Validation of a Patient-Reported Outcome Measure for Moist Desquamation among Breast Radiotherapy Patients

There has been an increasing interest in patient-reported outcome (PRO) measures in both the clinical and research settings to improve the quality of life among patients and to identify when clinical intervention may be needed. The primary purpose of this prospective study was to validate an acute breast skin toxicity PRO measure across a broad sample of patient body types undergoing radiation therapy. Between August 2018 and September 2019, 134 women undergoing adjuvant breast radiotherapy (RT) consented to completing serial PRO measures both during and post-RT treatment and to having their skin assessed by trained trial radiation therapists. There was high patient compliance, with 124 patients (92.5%) returning to the clinic post-RT for at least one staff skin assessment. Rates of moist desquamation (MD) in the infra-mammary fold (IMF) by PRO were compared with skin assessments completed by trial radiation therapists. There was high sensitivity (86.5%) and good specificity (79.4%) between PRO and staff-reported presence of MD in the IMF, and there was a moderate correlation between the peak severity of the MD reported by PRO and assessed by staff (rho = 0.61, p < 0.001). This prospective study validates a new PRO measure to monitor the presence of MD in the IMF among women receiving breast RT.     

Ultrastructural and biochemical characterization of glycosaminoglycans in HNK-1-positive large granular lymphocytes

Natural killer (NK) cells are large granular lymphocytes (LGLs) that contain distinct lysosomal granules. The present study was undertaken to determine if these lysosomes contain glycosaminoglycans (GAGs) similar to those previously described in myeloid cells. Mononuclear cells from human blood were stained with HNK-1 fluoresceinated monoclonal antibody, and the NK cell population reactive with this antibody were isolated with a fluorescence-activated cell sorter (FACS). Specific staining of sulfated macromolecules with the cationic reagent, high iron diamine, was observed in the lysosomal granules of 90% of the HNK-1 positive cells. Staining in the same location was also observed in the unsorted LGLs, presumed to be NK cells, and intense staining of the cell surface was also a prominent feature of these cells. Surface staining was not evident in the majority of the FACS- separated NK cells. Digestion with chondroitinase ABC or treatment with nitrous acid reduced the staining in both locations; after sequential treatment with both chondroitinase and nitrous acid, little or no staining was seen. The presence of chondroitin sulfate (and/or dermatan sulfate) and heparan sulfate was also shown by the finding that incubation of the isolated NK cells with 35S-sulfate yielded cell- associated radiolabeled macromolecules with the characteristics of these two groups of GAGs. Of the labeled GAG pool, 60% was degraded by chondroitinase and 40% was susceptible to nitrous acid treatment. LGLs of a patient with Chediak-Higashi syndrome was also stained, and intracellular sulfate staining was clearly localized to the enlarged granules, supporting the conclusion that the lysosomes are the major site of intracellular accumulation of GAGs in normal NK cells.     

Safety and Efficacy of Reteplase for the Treatment of Acute Arterial Occlusion: Complexity of Underlying Lesion Predicts Outcome

We evaluated both the safety and efficacy of reteplase for treatment of acute arterial occlusion as well as outcomes based on treatment of the underlying lesion. From November 2000 to February 2004, reteplase was used to treat arterial occlusions in 81 patients. Catheter-directed intrathrombus thrombolysis was performed with reteplase (0.5 units/hr) continuous infusion. Percutaneous mechanical thrombectomy (Angiojet) was performed in 61% (n = 50) of patients prior to thrombolysis. Unmasking of significant lesions resulted in endovascular intervention (39.5%), open surgical repair (24.6%), or both endovascular and surgical repair (9.8%) of the lesion. No lesion was found in 25.9% of patients. Major and minor complication rates as well as restoration of patency, limb salvage, and amputation-free survival were evaluated. Eighty-one patients received reteplase therapy (median = 10.3 +/- 5.3 units, 19.5 +/- 7.4 hr) followed by next-day arteriogram to assess thrombus removal. Technical success was achieved in 96.2% (n = 78) of cases. Kaplan-Meier life table analysis revealed overall primary patency rates of 76.3%, 60.1%, and 51.6%, at 1, 6, and 12 months, respectively. Overall amputation-free survival rates were 86.4%, 76.4%, and 69.7% at 1, 6, and 12 months, respectively. When subdivided into postlysis intervention, the lysis-only group achieved increased patency (p = 0.0143) and increased limb salvage (p = 0.0219) at 1 year compared to the lysis and endovascular intervention and the lysis and surgical groups. The 30-day complication rate was 17.3% (n = 14), with a major complication rate of 4.9% (n = 4) and a minor complication rate of 12.3% (n = 10). There were no intracranial hemorrhagic complications. Intra-arterial catheter-directed infusion of reteplase for acute lower extremity ischemia is safe and efficacious, as shown by the low risk of bleeding complications, high limb salvage rates, and low mortality rates in this study. The complexity of the lesion that is unmasked through thrombolytic therapy is a predictor of patency and limb salvage.     

Acute surgical removal of low-grade (Spetzler-Martin I-II) bleeding arteriovenous malformations

Background

Early surgical removal of cerebral AVMs is a relatively infrequent therapeutic option when dealing with a cerebral hemorrhage caused by AVM rupture: even in the case of low-grade AVMs, delayed treatment is, if possible, preferred because it is considered safer for patients and more comfortable for surgeons. To assess whether acute surgery may be a safe and effective management, we conducted a retrospective analysis of our early surgery strategy for ruptured low-grade AVMs.

Methods

We reviewed 27 patients with SM grade I-II AVM treated during 2004 to 2008 in the acute stage of bleeding (within the first 6 days after bleed). All patients showed a cerebral AVM on DSA at admission, and surgical removal was controlled by postoperative angiography. Neurological outcomes were assessed with GOS. The average length of follow-up was 22 months (48-3 months).

Results

Before surgery, 16 (59%) patients showed a GCS of 8 or less, 2 of them presenting an acute rebleeding after first hemorrhage. All patients underwent radical AVM surgical removal and hematoma evacuation in a single-stage procedure. Most patients (78%) were operated within the first day of hemorrhage. A favorable functional outcome (GOS: good recovery or moderate disability) was observed in 23 patients (85%). Mortality was 7.4%. Outcome was not significantly correlated with GCS at presentation and with presence of preoperative anisocoria.

Conclusions

Early surgery for grade I-II AVMs is a safe and definitive treatment, achieving both immediate cerebral decompression and patient protection against rebleeding, reducing time of hospital stay and allowing a more rapid rehabilitative course whenever necessary.     

Motion artifact reduction of diffusion‐weighted MRI of the liver: Use of velocity‐compensated diffusion gradients combined with tetrahedral gradients

Purpose:

To assess the effect of motion artifact reduction on the diffusion‐weighted magnetic resonance imaging (DWI‐MRI) of the liver, we compared velocity‐compensated DWI (VC‐DWI) and VC‐DWI combined with tetrahedral gradients (t‐VC‐DWI) to conventional DWI (c‐DWI) in the assessment of apparent diffusion coefficients (ADCs) of the liver.

Materials and Methods:

In 12 healthy volunteers, the liver was scanned with c‐DWI, VC‐DWI, and t‐VC‐DWI sequences. The signal‐to‐noise ratio (SNR) and ADC of the liver parenchyma were measured and compared among sequences.

Results:

The image quality was visually better for t‐VC‐DWI than for the others. The SNR for t‐VC‐DWI was significantly higher than that for VC‐DWI (P < 0.05) and comparable to that for c‐DWI. ADCs in both hepatic lobes were significantly lower for t‐VC‐DWI than for c‐DWI (P < 0.01). ADC in the left lobe was significantly lower for VC‐DWI than for c‐DWI (P < 0.01). Although ADC in the left lobe was significantly higher for c‐DWI (P < 0.01), no significant differences in ADCs were found between the right and left lobes for VC‐DWI and t‐VC‐DWI.

Conclusion:

The use of a t‐VC‐DWI sequence enables us to correct ADCs of the liver for artificial elevation due to cardiac motion, with preserved SNR. J. Magn. Reson. Imaging 2013;37:172–178. © 2012 Wiley Periodicals, Inc.     

The use of deep inspiration preceding the valsalva maneuver and rapid expiration in color doppler imaging of the lower extremity veins

Deep inspiration preceding Valsalva maneuver and rapid expiration immediately following it (DIVE) enhance venous blood flow on color Doppler flow imaging (CDI). The effect of DIVE was assessed in 115 consecutive lower extremity examinations. Of these, 95 or 115 (83%) had negative CDI sonograms, and 20 of 115 (17%) had partially (six of 115) or completely (14 of 115) occluding deep vein thrombosis. DIVE enhanced venous blood flow in 68% of the negative cases, resulting in transient venous distention, and/or more complete color filling, and/or greater spectral flow velocities. The 14 cases with completely occluding thrombi showed no response to DIVE. Six cases with partially occluding thrombi showed moderate to mild response to DIVE, with improved color delineation of the residual patent lumen around the thrombus. The authors conclude that DIVE facilitates deep venous CDI, especially when compression cannot be used to augment venous flow.     

Energy Expenditure and Caloric Balance After Burn: Increased Feeding Leads to Fat Rather Than Lean Mass Accretion

OBJECTIVE: Resting energy expenditure (REE) is commonly measured in critical illness to determine caloric "demands" and thus nutritive needs. SUMMARY BACKGROUND DATA: The purpose of this study was to 1) determine whether REE is associated with clinical outcomes and 2) determine whether an optimal caloric delivery rate based on REE exists to offset erosion of lean mass after burn. METHODS: From 1995 to 2001, REE was measured by indirect calorimetry in 250 survivors of 10 to 99%TBSA burns. Caloric intake and REE were correlated with muscle protein catabolism, length of stay, ventilator dependence, sepsis, and mortality. From 1998 to 2000, 42 patients (>60%TBSA burns) received continuous enteral nutrition at a spectrum of caloric balance between 1.0x REE kcal/d -1.8x REE kcal/d. Serial body composition was measured by dual energy x-ray absorptiometry. Lean mass, fat mass, morbidity, and mortality were determined. RESULTS: REE/predicted basal metabolic rate correlated directly with burn size, sepsis, ventilator dependence, and muscle protein catabolism (P <.05). Declining REE correlated with mortality (P <.05). 2) Erosion of lean body mass was not attenuated by increased caloric balance, however, fat mass increased with caloric supply (P <.05). CONCLUSION: In surviving burned patients, caloric delivery beyond 1.2 x REE results in increased fat mass without changes in lean body mass. Declining energy expenditure appears to be a harbinger of mortality in severely burned patients.     

A comparison of percutaneous transluminal angioplasty versus amputation for critical limb ischemia in patients unsuitable for open surgery

BACKGROUND: Percutaneous transluminal angioplasty (PTA), although not the traditional therapy, seems to be a safe alternative for patients with critical limb ischemia who are believed to be unsuitable candidates for open surgery. However, the efficacy of PTA in this setting has not been analyzed. The purpose of this study was to compare the outcomes of PTA for limb salvage with outcomes of major limb amputation in physiologically impaired patients believed to be unsuitable for open surgery. METHODS: From a prospective vascular registry, 314 patients (183 underwent amputation, and 131 underwent complex PTA for limb salvage) were identified as physiologically impaired or unsuitable for open surgery. This was defined as having at least one of the following: functional impairment (homebound ambulatory or transfer only), mental impairment (dementia), or medical impairment (two of the following: end-stage renal disease, coronary artery disease, and chronic obstructive pulmonary disease). Patients undergoing PTA were compared with patients undergoing amputation by examining the outcome parameters of survival, maintenance of ambulation, and maintenance of independent living status. Parameters were assessed by using Kaplan-Meier life-table curves (log-rank test and 95% confidence intervals [CIs]) and hazard ratios (HRs) from the Cox model. RESULTS: PTA resulted in a 12-month limb salvage rate of 63%. Thirty-day mortality was 4.4% for the amputation group and 3.8% for the PTA group. After adjustment for age, race, diabetes, prior vascular procedure, dementia, and baseline functional status, PTA patients had significantly lower rates of ambulation failure (HR, 0.44; P = .0002) and loss of independence (HR, 0.53; P = .025) but had significantly higher mortality (HR, 1.62; P = .006) than amputees. However, when life tables were examined, the maintenance of ambulation advantage lasted only 12 months (PTA, 68.6%; 95% CI, 59.6%-77.7%; amputation, 48%; 95% CI, 40.4%-55.5%) and was not statistically significant at 2 years (62.2% [95% CI, 48.8%-71.5%] and 44% [95% CI, 35.8%-52.2%], respectively). Maintenance of independent living status advantage lasted only 3 months, with no statistically significant difference at 2 years (PTA, 60.5%; 95% CI, 45.4%-75.6%; amputation, 52.6%; 95% CI, 40.4%-64.9%). Although mortality was high in both cohorts, patients who underwent amputation had a survival advantage for all time intervals examined (at 2 years: PTA, 29%; 95% CI, 19.9%-38.1%; amputation, 48.1%; 95% CI, 39.2%-56.9%). CONCLUSIONS: Patients who present with critical limb ischemia and physiologic impairments that preclude open surgery seem to have comorbidities that blunt any functional advantage achieved after PTA for limb salvage. PTA in this setting affords very little benefit compared with amputation alone.