Sleep disturbance in adults with cancer: a systematic review of evidence for best practices in assessment and management for clinical practice.

Sleep disturbance is prevalent in cancer with detrimental effects on health outcomes. Sleep problems are seldom identified or addressed in cancer practice. The purpose of this review was to identify the evidence base for the assessment and management of cancer-related sleep disturbance (insomnia and insomnia syndrome) for oncology practice. The search of the health literature included grey literature data sources and empirical databases from June 2004 to June 2012. The evidence was reviewed by a Canadian Sleep Expert Panel, comprised of nurses, psychologists, primary care physicians, oncologists, physicians specialized in sleep disturbances, researchers and guideline methodologists to develop clinical practice recommendations for pan-Canadian use reported in a separate paper. Three clinical practice guidelines and 12 randomized, controlled trials were identified as the main source of evidence. Additional guidelines and systematic reviews were also reviewed for evidence-based recommendations on the assessment and management of insomnia not necessarily in cancer. A need to routinely screen for sleep disturbances was identified and the randomized, controlled trial (RCT) evidence suggests benefits for cognitive behavioural therapy for improving sleep quality in cancer. Sleep disturbance is a prevalent problem in cancer that needs greater recognition in clinical practice and in future research.

A diamond target for megavoltage cone-beam CT.

PURPOSE: To determine the properties of a megavoltage cone-beam CT system using the unflattened beam from a sintered diamond target at 4 and 6 MV. METHODS: A sintered diamond target was used in place of a graphite target as part of an imaging beam line (an unflattened beam from a graphite target) installed on a linear accelerator. The diamond target, with a greater density than the graphite target, permitted imaging at the lower beam energy (4 MV) required with the graphite target and the higher beam energy (6 MV) conventionally used with the tungsten/stainless steel target and stainless steel flattening filter. Images of phantoms and patients were acquired using the different beam lines and compared. The beam spectra and dose distributions were determined using Monte Carlo simulation. RESULTS: The diamond target allowed use of the same beam energy as for treatment, simplifying commissioning and quality assurance. Images acquired with the diamond target at 4 MV were similar to those obtained with the graphite target at 4 MV. The slight reduction in low energy photons due to the higher-Z sintering material in the diamond target had minimal effect on image quality. Images acquired at 6 MV with the diamond target showed a small decrease in contrast-to-noise ratio, resulting from a decrease in the fraction of photons in the beam in the energy range to which the detector is most sensitive. CONCLUSIONS: The diamond target provides images of a similar quality to the graphite target. Diamond allows use of the higher beam energy conventionally used for treatment, provides a higher dose rate for the same beam current, and potentially simplifies installation and maintenance of the beam line.

Characteristics of megavoltage cone-beam digital tomosynthesis.

This article reports on the image characteristics of megavoltage cone-beam digital tomosynthesis (MVCB DT). MVCB DT is an in-room imaging technique, which enables the reconstruction of several two-dimensional slices from a set of projection images acquired over an arc of 20 degrees-40 degrees. The limited angular range reduces the acquisition time and the dose delivered to the patient, but affects the image quality of the reconstructed tomograms. Image characteristics (slice thickness, shape distortion, and contrast-to-noise ratio) are studied as a function of the angular range. Potential clinical applications include patient setup and the development of breath holding techniques for gated imaging.

[Megavoltage cone-beam CT: Recent developments and clinical applications]. / Mégavoltage cone-beam CT: récents développements et applications cliniques pour la radiothérapie conformationnelle avec modulation d'intensité.

The Megavoltage cone-beam (MV CBCT) system consists of a new a-Si flat panel adapted for MV imaging and an integrated workflow application allowing the automatic acquisition of projection images, cone-beam CT image reconstruction, CT to CBCT image registration and couch position adjustment. This provides a 3D patient anatomy volume in the actual treatment position, relative to the treatment isocenter, moments before the dose delivery, that can be tightly aligned to the planning CT, allowing verification and correction of the patient position, detection of anatomical changes and dose calculation. In this paper, we present the main advantages and performance of this MV CBCT system and summarize the different clinical applications. Examples of the image-guided treatment process from the acquisition of the MV CBCT scan to the correction of the couch position and dose delivery will be presented for spinal and lung lesions and for head and neck, and prostate cancers.

Calorimetric study of water in muscle tissue.

Differential scanning calorimetry has been used to investigate the state of water in intact single muscle fibers of the giant barnacle, Balanus nubilus. The shapes of the melting curves suggest the presence of three types of water: unfrozen (or bound), free (or bulk) and intermediate water. The amount of unfrozen water per g protein was constant within experimental error. An increase in water content changed almost exclusively the amounts of free water. The amount of intermediate water varies only slightly with the fiber water content.

Evaluation of ultrasound-based prostate localization for image-guided radiotherapy.

To evaluate the use of the ultrasound-based BAT system for daily prostate alignment. Prostate alignments using the BAT system were compared with alignments using radiographic images of implanted radiopaque markers. The latter alignments were used as a reference. The difference between the BAT and marker alignments represents the displacements that would remain if the alignments were done using ultrasonography. The inter-user variability of the contour alignment process was assessed. On the basis of the marker alignments, the initial displacement of the prostate in the AP, superoinferior, and lateral direction was -0.9 +/- 3.9, 0.1 +/- 3.9, and 0.2 +/- 3.4 mm respectively. The directed differences between the BAT and marker alignments in the respective directions were 0.2 +/- 3.7, 2.7 +/- 3.9, and 1.6 +/- 3.1 mm. The occurrence of displacements >/=5 mm was reduced by a factor of two in the AP direction after the BAT system was used. Among eight users, the average range of couch shifts due to contour alignment variability was 7, 7, and 5 mm in the antero-posterior (AP), superoinferior, and lateral direction, respectively. In our study, the BAT alignments were systematically different from the marker alignments in the superoinferior, and lateral directions. The remaining random variability of the prostate position after the ultrasound-based alignment was similar to the initial variability. However, the occurrence of displacements >/=5 mm was reduced in the AP direction. The inter-user variation of the contour alignment process was significant.

The role of electronic portal imaging in tangential breast irradiation: a prospective study.

Side effects due to irradiation of normal tissues and local failure can be associated with deviations in the patient positioning in radiation therapy. In particular, tangential breast irradiation may include normal lung tissue or even a small portion of the heart in the field. A prospective study was performed to assess the precision and the reproducibility of the tangential breast irradiation technique with the help of on-line electronic portal imaging devices (EPID). The influence of respiration on the treatment set-up was evaluated. Also, a comparison was made with simulation films to study the degree of concordance with the intended treatment. Twenty patients with early breast cancer receiving post-operative radiotherapy were entered in the study. Geometrical parameters were measured from daily on-line portal images taken for approximately 17 fractions of each tangential fields. Multiple images were also acquired (six per field) for six fractions for all patients, yielding a total of 2120 images including the simulator films. Random and systematic errors were obtained. Variations of the parameters between various fractions and within the same fraction were about 3 mm (1 SD) or less. Variation between simulation and treatment set-up was 4.3 mm or less. Large maximum deviations, reaching 22.9 mm, were observed in rare cases. This confirms the need to implement daily verification procedures and to correct deviations in the treatment set-up. The study has shown that EPID can help reaching a high accuracy in patient treatment.

Safety and efficacy of a sustained inflation for alveolar recruitment in adults with respiratory failure.

OBJECTIVE: To assess the safety and efficacy of a sustained inflation, used as a lung volume recruitment maneuver in ventilated patients with hypoxemic respiratory failure. DESIGN: Prospective data collection as part of a quality assurance program following introduction of a lung volume recruitment guideline in the intensive care unit. SETTING: Academic medical-surgical critical care unit. PATIENTS: Hypoxemic patients with bilateral pulmonary infiltrates. Patients with chronic obstructive pulmonary disease, pulmonary barotrauma and hemodynamic instability were excluded. INTERVENTIONS: A sustained inflation using a pressure of 30 to 45 cmH2O was applied for 20 s. The pressure was determined as the lesser of 45 cmH2O or the peak pressure while ventilated at a tidal volume of 12 ml/kg. Intra-arterial blood pressure and pulse oximetry were monitored continuously. MEASUREMENTS AND RESULTS: Significant improvement in oxygenation occurred in the majority of patients within 10 min. The mean oxygen saturation improved from 86.9 +/- 5.5 to 94.3 +/- 2.3% (p < 0.01). No significant adverse effects were noted: hypotension and mild oxygen desaturation occurred in some patients during the 20-s inflation, reversing rapidly after inflation was terminated. No barotrauma occurred. CONCLUSIONS: A sustained inflation is a safe, clinically applicable method of lung volume recruitment which improves oxygenation in selected patients and may have a role in ventilatory management.

Comparison of sonography and computed tomography in the study of orbital space-occupying lesions.

Seventy cases of space-occupying lesions in the eyeball and 140 extraocular masses in the orbit were explored by both sonography and compute tomography (CT). The merits of each method were demonstrated relative to defining the location, extension, and nature of the lesion. In adults with ocular masses, sonography is usually sufficient. For retinoblastoma, CT is usually necessary to rule out an extraocular extension. When an orbital process is involved, greater diagnostic accuracy can be achieved if the two methods are combined.

Computed tomography in 75 clinical cases of syringomyelia.

Seventy-five patients with a clinical diagnosis of syringomyelia were examined by computed tomography after intrathecal injection of metrizamide. A central cavity was demonstrated in 67 patients. Tilting the patient head down did not increase the rate of cavity opacification. This evidence favors transneural migration of metrizamide into the cavity. The spinal cord was measurably enlarged in only a minority of the patients. In some, the cavity appeared to have clefts or wall defects. These results are discussed according to the etiopathogenic theories advanced by Gardner, Aboulker, and Williams.

Intraocular pressure in normal llamas (Lama glama) and alpacas (Lama pacos).

OBJECTIVE: To determine the mean intraocular pressure in llamas (Lama glama) and alpacas (Lama pacos) using applanation tonometry.Animals studied: Ten llamas and 10 alpacas.Procedures: Intraocular pressure (IOP) was measured with a Tono-Pentrade mark XL (Mentor Ophthalmics, Inc., Norwell, MA, USA). Three values, with 5% variance, were recorded for each eye. Least-squares means were determined for IOP for each eye of llamas and alpacas. Controlling for age, differences between left and right eye were analyzed using ANOVA. Two age groups were established, less than 5 years and greater than 5 years. The effect of age on IOP within each group was analyzed by linear regression. Probability values of less than 0.05 were considered significant. RESULTS: Comparison of mean IOP between right (n = 20) and left eyes (n = 20), independent of species type, showed no differences in IOPs for llamas and alpacas. Mean IOP declined with increasing age in llamas and alpacas. Mean IOPs for 20 eyes in 10 llamas was 16.96 +/- 3.51 mmHg. Mean IOP for 20 eyes in 10 alpacas was 16.14 +/- 3.74 mmHg. Mean IOP for all eyes (n = 40), independent of species, was 16.55 +/- 3.55 mmHg. The range of IOP in normal llamas and alpacas within 2 SD (95% of the population) was 14.89+/-18.21 mmHg. CONCLUSIONS: There was no significant difference in IOP between alpacas and llamas. Mean IOP in both species decreased with increased age.

Analysis of aqueous humor obtained from normal eyes of llamas and alpacas.

OBJECTIVE: To evaluate composition of aqueous humor obtained from normal eyes of llamas (Lama glama) and alpacas (Lama pacos). SAMPLE POPULATION: Aqueous humor obtained from 10 male llamas and 10 male alpacas. PROCEDURE: All animals had normal eyes, as determined by ocular examination. Aqueous humor samples were obtained via paracentesis of the anterior chamber of animals that were heavily sedated. Chemical analysis included measurement of concentrations of sodium, potassium, magnesium, chloride, bicarbonate, phosphorus, and glucose as well as osmolality and pH. RESULTS: With the exception of potassium concentrations, values for aqueous humor composition did not differ significantly between llamas and alpacas. Mean +/- SD values for llamas and alpacas, respectively, were: sodium, 154.7 +/- 2.1 and 152.7 +/- 2.1 mEq/L; potassium, 5.3 +/- 0.4 and 4.6 +/- 0.4 mEq/L; magnesium, 1.8 +/- 0.1 and 1.7 +/- 0.1 mg/dl; chloride, 130.0 +/- 1.6 and 127.0 +/- 3.3 mEq/L; bicarbonate, 19.2 +/- 1.5 and 20.2 +/- 2.3 mEq/L; phosphorous, 2.7 +/- 0.3 and 2.5 +/- 0.4 mg/dl; glucose, 80.3 +/- 3.9 and 80.8 +/- 7.3 mg/dl; total protein, 29.0 +/- 8.6 and 31.5 +/- 10.1 mg/dl; and osmolality, 305.8 +/- 11.8 and 306.2 +/- 4.9 mOsm. The pH ranged from 7.5 to 8.0 for both species. Potassium concentrations were significantly higher in llamas than alpacas. CONCLUSIONS AND CLINICAL RELEVANCE: Except for potassium, composition of aqueous humor did not differ significantly between llamas and alpacas. Aqueous humor composition of llamas and alpacas is similar to that of other species that have been examined.

[Value of computer assisted tomography in the exploration of the sellar and supra sellar structures (author's transl)]. / Apport de la tomodensitométrie a l'exploration de la région sellaire et supra-sellaire.

The results obtained in 145 cases of space-occupying lesions in the sellar and suprasellar structures, after exploration with computer assisted tomography, were used to assess the technical and diagnostic value of this procedure. Precise details of the localization and extent of the lesion can be obtained, but not the nature of the lesion in many cases.

[Oculomotor lesions and myeloma: a case with a CT scan study (author's transl)]. / Les atteintes oculo-motrices au cours des myélomes. A propos d'un cas étudié par tomodensitométrie.

A 62 year-old woman presented with a unilateral, incomplete ophthalmoplegia, and pain in the territory of the ophthalmic branch of the trigeminal nerve. She had an IgG gamma 2-lambda 2 type myeloma. Opacification by phlebography of the cavernous sinus on the affected side was not possible, neither through the ophthalmic vein nor through the anastomotic coronal veins. This suggested invasion of the sella turcica. Combined radiotherapy and chemotherapy led to rapid and almost total recovery. The lesion recurred 15 months later. Then there was a bilateral oculomotor palsy involving both external recti, and exophthalmos. CT Scan demonstrated a marked increase in size of the external recti. Special features in this case were the oculomotor paralysis and its occurrence as the initial sign of the disease, and its secondary localization in the orbits with bilateral muscle lesions.

[Computed tomography in multiple sclerosis]. / La tomodensitométrie dans la sclérose en plaques.

Sixty patients with multiple sclerosis were examined by computed tomography using an Acute 200 Pfizer apparatus (matrix: 256 X 256; sections: 8 mm thick). In 48 cases iodine contrast medium was injected prior to examination, and in 6 cases the examination was repeated after several months. Abnormal C.T. readings were found in three quarters of the patients; increased image density in 10 patients, reduced density in 10 other cases; isolated cerebral atrophy in 26 patients, associated in 10 other cases with increased or reduced density of the image. Increased densities were seen mainly during acute episodes, then tended to isodensities or low densities. Though these different images are not specific, their association, the absence of mass effect and the absence of correlation between their location and the clinical signs, are elements in favor of the diagnosis of multiple sclerosis. Regions of increased density probably represent active foci of demyelinization and their investigation could be of value during long-term follow-up of these patients.

[Scannography apport in syringomyelic study. 40 syringolyelic cases (author's transl)]. / Apport de la scannographie a l'étude des syringomyélies. 40 cas de syringomyélie de l'adulte.

Forty patients with a syringomyelic syndrome were studied by means of scannography of the cervical spine and cervico-occipital joint before and after intrathecal injection of metrizamide. metrizamide transit, and more particularly the opacification of the syringomyelic cyst by metrizamide were assessed by delayed passages. This study demonstrates the value of this technique both from the morphological and dynamic point of view.

[Lobar holoprosencephaly associated with heterotopic gray matter. A case disclosed in adulthood by epilepsy]. / Holoprosencéphalie lobaire associée à des hétérotopies de substance grise. Un cas révélé à l'âge adulte par une épilepsie.

A case of lobar holoprosencephaly associated with heterotopias of the grey matter is reported. The patient was a young woman whose cerebral malformation was revealed by epileptic seizures at the age of 22. There was no intellectual deficit. Computerized tomography and, chiefly, magnetic resonance imaging, enabled the study of the malformation.

[Echotomography of the carotid bifurcation (author's transl)]. / Examen de la bifurcation carotidienne par échotomographie.

Echotomography examinations of carotid bifurcation were conducted in 19 patients, with a real-time apparatus (71 crystals, 7 MHz). Serial transversal sections plus two or more longitudinal sections enabled identification by Echo-B of the three carotid arteries, and thus the bifurcation, in 37 instances. Arteriography was performed in 11 patients (21 carotid arteries). Correlation between Echo-B and arteriographic findings was good in 10 cases (including 1 case of occlusion and 2 of stenosis). There were 3 false negatives but no false positives. Echo-B did not detect the bifurcation on either side in one patient. The method is non-invasive, painless, and can be repeated without risk. It enables the detection of stenotic and occlusive lesions with a certain degree of reliability. It is also of value for demonstrating the presence of atheromatous plaques, and to some extent, irregularities in the arterial wall or variations of its diameter. It allows new perspectives for long-term following of patients after medical or surgical treatment.

[Wilson's disease. X-ray CT and MRI aspects of the brain in a case before treatment]. / Maladie de Wilson. Aspects TDM et IRM de l'encéphale d'un cas avant traitement.

Wilson disease is an autosomal recessive disorder of copper metabolism. The case of a young girl is reported here, with CT and MRI data before any treatment. The unusual MR presentation on T2 weighted sequences is studied, and compared with those described in patients under treatment.

[Role of imaging in the diagnosis of coma]. / Place de l'imagerie dans le diagnostic des comas.

Imaging has become one of the main methods to diagnose and monitor coma. CT is the technique of choice in the exploration of traumatic coma or spontaneous intracerebral haemorrhage, but MRI is better than CT to explore comas of ischaemic, infective, tumoral or toxic origin, as it provides earlier and more precise images.