThis inter-institutional comparison provides prospective risk analysis for a new treatment delivery unit and illustrates the institution-specific nature of FM prioritization, primarily due to operational differences. Despite being subjective in nature, the FMEA is a valuable tool to ensure the identification of the most significant risks, particularly when implementing a novel treatment modality. The creation of a bi-institutional, multidisciplinary FMEA for this unique TBI technique has not only helped identify potential risks but also served as an opportunity to evaluate clinical and safety practices from the perspective of both multiple professional roles and different institutions.

Alert burden in pediatric hospitals: a cross-sectional analysis of six academic pediatric health systems using novel metrics.

Excessive electronic health record (EHR) alerts reduce the salience of actionable alerts. Little is known about the frequency of interruptive alerts across health systems and how the choice of metric affects which users appear to have the highest alert burden. (1) Analyze alert burden by alert type, care setting, provider type, and individual provider across 6 pediatric health systems. (2) Compare alert burden using different metrics. We analyzed interruptive alert firings logged in EHR databases at 6 pediatric health systems from 2016-2019 using 4 metrics: (1) alerts per patient encounter, (2) alerts per inpatient-day, (3) alerts per 100 orders, and (4) alerts per unique clinician days (calendar days with at least 1 EHR log in the system). We assessed intra- and interinstitutional variation and how alert burden rankings differed based on the chosen metric. Alert burden varied widely across institutions, ranging from 0.06 to 0.76 firings per encounter, 0.22 to 1.06 firings per inpatient-day, 0.98 to 17.42 per 100 orders, and 0.08 to 3.34 firings per clinician day logged in the EHR. Custom alerts accounted for the greatest burden at all 6 sites. The rank order of institutions by alert burden was similar regardless of which alert burden metric was chosen. Within institutions, the alert burden metric choice substantially affected which provider types and care settings appeared to experience the highest alert burden. Estimates of the clinical areas with highest alert burden varied substantially by institution and based on the metric used.

Variation in in-hospital mortality and its association with procedure-related bleeding complications: a report from nationwide percutaneous coronary intervention registry in japan

Abstract Background Large-scale registries have demonstrated that in-hospital mortality after percutaneous coronary intervention (PCI) varies widely across institutions; however, the underlying reasons are not fully understood. Bleeding has been regarded as one of the most serious PCI-related complications associated with increase in mortality. To date, reducing bleeding complications have tended to be addressed, though appropriate care for patients who developed bleeding complications may be also important. Therefore, we sought to investigate which was more involved in the inter-institutional variations in in-hospital mortality. Methods We analyzed 388,866 procedures at 718 hospitals performed from 2017 to 2018, using data from a representative nationwide PCI registry in Japan. A bleeding complication was defined as post-procedural bleeding that required a blood transfusion. We first divided the hospitals into quintiles according to their risk-adjusted in-hospital mortality (very low, low, medium, high, and very high). Then, the bleeding complication rate and in-hospital mortality rate among patients who developed bleeding complications were calculated for each quintile. Results In total, 4,048 (1.04%) in-hospital deaths and 1,535 (0.39%) bleeding complications occurred. In-hospital mortality varied widely from 0.22% to 2.46% in very-low- to very-high-mortality hospitals. The bleeding complication rate also increased modestly from 0.27% to 0.57% (odds ratio, 1.95; 95% confidence interval, 1.58–2.39). However, the mortality rate among patients who developed bleeding complications markedly increased by quintile; the mortality rate of very-high-morality hospitals was 6-fold higher than that of very-low-mortality hospitals (29.0% vs. 4.8%, respectively; odds ratio, 12.2; 95% confidence interval, 6.9–21.7). Conclusions Wide variation in in-hospital mortality was observed within the Japanese nationwide PCI registry, and this variation was largely driven by differences in mortality among patients with bleeding complications, rather than crude incidence of bleeding complications. These results underscore the importance of efforts toward reducing not only bleeding complications but also, even more importantly, mortality once bleeding has occurred. Funding Acknowledgement Type of funding sources: None.

Inter-institutional Variation in Intensity-modulated Radiotherapy for Breast Cancer in Korea (KROG 19-01).

To present the variations in the target delineation and the planning results of intensity-modulated radiation therapy (IMRT) for breast cancers. We requested the target volumes and organs at risk delineation for two cases of left breast cancers, and evaluated the IMRT plans including the supraclavicular and internal mammary node irradiation. Twenty-one institutions participated in this study. Differences in the planning target volume among institutions reached up to three-times for breast-conserving surgery (BCS) case and five-times for mastectomy case. Mean heart doses ranged from 3.3 to 24.1 Gy for BCS case and from 5.0 to 26.5 Gy for mastectomy case. Ipsilateral lung volumes receiving more than 20 Gy ranged from 4.7 to 57.4% for BCS case and from 16.4 to 55.5% for mastectomy case. There were large variations in the target delineation and planning results of IMRT for breast cancers among institutions. Considering the increased use of breast IMRT, more standardized protocols are needed.

Extensive culturing and metagenomics enable functional and taxonomic comparison of mouse and human gut microbiotas

Abstract The gut microbiota has been identified as a leading cause of irreproducibility in mouse models, but current resources are insufficient to address this core challenge in immunology research. Furthermore, although mouse models are central tools for biomedical science, it is not known how the bacteria in the mouse gut – important determinants of immunological phenotypes – affect their ability to recapitulate human disease. To better characterise the mouse gut microbiota and facilitate its functional and taxonomic comparison to the human microbiota, we developed the Mouse Microbial Genome Collection (MMGC), the most comprehensive representation of the global laboratory mouse microbiome to date. The MMGC is a repository of 276 genomes from cultured isolates and 18,075 non-redundant, near-complete metagenome-assembled genomes (MAGs) reassembled from 1,960 mouse metagenomes. Using the MMGC, we define species-level signatures of inter-institutional variation in the mouse gut microbiota and provide a roadmap to achieve more relevant and reproducible mouse models. In addition, we confirm that while only 2.65% of bacterial species are common to human and mouse gut microbiotas, over 80% of annotatable functions are shared between hosts. The MMGC further enables the identification of functionally equivalent taxa in the mouse and human gut microbiotas, which we illustrate by comparing the pathways for butyrate synthesis and drug metabolism as proof-of-concept examples. In conclusion, the MMGC facilitates unprecedented insights into the mouse gut microbiota and enhances the use of mouse models in immunology research by providing access to the conservation status and taxonomic locations of microbial functions of interest.

Examining institutional translation through a legal lens

Abstract Studies of institutional translation have traditionally focused on European Union (EU) institutions and legislative genres. In order to develop a more comprehensive characterization of translation at international organizations beyond EU supranational law, this study compares a full mapping of multilingual text production at EU institutions to that of two representative intergovernmental organizations (IGOs), the United Nations (UN) and the World Trade Organization (WTO), over three years (2005, 2010, and 2015) in three common official languages (English, French, and Spanish). The corpus-driven quantitative analysis and categorization of all texts from a legal-functional perspective corroborate the interconnection of a wide range of textual genres that perform, support, or derive from central law-making, monitoring, and adjudicative functions, or fulfill other administrative purposes. The findings also highlight interinstitutional variation that reflects the features of each legal order, in particular the prominence of hard law-making at the EU (with a high proportion of drafts and input documents) as opposed to larger translation volumes in monitoring procedures at the UN and the WTO. This mapping is considered instrumental to further analyze legal and other specialized translation practices in international institutional settings, and ultimately to inform translator training and translation quality management.

Multicenter Study of Quantitative SPECT: Reproducibility of 99mTc Quantitation Using a Conjugated-Gradient Minimization Reconstruction Algorithm.

This multicenter study aimed to determine the reproducibility of quantitative SPECT images reconstructed using a commercially available method of ordered-subset conjugate-gradient minimization. Methods: A common cylindric phantom containing a 100 kBq/mL concentration of 99mTc-pertechnetate solution in a volume of 7 L was scanned under standard imaging conditions at 6 institutions using the local clinical protocol of each. Interinstitutional variation among the quantitative SPECT images was evaluated using the coefficient of variation. Dose calibrator accuracy was also investigated by measuring the same lot of commercially available 99mTc vials at each institution. Results: The respective radioactivity concentrations under standard and clinical conditions ranged from 95.71 ± 0.60 (mean ± SD) to 108.35 ± 0.36 kBq/mL and from 96.78 ± 0.64 to 108.49 ± 0.11 kBq/mL, respectively. Interinstitutional variation in radioactivity concentration was 4.20%. The bias in the radioactivity concentrations in SPECT images was associated with the accuracy of the dose calibrator at each institution. Conclusion: The reproducibility of the commercially available quantitative SPECT reconstruction method is high and comparable to that of PET, for comparatively large (∼7 L), homogeneous objects.

Post-mastectomy radiation therapy in breast reconstruction: a patterns of care study of the Korean Radiation Oncology Group.

PurposeThe details of breast reconstruction and radiation therapy (RT) vary between institutions; therefore, we sought to investigate the practice patterns of radiation oncologists who specialize in breast cancer.Materials and MethodsWe identified the practice patterns and inter-hospital variations from a multi-center cohort of women with breast cancer who underwent post-mastectomy RT (PMRT) to the reconstructed breast at 16 institutions between 2015 and 2016. The institutions were requested to contour the target volume and produce RT plans for one representative case with five different clinical scenarios and answer questionnaires which elicited infrastructural information. We assessed the inter-institutional variations in RT in terms of the target, normal organ delineation, and dose-volume histograms.ResultsThree hundred fourteen patients were included; 99% of them underwent immediate reconstruction. The most irradiated material was tissue expander (36.9%) followed by transverse rectus abdominis musculocutaneous flap (23.9%) and silicone implant (12.1%). In prosthetic-based reconstruction with tissue expander, most patients received PMRT following partial deflation. Conventional fractionation and hypofractionation RT were used in 66.6% and 33.4% patients, respectively (commonest: 40.05 Gy in 15 fractions [17.5%]). Furthermore, 15.6% of the patients received boost RT and 53.5% were treated with bolus. Overall, 15 physicians responded to the questionnaires and six submitted their contours and RT plans. There was a significant variability in target delineations and RT plans between physicians, and between clinical scenarios. ConclusionAdjuvant RT following post-mastectomy reconstruction has become a common practice in Korea. The details vary significantly between institutions, which highlights an urgent need for standard protocol in this clinical setting.

Neurologic Injury in Patients Treated With Extracorporeal Membrane Oxygenation for Postcardiotomy Cardiogenic Shock

To investigate the frequency, predictors, and outcomes of neurologic injury in adults treated with postcardiotomy extracorporeal membrane oxygenation (PC-ECMO). A retrospective multicenter registry study. Twenty-one European institutions where cardiac surgery is performed. A total of 781 adult patients who required PC-ECMO during 2010 to 2018 were divided into patients with neurologic injury (NI) and patients without neurologic injury (NNI). Baseline and operative data, in-hospital outcomes, and long-term survival were compared between the NI and the NNI groups. Predictors of neurologic injury were identified. A subgroup analysis according to the type of neurologic injury was performed. Overall, NI occurred in 19% of patients in the overall series, but the proportion of patients with NI ranged from 0% to 65% among the centers. Ischemic stroke occurred in 84 patients and hemorrhagic stroke in 47 patients. Emergency procedure was the sole independent predictor of NI. In-hospital mortality was higher in the NI group than in the NNI group (79% v 61%, p < 0.001). The one-year survival was lower in the NI group (17%) compared with the NNI group (37%). Long-term survival did not differ between patients with ischemic stroke and those with hemorrhagic stroke. Neurologic injury during PC-ECMO is common and associated with a dismal prognosis. There is considerable interinstitutional variation in the proportion of neurologic injury in PC-ECMO-treated adults. Well-known risk factors for stroke are not associated with neurologic injury in this setting.