Effects of Endotracheal Epinephrine on Pharmacokinetics and Survival in a Swine Pediatric Cardiac Arrest Model.

OBJECTIVES: The aim of this study was to compare the endotracheal tube (ET) and intravenous (IV) administration of epinephrine relative to concentration maximum, time to maximum concentration, mean concentration over time (MC), area under the curve, odds, and time to return of spontaneous circulation (ROSC) in a normovolemic pediatric cardiac arrest model. METHODS: Male swine weighing 24-37 kg were assigned to 4 groups: ET (n = 8), IV (n = 7), cardiopulmonary resuscitation (CPR) + defibrillation (CPR + Defib) (n = 5), and CPR only (n = 3). Swine were placed arrest for 2 minutes, and then CPR was initiated for 2 minutes. Epinephrine (0.1 mg/kg) for the ET group or 0.01 mg/kg for the IV was administered every 4 minutes or until ROSC. Defibrillation started at 3 minutes and continued every 2 minutes for 30 minutes or until ROSC for all groups except the CPR-only group. Blood samples were collected over a period of 5 minutes. RESULTS: The MC of plasma epinephrine for the IV group was significantly higher at the 30- and 60-second time points (P = 0.001). The ET group had a significantly higher MC of epinephrine at the 180- and 240-second time points (P < 0.05). The concentration maximum of plasma epinephrine was significantly lower for the ET group (195 ± 32 ng/mL) than for the IV group (428 ± 38 ng/mL) (P = 0.01). The time to maximum concentration was significantly longer for the ET group (145 ± 26 seconds) than for the IV group (42 ± 16 seconds) (P = 0.01). No significant difference existed in area under the curve between the 2 groups (P = 0.62). The odds of ROSC were 7.7 times greater for the ET versus IV group. Time to ROSC was not significantly different among the IV, ET, and CPR + Defib groups (P = 0.31). CONCLUSIONS: Based on the results of this study, the ET route of administration should be considered a first-line intervention.

MB-DECTNet: a model-based unrolling network for accurate 3D dual-energy CT reconstruction from clinically acquired helical scans.

Objective.Over the past several decades, dual-energy CT (DECT) imaging has seen significant advancements due to its ability to distinguish between materials. DECT statistical iterative reconstruction (SIR) has exhibited potential for noise reduction and enhanced accuracy. However, its slow convergence and substantial computational demands render the elapsed time for 3D DECT SIR often clinically unacceptable. The objective of this study is to accelerate 3D DECT SIR while maintaining subpercentage or near-subpercentage accuracy.Approach.We incorporate DECT SIR into a deep-learning model-based unrolling network for 3D DECT reconstruction (MB-DECTNet), which can be trained end-to-end. This deep learning-based approach is designed to learn shortcuts between initial conditions and the stationary points of iterative algorithms while preserving the unbiased estimation property of model-based algorithms. MB-DECTNet comprises multiple stacked update blocks, each containing a data consistency layer (DC) and a spatial mixer layer, with the DC layer functioning as a one-step update from any traditional iterative algorithm.Main results.The quantitative results indicate that our proposed MB-DECTNet surpasses both the traditional image-domain technique (MB-DECTNet reduces average bias by a factor of 10) and a pure deep learning method (MB-DECTNet reduces average bias by a factor of 8.8), offering the potential for accurate attenuation coefficient estimation, akin to traditional statistical algorithms, but with considerably reduced computational costs. This approach achieves 0.13% bias and 1.92% mean absolute error and reconstructs a full image of a head in less than 12 min. Additionally, we show that the MB-DECTNet output can serve as an initializer for DECT SIR, leading to further improvements in results.Significance.This study presents a model-based deep unrolling network for accurate 3D DECT reconstruction, achieving subpercentage error in estimating virtual monoenergetic images for a full head at 60 and 150 keV in 30 min, representing a 40-fold speedup compared to traditional approaches. These findings have significant implications for accelerating DECT SIR and making it more clinically feasible.

Frequency of technical success of ultrasound-guided arthrogram injections in children.

BACKGROUND: MR arthrography is an essential diagnostic tool to assess and guide management of labral, ligamentous, fibrocartilaginous, and capsular abnormalities in children. While fluoroscopy is traditionally used for intra-articular contrast administration, ultrasound offers advantages of portability and lack of ionizing radiation exposure for both the patient and proceduralist. OBJECTIVE: The purpose of this retrospective study is to quantify technical success and frequency of complications of ultrasound-guided arthrogram injections at our institution. MATERIALS AND METHODS: This retrospective analysis investigates the results of 217 ultrasound-guided arthrograms of the shoulder, elbow, and hip in patients aged 5-18 years. Successful injection of contrast into the target joint, clinical indication for MR arthrography, and complications were reviewed. RESULTS: Accurate ultrasound-guided intra-articular administration of contrast into the target joint was successful for 100% of shoulder cases (90/90), 97% of elbow cases (77/79), and 98% of hip cases (47/48). Leak of contrast outside the target joint occurred in 1.4% (3/217) of cases. No major side effects including excessive bleeding, paresthesia, allergic reactions, or infection occurred during or after the procedure. Additionally, no major vessel, nerve, or tendon complications were observed on MR images. CONCLUSION: Ultrasound guidance is a reliable, effective, and safe approach to arthrography in children.

Motion-compensated scheme for sequential scanned statistical iterative dual-energy CT reconstruction.

Objective.Dual-energy computed tomography (DECT) has been widely used to reconstruct numerous types of images due its ability to better discriminate tissue properties. Sequential scanning is a popular dual-energy data acquisition method as it requires no specialized hardware. However, patient motion between two sequential scans may lead to severe motion artifacts in DECT statistical iterative reconstructions (SIR) images. The objective is to reduce the motion artifacts in such reconstructions.Approach.We propose a motion-compensation scheme that incorporates a deformation vector field into any DECT SIR. The deformation vector field is estimated via the multi-modality symmetric deformable registration method. The precalculated registration mapping and its inverse or adjoint are then embedded into each iteration of the iterative DECT algorithm.Main results.Results from a simulated and clinical case show that the proposed framework is capable of reducing motion artifacts in DECT SIRs. Percentage mean square errors in regions of interest in the simulated and clinical cases were reduced from 4.6% to 0.5% and 6.8% to 0.8%, respectively. A perturbation analysis was then performed to determine errors in approximating the continuous deformation by using the deformation field and interpolation. Our findings show that errors in our method are mostly propagated through the target image and amplified by the inverse matrix of the combination of the Fisher information and Hessian of the penalty term.Significance.We have proposed a novel motion-compensation scheme to incorporate a 3D registration method into the joint statistical iterative DECT algorithm in order to reduce motion artifacts caused by inter-scan motion, and successfully demonstrate that interscan motion corrections can be integrated into the DECT SIR process, enabling accurate imaging of radiological quantities on conventional SECT scanners, without significant loss of either computational efficiency or accuracy.

The value of routine radiographic follow up in the postoperative management of canine medial patellar luxation.

OBJECTIVE: To determine the influence of radiographic examination on the recommendations made at the time of planned re-evaluation of dogs after medial patellar luxation (MPL) surgery. STUDY DESIGN: Retrospective multi-institutional case series. ANIMALS: Client-owned dogs (N = 825) that underwent MPL surgery. METHODS: Records of 10 referral institutions were searched for dogs that had been treated surgically for unilateral MPL and underwent a planned follow-up visit, including radiographs. The frequency of, and reasons for, changes in further recovery recommendations were investigated. RESULTS: Follow up was performed at a median of 6 (range, 4-20) weeks postoperatively. Isolated radiographic abnormalities were identified in 3.3% (27/825) of dogs following MPL surgery and led to a change in recommendations in 3% (13/432) of dogs that were presented without owner or clinician concerns. Lameness, administration of analgesia at follow up, and history of unplanned visits prior to routine re-examination were associated with a change in postoperative plan (P < .001). In the absence of owner and clinician concerns, the odds of having a change in convalescence plans were not different, whether or not isolated radiographic abnormalities were present (P = .641). CONCLUSION: Routine radiographs at follow up did not influence postoperative management of most dogs after MPL surgery in the absence of abnormalities on clinical history or orthopedic examination. CLINICAL SIGNIFICANCE: Dogs that were presented for routine follow up after unilateral MPL surgery without owner concerns, lameness, analgesic treatment or a history of unplanned visits, and for which examination by a surgical specialist was unremarkable, were unlikely to benefit from radiographs.

Standardized Reporting on the Preoperative CT Assessment of Potential Living Renal Transplant Donors: Can We Create a Universal Report Standard to Meet the Needs of Transplant Urologists?

Purpose: Determine whether standardized template reporting for the preoperative assessment of potential living renal transplant donors improves the comprehensiveness of radiology reports to meet the needs of urologists performing renal transplants. Methods: Urologist and radiologist stakeholders from renal transplant centres in our province ratified a standardized reporting template for evaluation of potential renal donors. Three centres (A, B, and C) were designated "intervention" groups. Centre D was the control group, given employment of a site-specific standardized template prior to study commencement. Up to 100 consecutive CT scan reports per centre, pre- and post-implementation of standardized reporting, were evaluated for reporting specific outcome measures. Results: At baseline, all intervention groups demonstrated poor reporting of urologist-desired outcome measures. Centre A discussed 5/13 variables (38%), Centre B discussed 6/13 variables (46%), and Centre C only discussed 1/13 variables (8%) with ≥90% reliability. The control group exhibited consistent reporting, with 11/13 variables (85%) reported at ≥90% reliability. All institutions in the intervention group exhibited excellent compliance to structured reporting post-template implementation (Centres A = 95%, B = 100%, and C = 77%, respectively). Additionally, all intervention centres demonstrated a significant improvement in the comprehensiveness of reports post-template implementation, with statistically significant increases in the reporting of all variables under-reported at baseline (P > .01). Conclusion: Standardized templates across our province for CT scans of potential renal donors promote completeness of reports. Radiologists can reliably provide our surgical colleagues with needed preoperative anatomy and incidental findings, helping to determine suitable transplant donors and reduce potential complications associated with organ retrieval.

Beyond GalNAc! Drug delivery systems comprising complex oligosaccharides for targeted use of nucleic acid therapeutics.

Nucleic Acid Therapeutics (NATs) are establishing a leading role for the management and treatment of genetic diseases following FDA approval of nusinersen, patisiran, and givosiran in the last 5 years, the breakthrough of milasen, with more approvals undoubtedly on the way. Givosiran takes advantage of the known interaction between the hepatocyte specific asialoglycoprotein receptor (ASGPR) and N-acetyl galactosamine (GalNAc) ligands to deliver a therapeutic effect, underscoring the value of targeting moieties. In this review, we explore the history of GalNAc as a ligand, and the paradigm it has set for the delivery of NATs through precise targeting to the liver, overcoming common hindrances faced with this type of therapy. We describe various complex oligosaccharides (OSs) and ask what others could be used to target receptors for NAT delivery and the opportunities awaiting exploration of this chemical space.

How should we interpret lactate in labour? A reference study.

OBJECTIVE: To investigate maternal lactate concentrations in labour and the puerperium. DESIGN: Reference study. SETTING: Tertiary obstetric unit. POPULATION: 1279 pregnant women with good perinatal outcomes at term. METHODS: Electronic patient records were searched for women who had lactate measured on the day of delivery or in the following 24 hours, but who were subsequently found to have a very low likelihood of sepsis, based on their outcomes. MAIN OUTCOME MEASURES: The normative distribution of lactate and C-reactive protein (CRP), differences according to the mode of birth, and the proportion of results above the commonly used cut-offs (≥2 and ≥4 mmol/l). RESULTS: Lactate varied between 0.4-5.4 mmol/l (median 1.8 mmol/l, interquartile range [IQR] 1.3-2.5). It was higher in women who had vaginal deliveries than caesarean sections (median 1.9 vs. 1.6 mmol/l, pdiff  < 0.001), demonstrating the association with labour (particularly active pushing in the second stage). In contrast, CRP was more elevated in women who had caesarean sections (median 71.8 mg/l) than those who had vaginal deliveries (33.4 mg/l, pdiff  < 0.001). In total, 40.8% had a lactate ≥2 mmol/l, but 95.3% were <4 mmol/l. CONCLUSIONS: Lactate in labour and the puerperium is commonly elevated above the levels expected in healthy pregnant or non-pregnant women. There is a paucity of evidence to support using lactate or CRP to make decisions about antibiotics around the time of delivery but, as lactate is rarely higher than 4 mmol/l, this upper limit may still represent a useful severity marker for the investigation and management of sepsis in labour.

Classification System for Inferior Vena Cava (IVC) Appearance Following Percutaneous IVC Filter Retrieval.

OBJECTIVE: There is no classification system for describing inferior vena cava (IVC) injuries. The objective of this study was to develop a standardized grading system for venographic appearance of the IVC following percutaneous IVC filter retrieval. METHODS: A classification system for the appearance of the IVC on cavograms following percutaneous IVC filter removal was developed consisting of two grading elements; luminal characteristics and extravasation. Luminal narrowing from 0% up to 50% from any cause is grade 1; narrowing between 50 and 99% is grade 2; occlusion is grade 3; and avulsion is grade 4. Absence of extravasation is grade A, contained extravasation is grade B, and free extravasation is grade C. This system was then applied retrospectively to pre- and post-IVC filter retrieval cavograms performed at a single institution from October 2004 through February 2019. RESULTS: 546 retrieval attempts were identified with 509 (93.2%) filters successfully retrieved. 449 cases (88.2%) had both pre-retrieval and post-retrieval imaging appropriate for application of the proposed classification system. Inter-rater reliability was 0.972 for luminal characteristics, 0.967 for extravasation, and 0.969 overall. Consensus grading demonstrated a distribution of 97.3% grade 1, 1.3% grade 2, 1.3% grade 3, and 0.0% grade 4 for post-retrieval luminal characteristics. For extravasation classification, 96.4% of the cases were classified as grade A, 2.7% grade B, and 0.9% grade C. CONCLUSION: A classification system was developed for describing IVC appearance after IVC filter retrieval, and retrospectively validated using a single center dataset.

Towards subpercentage uncertainty proton stopping-power mapping via dual-energy CT: Direct experimental validation and uncertainty analysis of a statistical iterative image reconstruction method.

PURPOSE: To assess the potential of a joint dual-energy computerized tomography (CT) reconstruction process (statistical image reconstruction method built on a basis vector model (JSIR-BVM)) implemented on a 16-slice commercial CT scanner to measure high spatial resolution stopping-power ratio (SPR) maps with uncertainties of less than 1%. METHODS: JSIR-BVM was used to reconstruct images of effective electron density and mean excitation energy from dual-energy CT (DECT) sinograms for 10 high-purity samples of known density and atomic composition inserted into head and body phantoms. The measured DECT data consisted of 90 and 140 kVp axial sinograms serially acquired on a Philips Brilliance Big Bore CT scanner without beam-hardening corrections. The corresponding SPRs were subsequently measured directly via ion chamber measurements on a MEVION S250 superconducting synchrocyclotron and evaluated theoretically from the known sample compositions and densities. Deviations of JSIR-BVM SPR values from their theoretically calculated and directly measured ground-truth values were evaluated for our JSIR-BVM method and our implementation of the Hünemohr-Saito (H-S) DECT image-domain decomposition technique for SPR imaging. A thorough uncertainty analysis was then performed for five different scenarios (comparison of JSIR-BVM stopping-power ratio/stopping power (SPR/SP) to International Commission on Radiation Measurements and Units benchmarks; comparison of JSIR-BVM SPR to measured benchmarks; and uncertainties in JSIR-BVM SPR/SP maps for patients of unknown composition) per the Joint Committee for Guides in Metrology and the Guide to Expression of Uncertainty in Measurement, including the impact of uncertainties in measured photon spectra, sample composition and density, photon cross section and I-value models, and random measurement uncertainty. Estimated SPR uncertainty for three main tissue groups in patients of unknown composition and the weighted proportion of each tissue type for three proton treatment sites were then used to derive a composite range uncertainty for our method. RESULTS: Mean JSIR-BVM SPR estimates deviated by less than 1% from their theoretical and directly measured ground-truth values for most inserts and phantom geometries except for high-density Delrin and Teflon samples with SPR error relative to proton measurements of 1.1% and -1.0% (head phantom) and 1.1% and -1.1% (body phantom). The overall root-mean-square (RMS) deviations over all samples were 0.39% and 0.52% (head phantom) and 0.43% and 0.57% (body phantom) relative to theoretical and directly measured ground-truth SPRs, respectively. The corresponding RMS (maximum) errors for the image-domain decomposition method were 2.68% and 2.73% (4.68% and 4.99%) for the head phantom and 0.71% and 0.87% (1.37% and 1.66%) for the body phantom. Compared to H-S SPR maps, JSIR-BVM yielded 30% sharper and twofold sharper images for soft tissues and bone-like surrogates, respectively, while reducing noise by factors of 6 and 3, respectively. The uncertainty (coverage factor k = 1) of the DECT-to-benchmark values comparison ranged from 0.5% to 1.5% and is dominated by scanning-beam photon-spectra uncertainties. An analysis of the SPR uncertainty for patients of unknown composition showed a JSIR-BVM uncertainty of 0.65%, 1.21%, and 0.77% for soft-, lung-, and bony-tissue groups which led to a composite range uncertainty of 0.6-0.9%. CONCLUSIONS: Observed JSIR-BVM SPR estimation errors were all less than 50% of the estimated k = 1 total uncertainty of our benchmarking experiment, demonstrating that JSIR-BVM high spatial resolution, low-noise SPR mapping is feasible and is robust to variations in the geometry of the scanned object. In contrast, the much larger H-S SPR estimation errors are dominated by imaging noise and residual beam-hardening artifacts. While the uncertainties characteristic of our current JSIR-BVM implementation can be as large as 1.5%, achieving < 1% total uncertainty is feasible by improving the accuracy of scanner-specific scatter-profile and photon-spectrum estimates. With its robustness to beam-hardening artifact, image noise, and variations in phantom size and geometry, JSIR-BVM has the potential to achieve high spatial-resolution SPR mapping with subpercentage accuracy and estimated uncertainty in the clinical setting.

Endotracheal Administered Epinephrine Is Effective in Return of Spontaneous Circulation Within a Pediatric Swine Hypovolemic Cardiac Arrest Model.

OBJECTIVE: Early administration of epinephrine increases the incidence of return of spontaneous circulation (ROSC) and improves outcomes among pediatric cardiac arrest victims. Rapid endotracheal (ET) intubation can facilitate early administration of epinephrine to pediatric victims. To date, no studies have evaluated the use of ET epinephrine in a pediatric hypovolemic cardiac arrest model to determine the incidence of ROSC. METHODS: This prospective, experimental study evaluated the pharmacokinetics and/or incidence of ROSC following ET administered epinephrine and compared it to these experimental groups: intravenous (IV) administered epinephrine, cardiopulmonary resuscitation only (CPR), and CPR + defibrillation (CPR + Defib). RESULTS: Endotracheal administered epinephrine, at the Pediatric Advanced Life Support (PALS) recommended dose, was not significantly different than IV administered epinephrine in maximum plasma concentrations, time to maximum plasma concentration, area under the curve, or ROSC, or mean plasma concentrations at various time points (P > 0.05). The odds of ROSC in the ET group were 2.4 times greater than the IV group. The onset to ROSC in the ET group was significantly shorter than the IV group (P < 0.0001). CONCLUSIONS: These data support that ET epinephrine administration remains an alternative to IV administered epinephrine and faster at restoring ROSC among pediatric hypovolemic cardiac arrest victims in the acute setting when an endotracheal tube is present. Although further research is required to determine long-term outcomes of high-dose ET epinephrine administration, these data reinforce the therapeutic potential of ET administration of epinephrine to restore ROSC before IV access.

Humerus Intraosseous and Intravenous Administration of Epinephrine in Normovolemic and Hypovolemic Cardiac Arrest Porcine Models.

OBJECTIVE: The aim of this study was to compare area under the curve (AUC), frequency, and odds of return of spontaneous circulation (ROSC) when epinephrine was administered in hypovolemic and normovolemic cardiac arrest models. METHODS: Twenty-eight adult swine were randomly assigned to 4 groups: HIO Normovolemia Group (HIONG); HIO Hypovolemia Group (HIOHG); IV Normovolemia (IVNG); and IV Hypovolemia Group (IVHG). Swine were anesthetized. The HIOH and IVH subjects were exsanguinated 35% of their blood volume. Each was placed into arrest. After 2 minutes, cardiopulmonary resuscitation was initiated. After another 2 minutes, 1 mg of epinephrine was given by IV or HIO routes; blood samples were collected over 5 minutes and analyzed by high-performance liquid chromatography. Subjects were defibrillated every 2 minutes. RESULTS: The AUC in the HIOHG was significantly less than both the HIONG (p = 0.047) and IVHG (p = 0.021). There were no other significant differences in the groups relative to AUC (p > 0.05). HIONG had a significantly higher occurrence of ROSC compared to HIOHG (p = 0.018) and IVH (p =0.018) but no other significant differences (p > 0.05). The odds of ROSC were 19.2 times greater for HIONG compared to the HIOHG. CONCLUSION: The study strongly supports the effectiveness of HIO administration of epinephrine and should be considered as a first-line intervention for patients in cardiac arrest related to normovolemic causes. However, our findings do not support using HIO access for epinephrine administration for patients in cardiac arrest related to hypovolemic reasons.

Tibial Intraosseous Administration of Epinephrine Is Effective in Restoring Return of Spontaneous Circulation in a Pediatric Normovolemic But Not Hypovolemic Cardiac Arrest Model.

OBJECTIVE: We compared the efficacy of tibial intraosseous (TIO) administration of epinephrine in a pediatric normovolemic versus hypovolemic cardiac arrest model to determine the incidence of return of spontaneous circulation (ROSC) and plasma epinephrine concentrations over time. METHODS: This experimental study evaluated the pharmacokinetics of epinephrine and/or incidence of ROSC after TIO administration in either a normovolemic or hypovolemic pediatric swine model. RESULTS: All subjects in the TIO normovolemia cardiac arrest group experienced ROSC after TIO administration of epinephrine. In contrast, subjects experiencing hypovolemia and cardiac arrest were significantly less likely to experience ROSC when epinephrine was administered TIO versus intravenous (TIO hypovolemia: 14% [1/7] vs IV hypovolemia: 71% [5/7]; P = 0.031). The TIO hypovolemia group exhibited significantly lower plasma epinephrine concentrations versus IV hypovolemia at 60, 90, 120, and 150 seconds (P < 0.05). Although the maximum concentration of plasma epinephrine was similar, the TIO hypovolemia group exhibited significantly slower time to maximum concentration times versus TIO normovolemia subjects (P = 0.004). CONCLUSIONS: Tibial intraosseous administration of epinephrine reliably facilitated ROSC among normovolemic cardiac arrest pediatric patients, which is consistent with published reports. However, TIO administration of epinephrine was ineffective in restoring ROSC among subjects experiencing hypovolemia and cardiac arrest. Tibial intraosseous-administered epinephrine during hypovolemia and cardiac arrest may have resulted in a potential sequestration of epinephrine in the tibia. Central or peripheral intravascular access attempts should not be abandoned after successful TIO placement in the resuscitation of patients experiencing concurrent hypovolemia and cardiac arrest.

Performance comparison of a dedicated total breast PET system with a clinical whole-body PET system: a simulation study.

This paper presents a novel PET geometry for breast cancer imaging. The scanner consists of a 'stadium' (a rectangle with two semi-circles on opposite sides) shaped ring, along with anterior and posterior panels to provide high sensitivity and high spatial resolution for an imaging field-of-view (FOV) that include both breasts, mediastinum and axilla. We simulated this total-breast PET system using GATE and reconstructed the coincidence events using a GPU-based list-mode image reconstruction implementing maximum likelihood expectation-maximization (ML-EM) algorithm. The rear-panel is made up of a single layer of LSO crystals (3.2 × 3.2 × 20 mm3each), while the 'stadium'-shaped elongated ring and the anterior panel are made with dual-layered LSO crystals (1.6 × 1.6 × 6 mm3each). The energy resolution and coincidence resolving time of all detectors are assumed to be 12% and 250 ps full-width-at-half-maximum, respectively. Various sized simulated lesions (4, 5, 6 mm) having 4:1, 5:1, and 6:1 lesion-to-background radioactivity concentration ratios, mimicking different biological uptakes, were strategically located throughout a volumetric torso phantom. We compared system sensitivity and lesion detectability of the dedicated total-breast PET system to a state-of-the-art clinical whole-body PET scanner. The mean sensitivity of the total-breast PET system is 3.21 times greater than that of a whole-body PET scanner in the breast regions. The total-breast PET system also provides better contrast-recovery coefficients for lesions of all sizes and lesion-to-background ratios in the breast when compared to a reference clinical whole-body PET scanner. Receiver operating characteristics (ROC) study shows the area under the ROC curve is 0.948 and 0.924 for the total-breast system and the whole-body PET scanner, respectively, in the detection of 4 mm diameter lesions with 4:1 lesion-to-background ratio. This study demonstrates our novel geometry can provide an imaging FOV larger than conventional PEM systems to simultaneously image both breasts, chest wall and axillae with significantly improved lesion detectability in the breasts when compared to a whole-body PET scanner.

Dosimetric impact of range uncertainty in passive scattering proton therapy.

PURPOSE: The objective of this study was to investigate the dosimetric impact of range uncertainty in a large cohort of patients receiving passive scatter proton therapy. METHODS: A cohort of 120 patients were reviewed in this study retrospectively, of which 61 were brain, 39 lung, and 20 prostate patients. Range uncertainties of ±3.5% (overshooting and undershooting by 3.5%, respectively) were added and recalculated on the original plans, which had been planned according to our clinical planning protocol while keeping beamlines, apertures, compensators, and dose grids intact. Changes in the coverage on CTV and DVH for critical organs were compared and analyzed. Correlation between dose change and minimal distance between CTV and critical organs were also investigated. RESULTS: Although CTV coverages and maximum dose to critical organs were largely maintained for most brain patients, large variations over 5% were still observed sporadically. Critical organs, such as brainstem and chiasm, could still be affected by range uncertainty at 4 cm away from CTV. Coverage and OARs in lung and prostate patients were less likely to be affected by range uncertainty with very few exceptions. CONCLUSION: The margin recipe in modern TPS leads to clinically acceptable OAR doses in the presence of range uncertainties. However, range uncertainties still pose a noticeable challenge for small but critical serial organs near tumors, and occasionally for large parallel organs that are located distal to incident proton beams.

Impact of bowtie filter and detector collimation on multislice CT scatter profiles: A simulation study.

PURPOSE: To investigate via Monte Carlo simulations, the impact of scan subject size, antiscatter grid (ASG), collimator size, and bowtie filter on the distribution of scatter radiation in a typical realistically modeled third generation 16 slice diagnostic computed tomography (CT) scanner. METHODS: Full radiation transport was simulated with Geant4 in a realistic CT scanner geometric model, including the imaging phantom, bowtie filter (BTF), collimators and detector assembly, except for the ASGs. An analytical method was employed to quantify the probable transmission through the ASG of each photon intersecting the detector array. Normalized scatter profiles (NSP) and scatter-to-primary-ratio (SPR) profiles were simulated for 90 and 140 kVp beams for different size phantoms and slice thicknesses. The impact of CT scatter on the reconstructed attenuation coefficient factor was also studied as were the modulating effects of phantom- and patient-tissue heterogeneities on scatter profiles. A method to characterize the relative spatial frequency content of sinogram signals was developed to assess the latter. RESULTS: For the 21.4-cm diameter phantom, NSP and SPR increase linearly with collimator opening for both tube potentials, with the 90 kVp scan exhibiting slightly larger NSP and SPR. The BTF modestly modulates scatter under the phantom center, reducing the prominent off-axis lobes by factors of 1.1-1.3. The ASG reduces scatter on the central axis NSP threefold, and reduces scatter at the detectors outside the phantom shadow by factors of 25 to 500. For the phantoms with diameters of 27 and 32 cm, the scatter increases roughly three- and fourfold, respectively, demonstrating that scatter monotonically increases with phantom size, despite deployment of the ASG and BTF. In the absence of a scan subject, the ASG reduces the signal profile arising photons scattered by the BTF. Without ASG, the in-air scatter profile is relatively flat compared to the scatter profile when the ASG is present. For both 90 and 140 kVp photon spectra, the calculated attenuation coefficient decreases linearly with increasing collimation size. For both homogeneous and heterogeneous objects, NSPs are dominated by low spatial frequency content compared to the primary signal. However, the SPR, which quantifies the local magnitude of nonlinear detector response and is dominated by the high frequency content of the primary profile, can contribute strongly to high-spatial frequency streaking artifacts near high-density structures in reconstructed image artifacts. CONCLUSION: Public-domain Monte Carlo codes, Geant-4 in particular, is a feasible method for characterizing CT detector response to scattered- and off-focal radiation. Our study demonstrates that the ASG substantially reduces the scatter radiation and reshapes scatter-radiation profiles and affects the accuracy with which the detector array can measure narrow-beam attenuation due its inability to distinguish between true uncollided primary and narrow-angle coherently scattered photons. Hence, incorporating the impact of detector array collimation into the forward-projection signal formation models used by iterative reconstruction algorithms is necessary to use CT for accurately characterizing material properties. While tissue heterogeneities exercise a modest influence on local NPS shape and magnitude, they do not add significant high spatial frequency content.

A systematic review of tuberosity healing and outcomes following reverse shoulder arthroplasty for fracture according to humeral inclination of the prosthesis.

BACKGROUND: Proximal humerus fractures are common in the elderly population and are often treated with reverse shoulder arthroplasty (RSA). The purpose of this systematic review was to compare tuberosity healing and functional outcomes in patients undergoing RSA with humeral inclinations of 135°, 145°, and 155°. METHODS: A systematic review was performed of RSA for proximal humerus fracture using Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) guidelines. Radiographic and functional outcome data were extracted to evaluate tuberosity healing according to humeral inclination. Analysis was also performed of healed vs. nonhealed tuberosities. RESULTS: A total of 873 patients in 21 studies were included in the analysis. The mean age was 77.5 years (range of 58-97) and the mean follow-up was 26.2 months. Tuberosity healing was 83% in the 135° group compared with 69% in the 145° group and 66% in the 155° group (P = .030). Postoperative abduction was highest in the 155° group (P < .001). No significant difference was found in forward flexion, external rotation, or postoperative Constant score between groups. Patients with tuberosity healing demonstrated 18° higher forward flexion (P = .008) and 16° greater external rotation (P < .001) than those with unhealed tuberosities. CONCLUSION: RSA for fracture with 135° humeral inclination is associated with higher tuberosity healing rates compared with 145° or 155°. Postoperative abduction is highest with a 155° implant, but there is no difference in in postoperative forward flexion, external rotation, or Constant score according to humeral inclination. Patients with healed tuberosities have superior postoperative forward flexion and external rotation than those with unhealed tuberosities.

Surgical Simulation Maximizing the Use of Fresh-Frozen Cadaveric Specimens: Examination of Tissue Integrity Using Ultrasound.

BACKGROUND: Arthroscopic surgical simulation, including the use of cadaveric tissue, is valuable for training orthopedic surgery residents. However, it is unclear how often fresh-frozen cadaveric tissue can be reused to provide a reproducible model for developing arthroscopic skills. OBJECTIVE: We determined the usefulness of ultrasound in evaluating tissue degradation in fresh-frozen shoulder and knee joints used for surgical simulation. METHODS: Between February 7 and April 11, 2017, orthopedic residents participated in 6 wet lab sessions during 1 rotation. Knee and shoulder specimens were subjected to ultrasound using a SonoSite Edge machine and a linear probe after each freeze-and-thaw cycle. Degradation of each structure was determined based on standards created for living tissue and comparisons to previous images of the same tissue before initial use. RESULTS: Ultrasonographic assessment of the 2 knee and 2 shoulder specimens revealed lost integrity in subcutaneous fat and muscle with evidence of increased hypoechoicity and loss of normal fiber orientation and density in all specimens examined. Tendons, ligaments, cartilage, iliotibial band, and bone did not lose integrity during freezing and thawing. Ultrasonographic assessment revealed no loss of joint structure integrity. However, the intra-articular work assigned for the simulation curriculum had been carried out to a degree that by the third use, little opportunity remained for further arthroscopic practice on that specimen. CONCLUSIONS: In this study, ultrasound findings showed that fresh-frozen shoulder and knee specimens maintained structural integrity useful for simulation training after 3 cycles of freezing.

Effects of humeral intraosseous epinephrine in a pediatric hypovolemic cardiac arrest porcine model.

BACKGROUND: Aims of the study were to determine the effects of humerus intraosseous (HIO) versus intravenous (IV) administration of epinephrine in a hypovolemic, pediatric pig model. We compared concentration maximum (Cmax), time to maximum concentration (Tmax), mean concentration (MC) over time and return of spontaneous circulation (ROSC). METHODS: Pediatric pig were randomly assigned to each group (HIO (n=7); IV (n=7); cardiopulmonary resuscitation (CPR)+defibrillation (defib) (n=7) and CPR-only group (n=5)). The pig were anesthetized; 35% of the blood volume was exsanguinated. pigs were in arrest for 2 min, and then CPR was performed for 2 min. Epinephrine 0.01 mg/kg was administered 4 min postarrest by either route. Samples were collected over 5 min. After sample collection, epinephrine was administered every 4 min or until ROSC. The Cmax and MC were analyzed using high-performance liquid chromatography. Defibrillation began at 3 min postarrest and administered every 2 min or until ROSC or endpoint at 20 min after initiation of CPR. RESULTS: Analysis indicated that the Cmax was significantly higher in the IV versus HIO group (p=0.001). Tmax was shorter in the IV group but was not significantly different (p=0.789). The MC was significantly greater in the IV versus HIO groups at 90 and 120 s (p<0.05). The IV versus HIO had a significantly higher MC (p=0.001). χ2 indicated the IV group (5 out of 7) had significantly higher rate of ROSC than the HIO group (1 out of 7) (p=0.031). One subject in the CPR+defib and no subjects in the CPR-only groups achieved ROSC. DISCUSSION: Based on the results of our study, the IV route is more effective than the HIO route.