Assessment of efficacy in automated plan generation for Varian Ethos intelligent optimization engine.

Varian Ethos, a new treatment platform, is capable of automatically generating treatment plans for initial planning and for online, adaptive planning, using an intelligent optimization engine (IOE). The primary purpose of this study is to assess the efficacy of Varian Ethos IOE for auto-planning and intercompare different treatment modalities within the Ethos treatment planning system (TPS). A total of 36 retrospective prostate and proximal seminal vesicles cases were selected for this study. The prescription dose was 50.4 Gy in 28 fractions to the proximal seminal vesicles, with a simultaneous integrated boost of 70 Gy to the prostate gland. Based on RT intent, three treatment plans were auto-generated in the Ethos TPS and were exported to the Eclipse TPS for intercomparison with the Eclipse treatment plan. When normalized for the same planning target volume (PTV) coverage, Ethos plans Dmax% were 108.1 ± 1.2%, 108.4 ± 1.6%, and 109.6 ± 2.0%, for the 9-field IMRT, 12-field IMRT, and 2-full arc VMAT plans, respectively. This compared well with Eclipse plan Dmax% values, which was 108.8 ± 1.4%. OAR indices were also evaluated for Ethos plans using Radiation Therapy Oncology Group report 0415 as a guide and were found to be comparable to each other and the Eclipse plans. While all Ethos plans were comparable, we found that, in general, the Ethos 12-field IMRT plans met most of the dosimetric goals for treatment. Also, Ethos IOE consistently generated dosimetrically hotter VMAT plans versus IMRT plans. On average, Ethos TPS took 13 min to generate 2-full arc VMAT plans, compared to 5 min for 12-field IMRT plans. Varian Ethos TPS can generate multiple treatment plans in an efficient time frame and the quality of the plans could be deemed clinically acceptable when compared to manually generated treatment plans.

Value of ultrasound-guided aspiration of hip arthroplasties performed in an orthopedic clinic by orthopedic surgeons.

Background: Total joint arthroplasties continue to increase as do periprosthetic joint infections (PJIs). Ultrasound-guided aspiration can yield useful synovial fluid for analysis while avoiding radiation exposure. This study presents a high-yield, ultrasound-guided technique with analysis of aspiration results. Methods: All consecutive ultrasound-guided aspirations of hip arthroplasties performed from May 2016 through to April 2019 were retrospectively reviewed. Patient demographic information, component specifics, presence of draining sinus, and inflammatory markers were recorded. Results of aspiration including volume, appearance, lavage use, synovial fluid differential leukocyte count, synovial neutrophil percent, and culture results were recorded. Surgical results, specimen cultures, and surgeon description of purulence were recorded. Aspiration results were compared to the surgical specimen results in all patients who underwent reoperations. Results: Review of 349 hip aspirations demonstrated accuracy of 87 %, sensitivity of 83 %, specificity of 89 %, positive predictive value of 79 %, and negative predictive value 91 %. Surgical and aspiration cultures matched in 81 % of cases. Bloody aspirates and aspirates obtained after lavage had less accuracy at 69 % and 60 %, respectively. Specificity was 100 % for cultures obtained with lavage and 91 % for bloody aspirates. Synovial leukocyte count and neutrophil percentage was obtained in 85 % of aspirations, and cultures were obtained in 98 % of aspirates. Contamination rate was 2 %. Conclusion: Ultrasound-guided aspirations aid in the diagnosis of PJI. The use of lavage to obtain fluid is helpful when aspiration cultures are positive. Bloody aspirates are less accurate but have high specificity. A low contamination rate and 88 % accuracy results with this meticulous technique.

Knee-specific quality-of-life instruments: which ones measure symptoms and disabilities most important to patients?

BACKGROUND: Knee-specific quality-of-life instruments are commonly used outcome measures. However, they have not been compared for their ability to detect symptoms and disabilities important to patients. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 1. METHODS: Subjective portions of 11 knee-specific instruments were consolidated. The frequency and importance of each item were assessed. One hundred fifty-three patients with anterior cruciate ligament ruptures, isolated meniscal tears, or osteoarthritis were polled. Instruments were ranked according to the number of items with high mean importance, high frequency importance product, and low mean importance, and according to the number endorsed by at least 51% of patients. RESULTS: For anterior cruciate ligament tears, the Mohtadi quality-of-life instrument scored highest in 3 categories. For meniscal tears, the Western Ontario Meniscal Evaluation Tool scored highly in all 4 categories. For osteoarthritis, the Western Ontario and McMaster Universities Osteoarthritis Index scored highly in 4 categories. Of the general knee instruments, the International Knee Documentation Committee Standard Evaluation Form and the Knee Injury and Osteoarthritis Outcome Score scored favorably. CONCLUSION: The Mohtadi quality-of-life instrument, Western Ontario Meniscal Evaluation Tool, and Western Ontario and McMaster Universities Osteoarthritis Index-disease-specific instruments-contain many items important to patients. Of general knee instruments studied, the International Knee Documentation Committee Standard Evaluation Form and the Knee Injury and Osteoarthritis Outcome Score contain the most items important to patients. CLINICAL RELEVANCE: This study guides clinicians and researchers in selecting instruments that ensure that the patient's perspective is considered for outcome studies involving 3 common knee disorders.

Gender differences in frontal and sagittal plane biomechanics during drop landings.

PURPOSE: To determine gender differences in lower-extremity joint kinematics and kinetics between age- and skill-matched recreational athletes. METHODS: Inverse dynamic solutions estimated the lower-extremity flexion-extension and varus-valgus kinematics and kinetics for 15 females and 15 males performing a 60-cm drop landing. A mixed model, repeated measures analysis of variance (gender (*) joint) was performed on select kinematic and kinetic variables. RESULTS: Peak hip and knee flexion and ankle dorsiflexion angles were greater in females in the sagittal plane (group effect, P < 0.02). Females exhibited greater frontal plane motion (group (*) joint, P = 0.02). Differences were attributed to greater peak knee valgus and peak ankle pronation angles (post hoc tests, P = 0.00). Females exhibited a greater range of motion (ROM) in the sagittal plane (group main effect, P = 0.02) and the frontal plane (group (*) joint, P = 0.01). Differences were attributed to the greater knee varus-valgus ROM, ankle dorsiflexion, and pronation ROM (post hoc tests). Ground reaction forces were different between groups (group (*) direction, P = 0.05). Females exhibited greater peak vertical and posterior (A/P) force than males (post hoc tests). Females exhibited different knee moment profiles (Group main effect, P = 0.01). These differences were attributed to a reduced varus moment in females (post hoc tests). CONCLUSION: The majority of the differences in kinematic and kinetic variables between male and female recreational athletes during landing were observed in the frontal plane not in the sagittal plane. Specifically, females generated a smaller internal knee varus moment at the time of peak valgus knee angulation.

A modified test for patellar instability: the biomechanical basis.

OBJECTIVE: (1) Determine if displacement of the patella in a distal lateral direction results in a more sensitive method to show deficiency of the medial patellofemoral ligament (MPFL), the primary restraint to lateral patellar dislocation, than the traditional patellar apprehension test in a direct lateral direction. (2) Determine objective criteria for defining a positive patellar instability test rather than subjective evaluation of apprehension. DESIGN: In vitro biomechanical study. SPECIMENS: Ten above-the-knee amputation specimens. MAIN OUTCOME MEASURES: Force-displacement curves with direct lateral patellar displacement were compared with curves with distal lateral patellar displacement before and after sectioning the MPFL. RESULTS: After dividing the MPFL, average terminal restraining force to distal lateral patellar displacement declined by 53% (P=0.024), but force declined only by 30% (P=0.09) with lateral displacement. The greatest difference in terminal slope (eg, end point) was with the MPFL intact with lateral displacement compared with distal lateral displacement with the ligament divided (P=8.67x10(-5)). The terminal slope declined after ligament division with lateral (P=0.07) and distal lateral patellar displacement (P=0.09). CONCLUSION: Displacement of the patella in a distal lateral direction is a more sensitive maneuver to detect disruption of the MPFL, the primary soft tissue restraint, than with traditional lateral displacement. With the knee flexed 30 degrees and patella displaced 2 cm, objective criteria for a positive patellar instability test include greater ease of patellar translation and a softer end point compared with a normal, contralateral knee.

Evaluation of the Ottawa ankle rules in children.

OBJECTIVE: The Ottawa Ankle Rules (OAR) are criteria for predicting ankle fractures in adults allowing for insignificant fractures, defined as small avulsion fractures. Because the clinical significance of avulsion fractures and Salter-Harris type I fractures in children is unclear, we sought to prospectively evaluate the use of the OAR in children and to determine whether different criteria should be used for predicting ankle fractures in children. METHODS: In this prospective study, patients younger than 18 years presenting to a pediatric emergency department (ED) with an acute nonpenetrating ankle injury were eligible for study participation. Information on 22 clinical variables was recorded on a standardized data sheet. The OAR were included but not specifically identified on the data sheets. A standard ankle radiographic series was obtained on all subjects. All fractures were considered to be significant. Follow-up phone calls were performed to assess final diagnosis and outcome. Sensitivity and specificity of OAR and other potential criteria for predicting ankle fractures in children were calculated. RESULTS: A total of 195 patients with ankle injuries were evaluated. The mean age of patients was 12.6 years. Forty fractures (21%) were identified. The sensitivity of OAR was 83% (95% CI, 65-94%), specificity was 50% (95% CI, 41-59%), positive predictive value was 28%, and negative predictive value was 93%. Three independent factors were significantly associated with ankle fractures: inability to walk immediately after the event, inability to bear weight for four steps in the ED, and tender deltoid ligament. If one or more of these factors were present, sensitivity for predicting ankle fractures was 93% (95% CI, 78-99%), specificity was 27% (95% CI, 20-36%), positive predictive value was 23%, and negative predictive value was 95%. CONCLUSION: The OAR cannot be applied to children with the same sensitivity as adults.

Solar Injury and Heat Illness.

In brief Children are particularly susceptible to solar injury to the skin and eyes and to heat illness-heat cramps, heat exhaustion, and heatstroke. Because sunburn during childhood is linked to subsequent skin cancer, aggressive prevention through use of sunscreens and other protective measures is critical. Physicians should screen for risk factors for heat illness, such as hypohydration, obesity, poor conditioning, and certain illnesses. Heat illness can be effectively prevented through acclimation, proper hydration, and advance event planning.

Helping Active Women Avoid Anemia.

In brief Many active women, especially those in sports that place a premium on a lean physique, don't consume enough iron, which puts them at risk for anemia. When evaluating an active woman's iron status, it's important to determine her hemoglobin baseline and identify various sources of iron loss from the medical history. Hemoglobin, hematocrit, and serum ferritin levels are most often the only laboratory values needed for evaluation. Treatment of anemia and iron deficiency focuses on improving iron intake through food and supplements and monitoring the patient's progress. Prevention tactics include diet counseling for those with known risk factors for anemia.

Chest Pain in Active Young People.

In brief Chest pain in children and adolescents is usually benign and noncardiac, unlike that in adults. Some of the more common causes are activity related, such as chest wall trauma and exercise-induced asthma. A careful history and physical examination will often provide a diagnosis, though about one third of causes are idiopathic. Most patients will not require extensive testing or referral. Education and reassurance are essential for relieving patient and parent anxiety.