OhioHealth Mansfield Hospital

Craniectomies represent a lifesaving neurosurgical procedure for many severe neurological conditions, such as traumatic brain injury. Syndrome of trephined (SoT) is an important complication of decompressive craniectomy, and cranial reconstruction is the definitive treatment. However, many patients cannot undergo surgical intervention because of neurological status, healing of the primary surgical wound, or the presence of concurrent infection, which may prevent cranioplasty. To offer a customized external cranioplasty option for managing skull deformities for patients who could not undergo surgical intervention for definitive cranioplasty. We describe the design and clinical application of an external cranioplasty for a patient with a medical history of intractable epilepsy, for which she underwent multiple right cerebral resections with a large resultant skull defect and SoT. The patient had resolution of symptoms and restoration of a symmetrical skull contour with no complication at 17 months. Customized external cranioplasty can improve symptoms associated with SoT for patients who cannot undergo a definitive cranioplasty. In addition, inset monitoring options, such as electroencephalography or telemetric intracranial pressure sensors, could be incorporated in the future for comprehensive monitoring of the patient's neurological condition.

PURPOSEOur objective was to demonstrate the efficacy of a telehealth training course on high-dose-rate (HDR) brachytherapy for gynecologic cancer treatment for clinicians in low- and middle-income countries (LMICs)METHODSA 12-week course consisting of 16 live video sessions was offered to 10 cancer centers in the Middle East, Africa, and Nepal. A total of 46 participants joined the course, and 22 participants, on average, attended each session. Radiation oncologists and medical physicists from 11 US and international institutions prepared and provided lectures for each topic covered in the course. Confidence surveys of 15 practical competencies were administered to participants before and after the course. Competencies focused on HDR commissioning, shielding, treatment planning, radiobiology, and applicators. Pre- and post-program surveys of provider confidence, measured by 5-point Likert scale, were administered and compared.RESULTSForty-six participants, including seven chief medical physicists, 16 senior medical physicists, five radiation oncologists, and three dosimetrists, representing nine countries attended education sessions. Reported confidence scores, both aggregate and paired, demonstrated increases in confidence in all 15 competencies. Post-curriculum score improvement was statistically significant (P < .05) for paired respondents in 11 of 15 domains. Absolute improvements were largest for confidence in applicator commissioning (2.3 to 3.8, P = .009), treatment planning system commissioning (2.2 to 3.9, P = .0055), and commissioning an HDR machine (2.2 to 4.0, P = .0031). Overall confidence in providing HDR brachytherapy services safely and teaching other providers increased from 3.1 to 3.8 and 3.0 to 3.5, respectively.CONCLUSIONA 12-week, low-cost telehealth training program on HDR brachytherapy improved confidence in treatment delivery and teaching for clinicians in 10 participating LMICs.

In radiotherapy, accurate deposition of energy to the targeted volume is vital to ensure effective treatment. Gel dosimeters are attractive detection systems, as tissue substitutes with potential to yield three-dimensional dose distributions. Radio-fluorogenesis is creation fluorescent chemical products in response to energy deposition from high-energy radiation. This report shares studies of a radio-fluorogenic gel dosimetry system, gelatin with coumarin-3-carboxlyic acid (C3CA), for the quantification of imparted energy. Aqueous solutions exposed to ionizing radiation result in the production of hydroxyl free radicals through water radiolysis. Interactions between hydroxyl free radicals and coumarin-3-carboxylic acid produce a fluorescent product. 7-hydroxy-coumarin-3-carboxylic acid has a blue (445 nm) emission, following UV to near UV (365&amp;ndash;405 nm) excitation. Effects of C3CA concentration and pH buffers were investigated for this system. The response of the system was explored with respect to strength, type, and exposure rate of high-energy radiation. Results show a linear dose response relationship with a dose-rate dependency and no energy or type dependencies. This report supports the utility of gelatin-C3CA for phantom studies of radio-fluorogenic processes.

Chronic mesenteric ischemia most commonly occurs secondary to atherosclerotic disease of the mesenteric arteries. Patients are often older than 60 years and can present with postprandial abdominal pain, nausea, diarrhea, and significant weight loss. Symptomatic disease has traditionally been managed with open surgical repair, but endovascular strategies, such as percutaneous angioplasty and stenting, have emerged as the mainstays of therapy. Complications from stenting include plaque embolization, thrombosis, perforation, or dissection of the mesenteric arteries. We present a patient with symptomatic acute aortic dissection 18 months after celiac and superior mesenteric artery stent placement for chronic mesenteric ischemia.

PurposeFidaxomicin use in real-world clinical practice, especially for severe Clostridium difficile infection (CDI), is mainly based on single-center observational studies. The purpose of this pharmacoepidemiology study was to assess outcomes of patients given fidaxomicin based on episode number and use of concomitant antibiotics.MethodsFidaxomicin use over time across included hospitals in the United States was assessed using a large inpatient drug utilization database. A multicenter retrospective chart review was also conducted of hospitalized patients with CDI that received fidaxomicin between 2011 and 2013. Fidaxomicin utilization and clinical outcomes were stratified by use of fidaxomicin for first or second episode (early episodes) versus greater than or equal to episodes (later episodes).ResultsThe overall fidaxomicin use rate was 2.16 % which increased from 0.22 % in the last two quarters of 2011 to 3.16 % in the first two quarters of 2013. A total of 102 hospitalized patients that received fidaxomicin from 11 hospitals were identified in the multicenter study. Sixty-nine patients received fidaxomicin for early (68 % with severe CDI) and 33 received for later episodes. The majority of patients received other CDI therapy including 61 patients (88 %) for early episodes and 27 (82 %) for later episodes. Concomitant non-CDI antibiotics were received by 48 patients (47 %). Rates of clinical outcomes were similar regardless of CDI episode.ConclusionThis study demonstrated a slow but steady increase in fidaxomicin utilization over time; most of which was combined with other systemic antibiotics. Antimicrobial stewardship teams should provide guidance on appropriate use of fidaxomicin to optimize therapy and assess the need to continue other antibiotics during CDI treatment.