Psychological Impact of Cancellation of Elective Surgeries for Ophthalmic Patients during COVID-19 Pandemic.

The COVID-19 pandemic has disrupted routine hospital services globally. The cancellation of elective surgeries placed a psychological burden on patients. A questionnaire study was conducted to identify the psychological impact of canceling cataract operations on patients at Kowloon East Cataract Center, Tseung Kwan O Hospital, Hong Kong, from April to June 2020. In total, 99 participants aged 59 years old and above, who had their cataract surgeries postponed or as scheduled, were studied using the standardized patient health questionnaire (PHQ-9) and generalized anxiety disorder questionnaire (GAD-7). None of the patients who had their cataract surgeries rescheduled reached the cutoff score for major depression in PHQ-9, whereas, according to GAD-7, five patients had mild symptoms of anxiety, and one had severe symptoms. There was no significant psychosocial impact of the cancellation of cataract surgeries on patients.

Evaluation of VMAT Planning Strategies for Prostate Patients with Bilateral Hip Prosthesis.

Purpose: In this study, we investigate linac volumetric-modulated arc therapy (VMAT) planning strategies for bilateral hip prostheses prostate patients with respect to plan quality and deliverability, while limiting entrance dose to the prostheses. Methods: Three VMAT plans were retrospectively created for 20 patients: (1) partial arcs (PA), (2) 2 full arcs optimized with 500 cGy max prostheses dose (MD), and (3) 2 full arcs optimized with max dose-volume histogram (DVH) constraint of 500 cGy to 10% prostheses volume (MDVH). PA techniques contained 6 PA with beam angles that avoid entering each prosthesis. For each patient, other than prostheses constraints, the same Pinnacle VMAT optimization objectives were used. Plans were normalized with PTV D95% = 79.2 Gy prescription dose. Organ-at-risk DVH metrics, monitor units (MUs), conformality, gradient, and homogeneity indices were evaluated for each plan. Mean entrance prosthesis dose was determined in Pinnacle by converting each arc into static beams and utilizing only control points traversing each prosthesis. Plan deliverability was evaluated with SunNuclear ArcCheck measurements (gamma criteria 3%/2 mm) on an Elekta machine. Results: MD and MDVH had similar dosimetric quality, both improved DVH metrics for rectum and bladder compared to PA. Plan complexities among all plans were similar (average MUs: 441-518). Conformality, homogeneity, and gradient indices were significantly improved in MD and MDVH versus PA (P < .001). Gamma pass rates for MD (99.0 ± 1.2%) and MDVH (99.2 ± 0.99%) were comparable. A significant difference over PA was observed (96.8 ± 1.6%, P < .001). Field-by-field analysis demonstrated 12/20 PA plans resulted in fields with pass rates <95% versus 1/20 plans for MD and none for MDVH. Cumulative mean entrance doses to each prosthesis were 62.9 ± 17.7 cGy for MD plans and 83.4 ± 27.5 cGy for MDVH plans. Conclusion: MD and MDVH plans had improved dosimetric quality and deliverability over PA plans with minimal entrance doses (∼1% of prescription) to each prosthesis and are an improved alternative for bilateral prostheses prostate patients.

Extensor Tendon Entrapment on Computed Tomography Imaging of Distal Radius Fractures.

Objective To examine the association between distal radius fractures and tendon entrapment identified on computed tomography (CT) imaging. Patients and Methods After Institutional Review Board approval, we retrospectively reviewed distal radius fractures that underwent CT imaging from an electronic database between January 2006 to February 2018 at a single level 1 hospital trauma center. We categorized all distal radial fractures according to the AO-OTA (AO Foundation/Orthopaedic Trauma Association) classification. Distal upper extremity tendons were assessed for entrapment. Fisher's exact test was used for statistical analysis with significance at p < 0.05. Results A total of 183 distal radius fractures were identified in 179 patients. A total of 16 fractures (13 males and 3 females) were associated with tendon entrapment. Mechanism of injury included falls ( n = 7), motor vehicle accidents ( n = 6), dog bites ( n = 2), and gunshot wound ( n = 1). Entrapped tendons were limited to the extensor compartment and included the extensor pollicis longus (EPL; n = 11), extensor pollicis brevis ( n = 1), extensor carpi ulnaris ( n = 1), extensor carpi radialis longus ( n = 1), and extensor digitorum communis ( n = 2). The most commonly associated AO-OTA fracture pattern with tendon entrapment was complete articular radial fractures (2R3C; 69%), eight of which were simple articular with metaphyseal multifragmentary fractures (2R3C2). Of the distal radius fractures, 81% were associated with additional ulnar fractures of varying severity and displacement. Conclusion Approximately 8.7% of distal radius fractures were retrospectively identified to have tendon entrapment compared with a previously reported incidence of 1.3%. Wrist surgeons and radiologists should have higher suspicion for tendon entrapment and carefully review preoperative CT imaging for tendon entrapment in distal radius fractures especially if there is an intra-articular, multifragmentary injury pattern. Wrist surgeons and radiologists should also have increased suspicion for EPL tendon entrapments given its high incidence in association with distal radius fractures. Level of Evidence This is a Level III, retrospective cross-sectional study.

Single institution implementation of permanent 131Cs interstitial brachytherapy for previously irradiated patients with resectable recurrent head and neck carcinoma.

PURPOSE: Permanent interstitial brachytherapy is an appealing treatment modality for patients with locoregional recurrent, resectable head and neck carcinoma (HNC), having previously received radiation. Cesium-131 (131Cs) is a permanent implant brachytherapy isotope, with a low average photon energy of 30 keV and a short half-life of 9.7 days. Exposure to medical staff and family members is low; patient isolation and patient room shielding are not required. This work presents a single institution's implementation process of utilizing an intraoperative, permanent 131Cs implant for patients with completely resected recurrent HNC. MATERIAL AND METHODS: Fifteen patients receiving 131Cs permanent seed brachytherapy were included in this analysis. The process of pre-planning, selecting the dose prescription, seed ordering, intraoperative procedures, post-implant planning, and radiation safety protocols are described. RESULTS: Tumor volumes were contoured on the available preoperative PET/CT scans and a pre-implant treatment plan was created using uniform source strength and uniform 1 cm seed spacing. Implants were performed intraoperatively, following tumor resection. In five of the fifteen cases, intraoperative findings necessitated a change from the planned number of seeds and recalculation of the pre-implant plan. The average prescription dose was 56.1 ±6.6 Gy (range, 40-60 Gy). The average seed strength used was 2.2 ±0.2 U (3.5 ±0.3 mCi). Patients returned to a recovery room on a standard surgical floor and remained inpatients, without radiation safety restrictions, based on standard surgical recovery protocols. A post-implant treatment plan was generated based on immediate post-operative CT imaging to verify the seed distribution and confirm delivery of the prescription dose. Patients were provided educational information regarding radiation safety recommendations. CONCLUSIONS: Cesium-131 interstitial brachytherapy is feasible and does not pose major radiation safety concerns; it should be considered as a treatment option for previously irradiated patients with recurrent, resectable HNC.

Evaluation of Hybrid Arc and Volumetric-Modulated Arc Therapy Treatment Plans for Fractionated Stereotactic Intracranial Radiotherapy.

PURPOSE: The study was aimed to compare hybrid arc and volumetric-modulated arc therapy treatment plans for fractionated stereotactic radiotherapy of brain tumors. METHODS: Treatment plans of 22 patients were studied. Hybrid arc and volumetric-modulated arc therapy plans were generated using Brainlab iPlanDose and Varian Eclipse treatment planning systems, respectively, with 6 MV photon beams on a Varian TrueBeam STx linear accelerator (Palo Alto, CA). Prescription dose was 54 Gy. The fractionation was 1.8 Gy per fraction and 30 fractions in total, or 2 Gy per fraction and 27 fractions in total. Planning target volume ranged from 2.4 to 28.6 cm3. Dose conformity index, gradient index, homogeneity index, and maximum doses in organs at risk were compared. Wilcoxon signed rank test was used to determine statistical significance in paired comparison. RESULTS: Conformity indexes of hybrid arc and volumetric-modulated arc therapy plans are 1.10 ± 0.10 and 1.14 ± 0.07, respectively ( P = .4); gradient indexes are 5.02 ± 1.20 and 5.64 ± 1.28, respectively ( P = .0001); homogeneity indexes are 1.02 ± 0.01 and 1.05 ± 0.01, respectively ( P = .0001); brainstem maximum doses are 53.87 ± 1.63 Gy and 54.06 ± 3.17 Gy, respectively ( P = .1); and optic chiasm maximum doses are 53.86 ± 1.28 Gy and 53.95 ± 1.81, respectively ( P = .4). The monitor unit efficiencies of hybrid arc and volumetric-modulated arc therapy plans are 2.57 ± 0.25 MU/cGy and 2.68 ± 0.24 MU/cGy, respectively ( P = .2). The differences of conformity index, gradient index, and homogeneity index between hybrid arc and volumetric-modulated arc therapy plans are small: 0.08 ± 0.05, 0.65 ± 0.46, and 0.02 ± 0.01, respectively. The maximum doses in organs at risks are similar between hybrid arc and volumetric-modulated arc therapy plans. Hybrid arc and volumetric-modulated arc therapy plans, which have similar monitor unit efficiencies, present similar dosimetric results in the fractionated intracranial radiotherapy.

Impact of incorporating visual biofeedback in 4D MRI.

Precise radiation therapy (RT) for abdominal lesions is complicated by respiratory motion and suboptimal soft tissue contrast in 4D CT. 4D MRI offers improved con-trast although long scan times and irregular breathing patterns can be limiting. To address this, visual biofeedback (VBF) was introduced into 4D MRI. Ten volunteers were consented to an IRB-approved protocol. Prospective respiratory-triggered, T2-weighted, coronal 4D MRIs were acquired on an open 1.0T MR-SIM. VBF was integrated using an MR-compatible interactive breath-hold control system. Subjects visually monitored their breathing patterns to stay within predetermined tolerances. 4D MRIs were acquired with and without VBF for 2- and 8-phase acquisitions. Normalized respiratory waveforms were evaluated for scan time, duty cycle (programmed/acquisition time), breathing period, and breathing regularity (end-inhale coefficient of variation, EI-COV). Three reviewers performed image quality assessment to compare artifacts with and without VBF. Respiration-induced liver motion was calculated via centroid difference analysis of end-exhale (EE) and EI liver contours. Incorporating VBF reduced 2-phase acquisition time (4.7 ± 1.0 and 5.4 ± 1.5 min with and without VBF, respectively) while reducing EI-COV by 43.8% ± 16.6%. For 8-phase acquisitions, VBF reduced acquisition time by 1.9 ± 1.6 min and EI-COVs by 38.8% ± 25.7% despite breathing rate remaining similar (11.1 ± 3.8 breaths/min with vs. 10.5 ± 2.9 without). Using VBF yielded higher duty cycles than unguided free breathing (34.4% ± 5.8% vs. 28.1% ± 6.6%, respectively). Image grading showed that out of 40 paired evaluations, 20 cases had equivalent and 17 had improved image quality scores with VBF, particularly for mid-exhale and EI. Increased liver excursion was observed with VBF, where superior-inferior, anterior-posterior, and left-right EE-EI displacements were 14.1± 5.8, 4.9 ± 2.1, and 1.5 ± 1.0 mm, respectively, with VBF compared to 11.9 ± 4.5, 3.7 ± 2.1, and 1.2 ± 1.4 mm without. Incorporating VBF into 4D MRI substantially reduced acquisition time, breathing irregularity, and image artifacts. However, differences in excursion were observed, thus implementation will be required throughout the RT workflow.

Four dimensional magnetic resonance imaging optimization and implementation for magnetic resonance imaging simulation.

PURPOSE: Precise radiation therapy for abdominal lesions is complicated by respiratory motion and suboptimal soft tissue contrast from 4-dimensional (4D) computed tomography, whereas 4D magnetic resonance imaging MRI (4DMRI) provides superior tissue discrimination. This work evaluates a novel 4DMRI algorithm for motion management in radiation therapy. METHODS AND MATERIALS: Respiratory-triggered, T2-weighted, single-shot 4DMRI was evaluated for an open 1.0T magnetic resonance simulation platform. An in-house programmable platform was devised that translated objects for a variety of breathing patterns. Coronal 4DMRIs were acquired to evaluate the impact of number of phases on excursion and scan time. The impact of breathing period and regularity on scan time was assessed. A novel clinical 4D prototype phantom was scanned to characterize excursion and absolute volume differences between phase acquisitions. Optimized parameters were applied to abdominal 4DMRIs of 5 volunteers and 2 abdominal cancer patients on an institutional review board-approved protocol. Duty cycle, scan time, and waveform analysis were evaluated. Maximum intensity projection datasets were analyzed. RESULTS: Two- to 5-fold acquisition time increase was measured for 10-phase versus 2-phase phantom experiments. Regular breathing patterns yielded higher duty cycles than irregular (48.5% and 35.9%, respectively, P < .001), whereas faster breathing rates yielded shorter 4DMRI acquisition times. Volumes of a hypodense target were underestimated 4% to 5% for 2 and 4 phases compared with 10 phases. Better agreement was obtained for 6- and 8-phase acquisitions (~3% different from 10 phase). Internal target volume centroids on minimum and maximum images across all phases were <2 mm different across all 10 phases, although slight target excursion variations (up to 4 mm) were observed. In humans, a strong negative association between breathing rate and acquisition time (Pearson's r = -0.68, P < .05) was observed. Eight-phase acquisition times ranged from 7 to 15 minutes, depending on the patient. CONCLUSION: 4DMRI has been optimized and implemented. Irregular breathing patterns and slow breathing rate adversely impacted 4DMRI efficiency; thus, interventions such as biofeedback may be desirable.

Mini-mental state examination as a predictor of mortality among older people referred to secondary mental healthcare.

BACKGROUND: Lower levels of cognitive function have been found to be associated with higher mortality in older people, particularly in dementia, but the association in people with other mental disorders is still inconclusive. METHODS AND FINDINGS: Data were analysed from a large mental health case register serving a geographic catchment of 1.23 million residents, and associations were investigated between cognitive function measured by the Mini-Mental State Examination (MMSE) and survival in patients aged 65 years old and over. Cox regressions were carried out, adjusting for age, gender, psychiatric diagnosis, ethnicity, marital status, and area-level socioeconomic index. A total of 6,704 subjects were involved, including 3,368 of them having a dementia diagnosis and 3,336 of them with depression or other diagnoses. Descriptive outcomes by Kaplan-Meier curves showed significant differences between those with normal and impaired cognitive function (MMSE score<25), regardless of a dementia diagnosis. As a whole, the group with lower cognitive function had an adjusted hazard ratio (HR) of 1.42 (95% CI: 1.28, 1.58) regardless of diagnosis. An HR of 1.23 (95% CI: 1.18, 1.28) per quintile increment of MMSE was also estimated after confounding control. A linear trend of MMSE in quintiles was observed for the subgroups of dementia and other non-dementia diagnoses (both p-values<0.001). However, a threshold effect of MMSE score under 20 was found for the specific diagnosis subgroups of depression. CONCLUSION: Current study identified an association between cognitive impairment and increased mortality in older people using secondary mental health services regardless of a dementia diagnosis. Causal pathways between this exposure and outcome (for example, suboptimal healthcare) need further investigation.

Functional status and all-cause mortality in serious mental illness.

BACKGROUND: Serious mental illness can affect many aspects of an individual's ability to function in daily life. The aim of this investigation was to determine if the environmental and functional status of people with serious mental illness contribute to the high mortality risk observed in this patient group. METHODS: We identified cases of schizophrenia, schizoaffective and bipolar disorder aged ≥ 15 years in a large secondary mental healthcare case register linked to national mortality tracing. We modelled the effect of activities of daily living (ADLs), living conditions, occupational and recreational activities and relationship factors (Health of the Nation Outcome Scale [HoNOS] subscales) on all-cause mortality over a 4-year observation period (2007-10) using Cox regression. RESULTS: We identified 6,880 SMI cases (242 deaths) in the observation period. ADL impairment was associated with an increased risk of all-cause mortality (adjusted HR 1.9; 95% CI 1.3-2.8; p = 0.001, p for trend across ADL categories = 0.001) after controlling for a broad range of covariates (including demographic factors, physical health, mental health symptoms and behaviours, socio-economic status and mental health service contact). No associations were found for the other three exposures. Stratification by age indicated that ADLs were most strongly associated with mortality in the youngest (15 to <35 years) and oldest (≥ 55 years) groups. CONCLUSIONS: Functional impairment in people with serious mental illness diagnoses is a marker of increased mortality risk, possibly in younger age groups as a marker of negative symptomatology.

Associations between symptoms and all-cause mortality in individuals with serious mental illness.

OBJECTIVE: To determine if aggression, hallucinations or delusions, and depression contribute to excess mortality risk observed in individuals with serious mental illness (SMI). METHODS: We identified SMI cases (schizophrenia, schizoaffective and bipolar disorder) aged≥15years in a large secondary mental healthcare case register linked to national mortality tracing. We modelled the effect of specific symptoms (HoNOS subscales) on all-cause mortality using Cox regression. RESULTS: We identified 6880 SMI cases (242 deaths) occurring 2007-2010. Bipolar disorder was associated with reduced mortality risk compared to schizophrenia (HR 0.7; 95% CI 0.4-0.96; p=0.028). Mortality was not significantly associated with hallucinations and delusions or overactive-aggressive behaviour, but was associated with physical illness/disability. There was a positive association between mortality and subclinical depression among individuals with schizophrenia (HR 1.5; 1.1-2.2; p=0.019) but a negative association with subclinical and more severe depression among those with schizoaffective disorder (HR 0.1; 0.02-0.4; p=0.001 and 0.3; 0.1-0.8; p=0.021, respectively). CONCLUSIONS: The recognised increased risk of mortality in SMI did not appear to be influenced by severity of hallucinations, delusions, or overactive-aggressive behaviour. Physical illness and lifestyle may need to be addressed and the relationship between depression and mortality requires further investigation.