Using a reduced spot size for intensity-modulated proton therapy potentially improves salivary gland-sparing in oropharyngeal cancer

Purpose: To investigate whether intensity-modulated proton therapy with a reduced spot size (rsIMPT) could further reduce the parotid and submandibular gland dose compared with previously calculated IMPT plans with a larger spot size. In addition, it was investigated whether the obtained dose reductions would theoretically translate into a reduction of normal tissue complication probabilities (NTCPs). Methods: Ten patients with N0 oropharyngeal cancer were included in a comparative treatment planning study. Both IMPT plans delivered simultaneously 70 Gy to the boost planning target volume (PTV) and 54 Gy to the elective nodal PTV. IMPT and rsIMPT used identical three-field beam arrangements. In the IMPT plans, the parotid and submandibular salivary glands were spared as much as possible. rsIMPT plans used identical dose-volume objectives for the parotid glands as those used by the IMPT plans, whereas the objectives for the submandibular glands were tightened further. NTCPs were calculated for salivary dysfunction and xerostomia. Results: Target coverage was similar for both IMPT techniques, whereas rsIMPT clearly improved target conformity. The mean doses in the parotid glands and submandibular glands were significantly lower for three-field rsIMPT (14.7 Gy and 46.9 Gy, respectively) than for three-field IMPT (16.8 Gy and 54.6 Gy, respectively). Hence, rsIMPT significantly reduced the NTCP of patient-rated xerostomia and parotid and contralateral submandibular salivary flow dysfunction (27%, 17%, and 43% respectively) compared with IMPT (39%, 20%, and 79%, respectively). In addition, mean dose values in the sublingual glands, the soft palate and oral cavity were also decreased. Obtained dose and NTCP reductions varied per patient. Conclusions: rsIMPT improved sparing of the salivary glands and reduced NTCP for xerostomia and parotid and submandibular salivary dysfunction, while maintaining similar target coverage results. It is expected that rsIMPT improves quality of life during and after radiotherapy treatment.</p

Utilization and Workforce Integration of Physician Assistants

Background: The healthcare field is experiencing rapid growth in the number of advanced practice providers (APPs) with projections that demonstrate that this trend will only continue. Even though the number of APPs is growing, the development of facility-specific APP management infrastructure often grows at a slower pace. Specific policies and procedures on APP utilization and clinical efficiency metrics are lacking. This can lead to deficiencies in the understanding of the education and practice boundaries of APPs. Objective: Our study aimed to analyze the growth and utilization of physician assistants (PAs) in several hospitals located within Texas Medical Center (TMC) in Houston, Texas. We investigated potential factors influencing PA utilization and professional growth and information on the workflow structure, perceived barriers to the efficient utilization of PAs, and the integration of PAs into clinical teams and practice. Methods: We used a mixed methods design to investigate the trends of PAs in hospitals within a large urban medical center. Eight clinical managers at eight different TMC institutions were invited to participate in an email survey and qualitative phone interview. Results: The survey response rate was 62.5% (n=5). Analysis of interviews and survey responses identified five major themes regarding the utilization of the PA within the organizations: 1) the majority of locations employ PAs in team-based workflow structures with the main goal of creating increased access to care, 2) PAs provide an important degree of continuity and consistency for healthcare services, 3) most locations attempted to measure PA clinical efficiency, but struggled in regards to the best methods to do so, 4) hospitals have a favorable trend in retention rates of PAs and offer research opportunities and professional growth resources to their advanced practice providers, and 5) institutions encountered difficulty when it came to optimal billing practices for PAs. Conclusions: The primary focus of a PA’s job responsibility has shifted from providing physician satisfaction to an increased focus on providing quality patient care and increased patient access. PAs help facilitate coordination of care and create a solid foundation for continuity of care. There is a need for an updated method to measure PA clinical efficiency and a need for standardized PA billing practices

POTENTIAL BENEFITS OF SCANNED INTENSITY-MODULATED PROTON THERAPY VERSUS ADVANCED PHOTON THERAPY WITH REGARD TO SPARING OF THE SALIVARY GLANDS IN OROPHARYNGEAL CANCER

Purpose: To test the hypothesis that scanned intensity-modulated proton therapy (IMPT) results in a significant dose reduction to the parotid and submandibular glands as compared with intensity-modulated radiotherapy with photons (IMRT) and three-dimensional conformal radiotherapy (3D-CRT) for oropharyngeal cancer. In addition, we investigated whether the achieved dose reductions would theoretically translate into a reduction of salivary dysfunction and xerostomia. Methods and Materials: Ten patients with NO oropharyngeal carcinoma were used. The intensity-modulated plans delivered simultaneously 70 Gy to the boost planning target volume (PTV2) and 54 Gy to the elective nodal areas (PTV1). The 3D-CRT technique delivered sequentially 70 Gy and 46 Gy to PTV2 and PTV1, respectively. Normal tissue complication probabilities were calculated for salivary dysfunction and xerostomia. Results: Planning target volume coverage results were similar for IMPT and IMRT. Intensity-modulated proton therapy clearly improved the conformity. The 3D-CRT results were inferior to these results. The mean dose to the parotid glands by 3D-CRT (50.8 Gy), IMRT (25.5 Gy), and IMPT (16.8 Gy) differed significantly. For the submandibular glands no significant differences between BIRT and IMPT were found. The dose reductions obtained with IMPT theoretically translated into a significant reduction in normal tissue complication probability. Conclusion: Compared with IMRT and 3D-CRT, IMPT improved sparing of the organs at risk, while keeping similar target coverage results. The dose reductions obtained with IMPT vs. IMRT and 3D-CRT varied widely per individual patient. Intensity-modulated proton therapy theoretically translated into a clinical benefit for most cases, but this requires clinical validation. (C) 2011 Elsevier Inc

Additional file 1: of Pseudoprogression manifesting as recurrent ascites with anti-PD-1 immunotherapy in urothelial bladder cancer

Supplementary Table 1: Ratio of ascites-to-stimulated PBMC control values for cytokine arrayanalytes. (XLSX 9 kb

Analysis of Outcomes in Ischemic vs Nonischemic Cardiomyopathy in Patients With Atrial Fibrillation A Report From the GARFIELD-AF Registry

IMPORTANCE Congestive heart failure (CHF) is commonly associated with nonvalvular atrial fibrillation (AF), and their combination may affect treatment strategies and outcomes