Saint Joseph Medical Center Joliet

Background: Endovascular treatment with mechanical thrombectomy (MT) is beneficial for patients with acute stroke suffering a large-vessel occlusion, although treatment efficacy is highly time-dependent. We hypothesized that interhospital transfer to endovascular-capable centers would result in treatment delays and worse clinical outcomes compared with direct presentation. Methods: STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) was a prospective, multicenter, observational, single-arm study of real-world MT for acute stroke because of anterior-circulation large-vessel occlusion performed at 55 sites over 2 years, including 1000 patients with severe stroke and treated within 8 hours. Patients underwent MT with or without intravenous tissue plasminogen activator and were admitted to endovascular-capable centers via either interhospital transfer or direct presentation. The primary clinical outcome was functional independence (modified Rankin Score 0–2) at 90 days. We assessed (1) real-world time metrics of stroke care delivery, (2) outcome differences between direct and transfer patients undergoing MT, and (3) the potential impact of local hospital bypass. Results: A total of 984 patients were analyzed. Median onset-to-revascularization time was 202.0 minutes for direct versus 311.5 minutes for transfer patients ( P <0.001). Clinical outcomes were better in the direct group, with 60.0% (299/498) achieving functional independence compared with 52.2% (213/408) in the transfer group (odds ratio, 1.38; 95% confidence interval, 1.06–1.79; P =0.02). Likewise, excellent outcome (modified Rankin Score 0–1) was achieved in 47.4% (236/498) of direct patients versus 38.0% (155/408) of transfer patients (odds ratio, 1.47; 95% confidence interval, 1.13–1.92; P =0.005). Mortality did not differ between the 2 groups (15.1% for direct, 13.7% for transfer; P =0.55). Intravenous tissue plasminogen activator did not impact outcomes. Hypothetical bypass modeling for all transferred patients suggested that intravenous tissue plasminogen activator would be delayed by 12 minutes, but MT would be performed 91 minutes sooner if patients were routed directly to endovascular-capable centers. If bypass is limited to a 20-mile radius from onset, then intravenous tissue plasminogen activator would be delayed by 7 minutes and MT performed 94 minutes earlier. Conclusions: In this large, real-world study, interhospital transfer was associated with significant treatment delays and lower chance of good outcome. Strategies to facilitate more rapid identification of large-vessel occlusion and direct routing to endovascular-capable centers for patients with severe stroke may improve outcomes. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02239640.

BACKGROUND: Limited post-marketing data exist on the use of the Solitaire FR device in clinical practice. The North American Solitaire Stent Retriever Acute Stroke (NASA) registry aimed to assess the real world performance of the Solitaire FR device in contrast with the results from the SWIFT (Solitaire with the Intention for Thrombectomy) and TREVO 2 (Trevo versus Merci retrievers for thrombectomy revascularization of large vessel occlusions in acute ischemic stroke) trials. METHODS: The investigator initiated NASA registry recruited North American sites to submit retrospective angiographic and clinical outcome data on consecutive acute ischemic stroke (AIS) patients treated with the Solitaire FR between March 2012 and February 2013. The primary outcome was a Thrombolysis in Myocardial Ischemia (TIMI) score of ≥2 or a Treatment in Cerebral Infarction (TICI) score of ≥2a. Secondary outcomes were 90 day modified Rankin Scale (mRS) score, mortality, and symptomatic intracranial hemorrhage. RESULTS: 354 patients underwent treatment for AIS using the Solitaire FR device in 24 centers. Mean time from onset to groin puncture was 363.4±239 min, mean fluoroscopy time was 32.9±25.7 min, and mean procedure time was 100.9±57.8 min. Recanalization outcome: TIMI ≥2 rate of 83.3% (315/354) and TICI ≥2a rate of 87.5% (310/354) compared with the operator reported TIMI ≥2 rate of 83% in SWIFT and TICI ≥2a rate of 85% in TREVO 2. CLINICAL OUTCOME: 42% (132/315) of NASA patients demonstrated a 90 day mRS ≤2 compared with 37% (SWIFT) and 40% (TREVO 2). 90 day mortality was 30.2% (95/315) versus 17.2% (SWIFT) and 29% (TREVO 2). CONCLUSIONS: The NASA registry demonstrated that the Solitaire FR device performance in clinical practice is comparable with the SWIFT and TREVO 2 trial results.

OBJECTIVES: Neck pain commonly accompanies recurrent headaches such as migraine, tension-type and cervicogenic headache. Neck pain may be part of the headache symptom complex or a local source. Patients commonly seek neck treatment to alleviate headache, but this is only indicated when cervical musculoskeletal dysfunction is the source of pain. Clinical presentation of reduced cervical extension, painful cervical joint dysfunction and impaired muscle function collectively has been shown to identify cervicogenic headache among patients with recurrent headaches. The pattern's validity has not been tested against the 'gold standard' of controlled diagnostic blocks. This study assessed the validity of this pattern of cervical musculoskeletal signs to identify a cervical source of headache and neck pain, against controlled diagnostic blocks, in patients with headache and neck pain. DESIGN: Prospective concurrent validity study that employed a diagnostic model building approach to analysis. SETTING: Hospital-based multidisciplinary outpatient clinic in Joliet, Illinois. PARTICIPANTS: A convenience sample of participants who presented to a headache clinic with recurrent headaches associated with neck pain. Sixty participants were enrolled and thirty were included in the analysis. OUTCOME MEASURES: Participants underwent a clinical examination consisting of relevant tests of cervical musculoskeletal dysfunction. Controlled diagnostic blocks of C2/C3-C3/C4 established a cervical source of neck pain. Penalised logistic regression identified clinical signs to be included in a diagnostic model that best predicted participants' responses to diagnostic blocks. RESULTS: Ten of thirty participants responded to diagnostic blocks. The full pattern of cervical musculoskeletal signs best predicted participants' responses (expected prediction error = 0.57) and accounted for 65% of the variance in responses. CONCLUSIONS: This study confirmed the validity of the musculoskeletal pattern to identify a cervical source of headache and neck pain. Adopting this criterion pattern may strengthen cervicogenic headache diagnosis and inform differential diagnosis of neck pain accompanying migraine and tension-type headache.

BACKGROUND AND OBJECTIVES: Despite multiple clinical trials comparing the adductor canal block (ACB) with femoral nerve block (FNB) for total knee arthroplasty, none looked at the aforementioned nerve blocks from early functional results to up to 6 months after surgery. METHODS: For this prospective, double-blind, randomized, single-center trial, we enrolled 98 patients set to undergo total knee arthroplasty. The patients were randomized, with 93 patients included in the intention-to-treat analysis. Subjects received injections of both ACB and an FNB, with 1 containing 30 mL of saline (placebo) and the other 30 mL of local anesthetic (treatment) depending on randomization. Adductor canal block and FNB were compared using percentage of baseline maximum voluntary isovolumetric contraction (MVIC) of the quadriceps muscle retained at 6 (primary endpoint), 24, and 48 hours and 6 months postoperatively. Secondary endpoints also included Timed Up and Go, range of motion, 6-minute walking test, pain score, and postoperative pain medication use. RESULTS: Percent MVIC retained was significantly higher in ACB patients at 6 (P < 0.0001) and 24 hours (P < 0.0001). Comparing Timed Up and Go results yielded significant difference between treatment groups at 6 hours (P = 0.0213) and 24 hours (P = 0.0424). Pain scores, pain medication intake, range of motion, and 6-minute walking test were not significantly different between the treatment groups. A linear relationship exists between the change in quadriceps MVIC and pain score in the ACB group, with increasing pain leading to a decreased MVIC (P = 0.0039). CONCLUSIONS: The ACB showed better preservation of quadriceps muscle strength and improved ambulation in the first 24 hours postoperatively without compromising pain control.

Background Limited post-marketing data exist on the use of the Solitaire FR device in clinical practice. The North American Solitaire Stent Retriever Acute Stroke (NASA) registry aimed to assess the real world performance of the Solitaire FR device in contrast with the results from the SWIFT (Solitaire with the Intention for Thrombectomy) and TREVO 2 (Trevo versus Merci retrievers for thrombectomy revascularization of large vessel occlusions in acute ischemic stroke) trials. Methods The investigator initiated NASA registry recruited North American sites to submit retrospective angiographic and clinical outcome data on consecutive acute ischemic stroke (AIS) patients treated with the Solitaire FR between March 2012 and February 2013. The primary outcome was a Thrombolysis in Myocardial Ischemia (TIMI) score of ≥2 or a Treatment in Cerebral Infarction (TICI) score of ≥2a. Secondary outcomes were 90 day modified Rankin Scale (mRS) score, mortality, and symptomatic intracranial hemorrhage. Results 354 patients underwent treatment for AIS using the Solitaire FR device in 24 centers. Mean time from onset to groin puncture was 363.4±239 min, mean fluoroscopy time was 32.9±25.7 min, and mean procedure time was 100.9±57.8 min. Recanalization outcome: TIMI ≥2 rate of 83.3% (315/354) and TICI ≥2a rate of 87.5% (310/354) compared with the operator reported TIMI ≥2 rate of 83% in SWIFT and TICI ≥2a rate of 85% in TREVO 2. Clinical outcome: 42% (132/315) of NASA patients demonstrated a 90 day mRS ≤2 compared with 37% (SWIFT) and 40% (TREVO 2). 90 day mortality was 30.2% (95/315) versus 17.2% (SWIFT) and 29% (TREVO 2). Conclusions The NASA registry demonstrated that the Solitaire FR device performance in clinical practice is comparable with the SWIFT and TREVO 2 trial results.

Purpose: This study used a cross-sectional design to examine the relationship between self-efficacy and exercise compliance in a cardiac population. Methods. The study sample was comprised of 20 females and 118 males who had completed a Phase II cardiac rehabilitation program. Of the sample, 43 were enrolled in a Phase III program, and 77 reportedly were exercising on their own. Only 18 of the respondents reportedly did not exercise at all. Exercise compliance/behavior was assessed according to guidelines developed by the American College of Sports Medicine. Frequency, intensity, and duration of exercise were assessed and then combined to produce the dependent variable (exercise behavior). Two measures were used to assess self-efficacy: the aggregation of six self-efficacy activity scales (total self-efficacy) and the aggregation of 16 perceived barriers to exercise (exercise barriers efficacy measure). Results. A positive correlation was observed between total self-efficacy and the exercise behavior measure (R = 0.3567, P < 0.001) as well as between the exercise behavior measure and the exercise barriers efficacy measure (R = 0.6727, P < 0.001). The exercise barriers efficacy measure was found to be the most significant predictor of exercise behavior (R2 = 0.270, P < 0.001), although total self-efficacy was also found to be a significant predictor of exercise behavior (R2 = 0.180, P < 0.005). Conclusions. Because exercise barriers efficacy was found to be the most predictive of exercise behavior, perceived barriers should be assessed of all graduates of the formal program (Phase II) and periodically of those enrolled in Phase III. Methodologies for implementing the sources of self-efficacy are offered.

PURPOSE: To provide the practitioner with updated information about pressure ulcers and their management. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in better understanding the scientific principles governing pressure ulcer development and treatment. OBJECTIVES: After reading this article and taking this test, the participant should be able to: 1. Discuss the etiology and assessment of pressure ulcers. 2. Describe treatment options for pressure ulcers.

Sharon Baranoski is director of medical-surgical nursing and the wound and hyperbaric center at Provena St. Joseph Medical Center in Joliet, Ill.

Closed claims analysis of adverse anesthesia outcomes was initiated through the AANA Foundation in 1995 to examine adverse outcomes of anesthesia care provided by Certified Registered Nurse Anesthetists (CRNAs). A research team of 8 CRNAs using an instrument incorporating more than 150 variables undertook document analyses of closed claim files. All files reviewed involved incidents in which the CRNA named in the policy was potentially involved in the adverse patient outcome. Thirty-eight percent (58/151) of CRNA-related claims involved a respiratory incident as the primary cause of the negative patient outcome. Patient outcomes involving respiratory incidents were more likely to result in death or permanent injury compared with nonrespiratory incidents (P < .01). Reviewers found that respiratory claims were more likely to have involved inappropriate anesthesia management (P < .01), more likely to have involved a lack of vigilance (P < .01), and more likely to have been judged by the reviewer as preventable (P < .01). A higher percentage of respiratory incidents occurred in emergency cases (75% vs 34%, P < .01) and in cases involving general anesthesia (44% vs 17%, P < .01). Adverse respiratory incidents are largely preventable and frequently result in serious patient morbidity and mortality.

BACKGROUND AND PURPOSE: Few studies have explored optimal advancement and variation in mobility and length of stay (LOS) data with critically ill patients in the intensive care unit (ICU). The purpose of this study was to analyze the outcomes and LOS of critically ill patients in the neurotrauma ICU involved in rehabilitation. METHODS: A bidirectional case-control study of a total of 30 patients admitted to a level 1 trauma hospital in the metropolitan Chicago area with Glasgow Coma Score (GCS) of ≤12 (3-12) were studied. Functional outcomes of a structured mobility group were compared at first upright sitting and at ICU discharge using the functional independence measure (FIM). Retrospective LOS review of a group (n = 15) with unstructured activity advancement was compared. RESULTS: The main outcome measures were FIM scores and LOS in number of days. In the structured mobility group, a significant increase in functional performance between first upright sitting and ICU discharge was found (P < .005). Length of stay was shorter in the structured mobility groups but the difference was not statistically significant. CONCLUSIONS: Results from this study revealed favorable functional outcomes for patients involved in a structured mobility program with physical therapy in the neuro/trauma ICU.

BACKGROUND: Time to reperfusion following endovascular treatment (ET) predicts outcomes after acute ischemic stroke (AIS). OBJECTIVE: To assess the time-outcome relationship within reperfusion grades in the North American Solitaire Acute Stroke registry. METHODS: We identified patients given ET for anterior circulation ischemic stroke within 8 h from onset and in whom reperfusion was achieved. Together with clinical and outcome data, site-adjudicated modified Thrombolysis in Cerebral Ischemia (TICI) was recorded. We assessed the impact of time to reperfusion (onset to procedure completion time) on good outcome (modified Rankin Scale 0-2 at 3 months) in patients who achieved TICI 2 or higher reperfusion in multivariable models. We further assessed this relationship within strata of reperfusion grades. A p<0.05 was considered significant. RESULTS: Independent predictors of good outcome at 3 months among those achieving TICI ≥2a reperfusion (n=188) were initial National Institutes of Health Stroke Scale score (adjusted OR=0.90, 95% CI 0.85 to 0.95), symptomatic hemorrhage (adj. OR=0.16, 95% CI 0.05 to 0.60), TICI grade (TICI 3: adj. OR=11.52, 95% CI 3.34 to 39.77; TICI 2b: adj. OR=5.14, 95% CI 1.61 to 16.39), and time to reperfusion per 30 min interval (adj. OR=0.91, 95% CI 0.82 to 0.99). There was an interaction between final TICI grade and 30 min time to reperfusion intervals (p=0.001) such that the effect of time was strongest in TICI 2a patients. CONCLUSIONS: Time to reperfusion was a strong predictor of outcome following ET for AIS. However, the effect varied by TICI grade such that its greatest effect was in those achieving TICI 2a reperfusion.

Sharon Baranoski is director of medical-surgical nursing and the wound and hyperbaric center at Provena St. Joseph Medical Center in Joliet, Ill. Meet Ms. Baranoski, who's speaking at the Nursing2008 Symposium in Las Vegas, Nev., March 18 to 21, 2008.

BACKGROUND: The Interventional Management of Stroke III (IMS-III) trial demonstrated no benefit for intravenous recombinant tissue plasminogen activator (IV rt-PA) followed by endovascular therapy versus IV rt-PA alone. However, IMS-III mostly included earlier generation devices. The recent thrombectomy trials have incorporated the stent-retriever technology, but their generalizability remains unknown. METHODS: The North American Solitaire Acute Stroke (NASA) registry recruited patients treated with the Solitaire FR™ device between March 2012 and February 2013. The NASA-IMS-III-Like Group (NILG baseline NIHSS score ≥10 who received IV rt-PA) was compared to the IV rt-PA and IV + intra-arterial (IA)-IMS-III groups and the MR CLEAN, ESCAPE, SWIFT Prime, and REVASCAT trial controls to assess the stent-retriever treatment in the 'real-world' setting. The NILG was also compared to non-IV rt-PA NASA patients to evaluate the impact of IV rt-PA on thrombectomy. RESULTS: A total of 136 of the 354 NASA patients fulfilled criteria for the NILG. Baseline characteristics were well balanced across groups. Time from onset to puncture was higher in NILG than IV+IA-IMS-III patients (274 ± 112 vs. 208 ± 47 min, p < 0.0001). Occlusions involving the intracranial ICA, MCA-M1, or basilar arteries were more common in NILG than IV+IA-IMS-III patients (91.2 vs. 47.2%, p < 0.00001). Modified thrombolysis in cerebral infarction ≥2b reperfusion was higher in NILG than IV+IA-IMS-III patients (74.3 vs. 39.6%, p < 0.00001). A 90-day modified Rankin Scale score ≤2 was more frequent in the NILG than IV+IA-IMS-III patients (51.9 vs. 40.8%, p = 0.03) and MR CLEAN (51.9 vs. 19.1%, p < 0.00001), ESCAPE (51.9 vs. 29.3%, p = 0.0002), SWIFT Prime (51.9 vs. 35.5%, p = 0.02), and REVASCAT (51.9 vs. 28.2%, p = 0.0003) controls. Symptomatic intracranial hemorrhage definitions varied across the different studies with rates ranging from 2.7% (ESCAPE) to 11.9% (NILG). The NILG 90-day mortality (24.4%) was higher than in SWIFT Prime but comparable to all other groups. IV rt-PA was an independent predictor of good outcome in NASA (OR = 2.3, 95% CI 1.2-4.7). CONCLUSION: Our results support the 'real-world' applicability of the recent thrombectomy trials.

Cancer pain continues to remain a significant problem for oncology patients treated in both the university and the community setting. Nursing knowledge regarding pain management has advanced significantly in recent years. This article provides health care professionals with current factual information on cancer pain management. The information focuses on the emotional aspects of cancer pain, specific principles of analgesic management, opioid equianalgesics, multiple approaches to opioid administration, management of unwanted side effects, and a description of inappropriate drug therapies.

<i>Background:</i> Premenstrual syndrome (PMS) is characterized by any of a number of physical and psychological symptoms consistently occurring in the late luteal phase. Progesterone therapy is often recommended based on anecdotal evidence, although controlled studies have shown it to be ineffective. Oral contraceptives are more often used with mixed results. When hormonal therapy for PMS is indicated, the most appropriate choice remains a challenge. <i>Methods:</i> We describe a case report of successful hormonal therapy for PMS and a review of the literature on the effectiveness of hormonal therapies. <i>Results and Conclusions:</i> Estrogen is clearly effective in relieving symptoms of PMS, whereas progesterone is ineffective and might even worsen symptoms. Combination oral contraceptives are effective, undoubtedly as a result of the estrogen component. While little comparative data exist to guide choice of an oral contraceptive, maximizing the relative estrogenic potency of the oral contraceptive seems logical. Depressive symptoms might not respond to hormonal treatment, and new research suggests that selective serotonin reuptake inhibitors might be particularly effective.

In Brief All health care providers need to be involved in preventing and treating these problematic wounds. Here's what you need to know. Wake up to what all nurses need to know about pressure ulcers. Read about evidence-based initiatives for preventing and managing these debilitating wounds to make sure you're meeting current patient-care standards.

A new method of generating wedge-shaped dose distributions through dynamic multileaf collimator dose delivery rather than computer-controlled jaw motion is presented. The method starts with the calculation of a wedge-shaped beam profile for the desired wedge angle. The resultant wedge beam profile is then passed to the intensity-modulated radiation therapy (IMRT) leaf sequence generation algorithm to create multileaf collimator (MLC) segments for dose delivery. Wedge-shaped dose distributions are achieved through dynamic MLC dose delivery guided with the generated MLC segments. The method has been tested by generating wedgeshaped doses for a set of conventional wedge angles (i.e., 15 degrees, 30 degrees, 45 degrees, and 60 degrees). Film dosimetry is used for dose distribution verification. For each dose delivery guided with MLC segments created for the indicated wedge angle, the desired wedge-shaped dose distributions are observed. It is concluded that the dynamic MLC can be used to implement dynamic wedges in the clinic. This technique is different from the virtual wedge or the dynamic wedge developed for a particular type of LINAC. The same method can be applied to any machine equipped with a MLC. Other advantages are that it can generate a wedge field at an arbitrary orientation as the omni wedge does, and it creates wedged and shaped fields using a MLC only.

&lt;b&gt;&lt;i&gt;Background:&lt;/i&gt;&lt;/b&gt; Various techniques are used to enhance the results of mechanical thrombectomy with stent-retrievers, including proximal arrest with balloon guide catheter (BGC), conventional large bore proximal catheter (CGC), or in combination with local aspiration through a large-bore catheter positioned at the clot interface (Aspiration-Retriever Technique for Stroke [ARTS]). We evaluated the impact of ARTS in the North American Solitaire Acute Stroke (NASA) registry. &lt;b&gt;&lt;i&gt;Summary:&lt;/i&gt;&lt;/b&gt; Data on the use of the aspiration technique were available for 285 anterior circulation patients, of which 29 underwent ARTS technique, 131 CGC, and 125 BGC. Baseline demographics were comparable, except that ARTS patients are less likely to have hypertension or atrial fibrillation. The ARTS group had more ICA occlusions (41.4 vs. 22% in the BGC, &lt;i&gt;p&lt;/i&gt; = 0.04 and 26% in CGC, &lt;i&gt;p&lt;/i&gt; = 0.1) and less MCA/M1 occlusions (44.8 vs. 68% in BGC and 62% in CGC). Time from arterial puncture to reperfusion or end of procedure with ARTS was shorter than with CGC (54 vs. 91 min, &lt;i&gt;p&lt;/i&gt; = 0.001) and was comparable to the BGC time (54 vs. 67, &lt;i&gt;p&lt;/i&gt; = 0.11). Final degree of reperfusion was comparable among the groups (TICI [modified Thrombolysis in Cerebral Infarction] score 2b or higher was 72 vs. 70% for CGC vs. 78% for BGC). Procedural complications, mortality, and good clinical outcome at 90 days were similar between the groups. &lt;b&gt;&lt;i&gt;Key Messages:&lt;/i&gt;&lt;/b&gt; The ARTS mechanical thrombectomy in acute ischemic stroke patients appears to yield better results as compared to the use of CGCs with no significant difference when compared to BGC. This early ARTS technique NASA registry data are limited by the earlier generation distal large bore catheters and small sample size. Future studies should focus on the comparison of ARTS and BGC techniques.

Strangulation of the genitalia with constricting metal bands presents a difficult problem with removal. We report the easy and safe removal by cutting the metal bands in two places using a hand-held Dremel Moto-Tool [corrected] with a metal cutting disk.

PURPOSE: The optically guided target localization had been developed for linear accelerator based stereotactic radiosurgery (SRS). Unlike the traditional laser localization, the optical guided target localization utilizes a digital system to position patient. Although the system has been proven accurate and robust, it takes away the capability of physicist to directly double check the target position prior to irradiation. Any error from system calibration, data transformation, or head ring position maintenance will not be caught. The purpose of this work is to investigate the possibility of using cone-beam CT (CBCT) to double check the optically guided SRS target localization and reposition the patient. METHODS: A SRS quality assurance (QA) phantom was used in the study. The phantom mounted with SRS head frame was scanned by computer tomography (CT) and planned according to the SRS radiation treatment planning process. A target isocenter is defined and transferred to the optically guided target localization system. The phantom was then transported to the linear accelerator room and localized at the initial position agreed by the optically guided target localization system and the CBCT system. Tests were conducted by moving/rotating the phantom to a set of preset offsets and taking CBCT images. Shifts detected by CBCT were compared with the preset offsets. Agreements between them were studied to see how well the CBCT was in discovering the optically guided target localization error. RESULTS: Experiment results demonstrated good agreement between the CBCT detected phantom shift and the preset offset, when the offset is above 1 mm shift or 0.2 degree rotation. Offset less than 1 mm shift or 0.2 degree rotation was not detectable by CBCT. CONCLUSIONS: The study concludes that the CBCT is able to discover the optically guided target localization error due to the system calibration or had ring migration. It is a valuable second check tool for SRS target localization quality assurance. The accuracy of CBCT in estimating patient positioning deviation satisfies the SRS procedures with generous tumor size and margin that can tolerate 1 mm or 0.2 degree accuracy. This avoids sending patient home without treatment. CBCT can be neither used as a primary SRS target localization nor can it be used to reposition the patient that cannot tolerate 1 mm shift or 0.2 degree rotation.