BACKGROUND:The impact of intraoperative ventilation on postoperative pulmonary complications is not defined. The authors aimed at determining the effectiveness of protective mechanical ventilation ...during open abdominal surgery on a modified Clinical Pulmonary Infection Score as primary outcome and postoperative pulmonary function.
METHODS:Prospective randomized, open-label, clinical trial performed in 56 patients scheduled to undergo elective open abdominal surgery lasting more than 2 h. Patients were assigned by envelopes to mechanical ventilation with tidal volume of 9 ml/kg ideal body weight and zero-positive end-expiratory pressure (standard ventilation strategy) or tidal volumes of 7 ml/kg ideal body weight, 10 cm H2O positive end-expiratory pressure, and recruitment maneuvers (protective ventilation strategy). Modified Clinical Pulmonary Infection Score, gas exchange, and pulmonary functional tests were measured preoperatively, as well as at days 1, 3, and 5 after surgery.
RESULTS:Patients ventilated protectively showed better pulmonary functional tests up to day 5, fewer alterations on chest x-ray up to day 3 and higher arterial oxygenation in air at days 1, 3, and 5 (mmHg; mean ± SD)77.1 ± 13.0 versus 64.9 ± 11.3 (P = 0.0006), 80.5 ± 10.1 versus 69.7 ± 9.3 (P = 0.0002), and 82.1 ± 10.7 versus 78.5 ± 21.7 (P = 0.44) respectively. The modified Clinical Pulmonary Infection Score was lower in the protective ventilation strategy at days 1 and 3. The percentage of patients in hospital at day 28 after surgery was not different between groups (7 vs. 15% respectively, P = 0.42).
CONCLUSION:A protective ventilation strategy during abdominal surgery lasting more than 2 h improved respiratory function and reduced the modified Clinical Pulmonary Infection Score without affecting length of hospital stay.
Source localisation and real-time dose verification are at the forefront of medical research in brachytherapy, an oncological radiotherapy procedure based on radioactive sources implanted in the ...patient body. The ORIGIN project aims to respond to this medical community's need by targeting the development of a multi-point dose mapping system based on fibre sensors integrating a small volume of scintillating material into the tip and interfaced with silicon photomultipliers operated in counting mode. In this paper, a novel method for the selection of the optimal silicon photomultipliers to be used is presented, as well as a laboratory characterisation based on dosimetric figures of merit. More specifically, a technique exploiting the optical cross-talk to maintain the detector linearity in high-rate conditions is demonstrated. Lastly, it is shown that the ORIGIN system complies with the TG43-U1 protocol in high and low dose rate pre-clinical trials with actual brachytherapy sources, an essential requirement for assessing the proposed system as a dosimeter and comparing the performance of the system prototype against the ORIGIN project specifications.
Purpose
To compare the diagnostic performance of cone-beam CT (CBCT)-guided and CT fluoroscopy (fluoro-CT)-guided technique for transthoracic needle biopsy (TNB) of lung nodules.
Methods
The hospital ...records of 319 consecutive patients undergoing 324 TNBs of lung nodules in a single radiology unit in 2009–2013 were retrospectively evaluated. The newly introduced CBCT technology was used to biopsy 123 nodules; 201 nodules were biopsied by conventional fluoro-CT-guided technique. We assessed the performance of the two biopsy systems for diagnosis of malignancy and the radiation exposure.
Results
Nodules biopsied by CBCT-guided and by fluoro-CT-guided technique had similar characteristics: size, 20 ± 6.5 mm (mean ± standard deviation) vs. 20 ± 6.8 mm (
p
= 0.845); depth from pleura, 15 ± 15 mm vs. 15 ± 16 mm (
p
= 0.595); malignant, 60 % vs. 66 % (
p
= 0.378). After a learning period, the newly introduced CBCT-guided biopsy system and the conventional fluoro-CT-guided system showed similar sensitivity (95 % and 92 %), specificity (100 % and 100 %), accuracy for diagnosis of malignancy (96 % and 94 %), and delivered non-significantly different median effective doses 11.1 mSv (95 % CI 8.9–16.0) vs. 14.5 mSv (95 % CI 9.5–18.1);
p
= 0.330.
Conclusion
The CBCT-guided and fluoro-CT-guided systems for lung nodule biopsy are similar in terms of diagnostic performance and effective dose, and may be alternatively used to optimize the available technological resources.
Key Points
•
CBCT-guided and fluoro-CT-guided lung nodule biopsy provided high and similar diagnostic accuracy.
•
Effective dose from CBCT-guided and fluoro-CT-guided lung nodule biopsy was similar.
•
To optimize resources, CBCT-guided lung nodule biopsy may be an alternative to fluoro-CT-guided.
Purpose
To assess whether a correlation between the calcaneal pronation angle and the presence of internal plantar arch overload signs (such as upper-medial spring ligament lesion, posterior tibial ...tendon tenosynovitis, etc.) could lead to a better understanding of coxa pedis pathology.
Material and methods
One hundred ankle MRIs of consecutive patients were retrospectively reviewed measuring the calcaneal pronation angle and either the presence or absence of internal plantar arch overload signs. Next, the association of overload signs with increasing pronation angle was evaluated to establish a cut-off point beyond which coxa pedis pathology could be defined.
Results
The tibial-calcaneal angle values in patients with and without effusion proved to be significantly different (
p
< 0.0001). The tibial-calcaneal angle values in patients with and without oedema also demonstrated a significant difference (
p
< 0.0056). Regarding posterior tibial tendon, a significant difference was found between the two groups (
p
< 0.0001). For plantar fascia enthesopathy, the result was borderline significant (
p
< 0.054). A linear correlation was found between the value of pronation angle and the extent of spring ligament injury (
p
< 0.0001). In contrast, no correlation with age was found.
Conclusion
In conclusion, the literature associates medial longitudinal plantar arch overload with posterior tibial tendinopathy and spring ligament complex injuries. Our data show that both injuries are highly correlated with increased calcaneal pronation angle, which could be considered a predictive sign of internal plantar arch overload, prior to the development of the associated signs.
Critically ill patients admitted to intensive care unit (ICU) may suffer from different painful stimuli, but the assessment of pain is difficult because most of them are almost sedated and unable to ...self-report. Thus, it is important to optimize evaluation of pain in these patients. The main aim of this study was to compare two commonly used scales for pain evaluation: Critical Care Pain Observation Tool (CPOT) and Behavioral Pain Scale (BPS), in both conscious and unconscious patients. Secondary aims were (1) to identifying the most relevant parameters to determine pain scales changes during nursing procedures, (2) to compare both pain scales with visual analog scale (VAS), and (3) to identify the best combination of scales for evaluation of pain in patients unable to communicate.
In this observational study, 101 patients were evaluated for a total of 303 consecutive observations during 3 days after ICU admission. Measurements with both scales were obtained 1 min before, during, and 20 min after nursing procedures in both conscious (n.41) and unconscious (n.60) patients; furthermore, VAS was recorded when possible in conscious patients only. We calculated criterion and discriminant validity to both scales (Wilcoxon, Spearman rank correlation coefficients). The accuracy of individual scales was evaluated. The sensitivity and the specificity of CPOT and BPS scores were assessed. Kappa coefficients with the quadratic weight were used to reflect agreement between the two scales, and we calculated the effect size to identify the strength of a phenomenon.
CPOT and BPS showed a good criterion and discriminant validity (
< 0.0001). BPS was found to be more specific (91.7 %) than CPOT (70.8 %), but less sensitive (BPS 62.7 %, CPOT 76.5 %). COPT and BPS scores were significantly correlated with VAS (
< 0.0001). The combination of BPS and CPOT resulted in better sensitivity 80.4 %. Facial expression was the main parameter to determine pain scales changes effect size = 1.4.
In critically ill mechanically ventilated patients, both CPOT and BPS can be used for assessment of pain intensity with different sensitivity and specificity. The combination of both BPS and CPOT might result in improved accuracy to detect pain compared to scales alone.
NCT01669486.
Purpose
In an attempt to evaluate the exposure level of magnetic resonance imaging (MRI) workers to static magnetic fields, the isotropic magnetic flux density values were integrated over time to ...produce the cumulative exposure. To protect occupational staff a further precautionary step is proposed by introducing a weighting function incorporating the limits imposed by the Italian legislation. The results obtained should be reported, at the end of each working day, on a special dose card, in order to record each worker’s exposure to the static magnetic field. Moreover, this dose card could be an important tool if long-term effects occur because it provides a complete history of the occupational exposure in an MRI site.
Materials and methods
To conduct measurements, three Hall-sensor probes were used. The consistency of experimental data, tools and methodologies used was evaluated by performing the Kruskal–Wallis test. Finally, the weighted magnitude of the magnetic flux density was integrated over time to obtain global exposure.
Results
Measurements were performed on different MRI scanners ranging from 0.25 up to 3.0 T. The results obtained were compared with the 200 mT·h, which represents the upper limit of the Italian regulation. In no case was the 200 mT·h per day exposure exceeded: however, when the strength of the magnetic field was >200 mT the weighted function overestimated the exposure, so that it represents a highly precautionary measure taking into account possible acute and long-term effects. In addition, from the data recorded during patient positioning operations by MRI staff the d
B
/d
t
curve was obtained.
Conclusions
The areas obtained from the integral of the weighted static magnetic field strength over time can be indicative of the global exposure of the occupational staff. These values should be reported on a special dose card that could be considered as an important tool if long-term effects occur because it provides a complete history of the occupational exposure in an MRI site.
The goals of the study described here were to evaluate the feasibility and reproducibility of measuring spleen stiffness (SS) using point shear wave elastography in a series of cirrhotic patients and ...to investigate whether SS, liver stiffness (LS) and other non-invasive parameters are correlated with the presence of esophagogastric varices (EVs). Fifty-four cirrhotic patients with low-grade EVs or without EVs at esophago-gastro-duodenoscopy were enrolled. They underwent abdominal ultrasound and Doppler ultrasound of hepatic vessels simultaneously with p-SWE of the liver and spleen. In 42 patients, the accuracy of LS and SS, as well as of platelet count and spleen longitudinal diameter, in predicting the presence of EVs was evaluated. The technical success was 90.74% for LS (49/54 patients) and 77.78% for SS (42/54 patients). Inter-observer agreement for SS measurement was high. Both LS and SS correlated with esophago-gastro-duodenoscopy: LS had the highest accuracy in predicting the presence of EVs (area under the receiver operating characteristic curve AUROC = 0.913); SS had the lowest accuracy (AUROC = 0.675); platelet count and spleen diameter had intermediate accuracy (AUROC = 0.731 and 0.729, respectively). SS did not have an advantage over LS in predicting low-grade EVs and cannot be proposed as a useful tool in the diagnostic process of cirrhotic patients who require screening esophago-gastro-duodenoscopy.
The work describes a method to quantitatively evaluate spatial resolution in B-mode quality control images as radial modulation transfer function (MTF). The method is easy to use in in-field quality ...assurance programs in clinical institutions, as it is fast and can be performed with the help of phantoms that are already used for routine quality control. It uses a round insert with different echogenic characteristics compared with the phantom background. The method was automated with a MATLAB® routine, which can be run in full automatic mode or with a grade of interaction by the user, as is sometimes necessary with low-quality images. Radial MTF was evaluated for several ultrasound (US) images produced with different clinical US scanners from various vendors and equipped with different types of transducers (linear, convex, sector, vector) working at various frequencies (from 2 to 14 MHz) and with different modalities. It was also evaluated on various computed tomography (CT) images including round inserts. This was done to compare these results with the MTF calculated from the same images using the well-known method from the point spread function (PSF) of a high-contrast bead. Our radial MTF method, adapted to the specific characteristics of US images, was found to be reasonably robust and in line with other methods commonly used for USs (e.g., the pin method, which has repeatability issues) and in other fields, such as X-ray CT.
Purpose
To evaluate whether the addition of gadolinium-enhanced MRI and diffusion-weighted imaging (DWI) improves T2 sequence performance for the diagnosis of local recurrence (LR) from rectal cancer ...and to assess which approach is better at formulating this diagnosis among readers with different experience.
Methods
Forty-three patients with suspected LR underwent pelvic MRI with T2 weighted (T2) sequences, gadolinium fat-suppressed T1 weighted sequences (post-contrast T1), and DWI sequences. Three readers (expert: G, intermediate: E, resident: V) scored the likelihood of LR on T2, T2 + post-contrast T1, T2 + DWI, and T2 + post-contrast T1 + DWI.
Results
In total, 18/43 patients had LR; on T2 images, the expert reader achieved an area under the ROC curve (AUC) of 0.916, sensitivity of 88.9%, and specificity of 76%; the intermediate reader achieved values of 0.890, 88.9%, and 48%, respectively, and the resident achieved values of 0.852, 88.9%, and 48%, respectively. DWI significantly improved the AUC value for the expert radiologist by up to 0.999 (
p
= 0.04), while post-contrast T1 significantly improved the AUC for the resident by up to 0.950 (
p
= 0.04). For the intermediate reader, both the T2 + DWI AUC and T2 + post-contrast T1 AUC were better than the T2 AUC (0.976 and 0.980, respectively), but with no statistically significant difference. No statistically significant difference was achieved by any of the three readers by comparing either the T2 + DWI AUCs to the T2 + post-contrast T1 AUCs or the AUCs of the two pairs of sequences to those of the combined three sequences.
Furthermore, using the T2 sequences alone, all of the readers achieved a fair number of “equivocal” cases: they decreased with the addition of either DWI or post-contrast T1 sequences and, for the two less experienced readers, they decreased even more with the three combined sequences.
Conclusions
Both DWI and T1 post-contrast MRI increased diagnostic performance for LR diagnosis compared to T2; however, no significant difference was observed by comparing the two different pairs of sequences with the three combined sequences.
Background:
Ultrasonography-guided alcohol injection (USGAI) of Morton’s neuroma represents an alternative to operative treatment. Nonetheless, the literature only reports few small studies ...evaluating the effectiveness of the treatment. The aim of the present retrospective study was to assess the effectiveness of USGAI to treat Morton’s neuroma in 508 patients at 2 medical centers.
Methods:
Between January 2001 and January 2012, 508 patients with 540 Morton’s neuroma had USGAI for Morton’s neuroma. Only second and third web-space neuromas were included in this study.
Results:
A mean number of 3.0 (range, 1 to 4) injections were performed for each neuroma. Mean local inflammatory reaction was 0.7 (range, 0 to 2). There were no other local or systemic complications. The overall mean pre-USGAI VAS score was 8.7 (range, 6 to 10), while the post-USGAI VAS score at 1 year was 3.6 (range, 0 to 9). The delta VAS between the pre- and post-USGAI was statistically significant (P < .0001). At 1-year follow-up 74.5% of patients were satisfied with the procedure.
Conclusion:
USGAI produced encouraging results in over 500 patients affected by Morton’s neuroma. The procedure proved to be safe in all patients.
Level of Evidence:
Level IV, retrospective case series.
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