Thoracic Sites Research Articles

Extensive Epidural Hemorrhage Associated with Thoracolumbar Disc Extrusion in French Bulldogs.

(1) Background: Intervertebral disc extrusion may be accompanied by extensive epidural hemorrhage (EEH) and result in spinal cord compression. EEH is more commonly seen in French Bulldogs compared to other breeds. The majority of French Bulldogs have lumbar intervertebral disc extrusion, but it is unclear if there is an association between the site of thoracolumbar disc extrusion and EEH. This retrospective study's aim was to investigate the association and prevalence between the site of thoracolumbar intervertebral disc extrusion and EEH in French Bulldogs. (2) Methods: Thoracolumbar MRI of French Bulldogs was examined for the site of intervertebral disc extrusion and the presence, distribution, and extent of EEH. (3) Results: In 148 French Bulldogs with thoracolumbar intervertebral disc extrusion, the most common location was L4/L5 (22%), followed by L3/L4 (20%) and T13/L1 (15%), and 70.3% had EEH. The highest incidence of EEH across all thoracolumbar sites was seen at L1/L2 (84.2%), followed by L5/L6 (81.3%) and L2/L3 (72.2%). The incidence of EEH was 70.5% across all lumbar sites and 66.9% for all thoracic sites. (4) Conclusion: In this population of French Bulldogs, the prevalence of lumbar disc extrusion was high, and 70.3% had EEH. There was no significant difference between the site of thoracolumbar intervertebral disc extrusion and EEH.

Clinical experience of consolidative radiotherapy for localized metastatic non-small cell lung cancer who showed favorable tumor response after systemic treatment

BackgroundOur study has aimed to assess the effects of consolidative high-dose radiotherapy on clinical outcomes in patients with localized metastatic non-small cell lung cancer (NSCLC) who showed favorable tumor response after systemic treatment.MethodsWe retrospectively reviewed the medical records of 83 patients with localized metastatic NSCLC, who received systemic therapy followed by consolidative local radiotherapy at the Korea University Guro Hospital between March 2017 and June 2022. In the current study, we defined localized metastatic disease as the presence of one to three metastatic sites at the time of diagnosis. And patients who showed favorable tumor response after systemic treatment, including oligo-progressive disease at the thoracic site which was amenable to curative high-dose local radiotherapy, were included. The planned total dose and fraction size mainly depended on the location of lesions.ResultsThe median follow-up time after consolidative radiotherapy was 16 months (range: 5–52 months). The overall 2-year progression-free survival rates were 81.4%. Of 83 patients, only four (4.3%), treated with intensity-modulated radiation therapy, showed an in-field local recurrence. Interestingly, only one patient experienced a local failure among the 20 patients who showed an oligo-progressive disease at the thoracic site on the tumor response evaluation after systemic treatment. Regarding treatment-related pulmonary toxicity, three patients with grade-3 and one patient with grade-4 radiation pneumonitis were presented.ConclusionsIf the disease is sufficiently controlled and localized by systemic therapy, local consolidative radiotherapy is thought to improves local control rates with acceptable treatment-related toxicities in patients with localized metastatic NSCLC, especially those with oligo-progressive disease.

Optimizing Gantry Breakpoint Angles in Proton Therapy: Enhancing Efficiency and Patient Experience

PurposeThe breakpoint for a 360° radiotherapy gantry is typically positioned at 180°. This arbitrary setting has not been systematically evaluated for efficiency and may cause redundant gantry rotation and extended setup times. Our study aimed to identify an optimal gantry breakpoint angle for a full-gantry proton therapy system, with the goal of minimizing gantry movement. Materials and MethodsWe analyzed 70 months of clinically delivered proton therapy plans (9152 plans, 131 883 fractions), categorizing them by treatment site and mapping the fields from a partial-gantry to full-gantry orientation. For each delivered fraction, we computed the minimum total gantry rotation angle as a function of gantry breakpoint position, which was varied between 0° and 360° in 1° steps. This analysis was performed separately within the entire plan cohort and individual treatment sites, both with and without the capability of over-rotating 10° past the breakpoint from either direction (20° overlap). The optimal gantry breakpoint was identified as one which resulted in a low average gantry rotation per fraction. ResultsConsidering mechanical constraints, 130° was identified as a reasonable balance between increased gantry-rotation efficiency and practical treatment considerations. With a 20° overlap, this selection reduced the average gantry rotation by 41.4° per fraction when compared to the standard 180° breakpoint. Disease site subgroups showed the following reduction in average gantry rotation: gastrointestinal 192.2°, thoracic 56.3°, pediatric 44.9°, genitourinary 19.9°, central nervous system 10.7°, breast 2.8°, and head and neck 0.1°. ConclusionFor a full-gantry system, a breakpoint of 130° generally outperforms the conventional 180° breakpoint. This reduction is particularly impactful for gastrointestinal, pediatric, and thoracic sites, which constitute a significant proportion of cases at our center. The adjusted breakpoint could potentially streamline patient delivery, alleviate mechanical wear, and enhance treatment precision by reducing the likelihood of patient movement during delivery.

Imaging of thoracic tuberculosis: pulmonary and extrapulmonary.

Tuberculosis (TB) remains the leading cause of death from a single infectious agent globally, despite being a potentially curable disease. This disease typically affects the lungs but may involve many extrapulmonary sites, especially in patients with risk factors such as HIV infection. The clinical features of extrapulmonary TB may mimic many different disease entities, particularly at less common thoracic sites such as the heart, chest wall, and breast. Imaging has an important role in the early diagnosis of TB, helping to detect disease, guide appropriate laboratory investigation, demonstrate complications, and monitor disease progress and response to treatment. Imaging supports the clinical objective of achieving effective treatment outcome and complication prevention. This review aims to highlight the imaging spectrum of TB affecting both pulmonary and extrapulmonary sites in the thorax. We also briefly provide key background information about TB, such as epidemiology, pathogenesis, and diagnosis.

Definitive Radiotherapy for Oligometastatic and Oligoprogressive Thyroid Cancer

Local consolidative radiotherapy (LCT) for oligometastatic disease is a promising paradigm improving outcomes for various malignancies but has been underexplored for metastatic thyroid cancer. We hypothesize that LCT to distant sites with definitive RT doses can yield favorable outcomes and defer systemic therapy escalation for these patients. We reviewed 96 thyroid cancer patients who received 175 LCT courses from 2010-2022 to 228 metastatic sites, including: thorax (45%), bone (40%), brain (6%), head/neck (5%), and abdomen (3%). Common prescriptions were 50-55Gy/4-5fxs or 56-70Gy/8-10fxs for lung; 52.5-60Gy/15fxs for mediastinum; and 18-24Gy/1fx or 27-30Gy/3fxs for bone. RECIST v1.1 and CTCAE v5.0 were used to define progression and toxicities, respectively. Outcomes were evaluated via Kaplan-Meier and associations examined via Cox proportional hazards modeling. Median age was 63 years (range: 26-92), with 62 oligometastatic cases (total 1-5 sites) and 34 oligoprogressive (with 1-5 growing sites). Primary disease was controlled in all patients, with 39% receiving post-op RT and 66% prior RAI. Histologies included papillary (40%), anaplastic (25%), follicular (12%), medullary (9%), Hurthle (7%), and poorly-differentiated (7%). Median time from initial diagnosis to LCT was 3 yrs (IQR 1-8), and median follow-up from 1st LCT was 21 mos (IQR 9-51). Patients received an average 2 LCT courses (range 1-8) treating 1-4 sites. Median survival (OS) from 1st LCT was 9 yrs (95% CI = 5-14). On multivariable analysis (MVA), worse OS was associated with anaplastic histology (HR 4.6, p<.01), but longer OS was associated with prior RAI (HR 0.33, p = .02) and oligometastatic disease (HR 0.3, p = .01). For anaplastic histology, median OS was 1.2 years vs. 9.3 years for non-anaplastic; 3-yr OS was 36% vs. 88% (log-rank, p<.01). Five-year OS for oligometastatic cases was 75% vs 53% for oligoprogressive (log-rank, p = .04). Median progression free survival (PFS) from 1st LCT was 15.5 mos (95% C I = 11-20). On MVA for all LCT courses, time to any progression (TTP) was negatively associated with anaplastic histology (HR 1.7, p = .02) and 2nd or higher LCT course (HR 1.45, p = .05), but favorably associated with thoracic site (HR 0.49, p<.01). Following later LCT courses, median TTP was 11 mos vs 17 mos for initial LCT course (log-rank, p = .03). After LCT to lung/chest, TTP was 18.6 mos vs 9.5 mos for non-thoracic sites (log-rank, p<.01). Only 6% of failures occurred at previously treated lesions. Most LCT courses (67%) were without ongoing chemotherapy, while 25% entailed continuing the same regimen and 9% had planned treatment post-RT. There were 2 Grade 3 toxicities (pneumonitis and esophagitis) and no Grade 4-5 events. With high local control rates and minimal toxicity, LCT can be a feasible strategy to defer systemic therapy escalation for oligometastatic and oligoprogressive thyroid cancer.

DeepBreath—automated detection of respiratory pathology from lung auscultation in 572 pediatric outpatients across 5 countries

The interpretation of lung auscultation is highly subjective and relies on non-specific nomenclature. Computer-aided analysis has the potential to better standardize and automate evaluation. We used 35.9 hours of auscultation audio from 572 pediatric outpatients to develop DeepBreath : a deep learning model identifying the audible signatures of acute respiratory illness in children. It comprises a convolutional neural network followed by a logistic regression classifier, aggregating estimates on recordings from eight thoracic sites into a single prediction at the patient-level. Patients were either healthy controls (29%) or had one of three acute respiratory illnesses (71%) including pneumonia, wheezing disorders (bronchitis/asthma), and bronchiolitis). To ensure objective estimates on model generalisability, DeepBreath is trained on patients from two countries (Switzerland, Brazil), and results are reported on an internal 5-fold cross-validation as well as externally validated (extval) on three other countries (Senegal, Cameroon, Morocco). DeepBreath differentiated healthy and pathological breathing with an Area Under the Receiver-Operator Characteristic (AUROC) of 0.93 (standard deviation [SD] ± 0.01 on internal validation). Similarly promising results were obtained for pneumonia (AUROC 0.75 ± 0.10), wheezing disorders (AUROC 0.91 ± 0.03), and bronchiolitis (AUROC 0.94 ± 0.02). Extval AUROCs were 0.89, 0.74, 0.74 and 0.87 respectively. All either matched or were significant improvements on a clinical baseline model using age and respiratory rate. Temporal attention showed clear alignment between model prediction and independently annotated respiratory cycles, providing evidence that DeepBreath extracts physiologically meaningful representations. DeepBreath provides a framework for interpretable deep learning to identify the objective audio signatures of respiratory pathology.

Deep learning diagnostic and severity-stratification for interstitial lung diseases and chronic obstructive pulmonary disease in digital lung auscultations and ultrasonography: clinical protocol for an observational case–control study

BackgroundInterstitial lung diseases (ILD), such as idiopathic pulmonary fibrosis (IPF) and non-specific interstitial pneumonia (NSIP), and chronic obstructive pulmonary disease (COPD) are severe, progressive pulmonary disorders with a poor prognosis. Prompt and accurate diagnosis is important to enable patients to receive appropriate care at the earliest possible stage to delay disease progression and prolong survival. Artificial intelligence-assisted lung auscultation and ultrasound (LUS) could constitute an alternative to conventional, subjective, operator-related methods for the accurate and earlier diagnosis of these diseases. This protocol describes the standardised collection of digitally-acquired lung sounds and LUS images of adult outpatients with IPF, NSIP or COPD and a deep learning diagnostic and severity-stratification approach.MethodsA total of 120 consecutive patients (≥ 18 years) meeting international criteria for IPF, NSIP or COPD and 40 age-matched controls will be recruited in a Swiss pulmonology outpatient clinic, starting from August 2022. At inclusion, demographic and clinical data will be collected. Lung auscultation will be recorded with a digital stethoscope at 10 thoracic sites in each patient and LUS images using a standard point-of-care device will be acquired at the same sites. A deep learning algorithm (DeepBreath) using convolutional neural networks, long short-term memory models, and transformer architectures will be trained on these audio recordings and LUS images to derive an automated diagnostic tool. The primary outcome is the diagnosis of ILD versus control subjects or COPD. Secondary outcomes are the clinical, functional and radiological characteristics of IPF, NSIP and COPD diagnosis. Quality of life will be measured with dedicated questionnaires. Based on previous work to distinguish normal and pathological lung sounds, we estimate to achieve convergence with an area under the receiver operating characteristic curve of > 80% using 40 patients in each category, yielding a sample size calculation of 80 ILD (40 IPF, 40 NSIP), 40 COPD, and 40 controls.DiscussionThis approach has a broad potential to better guide care management by exploring the synergistic value of several point-of-care-tests for the automated detection and differential diagnosis of ILD and COPD and to estimate severity.Trial registration Registration: August 8, 2022. ClinicalTrials.gov Identifier: NCT05318599.

Safety and Feasibility of Cervical and Thoracic Transcutaneous Spinal Cord Stimulation to Improve Hand Motor Function in Children With Chronic Spinal Cord Injury

ObjectiveIn adults with cervical spinal cord injury (SCI), transcutaneous spinal stimulation (scTS) has improved upper extremity strength and control. This novel noninvasive neurotherapeutic approach combined with training may modulate the inherent developmental plasticity of children with SCI, providing even greater improvements than training or stimulation alone. Because children with SCI represent a vulnerable population, we first must establish the safety and feasibility of any potential novel therapeutic approach. The objectives of this pilot study were to determine the safety, feasibility, and proof of principle of cervical and thoracic scTS for short-term effect on upper extremity strength in children with SCI. Materials and MethodsIn this nonrandomized, within-subject repeated measure design, seven participants with chronic cervical SCI performed upper extremity motor tasks without and with cervical (C3–C4 and C6–C7) and thoracic (T10–T11) site scTS. Safety and feasibility of using cervical and thoracic sites scTS were determined by the frequency count of anticipated and unanticipated risks (eg, pain, numbness). Proof-of-principle concept was tested via change in force production during hand motor tasks. ResultsAll seven participants tolerated cervical and thoracic scTS across the three days, with a wide range of stimulation intensities (cervical sites = 20–70 mA and thoracic site = 25–190 mA). Skin redness at the stimulation sites was observed in four of 21 assessments (19%) and dissipated in a few hours. No episode of autonomic dysreflexia was observed or reported. Hemodynamic parameters (systolic blood pressure and heart rate) remained within stable limits (p > 0.05) throughout the assessment time points at baseline, with scTS, and after the experiment. Hand-grip and wrist-extension strength increased (p < 0.05) with scTS. ConclusionsWe indicated that short-term application of scTS via two cervical and one thoracic site is safe and feasible in children with SCI and resulted in immediate improvements in hand-grip and wrist-extension strength in the presence of scTS. Clinical Trial RegistrationThe Clinicaltrials.gov registration number for the study is NCT04032990.

The role of VATS in the removal of intrathoracic foreign bodies - a systematic review.

To date, no systematic review or meta-analysis study has been conducted regarding the use of video-assisted thoracoscopic surgery (VATS) in the removal of intrathoracic foreign bodies (FB). This systematic review aims to evaluate the feasibility of VATS in the removal of intrathoracic FBs. PubMed/MEDLINE, CINAHL, Web of Science, EMBASE, and Cochrane Library databases were systematically searched to identify reports published up to April 1, 2022. The initial systematic search revealed a total of 208 papers, of which only 54 studies reporting 71 cases were included in this systematic review. Among the patients, 46 (64.8%) were male, 22 (31%) were female, and 3 (4.2%) were unknown. The mean age was 34.5 ± 24.3years (1day to 98years). The patients were of 3 etiologic groups: iatrogenic (31, 43.7%), traumatic (28, 39.4%), and accidental (9, 12.7%). Most of the patients were emergency cases (27, 38%). The most frequently used imaging modalities to diagnose these foreign bodies were X-ray (46, 64.8%), followed by computed tomography (44, 62%), and ultrasonography (16, 22.5%). About 43% of all the foreign bodies were therapeutic equipment. The pleural cavity had the highest involvement (36.8%), followed by the lung parenchyma (14.6%) and thoracic cavity (13.2%). Regardless of the number of access ports, all the patients had a good clinical outcome. VATS is a safe and effective method for the removal of intrathoracic FBs from various thoracic sites that are associated with a good clinical outcome - in both elective and emergency cases.

Small cell lung carcinomaMultiple metastases in Inguinal node and Anterior abdominal wall -A rare presentation and FNAC diagnosis - an oddity in rarity

Small cell lung carcinoma (SCLC), a highly aggressive cancer accounts for about 13% of all lung cancers, has a strong association with heavy smoking. The common sites of metastases are intrathoracic and supraclavicular nodes. The extrathoracic nodal metastases is a rare clinical presentation. Here we report a rare case of Small cell lung carcinoma metastasing to extra thoracic sites as an interesting first clinical presentation. With the first diagnostic modality, Fine needle aspiration cytology (FNAC), it was reported as Metastatic deposits with the possibility of Primary from Small cell lung Carcinoma which was further followed by lung biopsy with Histopathological examination(HPE) and Immunohistochemistry (IHC) confirmation.

Retrospective Review of the Safety of Osimertinib with Thoracic Radiotherapy

<h3>Purpose/Objective(s)</h3> Tyrosine Kinase inhibitor [TKI] therapy is the backbone of treatment for patients who progress after definitive treatment for EGFR mutated non-small cell lung carcinoma [NSCLC], or those who are diagnosed with metastatic disease. Evidence from phase II and III clinical trials have suggested that ablative consolidation of oligometastatic or progressive sites leads to improved progression-free, and overall survival. For patients on TKI therapy, there is little information regarding the safety of combining therapy with radiation therapy [RT]. There are 5 FDA approved EGFR TKI's but simertinib is most used today and is the focus of this review. We present the risk of toxicity of concurrent simertinib and thoracic RT in a large institutional cohort. <h3>Materials/Methods</h3> A prospectively collected database of patients treated with simertinib from September 2014 through March of 2021 was reviewed to identify those who had RT at some point in their treatment. 206 individual patients were identified of whom 60 had treatment directed to a thoracic target. 13 patients were treated to 2 metachronous thoracic sites yielding 73 individual treatments. Patient records were retrospectively reviewed to identify practice patterns regarding sequencing of RT and TKI, and the incidence of toxicity. <h3>Results</h3> In these 73 targets, most volumes were treated with SBRT [3-5 fractions] 42(57%). Twenty-one targets (29%) were treated with hypofractionation [8-20 fractions; HFRT], 8(11%) were treated with conventional radiation, [200cGY per fraction; CFR] and 2 with quad shot fractionation [QS]. The median PTV size was 91.25cc (range 8.55cc – 767.95cc). In 43 treatments radiation was delivered concurrently with simertinib, drug was held for 20 radiation treatments, and 10 treatments were delivered before simertinib initiation. Of those tumors treated with continuous simertinib dosing, 28 tumors were treated with SBRT, 13 with HFRT, 1 CFR and 1 with QS. 24 patients were diagnosed with radiation pneumonitis following thoracic RT; 4/11(36%) tumors treated prior to TKI; 6/20(30%) treatments when medication was held; and 14/44(32%) tumors when simertinib was continued through radiation (p=0.14). Most cases of pneumonitis were grade 1-2 and only 2 patients developed grade 3 pneumonitis. Grade 3 pneumonitis was not associated with continuous simertinib dosing. The median PTV for any grade pneumonitis was 112.27cc. Institutional V20 planning constraints were met in all but 1 patient who was treated with CFR. Other toxicities reported included 7 events of esophagitis, and 4 events of dermatitis all of which were grade 1-2. <h3>Conclusion</h3> Patients receiving osimertininb concurrently with thoracic RT did not appear to have higher rates of pneumonitis relative to those who held drug during RT or initiated it after RT. This suggests it is safe to continue simertinib concurrently with thoracic RT when standard planning dose limits are followed.

Intensity Modulated Radiotherapy on a Novel Ring Gantry-Based Linac with Integrated Dual PET-CT Imaging Systems: Dosimetric Plan Comparison and Initial Clinical Delivery Experience

<h3>Purpose/Objective(s)</h3> This study aims to report our initial clinical experience on using a new external-beam radiotherapy delivery system on a ring gantry with dual PET-CT imaging capabilities for IMRT treatments at different anatomical sites. The study also evaluates the system's plan quality compared to an existing ring gantry-based Linac. This new external-beam radiotherapy delivery system has the potential to be used for biology-guided radiotherapy. <h3>Materials/Methods</h3> We performed a single-institution retrospective review of patients treated on the machine since commissioning. The initial five patients treated to a thoracic site and five patients treated to a pelvic site were included in this study. The dose per fraction ranged from 1.8 to 3.0 Gy. The treatment plans for the machine used a 2-cm jaw size along the longitudinal direction and used the IMRT delivery mode. A 64-leaf binary MLC was used to modulate a flattening filter free 6-MV photon beam. A helical tomotherapy plan (HT plan) using a 2.5-cm jaw size was generated for each RFX plan to serve as the backup plan in clinical treatments. Dosimetric parameters used in institutional treatment protocols were compared between RFX plans and HT plans. Daily delivery records were reviewed, and actual beam-on time was compared between the two machine types. <h3>Results</h3> On average, 12 dosimetric parameters (range: 7 – 14) for critical organs and the primary PTV were used in each treatment plan as clinically relevant planning optimization parameters and were analyzed in this study. Among the critical organ dose parameters, 19 (22.4%) dosimetric parameters were lower by more than 10% in the study's plans compared to the HT plans, while 11 (12.9%) dosimetric parameters were higher by more than 10% in the study's plans compared to the HT plans. The other dosimetric parameters had less than 10% or no clinically relevant difference between the two plans. There was no statistically significant difference in integrated dose between the new machine and HT plans. All the plans were normalized so that the prescription dose covered 95% of the primary planning target volume (PTV). The average D_mean of the primary PTV were 103.5±1.1% and 102.6±0.8% of the prescription dose in the new external-beam radiotherapy delivery system and HT plans, respectively, and the average D(1%) of the primary PTV (dose covering the hottest 1% of the PTV) were 107.1±2.0% and 105.2%±1.6% in the new external-beam radiotherapy delivery system and HT plans, respectively (two-tailed p-value = 0.06 in the paired t-test). The beam-on time was not significantly different between the two machines. The average daily beam-on time was 438.8±151.2 seconds and 427.6±183.1 seconds with the new external-beam radiotherapy delivery system and HT systems, respectively (two-tailed p-value = 0.76 in the paired t-test). <h3>Conclusion</h3> Our initial clinical experience with the external-beam radiotherapy delivery system showed that image guided IMRT could be delivered to different anatomical sites with adequate clinical workflow efficiency. The new machine achieved clinically comparable treatment plan quality compared to helical tomotherapy. The beam-on time was comparable to that on helical tomotherapy.

Occurrence of community-acquired Panton-Valentine leukocidin-producing and enterotoxin-producing methicillin-resistant staphylococci in companion dogs

In Nigeria, available data on drug-resistant bacterial infections that are caused by companion dogs are scarce. Hence the present study evaluated the occurrence of some community-acquired toxigenic methicillin-resistant staphylococci (MRS) on companion dogs harboured in Nigerian homes, as a pointer to the extent of exposure of humans to these pathogens. Samples were collected from 70 healthy companion dogs during dry and rainy season periods by swabbing a 125 cm2 fur area on the lumbar and thoracic sites. Phenotypic tests, Kirby Bauer disc diffusion test and 16S rRNA gene analysis were used to identify presumptive colonies of staphylococci and MRS. Molecular methods were employed to detect Panton-Valentine leukocidin (PVL) and prototypic enterotoxin B in MRS isolates. The counts of staphylococci on fur of companion dogs during the rainy season exceeded usual limits of bacteria (≤ 2.54 log10 CFU cm-2) on a healthy dog, thus, suggesting that companion dogs harboured in homes situated in Nigeria may be reservoirs of bacteria, especially during rainy season. The mean counts of staphylococci during the rainy season were estimated at 3.09 ± 2.78 log10 CFU cm-2 and 2.77 ± 2.43 log10 CFU cm-2 in Edo and Delta States, respectively. The main Staphylococcus species that were carried on fur of companion dogs included S. pseudintermedius, S. aureus, S. epidermidis, S. simulans and S. saprophyticus. Amongst the staphylococci, expression of methicillin and multidrug resistance was mainly exhibited by S. pseudintermedius and S. aureus, while enterotoxigenicity was mainly expressed by methicillin-resistant S. aureus. Enterotoxigenic S. aureus was carried on the fur of companion dogs during the rainy season at estimated prevalence of 8.57% in both Edo and Delta States, respectively; while PVL-producing S. aureus was estimated at 5.71% and 2.86%, with PVL-producing S. pseudintermedius estimated at 25.71% and 34.29%, respectively. The high prevalence of toxigenic-producing isolates seen on the fur of companion dogs, especially during rainy season, could pose a risk for humans, particularly those that harbour pet dogs at their homes.

Patterns of recurrence after intracranial stereotactic radiosurgery for brain-only metastases from non-small cell lung cancer and the impact of upfront thoracic therapy with synchronous presentation.

BackgroundWe characterized long-term organ-specific patterns of recurrence, time to progression (TTP) and overall survival (OS) in patients with non-small cell lung cancer (NSCLC) with brain-only metastases treated with single-fraction stereotactic radiosurgery (SRS) and analyzed the impact of upfront thoracic therapy (UTT) in those with synchronous presentation of primary NSCLC and brain metastases.MethodsThe clinical records of 137 patients with brain metastases from NSCLC treated with intracranial SRS, and no other metastatic sites, were retrospectively reviewed. Patients with available follow-up imaging (n=124) were analyzed for patterns of recurrence; all were analyzed for OS.ResultsThe majority of first distant recurrences were in brain and thoracic sites, while extra-thoracic sites were relatively uncommon. After median follow-up of 16.0 months, 24.8% did not develop recurrence outside of brain and/or thoracic sites and 43.5% were free of distant extracranial recurrence. Whole brain radiotherapy (WBRT) and UTT, but not systemic therapy, altered patterns of recurrence and intracranial or extracranial TTP. Multivariable analysis revealed UTT, but not systemic therapy or WBRT, was associated with more favorable OS [hazard ratio (HR) 0.515, P=0.029] among 88 patients with synchronous presentation. Within the subgroup of thoracic stage III patients (n=69), those treated with UTT experienced remarkable median extracranial TTP and OS of 19.3 and 22.7 months, respectively.ConclusionsFirst and cumulative recurrences in patients treated with intracranial SRS for NSCLC metastases limited to brain are most often in the brain and thorax. Long-term survival is possible, regardless of thoracic stage, and is dependent on UTT among other factors.

Effect of Water Depth on Limb and Back Kinematics in Horses Walking on a Water Treadmill.

Water treadmill (WT) exercise is frequently used for training/rehabilitation of horses. There is limited study into the effect of water depth on limb/back kinematics warranting investigation. The objective was to determine the effect of walking in different water depths, at the same speed, on limb/back kinematics measured simultaneously in a group of horses. Six horses (age:15 ± 6.5 years) completed a standardized WT exercise session (19 minutes duration; speed:1.6 m/s; water depths: 0.0/7.5/21.0/32.0/47.0 cm). Ten waterproof light-emitting-diode tea-light-markers and reflective-spheres were affixed to the skin at predetermined locations; inertial-measurement-units were fixed to the poll/withers/left and right tubera coxae (TC)/sacrum to determine range-of-motion (ROM) changes of these locations. Univariable-mixed-effects-linear-regression-analyses were carried out, with a significance value of P ≤ .05. At maximum carpal/tarsal flexion during swing, regression analyses showed a clear and consistent nonlinear increase in carpal and tarsal flexion at increasing water depths (P < 0.0001 for both variables). As water depth increased there was a significant increase in thoracic spine flexion-extension ROM (P < 0.0001 at all thoracic sites) and increased dorsoventral and mediolateral ROM of the sacrum/left and right TC (P < 0.001 for all variables) as water depth increased. Results suggest that horses responded to an increase in water depth until a threshold depth was reached when the biomechanical response levelled off, and there was increased pelvic roll. In conclusion, changes in limb kinematics brought about by relatively modest increases in water depth at walking speed of 1.6 m/s are sufficient to induce significant changes in back/pelvic movement highlighting key issues with relevance for WT program design.

Pulmonary Congestion Assessed by Lung Ultrasound and Cardiovascular Outcomes in Patients With ST-Elevation Myocardial Infarction.

Background: Lung ultrasound (LUS) shows a higher sensitivity when compared with physical examination for the detection of pulmonary congestion. The objective of our study was to evaluate the association of pulmonary congestion assessed by LUS after reperfusion therapy with cardiovascular outcomes in patients with ST-segment Elevation acute Myocardial Infarction (STEMI) who received reperfusion therapy. Methods: A prospective observational study including patients with STEMI from the PHASE-Mx study. LUS was performed in four thoracic sites (two sites in each hemithorax). We categorized participants according to the presence of pulmonary congestion. The primary endpoint of the study was the composite of death for any cause, new episode or worsening of heart failure, recurrent myocardial infarction and cardiogenic shock at 30 days of follow-up. Results: A total of 226 patients were included, of whom 49 (21.6%) patients were classified within the “LUS-congestion” group and 177 (78.3%) within the “non-LUS-congestion” group. Compared with patients in the “non-LUS-congestion” group, patients in the “LUS-congestion” group were older and had higher levels of blood urea nitrogen and NT-proBNP. Pulmonary congestion assessed by LUS was significantly associated with a higher risk of the primary composite endpoint (HR: 3.8, 95% CI 1.91–7.53, p = 0.001). Differences in the primary endpoint were mainly driven by an increased risk of heart failure (HR 3.91; 95%CI 1.62–9.41, p = 0.002) and cardiogenic shock (HR 3.37; 95%CI 1.30–8.74, p = 0.012). Conclusion: The presence of pulmonary congestion assessed by LUS is associated with increased adverse cardiovascular events, particularly heart failure and cardiogenic shock. The application of LUS should be integrated as part of the initial risk stratification in patients with STEMI as it conveys important prognostic information.

MRI for in vivo Analysis of Ablation Zones Formed by Cooled Radiofrequency Neurotomy to Treat Chronic Joint Pain Across Multiple Axial Spine Sites.

PurposeRadiofrequency (RF) ablation is the targeted damage of neural tissues to disrupt pain transmission in sensory nerves using thermal energy generated in situ by an RF probe. The present study aims to evaluate the utility of magnetic resonance imaging (MRI) for in vivo quantitative assessment of ablation zones in human subjects following cooled radiofrequency neurotomy for chronic pain at spinal facet or sacroiliac joints. Ablation zone size and shape have been shown in animal models to be influenced by size and type of RF probe – with cooled RF probes typically forming larger, more spherical ablation zones. To date, MRI of RF ablation zones in humans has been limited to two single retrospective case reports.Patients and MethodsA prospective, open-label pilot study of MRI for evaluation of cooled radiofrequency ablation zones following standard of care procedures in adult outpatients was conducted. Adult subjects (n=13) received monopolar cooled RF (CRF) ablation (COOLIEF™, Avanos Medical) of sensory nerves at spinal facet or sacroiliac joints, followed by an MRI 2–7 days after the procedure. MRI data were acquired using both Short Tau Inversion Recovery (STIR) and contrast-enhanced T1-weighted (T1C) protocols. T1C MRI was used to calculate 3-dimensional ellipsoid ablation zone volumes (V), where well-defined regions of signal hyperintensity were used to identify three orthogonal diameters (T, D, L) and apply the formula V=π/6×T×D×L.ResultsAmong 13 patients, 96 CRF ablation zones were created at 4 different anatomic sites (sacroiliac, lumbar, thoracic and cervical). CRF ablation zone morphology varied by anatomical location and structural features of surrounding tissues. In some cases, proximity to bone and striations of surrounding musculature obscured ablation zone borders. The volumes of 75 of the 96 ablation zones were measurable from MRI, with values (mean±SD) ranging from 0.4679 (±0.29) cm3 to 2.735 (±2.62) cm3 for the cervical and thoracic sites, respectively.ConclusionIn vivo T1C MRI analysis of cooled RF ablation zones at spinal facet and sacroiliac joints demonstrated variable effects of local tissues on ablation zone morphology. Placement of the CRFA probe very close to bone alters the ablation zone in a negative way, causing non-spherical and incomplete lesioning. These new data may serve to inform practicing physicians about optimal cooled RF probe placement in clinical procedures.

Analysis of Cardiac Vibration Signals Acquired From a Novel Implant Placed on the Gastric Fundus

The analysis of cardiac vibration signals has been shown as an interesting tool for the follow-up of chronic pathologies involving the cardiovascular system, such as heart failure (HF). However, methods to obtain high-quality, real-world and longitudinal data, that do not require the involvement of the patient to correctly and regularly acquire these signals, remain to be developed. Implantable systems may be a solution to this observability challenge. In this paper, we evaluate the feasibility of acquiring useful electrocardiographic (ECG) and accelerometry (ACC) data from an innovative implant located in the gastric fundus. In a first phase, we compare data acquired from the gastric fundus with gold standard data acquired from surface sensors on 2 pigs. A second phase investigates the feasibility of deriving useful hemodynamic markers from these gastric signals using data from 4 healthy pigs and 3 pigs with induced HF with longitudinal recordings. The following data processing chain was applied to the recordings: (1) ECG and ACC data denoising, (2) noise-robust real-time QRS detection from ECG signals and cardiac cycle segmentation, (3) Correlation analysis of the cardiac cycles and computation of coherent mean from aligned ECG and ACC, (4) cardiac vibration components segmentation (S1 and S2) from the coherent mean ACC data, and (5) estimation of signal context and a signal-to-noise ratio (SNR) on both signals. Results show a high correlation between the markers acquired from the gastric and thoracic sites, as well as pre-clinical evidence on the feasibility of chronic cardiovascular monitoring from an implantable cardiac device located at the gastric fundus, the main challenge remains on the optimization of the signal-to-noise ratio, in particular for the handling of some sources of noise that are specific to the gastric acquisition site.

Suicide Among Adult Cancer Survivors, 2000-2019

<h3>Purpose/Objective(s)</h3> Cancer patients are at elevated risk of suicide due to additional disease-specific factors relating to cancer and its treatments. Given that cancer survivorship in the United States continues to improve, evaluating the risk and identifying factors associated with suicide among cancer survivors is warranted. <h3>Materials/Methods</h3> This population-based study examined the National Center for Health Statistics Multiple-Cause Mortality data for adult cancer survivors aged ≥ 20 with suicide and self-inflicted injury as the underlying cause and malignant neoplasm as a contributing cause of death. Associations with death by suicide were assessed with multivariable logistic regression for demographic and comorbid factors, and univariate logistic regression for anatomic site of cancer stratified by sex. Trends in suicide rates of non-cancer and cancer survivors were assessed with Pearson's correlation coefficient. <h3>Results</h3> Among 12,180,902 adult cancer survivors, 6,254 (0.051%) deaths were by suicide. Male sex, White race, being not married, and having a high school education or higher, were associated with increased odds of suicide. Cancer survivors with a documented history of substance use disorder (OR [95% CI], 0.35 [0.31-0.39], <i>P</i> < .001) or chronic medical condition (0.36 [0.34-0.39], <i>P</i> < .001) had decreased odds, while history of depressive disorder had significantly increased odds of suicide (97.44 [90.61-104.78], <i>P</i> < .001), compared to those without the respective comorbidity. Survivors of head and neck, female breast, or genitourinary cancers had increased likelihood of death by suicide compared to those of thoracic sites (Table). Over the study period, the suicide rate of those without a history of cancer increased (r = 0.95, <i>P</i> < .0005) while the overall suicide rate of cancer survivors decreased (r = -0.60, <i>P</i> = 0.005). Specifically, suicide rates decreased for thoracic, gastrointestinal, genitourinary, and head and neck cancers, with the largest decline in multiple, metastatic, not otherwise specified sites (r = -0.67, <i>P</i> = 0.001). <h3>Conclusion</h3> Among adult cancer survivors, suicide risk varies with sociodemographic status, comorbid conditions, and anatomic cancer site. Although the suicide rate of cancer survivors has declined overall, further research is needed to develop interventions in high-risk cancer patients, particularly those with a history of depression, to mitigate suicide risk and improve survivorship care.

Potential of a probabilistic framework for target prediction from surrogate respiratory motion during lung radiotherapy

Purpose. Respiration-induced motion introduces significant positioning uncertainties in radiotherapy treatments for thoracic sites. Accounting for this motion is a non-trivial task commonly addressed with surrogate-based strategies and latency compensating techniques. This study investigates the potential of a new unified probabilistic framework to predict both future target motion in real-time from a surrogate signal and associated uncertainty. Method. A Bayesian approach is developed, based on a Kalman filter theory adapted specifically for surrogate measurements. Breathing motions are collected simultaneously from a lung target, two external surrogates (abdominal and thoracic markers) and an internal surrogate (liver structure) for 9 volunteers during 4 min, in which severe breathing changes occur to assess the robustness of the method. A comparison with an artificial non-linear neural network (NN) is performed, although no confidence interval prediction is provided. A static worst-case scenario and a simple static design are investigated. Results. Although the NN can reduce the prediction errors from thoracic surrogate in some cases, the Bayesian framework outperforms in most cases the NN when using the other surrogates: bias on predictions is reduced by 38% and 16% on average when using respectively the liver and the abdomen for the simple scenario, and by respectively 40% and 31% for the worst-case scenario. The standard deviation of residuals is reduced on average by up to 42%. The Bayesian method is also found to be more robust to increasing latencies. The thoracic marker appears to be less reliable to predict the target position, while the liver shows to be a better surrogate. A statistical test confirms the significance of both observations. Conclusion. The proposed framework predicts both the future target position and the associated uncertainty, which can be valuably used to further assist motion management decisions. Further investigation is required to improve the predictions by using an adaptive version of the proposed framework.