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Background: Patients with unresectable locoregional cancer recurrences have limited management options. Reirradiation increases the risk of toxicity, particularly when perilesional dose-volume constraints are exceeded. We present and discuss two cases of previously irradiated tumors in the central nervous system (CNS) that was reirradiated using the pulsed reduced dose-rate radiotherapy (PRDR) technique. Case Description: A 58-year-old female with a history of metastatic small cell lung cancer to the brain status post multiple rounds of radiation and chemotherapy presented with increasing weakness in her right arm and leg. Magnetic resonance imaging (MRI) revealed a growly peripherally enhancing 1.2 cm mass in the left precentral gyrus that had previously received prophylactic cranial irradiation and stereotactic radiosurgery. The patient was re-irradiated with 35 Gy in 100 fractions over 3 weeks, using PRDR with improved motor function at 3-month follow-up. A 41-year-old male with recurrent glioblastoma of the thoracic spinal cord presented with worsening neurological symptoms, including inability to ambulate due to bilateral leg weakness, causing wheelchair use. MRI thoracic spine revealed a recurrent thoracic lesion 2.2 × 1 × 0.8 cm. In addition to chronic chemotherapy, the patient was retreated palliatively in the same area at 50 Gy in 250 fractions, over 6 weeks, using PRDR. The treated lesion was stable on follow-up imaging, and the patient was able to walk with the assistance of a walker. Conclusion: In our two cases, PRDR proved effective in the treatment of recurrent malignant CNS tumors that were previously irradiated. Prospective studies are needed to delineate the efficacy and toxicity of PRDR. [ABSTRACT FROM AUTHOR]

The internet is increasingly used to access patient education materials. The average American reading level has been found to be that of a 7th- to 8th-grade student, prompting the National Institutes of Health (NIH) and the American Medical Association (AMA) to advise that patient education materials be written between the 4th- to 6th-grade reading level. The purpose of this study was to evaluate the reading level of current patient education materials for the most common musculoskeletal oncological tumors. A Google search was performed with all location filters off to account for geographic variability for patient education materials related to 28 orthopedic primary or secondary tumors. All patient education articles from the first 10 website hits for each tumor type were analyzed. Patient education materials from these websites were evaluated using 8 validated readability scales. Patient resources were found to be written at an average grade level nearly double the NIH and AMA recommendation. Patient education materials for soft tissue chondromas were written at the highest level (14.8±1.9), whereas education materials for chordomas (10.1±1.0) most closely approached national recommendations, despite still being written at a readability level nearly 4 grade levels higher than has been recommended. The Flesch Reading Ease assessment provided a mean score of 46.5±7.7, corresponding with a "difficult to read" result. Current patient education materials regarding oncological musculoskeletal-related patient education materials are written significantly above the recommended reading level. Further modification of these resources is warranted to ensure adequate comprehension and informed decision making in the clinical setting. [Orthopedics. 2021;44(1):38-42.]. [ABSTRACT FROM AUTHOR]

Introduction: Patients use the internet to search for health-related information. We sought to characterize the information that patients find when searching for dermatologists on Google. Methods: The Centers for Medicare and Medicaid Services (CMS) Physician Comparable Downloadable File was utilized to identify all Medicare-participating dermatologists practicing in Pennsylvania (PA). A custom Google-based search engine was used to search each dermatologist. Up to the top 10 results for each physician were then sorted into: (1) physician, hospital, or healthcare system, (2) third-party, (3) social media, (4) academic journal articles, or (5) other. Results: Within the CMS, 519 health care providers (53.9% male, 46.1% female) self-identified as dermatologists practicing in PA. At least one search result was obtained for each physician (4,963 total search results). About 30.6% (1,519) search results were hospital, health system, or physician-controlled websites, and 26.6% (1,318) were third-party websites (1,318; 26.6%). Social media websites accounted for 601 (12.1%) hits whereas peer-reviewed academic journal websites generated 135 (2.7%) results. One-way chi-square analysis showed domains were not randomly distributed across the five categories (P<0.0001). Conclusion: Dermatologists should be better aware of their digital presence and the strategies to better control their online identity. [ABSTRACT FROM AUTHOR]

Stereotactic radiosurgery (SRS) involves the delivery of a highly conformal ablative dose of radiation to both benign and malignant targets. This has traditionally been accomplished in a single fraction; however, fractionated approaches involving five or fewer treatments have been delivered for larger lesions, as well as lesions in close proximity to radiosensitive structures. The clinical utilization of SRS has overwhelmingly involved photon-based sources via dedicated radiosurgery platforms (e.g., Gamma Knife® and Cyberknife®) or specialized linear accelerators. While photon-based methods have been shown to be highly effective, advancements are sought for improved dose precision, treatment duration, and radiobiologic effect, among others, particularly in the setting of repeat irradiation. Particle-based techniques (e.g., protons and carbon ions) may improve many of these shortcomings. Specifically, the presence of a Bragg Peak with particle therapy at target depth allows for marked minimization of distal dose delivery, thus mitigating the risk of toxicity to organs at risk. Carbon ions also exhibit a higher linear energy transfer than photons and protons, allowing for greater relative biological effectiveness. While the data are limited, utilization of proton radiosurgery in the setting of brain metastases has been shown to demonstrate 1-year local control rates >90%, which are comparable to that of photon-based radiosurgery. Prospective studies are needed to further validate the safety and efficacy of this treatment modality. We aim to provide a comprehensive overview of clinical evidence in the use of particle therapy-based radiosurgery. [ABSTRACT FROM AUTHOR]

Background: Occurring in up to 40% of all patients with cancer, the incidence of brain tumors has caused limited survival, a high psychosocial burden, and an increase in the loss of decision-making capability for the unique population. Although specific symptoms depend on the type of brain tumor, a clinical team of physicians, nurses, and other individuals commonly assist patients and their caregivers with how to tackle the upcoming challenges of their diagnosis. Despite the support from clinical team members, many patients and caregivers may still seek outside support through social media to process their emotions and seek comfort outside of the clinical setting. Specifically, online resources such as Reddit are used where users are provided with the anonymity they need to show their true behavior without fear of judgment. In this study, we aimed to examine trends from Reddit discussion threads on brain tumors to identify areas of need in patient care., Objective: Our primary aims were to determine the type of Reddit user posting, classify the specific brain tumors that were the subject of the posts, and examine the content of the original posts., Methods: We used a qualitative descriptive design to understand patients' and caregivers' unmet and met needs. We selected posts from the top-rated 100 posts from the r/braincancer subreddit from February 2017 to June 2020 to identify common themes using content analysis., Results: The qualitative content analysis revealed how Reddit users primarily used the forum as a method to understand and process the emotions surrounding a brain tumor diagnosis. Three major topic areas from content analysis emerged as prominent themes, including (1) harnessing hope, (2) moving through the grief process, and (3) expressing gratitude toward other Reddit users. Most of the authors of the posts were patients with brain tumors (32/88, 36%) who used Reddit as a reflective journaling tool to process the associated emotions of a challenging diagnosis., Conclusions: This study shows the potential of Reddit to serve as a unique group therapy platform for patients affected by brain tumors. Our results highlight the support provided by the Reddit community members as a unique mechanism to assist cancer survivors and caregivers with the emotional processing of living with brain tumors. Additionally, the results highlight the importance of recommending Reddit as a therapeutic virtual community and the need for implementing online resources as a part of a health care professional's repertoire to understand the level of support they can give their patients., (©Sanidhya D Tripathi, Pearman D Parker, Arpan V Prabhu, Kevin Thomas, Analiz Rodriguez. Originally published in JMIR Cancer (https://cancer.jmir.org), 22.06.2022.)

Background: The COVID-19 pandemic spurred an increase in online information regarding disease spread and symptomatology., Objective: Our purpose is to systematically assess the quality and readability of articles resulting from frequently Google-searched COVID-19 terms in the United States., Methods: We used Google Trends to determine the 25 most commonly searched health-related phrases between February 29 and April 30, 2020. The first 30 search results for each term were collected, and articles were analyzed using the Quality Evaluation Scoring Tool (QUEST). Three raters scored each article in authorship, attribution, conflict of interest, currency, complementarity, and tone. A readability analysis was conducted., Results: Exactly 709 articles were screened, and 195 fulfilled inclusion criteria. The mean article score was 18.4 (SD 2.6) of 28, with 7% (14/189) scoring in the top quartile. National news outlets published the largest share (70/189, 36%) of articles. Peer-reviewed journals attained the highest average QUEST score compared to national/regional news outlets, national/state government sites, and global health organizations (all P<.05). The average reading level was 11.7 (SD 1.9, range 5.4-16.9). Only 3 (1.6%) articles were written at the recommended sixth grade level., Conclusions: COVID-19-related articles are vastly varied in their attributes and levels of bias, and would benefit from revisions for increased readability., (©Vismaya S Bachu, Heba Mahjoub, Albert E Holler, Tudor Crihalmeanu, Dheevena M Bachu, Varun Ayyaswami, Pearman D Parker, Arpan V Prabhu. Originally published in JMIR Formative Research (https://formative.jmir.org), 11.02.2022.)

Background: Treatment of refractory/relapsing diffuse large B cell (R/R DLBCL) lymphoma remains a challenge. Radiation therapy (RT) has versatile roles in R/R DLBCL treatment: it can be used in the peri-transplant setting for transplant-eligible candidates, or as a salvage or palliation therapy depending on the extent of the disease in transplant-ineligible patients. The introduction of chimeric antigen receptor (CAR) T-cell therapy has changed the landscape of R/R DLBCL. RT has been used as a bridging therapy to CAR T-cell therapy in order to control disease progression during its manufacturing period. However, optimal RT and CAR T-cell therapy integration is still unknown. Salvage strategies for R/R DLBCL post-CAR T-cell therapy have been little studied., Case Report: Here, we present a case of primary refractory DLBCL with residual disease post-CAR T-cell therapy successfully treated with salvage RT., Conclusion: Radiotherapy could be an effective salvage strategy for R/R DLBCL post-CAR T-cell therapy. Exact mechanisms await exploring., (Copyright © 2021 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Introduction Physicians are increasingly practicing defensive medicine as a response to society's litigious climate. This study sought to characterize cardiology malpractice claims and elucidate the allegations underlying the use of defensive medicine. Methods The WestlawNext™ database was queried to obtain state and federal jury verdicts and settlements related to medical malpractice and cardiology that occurred in the United States between 2010 and 2015. Cardiology cases were identified using the search terms "medical malpractice" and "cardiology" and reviewed by two individuals utilizing available case documents. Duplicate and nonpertinent cases were excluded. Binary logistic regression models were created to predict the likelihood of defendant verdict, plaintiff verdict, and settlement based on the various reasons for litigation cited. Results Inclusion criteria were met in 166 cases. The plaintiffs were predominantly male (94 cases; 56.6%), and the average patient age was 53.3±17.5 years. More than half of the cases involved a cardiologist as a defendant. The most common reasons for litigation were: failure to treat (129; 77.7%), failure to diagnose (115; 69.3%), failure to refer/order diagnostic tests (107; 64.5%), and patient death (118; 71.1%). Among cases tried for failure to diagnose, the most commonly missed diagnosis was myocardial infarction. Cases most commonly resulted in a defendant verdict (94; 56.6%). However, odds of a plaintiff verdict were significantly higher when failure to diagnose was alleged with an odds ratio (OR) of 7.60 (95% confidence interval 1.14 - 50.87, p = 0.0365). Conclusions Failure to diagnose remains a commonly alleged base for litigation. In conclusion, our analysis suggests increased training for non-cardiologists in the recognition of the acute coronary syndrome and enhanced awareness of inherent biases among all physicians may facilitate reducing missed diagnoses., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2019, Patel et al.)

Purpose: Reddit is a social media platform that allows health care professionals (HPs) to anonymously interact with patients. We analyzed content about radiation therapy (RT) on Reddit., Methods and Materials: Reddit.com/r/cancer was queried with 20 search terms related to RT: IMRT, 3D-CRT, SBRT, EBRT, XRT, radiation, radiotherapy, RT, radio, rad, rads, gamma, gamma knife, gammaknife, cyber knife, cyberknife, cyber, brachytherapy, brachy, and cobalt. The search aimed to identify all posts discussing RT. A random sample of posts and their top 3 comments was selected to generate qualitative thematic codes per author consensus, which were used to characterize all posts and their top 3 voted comments. Posts were analyzed for time to first reply, mention of any specific RT modality, whether a self-identified HP responded, and time to first highly voted comment by an HP., Results: Exactly 190 posts about RT by 178 users were shared from February 2011 to May 2018, and 468 replies by 295 users were also analyzed. Twenty-nine of these users (9.8%) were HPs; however, 48 of 181 top comments were contributed by HPs compared with 45 of 288 non-top comments by HPs (odds ratio, 1.95; 95% confidence interval [CI], 1.23-3.08; P  < .004). The most common themes were treatment questions, chronology, and information; toxicities; and social support. The median time to first comment after posting was 64.0 minutes (95% CI, 53.0-82.0), and median time to first highly voted comment from an HP was 264.0 minutes (95% CI, 153.5-427.9; U  = 4123.5; P  < .0001 2-tailed). Fifty-three posts (27.9%) identified a specific RT modality, with proton therapy (7.4%), CyberKnife (5.3%), brachytherapy (4.2%), and whole brain radiation (4.2%) being the most common., Conclusions: HPs did not reply often to RT posts and generally took longer to do so, but their replies were valued by users. Common themes included treatment questions, chronology, and treatment; toxicities; and social support. Proton therapy received notable attention.

Introduction The popularity of online physician rating websites has risen substantially. These third-party sites have the potential to significantly influence patients' perception of their healthcare providers. The purpose of this study was to evaluate online ratings of U.S. radiation oncologists (ROs) on Vitals.com, one of the most popular physician rating websites, and the variables that most significantly affect patients' overall rating (OR) of their ROs.  Methods The Centers for Medicare and Medicaid Physician Comparable Downloadable File was analyzed to obtain data on all self-identified ROs in the U.S. and Puerto Rico. Patient Review Satisfaction Scores (PRSS) that ranged from one (poor) to five (excellent) for the following variables were recorded: OR, accurate diagnosis, spending appropriate time with patients, ease of appointment, courteous staff, bedside manner, follow-up after visit, promptness, and wait time. Associations among these factors were assessed.  Results Of 4,443 self-identifying Medicare-accepting ROs, 1,797 (40.4%) ROs who had at least one OR rating and at least one written comment were included in this study. The ROs' mean OR was 4.34 ± 0.2 (median 4; 30% received a score of 5; 78% received a score greater than 4). OR was found to have a strong correlation with accuracy of diagnosis ( r = 0.69), bedside manner ( r = 0.71), and spends appropriate time with patients ( r = 0.69). With the exception of the number of ratings ( p = 0.07), physicians with over 10 years of experience showed statistically significant differences in how much better they scored in each of the variables compared to those with less than 10 years of experience ( p < 0.01 for each characteristic). Significant differences in OR were also observed between ROs whose wait times exceeded 20 minutes compared to those with wait times less than 10 minutes ( p < 0.01) for all internal and external metrics except for the number of ratings ( p = 0.42) and number of reviews ( p = 0.88) Conclusion Patients are providing high ratings for their ROs on Vitals.com and are more frequently recommending them to friends and family. Given the rise in popularity of third-party physician rating sites, it is important for ROs to understand the various factors that may influence their online ratings., Competing Interests: The authors have declared that no competing interests exist.

Introduction An increasing number of patients search for their physicians online. Many hospital systems utilize Press-Ganey studies as internal tools to analyze patient satisfaction, but independent third-party websites have a large presence online. Patients' trust in these third-party sites may occur despite a low number of reviews and a lack of validity of patients' entries. Healthgrades.com has been shown as the most popular site to appear on Google searches for radiation oncologists (ROs) in the United States (US). The aim of this study was to analyze patient satisfaction scores and the factors that influence those scores for American ROs on Healthgrades. Methods The physician ratings website Healthgrades was manually queried to obtain reviews from all Medicare-participating ROs with reviews ( n =2,679). Patient Review Satisfaction Scores (PRSS) were recorded in response to a variety of questions. All information in the survey was scored from 1 (poor) to 5 (excellent) for the following characteristics: likelihood to recommend (LTR), office environment, ease of scheduling, trust in the physician's decision, staff friendliness, ability of the physician to listen and answer questions, ability of the physician to explain the condition, and whether the physician spent sufficient time with the patients. Associations amongst these factors were considered by computing Spearman correlation coefficients and utilizing Mann-Whitney and Kruskal-Wallis tests. Results The ROs' mean LTR score was 4.51±0.9 (median 5.0, 66% received the highest possible score of 5; 95% received a score>2). Patient reviews per RO ranged from 1 to 242 (4.50±0.9, median 2.0). LTR scores correlated very strongly with physician-related factors, ranging from r =0.85 (with appropriate time spent with patients) to r =0.89 (with level of trust in physician). LTR scores were not statistically significantly associated with gender, wait time, ROs' years since graduation, academic status, or geographic region. Conclusion Satisfaction scores for ROs on a leading physician ratings website are very strong, and most patients leaving reviews are likely to recommend their own ROs to their friends and family. Understanding online ratings and identifying factors associated with positive ratings are important for both patients and ROs due to the recent growth in physician-rating third-party sites. ROs should have increased awareness regarding sites like Healthgrades and their online reputation., Competing Interests: The authors have declared that no competing interests exist.