Methodological guide for assessing the carbon footprint of external beam radiotherapy: A single-center study with quantified mitigation strategies.

Background and purposes: Data on the carbon footprint of external beam radiotherapy (EBRT) are scarce. Reliable and exhaustive data, including a detailed carbon inventory, are needed to determine effective mitigation strategies. Materials and methods: This study proposes a methodology for calculating the carbon footprint of EBRT and applies it to a single center. Mitigation strategies are derived from the carbon inventory, and their potential reductions are quantified whenever possible. Results: The average emission per treatment and fraction delivered was 489 kg CO2eq and 27 kg CO2eq, respectively. Patient transportation (43 %) and the construction and maintenance of linear accelerators (LINACs) and scanners (17 %) represented the most significant components. Electricity, the only energy source used, accounted for only 2 % of emissions.Derived mitigation strategies include a data deletion policy (reducing emissions in 30 years by 12.5 %), geographical appropriateness (-12.2 %), transportation mode appropriateness (-9.3 %), hypofractionation (-5.9 %), decrease in manufacturers' carbon footprint (-5.2 %), and an increase in machine durability (-3.5 %). Conclusion: Our findings indicate that a significant reduction in the carbon footprint of a radiotherapy unit can be achieved without compromising the quality of care.This study provides a methodology and a starting point for comparison and proposes and quantifies mitigation strategies, paving the way for others to follow.

Bruxism and dental implants: A systematic review and meta-analysis.

BACKGROUND: Overload from bruxism may affect survival of dental implants. OBJECTIVES: To evaluate implant failure and marginal bone loss (MBL) in patients presenting with probable bruxism compared to non-bruxers. The study was registered in PROSPERO (CRD42021238397). METHODS: An electronic search September 2022 in PubMed/Medline, Web of Science and Science Direct was combined with a hand search. Two independent reviewers carried out abstract screening, full-text assessment, quality assessment (National Institutes of Health tool) and data extraction. Only studies that provided information on self-report and clinical examination needed for the diagnosis of at least 'probable' bruxism were included. A pairwise random-effect meta-analysis was carried out. RESULTS: In total 1338 studies were identified, and after screening and full-text assessment 27 studies that presented data on 2105 implants in probable bruxers and 10 264 implants in non-bruxers were included, with 138 and 352 implant failures in respective groups. the meta-analysis showed that implants placed in probable bruxers had a higher risk of failure than in non-bruxers (OR 2.189; 95% CI 1.337, 3.583, p = .002). A meta-regression showed that follow-up time did not affect this OR. Eighteen studies provided general data on MBL but did not report results separated between bruxers and non-bruxers. Therefore, an analysis of MBL was not possible. CONCLUSION: The results of the present systematic review show that implants placed in probable bruxers present a significantly higher risk of failure than implants placed in non-bruxers. This should be considered in treatment planning and management of implant patients.

Treatment of Epstein-Barr Virus-Related Post-Renal Transplantation Development of Diffuse Large B Cell Lymphoma of the Distal Ureter: A Case Report.

Posttransplant lymphoproliferative disorder with involvement of the donor urogenital tissue is a rare and serious complication of solid organ transplant. We report an adult kidney transplant recipient who developed the diffuse large B cell lymphoma of the distal ureter in the setting of new allograft nephropathy. Early intervention, reduction of immunosuppression, surgical reconstruction and chemotherapy salvaged the allograft kidney and averted a fatal outcome. The renal function recovered to the baseline with creatinine ranging between 1.3 and 1.5. The patient did not require dialysis at any point after ureteral stent placement and reconstructive surgery. In addition, the case highlights the importance of multidisciplinary management involving transplant nephrology, oncology, transplant surgery, and urology in such a complicated disease process.

Serous cystadenoma of the tunica testis: A case of malignancy mimicry.

Cystadenoma of the tunica of the adult male testis has rarely been reported in the literature. We report a case of an adult serous cystadenoma along with the radiological and pathological findings. The patient was a 40-year-old male with a slowly growing mass on the left testis. An ultrasound scan of left testis showed features highly suspicious for malignancy. Lactate dehydrogenase (LDH) was mildly elevated. Alpha feta-protein (AFP) and beta-human chorionic gonadotropin (beta hCG) were negative. We performed left radical orchiectomy. The pathological findings showed serous cystadenoma of the tunica of the testis. The patient remains asymptomatic.

Single-Port Robotic Radical Cystectomy with Intracorporeal Bowel Diversion: Initial Experience and Review of Surgical Outcomes.

Introduction and Objective: Scant literature is available on surgical outcomes of radical cystectomies on the new single-port (SP) system. This study compares short-term outcomes in patients undergoing radical cystectomy with those undergoing intracorporeal urinary diversion (ICUD) on the multiport (MP) vs SP platform. Methods: This institutional review board approved study used a prospective cystectomy database and nonparametric testing including chi-squared, Mann-Whitney U, and Fisher exact tests to analyze all variables stratified by surgical approach. Results: Thirty-four patients underwent radical cystectomy with ICUD from September 1, 2019, to February 8, 2021. Twenty patients were in the MP cohort, whereas 14 were in the SP group. Table 1 presents the demographics of both groups and shows no statistically significant differences. Intra- and postoperative as well as pathology data are given in Table 2. Patients in the SP group had less narcotic use (MP: 25 morphine milligram equivalent [MME] vs SP: 11.5 MME, p = 0.047) and shorter return of bowel function (MP: 3 days vs SP: 2 days, p = 0.032). Operative times were similar between both groups despite having fewer patients undergoing ileal conduit (MP: 85% vs SP: 50%, p = 0.027) in the SP group. In Table 3, we list the early short-term postoperative follow-up data for each group that showed no significant differences between the two groups with an average follow-up of 4.9 months for MP and 4.4 months for SP. Conclusions: Our initial experience with SP robotic cystectomy and ICUD appears to be safe and an effective alternative to MP cystectomies. A learning curve was involved but the overall transition from MP to SP was smooth. Operative times were similar despite fewer patients undergoing ileal diversion, shorter return of bowel function, and less narcotic use in the SP group. Further studies including longer follow-ups with multi-institutional data are underway.

Symptomatic corpus spongiosum defect in adolescents and young adults who underwent distal hypospadias repair during childhood.

INTRODUCTION AND OBJECTIVE: Several popular surgical techniques have been described for the repair of distal hypospadias; however, the role of repairing the corpus spongiosum was rarely discussed. Herein we review our experience with adolescents who underwent hypospadias repair during childhood. Their main complaints were partially or totally related to spongiosum deficiency, the surgical outcomes are also discussed. METHODS: Between 2007 and 2018, 25 patients aged between 13 and 28 years of age (median 19 years) were operated upon to repair the deficiency or absence of corpus spongiosum in addition to a Thiersch-Duplay urethroplasty. Their records indicated that the primary hypospadias repairs during childhood included MAGPI (N = 10) and TIPU (N = 9), in 6 patients the repair of the distal hypospadias was unknown. The main complaints were; abnormal urinary stream which patients described as spraying and/or dripping of urine (N = 10) and distal urethral swelling during voiding and dripping of urine post voiding (N = 15). Eight patients reported that they were treated for symptomatic recurrent urinary tract infections by their primary physicians. In 5 patients, the urethral wall was thin and covered with adherent epidermis only. In 20 patients, the laterally displaced spongiosum pillars were well-defined, 4 of whom exhibited mild chordee. In 14 patients the spongiosum pillars were mobilized and approximated using interrupted absorbable sutures. Four patients had spongiosum deficiency and urethral swelling resulting in mild diverticulum formation. The urethral wall was plicated and covered with the spongiosum and/or dartos flaps. In 4 patients the spongiosum pillars were fixed and could not be mobilized to provide a tension-free closure. In these cases, a dartos flap harvested from the scrotum, and used to cover the urethral wall and was sutured on either side to the spongiosum pillars. 12/25 patients underwent glandular contouring and/or meatoplasty simultaneously to improve the penile esthetics. RESULTS: The follow-up period varied between 18 months and 7 years (mean 3.5 years). 24/25 patients reported a normal steady urinary stream, absence of urethral swelling during voiding and none (22) or minimal (2) postvoid droplets of urine which soiled the underwear. One patient developed glans dehiscence and is voiding through a coronal meatus; he declined further surgery. None developed symptomatic urinary infection. The spongioplasty corrected the mild curvature in all 4 patients. CONCLUSIONS: Failure to recognize and/or correct the deficient corpus spongiosum during the repair of distal hypospadias during childhood may become symptomatic during adolescence however, the abnormality can be corrected successfully.

Impact of Dialysis Requirement in Community-acquired Pneumonia Hospitalizations.

Background Community-acquired pneumonia (CAP) is a common cause of hospitalization. While there are single-center studies on acute kidney injury requiring dialysis (AKI-D) and CAP, data on national trends and outcomes regarding AKI-D in CAP hospitalizations is lacking. Methods We utilized the Nationwide Inpatient Sample to analyze trends overall and within subgroups. We also utilized multivariate regression to adjust for potential confounders of annual trends and to generate adjusted odds ratios (aOR) for predictors and outcomes, including mortality and adverse discharge. Results There were 11,500,456 pneumonia hospitalizations between 2002 and 2013, of which 3675 (0.3%) were complicated by AKI-D. The AKI-D rate increased from 2.7/1000 hospitalizations in 2002 to 4.3/1000 hospitalizations in 2013. The rate of increase was higher in males and African Americans. Although temporal changes in demographics and comorbidities explained a substantial proportion, they could not explain the entire trend. The predictor with the highest odds of AKI-D required mechanical ventilation during hospitalization (aOR 12.47; 95% CI 11.66-13.34). Other significant predictors included sepsis (aOR 4.37; 95% CI 4.09-4.66), heart failure (aOR 2.40; 95% CI 2.25-2.55), and chronic kidney disease (CKD) (aOR 2.00; 95% CI 1.86-2.16). AKI-D was associated with increased in-hospital mortality (aOR 3.08; 95% CI 2.88-3.30) and adverse discharge (aOR 2.09; 95% CI 1.92-2.26). Although adjusted mortality decreased per year, attributable mortality remained stable. Conclusion Pneumonia hospitalizations complicated by AKI-D have increased with a differential increase by demographic groups. AKI-D is associated with significant morbidity and mortality. In the absence of effective AKI-D therapies, the focus should be on early risk stratification and prevention to avoid this devastating complication.

Intensity modulated arc therapy in bilaterally irradiated head and neck cancer: a comparative and prospective multicenter planning study.

A dosimetric comparison was made of Helical Tomotherapy (HT) and Rapid'Arc(®) (RA) in 115 patients with head and neck carcinoma included in a prospective and multicentric study. HT and RA provided highly conformal plans that easily complied with dose volume constraints for organs at risk. HT reduced high doses to the planning target volumes (PTVs) compared to RA and provided a more homogeneous dose distribution but with an increased Non Tumoral Integral Dose (NTID) than RA. However, the clinical consequences of these dosimetric advantages and disadvantages need further investigation.

Is IMAT the ultimate evolution of conformal radiotherapy? Dosimetric comparison of helical tomotherapy and volumetric modulated arc therapy for oropharyngeal cancer in a planning study.

BACKGROUND: Intensity Modulated Arc Therapy (IMAT) can be planned and delivered via several techniques. Advanced Radiotherapy (ARTORL) is a prospective study that aims to evaluate the treatment costs and clinical aspects of implementing these IMAT techniques for head and neck cancers. In this context, we evaluated the potential dosimetric gain of Helical Tomotherapy (TomoTherapy, Accuray, HT) versus VMAT (Rapid'Arc(®), Varian Medical System, RA) for oropharyngeal cancer (OC). MATERIAL AND METHODS: Thirty patients were selected from our database in whom bilateral neck irradiation and treatment to the primary were indicated. Each patient was planned twice using both HT and RA planning systems using a simultaneous integrated boost approach. For the planning target volumes (PTV) and organs at risk, ICRU 83 reporting guidelines were followed. RA and HT plans were compared using paired Student's t-test. RESULTS: RA and HT produced plans with a good coverage of PTVs and acceptable sparing of OARs. Although some dosimetric differences were statistically significant, they remained small. However, the near maximal dose to the PRV of spinal cord and brain stem was lower with HT. Regarding normal tissue, HT increased the volume irradiated at doses between 4 and 20 Gy compared to RA. CONCLUSION: In OC, HT and RA showed similar dosimetric results. They represent the maximum gains obtained with photon beams. The medicoeconomic evaluation of our study is ongoing and may reveal differences between these techniques in terms of MU number, fraction time, and clinical evaluation.

[Radiation induced side effects]. / Effets indésirables de la radiothérapie.

More than half of all people with cancer are treated with radiation therapy. Over the last decade the technical advances, both in therapy beam precision and imaging, have greatly improved the therapeutic ratio and accuracy of modern radiotherapy. However, damaging healthy tissues near the tumor leads to radiation induced injury that develops immediately and continue to progress long after exposure to radiation. Recently dramatic advances have been made in understanding the determinant of tissue response to radiation exposure.

Exclusive and adjuvant radiotherapy in breast cancer patients with synchronous metastases.

BACKGROUND: Data from the Surveillance, Epidemiology, and End Results program and the European Concerted Action on survival and Care of Cancer Patients (EUROCARE) project indicate that about 6% of women newly diagnosed with breast cancer have stage IV disease, representing about 12 600 new cases per year in the United States in 2005. Historically, local therapy of the primary tumor in this setting has been aimed solely at symptom palliation. However, several studies suggest that surgical excision of the primary tumor can prolong these patients' survival. DISCUSSION: Exclusive locoregional radiotherapy is an alternative form of locoregional treatment in this setting and may represent an effective alternative to surgery in this setting. Here we discuss current issues regarding exclusive and adjuvant locoregional radiotherapy in breast cancer patients with synchronous metastases. SUMMARY: Several studies suggest that surgery or exclusive irradiation of the primary tumor is associated with better survival in breast cancer patients with synchronous metastases and that exclusive locoregional radiotherapy may represent an effective alternative to surgery in this setting. Results of well-designed prospective studies are needed to re-evaluate treatment of the primary breast tumor in patients with metastases at diagnosis, and to identify those patients who are most likely to benefit.

Prenatal acetaminophen exposure and risk of wheeze at age 5 years in an urban low-income cohort.

BACKGROUND: Acetaminophen has been associated with asthma and is in part metabolised via the glutathione pathway. Inner-city minority children have high asthma morbidity and a relatively high frequency of a minor allele variant in the glutathione S transferase Pi gene (GSTP1). We hypothesised that prenatal acetaminophen exposure would predict wheeze at age 5 years in an inner-city minority cohort and examined whether this association was modified by common polymorphisms in genes related to the glutathione pathway. METHODS: An ongoing population-based birth cohort study of Dominican Republic and African-American children in New York prospectively assessed the use of analgesics during pregnancy and current wheeze at age 5 years in 301 children. Genotyping was conducted for GST polymorphisms. Binomial regression was used to adjust for potential confounders including postnatal acetaminophen use. RESULTS: 34% of mothers reported acetaminophen use during pregnancy and 27% of children had current wheeze at 5 years. Prenatal exposure to acetaminophen predicted current wheeze (multivariate relative risk 1.71; 95% CI 1.20 to 2.42; p=0.003), and the risk increased monotonically with increasing number of days of prenatal acetaminophen exposure (p trend <0.001). 68% of children had at least one copy of the GSTP1 minor allele (Val). The risk of wheeze was modified by GSTP1 (additive interaction p=0.009) and was observed only among children with the GSTP1 minor allele. CONCLUSIONS: Prenatal exposure to acetaminophen predicted wheeze at age 5 years in an inner-city minority cohort. The risk was modified by a functional polymorphism in GSTP1, suggesting a mechanism involving the glutathione pathway.

Breast cancer with synchronous metastases: survival impact of exclusive locoregional radiotherapy.

PURPOSE: Several studies suggest that surgical excision of the primary tumor improves survival among patients with stage IV breast cancer at diagnosis. Exclusive locoregional radiotherapy (LRR) is an alternative form of locoregional treatment (LRT) in this setting. We retrospectively studied the impact of LRT on the survival of breast cancer patients with synchronous metastases. PATIENTS AND METHODS: Among 18,753 breast cancer patients treated in our institution between 1980 and 2004, 598 patients (3.2%) had synchronous metastasis at diagnosis. Demographic data, tumor characteristics, metastatic sites, and treatments were prospectively recorded. The impact of LRT on overall survival (OS) was evaluated by multivariate analysis including known prognostic factors. RESULTS: Among 581 eligible patients, 320 received LRT (group A), and 261 received no LRT (group B). LRT consisted of exclusive LRR in 249 patients (78%), surgery of the primary tumor with adjuvant LRR in 41 patients (13%), and surgery alone in 30 patients (9%). With a median follow-up time of 39 months, the 3-year OS rates were 43.4% and 26.7% in group A and group B (P =.00002), respectively. The association between LRT and improved survival was particularly marked in women with visceral metastases. LRT was an independent prognostic factor in multivariate analysis (hazard ratio [HR] = 0.70; 95% CI, 0.58 to 0.85; P = .0002). The adjusted HR for late death (>or= 1 year) was 0.76 (95% CI, 0.61 to 0.96; P = .02). CONCLUSION: In our experience, LRT, consisting mainly of exclusive LRR, was associated with improved survival in breast cancer patients with synchronous metastases. Exclusive LRR may thus represent an active alternative to surgery.