Dosimetric Effect of Thymus and Thoracic Duct on Radiation-Induced Lymphopenia in Patients With Primary Lung Cancer Who Received Thoracic Radiation.

Purpose: Radiation-induced lymphopenia is a well-recognized factor for tumor control and survival in patients with cancer. This study aimed to determine the role of radiation dose to the thymus and thoracic duct on radiation-induced lymphopenia. Methods and Materials: Patients with primary lung cancer treated with thoracic radiation therapy between May 2015 and February 2020 with whole blood count data were eligible. Clinical characteristics, including age, gender, histology, stage, chemotherapy regimen, radiation dosimetry, and absolute lymphocyte count (ALC) were collected. The thymus and thoracic duct were contoured by one investigator for consistency and checked by one senior physician. The primary endpoint was radiation-induced decrease in lymphocytes, defined as the difference in ALC (DALC) before and after radiation therapy. Results: The data of a total of 116 consecutive patients were retrospectively retrieved. Significant correlations were found between DALC and several clinical factors. These factors include stage, chemotherapy or concurrent chemoradiation, biologically effective dose (BED), mean lung dose, mean body dose, effective dose to immune cells (EDIC), mean thymus dose (MTD), and mean thoracic duct dose (MTDD) (all P < .05). Ridge regression showed that DALC = 0.0063 × BED + 0.0172 × EDIC + 0.0002 × MTD + 0.0147 × MTDD + 0.2510 (overall P = .00025 and F = 5.85). The combination model has the highest area under the curve of 0.77 (P < .001) when fitting the logistic regression model on DALC categorized as binary endpoint. The sensitivity and specificity of the combined model were 89% and 58%, respectively. Conclusions: This study demonstrated for the first time that radiation doses to the thymus and thoracic duct are strongly associated with radiation-induced lymphopenia patients with lung cancer. Further validation studies are needed to implement thymus and thoracic duct as organs at risk.

The Geography of Social Distancing in Canada: Evidence from Facebook.

This article analyzes which characteristics are correlated with mobility reductions during the COVID-19 pandemic, using census-division-level mobility data for Canada from Facebook. There is significant variation in the extent to which social distancing was applied in April, relative to a preperiod of February. I find that the population and population density of a census division are strongly correlated with larger mobility reductions. Conversely, I find that areas with a larger share of dwellings that are apartments exhibit smaller mobility reductions, suggesting that those in tighter living conditions may find it less possible to stay at home during the pandemic. Finally, I examine the persistence of mobility reductions into May and show that areas with a larger apartment dwelling share are more likely to maintain their social distancing over time.

L'auteur analyse quelles caractéristiques sont en corrélation avec les réductions de la mobilité au cours de la pandémie de la COVID­19, à partir de données sur la mobilité, au niveau des divisions de recensement pour le Canada, tirées de Facebook. La mesure dans laquelle la distanciation physique a été appliquée en avril, par rapport à la période qui a précédé en février, varie sensiblement. Selon les constatations de l'auteur, la population et la densité de population d'une division de recensement sont en étroite corrélation avec de plus importantes réductions de la mobilité. Inversement, l'auteur observe que les secteurs dans lesquels la proportion d'immeubles d'appartements affichent des réductions de la mobilité plus modestes, ce qui laisse croire que les personnes dont les conditions de vie sont plus rigoureuses risquent de se rendre compte qu'il leur est moins possible de rester à la maison durant la pandémie. Enfin, l'auteur s'intéresse à la persistance des réductions de la mobilité en mai et montre que dans les secteurs dont la proportion d'immeubles d'appartements est plus grande, le maintien de la distanciation physique dans le temps est davantage probable.

Proximal interphalangeal joint dislocations and treatment: an evolutionary process.

BACKGROUND: Proximal interphalangeal joint (PIPJ) dislocations represent a significant proportion of hand clinic visits and typically require frequent follow-ups for clinical assessment, orthotic adjustments, and physiotherapy. There are a large number of treatment options available for PIPJ dislocations, yet no prospective or controlled studies have been carried out, largely due to the diversity of the various types of injuries. METHODS: We retrospectively reviewed all the PIPJ dislocations in our institution over a five-year period and directly compared the different splinting techniques that we have used over this time frame. RESULTS: There were a total of 77 dislocations of the PIPJ (57 men and 20 women) that were included in our study. We found that our management has shifted gradually from complete immobilisation to controlled early mobilisation with figure-of-eight splints. Following treatment, the range of motion of the PIPJ in the figure-of-eight group was significantly greater than that in the other three methods (P<0.05) used. There were significantly fewer hospital visits in the figure-of-eight splint group than in the other treatment groups. CONCLUSIONS: The treatment of PIPJ dislocations has undergone a significant evolution in our experience. Early controlled mobilisation has become increasingly important, and therefore, splints have had to be adapted to allow for this. The figure-of-eight splint has yielded excellent results in our experience. It should be considered for all PIPJ dislocations, but careful patient selection is required to achieve optimum results.

Mesenteric fat thickness is associated with increased risk of obstructive sleep apnoea.

BACKGROUND AND OBJECTIVE: Mesenteric fat is a type of intraperitoneal adipose tissue draining into portal circulation. The objective of this study was to investigate the relationships between mesenteric fat thickness and obstructive sleep apnoea (OSA) in patients with suspected OSA. METHODS: One hundred forty-nine subjects (men: 114; women: 35) with suspected OSA underwent ultrasound examinations of mesenteric, preperitoneal and subcutaneous fat thickness after overnight polysomnography. Body mass index (BMI) and neck circumference were recorded. RESULTS: The subjects with OSA (n = 130, apnoea/hypopnoea index (AHI) >5/h) had greater neck circumference, higher BMI, and greater mesenteric and preperitoneal fat thickness than those without OSA (n = 19, AHI ≤ 5/h). There was positive correlation of AHI with mesenteric (r = 0.43, P < 0.001) and preperitoneal fat thickness (r = 0.3, P < 0.001), whereas no significant association was observed between AHI and subcutaneous fat thickness (r = 0.09, P = 0.27). On multivariate logistic regression, after adjustments for gender, age, BMI, neck circumference, and preperitoneal and subcutaneous fat thickness, the mesenteric fat thickness had a positive association with the presence of moderate OSA and severe OSA, with odds ratios of 7.18 and 7.45 for every 1 cm increase in mesenteric fat thickness when AHI was defined as ≥15/h and AHI ≥ 30/h, respectively. CONCLUSIONS: Mesenteric fat thickness is associated with increased risk of OSA, independent of other abdominal fat thickness, BMI and neck circumference. Sonographic measurement is potentially a useful tool for further evaluating the complex association of visceral fat, metabolic syndrome and OSA.

Intrarenal arterial resistance is associated with microvascular complications in Chinese type 2 diabetic patients.

BACKGROUND: Increased renal arterial resistance is associated with various types of chronic renal parenchymal diseases. A resistance index (RI) > 0.8 predicts deterioration in renal function in diabetic subjects. However, the association between renal RI and other diabetic complications has not been investigated. In this study, we examined the association between intrarenal arterial RI and diabetic complications in Chinese type 2 diabetic subjects. METHODS: Three hundred and eighty-seven Chinese type 2 diabetic patients were recruited from a structured assessment programme to evaluate their risk factors and complications as a part of the quality improvement programme at the Prince of Wales Hospital. All subjects underwent ultrasound examinations for the assessment of intrarenal arterial RI of both kidneys. Clinical and biochemical parameters, including diabetes-related microvascular complications (nephropathy, retinopathy and sensory neuropathy) and macrovascular diseases, were examined. RESULTS: The mean RI of patients with any microvascular complications (0.70 ± 0.09 versus 0.65 ± 0.06) such as nephropathy (0.71 ± 0.09 versus 0.66 ± 0.06), retinopathy (0.71 ± 0.08 versus 0.67 ± 0.08) and sensory neuropathy (0.75 ± 0.07 versus 0.68 ± 0.08) and with any macrovascular complications (0.71 ± 0.09 versus 0.68 ± 0.08) was higher than those without (P < 0.05). On multivariate analysis, after controlling for confounding variables, an RI ≥0.75 was associated with microvascular complications, nephropathy, retinopathy and sensory neuropathy, with odds ratio of 4.02 [95% confidence interval (CI) 1.72-9.4], 4.99 (2.61-9.56), 2.78 (1.52-5.09) and 5.74 (1.8-18.3), respectively. The association of RI with macrovascular complications was not significant in multivariate analysis. CONCLUSION: Increased intrarenal arterial resistance was independently associated with an increased risk of microvascular complications including diabetic nephropathy, diabetic retinopathy and diabetic sensory neuropathy in Chinese type 2 diabetic patients.

Avoiding "culture rejection" in healthcare mergers and acquisitions: how New Heights Community Health Centres and York Community Services minimized the culture risk when forming Unison Health and Community Services.

Among the requirements for a successful merger or acquisition are strategic rationale, rigorous due diligence, the right price and revenue and cost synergies. However, bridging the culture gap between organizations is frequently overlooked. The leaders of New Heights Community Health Centres and York Community Services explicitly considered culture in their merger to form Unison Health and Community Services, and they used employee engagement surveys to assess culture in their merger planning and post-merger integration. How Unison Health leaders avoided the risk of culture rejection to achieve a successful merger, and the lessons learned from their experience, is the focus of this article.

US assessment of medial arterial calcification: a sensitive marker of diabetes-related microvascular and macrovascular complications.

PURPOSE: To examine the sensitivity of ultrasonography (US) compared with conventional radiography in detection of lower limb (thigh) medial arterial calcification (MAC) in type 2 diabetic patients and evaluate its association with diabetes-related complications. MATERIALS AND METHODS: The study was approved by the local research ethics committee, and informed written consent was obtained. US was performed in 289 patients with type 2 diabetes mellitus, and MAC severity was assigned a score from 0 to 8. Among the patients, 263 underwent radiographic examinations. All subjects underwent clinical evaluation to detect the presence of diabetes-related complications. RESULTS: US helped detect MAC in more subjects compared with radiography (65.8% vs 12.2%). US helped detect MAC from mild (scores 1-4) to severe (scores 5-8) degrees, while mild degree of MAC was poorly demonstrated with radiography. The incidence of nephropathy, retinopathy, sensory neuropathy, and macrovascular complications increased with the severity of MAC (based on US scoring). With univariate analysis, the presence of MAC was associated with nephropathy (P<.001), retinopathy (P<.001), sensory neuropathy (P=.004), and macrovascular complications (P<.001). After adjustment for potential confounders, the presence of severe MAC was associated with nephropathy, retinopathy, and macrovascular complications, with the odds ratios of 3.4 (95% confidence interval [CI]: 1.53, 7.43; P=.003), 2.6 (95% CI: 1.22, 5.32; P=.013), and 3.8 (95% CI: 1.37, 10.6; P=.01), respectively. CONCLUSION: In type 2 diabetic Chinese patients, US was more sensitive than conventional radiography in the detection of MAC, particularly when the MAC was mild. The presence of severe MAC was associated with diabetic nephropathy, retinopathy, and macrovascular complications. US detection of MAC was a potential early marker to identify diabetes-related complications.

Manipulating the behavior-altering effect of the motivating operation: examination of the influence on challenging behavior during leisure activities.

We examined the behavior-altering effect of the motivating operation on challenging behavior during leisure activities for three individuals with severe disabilities. Prior functional analyses indicated that challenging behavior was maintained by positive reinforcement in the form of attention or tangible items for all participants. During leisure sessions, each participant played preferred games (cards, jigsaws) with two individuals without disabilities. The discriminative stimuli for challenging behavior were present during leisure sessions but challenging behavior was never reinforced. Immediately prior to leisure sessions, the participants received either access to the reinforcers that maintained challenging behavior or no access. Access versus no access to reinforcers for challenging behavior prior to leisure sessions was alternated in a multi-element design. Results demonstrated higher levels of challenging behavior during leisure sessions when the participants did not have access to the reinforcers prior to the sessions. Little challenging behavior occurred during leisure sessions when the participants had prior access to the reinforcers. Arguments for further examining the behavior-altering effects of the motivating operation in future applied research are presented.

Sonographic measurement of lateral parapharyngeal wall thickness in patients with obstructive sleep apnea.

INTRODUCTION: Lateral parapharyngeal wall (LPW) thickness may be a predominant anatomic factor causing airway narrowing in apneic subjects. In this study, we explored sonographic measurement of the LPW thickness and compared the results with LPW thickness measured by magnetic resonance imaging (MRI). We also investigated the association between sonographic measurement of LPW thickness and apnea-hypopnea index (AHI). METHOD: Seventy-six patients with suspected obstructive sleep apnea (OSA) underwent ultrasound examination of LPW thickness after overnight polysomnography. Fifteen out of 76 subjects also participated in correlation and reliability studies of sonographic and MRI measurements of LPW thickness. RESULTS: There was good correlation between measurements of LPW thickness on ultrasound and MRI (r = 0.78, P = 0.001), although Bland-Altman analysis indicated overestimation of LPW thickness by ultrasound, when compared with the LPW as measured by MRI. The sonographic measurement of LPW thickness had high reproducibility, with intraclass correlation coefficients of 0.90 and 0.97 for intraoperator and interoperator reliability, respectively. Fifty-eight subjects with significant OSA (AHI > or = 10/h) had a higher body mass index, larger neck circumference, and greater LPW thickness measured by ultrasound than those (n = 18) with an AHI of less than 10 per hour. LPW thickness had a positive correlation with AHI on univariate analysis (r = 0.37, P = 0.001). On multivariate analysis, LPW thickness had a positive independent association with AHI after adjustment for age, sex, neck circumference, and body mass index. The positive association of LPW thickness with AHI remained significant in both univariate and multivariate analyses of men only (n = 62). CONCLUSIONS: Sonographic measurement of LPW thickness is a novel and reliable technique and had good correlations with measurement by MRI and the severity of OSA. Ultrasound may provide an alternative imaging modality with easy accessibility and lower cost in OSA research.

NADPH oxidase activity is essential for Keap1/Nrf2-mediated induction of GCLC in response to 2-indol-3-yl-methylenequinuclidin-3-ols.

Glutamate cysteine ligase, the rate-limiting enzyme for the synthesis of glutathione, represents an important component of chemoprevention paradigms. GCLC and GCLM, the genes encoding glutamate cysteine ligase subunits, are induced by indoles, such as indomethacin. Novel functionalized indole analogues and other structurally related compounds were synthesized and used for a comparative structure analysis of GCLC induction. Use of mouse embryo fibroblasts null for Nrf2 (nuclear factor-erythroid 2p45-related transcription factor) and HepG2 cells overexpressing Keap1 demonstrated that indole analogue-mediated GCLC expression was regulated by Nrf2-Keap1 interactions. Indole analogues capable of inducing GCLC were found to increase NADPH oxidase activity. Indole analogues unable to induce GCLC did not increase oxidase activity. HepG2 cells transfected with FLAG/Keap1 were exposed to indomethacin, and the redox state of Keap1 cysteine residues was assessed. The data indicated that Keap1 exhibited several oxidation states that were sensitive to indomethacin treatment. These indomethacin-mediated changes in thiol oxidation states were suppressed by diphenyleneiodonium, a NADPH oxidase inhibitor. Diphenyleneiodonium also suppressed indole analogue-mediated increases in GCLC mRNA. In summary, the use of the indole analogues identified NADPH oxidase activity as a novel upstream activity regulating Nrf2/Keap1 signaling of GCLC, provided data supporting the hypothesis that Keap1 is a downstream effector for oxidase activity, and afforded in vivo data to support the hypothesis that Keap1 thiols can act as molecular sensors of reactive oxygen species. Finally, the comparative structure analysis suggests that 2-indol-3-yl-methylenequinuclidin-3-ols may represent a prototype for the development of novel chemopreventative agents able to activate Keap1/Nrf2 signaling.

Process measures for the assessment and improvement of quality of care for schizophrenia.

The development of process measures for the assessment and improvement of care for schizophrenia is at an early stage. As part of a national inventory of mental health quality measures, we identified 42 process measures developed to assess the quality of schizophrenia care. A greater proportion of measures assessed pharmacotherapy than assessed psychosocial interventions or other clinical processes, such as assessment, continuity, or coordination. Twenty-five measures (60%) were based on research evidence linking measure conformance with improved patient outcomes, while 17 (40%) were based on clinical consensus or opinion. Only 12 measures (29%) were fully operationalized. Few were tested for validity or reliability. A number of demonstration projects currently under way should expand the pool of well-developed and tested measures. Further research and consensus development will be needed to identify common measurement priorities, reduce the data collection burden, enhance the interpretability of results, and allow for comparisons of clinical practice across facilities and health care systems.