Warren Clinic

Silicon Valley Clean Water (SVCW) provides wastewater treatment for over 220,000 users in the San Francisco mid-peninsula area. The treatment plant, established in the 1970s, faced significant challenges due to an aging piping system. Particularly, the plant’s sludge under their digester and secondary clarifier started showing signs of corrosion, exacerbated by their location near the saline San Francisco Bay. To address this issue, SVCW explored several rehabilitation options, ultimately identifying spray-in-place pipe (SIPP) lining and cured-in-place pipe (CIPP) as the most practical and cost-effective solutions. Despite severe corrosion, varying pipe diameters, difficult access, and tight schedules, the project team successfully implemented SIPP rehabilitation. This accomplishment highlights the importance of innovative thinking, skilled craftsmanship, and teamwork in resolving complex infrastructure challenges.

BACKGROUNDStandard treatment for MB in patients age ≥ 3 years includes craniospinal radiation with tumor bed boost and chemotherapy. Radiation carries substantial risk of long-term issues, particularly in the youngest patients: second malignancy, neurocognitive issues, vasculopathy and endocrinopathies. Numerous trials have attempted to decrease or avoid the use of radiation by intensifying chemotherapy, some using high dose chemotherapy with autologous hematopoietic stem cell rescue (HDC). One of the most successful RA protocols, Children’s Oncology Group ACNS0334 enrolled children age < 36 months and treated with 3 cycles of induction (+/- high dose methotrexate) and 3 cycles HDC without planned radiation. Since 2012, we offer SDM with caregivers regarding treatment of their children ages 3-7 years with MB. Caregivers may choose standard radiation and chemotherapy (SRC) or the RA treatment above. OBJECTIVEDescribe patient and disease characteristics and outcomes in patients aged 3-7 years treated for MB with SDM regarding the use of radiation. METHODSRetrospective analysis of diagnosis, treatment and clinical outcomes in all children <8 y.o. who completed treatment for MB between 2012 and 2023. RESULTSThere were 16 patients offered SDM (all gross total resection without metastases) 7 chose RA and 9 SRC. The SRC group was enriched with molecularly high-risk patients (4 MYC or MYCN amplification, 1 SHH with P53 mutation). In the RA group, relapse occurred in 14% (n=1 of 7). In the SRC group, 44% relapsed (n=4 of 9). One patient developed high-grade glioma in the radiation boost field 10 years later. There was 1 death in the RA group due to disease progression and 5 deaths in the SRC group, 1 due to second malignancy. CONCLUSIONSWe report excellent survival with RA therapy for appropriately selected young children (age 3-7 years) when SDM is used with families to determine the best treatment for their child.

Clinical research has now shown that dietary supplements can be of benefit for geriatric patients, and many elders do take them. Understanding the science of dietary supplements is central to providing good medical counsel to geriatric patients. Like pharmaceuticals, there are attendant risks to the use of supplements, both intrinsic risks, and through drug-supplement interactions. In addition, the FDA does not regulate dietary supplements as stringently, so the medical provider must understand clearly the evidence of dietary supplements, as well as how to evaluate products on the market. This chapter reviews the science of dietary supplements, identifying mechanisms of action, indications, and adverse effects of beneficial dietary supplements. It also identifies a process of vetting supplements so as to optimize benefit while mitigating risks, with an emphasis on a shared decision-making model, so as to both inform patients and be clear in the medical record.

Evidence-based practitioners need to consider the sensitivity to change or “responsiveness” of outcome measures such as walking speed. The responsiveness of an outcome measure refers to its ability to accurately detect a change or difference when it has occurred. In this review, we first describe distribution-based and anchor-based methods and the most commonly reported indexes of responsiveness (ie, effect size, standard error of the measurement, minimal detectable change, standardized response mean, and minimal clinically important difference) for walking speed. We then summarize and synthesize the recent literature on the responsiveness of walking speed in different populations of older adults, patients with neurologic conditions (ie, stroke, Parkinson's disease, and Alzheimer's disease), and patients with orthopedic conditions (ie, hip fracture and knee osteoarthritis). In all of the studies cited, walking speed was sensitive to change over time and, when looking across studies, there is considerable agreement that meaningful change in walking speed is approximately 0.1 m/s.

DEPARTMENT EDITOR Denise Rizzolo is Clinical Assistant Professor at Seton Hall University Physician Assistant Program and is in private practice at the Care Station, Springfield, NJ. She has indicated no relationships to disclose relating to the content of this article. Joe Monroe practices in the dermatology department of the Warren Clinic, Tulsa, Okla, and is the founder and president of the Society of Dermatology Physician Assistants.

DEPARTMENT EDITOR The author practices at A Center for Dermatology in Pompano Beach, Fla. She has indicated no relationships to disclose relating to the content of this article. Joe Monroe practices in the dermatology department of the Warren Clinic, Tulsa, Okla, and is the founder and president of the Society of Dermatology Physician Assistants.