Evaluation of mega-voltage CT images for completed radiotherapy treatments for dogs and cats reveals uncommon but potentially consequential dose deviation in thoracic and abdominal tumors.

As advanced delivery techniques such as intensity-modulated radiation therapy (IMRT) become conventional in veterinary radiotherapy, highly modulated radiation delivery helps to decrease dose to normal tissues. However, IMRT is only effective if patient setup and anatomy are accurately replicated for each treatment. Numerous techniques have been implemented to decrease patient setup error, however tumor shrinkage, variations in the patient's contour and weight loss continue to be hard to control and can result in clinically relevant dose deviation in radiotherapy plans. Adaptive radiotherapy (ART) is often the most effective means to account for gradual changes such as tumor shrinkage and weight loss, however it is often unclear when adaption is necessary. The goal of this retrospective, observational study was to review dose delivery in dogs and cats who received helical radiotherapy at University of Wisconsin, using detector dose data (D2%, D50%, D98%) and daily megavoltage computed tomography (MVCT) images, and to determine whether ART should be considered more frequently than it currently is. A total of 52 treatment plans were evaluated and included cancers of the head and neck, thorax, and abdomen. After evaluation, 6% of the radiotherapy plan delivered had clinically relevant dose deviations in dose delivery. Dose deviations were more common in thoracic and abdominal targets. While adaptation may have been considered in these cases, the decision to adapt can be complex and all factors, such as treatment delay, cost, and imaging modality, must be considered when adaptation is to be pursued.

A pragmatic assessment of the British Thyroid Association "U classification" of thyroid nodules with a focus on their follow-up.

AIM: To assess the predictive value of the U classification and the significance of follow-up ultrasound in those managed conservatively. MATERIALS AND METHODS: A retrospective observational study was carried out among 1,465 patients who underwent thyroid ultrasound in 2016 at a teaching hospital in UK. Details regarding U classification of nodules, cytology, histology in patients who underwent surgery, and follow-up ultrasound in those managed conservatively were obtained. RESULTS: Thyroid surgery was performed in 129 patients of which malignancy was seen in 35 (27.1%). The proportion of patients with cancer in U1-U5 categories were 0%, 13.6%, 30.4%, 40%, and 100%, respectively (Fisher's exact test p=0.001). There was no significant difference in U stage, cytology, or histology between incidental and symptomatic nodules. Among patients who did not undergo surgery 5% of U1, 14.6% of U2, 75% of U3, and 71.4% of U4 underwent repeat ultrasound. Radiological progression in nodule size was seen in 4.2% of U1, 1.9% of U2, 0% of U3, and 40% of U4 nodules at median duration of 306, 439, 274, and 748 days, respectively. CONCLUSIONS: U classification is reliable in risk-stratifying thyroid nodules. Patients with benign nodules without high-risk features do not require follow-up. The interval between scans in patients with indeterminate nodules can be extended to a period of 6-12 months.

Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

We conducted a systematic review of guidelines on the management of low back pain (LBP) to assess their methodological quality and guide care. We synthesized guidelines on the management of LBP published from 2005 to 2014 following best evidence synthesis principles. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane, DARE, National Health Services Economic Evaluation Database, Health Technology Assessment Database, Index to Chiropractic Literature and grey literature. Independent reviewers critically appraised eligible guidelines using AGREE II criteria. We screened 2504 citations; 13 guidelines were eligible for critical appraisal, and 10 had a low risk of bias. According to high-quality guidelines: (1) all patients with acute or chronic LBP should receive education, reassurance and instruction on self-management options; (2) patients with acute LBP should be encouraged to return to activity and may benefit from paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), or spinal manipulation; (3) the management of chronic LBP may include exercise, paracetamol or NSAIDs, manual therapy, acupuncture, and multimodal rehabilitation (combined physical and psychological treatment); and (4) patients with lumbar disc herniation with radiculopathy may benefit from spinal manipulation. Ten guidelines were of high methodological quality, but updating and some methodological improvements are needed. Overall, most guidelines target nonspecific LBP and recommend education, staying active/exercise, manual therapy, and paracetamol or NSAIDs as first-line treatments. The recommendation to use paracetamol for acute LBP is challenged by recent evidence and needs to be revisited. SIGNIFICANCE: Most high-quality guidelines recommend education, staying active/exercise, manual therapy and paracetamol/NSAIDs as first-line treatments for LBP. Recommendation of paracetamol for acute LBP is challenged by recent evidence and needs updating.

Preoperative identification of anomalous arterial anatomy at pancreaticoduodenectomy.

The understanding of abdominal vascular anatomy and its anatomical variations is of considerable importance in upper abdominal surgery. We present the rare finding of a common hepatic artery arising from the superior mesenteric artery and passing anterior to the pancreatic gland in a patient undergoing a pancreaticoduodenectomy.

Study of the effect of age changes on lip print pattern and its reliability in sex determination.

Cheiloscopy, a forensic investigation technique, deals with the study of elevations and depressions which form a characteristic pattern on the external surface of the lips. The objective of the study was to determine the most common lip patterns in North Indian population, to evaluate whether sex determination is possible on the basis of lip prints and to ascertain if there is any co-relation between advancing age and its effect on lip pattern. A total of 600 subjects, 289 males and 311 females were selected and divided into three age groups (group 1: 1-20 years, group 2: 21-40 years, group 3: 40 years and above). Statistical analysis (applying Chi square test) showed very highly significant difference for different lip patterns (p < 0.0001) in males and females in group 2 and no significant difference in group 1 and group 3. The most predominant pattern in the entire study population was Type I (32.33%). Age changes like immaturity of lips in younger age and diminished anatomic details and tonicity in older age can have a considerable effect on the lip pattern, thereby making the correct identification of sex in these age groups debatable.

A prospective study of hip revision surgery using the Exeter long-stem prosthesis: function, subsidence, and complications for 57 patients.

BACKGROUND: The long-stem Exeter femoral component is commonly used in revision hip surgery. Subsidence of the femoral stem in primary hip arthroplasty has been studied extensively, but much less is known about its significance in revision surgery. This prospective study examined the relationship between radiological subsidence, Western Ontario and McMaster (WOMAC) osteoarthritis index pain score, patient satisfaction and complication rates for the long-stem Exeter hip prosthesis. MATERIALS AND METHODS: Data was prospectively collected for a single-surgeon series of 96 patients undergoing revision surgery with a mean follow-up period of 36 months. Pre- and post-operative clinical evaluation was carried out using the validated WOMAC osteoarthritis index. Radiographic evaluation was carried out on magnification-adjusted digital radiographic images. RESULTS: Data from 57 patients were analysed. The mean rate of subsidence recorded was 0.43 mm/year, with a mean total subsidence of 0.79 mm [95% confidence interval (CI) 0.57-1.01] at 36.3 months. There was no correlation between subsidence and post-operative WOMAC score, complication rate or patient satisfaction. There was a statistically significant reduction between pre-operative and post-operative WOMAC scores, with means of 33.5 and 10.7, respectively (P < 0.001), and high patient satisfaction. CONCLUSION: Our subsidence rates for long-stem revision femoral components are lower than the published data but demonstrate the same plateau. Radiographic subsidence does not appear to relate to functional outcome or complication rates in our data.

Cauda equina syndrome: an anatomically driven review.

Cauda equina syndrome results from an injury to the lumbosacral nerve roots below the tip of the conus medullaris, occuring in between 2 and 6% of all laminectomies performed for lumbar disc herniation. This article relates the anatomy of the nervous system of the bladder, rectum, anus and sexual organs to the signs and symptoms of cauda equina syndrome, and reviews the literature for the acute management of these patients.