Cochlear implants (CIs) are a key option of hearing rehabilitation in certain children. Scientific, surgical and technological advances in CI technology have enabled implantation in a significant number of children with sensorineural hearing loss (SNHL). There are established criteria to characterize appropriate patients, improving successful performance post operatively by standard metrics of speech perception. Clinical outcomes are, however, modified by several patient-related. An increasing body of evidence in such domains has resulted in expansion of candidacy criteria. Approximately 20% of all congenital hearing loss is associated with inner ear malformations (IEMs). Implantation of such children was associated with uncertain surgical and clinical success, and hence was limited in the early years of CI surgery. To date, the literature regarding outcomes in this special population has varied. Studies have been mixed when comparing children with IEMs to those with normal anatomy regarding success with CI. Results may be related to the type and severity of IEM. There may also be differences in children with congenital deafness versus progressive hearing loss. The current data are limited as there is not a standardized testing paradigm for evaluation in children. The variability in the data suggests further research is required to fully understand the nuances in management of these complex children. The goal of this review is to discuss surgical management and outcomes of children who meet criteria for CI in the setting of an IEM.

Introduction: Pulmonary embolism (PE) is a common cardiovascular condition with high mortality rates if left untreated. Given the non-specific and varied symptoms of PE, its diagnosis remains challenging and approaches can lend themselves to inefficiencies through over-testing and over-diagnosis. Clinicians rely on a multi-component and sequential approach, including clinical risk assessment, rule-out biomarkers, and diagnostic imaging. This study assessed the potential cost-effectiveness of different diagnostic algorithms. Methods: A cost-utility model was developed with an upfront decision tree capturing the diagnostic accuracy and a Markov cohort model reflecting the lifetime disease progression and clinical utility of each diagnostic strategy. 57 diagnostic strategies were evaluated that were permutations of various clinical risk assessment, rule-out biomarkers and diagnostic imaging modalities. Diagnostic test accuracy was informed by systematic reviews and meta-analyses, and costs (2016 CAD) were obtained from Canadian costing databases to reflect a health-care payer perspective. Separate scenario analyses were conducted on patients contra-indicated for computed tomography (CT) or who are pregnant as this entails a comparison of a different set of diagnostic strategies. Results: Six diagnostic strategies formed the efficiency frontier. Diagnosing patients with PE was generally cost-effective if willingness-to-pay was greater than $1,481 per quality-adjusted-life year (QALY). CT dominated other imaging modality given its greater diagnostic accuracy, lower rates of non-diagnostic findings and lowest overall costs. The use of clinical prediction rules to determine clinical pre-test probability of PE and the application of rule-out test for patients with low-to-moderate risk of PE may be cost-effective while reducing the proportion of patients requiring CT and lowering radiation exposure. At a willingness-to-pay of $50,000 per QALY, the strategy of Wells (2 tier) --> d-dimer --> CT --> CT was the most likely cost-effective diagnostic strategy. However, different diagnostic strategies were considered cost-effective for pregnant patients and those contra-indicated for CT. Conclusion: This study highlighted the value of economic modelling to inform judicious use of resources in achieving a diagnosis for PE. These findings, in conjunction with a recent health technology assessment, may help to inform clinical practice and guidelines. Which strategy would be considered cost-effective reflected ones willingness to trade-off between misdiagnosis and over-diagnosis.

For an effective model-based mechatronic system engineering software tools are necessary which support collaboration between the involved disciplines, a single source of information and – among other things – enables integrated workflows. But it is not enough just to rollout a new software tool in the company, in order to use all advantages, also the organizational structure has to be adjusted. This contribution discusses these influences on organizational structures and illustrates an analyzing methodology which can be performed before a rollout in order to give recommendations and hints for necessary changes. The methodology is shown on the industrial example of the rollout of the tool COMOS which is used for the design of sinter plants.

Purpose:The increasing application of VMAT demands a more efficient workflow and QA solution. This study aims to investigate the feasibility of performing VMAT QA measurements on one linac for plans treated on other beam‐matched Elekta Agility linacs.Methods:A single model was used to create 24 clinically approved VMAT plans (12 head‐and‐neck and 12 prostate using 6MV and 10MV respectively) on Pinnacle v9.10 (Philips, Einhoven, Netherlands). All head‐and‐neck plans were delivered on three beam‐matched machines while all prostate cases were delivered on two beam‐matched 10MV Agility machines. All plans were delivered onto PTW Octavius 4D phantom with 1500 detector array (PTW, Freiburg, Germany). Reconstructed volume doses were then compared with the Pinnacle reference plans in Verisoft 6.1 under 3%/3mm gamma criteria at local dose. Plans were considered clinically acceptable if >90% of the voxels passing the gamma criteria.Results:All measurements were passed (3D gamma passing rate >90%) and the result shows that the mean difference of 3D gamma of 12 head‐and‐neck cases is 1.2% with standard deviation of 0.6%. While for prostate cases, the mean difference of 3D gamma is 0.9% with standard deviation of 0.7%. Maximum difference of 3D gamma of all measurements between beam‐matched machines is less than 2.5%. The differences of passing rates between different machines were statistically insignificant (p>0.05). Conclusion. The result suggests that therConclusion:The result suggests that there exists a 3D gamma threshold, in our case 92.5%, above which the VMAT QA performed in any one of beam‐matched machine will also pass in another one. Therefore, VMAT QA efficiency may be increased and phantom set up time can be saved by implementing such method. A constant performance across all beam matched machines must be maintained to make this QA approach feasible.

Purpose:To compare the dose of an in‐house 3D‐printed gynecology applicator (TMHGA) for vaginal vault recurrence of corpus cancer patients after operation for high dose rate brachytherapy treatment with commercially available applicators.Methods:A newly designed applicator is made from 3D‐printing methods using ABSM30i. The isodose of the applicator is compared with Elekta multi‐channel (MC) applicator and titanium Rotterdam applicator with coupling central tube and vaginal cylinder (RC). Three plans are created using three applicators in a CT set of water phantom. The applicators are anchored using the applicator library and implant library in the Elekta Oncentra treatment planning system (ver.4.5). The rectum is mimicked by creating a 2cm diameter cylinder, with a distance 1mm posteriorly away from the high risk CTV (HR‐CTV). Similarly, the bladder is replicated by a 6cm diameter cylinder with distance 1mm anteriorly from the HR‐CTV. Three plans are all normalized 1.5cm superior, 0.5cm anterior and 0.5cm posterior of the applicator surface. By fixing D90 of HR‐CTV to 6Gy, the D2cc of rectum and bladder of three plans are compared.Results:The D2cc of the bladder for using TMHGA is lower than MC and RC by 14.0% and 11.9% respectively. While the D2cc of the rectum for using TMHGA is lower than MC and RC by 18.9% and 12.4% respectively. The total treatment time of TMHGA plan is shorter than MC and RC by 11.2% and 12.9%.Conclusion:The applicator created via 3D printing delivers a lower dose to the bladder and the rectum while keeping the same coverage to HR‐CTV as other commercially available applicators. Additionally, the new applicator resulted in a reduction of treatment time, which is always welcome.

BACKGROUND Commercial treatment planning system Pinnacle3 (Philips, Fitchburg, WI, USA) employs a convolution-superposition algorithm for volumetric-modulated arc radiotherapy (VMAT) optimization and dose calculation. Study of Monte Carlo (MC) dose recalculation of VMAT plans for advanced-stage nasopharyngeal cancers (NPC) is currently limited. METHODS Twenty-nine VMAT prescribed 70Gy, 60Gy, and 54Gy to the planning target volumes (PTVs) were included. These clinical plans achieved with a CS dose engine on Pinnacle3 v9.0 were recalculated by the Monaco TPS v5.0 (Elekta, Maryland Heights, MO, USA) with a XVMC-based MC dose engine. The MC virtual source model was built using the same measurement beam dataset as for the Pinnacle beam model. All MC recalculation were based on absorbed dose to medium in medium (Dm,m). Differences in dose constraint parameters per our institution protocol (Supplementary Table 1) were analyzed. RESULTS Only differences in maximum dose to left brachial plexus, left temporal lobe and PTV54Gy were found to be statistically insignificant (p> 0.05). Dosimetric differences of other tumor targets and normal organs are found in supplementary Table 1. Generally, doses outside the PTV in the normal organs are lower with MC than with CS. This is also true in the PTV54-70Gy doses but higher dose in the nasal cavity near the bone interfaces is consistently predicted by MC, possibly due to the increased backscattering of short-range scattered photons and the secondary electrons that is not properly modeled by the CS. The straight shoulders of the PTV dose volume histograms (DVH) initially resulted from the CS optimization are merely preserved after MC recalculation. CONCLUSION Significant dosimetric differences in VMAT NPC plans were observed between CS and MC calculations. Adjustments of the planning dose constraints to incorporate the physics differences from conventional CS algorithm should be made when VMAT optimization is carried out directly with MC dose engine.

To assist decision-makers with reimbursement decisions, model-based cost-effectiveness analyses provide an approach whereby costs and clinical effects from multiple sources can be combined. The CADTH Cost Guidance document highlights some of the current challenges associated with identifying appropriate costing information for non-drug technologies. The objective of this study is to highlight challenges in identifying and measuring costs from recently conducted economic evaluations of non-drug technologies in the Canadian setting. The authors reviewed economic evaluations of non-drug technologies recently undertaken by CADTH. Issues with identification and measurement of costs used in the economic evaluations were noted. Common themes and how they impact decisions making are discussed. Between 2014 and 2016, CADTH conducted economic evaluations on diagnostic and investigational services in a broad range of clinical areas including: monitoring end-tidal COs; molecular diagnostics for colon cancer screening; genetic test for routine factor V Leiden and prothrombin mutation; and, laboratory diagnostic tests for inflammatory conditions. From these evaluations, common themes emerged regarding the challenges in conducting analyses of non-drug technologies: i) paucity of publicly available information on pricing and resource utilization; ii) large variability in prices and availability of data across jurisdictions; iii) rapidly evolving costs in parallel with technological developments; iv) broader impact of medical device beyond clinical effectiveness; v) multiple application across different clinical areas; vi) differences between the published price and actual cost of testing/diagnostics; vii) differences in procurement and reimbursement mechanisms across jurisdictions; viii) reduced confidence in results of the economic evaluation. This case study highlights key challenges in determining and measuring appropriate cost information when conducting economic evaluations of non-drug technologies in Canada, although this may not be unique to Canada. In the absence of good cost information, following appropriate guidance and exploring the parameter values in sensitivity analyses is required.

Purpose:To evaluate the use of measurement guided dose reconstruction (MGDR) in quality assurance (QA) of stereotactic radiosurgery (SRS) of multiple brain metastases (MBM) planned with single isocenter (SI).Methods:Seven clinically approved multi‐isocenter MBM (MI‐MBM) plans were re‐optimized using SI (SI‐MBM) by coplanar volumetric arc therapy (VMAT) in Monaco v5.0 (Elekta CMS, Maryland Heights, MO, USA). These plans were delivered on an Elekta Agiltiy Linac and measured by OCTAVIUS 4D system with OCTAVIUS 1500 2D array (PTW, Freiburg, Germany). Measurements were repeated with a shift of the phantom by 5mm to double the detector resolution. 3D γ analysis in Verisoft 6.1 with 1.5mm/1.5%, 1.5mm/2% and 2mm/2% at local‐dose passing criteria and 20% dose suppression were made.Results:3D γ passing rates are 94.3±2.7%, 85.2±5.4% and 84±5.7% at 1.5mm/1.5%, 1.5mm/2% and 2mm/2% criteria.Conclusion:MGDR of OCTAVIUS 4D system provides adequate and efficient VMAT QA solution for SI‐MBM SRS. However, the results showed significant spatial dependence due to rapid dose fall‐off in radiosurgery. Further improvement in detector spatial resolution is desired. PTV margins should be carefully adopted for those MBM treated with single isocenter.

Thermal budget, stack thickness, and dipolar offset field control are crucial for seamless integration of perpendicular magnetic junctions (pMTJ) into semiconductor integrated circuits to build scalable spin-transfer-torque magnetoresistive random access memory. This paper is concerned with materials and process tuning to deliver thermally robust (400 degrees C, 30 min) and thin (i.e., fewer layers and integration-friendly) pMTJ utilizing Co/Pt-based bottom pinned layers. Interlayer roughness control is identified as a key enabler to achieve high thermal budgets. The dipolar offset fields of the developed film stacks at scaled dimensions are evaluated by micromagnetic simulations. This paper shows a path towards achieving sub-15 nm-thick pMTJ with tunneling magnetoresistance ratio higher than 150% after 30 min of thermal excursion at 400 degrees C. (C) 2015 AIP Publishing LLC.