Clinical outcomes of marginal ulcer bleeding compared with those of peptic ulcer bleeding.

BACKGROUND: Marginal ulcer bleeding (MUB) is a complication that can occur following several types of surgery. However, few studies exist on it. Therefore, this study aimed to compare the clinical outcomes of MUB with those of peptic ulcer bleeding (PUB). METHODS: Between January 2013 and December 2017, 5,076 patients underwent emergent esophagogastroduodenoscopy for suspected upper gastrointestinal bleeding. We retrospectively reviewed and analyzed the medical records of MUB and PUB patients and developed a propensity score matching (PSM) method to adjust for between-group differences in baseline characteristics with 1:2 ratios. Sex, age, body mass index (BMI), underlying diseases, and drugs were included as matching factors. RESULTS: A total of 64 and 678 patients were diagnosed with MUB and PUB, respectively, on emergent esophagogastroduodenoscopy, and 62 and 124 patients with MUB and PUB, respectively, were selected after PSM. Rebleeding was significantly higher in patients with MUB than in those with PUB (57.8% vs 9.1%, p < 0.001). Mortality caused by bleeding was higher in patients with MUB than in those with PUB (4.7% vs. 0.4%, p < 0.001). Multivariate analysis revealed that proton pump inhibitor (PPI) administration (odds ratio [OR], 0.14; 95% confidence interval [CI], 0.03-0.56; p = 0.011) after first bleeding was inversely correlated with MUB rebleeding. Large ulcer size (> 1 cm) (OR, 6.69; 95% CI, 1.95-27.94; p = 0.005) and surgery covering pancreas (OR, 3.97; 95% CI, 1.19-15.04) were independent risk factors for MUB rebleeding. CONCLUSIONS: MUB showed a severe clinical course than PUB. Therefore, MUB should be managed more cautiously, especially for large ulcers and pancreatic surgery. Prophylactic PPI administration may be helpful in reducing rebleeding in MUB.

Impact of High-Flow Nasal Cannula Oxygenation on the Prevention of Hypoxia During Endoscopic Retrograde Cholangiopancreatography in Elderly Patients: A Randomized Clinical Trial.

BACKGROUND: Hypoxia is the most frequently occurring adverse effect during endoscopic retrograde cholangiopancreatography (ERCP) under sedation; thus, oxygen must be properly supplied to prevent a reduction of oxygen saturation. In this study, we intend to verify the preventive effect for hypoxia during ERCP, using a high-flow nasal cannula (HFNC), in elderly patients. METHODS: As a multicenter prospective randomized trial, patients who underwent ERCP with propofol-based sedation were randomly assigned into two groups: Patients in the HFNC group were supplied with oxygen via an HFNC, and those in the standard nasal cannula group were supplied with oxygen via a low-flow nasal cannula. The co-primary end points were the lowest oxygen saturation rate and hypoxia during the overall procedure. RESULTS: A total of 187 patients (HFNC group: 95; standard nasal cannula group: 92) were included in the analysis. Unexpected hypoxia events were more frequently observed among patients in the standard nasal cannula group than among patients in the HFNC group (13% vs. 4%, odds ratio 3.41, 95% confidence interval 1.06-11.00, p = 0.031). The mean of the lowest oxygen saturation rate during ERCP was significantly lower in the standard nasal cannula group than in the HFNC group (95% vs. 97%, p = 0.002). CONCLUSION: Oxygen supplementation with an HFNC can prevent oxygen desaturation and hypoxia events in patients undergoing ERCP under sedation. Trial registration Clinical Research Information Service (CRIS; KCT0004960).

Effect of ICRU report 90 recommendations on Monte Carlo calculated kQ for ionization chambers listed in the Addendum to AAPM's TG-51 protocol.

PURPOSE: The ICRU has published new recommendations for ionizing radiation dosimetry. In this work, the effect of recommendations on the water-to-air and graphite-to-air restricted mass electronic stopping power ratios (sw, air and sg, air ) and the individual perturbation correction factors Pi was calculated. The effect on the beam quality conversion factors kQ for reference dosimetry of high-energy photon beams was estimated for all ionization chambers listed in the Addendum to AAPM's TG-51 protocol. METHODS: The sw, air , sg, air , individual Pi, and kQ were calculated using EGSnrc Monte Carlo code system and key data of both ICRU report 37 and ICRU report 90. First, the Pi and kQ were calculated using precise models of eight ionization chambers: NE2571 (Nuclear Enterprise), 30013, 31010, 31021 (PTW), Exradin A12, A12S, A1SL (Standard imaging), and FC-65P (IBA). In this simulation, the radiation sources were one 60 Co beam and ten photon beams with nominal energy between 4 MV and 25 MV. Then, the change in kQ for ionization chambers listed in the Addendum to AAPM's TG-51 protocol was calculated by changing the specification of the simple-model of ionization chamber. The simple-models were made with only cylindrical component modules. In this simulation, the radiation sources of 60 Co beam and 24 MV photon beam were used. RESULTS: The significant changes (p < 0.05) were observed for sw, air , sg, air , the wall correction factor Pwall , and the waterproofing sleeve correction factor Psleeve . The decrease in sw, air varied from -0.57% for a 60 Co beam to -0.36% for the highest beam quality. The decrease in sg, air varied from -0.72% to -1.12% in the same range. The changes in Pwall and Psleeve were up to 0.41% and 0.14% and those maximum changes were observed for the 60 Co beam. All changes in the central electrode correction factor Pcel , the stem correction factor Pstem , and the replacement correction factor Prepl were from -0.02% to 0.12%. Those changes were statistically insignificant (p = 0.07 or more) and were independent of photon energy. The change in kQ was mainly characterized by the change in sw, air , Pwall , and Psleeve . The relationship between the change in kQ and the beam quality index was linear approximately. The changes in kQ of the simple-models were agreed with those of the precise-models within 0.08%. CONCLUSION: The effects of ICRU-90 recommendations on kQ for the ionization chambers listed in the Addendum to AAPM's TG-51 protocol were from -0.15% to 0.30%. To remove the known systematic effect on the clinical reference dosimetry, the kQ based on ICRU-37 should be updated to the kQ based on ICRU-90.

Small-cell Lung Cancer Presenting as Fatal Pulmonary Hemorrhage.

Small-cell lung cancer (SCLC) is a lung cancer histological subtype unusual in its favorable response to cytotoxic chemotherapy. Life-threatening manifestations at presentation are rarely reported and should be an important clinical concern. We report a case of a 63-year-old man presenting with rapid-onset refractory severe thrombocytopenia, development of massive hemoptysis, and death from respiratory failure. This case provides clinicians a reference for this unusual presentation and carries clinical implications for managing SCLC patients.

Dosimetric impact of 4-dimensional computed tomography ventilation imaging-based functional treatment planning for stereotactic body radiation therapy with 3-dimensional conformal radiation therapy.

PURPOSE: The purpose of this study was to clarify the dosimetric impact of 4-dimensional computed tomography (4D-CT)-derived, ventilation-guided functional avoidance for stereotactic body radiation therapy (SBRT) with 3-dimensional conformal radiation therapy. METHODS AND MATERIALS: Eleven lung cancer patients with peripheral tumors no greater than 5 cm in size were studied (average planning target volume, 42.4 ± 32.5 cm(3)). Four-dimensional-CT ventilation imaging was performed using deformable image registration for spatial mapping of the peak-exhale 4D-CT image to the peak-inhale 4D-CT image and computation of the Jacobian-based ventilation metric. For each patient, anatomical and functional plans were created using 7 to 9 noncoplanar beams for SBRT (40-56 Gy/4-8 fractions). The anatomical plan was generated without incorporating ventilation information. In the functional plan, functional dose-volume constraints were applied in planning to spare the high-functional lung that was defined as the 90th percentile functional volume. The beam directions of the 2 plans were automatically determined by beam angle optimization. RESULTS: The percentage of volume receiving a dose of ≥5 Gy (V5), V10, V20, and mean dose to the high-functional lung were 20.5%, 15.6%, 7.8%, and 4.6 Gy, respectively, for the anatomical plan, whereas they were 12.3%, 8.2%, 4.6%, and 3.2 Gy, respectively, for the functional plan. No significant differences in minimum dose, maximum dose, and conformity index of the planning target volume and in all dosimetric parameters for normal tissues between the anatomical and functional plans were seen. CONCLUSIONS: We compared anatomical and functional plans for SBRT with 3-dimensional conformal radiation therapy for the first time. Our results demonstrated that a functional plan for SBRT reduced the dose in the high-functional regions without a significant change in the total lung or planning target volume even if the radiation technique cannot modulate beam intensity. Thus, this technique can be safely used in functional planning for SBRT.

Evaluation of accuracy of B-spline transformation-based deformable image registration with different parameter settings for thoracic images.

Deformable image registration (DIR) is fundamental technique for adaptive radiotherapy and image-guided radiotherapy. However, further improvement of DIR is still needed. We evaluated the accuracy of B-spline transformation-based DIR implemented in elastix. This registration package is largely based on the Insight Segmentation and Registration Toolkit (ITK), and several new functions were implemented to achieve high DIR accuracy. The purpose of this study was to clarify whether new functions implemented in elastix are useful for improving DIR accuracy. Thoracic 4D computed tomography images of ten patients with esophageal or lung cancer were studied. Datasets for these patients were provided by DIR-lab (dir-lab.com) and included a coordinate list of anatomical landmarks that had been manually identified. DIR between peak-inhale and peak-exhale images was performed with four types of parameter settings. The first one represents original ITK (Parameter 1). The second employs the new function of elastix (Parameter 2), and the third was created to verify whether new functions improve DIR accuracy while keeping computational time (Parameter 3). The last one partially employs a new function (Parameter 4). Registration errors for these parameter settings were calculated using the manually determined landmark pairs. 3D registration errors with standard deviation over all cases were 1.78 (1.57), 1.28 (1.10), 1.44 (1.09) and 1.36 (1.35) mm for Parameter 1, 2, 3 and 4, respectively, indicating that the new functions are useful for improving DIR accuracy, even while maintaining the computational time, and this B-spline-based DIR could be used clinically to achieve high-accuracy adaptive radiotherapy.

Multidimensional sensory phenomena in antipsychotic-induced akathisia.

The primary distinguishing features of akathisia in comparison with other extrapyramidal syndromes are the prominent subjective manifestations, which include various sensory symptoms. The sensory symptoms are multidimensional in nature and encompass various forms of bodily and mental sensations. The purpose of the present study was to elucidate the multidimensional aspects of the sensory phenomena associated with antipsychotic-induced akathisia. Seventy stable and chronic schizophrenic subjects receiving maintenance antipsychotic treatment were evaluated for akathisia and other extrapyramidal side effects. Subjective sensory phenomena were evaluated in 3 dimensions (ie, bodily sensations, mental sensations, and autonomic sensations). The frequency of each dimension of these sensory phenomena was compared between the groups with and without akathisia using chi test with Bonferroni correction. The akathisia group (n = 29) reported significantly more frequent focal or generalized bodily sensations than the non-akathisia group (n = 41) (P < 0.001). The akathisia group also showed significantly more frequent mental sensations such as mental urge and a feeling of inner tension/pressure (P < 0.001). In autonomic phenomena, there was a trend for the akathisia group to show more frequent autonomic sensations. The most common autonomic phenomena associated with akathisia were palpitation and difficulty breathing. The results of the present study suggest that the sensory phenomena of antipsychotic-induced akathisia are characterized by multidimensional features such as bodily sensations, mental sensations, and several autonomic sensations. The assessment of these multidimensional sensory phenomena would be useful in evaluating the important phenotypic features of akathisia.