An Eye on the First Surgical Side: Appreciating the Potential Impacts of a Second DBS Lead on Ipsilateral Symptoms.

Clinical Vignette: A 63-year-old man with severe essential tremor underwent staged bilateral ventralis intermedius (Vim) deep brain stimulation (DBS). Left Vim DBS resulted in improved right upper extremity tremor control. Months later, the addition of right Vim DBS to the other brain hemisphere was associated with acute worsening of the right upper extremity tremor. Clinical Dilemma: In staged bilateral Vim DBS, second lead implantation may possibly alter ipsilateral tremor control. While ipsilateral improvement is common, rarely, it can disrupt previously achieved benefit. Clinical Solution: DBS programming, including an increase in left Vim DBS amplitude, re-established and enhanced bilateral tremor control. Gap in Knowledge: The mechanisms underlying changes in ipsilateral tremor control following a second lead implantation are unknown. In this case, worsening and subsequent improvement after optimization highlight the potential impact of DBS implantation on the ipsilateral side. Expert Commentary: After staged bilateral Vim DBS, clinicians should keep an eye on the first or original DBS side and carefully monitor for emergent side effects or worsening in tremor. Ipsilateral effects resulting from DBS implantation present a reprogramming opportunity with a potential to further optimize clinical outcomes. Highlights: This case report highlights the potential for ipsilateral tremor worsening following staged bilateral DBS and provides valuable insights into troubleshooting and reprogramming strategies. The report emphasizes the importance of vigilant monitoring and individualized management in optimizing clinical outcomes for patients undergoing staged bilateral DBS for essential tremor.

The impact of COVID-19 pandemic on patient selection and access to care, approach type, and postoperative outcomes in bariatric surgery.

BACKGROUND: The COVID-19 pandemic had affected the health systems across the world since early 2020 with a concern about access to medical care during the first wave of COVID-19 pandemic. OBJECTIVES: The objective of this study was to examine how the COVID-19 pandemic influenced patient selection, approach type, and postoperative outcomes in elective bariatric surgery. SETTING: United States. METHODS: Data from the MBSAQIP database for the years 2016-2020 were queried. Wilcoxon rank-sum test and Fisher's exact test were employed for continuous and categorical variables, respectively. Postoperative outcomes within 30 days were assessed separately and based on the Clavien-Dindo (CD) classification of III-V. χ2 test and logistic regression were used to compare outcomes between procedure and approach types, as well as surgical operation periods. RESULTS: A total of 741,620 patients underwent robotic and laparoscopic sleeve gastrectomy and Roux-en-Y gastric-bypass. The cases performed in 2020 exhibited lower comorbidities and postoperative complications compared to prepandemic years, regardless of the approach type. Notably, the proportion of White patients decreased during the pandemic, while there was an increase in the number of African American and Hispanic patients who had bariatric surgery. CONCLUSIONS: Patients who underwent bariatric surgery during the COVID-19 pandemic appeared to be healthier with fewer comorbidities and experienced fewer adverse postoperative outcomes compared to those who had surgery prior to the pandemic. This study highlights the limited access to bariatric surgery for high-risk patients during the pandemic.

Analysis of eligibility criteria in Alzheimer's and related dementias clinical trials.

Overly restrictive clinical trial eligibility criteria can reduce generalizability, slow enrollment, and disproportionately exclude historically underrepresented populations. The eligibility criteria for 196 Alzheimer's Disease and Related Dementias (AD/ADRD) trials funded by the National Institute on Aging were analyzed to identify common criteria and their potential to disproportionately exclude participants by race/ethnicity. The trials were categorized by type (48 Phase I/II pharmacological, 7 Phase III/IV pharmacological, 128 non-pharmacological, 7 diagnostic, and 6 neuropsychiatric) and target population (51 AD/ADRD, 58 Mild Cognitive Impairment, 25 at-risk, and 62 cognitively normal). Eligibility criteria were coded into the following categories: Medical, Neurologic, Psychiatric, and Procedural. A literature search was conducted to describe the prevalence of disparities for eligibility criteria for African Americans/Black (AA/B), Hispanic/Latino (H/L), American Indian/Alaska Native (AI/AN) and Native Hawaiian/Pacific Islander (NH/PI) populations. The trials had a median of 15 criteria. The most frequent criterion were age cutoffs (87% of trials), specified neurologic (65%), and psychiatric disorders (61%). Underrepresented groups could be disproportionately excluded by 16 eligibility categories; 42% of trials specified English-speakers only in their criteria. Most trials (82%) contain poorly operationalized criteria (i.e., criteria not well defined that can have multiple interpretations/means of implementation) and criteria that may reduce racial/ethnic enrollment diversity.

Practical management of oral treprostinil in patients with pulmonary arterial hypertension: Lessons from ADAPT, EXPEDITE, and expert consensus.

BACKGROUND: Oral treprostinil is a prostacyclin analogue approved to treat pulmonary arterial hypertension (PAH) by delaying disease progression and improving exercise capacity. Higher doses of oral treprostinil correlate with increased treatment benefit. Titrations may be challenging due to common side effects of prostacyclin-class therapies. STUDY DESIGN AND METHODS: The multicenter, prospective, real-world, observational ADAPT Registry study followed adult patients with PAH for up to 78 weeks after initiating oral treprostinil (NCT03045029). Dosing, titration, and transitions of oral treprostinil were at the discretion of the prescriber. Patient-reported incidence and treatment of common side effects were collected to understand side effect management and tolerability. Insights from literature and expert recommendations were added to provide a consolidated resource for oral treprostinil use. RESULTS: In total, 139 participants in ADAPT completed ≥1 weekly survey; (median age 60.0 years, 76% female). Median treatment duration of oral treprostinil was 13.1 months. During early therapy (Months 1-5), 62% (78/126) of patients reported headache and diarrhea, and 40% (50/126) reported nausea. At Month 6, many patients who reported side effects during early therapy reported an improvement (61% headache, 44% diarrhea, 70% nausea). Common side effect treatments, including acetaminophen, loperamide, and ondansetron were effective. Approximately one-quarter of patients reporting the most common side effects were untreated at Month 6. CONCLUSION: Patient selection for, and initiation and titration of oral treprostinil should be individualized and may include parenteral treprostinil induction-transition for faster titration. Assertive side effect management may help reach higher and more efficacious doses of oral treprostinil.

Advancing vascularized composite allotransplantation: essential factors for upper extremity transplant program development.

Vascularized Composite Allotransplantation (VCA) offers a unique option to restore form and function after limb loss or facial trauma that cannot be satisfactorily accomplished through traditional prosthetics or reconstructions. Establishing a successful Upper Extremity Transplantation (UET) program requires strong leadership and a structured surgical team, and extensive interdisciplinary collaboration. We conducted a qualitative study among 12 health care professionals and patients. Informed consent was obtained per protocol, and semi-structured interviews were conducted online and recorded. Participants reported their perceptions of factors that either favored or hindered a successful outcome, including functional status before and after surgery, preparation for transplant, shared decision-making, rehabilitation, and psychosocial support. Thematic analysis revealed that it is essential to establish a team comprising various disciplines well before performing VCA procedures. Defining a common goal and choosing a defined leader is a key factor in procedural success and requires open collaboration beyond what is typical. Primary described categories are interdisciplinary collaboration and skills of the VCA team, building and leading a VCA team, pre-transplant procedures, post-transplant course, and factors to consider when establishing a program. The basic roles of team science play an outsized role in establishing a VCA program. Transplantation medicine involves various overlapping scientific and medical categories requiring health professionals to consciously work together to establish complex vertical and horizontal communication webs between teams to obtain positive outcomes. In addition to medical considerations, patient-specific factors such as transparent communication, therapy plan establishment, plan adherence, and continual follow-up are significant factors to overall success.

Recipient blood group does not affect hepatocellular carcinoma recurrence after living donor liver transplantation in Korea.

PURPOSE: This study assessed whether or not the ABO blood type affects the incidence of HCC recurrence after living donor liver transplantation (LDLT). METHODS: This retrospective observational study included 856 patients with hepatocellular carcinoma (HCC) who underwent LDLT between January 2006 and December 2016 at the Asan Medical Center. RESULTS: This study included 324 patients (37.9%) with blood type A, 215 (25.1%) with blood type B, 210 (24.5%) with blood type O, and 107 (12.5%) with blood type AB. ABO-incompatible LT was performed in 136 (15.9%) patients. The independent risk factors for the disease-free survival (DFS) were maximal tumor diameter, microvascular invasion, and Milan criteria. The only independent risk factor for the overall survival (OS) was microvascular invasion. The ABO blood group did not affect the DFS (P = 0.978) or OS (P = 0.261). The DFS according to the ABO blood group did not differ significantly between the ABO-compatible (p = 0.701) and ABO-incompatible LDLT recipients (p = 0.147). The DFS according to the ABO blood group did not differ significantly between patients within the Milan criteria (p = 0.934) and beyond the Milan criteria (p = 0.525). The DFS did not differ significantly between recipients with and without type A blood (p = 0.941). CONCLUSIONS: This study demonstrated that the ABO blood group system had no prognostic impact on the oncological outcomes of patients undergoing LT for HCC.

Development Perspectives for Curative Technologies in Primary Demyelinating Disorders of the Central Nervous System with Neuromyelitis Optica Spectrum Disorder (NMOSD) and Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease (MOGAD) at the Forefront.

Primary demyelinating disorders of the central nervous system (CNS) include multiple sclerosis and the orphan conditions neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein IgG-associated disease (MOGAD). Curative technologies under development aim to selectively block autoimmune reactions against specific autoantigens while preserving the responsiveness of the immune system to other antigens. Our analysis focused on target patient selection for such developments, carefully considering the relevant clinical, regulatory, and market-related aspects. We found that the selection of patients with orphan conditions as target populations offers several advantages. Treatments for orphan conditions are associated with limited production capacity, qualify for regulatory incentives, and may require significantly shorter and lower-scale clinical programs. Furthermore, they may meet a higher acceptable cost-effectiveness threshold in order to compensate for the low numbers of patients to be treated. Finally, curative technologies targeting orphan indications could enter less competitive markets with lower risk of generic price erosion and would benefit from additional market protection measures available only for orphan products. These advantages position orphan conditions and subgroups as the most attractive target indications among primary demyelinating disorders of the CNS. The authors believe that after successful proof-of-principle demonstrations in orphan conditions, broader autoimmune patient populations may also benefit from the success of these pioneering developments.

Access to robotic assisted kidney transplant for recipients: a systematic review and call for reporting standards.

Robot-assisted kidney transplantation (RAKT) is a relatively novel, minimally invasive option for kidney transplantation. However, clarity on recipient selection in the published literature is lacking thereby significantly limiting interpretation of safety and other outcomes. This systematic review aimed to identify and synthesize the data on selection of RAKT recipients, compare the synthesized data to kidney transplant recipients across the USA, and explore geographical clusters of availability of RAKT. Systematic literature review, in accordance with PRISMA, via OVID MEDLINE, Embase, and Web of science from inception to March 5, 2023. All data entry double blinded and quality via Newcastle Ottawa Scale. 44 full-text articles included, encompassing approximately 2402 kidney transplant recipients at baseline but with considerable suspicion for overlap across publications. There were significant omissions of information across studies on patient selection for RAKT and/or analysis. Overall, the quality of studies was very low. Given suspicion of overlap across studies, it is difficult to determine how many RAKT recipients received living (LD) versus deceased donor (DD) organs, but a rough estimate suggests 89% received LD. While the current RAKT literature provides preliminary evidence on safety, there are significant omissions in reporting on patient selection for RAKT which limits interpretation of findings. Two recommendations: (1) international consensus is needed for reporting guidelines when publishing RAKT data and (2) larger controlled trials consistently reporting recipient characteristics are needed to clearly determine selection, safety, and outcomes across both LD and DD recipients.

Predictors of Extended Length of Stay Following Open Reduction and Internal Fixation for Proximal Humerus Fractures.

Purpose: An extended length of stay following open reduction and internal fixation (ORIF) for proximal humerus fractures (PHFs) is associated with increased patient morbidity and health care costs. The primary purpose of this study was to identify risk factors for an extended length of stay following ORIF for PHF. Methods: All patients who underwent ORIF for PHF between 2015 and 2021 were queried from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Patient demographics, comorbid conditions, and postoperative complications within 30 days of procedure were collected. Extended length of stay (eLOS) was defined by ≥ 3 days from operation to discharge. Multivariate logistic regression was employed to identify predictors of eLOS following ORIF. Results: Characteristics of patients significantly associated with eLOS included age ≥ 75 years (p < .001), male gender (p < 0.001), body mass index (BMI) < 18.5 (P = .001), American Society of Anesthesiologists (ASA) classification ≥ 3 (P < .001), dependent functional status (P < .001), noninsulin-dependent diabetes (P = .037), insulin-dependent diabetes (P < .001), chronic obstructive pulmonary disease (P < .001), congestive heart failure (CHF) (P < .001), hypertension (P < 0.001), dialysis (P < .013), disseminated cancer (P < 0.001), chronic steroid use (P = .004), and bleeding disorder (P < .001). Independent predictors of eLOS were age ≥ 75 years (OR = 2.69; P < .001), BMI < 18.5 (OR = 1.70; P = .016), ASA ≥ 3 (OR = 2.70; P < .001), dependent functional status (OR = 2.30; P < .001), CHF (OR = 3.57; P < .001), disseminated cancer (OR = 7.62; P < .001), and bleeding disorder (OR = 2.68; P < .001). Conclusion: Age ≥ 75, BMI < 18.5, ASA ≥ 3, functional dependence, CHF, disseminated cancer, and bleeding disorder were independently associated with eLOS. Clinical Relevance: Assessing specific patient factors prior to ORIF for PHF can assist in managing perioperative risks and decreasing expenses related to eLOS. Level of Evidence: Prognosis III.

Outpatient versus inpatient shoulder arthroplasty outcomes using an updated patient-selection algorithm: minimum two-year follow-up.

BACKGROUND: Previous studies have demonstrated the safety and cost-effectiveness of outpatient total shoulder arthroplasty (TSA), with the majority of studies focusing on 90-day outcomes and complications. Patient selection algorithms have helped appropriately choose patients for an outpatient TSA setting. This study aimed to determine the outcomes of TSA between outpatient and inpatient cohorts with at least a 2-year follow-up. METHODS: A retrospective review identified patients older than 18 years who underwent a TSA with a minimum of 2-year follow-up in either an inpatient or outpatient setting. Using a previously published outpatient TSA patient-selection algorithm, patients were allocated into three groups: outpatient, inpatient due to insurance requirements, and inpatient due to not meeting algorithm criteria. Outcomes evaluated included visual analog scale (VAS) pain, American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, range of motion (ROM), strength, complications, re-admissions, and re-operations. Analysis was performed between the outpatient and inpatient groups to demonstrate the safety and efficacy of outpatient TSA with midterm follow-up. RESULTS: A total of 779 TSA were included in this study, allocated into the outpatient (N = 108), inpatient due to insurance (N = 349), and inpatient due to algorithm (N = 322). The average age between these groups was significantly different (59.4 ± 7.4, 66.5 ± 7.5, and 72.5 ± 8.7, respectively; P < 0.0001). All patient groups demonstrated significant improvements in preoperative to final patient-outcomes scores, ROM, and strength. Analysis between cohorts showed similar final follow-up outcome scores, ROM, and strength, with few significant differences that are likely not clinically different, regardless of surgical location, insurance status, or meeting patient-selection algorithm. Complications, reoperations, and readmissions between all three groups were not significantly different. CONCLUSION: This study reaffirms prior short-term follow-up literature. Transitioning appropriate patients to outpatient TSA results in similar outcomes and complications compared to inpatient cohorts with mid-term follow-up.

Rapid Selection of Patients Suitable for Deep Inspiration Breath-Hold Using an Automatic Delineating System and RapidPlan Model in Left Breast Cancer Patients undergoing Adjuvant Radiotherapy with IMRT.

PURPOSE: This study aimed to determine whether radiotherapy plans created using an automatic delineating system and a RapidPlan (RP) module could rapidly and accurately predict heart doses and benefit from deep inspiratory breath-hold (DIBH)in left breast cancer patients. METHODS AND MATERIALS: One hundred thirty-six clinically approved free breathing (FB) plans for patients with left breast cancer were included, defined as manual delineation-manual plan (MD-MP). A total of 104/136 plans were selected for RP model training. A total of 32/136 patients were automatically delineated by software, after which the RP generated plans, defined as automatic delineation-RapidPlan (AD-RP). In addition, 40 patients who used DIBH were included to analyze differences in heart benefits from DIBH. RESULTS: Two RP models were established for post breast-conserving surgery (BCS) and post modified radical mastectomy (MRM). There were no significant differences in most of the dosimetric parameters between the MD-MP and AD-RP. The heart doses of the two plans were strongly correlated in patients after BCS (0.80 ≤ r ≤ 0.88, P < 0.05) and moderately correlated in patients after MRM (0.46 ≤ r ≤ 0.58, P < 0.05). The RP model predicted the mean heart dose (MHD) within ± 59.67 cGy and ± 63.32 cGy for patients who underwent the two surgeries described above. The heart benefits from DIBH were significantly greater in patients with FB-MHD ≥ 4 Gy than in those with FB-MHD < 4 Gy. CONCLUSIONS: The combined automatic delineation RP model allows for the rapid and accurate prediction of heart dose under FB in patients with left breast cancer. FB-MHD ≥ 4 Gy can be used as a dose threshold to select patients suitable for DIBH.

Interventional treatment for post-thrombotic chronic venous obstruction: Progress and challenges.

Chronic venous obstruction, including nonthrombotic iliac vein lesions and post-thrombotic syndrome, presents a significant burden on patients' quality of life and health care systems. Venous recanalization and stenting have emerged as promising minimally invasive approaches, yet challenges in patient selection, procedural techniques, and long-term outcomes persist. This review synthesizes current knowledge on the interventional treatment of post-thrombotic syndrome, focusing on the evolution of endovascular techniques and stenting. Patient selection criteria, procedural details, and the characteristics of dedicated venous stents are discussed. Particular emphasis is given to the role of inflow and other anatomical considerations, along with postoperative management protocols for an optimal long-term outcome.

[Urinary stress incontinence in men: diagnostic workup and modern surgical treatment]. / Belastungsinkontinenz des Mannes: sinnvolle Diagnostik und moderne operative Therapie.

Radical prostatectomy is the most common cause of urinary stress incontinence in male patients. The exact pathophysiology is not clearly defined but probably due multifactorial. Thorough preoperative diagnostic workup before surgical therapy appears to be crucial for good postoperative results. Various systems are available. The artificial urinary sphincter continues to be considered standard procedure with a high success rate, even in patients with more complex situations and severe urinary incontinence. However, there are also relevant complication and revision rates. Modern alternatives include various sling systems. The adjustable sling systems consist of a cushion that is placed against the urethral bulb and leads to a permanent increase in urethral resistance, which can be readjusted in different ways depending on the system implanted. The adjustable sling systems also seem to be an alternative in patients with a prior history of radiation therapy. The AdVance XP sling (Boston Scientific, Marlborough, MA, USA) is a fixed sling that corrects the postoperative hypermobility of the posterior urethra after radical prostatectomy and, thus, leads to a longer functional urethral length. Good long-term results after AdVance XP implantation are only possible in selected patients.

Development, content validation and standardization of an adult patient prioritization tool for hospital clinical pharmacy services.

BACKGROUND: Patient prioritization is a effective strategy to identify high risk patients for targeted Clinical Pharmacy Service (CPS) in hospital pharmacy. However, there is a paucity of patient prioritization tool to use in clinical practice. OBJECTIVES: Describe the development, content validation and standardization of an adult patient prioritization tool for hospital CPS named, PrioFarClinH. METHODS: The tool was developed using a stepwise design multi: Scoping Review to identify prioritization criteria/sub-criteria; Delphi technique to obtain consensus under the identified criteria/sub-criteria; Survey with pharmacists evaluating applicability of the criteria/sub-criteria obtained from Delphi; Definition of criteria/sub-criteria to be included in PrioFarClinH attribution of scores. Content validation was performed by a panel of experts evaluating relevance, feasibility, clarity and adequacy of the score. Content Validity Index (CVI) was calculated. Standardization occurred through a retrospective observational study carried out at 24 and 72 h and median of the patient's hospital stay. An intragroup norm was performed, determining percentile ranks of the instrument's total scores. Patients with a P90 score were classified with a high level of prioritization for CPS. RESULTS: PrioFarClinH is divided into three sections, with prioritization criteria for health issues; therapeutic classes; laboratory parameters. It comprises 51 criteria with specific scores with simple total calculation. None of the criteria presented CVI <0.78, maintaining the items from the initial version of PrioFarClinH. The scores were adjusted per suggestions from the panel of judges. Data were collected from 393 patients. The P90 percentile in the three hospitalization stages (24 h, 72 h, and median) was found, respectively, in the following scores: 18.0, 20.0, and 22.6. CONCLUSIONS: PrioFarClinH is a comprehensive tool to target and to prioritize adults patients most likely to benefit from CPS. Evidence for adequate content validity was provided. However, further validation of this tool is necessary to establish tool performance.

A Systematic Review of Patient Selection Criteria for Outpatient Total Shoulder Arthroplasty.

The utilization of total shoulder arthroplasty (TSA) is increasing, driving associated annual health care costs higher. Opting for outpatient over inpatient TSA may provide a solution by reducing costs. However, there is no single set of accepted patient selection criteria for outpatient TSA. Here, the authors identify and systematically review 14 articles to propose evidence-based criteria that merit postoperative admission. Together, the studies suggest that patients with limited ability to abmluate independently or a history of congestive heart failure may benefit from postoperative at least one night of hospital based monitoring and treatment.

Exploring Preconceptions as Barriers to Peritoneal Dialysis Eligibility: A Global Scenario-Based Survey of Kidney Care Physicians.

Introduction: Despite the growing number of patients requiring kidney replacement therapy (KRT), peritoneal dialysis (PD) is underutilized globally. A contributory factor may be clinician myths about its use. The aim of this study was to explore perceptions about PD initiation by clinicians according to various physical, social, and clinical characteristics of patients. Methods: An online global survey (in English and Thai) was administered to ascertain nephrologists' and nephrology trainees' decisions on recommending PD as a treatment modality. Results: A total of 645 participants (522 nephrologists and 123 trainees; 56% male) from 54 countries (66% from high-income countries [HICs], 22% from upper middle-income countries [UMICs], 12% from lower middle-income countries, and 1% from low-income countries [LICs]) completed the survey. Of the respondents, 81% identified as attending physicians or consultants, and 19% identified as trainees or other. PD was recommended for most scenarios, including repeated exposures to heavy lifting, swimming (especially in a private pool and ocean), among patients with cirrhosis or cognitive impairment with available support, and those living with a pet if a physical separation can be achieved during PD. Certain abdominal surgeries were more acceptable to proceed with PD (hysterectomy, 90%) compared to others (hemicolectomy, 45%). Similar variation was noted for different types of stomas (nephrostomies, 74%; suprapubic catheters, 53%; and ileostomies, 27%). Conclusion: The probability of recommending PD in various scenarios was greater among clinicians from HICs, larger units, and consultants with more clinical experience. There is a disparity in recommending PD across various clinical scenarios driven by experience, unit-level characteristics, and region of practice. Globally, evidence-informed education is warranted to rectify misconceptions to enable greater PD uptake.

Dosimetric and NTCP analyses for selecting parotid gland cancer patients for proton therapy.

PURPOSE/OBJECTIVE: To perform a dosimetric and a normal tissue complication probability (NTCP) comparison between intensity modulated proton therapy and photon volumetric modulated arc therapy in a cohort of patients with parotid gland cancers in a post-operative or radical setting. MATERIALS AND METHODS: From May 2011 to September 2021, 37 parotid gland cancers patients treated at two institutions were eligible. Inclusion criteria were as follows: patients aged ⩾ 18 years, diagnosis of parotid gland cancers candidate for postoperative radiotherapy or definitive radiotherapy, presence of written informed consent for the use of anonymous data for research purposes. Organs at risk (OARs) were retrospectively contoured. Target coverage goal was defined as D95 > 98%. Six NTCP models were selected. NTCP profiles were calculated for each patient using an internally-developed Python script in RayStation TPS. Average differences in NTCP between photon and proton plans were tested for significance with a two-sided Wilcoxon signed-rank test. RESULTS: Seventy-four plans were generated. A lower Dmean to the majority of organs at risk (inner ear, cochlea, oral cavity, pharyngeal constrictor muscles, contralateral parotid and submandibular gland) was obtained with intensity modulated proton therapy vs volumetric modulated arc therapy with statistical significance (p < .05). Ten (27%) patients had a difference in NTCP (photon vs proton plans) greater than 10% for hearing loss and tinnitus: among them, seven qualified for both endpoints, two patients for hearing loss only, and one for tinnitus. CONCLUSIONS: In the current study, nearly one-third of patients resulted eligible for proton therapy and they were the most likely to benefit in terms of prevention of hearing loss and tinnitus.

Avoiding pitfalls in conducting hand surgery research: the feasibility analysis.

This paper is intended to support hand surgeons who, at the beginning of their research career, are planning a clinical study. Besides establishing the research methodology of the study, the organizational planning of the work itself is essential. A feasibility analysis carried out before or during the writing of the study protocol helps to estimate the required resources and duration of a project. We highlight some tips and tricks as well as provide checklists that outline the important points to consider before starting a study.