Entire Course Of Treatment Research Articles

Antibiotic Appropriateness for Urinary Tract Infections in Children.

We examined local prescribing patterns across the entire treatment course for children treated for uncomplicated urinary tract infection (UTI) to determine opportunities for antibiotic stewardship initiatives. We conducted a retrospective review of emergency department and inpatient encounters for febrile and afebrile UTI in a children's hospital from 2021 to 2022. An antibiotic spectrum ranking was established, and providers' choices were assessed for appropriateness on the basis of the individuals' urine culture (UCx). Groups were stratified by fever presence and compared using χ2, Fisher's exact, and Mann-Whitney U tests. Of 172 encounters (83% emergency department), 99 (58%) had a positive UCx. Eighty (80%) grew Escherichia coli, with 67 (84%) being susceptible to cefazolin (minimum inhibitory concentration ≤16 mg/L). There were 229 antibiotic regimens and 39 (17%) were appropriate. Inappropriate antibiotic choices included unnecessary use of broad-spectrum antibiotics and misdiagnosed UTI. Grouping by encounter, at least 1 dose of a third cephalosporin was given in 51% of encounters, and 80% of these received it unnecessarily because of UTI misdiagnosis or suitability of a narrower-spectrum antibiotic. The median prescribed antibiotic duration was 7 days (interquartile range 7-10). Of 73 encounters with UCx growing mixed flora or a nonuropathogen, only 29 (40%) had antibiotics discontinued. Confirmed UTI was associated with fever and nitrite positivity. Our study revealed high prevalence of inappropriate antibiotics, particularly unnecessary prescribing of third cephalosporin, prescriptions not supported by laboratory data, and prolonged treatment courses. Our results identify factors that can be used to support UTI treatment pathways and ensure antibiotic stewardship.

Long-term survival in patients with para-aortic metastatic cervical cancer receiving simultaneous integrated boost chemoradiation to positive lymph nodes: a single-center experience

ObjectivesTo examine the benefits of extended-field chemoradiation with simultaneous integrated boost to positive lymph nodes, followed by image-guided adaptive brachytherapy in patients with cervical cancer with para-aortic metastasis.MethodsThis retrospective cohort...

The use of platelet-rich plasma in the treatment of patients with chronic dorsalgia

Background. The purpose of the study is to assess the clinical effectiveness of using platelet-rich plasma for functional recovery in patients with chronic back pain. Materials and methods. The research was carried out in the clinical units of the Ukrainian Research Institute of Transport Medicine and Petro Mohyla Black Sea National University in 2020–2023. Sixty patients with chronic dorsalgia were examined. Results. During the entire course of treatment, patients who received local platelet-rich plasma therapy did not experience any adverse reactions or intolerance, did not require adjustment or change of treatment regimen. After 2 weeks of therapy, compared to the initial level, a significant decrease in the severity of the pain syndrome according to the visual analog scale was found, by 2.1 ± 0.2 points in the main group and by 1.5 ± 0.3 points in the control group (p < 0.05). Conclusions. After the treatment, the functional capabilities of patients in the main group improved significantly — Neck Disability Index decreased from 51.9 ± 2.2 % to 34.5 ± 1.3 % in the main group and from 53.3 ± 2.4 % to 45.8 ± 2.4 % in the controls, and Oswestry Disability Index — from 68.8 ± 2.3 % to 49.6 ± 1.8 % and from 66.7 ± 2.6 % to 55.8 ± 1.6 % (p < 0.05), respectively.

Эффективность препарата «Ипекон®» при инфекционном перитоните кошек, доказанная в официально зарегистрированных мультицентровых рандомизированных клинических и постклинических исследованиях

Feline infectious peritonitis is a difficult-to-treat disease caused by a highly virulent biotype of a widespread feline coronavirus. Vetstem LLC has developed a drug Ipecon® based on a low-molecular compound with a direct antiviral effect against RNA-containing viruses. Ipekon® has passed all preclinical studies. The purpose of the study: to evaluate the therapeutic efficacy of the veterinary drug Ipecon® in the treatment of feline infectious peritonitis. Materials and methods: the study included 28 cats, aged 6 months to 11 years: 18 animals with exudative and 8 with non-exudative («dry») form of IPK/FIP. The animals were divided into 3 groups, taking into account the starting single dose of the drug Ipecon®: 8 mg/kg, 10 mg/kg, 12 mg/kg. The finished solution was administered subcutaneously daily, once a day, with an interval between injections of 24 hours during the entire course of treatment. The assessment of the treatment effectiveness was comprehensive, taking into account the data of the clinical examination, the results of general clinical and biochemical blood tests, ultrasound of internal organs. Results: of the 28 animals with diagnosed IPC/FIP included in the study, 4 (14.3%) patients had a fatal outcome caused by multiple organ failure; 85.7 % of patients had the status of «clinical recovery» at the end of the course of treatment. Good tolerability of the drug Ipecon® has been established with repeated subcutaneous use. Despite the noted discomfort during administration, there were no signs of intoxication or clinically pronounced abnormalities, deterioration in the functions of organs and systems. During the use of the drug Ipecon®, only one case was noted.

A Novel Combination Strategy of Ultrasound-Guided Percutaneous Radiofrequency Ablation and Corticosteroid Injection for Treating Recalcitrant Plantar Fasciitis: A Retrospective Comparison Study.

The best treatment yielding clinical benefits was still equivocal and controversial for the treatment of recalcitrant plantar fasciitis (PF). This study aimed to propose a novel combination strategy of ultrasound-guided percutaneous radiofrequency ablation (RFA) and corticosteroid injection (CI) for recalcitrant PF, and to compare its therapeutic effects with CI alone and continued conservative management. We retrospectively reviewed consecutive patients with recalcitrant PF who underwent combined strategy (RFA + CI), CI alone, and continue conservative treatment at our institution between October 2021 and February 2023. The technical pearls were described elaborately. A comparison of demographic data and clinical outcomes, including visual analog scale (VAS), Ankle-Hindfoot Scale (AOFAS-AHS), and plantar fascia thickness, were conducted among the three groups. Seventy-one eligible patients were enrolled in this study, with 17 in the combined strategy group, 25 in the CI group, and 29 in the continued conservative treatment group. Both the combined strategy group and the CI group showed significant improvements in VAS scores, AOFAS-AHS scores, and significant reductions in plantar fascia thickness during the 12-month follow-up period compared to those preoperatively (P < 0.05). The combined strategy group achieved comparable immediate pain relief to the CI group after the intervention ([25.7 ± 15.7] vs. [20.6 ± 17.6], P = 0.850). However, the combined strategy group demonstrated superior improvement in symptom and function compared to the CI group at the 3-month (VAS: [21.9 ± 13.5] vs. [39.6 ± 20.4]; AOFAS-AHS: [77.9 ± 12.4] vs. [60.5 ± 17.4], P < 0.05) and 12-month follow-up (VAS: [15.7 ± 12.0] vs. [56.8 ± 17.5]; AOFAS-AHS: [84.5 ± 10.7] vs. [53.8 ± 12.4], P < 0.05). Obvious adverse effects or complications were not identified in either group, while two cases (11.8%) in the combined strategy group and five cases (20.0%) in the CI group experienced unsatisfactory symptom remission. We introduced and detailed a novel combination strategy involving ultrasound-guided percutaneous RFA and CI for treating recalcitrant PF. The strategy is both effective and safe in alleviating pain and enhancing function throughout the entire treatment course.

Outpatient psychosocial screening in askin cancer center: acceptance, psychosocial distress and utilization of support : Aposthoc analysis in aquality management program

Psychosocial care of cancer patients is an important aspect throughout the entire course of oncological treatment. Since 2015, psychosocial screening has been implemented in the outpatient clinics of the Skin Cancer Center in Freiburg. We present here apost hoc analysis in the context of aquality management program. Acceptance, psychosocial distress and desire for counseling were evaluated. Exploratively, we investigated which patient and disease characteristics are related to increased subjective distress. In afull survey from 06/2015 to 12/2015, we evaluated acceptance, psychosocial distress by distress thermometer (DT), and desire for counseling. Of 753 patients, 345 (45.8%) participated in psychosocial screening and data from 310 (174men, 136women; 89.7% melanoma patients, mean time since initial diagnosis 4.7 ± 3.9years) could be analyzed. The mean burden on the DT was 2.97 ± 2.83 (median2, range 0-10). High distress (DT ≥ 5) was reported by 84patients (28.8%). Thirty-four patients (11%) indicated adesire for counseling, and 23patients took up the counseling offer. The patient group with high distress was younger, more often under ongoing or recently completed systemic therapy, and had more often adesire for counseling. In addition to assessing psychosocial distress with validated screening instruments, the survey of the subjective desire for care represents an important parameter for the identification of patients in need of care. Young patients and patients with ongoing systemic therapy should be the focus of attention.

MR-guided stereotactic radiation therapy for head and neck cancers

PurposeMR-guided radiotherapy (MRgRT) has the advantage of utilizing high soft tissue contrast imaging to track daily changes in target and critical organs throughout the entire radiation treatment course. Head and neck (HN) stereotactic body radiation therapy (SBRT) has been increasingly used to treat localized lesions within a shorter timeframe. The purpose of this study is to examine the dosimetric difference between the step-and-shot intensity modulated radiation therapy (IMRT) plans on Elekta Unity and our clinical volumetric modulated arc therapy (VMAT) plans on Varian TrueBeam for HN SBRT. MethodFourteen patients treated on TrueBeam sTx with VMAT treatment plans were re-planned in the Monaco treatment planning system for Elekta Unity MR-Linac (MRL). The plan qualities, including target coverage, conformity, homogeneity, nearby critical organ doses, gradient index and low dose bath volume, were compared between VMAT and Monaco IMRT plans. Additionally, we evaluated the Unity adaptive plans of adapt-to-position (ATP) and adapt-to-shape (ATS) workflows using simulated setup errors for five patients and assessed the outcomes of our treated patients. ResultsMonaco IMRT plans achieved comparable results to VMAT plans in terms of target coverage, uniformity and homogeneity, with slightly higher target maximum and mean doses. The critical organ doses in Monaco IMRT plans all met clinical goals; however, the mean doses and low dose bath volumes were higher than in VMAT plans. The adaptive plans demonstrated that the ATP workflow may result in degraded target coverage and OAR doses for HN SBRT, while the ATS workflow can maintain the plan quality. ConclusionThe use of Monaco treatment planning and online adaptation can achieve dosimetric results comparable to VMAT plans, with the additional benefits of real-time tracking of target volume and nearby critical structures. This offers the potential to treat aggressive and variable tumors in HN SBRT and improve local control and treatment toxicity.

Level of Distress Experienced by Glioblastoma Multiforme Patients and Caregivers in Relation to their Medical Education Background: A Qualitative Study

BACKGROUND: Glioblastoma multiforme (GBM) is a primary brain tumor with extensive infiltration of surrounding brain tissue and a high rate of recurrence, with an average survival of 13–16 months. Due to the rapid course of the disease, multimodality treatment, and poor prognosis, both the patients and their caregivers will face significant psychological distress. Identification of the types and severity of distress is crucial to control morbidity during treatment. AIM: This study aims to define the level of distress experienced by patients and their caregivers during the treatment period by considering their medical education background. At the time of publication, this type of study is unique and has never been done before. MATERIALS AND METHODS: This study was conducted at the Neurosurgery Outpatient Department of Mochtar Riady Comprehensive Cancer Center Siloam Hospital Jakarta. Patients with GBM and their caregivers were recruited during the early stages of radiation treatment (T1) and the follow-up chemotherapy (T2) and were assessed using the distress thermometer (DT) and National Comprehensive Cancer Network (NCCN) problem checklist followed by in-depth interviews. Participants were divided into two groups based on medical education background. Significant distress is defined as DT score &gt;4. RESULTS: Data from four pairs of patient-caregivers are collected during the early stages of T1. Two pairs of Patient-Caregivers without medical educational background (P-C non-D) are included later during T2. From T1, patients and caregivers with medical education (P-D) are higher than those without medical education (P-D &gt; P-non D; C-D &gt; C-non D). Another comparison shows that P-D is higher than C-D. In contrast, P-non D is lower than C-non D. Based on the time data collected, it shows DT: P-non D T2 &gt; P-non D T1, but there is no difference between T2 and T1 in the caregiver’s group: C-non D T1 = C- non D T2. From the NCCN problem checklist, it is known that they attribute their distress mostly to physical problems. CONCLUSION: The physical and mental changes experienced by patients cause distress for patients and their caregivers. Knowledge of disease and treatment possessed by patients or caregivers helps them deal with GBM and the entire course of treatment.

Older age associated with better antidepressant response to H1-coil transcranial magnetic stimulation in female patients

BackgroundTMS is increasingly used to treat depression, but predictors of treatment outcomes remain unclear. We assessed the association between age and TMS response given inconsistent prior reports limited by small sample size, heterogeneity, outdated TMS parameters, lack of assessment of H1-coil TMS, and lack of an a priori hypothesis. We hypothesized that older age would be associated with better treatment response based on trends in recent large exploratory analyses. MethodsWe conducted a naturalistic retrospective analysis of patients (n = 378) ages 18–80 with depression (baseline Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR) > 5) who received 29–35 sessions of TMS between 2014 and 2021. Response was assessed using percent reduction of QIDS-SR. The relationship between percent response or remission and age group was assessed using the chi-square test. Results85 % of patients received the standard protocol of H1-coil TMS to the left DLPFC. Percent response and remission rates for the entire study sample increased with age (response: p = .026; remission: p = .0023). This finding was stronger in female patients (response: p = .0033; remission: p = .00098) and was not observed in male patients (response: p = .73; remission: p = .26). This was confirmed in a sub-analysis of patients who only received the standard protocol with the H1-coil for the entire treatment course. LimitationsNaturalistic retrospective analysis from one academic center. ConclusionsOlder age is associated with a better antidepressant response to H1-coil TMS in female patients. This was demonstrated in a hypothesis-driven confirmation of prior exploratory findings in a large sample size with a homogeneous data collection protocol across all participants.

Assessment of the Changes in the Salivary Profile and Its Clinical Correlation in Children with Acute Lymphoblastic Leukemia Undergoing Chemotherapy: A Follow-up Study.

To assess the changes in salivary profile and its clinical correlation in patients with acute lymphoblastic leukemia (ALL) undergoing chemotherapy. Children who have been diagnosed with ALL undergoing chemotherapy at Bharati Hospital, Pune, were included in the study. Those children were included who fulfilled the following inclusion and exclusion criteria. Stimulated salivary samples were collected in sterile vials at 1-, 3-, and 6-month intervals and ware assessed for salivary pH and buffering capacity. Caries and oral manifestations were also checked at each interval. A total of 25 children with ALL undergoing chemotherapy were included to participate in the study. The results were analyzed using Statistical Package for the Social Sciences software. There was a statistically significant difference in the change in salivary pH during the 1st and 6th months of chemotherapy (p-value of 0.001). Salivary buffering capacity was also found to be low in these patients during the 1st month of chemotherapy, which gradually increased during the entire course of chemotherapy (p-value of 0.011). Progression of dental caries was seen during the entire course of treatment. All the major changes were seen in the 1st month, that is, the induction phase of chemotherapy. Hence, we can say this is the most affected phase of chemotherapy. The parents and children should be educated and motivated to maintain proper oral hygiene. Whenever possible, all preventive dental procedures should be undertaken before the start of chemotherapy to avoid future complications. Paranjape MN, Shah P, Patil S, et al. Assessment of the Changes in the Salivary Profile and Its Clinical Correlation in Children with Acute Lymphoblastic Leukemia Undergoing Chemotherapy: A Follow-up Study. Int J Clin Pediatr Dent 2023;16(S-3):S268-S271.

Insight into the Role of Optical Coherence Tomography in Acute Coronary Syndrome following Scrub Typhus: A Case Report

Scrub typhus, an illness stemming from the Orientia tsutsugamushi bacterium within the Rickettsiaceae family, is recognised for its febrile nature and frequently linked to vasculitis-induced complications. The challenges faced in the management of scrub typhus complicated by Acute Coronary Syndrome (ACS) and Multiple Organ Dysfunction Syndrome (MODS) is presented in this case report. Of particular significance, this report introduces a novel approach of employing Optical Coherence Tomography (OCT) to identify the underlying pathology, which guided us in making the treatment decision-a novel application of OCT in infectious disease management yet to be documented in the existing medical literature. In present case, OCT was used and the lesion was characterised to be vasculitic and not atherosclerotic, thereby changing the entire treatment course, benefiting the patient. This innovative utilisation of OCT throws light over vasculitic pathology of present case and emphasises the need for intracoronary imaging in the management of this rare complication of a fairly common tropical disease.

A study survey on molnupiravir treatment in COVID-19 patients at home in Ninh Thuan province, Vietnam.

Molnupiravir (MOV) is an oral antiviral drug that received use authorization in Vietnam for the treatment of mild COVID-19 (F0). There was a need to develop alternative approaches that allowed patients to access medication, decongest hospitals, clinics, and facilities, and protect people from infection. During the COVID-19 crisis, the Ninh Thuan Health Authorities implemented the home delivery of medication by community health workers. This study conducted in collaboration with two important Italian entities [the Aldo Moro University of Bari City and the 118 Department of Territorial Emergency System (118 SET) of Taranto City] aimed to evaluate the implementation of home delivery F0 treatment package assessing the rate of infection recovering during the coronavirus pandemic in Ninh Thuan province, Vietnam. A convergent mixed methods research, based on a longitudinal study with quantitative research and qualitative assessments, evaluated four implementation outcomes: the feasibility, fidelity, coverage, sustainability, and effectiveness of the initiative. Data sources included routinely collected data, a telephonic survey of patients, an analysis of set-up and recurrent costs, as well as descriptive exploratory qualitative and quantitative analysis. After taking the MOV for 5 days, only 35 out of the initial 400 F0 patients remained positive, while 365 patients (91.2%) were negative (CT≥30). Whilst, the successful rate after using the drug during the course accounted for 99.85% and 100% after the entire treatment course, without any death. After 5 days of taking the drug, a positive test result (CT<30) was associated with age group ≥60 (OR=2.7) and comorbidities (OR=3.0) (p<0.05) compared to negative and positive results (CT≥30). Negative factors impacting F0 at home include a shortage of healthcare workers, inadequate supply of thermometers and SpO2 meters, and insufficient financial support for healthcare workers. MOV caused a reduction in the risk of hospitalization or death in mild COVID-19 patients, and molnupiravir was also found to be well tolerated and safe without any major adverse events during the administration period.

Revolutionizing Patient Monitoring in Age-Related Macular Degeneration: A Comparative Study on the Necessity and Efficiency of the AMD VIEWER.

(1) Background: Age-related Macular Degeneration (AMD) is a critical condition leading to blindness, necessitating lifelong clinic visits for management, albeit with existing challenges in monitoring its long-term progression. This study introduced and assessed an innovative tool, the AMD long-term Information Viewer (AMD VIEWER), designed to offer a comprehensive display of crucial medical data-including visual acuity, central retinal thickness, macular volume, vitreous injection treatment history, and Optical Coherent Tomography (OCT) images-across an individual eye's entire treatment course. (2) Methods: By analyzing visit frequencies of patients with a history of invasive AMD treatment, a comparative examination between a Dropout group and an Active group underscored the clinical importance of regular visits, particularly highlighting better treatment outcomes and maintained visual acuity in the Active group. (3) Results: The efficiency of AMD VIEWER was proven by comparing it to manual data input by optometrists, showing significantly faster data display with no errors, unlike the time-consuming and error-prone manual entries. Furthermore, an elicited Net Promoter Score (NPS) of 70 from 10 ophthalmologists strongly endorsed AMD VIEWER's practical utility. (4) Conclusions: This study underscores the importance of regular clinic visits for AMD patients. It suggests the AMD VIEWER as an effective tool for improving treatment data management and display.

“Managing Class II Div I Malocclusion with Clear Path Aligners Utilizing an Extraction-Based Treatment Approach: A Case Report”

This case report is based on the clear aligner treatment of an adult patient presented with class II div I malocclusion. The case was treated with the extraction of upper first premolars and interproximal reduction in the lower arch. Total 35 sets of upper aligners and 25 sets of lower aligners were delivered with the wear time of 22 hours per day for 10 days. The entire treatment course spanned a period of 14 months. Thus, the case study underscores the reliability of orthodontic treatment with clear aligners for addressing class II malocclusion. The discreet nature of these aligners not only enhances periodontal health but also increases patient acceptance. As a result, they are more likely to embrace and adhere to the treatment, fostering better overall outcomes.

CNS Prophylaxis Among Patients with HIV-Associated Diffuse Large B-Cell Lymphoma - a Single Center Retrospective Study

Title: CNS Prophylaxis Among Patients with HIV-Associated Diffuse Large B-Cell Lymphoma - A Single Center Retrospective Study Introduction: Patients with Human Immunodeficiency Virus (HIV) are known to develop Lymphoma at a higher rate compared with the general population, with Diffuse Large B-Cell Lymphoma (DLBCL) being the most common subtype. Historically, before the advent of HIV treatment with antiretroviral therapy (ART), HIV-associated DLBCL was considered a more aggressive type of lymphoma and all patients were treated with central nervous system (CNS) prophylaxis. However, since ART has been widely adopted, there is some data to suggest that HIV-associated DLBCL among those taking ART more closely resembles de-novo DLBCL and may not need to be universally treated with CNS prophylaxis. There are no good prospective trials evaluating which patients who develop HIV-associated DLBCL while on ART should receive CNS prophylaxis. Furthermore, studies that tried to predict which DLBCL patients are at greater risk for CNS relapse explicitly excluded patients with HIV. Despite the absence of data, guidelines have shifted and current NCCN guidelines now recommend that HIV patients with DLBCL should be risk stratified as de-novo DLBCL patients with respect to CNS directed therapy. In this study, patients with HIV-associated DLBCL were retrospectively analyzed to understand the patterns of CNS prophylaxis and effects on relapse free survival. Methods: The Electronic Medical Record was queried at a large academic medical center in New York City for patients with HIV-associated DLBCL between the years of 2012 and 2021 using ICD-10 codes. Other subtypes of Lymphoma such as Burkitt's or Plasmablastic Lymphoma were excluded. Patients who did not receive their entire treatment course within the institution were also excluded. Clinical characteristics at diagnosis, treatment type, CNS prophylaxis, and survival data was collected and analyzed. Results: A total of 38 patients were identified according to the inclusion criteria. 26 patients (68%) underwent screening lumbar punctures (LPs) for CNS disease while 12 patients (32%) did not. The two groups were not statistically different within any categories except for LDH, where the LP group had a median LDH of 492 units/L and the non-LP group had a median LDH of 241 units/L (p-value: 0.031). The two groups were not statistically different in cell of origin subtypes, stage, bone marrow involvement, kidney/adrenal involvement, the use of ART prior to diagnosis, IPI or CNS-IPI scores. In addition, among the group that had an LP done with no CNS involvement (n=25), there was no statistical difference in relapse-free survival among those who received adequate CNS prophylaxis and those who did not (p-value 0.886). Conclusions: Among patients with HIV-associated DLBCL in a large academic medical center in New York City, there is no reliable indicator to predict which were offered screening lumbar punctures and which were not. Clinicians may be using additional measures of aggressiveness not accounted for in standard IPI and CNS-IPI scoring algorithms. Furthermore, there was no clear benefit in relapse free survival among high-risk patients who received adequate CNS prophylaxis versus those who did not in this limited sample size. Further research is needed to determine whether patients with HIV-associated DLBCL should be risk stratified similarly to de-novo DLBCL patients with respect to CNS prophylactic therapy.

Conceptual Study of TrividhChikitsa Karma in Shalya Tantra– A Review

Ayurveda focuses on integrating and balancing the body, mind, and spirit rather than on specific illnesses. Shalyatantrais associated with the sage-physician Sushruta. Given the early stage of human history and the absence of any supporting body ofknowledge before his era, his concepts of anatomy, pathophysiology, and therapeutic approaches were incomparable. AcharyaSushruta has described the entire course of medical treatment in connection with a disease, which may be grouped under thesesubheadings as the initial steps (Purva Karma), the main therapeutical or surgical appliances (Pradhana-Karma), and the follow-upsteps (Paschat Karma) regardless of the surgical procedure. Surgery comprises the main action (operation) but also the care ofthe patient before and after the technique. Acharya Sushrut, regarded as the father of surgery in Ayurveda, chose these threeKarma solely and only for the benefit of patients who undergo any surgical procedure. In this article, we compare ancient andcontemporary surgical practices, contrasting prior articles or research that solely focused on particular Karma, upkramas, andspecific topics.In our article, we contrasted several old and contemporary strategies in a simple way for students to grasp.Thisarticle compares several parts of trividha karma with contemporary surgical techniques, demonstrating the relevance of ouracharyas' siddhanta even today.

Investigation of Intra-fraction Stability and Inter-fraction Consistency of Active Breathing Coordinator (ABC)-Based Deep Inspiration Breath Holds in Left-Sided Breast Cancer.

Background Deep inspiration breath-hold (DIBH) has been established as a standard technique to reduce cardiac dose. The part of the heart exposed to radiation can be significantly decreased using the DIBH technique during tangential left-sided breast cancer (LSBC) irradiation. Aim The objective of this study was to investigate the intra-fraction breath-hold stability and inter-fraction consistency of patient breath-hold against the threshold as a function of air volumes in the setting of active breathing coordinator (ABC)-based DIBH (ABC-DIBH) treatment to LSBC. Methods A total of 34 patients treated with external beam radiation therapy (EBRT) to the left breast using the ABC-DIBH device were included. The frequency of breath-holds perfraction and the entire course of treatment along with the total treatment time was evaluated for all patients.A prescription dose of either 200 cGy (conventional) or 267 cGy (hypofractionation) was administered during 649 fractions, resulting in a total of 4,601 breath-hold measurements being evaluated. The amplitude of deviation in terms of air volumes between the baseline threshold and the patient-specific measurement (during each breath-hold) per fraction was used to define the DIBH stability. Likewise, the consistency of the breathing amplitudes was used to define the compliance of patient breath-holds throughout the entire treatment period. Positional accuracy was evaluated using orthogonal (portal) images. Results The average number of breath-holds measured over the entire course of treatment for each patient was 144 inspirations (58-351). Similarly, the average number of breath-holds for each fraction during the course of treatment was 11 inspirations (7-21), which included setup imaging and treatment. The total number of breath-holds reduced significantly (p-value < 0.05) with hypofractionation (104 inspirations; range 58-170) as compared to conventional fractionation (145 inspirations; 58-351). The average breath-hold threshold in terms of air volume was 1.41 L(0.6-2.1 L) for all patients. The total treatment time reduced significantly after the third fraction (p-value < 0.05).The average deviation between the measured and baseline threshold breath-holds during the course of treatment was 0.5 L/sec (0.12-1.32 L/sec). The consistency of the breathing amplitudes were maintained within±0.05 Lduring the entire treatment for all patients. The average translational shifts measured during setup were 0.28 cm ± 0.3 cm, 0.38 cm ± 0.4 cm, and 0.21 cm ± 0.3 cm in the lateral, longitudinal, and vertical directions, respectively. Conclusion The study has demonstrated the variations in intra-fraction breath-hold stability and inter-fraction breath-hold consistency in terms of air volumes for patients who were treated for LSBC. The frequency of breath-holds was observed to be higher with increased total treatment time for the first few fractions and reduced over the course of treatment.

Interventions for promoting patients’ adherence to 14-day primaquine treatment in a highly malaria-endemic township in Myanmar: a qualitative study among key stakeholders

BackgroundPlasmodium vivax malaria is considered a major threat to malaria eradication. The radical cure for P. vivax malaria normally requires a 14-day administration of primaquine (PQ) to clear hypnozoites. However, maintaining adherence to PQ treatment is a significant challenge, particularly in malaria-endemic rural areas. Hence, this study aimed to formulate interventions for promoting patients’ commitment to PQ treatment in a highly malaria-endemic township in Myanmar.MethodsA qualitative study was conducted in Waingmaw Township in northern Myanmar, where P. vivax malaria is highly endemic. Key stakeholders including public health officers and community members participated in focus group discussions (FGDs) and in-depth interviews (IDIs) in September 2022. Data were collected using validated guidelines, translated into English, and visualized through thematic analysis.ResultsResponsible individuals from different levels of the Myanmar National Malaria Control Programme participated in the IDIs. Most of them reported being aware of the markedly increasing trend of P. vivax and the possibility of relapse cases, especially among migrants who are lost to follow-up. Workload was a key concern surrounding intervention implementation. The respondents discussed possible interventions, such as implementing directly observed treatment (DOT) by family members, piloting a shorter PQ regimen, expanding the community’s malaria volunteer network, and strengthening health education activities using local languages to promote reasonable drug adherence. FGDs among community members revealed that although people were knowledgeable about malaria symptoms, places to seek treatment, and the use of bed nets to prevent mosquito bites, most of them still preferred to be treated by quack doctors and rarely used insecticide-treated nets at worksites. Many often stopped taking the prescribed drugs once the symptoms disappeared. Nevertheless, some respondents requested more bed nets to be distributed and health promotion activities to be conducted.ConclusionIn rural areas where human resources are limited, interventions such as implementing family member DOT or shortening PQ regimens should be introduced to enhance the radical cure for the P. vivax infection. Disseminating information about the importance of taking the entire treatment course and emphasizing the burden of relapse is also essential.

Early Prediction of Radiation Treatment Response via Longitudinal Analysis of CBCT Radiomic Features for Locally Advanced Rectal Cancer.

Patients respond to the same radiation treatment course differently due to inter- and intra- patient variability in radiosensitivity. Despite widespread use of AI/ML in radiation oncology, there is a lack of monitoring strategies used during treatment courses to evaluate early predictors of treatment response in a systematic fashion. This work advances a straightforward, yet effective, method for the early detection of treatment response through systematically analyzing daily CBCT radiomic features. The goal is to aid clinicians in assessing the treatment efficacy routinely with a view towards optimizing personalized treatment. We included a cohort of 30 patients diagnosed with locally advanced rectal cancer who underwent neo-adjuvant fractionated radiation treatment (RT) with a prescription dose of 50.4 Gy (28 fractions), followed by total mesorectal excision surgery after completion of ChemoRT. Daily IGRT imaging was acquired prior to each fraction resulting in a total of 840 CBCTs. Patients were divided into responder (14 patients) and non-responder (16 patients) groups based on post-RT pathological response. Mutual information algorithms were utilized to rigorously register daily CBCT images to the planning CT, and longitudinal radiomic features of the target were extracted from the daily CBCTs during the entire treatment course. All longitudinal features for a given patient were standardized with Z-Score normalization, followed by linear fitting using the least square method, resulting in radiomic feature trends (RFT) represented by slope values. Statistical significance was established via a two-sample U test and P-value with a threshold of 0.05. Logistic regression was performed to eliminate RFT with accuracy rates lower than 0.5. The final trending model was developed using random forest. For each patient at fraction N, our investigation involved independent 27 group experiments, where each experiment considered image group from fraction #1 to N, to confirm the effectiveness and stability of the model. The proposed RFT demonstrated a high level of precision and consistency for post-RT response based on longitudinal CBCT images for LARC patients. The trending model yielded an accuracy of 0.9556, 95% CI (0.94, 0.972) when each daily image was considered, the prediction consistency was 0.964. Given the first 14 experiments (considering group images of fraction #1-15), the prediction accuracy was 0.9357, 95% CI (0.915, 0.956) and the prediction consistency was 0.952. A strategy for monitoring and early prediction of LARC patients' radioresponse was evaluated via longitudinal CBCT assessment. Our trending models demonstrate a significant difference between the responder vs non-responder groups as early as the 15th fraction. Our strategy achieved superior accuracy and consistency to predict post-RT response of LARC patients.

A Comparison of Treatment Plan Adaptation Methods on PTV Margin Coverage in MR-Linac Prostate SBRT.

MRI-Linac guided radiotherapy is a novel treatment modality allowing for daily online adaptation of contours and treatment planning. MRI-Linac prostate SBRT (MRL-SBRT) has recently been shown to provide a tangible benefit in decreasing both acute and late toxicity, due to the ability to evaluate soft tissue contrast, directly monitor organ motion, and anatomical changes during the entire treatment course. Multiple MRI-Linac platforms are available, which provide different advantages with regards to imaging and motion management. We undertook this study to assess coverage of the clinical target volume with use of a standard PTV margin in patients receiving either adapt-to-position (ATP) only treatment or a combination of adapt-to-position and adapt-to-shape (ATP+ATS) on the Elekta Unity MR-Linac. Data was collected retrospectively in patients who underwent prostate SBRT using a 1.5 T MR-Linac (Unity, Elekta AB, Stockholm, Sweden). Prior to each fraction, determination of ATP or ATS planning was at the discretion of the treating physician. Prostate and organs at risk (OAR's) were contoured on the reference MRI and daily MR image sets acquired prior to each fraction. The prostate PTV consisted of a 5mm margin, except 3mm posteriorly. Contours were merged to account for target and OAR volumes during all fractions. Target volumes from the reference plan were then compared to the clinical target volume (CTV) on pre-treatment MR-Linac imaging as well as intersection with OAR's. Nineteen men, median age 72 years (range 67-75), with prostate cancer underwent treatment from May 2021 to January 2023 with MRL-SBRT. The average time for ATP vs ATP+ATS was 45 minutes (range 35-60) and 60 minutes (range 50-80), respectively. The mean CTV treated was 43.4cc (range 31-60) for ATP and 51.8cc (range 36-67) for ATP+ATS. Prior to plan adaptation, target volumes in 92.6% of fractions were not covered completely by the PTV. In the ATP cohort, 89% of fractions had a portion of the CTV uncovered with an average of 2.9cc. In the ATP+ATS cohort, 96.4% had a portion of the CTV uncovered, with an average of 6.9cc. There was no difference in the amount of PTV intersection for ATP or ATP+ATS plans with the rectum (1.1cc vs. 1.5cc) and bladder (9.2cc vs. 12.6cc), respectively. All patients completed the planned course of treatment. Adaptive radiation therapy for prostate cancer utilizing an MR-Linac based approach with the Elekta Unity was feasible for patients requiring either ATP only or ATP+ATS plans. As expected, ATS plans required longer treatment time, allowing for improved coverage of the target when deemed clinically necessary. Despite a larger overall volume treated in ATS plans, there was no difference in overlap with OARs between ATP and ATS plans. Adaption for each daily fraction and intrafraction motion monitoring improved CT coverage with our pre-specified PTV margin.