Median Delivery Time Research Articles

Axillary artery access considerations in Impella 5.5insertion: Insights from exclusive axillary approach forsuccessful support.

The Impella 5.5® is commonly inserted via the axillary artery (AX) in patients with cardiogenic shock. The right AX has traditionally been preferred to avoid crossing the aortic arch, and a minimum diameter of 7 mm has been recommended to accommodate the device (21 Fr). There is limited data on choice of laterality of access and AX size required, both in terms of technicality of the procedure as well as outcomes. We performed a single-center retrospective cohort analysis of patients who underwent Impella 5.5® implantation between December 2020 and February 2024 (N = 75). Data including demographics and outcomes were stratified both by diameter (small, <7 mm vs. normal, ≥7 mm) and laterality of access (right vs. left). Adverse events included stroke, limb ischemia, procedural bleeding or infection, and unplanned explant due to complications. Delivery time was defined as time from advancing the first wire to activation of the device. AX approach was attempted in all (N = 74) but one requiring innominate access, with a technical success rate of 95.9% (N = 71/74). The mean age was 58.8 ± 13.3 years, with 81.1% males. The median delivery time was 7.0 (25th, 75th percentiles: 4.0, 11.5) min with a median support duration of 13 (7.7, 24) days. Ten patients (13.5%) had a small AX, with a mean diameter of 6.3 ± 0.5 mm and were more likely to be younger compared to the normal AX group. Fifty-nine patients (79.7%) had insertion via the right AX. Median delivery time was comparable across all groups (small, 5.4 [3.5, 10.9] vs. normal, 7 [4.0, 12.1] min, p = 0.59) and (right, 10.4 [5.3, 15.2] vs. left, 6 [3.7, 10.4] min, p = 0.35). There was no difference between the rates of stroke, ischemia, bleeding, or infection when comparing by size or laterality. Survival to discharge was 59.5%, with 21.1% mortality on support, all in patients with a normal AX diameter, but with no difference between right versus left. In our study, laterality and a small diameter of AX access did not affect outcomes of Impella 5.5®, with a similar safety profile.

Lexicographic optimization-based planning for stereotactic radiosurgery of brain metastases

AimTo validate a fully-automated lexicographic optimization-planning system (mCycle, Elekta) for single-(SL) and multiple-(ML, up to 4 metastases) lesions in intracranial stereotactic radiosurgery (SRS, 21 Gy, single fraction). MethodsA pre-determined priority list, Wish-List (WL), represents a dialogue between planner and clinician, establishing strict constraints and pursuing objectives. In order to satisfy the clinical protocol without manual intervention, four patients were required to tweak and fine-tune each WL (SLp, MLp) for coplanar arcs. Thirty-five testing plans (20 SLp, 15 MLp) were automatically re-planned (mCP). Automatic and manual plans were compared including dose constraints, conformality, modulation complexity score (MCS), delivery time, and local gamma analysis (2%/2 mm). To ensure plan clinical acceptability, two radiation oncologists conducted an independent blind plan choice. ResultsEach WL-tuning took 3 days. Estimated median manual plans and mCP calculation time were 8 and 3 h, respectively. Significant increases in SLp and MLp target coverage and conformity were registered. mCP showed a not significant and clinically acceptable higher median brain V12Gy. SLp registered a −5.8% MU decrease with comparable median delivery time (MP 2.0 min, mCP 1.9 min) while MLp showed a +9.8% MU increase and longer delivery time (MP 3.5 min, mCP 4.4 min). mCP MCS resulted significantly higher without affecting gamma passing rates. At blind choice, mCP were preferred in the majority of cases. ConclusionsLexicographic optimization produced acceptable SRS plans with coplanar arcs significantly reducing the overall planning time in cases with up to 4 brain metastases. These planning improvements suggest further investigations by setting high-quality non-coplanar arc plans as a reference.

Single-Isocenter Linac-Based Radiosurgery for Brain Metastases with Coplanar Arcs: A Dosimetric and Clinical Analysis.

The efficacy of linac-based SRS/fSRS treatments using the single-isocenter coplanar FFF-VMAT technique for both single and multiple BM was investigated. Seventy patients (129 BM) treated with 15-21 Gy in 1 (n = 59) or 27 Gy in 3 (n = 11) fractions were analyzed. For each fraction, plans involving the intra-fractional errors measured by post-treatment CBCT were recalculated. The relationships of BM size, distance-to-isocenter, and barycenter shift with the difference in target coverage were evaluated. Clinical outcomes were assessed using logistic regression and Kaplan-Meier analysis. The median delivery time was 3.78 min (range, 1.83-9.25). The median post-treatment 3D error was 0.5 mm (range, 0.1-2.7) and the maximum rotational error was 0.3° (range, 0.0-1.3). In single BM patients, the GTV D95% was never reduced by >5%, whereas PTV D95% reductions >1% occurred in only 11 cases (29%). In multiple BM patients, dose deficits >5% and >1% occurred in 2 GTV (2%) and 34 PTV (37%), respectively. The differences in target coverage showed a moderate-to-strong correlation only with barycenter shift. Local failure of at least one treated BM occurred in 13 (21%) patients and the 1-year and 2-year local control rates for all lesions were 94% and 90%, respectively. The implemented workflow ensured that the degradation of target and brain dose metrics in delivered treatments was negligible. Along with encouraging clinical outcomes, these findings warrant a reduction in the PTV margins at our institution.

CARC8: Right versus Left Axillary Artery Access in Impella 5.5 Insertion

Background: The Impella 5.5® is commonly inserted via the axillary artery (AX) in patients with cardiogenic shock. Insertion of Impella through the left AX requires crossing the aortic arch, and possibly a divergent angle of insertion through the aortic valve. However, there is limited data on comparison of choice of laterality of access, both in terms of technicality of the procedure as well as outcomes on device support. Methods: We performed a single-center retrospective cohort analysis of patients who underwent Impella 5.5® implantation between December 2020 and November 2022 (N=28). Data including demographics and outcomes were stratified by laterality of AX access. Adverse events included stroke, ipsilateral upper extremity ischemia, bleeding related to vascular access, infection related to Impella use, and unplanned explant due to complications. Delivery time was defined as time from advancing the first wire to activation of the device. Results: Twenty patients had insertion via the right axillary artery and 8 patients had access through the left side. Average duration of support was comparable (right, 9.8 + 5.3 vs. left, 10.2 + 6.6 days, p=0.83). The median delivery time was lower through right side compared to left sided access (7.9 + 3.6 vs. 12.4 + 6.9 minutes, p=0.048). Overall survival to discharge was 64.3%, with a 21.4% mortality while on support, but there was no difference between groups. Explant rate was similar in both groups (right, 80% vs. left, 75%, p=0.77). Overall adverse event rate was 3.5%, with surgical evacuation of implantation site hematoma in 1 patient with left sided access. There was no difference between the rates of suction events, hemolysis, repositioning or removal required when comparing right versus left. Neither group had patients with stroke, arm ischemia, or infection. Conclusion: Overall, Impella 5.5 support via the AX demonstrated favorable outcomes regarding a low incidence of adverse events and stable support with a high explant rate. In our study, the choice of laterality of AX access for Impella insertion did not affect outcomes, with a similar safety profile. Access through the right AX may be preferable due to shorter delivery time in the absence of contraindications.

Pharmacogenomics decision support in the U-PGx project: Results and advice from clinical implementation across seven European countries

The clinical implementation of pharmacogenomics (PGx) could be one of the first milestones towards realizing personalized medicine in routine care. However, its widespread adoption requires the availability of suitable clinical decision support (CDS) systems, which is often impeded by the fragmentation or absence of adequate health IT infrastructures. We report results of CDS implementation in the large-scale European research project Ubiquitous Pharmacogenomics (U-PGx), in which PGx CDS was rolled out and evaluated across more than 15 clinical sites in the Netherlands, Spain, Slovenia, Italy, Greece, United Kingdom and Austria, covering a wide variety of healthcare settings. We evaluated the CDS implementation process through qualitative and quantitative process indicators. Quantitative indicators included statistics on generated PGx reports, median time from sampled upload until report delivery and statistics on report retrievals via the mobile-based CDS tool. Adoption of different CDS tools, uptake and usability were further investigated through a user survey among healthcare providers. Results of a risk assessment conducted prior to the implementation process were retrospectively analyzed and compared to actual encountered difficulties and their impact. As of March 2021, personalized PGx reports were produced from 6884 genotyped samples with a median delivery time of twenty minutes. Out of 131 invited healthcare providers, 65 completed the questionnaire (response rate: 49.6%). Overall satisfaction rates with the different CDS tools varied between 63.6% and 85.2% per tool. Delays in implementation were caused by challenges including institutional factors and complexities in the development of required tools and reference data resources, such as genotype-phenotype mappings. We demonstrated the feasibility of implementing a standardized PGx decision support solution in a multinational, multi-language and multi-center setting. Remaining challenges for future wide-scale roll-out include the harmonization of existing PGx information in guidelines and drug labels, the need for strategies to lower the barrier of PGx CDS adoption for healthcare institutions and providers, and easier compliance with regulatory and legal frameworks.

Can volumetric modulated arc radiation therapy reduce organ at risk dose in stage 4 sinonasal tumors in dogs treated with boost irradiation?

Intensity modulated radiation therapy (IMRT) introduced marked changes to cancer treatment in animals by reducing dose to organs at risk (OAR). As the next technological step, volumetric modulated arc therapy (VMAT) has advantages (increased degrees-of-freedom, faster delivery) compared to fixed-field IMRT. Our objective was to investigate a possible advantage of VMAT over IMRT in terms of lower OAR doses in advanced-disease sinonasal tumors in dogs treated with simultaneously-integrated boost radiotherapy. A retrospective, analytical, observational study design was applied using 10 pre-existing computed tomography datasets on dogs with stage 4 sinonasal tumors. Each dataset was planned with both, 5-field IMRT and 2 arc VMAT with 10x4.83 Gy to the gross tumor volume and 10x4.2 Gy to the planning target volume. Adequate target dose coverage and normal tissue complication probability of brain ≤5% was required. Dose constraints aspired to were D60 <15 Gy for eyes, D2 <35.4 Gy for corneae, and Dmean <20 Gy for lacrimal glands. OAR dose was statistically significantly higher in IMRT plans than in VMAT plans. Median eye D60% was 18.5 Gy (interquartile range (IQR) 17.5) versus 16.1 Gy (IQR 7.4) (p = 0.007), median lacrimal gland dose 21.8 Gy (IQR 20.5) versus 18.6 Gy (IQR 7.0) (p = 0.013), and median cornea D2% 45.5 Gy (IQR 6.8) versus 39.9 Gy (IQR 10.0) (p<0.005) for IMRT versus VMAT plans, respectively. Constraints were met in 21/40 eyes, 7/40 corneae, and 24/40 lacrimal glands. Median delivery time was significantly longer for IMRT plans than for VMAT plans (p<0.01). Based on these results, VMAT plans were found to be superior in sparing doses to eyes, lacrimal glands, corneae. However, not all ocular OAR constraints could be met while ensuring adequate dose coverage and restricting brain toxicity risk for both planning techniques.

Analysis on the Outcome of Tubal Interstitial Pregnancy after Partial Cornual Resection

Objective: To investigate the safety of re-pregnancy after partial cornual resection for tubal interstitial pregnancy. Methods: The clinical data of 22 cases of re-pregnancy after partial cornual resection from November 20J 3 to June 20J 9 were retrospectively analyzed, the operation condition, re-pregnancy outcome and neonatal outcome were analyzed. Results: 18 of the 21 cases were tubal interstitial pregnancy, the re-pregnancy interval was 6-36 months, the median delivery time was 17.4 moths, the median delivery time was 36 weeks (28-41+2W), there was 2 cases of birth weight &lt;2500 g. The remaining 4 cases were interstitial heterotopic pregnancy, the median delivery time was 36 weeks (32+4-38+2W), there was 1 case of birth weight &lt;2500g. Of the 22 patients, 21 were delivered by cesarean section and 1 was vaginal delivery, all the newborns survived. There were no cases of rupture of uterus, adhesion or implantation of placenta at uterine horn. Conclusion: The patients with tubal interstitial pregnancy after standard partial cornual resection have a good outcome of re-pregnancy.

Impact of pharmacy technicians as part of an integrated health-system pharmacy team on improvement of medication access in the care of cystic fibrosis patients.

Cystic fibrosis (CF) is a genetic disease requiring patients to take multiple medications per day. Multiple barriers exist affecting access and adherence. Studies have demonstrated the positive outcomes of pharmacist involvement in CF care. The purpose of this study is to characterize the impact of pharmacy technicians on medication access in the care of CF patients. A retrospective review and analysis of patient medication profiles for patients followed by the integrated pharmacy care process model was performed. Two electronic prescription pathways with pharmacy technician involvement were analyzed. One pathway using a specialty pharmacy CF pharmacy technician (SP technician) examined CF specialty medication delivery times. The other pathway examined the impact of the clinic-based CF pharmacy technician (CB technician) on the number of filling pharmacies for patients. One-hundred and fifty-three patients met inclusion criteria in the CF specialty medication delivery analysis, and 56 patients met inclusion criteria filling pharmacy analysis. The median delivery time for dornase alfa decreased from 8 days to 3 days, p < .00001. The number of patients utilizing one filling pharmacy increased from 8 (14%) to 21 (38%)(p = .005); and utilizing three filling pharmacies decreased from 14 (25%) to 1 (2%)(p = .003). The study demonstrated that pharmacy technicians as part of an integrated health-system pharmacy care process model improve medication access in the care of CF patients.

A survey of risk factors and quality of life in female medical staff with urinary incontinence

To explore risk factors of urinary incontinence (UI) and influences of UI on quality of life in female medical staff from Beijing. One hundred and forty-six female medical personnel were included in the present study through the convenient sampling method in Peking University First Hospital. The questionnaires contained the following information: demographic information, daily urination condition, the severity of UI [international consultation on incontinence questionnaire short form (ICI-Q-SF)], and the influences of UI on quality of life (QOL). We excluded the subjects who were in pregnancy or had urinary infection, neurogenic bladder, or urethral stricture. We used SPSS 21.0 software (IBM Corp, Armonk, NY) for statistical analysis. The Kolmogorov-Smirnov test determined the normality of the continuous variables. Means and standard deviation presented continuous variables in normality. Median and range presented continuous variables without normality. Frequency and percentile were used to present categorical or ranked variables. There were 63 out of 146 (43.2%) female medical staff suffering from UI. The mean age and body mass index of the whole study cohort were (39.4±9.9) years and (22.3±3.4) kg/m2. The median delivery times of all the subjects were 1 time (range: 0-3 times). Fifty out of 146 (34.2%) subjects had transvaginal delivery history. Chronic constipation was diagnosed in 32 subjects (21.9%). No significant difference in daytime micturition and nocturia times were found between the UI and non-UI subjects. According to the multivariate analysis, chronic constipation (OR=4.95, 95%CI=1.81-13.53, P=0.002) and transvaginal delivery history (OR=3.50, 95%CI=1.49-8.21, P=0.004) were independent risk factors for UI. The non-UI subjects had superior quality of life than the UI subjects in terms of incontinence quality of life (I-QOL) total scores and all sub-scores of avoidance and limiting behaviors, psychosocial impacts, and social embarrassment (P<0.001). In addition, avoidance and limiting behaviors (r=-0.449, P<0.001), psychosocial impacts (r=-0.538, P<0.001), and social embarrassment (r=-0.454, P<0.001) of the 63 UI subjects were equally influenced by the incontinence symptom. UI is not uncommon in female medical staff. The quality of life of medical faculty is influenced by UI in terms of avoidance and limiting behaviors, psychosocial impacts, and social embarrassment. Chronic constipation and transvaginal delivery history were independent risk factors for UI.

Effect of the Number of Arcs and Target Dose Homogeneity on the Normal Tissue Sparing for SBRT Plan in Liver Cancer Patients

To evaluate the effect of the number of arcs and target dose homogeneity on the dose sparing of normal tissue for stereotactic radiotherapy (SBRT) plans in liver cancer patients. Ten patients (4 males and 6 females) with primary or metastatic liver cancer were analyzed. Two groups of volumetric modulated arc therapy (VMAT) plans (Group A and B) with 1 to 4 arcs (239-359°) were generated by RayStation treatment planning system and customized to the Versa HD accelerator. In Group A, the PTV dose was controlled in 90% - 120% of the prescription dose (based on RTOG 0438), and the dose homogeneity of target was not restricted in Group B. A total dose of 48 Gy in 4 fractions was prescribed to the PTV. Ten rings (5 mm width for each ring) outside the PTV were created to limit the dose of normal tissue and evaluate the dose fall-off. All the plans were optimized by using an automatic optimizer developed by our team to avoid the effects of man-made factors. The dose-volume parameters, delivery time among ≥3 plans were analyzed by Friedman test and those between two values were compared by Wilcoxon signed ranks test; p < 0.05 (2-tailed, Friedman) and p < 0.05/N (2-tailed, Wilcoxon, N = n(n-1)/2, where n is the number of groups) was considered statistically significant. All the VMAT plans achieved acceptable target coverage with 43.2 Gy delivered to more than 99% of the PTV and 95% of the target receiving 48 Gy. As the number of arc increased, the doses of organs at risk (OARs, such as the mean liver dose, the maximum dose of stomach, etc.) were reduced by up to 21.5% (2 arcs vs. 1 arc), 17.8% (3 arcs vs. 2 arcs) in Group A (p < 0.008) and 23.4% (2 arcs vs. 1 arc), 32.2% (3 arcs vs. 2 arcs) in Group B (p < 0.008), while the value was only 1.38% (4 arcs vs. 3 arcs) in Group A and there was no statistic difference between 4 arcs and 3 arcs in Group B. The dose of ring 1-10 was improved when using more arcs, in which the mean dose was reduced by 9.1-13.3% (2 arcs vs. 1 arc), 1.5-5.1% (3 arcs vs. 2 arcs) for Group A and 12.3-17.2% (2 arcs vs. 1 arc), 0.9-3.2% (3 arcs vs. 2 arcs) for Group B. The gradient index (GI) was improved by approximately 14% (2 arcs vs. 1 arc) for both Group A and B (p < 0.008). The doses of OARs in Group B were improved by up to 7.5% compared to those in Group A (p < 0.05). Similarly, the value was 5.2% and 5.0% for the mean rings dose and GI (p < 0.05). The monitor units (MUs) and delivery time increased with the number of arc (p < 0.008). For 1-4 arcs VMAT plans, the median delivery time increased from approximately 3 min to 5min. The VMAT SBRT plans with inhomogeneous target dose yielded better dose fall-off and OARs sparing for liver cancer patients. Increasing the number of arcs reduced the dose of normal tissue but at the expense of more delivery time. The three arc VMAT plans without constraint of target dose homogeneity seemed to provide a good trade-off between delivery efficiency and plan quality for liver cancer SBRT.

Rapid Access Palliative Radiation Workflow Using MRI-Guided Single-Session Simulation, Online Adaptation, and Treatment

In the palliative setting, priority is placed on streamlining the process of radiation delivery to avoid unnecessary treatment delay and expedite symptom relief. We hypothesized that using magnetic resonance imaging (MRI) guidance, adaptive planning software, and pre-existing diagnostic computed tomography (CT) imaging, we could deliver palliative radiation without the need for a separate CT simulation scan, thus decreasing the time and steps required to start palliative treatment. For patients necessitating urgent palliative radiotherapy, a simple “pre-plan” was created on diagnostic CT imaging prior to patient transport to the treatment machine. For dose calculation purposes, the electron density of the CT was deformed to MRI in the pre-plan or was overridden to water density. In the treatment vault, the patient was imaged in treatment position with volumetric MRI. The pre-plan was then rapidly adapted online to the MRI, updating the target definition, re-defining fields, and re-balancing beam weights. Once the online-adapted plan was finalized and approved, the patient was treated. Eighteen patients with metastatic cancer were treated from October 2015 to November 2016 with urgent palliative radiation for indications such as pain, obstruction, and bleeding. Dose/fractionation regimens included 8 Gy in 1 fraction (8 pts), 25 Gy in 5 fractions (4 pts), and 30 Gy in 10 fractions (6 pts). Median planning target volume (PTV) size was 187cc. Online adaptive MRI-guided radiotherapy enabled plan changes to be made rapidly. Conformal 3D adaptive plans were delivered as quickly as more conventional AP/PA beam arrangements with a median delivery time of 122s. MRI-guided adaptive radiotherapy was planned and delivered in one-hour appointments for each patient, compared with a mean time from CT simulation to delivery of first treatment of 30 hours (95% CI, 24-35) for a similar sample of urgent palliative cases planned and treated with more traditional radiotherapy workflow. Clinical outcomes were similar to historical and sampled controls, with improvement in pain in 11 of 14 patients, relief of obstructive symptoms in 3 of 3 patients, and hemostasis in 1 of 1 patient treated with MRI-guided adaptive radiotherapy. Integrated treatment planning using available MRI-guided online adaptive radiotherapy allows a rapid-access treatment workflow obviating the need for a separate CT simulation. Conformal pre-plans can be created without time pressure and, if necessary, adapted to anatomy at treatment. This streamlined palliative radiation workflow makes efficient use of both staff and patient time and expedites palliative treatment with similarly successful clinical results.

Influence of tumor location on the intensity-modulated radiation therapy plan of helical tomotherapy

Given the design of the Helical TomoTherapy device, the patient's central axis is routinely aligned with the machine's rotational axis to prevent the patient's body from colliding with the machine walls. However, for treatment of tumors located away from the patient's central axis, this position may not be optimal as the adequate radiation dose may not reach the affected site. Our study aimed to investigate the influence of tumor location on dose quality and delivery efficiency of tomotherapy plans. A phantom and 15 patients were selected for this study. Two plans, A and B, were implemented for each case. In plan A, the patient's central axis was aligned with the machine's rotational axis, whereas in plan B, the center of the planning target volume (PTV) was aligned with the machine's rotational axis. Both plans were optimized with the same planning parameters, and the dose quality of the plans was evaluated using dosimetrics. The delivery efficiency was determined from delivery time and monitor units (MUs). A paired t-test or nonparametric Wilcoxon signed-rank test was performed for statistical comparison. In the phantom study, the median delivery times were 358 and 336 seconds for plans A and B, respectively, and this difference was significant (p = 0.005). In the patient study, the median delivery times were 348 and 317 seconds for plans A and B, respectively, and this difference was also significant (p = 0.001). The dose qualities of both plans for each patient were nearly identical. No significant differences were found in the conformal index, heterogeneity index, and mean dose delivered to normal tissue between the plans. Both phantom and patient studies showed that for normal-sized patients, the delivery time reduced as the distance between the PTV and the patient's central axis increased when the PTV center was aligned with the machine axis. In conclusion, aligning the PTV center with the machine's rotational axis by shifting the patient during tomotherapy reduces the delivery time without compromising the dose quality of intensity-modulated radiation therapy.

A Trial of Three Commercial Document Delivery Suppliers with Strong Holdings in Biomedicine

The University of Vermont's Medical Library evaluated the services of three commercial document delivery suppliers with significant holdings in biomedicine. The purpose of the trial was to determine whether journal articles could be procured in less time than routine interlibrary loan without greatly increasing costs. Each supplier offered a quick delivery method employing modern technology at a standard fee. The need to pay copyright royalties at times and a desire to test the possibility of substituting “access” for “collection” also prompted the trial. Results reported include: mean and median delivery times, percentages of requested titles held, and average price per transaction, including copyright fee. The Medical Library continues to use commercial services to augment interlibrary loan.