One-year clinical outcomes of MR-guided stereotactic body radiation therapy with rectal spacer for patients with localized prostate cancer.

BACKGROUND AND PURPOSE: This prospective study aimed to investigate adaptive magnetic resonance (MR)-guided stereotactic body radiation therapy (MRgSBRT) with rectal spacer for localized prostate cancer (PC) and report 1-year clinical outcomes. MATERIALS AND METHODS: Thirty-four consecutive patients with low- to high-risk localized PC that underwent 5-fraction adaptive MRgSBRT with rectal spacer were enrolled. The dosimetric comparison was performed on a risk- and age-matched cohort treated with MRgSBRT but without a spacer at a similar timepoint. Clinician-reported outcomes were based on Common Terminology Criteria for Adverse Events. Patient-reported outcomes were based on the Expanded Prostate Cancer Index Composite (EPIC) questionnaire at baseline, acute (1-3 months), subacute (4-12 months), and late (> 12 months) phases. RESULTS: The median follow-up was 390 days (range 28-823) and the median age was 70 years (range 58-82). One patient experienced rectal bleeding soon after spacer insertion that subsided before MRgSBRT. The median distance between the midline of the prostate midgland and the rectum after spacer insertion measured 7.8 mm (range 2.6-15.3), and the median length of the spacer was 45.9 mm (range 16.8-62.9) based on T2-weighted MR imaging. The use of spacer resulted in significant improvements in target coverage (V100% > 95% = 98.6% [range 93.4-99.8] for spacer vs. 97.8% [range 69.6-99.7] for non-spacer) and rectal sparing (V95% < 3 cc = 0.7 cc [range 0-4.6] for spacer vs. 4.9 cc [range 0-12.5] for non-spacer). Nine patients (26.5%) experienced grade 1 gastrointestinal toxicities, and no grade ≥ 2 toxicities were observed. During the 1-year follow-up period, EPIC scores for the bowel domain remained stable and were the highest among all other domains. CONCLUSIONS: MRgSBRT with rectal spacer for localized PC showed exceptional tolerability with minimal gastrointestinal toxicities and satisfactory patient-reported outcomes. Improvements in dosimetry, rectal sparing, and target coverage were achieved with a rectal spacer. Randomized trials are warranted for further validation.

Perioral Paresthesia, Generalize Muscle Cramps, and Rhabdomyolysis After a Socotra Island Blue Baboon Tarantula (Monocentropus Balfouri) Bite.

BACKGROUND: Literature on systemic envenomation caused by tarantula bites, particularly from the Theraphosidae family, is relatively scarce. This case report provides a formal description of the first known instance of systemic envenomation caused by the Socotra Island Blue Baboon Tarantula (Monocentropus balfouri). CASE REPORT: In this case, a 23-year-old employee of an exotic pet shop suffered from perioral paresthesia, generalized muscle cramps, and rhabdomyolysis because of a Monocentropus balfouri bite. His symptoms were successfully relieved with oral benzodiazepines. EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights the potential for serious complications resulting from the bite of Monocentropus balfouri, a species gaining popularity among global exotic pet collectors.

Reliability of radiomics features due to image reconstruction using a standardized T2 -weighted pulse sequence for MR-guided radiotherapy: An anthropomorphic phantom study.

PURPOSE: To prospectively investigate the impact of image reconstruction on MRI radiomics features. METHODS: An anthropomorphic phantom was scanned at 1.5 T using a standardized sequence for MR-guided radiotherapy under SENSE and compressed-SENSE reconstruction settings. A total of 93 first-order and texture radiomics features in 10 volumes of interest were assessed based on (1) accuracy measured by the percentage deviation from the reference, (2) robustness on reconstruction in all volumes of interest measured by the intraclass correlation coefficient, and (3) repeatability measured by the coefficient of variance over the repetitive acquisitions. Finally, reliable and unreliable radiomics features were comprehensively determined based on their accuracy, robustness, and repeatability. RESULTS: Better accuracy and robustness of the radiomics features were achieved under SENSE than compressed-SENSE reconstruction. The feature accuracy under SENSE reconstruction was more affected by acceleration factor than direction, whereas under compressed-SENSE reconstruction, accuracy was substantially impacted by the increasing denoising levels. Feature repeatability was dependent more on feature types than on reconstruction. A total of 45 reliable features and 13 unreliable features were finally determined for SENSE, compared with 22 reliable and 26 unreliable features for compressed SENSE. First-order and gray-level co-occurrence matrix features were generally more reliable than other features. CONCLUSION: Radiomics features could be substantially affected by MRI reconstruction, so precautions need to be taken regarding their reliability for clinical use. This study helps the guidance of the preselection of reliable radiomics features and the preclusion of unreliable features in MR-guided radiotherapy.

Attitudes and educational needs of emergency doctors providing palliative and end-of-life care in Hong Kong: a cross-sectional analysis based on a self-report study.

BACKGROUND: Due to the ageing population in Hong Kong, the importance and need of palliative care and end-of-life (EOL) care are coming under the spotlight. The objectives of this study were to evaluate the attitudes of emergency doctors in providing palliative and EOL care in Hong Kong, and to investigate the educational needs of emergency doctors in these areas. METHODS: A questionnaire was used to study the attitudes of ED doctors of six different hospitals in Hong Kong. The questionnaire recorded the attitudes of the doctors towards the role of palliative and EOL care in EDs, the specific obstacles faced, their comfort level and further educational needs in providing such care. The attitudes of emergency doctors of EDs with EOL care services were compared with those of EDs without such services. RESULTS: In total, 145 emergency doctors completed the questionnaire, of which 60 respondents were from EDs with EOL care services. A significant number of participants recognized that the management of the dying process was essential in ED. Providing palliative and EOL care is also accepted as an important competence and responsibility, but the role and priority of palliative and EOL care in ED are uncertain. Lack of time and access to palliative care specialists/ teams were the major barriers. Doctors from EDs with EOL care services are more comfortable in providing such care and discuss it with patients and their relatives. Further educational needs were identified, including the management of physical complaints, communication skills, and EOL care ethics. CONCLUSIONS: The study identified obstacles in promoting palliative and EOL care in the EDs Hong Kong. With the combination of elements of routine ED practice and a basic palliative medicine skill set, it would promote the development of palliative and EOL care in Emergency Medicine in the future.

Clinical Associations of Uveitis in Axial Spondyloarthritis Group and Ankylosing Spondylitis Group: Do They Represent the Same Disease?

OBJECTIVE: The aim of this study was to determine the prevalence and associated factors for uveitis in ethnic Chinese patients with axial spondyloarthritis (SpA) and ankylosing spondylitis (AS). METHODS: This was a cross-sectional study. Patients fulfilling the Assessment of SpondyloArthritis international Society axial SpA criteria were recruited consecutively from 3 rheumatology centers in Hong Kong from March 2014 to July 2017. Clinical and biochemical parameters were collected. History of uveitis was inquired from both history and medical records. All patients received lumbosacral spine x-rays and whole-spine and sacroiliac joint magnetic resonance imaging. Patients were defined as axial SpA if they fulfilled the Assessment of SpondyloArthritis international Society criteria and AS if they fulfilled the modified New York criteria. Clinical and radiological findings were compared between patients with and without uveitis in the 2 groups. Factors associated with uveitis were identified with univariate analyses and multivariate logistic regression analyses. RESULTS: Among 252 patients, 67 patients (26.6%) had a history of uveitis. The male-to-female ratio was 55.4 to 44.6. Disease duration was 12.3 ± 11.7 years. In the axial SpA group, multivariate regression showed that older age (odds ratio [OR], 1.05; p = 0.01), human leukocyte antigen B27 positivity (OR, 11.79; p = 0.01), and history of inflammatory bowel disease (OR, 9.74; p = 0.04) were positively associated with uveitis. In the AS group, multivariate regression showed that back pain duration (OR, 1.05; p = 0.01) and male sex (OR, 3.46; p = 0.03) were associated with uveitis. CONCLUSIONS: Axial SpA represents a spectrum of diseases. Its clinical associations with uveitis should be distinguished from those of traditional AS.

Predictive model integrating dynamic parameters for massive blood transfusion in major trauma patients: The Dynamic MBT score.

BACKGROUND: Currently existing predictive models for massive blood transfusion in major trauma patients had limitations for sequential evaluation of patients and lack of dynamic parameters. OBJECTIVE: To establish a predictive model for predicting the need of massive blood transfusion major trauma patients, integrating dynamic parameters. DESIGN: Multi-center retrospective cohort study. SETTING: Four designated trauma centers in Hong Kong. METHODS: Trauma patients aged >12years were recruited from the trauma registries from 2005 to 2012. MBT was defined as delivery of ≥10units of packed red cells within 24h. Split sampling method was adopted for model building and validation. Multivariate logistic regression was adopted for model building, with weight assigned based on logarithmic of adjusted odds ratios. The performance of the dynamic MBT score (DMBT) was compared with the PWH score and the Trauma Associated Severe Hemorrhage (TASH) score in the validation data set. RESULTS: 4991 patients were included in the study. The DMBT was established with 8 parameters: systolic blood pressure, heart rate, hemoglobin, hemoglobin drop within the first 2h, INR, base deficit, unstable pelvic fracture and hemoperitoneum in radiological imaging. At cut-off score of 6 the DMBT achieved sensitivity of 78.2% and specificity of 89.2%. In the validation set, the AUCs of the DMBT, PWH score, and TASH score were 0.907, 0.844, and 0.867 respectively. CONCLUSIONS: The DMBT score allows both snapshot and sequential activation along the trauma care pathway and has better performance than the PWH score and TASH score.

Intrasession and Intersession Repeatability of Diffusion Tensor Imaging in Healthy Human Liver.

OBJECTIVE: The aim of this study was to evaluate the effect of signal to noise ratio (SNR) and number of gradient directions (NGD) on intra- and intersession repeatability of liver diffusion tensor imaging (DTI) metrics. METHODS: At each of 3 liver DTI scan sessions, liver diffusion was assessed in 5 healthy volunteers using a 6-direction DTI scan performed 9 separate times (ie, number of signal averages [NSA]). In addition, 4 combinations of NSA and NGD were acquired (NSA/NGD = 1/30, 3/10, 3/12, and 5/6) to determine the combined effect to DTI metrics, which was based on intersubject variability and intrasession (Vintra) and intersession (Vinter) repeatability. RESULTS: Intersubject variability was less than 20%, whereas Vintra and Vinter repeatability were less than 5% and less than 10%, respectfully. Vinter was not affected by the NGD used. Decreases in Vinter(FA), Vinter(λ1), Vinter(RD), and Vinter(MD) were observed with increasing NSA, and hence SNR. CONCLUSION: Increased SNR may improve intrasession and intersession repeatability of liver DTI metrics. Scan repeatability was not influenced by NGD.

Evaluation and Minimization of the Pseudohepatic Anisotropy Artifact in Liver Intravoxel Incoherent Motion.

PURPOSE: The aim of this study was to evaluate the effect of the pseudohepatic anisotropy artifact on liver intravoxel incoherent motion (IVIM) metrics and whether the use of multiple gradient directions in the IVIM acquisition minimizes the artifact. MATERIALS AND METHODS: Multiple breath-holding and forced shallow free-breathing IVIM scans were performed on 8 healthy volunteers using 1 and 6 gradient directions. Cluster analysis was carried out to separate motion-contaminated parenchyma from liver parenchyma and vessels. Nonlinear motion analysis was also performed to look for a possible link between IVIM metrics and nonlinear liver motion. RESULTS: On the basis of the resulted clusters, motion-contaminated parenchyma is often noted in the left liver lobe, where the prominent pseudohepatic artifact has previously been identified. A significant reduction in outliers was obtained with the acquisition of 6 noncoplanar gradient directions and when using forced shallow free-breathing. CONCLUSION: The pseudohepatic anisotropy artifact can be minimized when using multiple diffusion-encoding gradient directions and forced free-breathing during IVIM acquisition.

Living With Dementia: An Exploratory Study of Caregiving in a Chinese Family Context.

This qualitative study explored themes that described families taking care of elderly relatives with dementia in Chinese society. Ten families were invited for two in-depth family interviews involving spousal caregivers, child caregivers, and care recipients. Five themes resulted: positive affection as coping strategies, power and control in the caregiving relationship, adult children's involvement in caregiving, sibling rivalry, and intergenerational conflicts. The ways these themes functioned and helped in dementia care, the research implications, and limitations are discussed.

The effect of respiratory and cardiac motion in liver diffusion tensor imaging (DTI).

OBJECTIVE: To evaluate the effect of respiratory and cardiac motion on diffusion tensor imaging (DTI) metrics in healthy human liver. METHODS: Fifteen healthy subjects, participating in either part of this study, were scanned using a 1.5-T magnetic resonance imaging (MRI) device. Coronal liver DTI (6 diffusion-encoding directions; b, 300 mm/s) during breath holding was compared to free breathing. Cardiac motion effects were evaluated by comparing breath-held DTI scans acquired during both diastole and systole. RESULTS: Free breathing resulted in a significantly increased mean diffusivity (P < 0.05), λ1 (P < 0.01), λ2 (P < 0.05), and λ3 (P < 0.01) compared to breath holding. During systole significant increases in fractional anisotropy (P < 0.05), mean diffusivity (P < 0.05), and λ1 (P < 0.05), compared to systole, were found in the left lobe. The right lobe, which is less affected by cardiac motion, showed no significant change in DTI metrics over the cardiac cycle. CONCLUSIONS: Respiratory and cardiac motion tends to increase liver DTI metrics.

Contextual barriers to the successful implementation of family-centered practice in mental health care: a Hong Kong study.

This article presents findings from an exploratory study to identify nurses' perspectives on factors that hinder the implementation of family-centered practice in mental health settings in Hong Kong. Thirty-four nurses participated in the study by completing the pre- and post-questionnaires. Ten nurses were invited to participate in focus group and case interviews. The analysis identified knowledge-practice gap, role of psychiatric nurses, professional identity of psychiatric nurses, and management support as negatively affecting the nurses in implementing a family-centered approach to mental health care. Suggestions about facilitating the implementation of the family-centered approach into clinical practice are offered.

CD38 x ICAM-1 Bispecific Antibody Is a Novel Approach for Treating Multiple Myeloma and Lymphoma.

The cluster of differentiation 38 (CD38) is a well-validated target for treating multiple myeloma. Although anti-CD38 mAbs have demonstrated outstanding initial responses in patients with multiple myeloma, nearly all patients eventually develop resistance and relapse. In addition, currently approved CD38 targeting therapies have failed to show monotherapy efficacy in lymphomas, where CD38 expression is present but at lower levels. To effectively target CD38 on tumor cells, we generated an antibody-dependent cellular cytotoxicity (ADCC) enhanced bispecific CD38 x intercellular cell adhesion molecule 1 (ICAM-1) antibody, VP301. This bispecific antibody targets unique epitopes on CD38 and ICAM-1 on tumor cells with reduced red blood cell binding compared with the benchmark CD38 antibody daratumumab. VP301 demonstrated potent ADCC and antibody-dependent cellular phagocytosis activities on a selected set of myeloma and lymphoma cell lines even those with low CD38 expression. In an ex vivo drug sensitivity assay, we observed responses to VP301 in multiple myeloma primary samples from relapsed/refractory patients. Moreover, VP301 demonstrated potent tumor inhibition activities in in vivo myeloma and lymphoma models. Interestingly, combination of VP301 with the immunomodulatory drug, lenalidomide, led to synergistic antitumor growth activity in an in vivo efficacy study. In conclusion, the CD38 x ICAM-1 bispecific antibody VP301 demonstrated promising efficacy and specificity toward CD38+ and ICAM-1+ tumor cells and represents a novel approach for treating multiple myeloma and lymphoma.

An unexpected computed tomography finding in a suspected body packer.

INTRODUCTION: Computed tomography can be used to screen and diagnose the presence of drug-filled packets in the body. We present an unusual computed tomography finding in a suspected body packer. CASE SUMMARY: A traveller suspected of being a body packer was brought to the emergency department complaining of low back pain. On examination, there was an abdominal cast circumferentially encasing his abdomen, which he alleged was part of the management of his lower back pain in his own country. IMAGES: A plain computed tomogram of the abdomen and pelvis revealed that the cast was made of materials with a nodular appearance and heterogeneous density, which was different from that of a plaster of Paris cast. An investigation later confirmed the cast contained cocaine. CONCLUSION: Our case demonstrates how a body packer can traffic drugs outside their body for an alleged medical reason.

A study of Bayesian deep network uncertainty and its application to synthetic CT generation for MR-only radiotherapy treatment planning.

BACKGROUND: The use of synthetic computed tomography (CT) for radiotherapy treatment planning has received considerable attention because of the absence of ionizing radiation and close spatial correspondence to source magnetic resonance (MR) images, which have excellent tissue contrast. However, in an MR-only environment, little effort has been made to examine the quality of synthetic CT images without using the original CT images. PURPOSE: To estimate synthetic CT quality without referring to original CT images, this study established the relationship between synthetic CT uncertainty and Bayesian uncertainty, and proposed a new Bayesian deep network for generating synthetic CT images and estimating synthetic CT uncertainty for MR-only radiotherapy treatment planning. METHODS AND MATERIALS: A novel deep Bayesian network was formulated using probabilistic network weights. Two mathematical expressions were proposed to quantify the Bayesian uncertainty of the network and synthetic CT uncertainty, which was closely related to the mean absolute error (MAE) in Hounsfield Unit (HU) of synthetic CT. These uncertainties were examined to demonstrate the accuracy of representing the synthetic CT uncertainty using a Bayesian counterpart. We developed a hybrid Bayesian architecture and a new data normalization scheme, enabling the Bayesian network to generate both accurate synthetic CT and reliable uncertainty information when probabilistic weights were applied. The proposed method was evaluated in 59 patients (13/12/32/2 for training/validation/testing/uncertainty visualization) diagnosed with prostate cancer, who underwent same-day pelvic CT- and MR-acquisitions. To assess the relationship between Bayesian and synthetic CT uncertainties, linear and non-linear correlation coefficients were calculated on per-voxel, per-tissue, and per-patient bases. For accessing the accuracy of the CT number and dosimetric accuracy, the proposed method was compared with a commercially available atlas-based method (MRCAT) and a U-Net conditional-generative adversarial network (UcGAN). RESULTS: The proposed model exhibited 44.33 MAE, outperforming UcGAN 52.51 and MRCAT 54.87. The gamma rate (2%/2 mm dose difference/distance to agreement) of the proposed model was 98.68%, comparable to that of UcGAN (98.60%) and MRCAT (98.56%). The per-patient and per-tissue linear correlation coefficients between the Bayesian and synthetic CT uncertainties ranged from 0.53 to 0.83, implying a moderate to strong linear correlation. Per-voxel correlation coefficients varied from -0.13 to 0.67 depending on the regions-of-interest evaluated, indicating tissue-dependent correlation. The R2 value for estimating MAE solely using Bayesian uncertainty was 0.98, suggesting that the uncertainty of the proposed model was an ideal candidate for predicting synthetic CT error, without referring to the original CT. CONCLUSION: This study established a relationship between the Bayesian model uncertainty and synthetic CT uncertainty. A novel Bayesian deep network was proposed to generate a synthetic CT and estimate its uncertainty. Various metrics were used to thoroughly examine the relationship between the uncertainties of the proposed Bayesian model and the generated synthetic CT. Compared with existing approaches, the proposed model showed comparable CT number and dosimetric accuracies. The experiments showed that the proposed Bayesian model was capable of producing accurate synthetic CT, and was an effective indicator of the uncertainty and error associated with synthetic CT in MR-only workflows.

Prostate diffusion-weighted imaging (DWI) in MR-guided radiotherapy: Reproducibility assessment on 1.5 T MR-Linac and 1.5 T MR-simulator.

PURPOSE: Diffusion-weighted imaging (DWI) holds promise for image-guided radiotherapy (MRgRT) in prostate cancer. However, challenges persist due to image distortion, artifacts, and apparent diffusion coefficient (ADC) reproducibility issues. This study aimed to assess DWI image quality and ADC reproducibility on both a 1.5 T MR-simulator and a 1.5 T MR-Linac, employing measurements from both an ACR MRI phantom and prostate cancer patients undergoing MRgRT. METHODS: DW-MRI scans were conducted on 19 patients (mean age = 69 ± 8 years, with 23 MR-visible intra-prostatic lesions) and an ACR MRI phantom using a 1.5 T MR-simulator (b-values = 0, 800, 1400s/mm2) and a 1.5 T MR-Linac (b-values = 50, 500, 800 s/mm2). ADC homogeneity in the phantom was evaluated via 1D profile flatness (FL) in three directions. Image quality was assessed through qualitative 5-point Likert scale ratings and quantitative ADC and signal-to-noise ratio (SNR) measurements. Intra-observer reproducibility of image quality scores was evaluated using ICC(1, 2). Geometric distortion was measured by comparing landmark sizes on the ACR phantom against the ground truth. Mean ADC and reproducibility were assessed using Bland-Altman plots. RESULTS: Both MR-simulator and MR-Linac demonstrated high ADC homogeneity (FL > 87.5% - MR-simulator: 97.23 ± 0.62%, MR-Linac: 94.75 ± 0.62%, p < 0.05) in the phantom. Image quality scores revealed acceptable ratings (≥3) for capsule demarcation, image artifacts, and geometric distortion in patients. However, intra-prostatic lesions were barely discernible in b800 images for both MR-simulator (average score = 2.37 ± 1.33) and MR-Linac (average score = 2.16 ± 1.28). While MR-Linac DWI scans exhibited significantly more severe geometric distortion than MR-simulator scans (p < 0.01), most phantom measurements fell within the image in-plane resolution of 3 mm. Significant differences were noted in MR-simulator ADC (CTV: 1.20 ± 0.14 × 10-3 mm2/s (MR-simulator) vs 1.06 ± 0.10 × 10-3 mm2/s (MR-Linac); GTV: 1.05 ± 0.21 × 10-3 mm2/s vs 0.91 ± 0.16 × 10 mm2/s, all p < 0.05), with a small non-zero bias observed in the Bland-Altman analysis (CTV: 12.3%; GTV: 14.5%). CONCLUSION: The significantly larger MR-simulator ADC and the small non-zero bias hint at potential systematic differences in ADC values acquired from an MR-simulator and an MR-Linac, both at 1.5 T. Although acceptable ADC homogeneity was noted, caution is warranted in interpreting MR-Linac DWI images due to occasional severe artifacts. Further studies are essential to validate DWI and ADC as reliable imaging markers in prostate cancer MRgRT.

A contrast in safety, pharmacokinetics and pharmacodynamics across age groups after a single 50 mg oral dose of the γ-secretase inhibitor avagacestat.

AIM: To evaluate the single dose pharmacokinetics, pharmacodynamics, and preliminary tolerability of the γ-secretase inhibitor BMS-708163 (avagacestat) in young and elderly men and women. METHODS: All subjects received double-blinded administration of a single 50 mg dose of avagacestat in capsule form or matching placebo. Main evaluations included pharmacokinetics, safety, plasma amyloid-ß (Aß)(1-40) concentratios and exploration of Notch biomarkers. RESULTS: Avagacestat 50 mg capsule was well tolerated and rapidly absorbed among young and elderly subjects, with a median t(max) between 1 and 2 h post dose and an average half-life between 41 and 71 h. In general, subjects aged 75 years or more had higher AUC(0,∞) values than those aged less than 75 years. An exploratory analysis of Aß(1-40) serum concentrations showed a pattern of decreasing concentrations over the first 4-6 h followed by a rise above baseline that was maintained until the end of the assessment period. Adverse events were generally mild, occurring more frequently in elderly subjects, with no observed difference between subjects receiving avagacestat and placebo. No dose limiting gastrointestinal effects of avagacestat were observed and exploratory biomarkers of Notch inhibition did not change significantly. CONCLUSIONS: The favourable safety profile and pharmacokinetic effects of avagacestat in this study support its continued development, especially in the target population of elderly subjects with mild cognitive impairment or Alzheimer's disease.

Extraocular Orbital and Peri-Orbital Masses.

In this article, we will describe relevant anatomy and imaging findings of extraocular and orbital rim pathologic conditions. We will highlight important clinical and imaging pearls that help in differentiating these lesions from one another, and provide a few practical tips for challenging cases.

Analysis of online plan adaptation for 1.5T magnetic resonance-guided stereotactic body radiotherapy (MRgSBRT) of prostate cancer.

PURPOSE: To analyze and characterize the online plan adaptation of 1.5T magnetic resonance-guided stereotactic body radiotherapy (MRgSBRT) of prostate cancer (PC). METHODS: PC patients (n = 107) who received adaptive 1.5 Tesla MRgSBRT were included. Online plan adaptation was implemented by either the adapt-to-position (ATP) or adapt-to-shape (ATS) methods. Patients were assigned to the ATS group if they underwent ≥ 1 ATS fraction (n = 51); the remainder were assigned to the ATP group (n = 56). The online plan adaptation records of 535 (107 × 5) fractions were retrospectively reviewed. Rationales for ATS decision-making were determined and analyzed using predefined criteria. Statistics of ATS fractions were summarized. Associations of patient characteristics and clinical factors with ATS utilization were investigated. RESULTS: There were 87 (16.3%) ATS fractions and 448 ATP fractions (83.7%). The numbers of ATS adoptions in fractions 1-5 were 29 (29/107, 27.1%), 18 (16.8%), 15 (14.0%), 16 (15.0%), and 9 (8.4%), respectively, with significant differences in adoption frequency between fractions (p = 0.007). Other baseline patient characteristics and clinical factors were not significantly associated with ATS classification (all p > 0.05). Underlying criteria for the determination of ATS implementation comprised anatomical changes (77 fractions in 50 patients) and discrete multiple targets (15 fractions in 3 patients). No ATS utilization was determined using dosimetric or online quality assurance criteria. CONCLUSIONS: This study contributes to facilitating the establishment of a standardized protocol for online MR-guided adaptive radiotherapy in PC.

Use of high flow nasal cannula oxygen therapy for patients infected with SARS-CoV-2 outside intensive care setting.

Background: In early 2022, there was a sudden surge of patients infected by the Omicron variant of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in Hong Kong (HK), resulting in 9,163 deaths as of 29 May 2022. Many of the local population had not been vaccinated before this wave. The number of patients who developed coronavirus disease 2019 (COVID-19) related respiratory failure outnumbered the capacity of intensive care unit (ICU) beds. Some of these patients had to be supported with high flow nasal cannula (HFNC) therapy outside ICU setting. HK was in crisis situation. The primary objective of this study is to assess the 28-day mortality of this group of patients. The secondary objective is to explore any predictors of non-survivors to help clinical decision-making in future crisis. Methods: This is a retrospective observational study of patients suffering from COVID-19 related respiratory failure who received HFNC therapy in general medical wards of two hospitals during the period of 17 Mar to 30 Apr 2022. Survival and risk factors were reviewed. Results: Forty-nine patients were recruited. Twenty-six patients (53%) survived at 28-day after initiation of HFNC support. Three clinical parameters were found to be significantly associated with mortality at 28-day: (I) SpO2/FiO2 (SF) ratio <160 at 48 hours; (II) SF ratio <191 at 72 hours; (III) serial SF ratio at 48 or 72 hours showing no improvement over that at the time of initiation of HFNC therapy. Conclusions: Use of HFNC outside ICU setting showed benefit to patients suffering from COVID-19 related acute hypoxemic respiratory failure (AHRF). Serial SF ratio monitoring at 48 and 72 hours after therapy initiation might serve as predictors of outcome and thus guide clinical decision-making for medical resource allocation in outbreak situation.