Volume Cutoff Research Articles

Prognostic role of primary tumor, nodal neck, and retropharyngeal GTVs for unresectable sinonasal cancers treated with IMRT and chemotherapy.

We evaluated the prognostic role of gross tumor volumes (GTVs) of primary tumor and positive lymph nodes on overall survival (OS) and progression-free survival (PFS) in locally advanced unresectable sinonasal cancer (SNC) treated with definitive intensity-modulated radiotherapy (IMRT) with or without chemotherapy. Primary tumor GTV (GTV-T), pathologic neck nodes GTV (GTV-N), and positive retropharyngeal nodes GTV (GTV-RPN) of 34 patients with epithelial nonglandular SNC receiving IMRT with or without chemotherapy were retrospectively measured. The GTV variables were analyzed in relation with OS and PFS. Survival curves were estimated using the Kaplan-Meier method and compared with the log-rank test. We also estimated the crude cumulative incidence of locoregional relapses only. The optimal volume cutoff value was determined using an outcome-oriented method among the observed values. GTV-T was significantly associated with decreased OS (P=0.003) and PFS (P=0.003). Moreover, patients with disease total volumes (GTV) smaller than 149.44 cm³ had better OS and PFS than patients with higher volumes (P<0.0001 for both). Neck nodal metastasis impacted on OS and PFS (P=0.030 and P=0.033, respectively), but GTV-N did not (P=0.961; P=0.958). Retropharyngeal nodes metastasis was not associated with prognosis (OS: P=0.400; PFS: P=0.104). When GTV-RPN was added to GTV-N (GTV-TN), a relation with PFS (P=0.041) and a trend toward significance for OS (P=0.075) were found. Our results show that tumor volume is a powerful predictor of outcome in SNC. This could be useful to identify patients with worse prognosis deserving different treatment strategies.

Identification and Validation of Hematoma Volume Cutoffs in Spontaneous, Supratentorial Deep Intracerebral Hemorrhage.

Background and Purpose- Clinical trials in spontaneous intracerebral hemorrhage (ICH) have used volume cutoffs as inclusion criteria to select populations in which the effects of interventions are likely to be the greatest. However, optimal volume cutoffs for predicting poor outcome in deep locations (thalamus versus basal ganglia) are unknown. Methods- We conducted a 2-phase study to determine ICH volume cutoffs for poor outcome (modified Rankin Scale score of 4-6) in the thalamus and basal ganglia. Cutoffs with optimal sensitivity and specificity for poor outcome were identified in the ERICH ([Ethnic/Racial Variations of ICH] study; derivation cohort) using receiver operating characteristic curves. The cutoffs were then validated in the ATACH-2 trial (Antihypertensive Treatment of Acute Cerebral Hemorrhage-2) by comparing the c-statistic of regression models for outcome (including dichotomized volume) in the validation cohort. Results- Of the 3000 patients enrolled in ERICH, 1564 (52%) had deep ICH, of whom 1305 (84%) had complete neuroimaging and outcome data (660 thalamic and 645 basal ganglia hemorrhages). Receiver operating characteristic curve analysis identified 8 mL in thalamic (area under the curve, 0.79; sensitivity, 73%; specificity, 78%) and 18 mL in basal ganglia ICH (area under the curve, 0.79; sensitivity, 70%; specificity, 83%) as optimal cutoffs for predicting poor outcome. The validation cohort included 834 (84%) patients with deep ICH and complete neuroimaging data enrolled in ATACH-2 (353 thalamic and 431 basal ganglia hemorrhages). In thalamic ICH, the c-statistic of the multivariable outcome model including dichotomized ICH volume was 0.80 (95% CI, 0.75-0.85) in the validation cohort. For basal ganglia ICH, the c-statistic was 0.81 (95% CI, 0.76-0.85) in the validation cohort. Conclusions- Optimal hematoma volume cutoffs for predicting poor outcome in deep ICH vary by the specific deep brain nucleus involved. Utilization of location-specific volume cutoffs may improve clinical trial design by targeting deep ICH patients that will obtain maximal benefit from candidate therapies.

Volume of Hypothalamus as a Diagnostic Biomarker of Chronic Migraine.

It is believed than hypothalamus (HTH) might be involved in generation of migraine, and evidence from high resolution fMRI reported that the more anterior part of HTH seemed to play an important role in migraine chronification. The current study was aimed to identify the alteration of morphology and resting-state functional connectivity (FC) of the hypothalamus (HTH) in interictal episodic migraine (EM) and chronic migraine (CM). High-resolution structural and resting-state functional magnetic resonance images were acquired in 18 EM patients, 16 CM patients, and 21 normal controls (NC). The volume of HTH was calculated and voxel-based morphometry (VBM) was performed over the whole HTH. Receiver operating characteristics (ROC) curve analysis was applied to evaluate the diagnostic efficacy of HTH volume. Correlation analyses with clinical variables were performed and FC maps were generated for positive HTH regions according to VBM comparison. The volume of the HTH significantly decreased in both EM and CM patients compared with NC. The cut-off volume of HTH as 1.429 ml had a good diagnostic accuracy for CM with sensitivity of 81.25% and specificity of 100%. VBM analyses identified volume reduction of posterior HTH in EM vs. NC which was negatively correlated with headache frequency. The posterior HTH presented decreased FC with the left inferior temporal gyrus (Brodmann area 20) in EM. Decreased volume of anterior HTH was identified in CM vs. NC and CM vs. EM which was positively correlated with headache frequency in CM. The anterior HTH presented increased FC with the right anterior orbital gyrus (AOrG) (Brodmann area 11) in CM compared with NC and increased FC with the right medial orbital gyrus (MOrG) (Brodmann area 11) in CM compared with EM. Our study provided evidence of structural plasticity and FC changes of HTH in the pathogensis of migraine generation and chronification, supporting potential therapeutic target toward the HTH and its peptide.

Is gynecomastia related to the disease characteristics and prognosis in testicular germ cell tumor patients?

We aimed to assess the relationship between gynecomastia and tumor markers, histologic subtypes, and prognosis in patients with testicular germ cell tumors. This study included 73 testicular germ cell cancer patients with pretreatment chest, abdomen and pelvis computed tomography (CT) scans and tumor markers (β-human chorionic gonadotropin [β-hCG], lactate dehydrogenase [LDH], α-fetoprotein [AFP]). The volumetric analysis of the breast glandular tissue, the presence of gynecomastia and metastatic disease were determined using CT scans. Patients were classified according to the International Germ Cell Cancer Collaborative Group (IGCCCG) prognostic classification. The association between gynecomastia, breast glandular tissue volume, tumor markers, metastatic disease, and disease prognosis were evaluated. Thirty-four of the patients (46.6%) had gynecomastia. A breast volume cutoff value of 0.78 cm3 to diagnose gynecomastia led to 85% sensitivity and 95% specificity. Serum β-hCG level correlated with the breast glandular tissue volume weakly (r=0.242, P = 0.039). Gynecomastia was more common in patients with elevated β-hCG levels (P = 0.047), and was not associated with pulmonary, nonpulmonary distant, or nodal metastases (P = 0.378, P = 0.884, P = 0.333, respectively). No significant association was found between the disease prognosis and gynecomastia (P = 0.556). Gynecomastia was common among testicular germ cell cancer patients with elevated β-hCG. However, it was not associated with metastatic disease and prognosis.

Relationship between operator and hospital volumes and short-term mortality for percutaneous coronary intervention in New York

BackgroundRecent studies have reported mixed findings regarding the inverse provider volume-outcome relationship for percutaneous coronary interventions (PCIs). MethodsWe included patients who underwent PCIs in New York during December 2012–November 2015. Using risk-adjusted in-hospital/30-day mortality rate and appropriateness of PCI, we tested for a continuous relationship and a variety of annual PCI volume cut points at hospital and operator levels in investigating volume-outcome relationships. ResultsThere were 144,196 patients undergoing PCI procedures from 63 non-federal hospitals. There was a significant inverse association between risk-adjusted mortality and both annual hospital PCI volume and annual operator PCI volume. However, we did not find that there was an inverse hospital volume-outcome relationship for the 2013 ACCF/AHA/SCAI's hospital PCI volume cutoff value of 200 per year (AOR, 1.15, 95% CI, 0.88–1.51, P = 0.32) or a significant inverse operator volume-outcome relationship using the operator PCI volume cutoff value of 50 per year (AOR, 0.89, 95% CI, 0.70–1.12, P = 0.32) or for any other practical volume cutoffs. There was also no significant volume-outcome relationship for STEMI patients. Higher volume hospitals (>400) and operators (>200) tended to perform a higher percentage of inappropriate PCI procedures than their lower volume counterparts. ConclusionThere were no significant PCI volume-mortality relationships for either hospitals or operators for any practical volume cuts. Higher volume hospitals and operators were associated with higher percentages of inappropriate PCIs.

Defining “high volume center” for pancreaticoduodenectomy

Background: The relationship between hospital volume and patient outcomes for pancreaticoduodenectomy has been demonstrated by multiple studies. Various cutoffs to define a high-volume center have been used in the literature and these range from 1 to 20 cases per year. However, controversy exits regarding the validity of hospital volume and outcome association. The purpose of this study was to re-evaluate the previously utilized definitions using a large sample of patients undergoing pancreaticoduodenectomy to determine an objective, evidence based threshold of hospital volume associated with improvement in perioperative mortality. Methods: Patients who underwent pancreaticoduodenectomy were identified using the National Cancer Database from 2004 to 2015. The relationship between hospital volume and 90-day mortality was assessed using a logistic regression model. Receiver Operator Characteristic analysis was performed to determine hospital volume cutoff which maximized the linear combination of specificity and sensitivity as shown in Figure 1a. Results: 42,402 patients underwent pancreaticoduodenectomy at 1,238 unique hospitals. 30- and 90-day mortality of the study population were 3.33% (n = 1411) and 6.81% (n = 2889), respectively. Mean annual mortality of individual hospitals is shown in Figure 1b. A logistic regression was performed which showed that institutional volume is significantly associated with decreased overall 90-day mortality. The maximum improvement in 90-day mortality is seen if the annual hospital volume was greater than 9 (p < 0.0001, OR = 0.458 (0.399–0.525). When analysis is limited to hospitals that performed greater than 9 cases per year, the maximum improvement in 90-day mortality was reached at 36 cases per year (p < 0.0001, OR = 0.647 (0.595–0.702). Conclusion: Based on the association of hospital volume to 90-day mortality after pancreaticoduodenectomy in the National Cancer Database we recommend defining low-volume hospitals as those performing 1 to 9 pancreaticoduodenectomies per year, medium-volume as those performing 10 to 36, and high-volume as those performing over 36 pancreaticoduodenectomies per year. These recommendations will need to be validated with additional studies.

Role of Diffusion and Perfusion Magnetic Resonance Imaging in Predicting the Histopathological Grade of Gliomas - A Prospective Study.

Context:Gliomas are the most common brain tumors. In addition to conventional magnetic resonance imaging (MRI) techniques, a variety of new techniques offers more than the anatomic information. The new MRI techniques include perfusion-weighted imaging (PWI) and diffusion-weighted imaging (DWI).Aims:The aim of this study is to assess the sensitivity, specificity, predictive value, and accuracy of diffusion- and perfusion-weighted MRI in the preoperative grading of gliomas.Setting/Design:The study was conducted in the Department of Neurosurgery, Pathology, and Radiodiagnosis, Sher-e-Kashmir Institute of Medical Sciences, Kashmir, India, which is the only tertiary care neurosurgical center in the state. It was a prospective study.Patients and Methods:Thirty-one consecutive patients with gliomas were included in the study. All the patients were evaluated by a standard conventional contrast-enhanced study on Siemens 1.5 Tesla MRI. In addition to the standard MRI, diffusion- and perfusion-weighted MRI were also performed. The histopathological grading of the tumor was done as per the WHO classification of 2007. The sensitivity, specificity, predictive value, and accuracy of diffusion- and perfusion-weighted MRI in determining tumor grade were calculated. Comparison was done between PWI, DWI findings, and WHO histopathological grading.Analysis Method:The statistical analysis was done using the Statistical Package for the Social Sciences, and receiver operating characteristic curves were used to estimate sensitivity, specificity, and accuracy.Results:The overall sensitivity of PWI (with regional cerebral blood volume cutoff of 1.7) in the preoperative assessment of high-grade gliomas was 82.6% and specificity was 75%, the positive predictive value (PPV) was 90.48%, and the negative predictive value (NPV) was 60%. The overall accuracy was 80.65%. In case of DWI, the sensitivity was 69.57% and the specificity was 75%, and the PPV and NPVs were 88.8% and 46.15%, respectively. The overall accuracy was 71%.Conclusion:Our results clearly show higher accuracy of diffusion- and perfusion-weighted MRI in assessment of glioma grade as compared to conventional MRI. This information can prove very useful for the operating neurosurgeon in preoperative assessment and surgical planning. Postoperatively, the neuropathologist can also benefit from such information.

Hemorrhagic burden in poor-grade aneurysmal subarachnoid hemorrhage: a volumetric analysis of different bleeding distributions.

Volumetric assessment of aneurysmal bleeding has been evaluated in few studies and emerged as a promising outcome predictor. There is a lack of studies evaluating its impact in the poor-grade population. Retrospective review of 63 consecutive poor-grade aneurysmal subarachnoid hemorrhage (aSAH) patients, defined as grade IV and V according to the World Federation of Neurological Surgeons (WFNS) classifications. Global intracranial bleeding volume was calculated with its subarachnoid, intracerebral (ICH), and intraventricular (IVH) portions by means of analytical software. Univariate and multivariate analyses were performed in order to identify independent predictors of outcome. Good outcome was defined as modified Rankin Scale (mRS) 0-2 and mortality as mRS 6. The cutoff values of bleeding volumes were derived by receiver operating curve (ROC) analysis. Mean follow-up was of 12.5 (± 1.5) months. Thirty (47.7%) patients achieved good outcome, whereas 19 (30.2) patients out of 63 died. Global intracranial bleeding resulted as an independent predictor of good outcome (cutoff 24mL). Furthermore, ICH relative percentage of global volume (10% of total) and pure SAH (64% of total) emerged respectively as independent predictors of worsened and improved outcome. Global bleeding volume (cutoff 51mL) along with global cerebral edema showed to independently predict mortality in the examined poor-grade aSAH population. Volumetric assessment of aneurysmal bleeding has the potential for identifying cutoff values that independently predict outcome. Further insights into the relative importance of different bleeding volumes may be implicated in better tailoring the management of this dismal aSAH population.

Defining a “High Volume” Radical Cystectomy Hospital: Where Do We Draw the Line?

BackgroundCentralization of radical cystectomy (RC) to “high volume” centers can lead to decreased morbidity but also limits access to care. In the context of centralization, there is a need to systematically define the hospital volume cutoffs for this procedure. ObjectiveTo systematically examine the effect of hospital volume on inpatient complications of RC for bladder cancer and to define a threshold to minimize RC morbidity. Design, setting, and participantsThis was a retrospective analysis of data for 6790 adults undergoing RC for nonmetastatic bladder cancer during 2008–2011 from the National Inpatient Sample (weighted population estimate of 33 249 RCs in the USA during this period). InterventionRC. Outcome measurements and statistical analysisOverall and major complications were defined according to International Classification of Diseases (9th revision) diagnosis and procedure codes. To define the relationship between hospital volume and morbidity, logistic regression analyses within a generalized estimating equation framework with restricted cubic splines were used. Results and limitationsThe inpatient complication rate was 4769/6790 (70.2%), of which 1572/6790 (23.2%) were major complications. Restricted cubic spline analysis revealed a significant inverse nonlinear association between hospital volume and complications. The odds of complications decreased with increasing volume, with a plateau at 50–55 cases/yr for any complications (p=0.024) and 45–50 cases/yr for major complications (p=0.007). ConclusionsThe relationship between hospital volume and RC morbidity is nonlinear, with a plateau for the complication rate at 50–55 cases/yr. Restricting RC to centers with such high thresholds will restrict access to care. There is a need to identify and publish best practices from high-volume centers in quality improvement initiatives to improve morbidity at low-volume centers. Patient summaryThere is a nonlinear relationship between the annual number of radical cystectomy procedures performed at a hospital and the inpatient complication rate. Complications decrease with increasing hospital volume and reach a plateau at 50–55 cases per year, beyond which the incremental benefit of increasing volume is minimal.

Estimation of Cutoff Values by Using Regression Lines Method in Mishrif Reservoir/ Missan oil Fields

Net pay is one of the most important parameters used in determining initial oil in place of a reservoir. It can be delineated through the using of limiting values of the petrophysical properties of the reservoir. Those limiting values are named as the cutoff. This paper provides an insight into the application of regression line method in estimating porosity, clay volume and water saturation cutoff values in Mishrif reservoir/ Missan oil fields. The study included 29 wells distributed in seven oilfields of Halfaya, Buzurgan, Dujaila, Noor, Fauqi, Amara and Kumait.&#x0D; This study is carried out by applying two types of linear regressions: Least square and Reduce Major Axis Regression.&#x0D; The Mishrif formation was divided into three main units. They are MA, MB, and MC. The methods were applied to each unit of Mishrif formation individually and as one unit. The division of Mishrif formation into subunits led to a great improvement in the accuracy of the porosity-permeability correlations. The Results indicated that the regression lines method of defining cutoffs gives unrealistic values with the common assumption of permeability cutoff = 0.1 md.&#x0D; Another assumption for permeability cutoff = 1 is made and it was chosen due to lithology and hydrocarbon type which are limestone and oil respectively. This assumption led to more realistic and higher porosity cutoff and smaller water saturation and clay volume cutoff values using the two types of regression lines.&#x0D;

Determining a cut-off residual tumor volume threshold for patients with newly diagnosed glioblastoma treated with temozolomide chemoradiotherapy: A multicenter cohort study

Standard-of-care treatment of glioblastomas involves maximal safe resection and adjuvant temozolomide chemo-radiotherapy. Although extent of resection (EOR) is a well-known surgical predictor for overall survival most lesions cannot be completely resected. We hypothesize that in the event of incomplete resection, residual tumor volume (RTV) may be a more significant predictor than EOR. This was a multicenter retrospective review of 147 adult glioblastoma patients (mean age 53 years) that underwent standard treatment. Semiautomatic magnetic resonance imaging segmentation was performed for pre- and postoperative scans for volumetric analysis. Cox proportional hazards regression and Kaplan-Meier survival analyses were performed for prognostic factors including: age, Karnofsky performance score (KPS), O(6)-methylguanine methyltransferase (MGMT) promoter methylation status, EOR and RTV. EOR and RTV cut-off values for improved OS were determined and internally validated by receiver operator characteristic (ROC) analysis for 12-month overall survival. Half of the tumors had MGMT promoter methylation (77, 52%). The median tumor volume, EOR and RTV were 43.20 cc, 93.5%, and 3.80 cc respectively. Gross total resection was achieved in 52 patients (35%). Cox proportional hazards regression, ROC and maximum Youden index analyses for RTV and EOR showed that a cut-off value of <3.50 cc (HR 0.69; 95% CI 0.48–0.98) and ≥84% (HR 0.64; 95% CI 0.43–0.96) respectively conferred an overall survival advantage. Independent overall survival predictors were MGMT promoter methylation (adjusted HR 0.35; 95% CI 0.23–0.55) and a RTV of <3.50 cc (adjusted HR 0.53; 95% CI 0.29–0.95), but not EOR for incompletely resected glioblastomas.

The volume–outcome relationship for hip fractures: a systematic review and meta-analysis of 2,023,469 patients

Background and purpose — It has been hypothesized that hospitals and surgeons with high caseloads of hip fracture patients have better outcomes, but empirical studies have reported contradictory results. This systematic review and meta-analysis evaluates the volume–outcome relationship among patients with hip fracture patients.Methods — A search of different databases was performed up to February 2018. Selection of relevant studies, data extraction, and critical appraisal of the methodological quality was performed by 2 independent reviewers. A random-effects meta-analysis using studies with comparative cut-offs was performed to estimate the effect of hospital and surgeon volume on outcome, defined as in-hospital mortality and postoperative complications.Results — 24 studies comprising 2,023,469 patients were included. Overall, the quality was reasonable. 11 studies reported better health outcomes in high-volume centers and 2 studies reported better health outcomes in low-volume centers. In the meta-analysis of 11 studies there was a statistically non-significant association between higher hospital volume and both lower in-hospital mortality (adjusted odds ratio (aOR) 0.87, 95% confidence interval (CI) 0.73–1.04) and fewer postoperative complications (aOR 0.87, CI 0.75–1.02). Four studies on surgeon volume were included in the meta-analysis and showed a minor association between higher surgeon volume and in-hospital mortality (aOR 0.92, CI 0.76–1.12).Interpretation — This systematic review and meta-analysis did not find an evident effect of hospital or surgeon volume on health outcomes. Future research without volume cut-offs is needed to examine whether a true volume–outcome relationship exists.

The Volume of Ischemic Brain Predicts Poor Outcome in Patients with Surgically Treated Malignant Stroke

Malignant middle cerebral artery stroke is a life-threatening condition. The outcomes of surgical treatments have presented strong evidence in favor of decompressive hemicraniectomy (DHC). A significant subpopulation of patients still experience very poor outcomes. In particular, indication for DHC is based on few objective parameters to facilitate decision making. We hypothesized that larger ischemic brain volume would have a large impact on the outcome. A cohort study of 34 patients undergoing DHC was performed using a volumetric analysis of infarction volume (measured preoperatively and again on postoperative day [POD] 1 and POD 3). Outcomes were assessed using the modified Rankin Scale (mRS), and a favorable outcome was defined as modified Rankin Scale score ≤3. Median age of patients was 53.5 years (range, 25-72 years), the median time from onset of first symptoms to surgical intervention was 38 hours (range, 10-150 hours), and male-to-female ratio was 2:1. The median ischemic volume was 250 cm3 preoperatively, 315 cm3 on POD1, and 349 cm3 on POD3. Modified Rankin Scale score ≤3 after 6 months was attained in 7 (20%) patients. Within the first 24 hours after DHC, ischemic volume increased significantly (P= 0.0003) and was associated with a worse outcome (P<0.0001) after exceeding a cutoff volume of 300 cm3. Volumetric analysis of infarction can predict the outcome of patients. DHC should be reserved for patients with prognosticated good outcome, which was observed only in patients with a volume <301 cm3.

Determination of appropriate urine volume cutoff values for voided urine specimens to assess adequacy

Incorporating urine volume into adequacy assessment was recommended by The Paris System for Reporting Urinary Cytology. The concept was relatively new, however, and supportive studies were sparse. We accordingly aimed to determine the role of urine volume in adequacy assessment and cutoff values for urine samples using ThinPrep (Hologic, Inc, MA) processing. Archived consecutive urine cytology cases (n = 2117) were analyzed. Patient age, sex, collection method, urine volume and fixative (CytoLyt, Hologic, Inc) added, adequacy and diagnoses were documented. Adequate samples were defined as samples with >50 well-preserved, well-visualized urothelial cells. Diagnoses of suspicious and positive for high-grade urothelial carcinoma were combined for analysis. Statistical analysis was performed using IBM SPSS Statistics for Windows. There was a correlation between urine volume and the unsatisfactory/less than optimal cellularity versus satisfactory samples (P ≤ 0.001) in voided urine specimens. A minimum of 10 mL of fresh voided urine was found to be a reasonable cutoff to achieve sufficient cellularity. Cutoff values of 30 mL for voided urine for the high-risk diagnosis were associated with the highest χ2 statistic, although this was not statistically significant. Urine volume was justified as an adequacy criterion in voided urine. Although 10 mL of fresh voided urine might achieve sufficient cellularity, higher volume (≥30 mL) is recommended in order to maximize the chance of detecting a high-risk diagnosis. Nevertheless, the presence of high-grade urothelial carcinoma can still be detected in low-volume (<20 mL) specimens. Hence, correlation of clinical information with voided urine volume cutoff values for individual cases might also be beneficial.

Intraoperative Fluid Administration and Surgical Outcomes Following Pancreaticoduodenectomy: External Validation at a Tertiary Referral Center.

While intraoperative fluid overload is associated with higher complication rates following surgery, data for pancreaticoduodenectomy are scarce and heterogeneous. We evaluated multiple prior definitions of restrictive and liberal fluid regimens and analyzed whether these affected surgical outcomes at our tertiary referral center. Studies evaluating different intraoperative fluid regimens on outcomes after pancreatic resections were retrieved. After application of all prior definitions of restrictive and liberal fluid regimens to our patient cohort, relative risks of each outcome were calculated using all reported infusion regimens. Five hundred and seven pancreaticoduodenectomies were included. Nine different fluid regimens were evaluated. Two regimens utilized absolute volume cutoffs, and the remaining evaluated various infusion rates, ranging from 5 to 15mL/kg/h. Total volume administration of >5000mL and >6000mL was associated with increased complications (RR 1.25 and RR 1.17, respectively) and >6000mL with increased sepsis (RR 2.14). Conversely, a rate of <5mL/kg/h was associated with increased risk of postoperative pancreatic fistula (POPF, RR 3.16) and sepsis (RR 3.20), <6.8mL/kg/h with increased major morbidity (RR 1.64) and sepsis (RR 2.27), and <8.2mL/kg/h with increased POPF (RR 2.16). No effects were observed on pulmonary complications, surgical site infections, length of stay, or mortality. In an uncontrolled setting with no standard intraoperative or postoperative care map, the volume of intraoperative fluid administration appears to have limited impact on early postoperative outcomes following pancreaticoduodenectomy, with adverse outcomes only seen at extreme values.

Tumor heterogeneity, hypoxia, and immune markers in surgically resected non-small-cell lung cancer.

This study aimed to determine the prognostic role of textural features and their association with metabolic parameters, hypoxia, and cancer-related immune markers in non-small-cell lung cancer (NSCLC) patients. The trial was registered at http://www.clinicaltrials.gov (NCT02519062). From January 2010 to May 2014, 44 patients (male : female=33 : 11; median age: 69.5 years), referred to our Institution for NSCLC resection, were enrolled. Tumor specimens were assessed for HIF-1α, CD68-TAMs, CD8-TILs, PD-1-TILs, and PD-L1 expressions. All patients underwent fluorine-18-fluorodeoxyglucose (F-FDG) PET before surgery. Semiquantitative parameters included maximum standardized uptake value (SUVmax), SUVpeak, SUVmean, metabolic tumor volume, and total lesion glycolysis, whereas for heterogeneity, we considered tumor sphericity, skewness, kurtosis, entropy, and energy. Parameters were correlated with disease-free survival (DFS) considering a median follow-up of 22.7 months. SUVmax (cutoff: 7.9; P=0.015), SUVpeak (cutoff: 6.7; P=0.013), SUVmean (cutoff: 5.5; P=0.028), metabolic tumor volume (cutoff: 3.6 cm; P=0.027), and entropy (cutoff: 1.89; P=0.045) showed a statistically significant association with DFS. Also, a high expression of cytoplasmic HIF-1α (score 3) was associated with DFS (hazard ratio: 0.09; P=0.003). All F-FDG PET variables differed significantly in tumors with high or low entropy (≤1.89). Also, a significantly higher level of mean CD8-TILs was observed in tumors with higher entropy (P=0.041).Using identified prognostic factors, we developed a scoring system, which was confirmed to be associated with DFS (P<0.004). On receiver operating characteristics analysis, a score above 3 was defined as the optimal cutoff point. Tumor heterogeneity, metabolic parameters, and high expression of hypoxia were found to be prognostic factors in NSCLC patients who were candidates for surgery. Higher levels of entropy appear to be associated with increased density of CD8-TILs. The combination of investigated prognostic factors enabled the development of a potential scoring system associated with DFS.

INTEGRATED AVO, ELASTIC SEISMIC INVERSION AND PETROPHYSICAL ANALYSIS FOR RESERVOIR CHARACTERIZATION: A CASE STUDY OF GAS FIELD, SOUTH SUMATERA BASIN

Integrated Amplitude Versus Offset ( AVO), elastic seismic inversion and petrophysical analysis have been successfully applied to estimate the elastic parameters of the reservoir for a case study of the gas field in south Sumatera basin. This paper aims to have better understanding the petrophysical properties of the reservoir. The petrophysical analysis was carried out by performing routine formation evaluation that includes calculation of shale volume, porosity, and water saturation of basic well log data. Sensitivity analysis was conducted to evaluate the sensitivity parameters of the log for changing in lithology, porosity, and fluid content in the reservoir. For completing the availability of elastic parameter from well log data, shear wave logs were derived from Castagna’s mudrock line relationship. Further, P-impedance, S-impedance, VpVs ratio, LambdaRho (λρ), MuRho (μρ) and density(ρ) were then calculated through a Lambda-Mu-Rho (LMR) transformation. Prior to performing AVO analysis and elastic seismic inversion, super gather technique was applied to improve the reliability of pre-stack seismic data. Elastic seismic inversion was carried out to extract the lateral elastic properties to capture lithology and fluid changes in the reservoir. In addition, AVO analysis of pre-stacked data was applied to identify hydrocarbon-bearing sandstone at target zone. The petrophysical analysis shows that porosity versus density crossplot is able to distinguish sand-shale based on 34% shale volume cutoff, while LMR crossplot is able to delineate hydrocarbon zone at water saturation value under 65%. The predicted lateral elastic parameter shows slightly higher value compare to overlying layer.

Characteristics of new solid nodules detected in incidence screening rounds of low-dose CT lung cancer screening: the NELSON study

PurposeNew nodules after baseline are regularly found in low-dose CT lung cancer screening and have a high lung cancer probability. It is unknown whether morphological and location characteristics can improve...

Left ventricular scar and the acute hemodynamic effects of multivein and multipolar pacing in cardiac resynchronization

BackgroundWe sought to determine whether presence, amount and distribution of scar impacts the degree of acute hemodynamic response (AHR) with multisite pacing.Multi-vein pacing (MVP) or multipolar pacing (MPP) with a multi-electrode left ventricular (LV) lead may offer benefits over conventional biventricular pacing in patients with myocardial scar. MethodsIn this multi-center study left bundle branch block patients underwent an hemodynamic pacing study measuring LV dP/dtmax. Patients had cardiac magnetic resonance scar imaging to assess the effect of scar presence, amount and distribution on AHR. Results24 patients (QRS 171 ± 20 ms) completed the study (83% male). An ischemic etiology was present in 58% and the mean scar volume was 6.0 ± 7.0%. Overall discounting scar, MPP and MVP showed no significant AHR increase compared to an optimized “best BiV” (BestBiV) site. In a minority of patients (6/24) receiver-operator characteristic analysis of scar volume (cut off 8.48%) predicted a small AHR improvement with MPP (sensitivity 83%, specificity 94%) but not MVP. Patients with scar volume > 8.48% had a MPP-BestBiV of 3 ± 6.3% vs. −6.4 ± 7.7% for those below the cutoff. There was a significant correlation between the difference in AHR and scar volume for MPP-BestBiV (R = 0.49, p = 0.02) but not MVP-BestBiV(R = 0.111, p = 0.62). The multielectrode lead positioned in scar predicted MPP AHR improvement (p = 0.04). ConclusionsMultisite pacing with MPP and MVP shows no AHR benefit in all-comers compared to optimized BestBiV pacing. There was a minority of patients with significant scar volume in relation to the LV site that exhibited a small AHR improvement with MPP.(Study identifier NCT01883141)

CT Prediction Model for Major Arterial Injury after Blunt Pelvic Ring Disruption.

Purpose To develop and test a computed tomography (CT)-based predictive model for major arterial injury after blunt pelvic ring disruptions that incorporates semiautomated pelvic hematoma volume quantification. Materials and Methods A multivariable logistic regression model was developed in patients with blunt pelvic ring disruptions who underwent arterial phase abdominopelvic CT before angiography from 2008 to 2013. Arterial injury at angiography requiring transarterial embolization (TAE) served as the outcome. Areas under the receiver operating characteristic (ROC) curve (AUCs) for the model and for two trauma radiologists were compared in a validation cohort of 36 patients from 2013 to 2015 by using the Hanley-McNeil method. Hematoma volume cutoffs for predicting the need for TAE and probability cutoffs for the secondary outcome of mortality not resulting from closed head injuries were determined by using ROC analysis. Correlation between hematoma volume and transfusion was assessed by using the Pearson coefficient. Results Independent predictor variables included hematoma volume, intravenous contrast material extravasation, atherosclerosis, rotational instability, and obturator ring fracture. In the validation cohort, the model (AUC, 0.78) had similar performance to reviewers (AUC, 0.69-0.72; P = .40-.80). A hematoma volume cutoff of 433 mL had a positive predictive value of 87%-100% for predicting major arterial injury requiring TAE. Hematoma volumes correlated with units of packed red blood cells transfused (r = 0.34-0.57; P = .0002-.0003). Predicted probabilities of 0.64 or less had a negative predictive value of 100% for excluding mortality not resulting from closed head injuries. Conclusion A logistic regression model incorporating semiautomated hematoma volume segmentation produced objective probability estimates of major arterial injury. Hematoma volumes correlated with 48-hour transfusion requirement, and low predicted probabilities excluded mortality from causes other than closed head injury. © RSNA, 2018 Online supplemental material is available for this article.