Evaluate the characteristics and clinical significance of “toxic twin-leaf” sign in spinal epidural metastases before percutaneous vertebroplasty

ObjectiveOur study aimed to analyze morphological features of spinal epidural metastases using magnetic resonance imaging (MRI) and investigate the formation mechanism and clinical significance of the “toxic twin-leaf” sign in spinal epidural metastasis.Materials and methodsWe retrospectively studied 108 patients with spinal epidural metastases who underwent MRI. Patients were divided into “toxic twin-leaf” sign group (group A) and irregular group (group B). Chi-square test was used to analyze data on sex, vertebra location, presence of fracture in the corresponding vertebral body, involvement of the corresponding pedicle, and the primary tumor. Further, group data were analyzed using the rank sum test; p ​< ​0.05 was considered significant.ResultsThe “twin-leaf” sign was noted in 88 cases with 136 epidural masses and 20 cases of irregular shape in 108 patients; the “toxic twin-leaf” sign accounted for 87.18% of spinal epidural metastases. A difference between groups in the vertebra location (p ​< ​0.01) was observed, but no differences were found in sex, presence of fractures in the corresponding vertebral body, involvement of the corresponding pedicle, and primary tumor (p ​> ​0.05). Intergroup differences in the rate of spinal stenosis on axial and sagittal images were significant.ConclusionsMRI axial sequences clearly revealed the morphology of spinal epidural metastases. Detection of the “toxic twin-leaf” sign in spinal epidural metastases was of great clinical significance. Furthermore, determining the degree of spinal stenosis in the axial sequence provided a more accurate evaluation of patients’ condition compared to the sagittal sequence.     

Axillary Pathologic Complete Response to Neoadjuvant Chemotherapy in Clinically Node-Positive Breast Cancer Patients: A Predictive Model Integrating the Imaging Characteristics of Ultrasound Restaging with Known Clinicopathologic Characteristics

The goal of this study was to evaluate various clinicopathologic and imaging characteristics as independent predictors of axillary pathologic complete response (pCR) to neoadjuvant chemotherapy (NAC) and to determine the added value of a model that integrates imaging characteristics of ultrasound (US) restaging with known clinicopathologic characteristics. A total of 227 clinically node-positive breast cancer patients underwent axillary US after NAC (termed US restaging) before surgery. We constructed a clinicopathologic model with independent predictors of clinicopathologic characteristics in multivariate analyses. A combined model was created by integrating imaging characteristics with clinicopathologic characteristics. The predictive values of the models were compared using the area under the receiver operating characteristic curve. Of the 227 patients, 106 (46.7%) achieved axillary pCR. Multivariate analysis revealed that higher histologic grades (odds ratio [OR]?=?4.21 and 10.11 for moderate and high grade, respectively), negative hormonal receptor status (OR?=?2.88), smaller (≤1.5 cm) residual tumor size (OR?=?2.83), absence of fatty hilum loss (OR?=?14.06) and absence of eccentric cortical thickening of the axillary lymph node (OR?=?4.42) were independently associated with the axillary pCR (all p values < 0.05). Integrating the imaging characteristics of the US restaging significantly increased the predictive capability of the model that applied only the clinicopathologic characteristics (c-index, 0.783 vs. 0.657; p < 0.001). Imaging characteristics of the US restaging were independently associated with axillary pCR after NAC and they significantly improved the predictive capability of the model that used only the clinicopathologic characteristics.     

Sondas endonasales como causa de las úlceras por presión en el paciente crítico

IntroductionOne of the risks of using endonasal tubes (ET) is the appearance of pressure ulcers (PU).ObjectiveTo ascertain the proportion of patients with nasal PU, study the risk factors of appearance, and find predictive variables.Material and methodsA six-month prospective, observational study of intensive care unit patients with ET.VariablesVariable response: “the appearance of pu as a result of the use of ET”. Explanatory variables: age, duration of stay, length of time with ET, gender, sedation, norepinephrine perfusion, mechanical ventilation, anemia, nutritional state.Analysismultivariate statistical techniques (multiple logistical regression). Statistics program g-stat 2.0. Significance level p < 0.05.ResultsSample of 48 patients. Proportion of patients with PU: 29.2%. Those patients with PU had similar ages, duration of stay and longer length of time with ET. Results of the Logistic Regression model: only the variable “time with ET” was statistically significant (p = 0.03; odds ratio: 1.047).ConclusionsThe length of time the patient is using an ET influences the appearance of nasal PU (risk increases 1.047 for each day with ET).None of the variables dealt with could be used as a predictive factor in the appearance of PU.     

Factors that Influence Kidney Shear Wave Speed Assessed by Acoustic Radiation Force Impulse Elastography in Patients without Kidney Pathology

Our aim was to assess kidney shear wave speed by means of acoustic radiation force impulse (ARFI) elastography in patients without kidney pathology (“normal” patients) and to identify the factors that influence it. We analyzed 91 “normal” patients in whom kidney shear wave speed was assessed by means of ARFI elastography. Five valid ARFI elastographic measurements were obtained in all “normal” patients in both kidneys. In univariate analysis, age (r = −0.370, p = 0.003), gender (female vs. male, r = −0.305, p = 0.003) and measurement depth (r = −0.285, p = 0.01) were significantly correlated with kidney shear wave speed values assessed by ARFI elastography, whereas body mass index, kidney length and renal parenchyma thickness were not correlated. In multivariate analysis, only age (p = 0.006) and gender (p = 0.03) were significantly correlated with kidney shear wave speed values. In conclusion, kidney shear wave speed values assessed by ARFI elastography in “normal” patients are influenced mainly by age and gender and less by measurement depth.     

Effect of conscious abdominal contraction on the activation of periscapular muscles in individuals with subacromial pain syndrome

BackgroundSynergism between shoulder and trunk muscles seems to be effective to increase periscapular muscle activation in asymptomatic subjects. The influence of conscious contraction of the abdominal muscles has not yet been studied in non-athlete subjects with pain. The study aimed to investigate the effect of the instruction for conscious activation of the abdominal muscles on the activity of the scapulothoracic muscles during shoulder exercises in subjects with subacromial pain syndrome.MethodThirty subjects with unilateral pain (mean age 52 ± 11 years) participated in this study. Three isometric and five dynamic exercises for the scapulothoracic muscles were assessed. The group without instruction just repeated the exercises, while the instruction group was evaluated before and after conscious abdominal training. The linear mixed model analysis was used to compare the muscle activation between groups.FindingsDifferences between groups after the conscious abdominal contraction for activation of middle and lower trapezius on the symptomatic side in the “Full can”(p = 0.03; effect size:0.92 middle trapezius); (p = 0.02; effect size:0.96 lower trapezius) and “Knee Push” (p = 0.01; effect size:0.75 lower trapezius). For asymptomatic side, the exercises “External Rotation Kneeling” (p = 0.04; effect size: 0.81 lower trapezius); (p = 0.00; effect size: 2.09 serratus anterior), “Knee Push” (p = 0.04; effect size:1.24 serratus anterior) and “Wall Slide” (p = 0.01; effect size: 1.03 serratus anterior).InterpretationConscious contraction of the abdominal muscle immediately alter the activation of the serratus anterior muscle during closed kinetic chain exercises on the asymptomatic side and increased activation of trapezius on the symptomatic side during shoulder open kinetic chain exercise.     

Peripheral Enhancement of Breast Cancers on Contrast-Enhanced Ultrasound: Correlation with Microvessel Density and Vascular Endothelial Growth Factor Expression

There is little evidence of an association between peripheral enhancement on contrast-enhanced ultrasound and histopathologic prognostic factors in breast cancer. The purpose of our study was to investigate the relationship of peripheral enhancement on contrast-enhanced ultrasound with microvessel density, vascular endothelial growth factor (VEGF) expression and other prognostic factors in patients with breast cancer. In 51 patients with BI-RADS (Breast Imaging Reporting and Data System) category 5 lesions scheduled for surgery, contrast-enhanced ultrasound with an 8-4 linear transducer and B-mode pulse inversion harmonic imaging was performed after administration of SonoVue. Forty-three histologically confirmed breast cancers were included in the study and divided into the peripheral enhancement group and non-peripheral enhancement group on the basis of their features on contrast-enhanced ultrasound. The ratio of peripheral to central microvessel density, VEGF expression, tumor size, histopathologic type, stage, lymph node metastasis and expression of estrogen receptor, progesterone receptor, c-erb-B2 and p53 were compared between the two groups. The ratio of peripheral to central microvessel density and a peripherally positive/centrally negative VEGF expression pattern were significantly higher in the peripheral enhancement group than in the non-peripheral enhancement group (t-test, p = 0.023, and χ² test, p = 0.035, respectively). There were no significant differences in breast cancer size, histopathologic type, stage, lymph node metastasis or expression of estrogen receptor, progesterone receptor, c-erb-B2 and p53 between the two groups (χ² test, p = 0.416, 0.877, 0.543, 0.124, 0.453, 0.554, 0.350 and 0.479 respectively). The peripheral enhancement pattern of breast cancer on contrast-enhanced ultrasound may be valuable in the evaluation of peripheral/central tumor angiogenesis and VEGF expression.     

Non-invasive evaluation of breast cancer response to chemotherapy using quantitative ultrasonic backscatter parameters

Tumor response to neoadjuvant chemotherapy in patients (n = 30) with locally advanced breast cancer (LABC) was examined using quantitative ultrasound. Three ultrasound backscatter parameters, the integrated backscatter coefficient (IBC), average scatterer diameter (ASD), and average acoustic concentration (AAC), were estimated from tumors prior to treatment and at four times during neoadjuvant chemotherapy treatment (weeks 0, 1, 4, 8, and prior to surgery) and compared to ultimate clinical and pathological tumor responses. Results demonstrated that among all parameters, AAC was the best indicator of tumor response early after starting treatment. The AAC parameter increased substantially in treatment-responding patients as early as one week after treatment initiation, further increased at week 4, and attained a maximum at week 8. In contrast, the backscatter parameters from non-responders did not show any changes after treatment initiation. The two patient populations exhibited a statistically significant difference in changes of AAC (p < 0.001) and ASD (p = 0.023) over all treatment times examined. The best prediction of treatment response was achieved with the combination of AAC and ASD at week 4 (82% sensitivity, 100% specificity, and 86% accuracy) of 12–18 weeks of treatment. The survival of patients with responsive ultrasound parameters was higher than patients with non-responsive ultrasound parameters (35 ± 11 versus 27 ± 11 months, respectively, p = 0.043). This study demonstrates that ultrasound parameters derived from the ultrasound backscattered power spectrum can potentially serve as non-invasive early measures of clinical tumor response to chemotherapy treatments.     

“Rolling Refreshers”: A novel approach to maintain CPR psychomotor skill competence

ObjectivesHigh quality CPR skill retention is poor. We hypothesized that “just-in-time” and “just-in-place” training programs would be effective and well-accepted to maintain CPR skills among PICU staff.Methods“Rolling Refreshers”, a portable manikin/defibrillator system with chest compression sensor providing automated corrective feedback to optimize CPR skills, were conducted daily in the PICU with multidisciplinary healthcare providers. Providers practiced CPR until skill success was attained, prospectively defined as <3 corrective prompts within 30 s targeting chest compression (CC) rate 90–120/min, CC depth >38 mm during continuous CPR. Providers completing ≥2 refreshers/month (Frequent Refreshers [FR]) were compared to providers completing <2 refreshers/month (Infrequent Refreshers [IR]) for time to achieve CPR skill success. Univariate analysis performed using non-parametric methods. Following actual cardiac arrests, CPR providers were surveyed for subjective feedback on training approach efficacy (5-point Likert scale; 1 = poor to 5 = excellent).ResultsOver 15 weeks, 420 PICU staff were “refreshed”: 340 nurses, 34 physicians, 46 respiratory therapists. A consecutive sample of 20 PICU staff was assessed before subsequent refresher sessions (FREQ n = 10, INFREQ n = 10). Time to achieve CPR skill success was significantly less in FREQ (median 21 s, IQR: 15.75–30 s) than in INFREQ (median 67 s, IQR: 41.5–84 s; p < 0.001). Following actual resuscitations, CPR providers (n = 9) rated “Rolling Refresher” training as effective (mean = 4.2; Likert scale 1–5; standard deviation 0.67).ConclusionsA novel “Rolling Refresher” CPR skill training approach using “just-in-time” and “just-in-place” simulation is effective and well received by PICU staff. More frequent refreshers resulted in significantly shorter times to achieve proficient CPR skills.     

Evaluation of dosimetric and volumetric changes in target volumes and organs at risk during adaptive radiotherapy in head and neck cancer: A prospective study

BackgroundDuring radiation therapy for head and neck malignancies, most patients experience significant anatomical alterations due to loss of weight, changes in tumor volumes, and immobilization issues. Adaptive radiotherapy adapts to the patient's actual anatomy through repetitive imaging and replanning. In the present study, dosimetric and volumetric changes in target volumes and organs at risk during adaptive radiotherapy in head and neck cancer was evaluated.Material and methodsThirty-four locally advanced Head and neck carcinoma patients with histologically proven Squamous Cell Carcinoma for curative treatment were included. Rescan was done at the end of 20 fractions of treatment. All quantitative data were analyzed with paired t-Test and Wilcoxon Signed Rank (Z) test.ResultsMost patients had oropharyngeal carcinoma (52.9%). There were significant volumetric changes in all the parameters - GTV-primary (10.95, p < 0.001), GTV- nodal (5.81, p = 0.001), PTV High Risk (26.1, p < 0.001), PTV – Intermediate Risk (46.9, p = 0.006), PTV – Low Risk (43.9, p = 0.003), lateral neck diameter (0.9, p < 0.001), right parotid volumes (6.36, p < 0.001) and left parotid volumes (4.93, p < 0.001). Dosimetric changes in the organs at risk were non-significant.ConclusionAdaptive replanning has been seen to be labour intensive. However, the changes in the volumes of both target and the OARs credit a mid-treatment replanning to be done. Long term follow-up is required to assess locoregional control after adaptive radiotherapy in head and neck cancer.     

Contrast-Enhanced Ultrasound Characteristics of Breast Cancer: Correlation with Prognostic Factors

The purpose of the work described here was to investigate the correlation of contrast-enhanced ultrasound (CEUS) characteristics with prognostic factors in breast cancer. Forty-five consecutive breast cancer patients were studied with CEUS. All patients were diagnosed with invasive ductal carcinoma on the basis of biopsy or surgery results. Lack of blood perfusion of the tumor was identified in 2 cases; blood perfusion was observed in 43 cases. Enhancement was heterogeneous in 25 cases, and centripetal in 25 cases. A blood perfusion defect was present in 27 cases. Enhancement shape was irregular in 37 cases, margins were poorly defined in 34 cases, and penetrating vessels were present in 32 cases. Compared with the surrounding normal tissue, tumor tissue had faster rising times and times to peak and higher peak intensities and wash-in slopes; the differences between the two groups were statistically significant (p < 0.05). Compared with the interior of the tumor, the periphery had faster times to peak and higher peak intensities and wash-in slopes (p < 0.05). Heterogeneous enhancement, perfusion defect, centripetal enhancement and penetrating vessels were correlated with prognosis (p < 0.05). Overall, some CEUS characteristics of breast cancer were associated with prognostic factors that can predict breast cancer prognosis in vivo.     

Impacts of the introduction of a triage system in Japan: A time series study

The aim of the present study was to measure and compare the effectiveness of nursing triage before and after introduction of the Japanese Triage and Acuity Scale (JTAS), the Japanese version of the Canadian Triage and Acuity Scale (CTAS), during emergency treatment. Surveys of triage nurses and emergency physicians were conducted before and after JTAS introduction. Respondents were triage nurses (before 112 cases, after 94 cases), emergency physicians (before 50, after 41), and triaged patients (before 1057, after 1025) from seven separate emergency medical facilities. The results showed that nursing triage using the JTAS shortened “time from registration to triage” by 3.8 min, “triage duration” by 1 min, “time from registration to physician” by 11.2 min, and “waiting time perceived by patients to see a physician” by 18.6 min (p < 0.001). The difference in assigned level of urgency between triage nurses and emergency physicians decreased from 34.2% to 12.2% (p < 0.001), over-triage decreased from 24.7% to 8.6% (p < 0.001), and under-triage decreased from 9.5% to 3.6% (p < 0.001). Furthermore, assessment agreement between triage nurses and emergency physicians increased significantly, from weighted κ = 0.486 to weighted κ = 0.820. These findings suggest that the introduction of the JTAS promoted more effective nursing triage and medical care.     

乳腺癌新辅助化疗疗效的影响因素分析

目的探讨影响乳腺癌新辅助化疗(NAC)疗效的影响因素。方法 120例接受NAC的乳腺癌患者,采用免疫组化法确定雌激素受体(ER)、孕激素受体(PR)及人表皮生长因子受体-2(HER-2)和Ki-67状态,并分析相关病历资料,Logistic回归分析患者达到病理完全缓解(p CR)的影响因素。结果 17例患者达到p CR,占14.2%。单因素分析结果显示,肿瘤大小、ER、PR和化疗方案为影响疗效达到p CR的相关因素。多元Logistic回归分析结果显示,肿瘤大小为影响疗效达到p CR的独立危险因素。结论乳腺癌NAC p CR与肿瘤大小、ER、PR和化疗方案等因素有关,其中肿瘤大小是其独立危险因素。     

Dysregulated circ_0004913, circ_0008160, circ_0000517, and their potential as biomarkers for disease monitoring and prognosis in hepatocellular carcinoma

ObjectiveCircular RNA_0004913 (circ_0004913), circular RNA_0008160 (circ_0008160), and circular RNA_0000517 (circ_0000517) are shown to be dysregulated in HCC tissues and cell lines, and also show potential in regulating hepatocellular carcinoma (HCC) pathogenesis. This current study attempted to find possible associations of circ_0004913, circ_0008160, and circ_0000517 with clinical features and prognosis of HCC patients.MethodsA hundred and fifty HCC patients who received hepatectomy were retrospectively reviewed, and their resected specimens including tumor tissues and paired adjacent tissues were obtained, in which the circ_0004913, circ_0008160, and circ_0000517 expressions were detected. Overall survival (OS) data were collected according to the clinical visit records.ResultsCirc_0004913 (p < 0.001) and circ_0008160 (p < 0.001) were downregulated, while circ_0000517 (p < 0.001) was upregulated in tumor tissue compared with paired adjacent tissue. Additionally, tumor circ_0004913 was negatively associated with largest tumor size (p = 0.009) and Barcelona clinic liver cancer (BCLC) stage (p = 0.020), while tumor circ_0008160 and circ_0000517 were not correlated with any clinicopathological features of HCC patients (all p > 0.05). Tumor circ_0004913 high expression was associated with prolonged OS in total HCC patients (p = 0.008) and in subgroup of patients with largest tumor size <5 cm (p = 0.008). Tumor circ_0008160 high expression was correlated with longer OS in patients with BCLC stage B (p = 0.026). Univariate Cox''s analysis disclosed that tumor circ_0004913 high expression was correlated with longer OS; while after adjustment by multivariate Cox''s analysis, it failed to predict OS independently.ConclusionCirc_0004913 was downregulated in tumor tissue and may serve as a biomarker for evaluating disease severity and prognosis in HCC patients.     

Predicting Long-Term Hepatocellular Carcinoma Response to Transarterial Radioembolization Using Contrast-Enhanced Ultrasound: Initial Experiences

Conventional cross-sectional imaging done shortly after radioembolization of hepatocellular carcinoma (HCC) does not reliably predict long-term response to treatment. This study evaluated whether quantitative contrast-enhanced ultrasound (CEUS) can predict the long-term response of HCC to yttrium-90 (Y-90) treatment. Fifteen patients underwent CEUS at three time points: immediately following treatment and 1 and 2 wk post-treatment. Response 3–6 mo after treatment was categorized on contrast-enhanced magnetic resonance imaging by two experienced radiologists using the Modified Response Evaluation Criteria in Solid Tumors. CEUS data were analyzed by quantifying tumor perfusion and residual fractional vascularity using time–intensity curves. Patients with stable disease on magnetic resonance imaging had significantly greater fractional vascularity 2 wk post-treatment (65.15%) than those with partial or complete response (13.8 ± 9.9%, p = 0.007, and 14.9 ± 15.4%, p = 0.009, respectively). Complete responders had lower tumor vascularity at 2 wk than at post-operative examination (–38.3 ± 15.4%, p = 0.045). Thus, this pilot study suggests CEUS may provide an earlier indication of Y-90 treatment response than cross-sectional imaging.     

Shoulder muscle force and electromyography activity during make versus break tests

BackgroundShoulder muscle force is commonly assessed during clinical examination using both an isometric “make” test against a fixed resistance or a “break” test where the examiner exerts enough force to break the isometric contraction. The purpose of this study was to explain the difference in force produced during these two forms of testing.MethodsData were collected on 25 subjects. Both shoulder external rotation and elevation force were measured over three trials, isometrically, for approximately 3 s, after which the examiner exerted enough force to move the arm. Surface EMG was recorded for the infraspinatus for external rotation and middle deltoid for elevation. Peak isometric and break forces, and normalized, averaged EMG data at peak isometric and break forces were compared with paired t-tests.FindingsExternal rotation peak break force was 46.9% (SD33.6, range − 3% to 108.6%) greater than isometric force (p < 0.01). EMG for the infraspinatus was 17.0% (20.8) greater at break (p < 0.01). For elevation, peak break force was 63% (73.1, range − 3.5 to 238.16%) greater than isometric force (p < 0.01). EMG for the middle deltoid was 11.1% (30.8) greater during peak break force (not significant).InterpretationsThere is a difference in both force and muscle activity between “make” and “break” tests. Clinicians should use a consistent method when measuring force and a break test will provide the maximum force. The cause of greater force produced during a break test is likely attributable to the brief eccentric contraction rather than greater recruitment. Future analysis will include examining the differences in make and break forces based on activity levels.