CHI Health Good Samaritan

This study is to evaluate the dose calculation accuracy using Varian's cone-beam CT (CBCT) for pelvic adaptive radiotherapy. We first calibrated the Hounsfield Unit (HU) to electron density (ED) for CBCT using a mini CT QC phantom embedded into an IMRT QA phantom. We then used a Catphan 500 with an annulus around it to check the calibration. The combined CT QC and IMRT phantom provided correct HU calibration, but not Catphan with an annulus. For the latter, not only was the Teflon an incorrect substitute for bone, but the inserts were also too small to provide correct HUs for air and bone. For the former, three different scan ranges (6 cm, 12 cm and 20.8 cm) were used to investigate the HU dependence on the amount of scatter. To evaluate the dose calculation accuracy, CBCT and plan-CT for a pelvic phantom were acquired and registered. The single field plan, 3D conformal and IMRT plans were created on both CT sets. Without inhomogeneity correction, the two CT generated nearly the same plan. With inhomogeneity correction, the dosimetric difference between the two CT was mainly from the HU calibration difference. The dosimetric difference for 6 MV was found to be the largest for the single lateral field plan (maximum 6.7%), less for the 3D conformal plan (maximum 3.3%) and the least for the IMRT plan (maximum 2.5%). Differences for 18 MV were generally 1-2% less. For a single lateral field, calibration with 20.8 cm achieved the minimum dosimetric difference. For 3D and IMRT plans, calibration with a 12 cm range resulted in better accuracy. Because Catphan is the standard QA phantom for the on-board imager (OBI) device, we specifically recommend not using it for the HU calibration of CBCT.

PURPOSE: The authors propose a combined scatter reduction and correction method to improve image quality in cone-beam computed tomography (CBCT). Although using a beam-block approach similar to previous techniques to measure the scatter, this method differs in that the authors utilize partially blocked projection data obtained during scatter measurement for CBCT image reconstruction. This study aims to evaluate the feasibility of the proposed approach. METHODS: A 1D grid, composed of lead septa, was placed between the radiation source and the imaging object for scatter measurement. Image data were collected from the grid interspace regions while the scatter distribution was measured in the blocked regions under the grid. Scatter correction was performed by subtracting the measured scatter from the imaging data. Image information in the penumbral regions of the grid was derived. Three imaging modes were developed to reconstruct full CBCT images from partial projection data. The single-rotation half-fan mode uses interpolation to fill the missing data. The dual-rotation half-fan mode uses two rotations, with the grid offset by half a grid cycle, to acquire two complementary sets of projections, which are then merged to form complete projections for reconstruction. The single-rotation full-fan mode was designed for imaging a small object or a region of interest. Full-fan projection images were acquired over a 360 degrees scan angle with the grid shifting a distance during the scan. An enlarged Catphan phantom was used to evaluate potential improvement in image quality with the proposed technique. An anthropomorphic pelvis phantom was used to validate the feasibility of reconstructing a complete set of CBCT images from the partially blocked projections using three imaging modes. Rigid-body image registration was performed between the CBCT images from the single-rotation half-fan mode and the simulation CT and the results were compared to that for the CBCT images from dual-rotation mode and conventional CBCT images. RESULTS: The proposed technique reduced the streak artifact index from 58% to 1% in comparison with the conventional CBCT. It also improved CT number linearity from 0.880 to 0.998 and the contrast-to-noise ratio (CNR) from 4.29 to 6.42. Complete sets of CBCT images with overall improved image quality were achieved for all three image modes. The longitudinal resolution was slightly compromised for the single-rotation half-fan mode. High resolution was retained for the dual-rotation half-fan and single-rotation full-fan modes in the longitudinal direction. The registration error for the CBCT images from the single-rotation half-fan mode was 0.8 +/- 0.3 mm in the longitudinal direction and negligible in the other directions. CONCLUSIONS: The proposed method provides combined scatter correction and direct scatter reduction. Scatter correction may eliminate scatter artifacts, while direct scatter reduction may improve the CNR to compensate the CNR degradation due to scatter correction. Complete sets of CBCT images are reconstructed in all three imaging modes. The single-rotation mode can be used for rigid-body patient alignment despite degradation in longitudinal resolution. The dual-rotation mode may be used to improve CBCT image quality for soft tissue delineation in adaptive radiation therapy.

PURPOSE: Cone beam CT is increasingly being used for daily patient positioning verification during radiation therapy treatments. The daily use of CBCT could lead to accumulated patient doses higher than the older technique of weekly portal imaging. There have been several studies focusing on measurement or calculation of the patient dose from CBCT recently. METHODS: This study investigates the feasibility of configuring a kV x-ray source in a commercial treatment planning system to calculate the dose to patient resulting from an IGRT procedure. The method proposed in this article can be used to calculate dose from CBCT imaging procedure and include that in the patient treatment plans. RESULTS: The kilovoltage beam generated by the CBCT imager has been modeled using the planning system. The modeled profiles agree with the measured ones to within 5%. The modeled beam was used to calculate dose to phantom in the pelvic region and the calculations were compared to TLD measurements. The agreement between calculated and measured doses ranges from 0% to 19% in soft tissue with larger variations observed near and within the bone. CONCLUSIONS: The modeling of the beam produces reasonable results and the dose calculation comparisons indicate the potential for computing kilovoltage CBCT doses using a treatment planning system. Further improvements in the dose calculation algorithm are necessary, especially for dose calculations in and near the bone.

A multilayered implementation of safety measures in an inpatient psychiatric facility created a sustained change in culture related to patient and staff safety. The model was developed over a 5-year period in a freestanding 80-bed behavioral health facility that is part of a Level II trauma center in the Midwest. The model has nine components that the nursing leadership team saw as integral to maintaining a safe environment. The nine elements include trauma-informed care principles, aggression management, code event review, leadership involvement, quality feedback, recovery orientation, patient assessment, education, and collaboration. The metrics collected to determine the effectiveness of the model included patient violence events and staff injuries. This article describes the development of this model and its impact on the reduction of patient violence events and staff injuries at this facility. The recommendations include considerations for the replication of this model at other facilities.

Abstract Salvinorin A is a unique hallucinogen that is seeing increased use in humans. It is not currently a controlled substance and is used as a legal alternative to controlled substances. Usually smoked or buccally absorbed by chewing, doses of approximately 200mcg can produce profound hallucinogenic effects of short duration. The mechanism of action of salvinorin A is at the k-opioid receptor. Little data is available on the medical effects of this substance so animal studies were undertaken to explore the acute toxic effects of this substance in rats and the chronic effects in mice. Rats were anesthetized and administered salvinorin A at 1600mcg/kg or vehicle. Recordings were made of galvanic skin response, EKG, temperature, and pulse pressure for 100 minutes. Mice were chronically exposed to vehicle or 400, 800, 1600, 3200, or 6400 meg/kg of salvinorin A for two weeks. After exposure the animals were sacrificed and brain, heart, kidney, bone marrow, blood and spleen were removed, fixed, sectioned, stained and examined by light microscopy. No effects were seen on cardiac conduction, temperature, or galvanic skin response. A nonsignificant rise was seen in pulse pressure. Histologic studies of spleen, blood, brain, liver, kidney, and bone marrow did not find any significant histologic changes at any of the doses examined. These data suggests that the toxicity of salvinorin A is relatively low, even at doses many times greater than what humans are exposed to. However, further studies should be done on blood pressure effects. The psychological impact of this potent hallucinogen should also be investigated.

The Breast Cancer Collaborative Registry (BCCR) is a multicenter web-based system that efficiently collects and manages a variety of data on breast cancer (BC) patients and BC survivors. This registry is designed as a multi-tier web application that utilizes Java Servlet/JSP technology and has an Oracle 11g database as a back-end. The BCCR questionnaire has accommodated standards accepted in breast cancer research and healthcare. By harmonizing the controlled vocabulary with the NCI Thesaurus (NCIt) or Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT), the BCCR provides a standardized approach to data collection and reporting. The BCCR has been recently certified by the National Cancer Institute's Center for Biomedical Informatics and Information Technology (NCI CBIIT) as a cancer Biomedical Informatics Grid (caBIG(®)) Bronze Compatible product.The BCCR is aimed at facilitating rapid and uniform collection of critical information and biological samples to be used in developing diagnostic, prevention, treatment, and survivorship strategies against breast cancer. Currently, seven cancer institutions are participating in the BCCR that contains data on almost 900 subjects (BC patients and survivors, as well as individuals at high risk of getting BC).

A positioning QA procedure for Varian's 2D/2D (kV/MV) and 3D/3D (planCT/CBCT) matching was developed. The procedure was to check: (1) the coincidence of on-board imager (OBI), portal imager (PI), and cone beam CT (CBCT)'s isocenters (digital graticules) to a linac's isocenter (to a pre-specified accuracy); (2) that the positioning difference detected by 2D/2D (kV/MV) and 3D/3D(planCT/CBCT) matching can be reliably transferred to couch motion. A cube phantom with a 2 mm metal ball (bb) at the center was used. The bb was used to define the isocenter. Two additional bbs were placed on two phantom surfaces in order to define a spatial location of 1.5 cm anterior, 1.5 cm inferior, and 1.5 cm right from the isocenter. An axial scan of the phantom was acquired from a multislice CT simulator. The phantom was set at the linac's isocenter (lasers); either AP MV/R Lat kV images or CBCT images were taken for 2D/2D or 3D/3D matching, respectively. For 2D/2D, the accuracy of each device's isocenter was obtained by checking the distance between the central bb and the digital graticule. Then the central bb in orthogonal DRRs was manually moved to overlay to the off-axis bbs in kV/MV images. For 3D/3D, CBCT was first matched to planCT to check the isocenter difference between the two CTs. Manual shifts were then made by moving CBCT such that the point defined by the two off-axis bbs overlay to the central bb in planCT. (PlanCT can not be moved in the current version of OBI1.4.) The manual shifts were then applied to remotely move the couch. The room laser was used to check the accuracy of the couch movement. For Trilogy (or Ix-21) linacs, the coincidence of imager and linac's isocenter was better than 1 mm (or 1.5 mm). The couch shift accuracy was better than 2 mm.

A provider must demonstrate superior performance in several areas, such as cost, utilization, and clinical outcomes, to obtain designation as a Center of Excellence. A comprehensive orthopedic strategy was designed for use by Good Samaritan Health Systems to obtain this designation. The strategy included the development of clinical pathways and a profiling system. Acute, subacute, home care, and patient/family pathways were developed for diagnosis-related group 209: total joint replacement. Six months after implementation, a profile was developed using the Dartmouth Clinical Value Compass. Dimensions profiled included patient satisfaction, clinical variance data, functional status, and cost/utilization data. Improvements were identified in patient satisfaction, cost/utilization, and patient care.

We describe a novel technique for repair of the superior glenoid labrum posterior to the biceps anchor. This approach optimizes access for fixation of the superior and posterosuperior labrum, but involves significantly less trauma to the rotator cuff and subacromial space compared with previously described transrotator cuff methods. We suspect that the relative lack of trauma to the rotator cuff and subacromial space accounts for the superior clinical scores and lower incidence of postoperative impingement symptoms with this technique compared with previously reported transrotator cuff methods.

Abstract Background Coexistence of fibrillary glomerulonephritis (FGN) and immunoglobulin A (IgA) nephropathy (IgAN) in the same kidney biopsy (FGN–IgAN) is rare, and the clinicopathologic characteristics and outcome of this dual glomerulopathy are unknown. Methods In this study, 20 patients with FGN–IgAN were studied and their characteristics were compared with 40 FGN and 40 IgAN control patients. Results Concurrent IgAN was present in 1.8% of 847 consecutive FGN cases and was the second most common concurrent glomerulopathy after diabetic nephropathy. FGN–IgAN patients were overwhelmingly White (94%) and contrary to FGN patients were predominantly (60%) males. Compared with IgAN patients, FGN–IgAN patients were older, had higher proteinuria, a higher incidence of renal insufficiency, and a lower incidence of microhematuria and gross hematuria at diagnosis. Six (30%) patients had malignancy, autoimmune disease or hepatitis C infection, but none had a secondary cause of IgAN or clinical features of Henoch–Schonlein purpura. Histologically, all cases exhibited smudgy glomerular staining for immunoglobulin G and DnaJ homolog subfamily B member 9 (DNAJB9) with corresponding fibrillary deposits and granular mesangial staining for IgA with corresponding mesangial granular electron-dense deposits. On follow-up (median 27 months), 10 of 18 (56%) FGN–IgAN patients progressed to end-stage kidney disease (ESKD), including 5 who subsequently died. Serum creatinine at diagnosis was a poor predictor of renal survival. The proportion of patients reaching ESKD or died was higher in FGN–IgAN than in IgAN. The median Kaplan–Meier ESKD-free survival time was 44 months for FGN–IgAN, which was shorter than IgAN (unable to compute, P = 0.013) and FGN (107 months, P = 0.048). Conclusions FGN–IgAN is very rare, with clinical presentation and demographics closer to FGN than IgAN. Prognosis is guarded with a median renal survival of 3.6 years. The diagnosis of this dual glomerulopathy requires careful evaluation of immunofluorescence findings, and electron microscopy or DNAJB9 immunohistochemistry.

Abstract: The management of a child with disorders of sex development is complex from both a medical and sociocultural perspective. Decisions impacting the future sexual function and sex identity of the child are made on behalf of the child by their parents and health care providers. Such decisions are rarely straightforward and outcome data to guide practice are limited and conflicting. This manuscript explores the ethical issues present in prenatal diagnosis, sex assignment, medical management, and surgical intervention in the case of children with disorders of sex development. Suggestions for an ethics-based approach to management are offered including the use of multidisciplinary teams and guidelines, improved communication between providers and parents, the early and continued inclusion of mental health professionals, and the use of an independent review of treatment plans. The goal of an ethics-based management approach is the promotion of the autonomy and wellbeing of the affected child. Keywords: intersex, disorders of sex development, ethics, decision-making

Health care staffing challenges for the next few years necessitate the need to develop strategies to integrate the Generation Xer into a predominantly Baby Boomer work force. Strategies to assist Baby Boomers and Generation Xers to engage one another in constructive relationships are discussed. Misunderstanding and stereotyping create barriers that focus on differences and perceived limitations rather than identification of common thinking and focusing on strengths of each generation.

We report a case of a young male patient presenting with accidental carbon monoxide poisoning leading to pulmonary embolism, acute myocardial infarction, right and left ventricular thromboses, acute limb ischemia, and acute renal failure. We review clinical aspects of carbon monoxide poisoning with a specific focus on cardiovascular and systemic thrombotic complications.

Introduction While there is strong evidence supporting family cancer history screening as a tool for risk-stratified cancer screening, challenges in implementation remain. Many efforts tend to focus solely on the high-risk pathway neglecting the entire patient population. This study aims to capture primary care providers' perspectives on implementing genetic-informed, risk-stratified mammography screening guidelines. Methods Semistructured interviews were conducted involving 14 providers and 5 practice leaders across 2 Georgia healthcare systems between November 2020 and May 2021. Interviews assessed the barriers and facilitators at patient, provider, and system levels using the Consolidated Framework for Implementation Research. Thematic analysis was conducted using MAXQDA, and Fishbone analysis was applied to summarize the results. Results Barriers and facilitators differed between high- and low-risk pathways. For high-risk pathways, barriers included limited provider knowledge and unclear referral protocols, while facilitators included established relationships between providers and genetic professionals and effective electronic health record systems. For low-risk pathways, barriers centered on provider acceptance, guideline inconsistency, and risk communication challenges. Conclusion Effective implementation of risk-stratified breast cancer screening requires tailored strategies to address pathway-specific barriers. Integrating ongoing education, clinical decision support, and workflow alignment may enhance program adoption.

The aim of this study was to determine the effect of demographics, substance abuse, and chronic illnesses on length of hospitalization and mortality of pneumonia. 866 patients admitted to a community hospital with diagnosis of community-acquired pneumonia were studied. Linear and logistic regression analyses were performed for the effect of chronic illnesses on length of stay and mortality. Age (p=0.064), coronary artery disease (p=0.017), congestive heart failure (p=0.011), history of neoplasm (p=0.079) and chronic kidney disease (p<0.001) were associated with increased length of stay. Age (p<0.001), history of stroke (p=0.013), history of neoplasm (p=0.028), and chronic kidney disease (p=0.005) were associated with higher mortality from community-acquired pneumonia. Asthma was associated with decreased length of stay (p=0.006) but no difference in mortality. Respiratory failure and congestive heart failure exacerbation were associated with longer length of stay (p<0.001) but no difference in mortality. ICU admission was associated with longer hospital stay and higher mortality (p<0.001). Septic shock secondary to pneumonia was associated with longer length of stay and higher mortality (p<0.0001). Age (p=0.04), alcohol abuse (p=0.03), coronary artery disease (p=0.05), congestive heart failure (p=0.009) and chronic kidney disease (p=0.011) were predictors of higher level of care needed during hospital stay for community acquired pneumonia.

INTRODUCTION: Video capsule endoscopy (VCE) is increasingly being used in the diagnosis of small bowel disorders and the evaluation of suspected small bowel bleeding in adults. VCE is considered a safe procedure with no attributable deaths. Clinically significant complications include symptomatic capsule retention and aspiration that occur in less than 2% of examinations. CASE DESCRIPTION/METHODS: A 67-year-old male with history of developmental delay and with no history of swallowing disorder or stroke was initially admitted to the hospital with severe symptomatic anemia. His hemoglobin was 7.1g/dl. Anemia work up revealed serum iron level of &lt;10g/dl and a ferritin level of 4.30. He underwent upper GI endoscopy and colonoscopy with findings of a short segment Barrett’s esophagus and small non-bleeding hemorrhoids. He was then scheduled an outpatient VCE. He was given the capsule and asked to swallow it. He initially had some difficulty in swallowing it but then took a big gulp and apparently swallowed it. Immediately upon swallowing, he started experiencing difficulty breathing. Nursing staff present immediately checked his oxygen saturation and noted a transient drop which corrected with minimal oxygen supplementation. An X-ray was immediately ordered and the monitor activated. Images suggested ingestion into the bronchus and a chest X-ray confirmed presence of a pill camera overlying the right main stem bronchus. He underwent an emergent flexible bronchoscopy with successful extraction of the capsule. This was followed by endoscopy assisted capsule insertion into his duodenum.He tolerated the procedure well. DISCUSSION: VCE is increasingly being used to provide diagnostic imaging of the small intestines, an anatomic site that is peculiarly difficult to visualize. Suspected small bowel bleeding and tumors of the small bowel are some of the common indications of VCE.Capsule aspiration although a rare complication with VCE can be life threatening. Early detection with emergent timely retrieval of the capsule is recommended. In order to prevent such complications and to be able to intervene expeditiously, it is recommended that VCE should be administered in an office with oxygen and where other resuscitative facilities are available. In conclusion, though rare, capsule aspiration is a serious complication of VCE and physicians should pay attention to patients who have any delay in capsule ingestion and if possible confirm passage of the capsule endoscope into the stomach before the patient leaves the clinic.

Coronary artery aneurysms (CAA) are defined as a dilation of a coronary vessel greater than 1.5 times the diameter of a local reference vessel. While CAAs tend to be incidental findings on imaging, they result in complications, such as thrombosis, embolization, ischemia, arrhythmias, and heart failure. Among symptomatic cases, chest pain has been the most common manifestation of CAAs. This necessitates an understanding of CAAs as a cause of acute coronary syndrome (ACS) presentation. However, due to the unclear pathophysiology of CAAs and their variable presentation complicated by similar ACS conditions, there is no clear strategy for CAA management. In this article, we will discuss the contribution of CAAs to ACS presentations and review the current management options for CAAs.

Acinetobacter baumannii are Gram-negative aerobic bacteria, that are ubiquitous in the environment. They are difficult to treat given their numerous intrinsic resistance and ability to acquire resistance genes. Infections caused by carbapenem-resistant A. baumannii (CRAb) with New Delhi Metallo-beta-lactamases (NDM) are rare in the US but have risen in the past few years. There are limited treatment options available. We present a case of NDM-CRAb pneumonia in a 75-year-old man with a history of penicillin anaphylaxis with severe hypoxia requiring intubation and vasopressor support. In the absence of cefiderocol at the medical facility and the inability to use high-dose ampicillin-sulbactam infusion, a combination of polymyxin B and minocycline was used. Two courses of the combination antibiotic therapy were given, initially four days course then another course of 10 days. After this, he improved clinically and was able to be weaned off the ventilator and vasopressors. However, he experienced acute renal failure from polymyxin B and vancomycin, requiring hemodialysis for four months.

A quantitative method of monitoring neuromuscular blockade has been recently introduced. It has been suggested, when using mivacurium, that a standardized passage of time be used for induction. The purpose of this study was to determine whether a difference existed in intubating conditions when using mivacurium between a timed-dose technique and the ParaGraph (Vital Signs, Inc., Totowa, New Jersey). In this prospective, experimental, clinical trial, 40 patients were randomized into two groups. Standardized induction sequences were used for both groups. A standardized rating tool was used to grade each intubation. Intubation commenced in the ParaGraph group when the monitor read one twitch. Intubation in the timed-dose group occurred 90 seconds after the first dose of mivacurium. The difference in intubating conditions score and time to intubation was tested by the Mann-Whitney-Wilcoxon lest. The ParaGraph group had superior intubating conditions when compared with the timed dose group (P = .0001). Of the ParaGraph group, 100% had good to excellent intubating conditions, and 85% of the timed-dose group had fair to excellent intubating conditions. Time to intubation was longer in the ParaGraph group, with a mean of 216 seconds compared with 121 seconds in the timed-dose group. The variable time to onset of mivacurium indicates that a timed-dose technique may yield less than optimal intubating conditions despite manufacturer recommendations.

Introduction: Nebraska Mission: Lifeline Stroke is a 4-year initiative to increase guideline-based treatment of acute stroke across the continuum of care. Guidelines advise post-stroke assessment by a multi-disciplinary team to guide discharge process and select ideal rehab setting. Purpose: To develop resources to facilitate the transition of Nebraskans with stroke to the most appropriate level of post-acute care. Methods: Healthcare Providers (HCPs) from various settings completed two surveys: hospital stroke rehab referral strategies and practices (N=23), and individual experiences related to stroke rehab (N=260). In addition, a literature review was conducted to find published guidelines and research on clinical decision making. Lastly, a focus group consisting of social worker/case managers was held to provide input on resources developed. Results: Hospitals (N=23) believe higher numbers of stroke patients should be referred to IRFs (42%) and stated that patients’ “health status” (91%), “opinions from hospital team members” (87%), and “opinions from patient, family, or caregivers” (78%) are most relevant in the decision process. Factors that impact referral process include: HCPs may not be familiar with all options for post-acute rehab care (17%) and patient or family/caregivers are not educated about options (30%). Most (57%) of HCPs surveyed and all focus group participants indicated discharge referral process could be improved with a standardized decision-making tool. Based on this input, two discharge planning guides were developed. The first assists HCPs in determining appropriate level of post-acute stroke care by comparing various types and settings in an easy-to-read format. The second is patient/caregiver focused and includes information to assist in decision-making process and a table comparing rehab settings. These guides have been disseminated through conference presentations, direct mailings, and web-based resources. Conclusions: Discharge tools with clear descriptions of options are necessary to assist HCPs and patients/caregivers in matching appropriate care with patient’s rehab needs. These care choices are key to patients achieving their highest level of independence.