A deep-learning-based scatter correction with water equivalent path length map for digital radiography.

We proposed a new deep learning (DL) model for accurate scatter correction in digital radiography. The proposed network featured a pixel-wise water equivalent path length (WEPL) map of subjects with diverse sizes and 3D inner structures. The proposed U-Net model comprises two concatenated modules: one for generating a WEPL map and the other for predicting scatter using the WEPL map as auxiliary information. First, 3D CT images were used as numerical phantoms for training and validation, generating observed and scattered images by Monte Carlo simulation, and WEPL maps using Siddon's algorithm. Then, we optimised the model without overfitting. Next, we validated the proposed model's performance by comparing it with other DL models. The proposed model obtained scatter-corrected images with a peak signal-to-noise ratio of 44.24 ± 2.89 dB and a structural similarity index measure of 0.9987 ± 0.0004, which were higher than other DL models. Finally, scatter fractions (SFs) were compared with other DL models using an actual phantom to confirm practicality. Among DL models, the proposed model showed the smallest deviation from measured SF values. Furthermore, using an actual radiograph containing an acrylic object, the contrast-to-noise ratio (CNR) of the proposed model and the anti-scatter grid were compared. The CNR of the images corrected using the proposed model are 16% and 82% higher than those of the raw and grid-applied images, respectively. The advantage of the proposed method is that no actual radiography system is required for collecting training dataset, as the dataset is created from CT images using Monte Carlo simulation.

Evaluation of the availability of single-position treatment with a rotating gantry and the validity of deformable image registration dose assessment for pancreatic cancer carbon-ion radiotherapy.

BACKGROUND: This study aimed to evaluate the clinical acceptability of rotational gantry-based single-position carbon-ion radiotherapy (CIRT) to reduce the gastrointestinal (GI) dose in pancreatic cancer. We also evaluated the usefulness of the deformable image registration (DIR)-based dosimetry method for CIRT. MATERIAL AND METHODS: Fifteen patients with pancreatic cancer were analyzed. The treatment plans were developed for four beam angles in the supine (SP plan) and prone (PR plan) positions. In the case of using multiple positions, the treatment plan was created with two angles for each of the supine and prone position (SP + PR plan). Dose evaluation for multiple positions was performed in two ways: by directly adding the values of the DVH parameters for each position treatment plan (DVH sum), and by calculating the DVH parameters from the accumulative dose distribution created using DIR (DIR sum). The D2cc and D6cc of the stomach and duodenum were recorded for each treatment plan and dosimetry method and compared. RESULTS: There were no significant differences among any of the treatment planning and dosimetry methods (p > 0.05). The DVH parameters for the stomach and duodenum were higher in the PR plan and SP plan, respectively, and DVH sum tended to be between the SP and PR plans. DVH sum and DIR sum, DVH sum tended to be higher for D2cc and DIR sum tended to be higher for D6cc . CONCLUSION: There were no significant differences in the GI dose, which suggests that treatment with a simple workflow performed in one position should be clinically acceptable. In CIRT, DIR-based dosimetry should be carefully considered because of the potential for increased uncertainty due to the steep dose distributions.

High-Linear Energy Transfer Irradiation in Clinical Carbon-Ion Beam With the Linear Energy Transfer Painting Technique for Patients With Head and Neck Cancer.

Purpose: Dose-averaged linear energy transfer (LETd) is one of the important factors in determining clinical outcomes for carbon-ion radiation therapy. Innovative LET painting (LP) has been developed as an advanced form of conventional intensity modulated carbon-ion radiation therapy (IMIT) at the QST Hospital. The study had 2 motivations: to increase the minimum LETd (LETdmin) and to improve uniformity of the LETd distribution within the gross tumor volume (GTV) by using LP treatment plans for patients with head and neck cancer while maintaining the relative biologic effectiveness (RBE)-weighted dose coverage within the planning tumor volume (PTV) the same as in the conventional IMIT plan. Methods and Materials: The LP treatment plans were designed with the in-house treatment planning system. For the plans, LETd constraints and LETdmin, goal-LETd, and maximum-LETd (LETdmax) constraints for the GTV were added to the conventional dose constraints in the IMIT prescription. For 13 patients with head and neck cancer, the RBE-weighted dose to 90% (D90) and 50% (D50) of the PTV and the LETdmin, mean (LETdmean), and LETdmax values within the GTV in the LP plans were evaluated by comparing them with those in the conventional IMIT plans. Results: The LP for 13 patients with head and neck cancer could keep D90s and D50s for the PTV within 1.0% of those by the conventional IMIT. Among the 13 patients, the mean LETdmin of the LP plans for the GTV was 59.2 ± 7.9 keV/µm, whereas that of the IMIT plans was 45.9 ± 6.0 keV/µm. The LP increased the LETdmin to 8 to 24 keV/µm for the GTV compared with IMIT. Conclusions: While maintaining the dose coverage to the PTV as comparable to that for IMIT, the LP increased the mean LETdmin to 13.2 keV/µm for the GTV. For a GTV up to 170 cm3, LETd > 44 keV/µm could be achieved using LP, which according to previous studies was associated with lower recurrence. In addition, the LP method delivered more uniform LETd distributions compared with IMIT.

A robust treatment planning approach for chest motion in postmastectomy chest wall intensity modulated radiation therapy.

PURPOSE: Chest wall postmastectomy radiation therapy (PMRT) should consider the effects of chest wall respiratory motion. The purpose of this study is to evaluate the effectiveness of robustness planning intensity modulated radiation therapy (IMRT) for respiratory movement, considering respiratory motion as a setup error. MATERIAL AND METHODS: This study analyzed 20 patients who underwent PMRT (10 left and 10 right chest walls). The following three treatment plans were created for each case and compared. The treatment plans are a planning target volume (PTV) plan (PP) that covers the PTV within the body contour with the prescribed dose, a virtual bolus plan (VP) that sets a virtual bolus in contact with the body surface and prescribing the dose that includes the PTV outside the body contour, and a robust plan (RP) that considers respiratory movement as a setup uncertainty and performs robust optimization. The isocenter was shifted to reproduce the chest wall motion pattern and the doses were recalculated for comparison for each treatment plan. RESULT: No significant difference was found between the PP and the RP in terms of the tumor dose in the treatment plan. In contrast, VP had 3.5% higher PTV Dmax and 5.5% lower PTV V95% than RP (p < 0.001). The RP demonstrated significantly higher lung V20Gy and Dmean by 1.4% and 0.4 Gy, respectively, than the PP. The RP showed smaller changes in dose distribution affected by chest wall motion and significantly higher tumor dose coverage than the PP and VP. CONCLUSION: We revealed that the RP demonstrated comparable tumor doses to the PP in treatment planning and was robust for respiratory motion compared to both the PP and the VP. However, the organ at risk dose in the RP was slightly higher; therefore, its clinical use should be carefully considered.

Dynamic Arterial Elastance as a Predictor of Supine-to-Prone Hypotension (SuProne Study): An Observational Study.

Background and Objectives: Supine-to-prone hypotension is caused by increased intrathoracic pressure and decreased venous return in the prone position. Dynamic arterial elastance (Eadyn) indicates fluid responsiveness and can be used to predict hypotension. This study aimed to investigate whether Eadyn can predict supine-to-prone hypotension. Materials and Methods: In this prospective, observational study, 47 patients who underwent elective spine surgery in the prone position were enrolled. Supine-to-prone hypotension is defined as a decrease in Mean Arterial Pressure (MAP) by more than 20% in the prone position compared to the supine position. Hemodynamic parameters, including systolic blood pressure (SAP), diastolic blood pressure, MAP, stroke volume variation (SVV), pulse pressure variation (PPV), stroke volume index, cardiac index, dP/dt, and hypotension prediction index (HPI), were collected in the supine and prone positions. Supine-to-prone hypotension was also assessed using two different definitions: MAPprone < 65 mmHg and SAPprone < 100 mmHg. Hemodynamic parameters were analyzed to determine the predictability of supine-to-prone hypotension. Results: Supine-to-prone hypotension occurred in 13 (27.7%) patients. Eadyn did not predict supine-to-prone hypotension [Area under the curve (AUC), 0.569; p = 0.440]. SAPsupine > 139 mmHg (AUC, 0.760; p = 0.003) and dP/dtsupine > 981 mmHg/s (AUC, 0.765; p = 0.002) predicted supine-to-prone hypotension. MAPsupine, SAPsupine, PPVsupine, and HPIsupine predicted MAPprone <65 mm Hg. MAPsupine, SAPsupine, SVVsupine, PPVsupine, and HPIsupine predicted SAPprone < 100 mm Hg. Conclusions: Dynamic arterial elastance did not predict supine-to-prone hypotension in patients undergoing spine surgery. Systolic arterial pressure > 139 mmHg and dP/dt > 981 mmHg/s in the supine position were predictors for supine-to-prone hypotension. When different definitions were employed (mean arterial pressure < 65 mmHg in the prone position or systolic arterial pressure < 100 mmHg in the prone position), low blood pressures in the supine position were related to supine-to-prone hypotension.

Magnetic Resonance Imaging Characteristics of a Lateral Ligament Injury in Acute Ankle Sprains Among Athletes.

Background: It is important to identify the location and pattern of lateral ligament injuries that are related to the development and prognosis of chronic ankle instability in athletes with ankle sprains. Purpose: To describe the location and pattern of lateral ligament injuries on magnetic resonance imaging (MRI) in elite-level or amateur athletes with acute ankle sprains and to further assess the risk of associated concomitant injuries. Study Design: Cross-sectional study; Level of evidence, 3. Methods: The anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) of 110 athletes with an ankle lateral ligament injury (mean age, 24.7 years) were evaluated. MRI scans were evaluated for the location and pattern of ATFL and CFL tears such as sleeve avulsions as well as concomitant deltoid ligament injuries, bone contusions, and osteochondral lesions of the talus (OLTs). Results: On MRI, 52 (47.3%) athletes had an isolated ATFL tear, 56 (50.9%) athletes had both ATFL and CFL tears, and 2 (1.8%) athletes had an isolated CFL tear. ATFL injuries occurred at the fibula, midsubstance, and talus in approximately equal numbers, whereas the majority of CFL injuries occurred at the calcaneal insertion. Concomitant deltoid ligament injuries were identified in 18 (16.4%) athletes. In addition, concomitant bone contusions and OLTs were identified in 38 (34.5%) and 6 (5.5%) athletes, respectively. Using linear-by-linear analysis, CFL injuries correlated with concomitant deltoid ligament and bone injuries (P = .023 and P = .001, respectively) and a sleeve injury pattern (P = .005). Conclusion: After an acute ankle ligament rupture, almost all athletes involved in this study had injured their ATFL, and approximately 50% had a concomitant injury to the CFL. The rate of sleeve-type CFL injuries at the calcaneal insertion was high, and concomitant deltoid ligament injuries and OLTs were associated with this pattern of injury.

Debulking surgery for macrodystrophia lipomatosa of the lesser toe: a rare case report.

Macrodystrophia lipomatosa (MDL) is a rare disorder characterized by overgrowth of mesenchymal cells, resulting in gigantism of one or more digit. We report a case of a woman in her late 60s who presented with abnormal enlargement of the right second toe. By debulking the pathological tissue while preserving the shape of the toe as much as possible without amputation of the entire phalanx, debulking surgery not only helps walking, but also allows wearing shoes of the same size on both feet and achieves cosmetic satisfaction for patients. The functional and cosmetic improvement obtained through debulking surgery in this case resulted in no recurrence of disease 5 years postoperatively and provided a desirable alternative to amputation. Therefore, through this case, we demonstrated that debulking surgery can be a reasonable option for MDL patients.

Association between body composition and chronic low back pain in Korean adults aged over 50 years: The Korea National Health and Nutrition Examination Survey (KNHANES) 2010-2011.

Background The relationship between overweight or obesity and low back pain (LBP) has previously been investigated. Several recent studies have focused on the relationship between other indicators of obesity, particularly indicators of fat and the risk of LBP. However, the results of body composition and LBP have been inconsistent. Methods All data for the present retrospective, cross-sectional study was extracted from the Korea National Health and Nutrition Examination Survey (KNHANES) versions V-1 and 2 conducted in 2010 and 2011 by the Korean Centers for Disease Control and Prevention. In KNHANES V-1 (2010) and V-2 (2011), those over 50 years of age completed the surveys on LBP, body weight, and body composition assessed using dual-energy X-ray absorptiometry (DXA) were included. The multivariable logistic regression analysis was used to examine the relationship between the presence of chronic LBP and body composition adjusting for confounders. Results We analyzed 3,579 persons who completed the question. In the multivariable analyses adjusting for age and sex, none of the variables, including fat mass and fat-free mass, remained positively or negatively associated with LBP. Additionally, when depression, smoking, alcohol intake, physical activity, diabetes mellitus, and fat or lean tissue mass were included in the multivariable logistic model, no significant associations were found between all measures of fat mass, fat-free mass, and LBP Conclusion This study is contrary to previous studies that concluded that there is a correlation between obesity and fat mass and LBP. LBP is not associated with increased levels of obesity and fat mass.

The insufficiency of a simple stress question in assessing stress for chronic daily headache in clinical practice.

BACKGROUND: In managing chronic daily headaches (CDH), a comprehensive approach is necessary to evaluate stress, a closely linked factor. However, limited time and costs often lead to the use of a simple stress question in clinical settings. This study aims to assess the validity of using a simple stress question for CDH patients and explore its implications for clinical practice. METHODS: We recruited 103 patients with CDH who completed structured self-administered questionnaires, including a simple stress question ("Have you had any stress or concerns in the last 4 weeks?") and validated Korean versions of questionnaires for depression, anxiety, insomnia, and the Brief Encounter Psychosocial Instrument (BEPSI). A headache specialist conducted clinical interviews. The stress group consisted of patients who acknowledged overt stress (answering "yes" to the simple question) and covert stress (initially answering "no" but later admitting during the interview). Results showed no statistical difference between the subgroups, so they were combined as the "acknowledged stress" group. RESULTS: Out of 103 patients, 54.4% had chronic migraine, 45.6% had chronic tension-type headache, and 66 patients (64.1%) acknowledged experiencing stress. No significant differences were found in demographic and clinical characteristics, BEPSI stress assessment, or depression, anxiety, and insomnia profiles between patients with overt stress (n = 51) and covert stress (n = 15). The average BEPSI score was 2.3 ± 0.9, with 45.6% of patients exceeding the criteria (>2.4). Two (5.4%) patients in denial of stress had scores above the BEPSI criteria. Among patients below the criteria of BEPSI, 21 acknowledged stress, while 35 denied stress, with no significant differences observed. CONCLUSIONS: This study suggests the limitations of relying solely on a simple stress question for assessing stress in patients with CDH in clinical practice. It is possible to encounter covert stress, include individuals who do not exhibit noticeable stress, and misclassify stress levels. To overcome these limitations, it is necessary to foster a supportive environment for open communication on stress and implement a comprehensive assessment strategy when needed.

Outcomes After Superior Capsular Reconstruction With an Achilles Tendon-Bone Allograft Using the Modified Keyhole Technique: A 2-Year Follow-up of a Novel Technique for Irreparable Rotator Cuff Tears.

Background: Despite improved outcomes, failure or nonhealing of graft materials has been reported after superior capsular reconstruction (SCR) for massive irreparable rotator cuff tears. Purpose: To evaluate the short-term clinical and radiological outcomes of a novel technique for SCR using an Achilles tendon-bone allograft. Study Design: Case series; Level of evidence, 4. Methods: We performed a retrospective review of patients who underwent SCR using an Achilles tendon-bone allograft with the modified keyhole technique and who had a minimum follow-up of 2 years. The visual analog scale score for pain, American Shoulder and Elbow Surgeons score, and Constant score were evaluated as subjective outcomes, while range of motion of the shoulder joint and isokinetic strength were evaluated as objective outcomes. The acromiohumeral interval (AHI), bone-to-bone healing of the allograft and humeral head on computed tomography, and graft integrity on magnetic resonance imaging were evaluated as radiological outcomes. Results: This study included 32 patients with a mean age of 56.8 ± 4.2 years and a mean follow-up of 28.4 ± 6.2 months. A significant improvement from preoperatively to the last follow-up was seen in the mean visual analog scale score for pain (from 6.7 to 1.8), American Shoulder and Elbow Surgeons score (from 42.7 to 83.8), Constant score (from 47.2 to 78.5), and AHI (from 4.8 to 8.2 mm) (P < .001 for all) as well as range of motion in forward elevation and internal rotation (P < .001 for both). Medial-to-lateral graft integrity was good in all patients. Nonunion at the fitting zone of the keyhole on the greater tuberosity was diagnosed in 1 case (3.1%), and failure of incorporation between the allograft and remnant tendon at the site of posterior margin convergence was observed in 4 cases (12.5%). Conclusion: The outcomes after SCR using an Achilles tendon-bone allograft and the keyhole technique improved, with an increased AHI and excellent integrity in the medial and lateral directions compared with preoperatively. This technique is a reasonable option for the surgical treatment of irreparable rotator cuff tears.

An integrated mechanistic and data-driven computational model predicts cell responses to high- and low-affinity EGFR ligands.

The biophysical properties of ligand binding heavily influence the ability of receptors to specify cell fates. Understanding the rules by which ligand binding kinetics impact cell phenotype is challenging, however, because of the coupled information transfers that occur from receptors to downstream signaling effectors and from effectors to phenotypes. Here, we address that issue by developing an integrated mechanistic and data-driven computational modeling platform to predict cell responses to different ligands for the epidermal growth factor receptor (EGFR). Experimental data for model training and validation were generated using MCF7 human breast cancer cells treated with the high- and low-affinity ligands epidermal growth factor (EGF) and epiregulin (EREG), respectively. The integrated model captures the unintuitive, concentration-dependent abilities of EGF and EREG to drive signals and phenotypes differently, even at similar levels of receptor occupancy. For example, the model correctly predicts the dominance of EREG over EGF in driving a cell differentiation phenotype through AKT signaling at intermediate and saturating ligand concentrations and the ability of EGF and EREG to drive a broadly concentration-sensitive migration phenotype through cooperative ERK and AKT signaling. Parameter sensitivity analysis identifies EGFR endocytosis, which is differentially regulated by EGF and EREG, as one of the most important determinants of the alternative phenotypes driven by different ligands. The integrated model provides a new platform to predict how phenotypes are controlled by the earliest biophysical rate processes in signal transduction and may eventually be leveraged to understand receptor signaling system performance depends on cell context. One-sentence summary: Integrated kinetic and data-driven EGFR signaling model identifies the specific signaling mechanisms that dictate cell responses to EGFR activation by different ligands.

Differences in preoperative gastric ultrasound findings in elderly compared to the mid-aged surgical patients: A retrospective observational study.

This study aimed to compare gastric ultrasound assessments between young and elderly patients, to determine whether the cross-section area (CSA) cutoff values for elderly and young patients should be different, and to suggest CSA cutoff values for elderly patients. This study evaluated the data of 120 patients who underwent elective surgery under general anesthesia between July 2019 and August 2020. Demographic and gastric ultrasound assessment data were retrieved. Patients were divided into the elderly group (n = 58, age: ≥65 years) and young group (n = 62, age: <65 years). The CSAs in the supine and right lateral decubitus positions (RLDP), semiquantitative 3-point Perlas grade (grades 0, 1, and 2), and gastric volume (GV) were determined. CSAs according to different Perlas grades were compared between the 2 groups. To compare normally and non-normally distributed continuous data, Student t test and the Mann-Whitney U test were used, respectively. Categorical data were compared using the chi-square test or Fisher exact test, as appropriate. The receiver operating characteristic (ROC) curves were built for the CSAs to predict pulmonary aspiration. The CSA cutoff values for predicting a high risk of pulmonary aspiration in both the groups were determined. Among patients with Perlas grade 0, the CSAsupine (P = .002) and CSARLDP (P = .002) were greater in the elderly group than in the young group. The specificity, positive predictive value, and accuracy of the CSA decreased when the CSA cutoff value for the young group was applied to the elderly group. The CSA cutoff values for the elderly group were: CSAsupine, 6.92 cm2 and CSARLDP, 10.65 cm2. The CSA of the empty stomach was greater in elderly patients than in young patients. We suggest that the following CSA cutoff values should be used for predicting pulmonary aspiration risk in elderly patients: CSAsupine, 6.92 cm2 and CSARLDP, 10.65 cm2.

Error on the stopping power ratio of ERKODENT's mouthpiece for head and neck carbon ion radiotherapy treatment.

The errors on the stopping power ratio (SPR) of mouthpiece samples from ERKODENT were evaluated. Erkoflex and Erkoloc-pro from ERKODENT and samples that combined Erkoflex and Erkoloc-pro were computed tomography (CT)-scanned using head and neck (HN) protocol at the East Japan Heavy Ion Center (EJHIC), and the values were averaged to obtain the CT number. The integral depth dose of the Bragg curve with and without these samples was measured for 292.1, 180.9, and 118.8 MeV/u of the carbon-ion pencil beam using an ionization chamber with concentric electrodes at the horizontal port of the EJHIC. The average value of the water equivalent length (WEL) of each sample was obtained from the difference between the range of the Bragg curve and the thickness of the sample. To calculate the difference between the theoretical and measured values, the theoretical CT number and SPR value of the sample were calculated using the stoichiometric calibration method. Compared with the Hounsfield unit (HU)-SPR calibration curve used at the EJHIC, the SPR error on each measured and theoretical value was calculated. The WEL value of the mouthpiece sample had an error of approximately 3.5% in the HU-SPR calibration curve. From this error, it was evaluated that for a mouthpiece with a thickness of 10 mm, a beam range error of approximately 0.4 mm can occur, and for a mouthpiece with a thickness of 30 mm, a beam range error of approximately 1 mm can occur. For a beam passing through the mouthpiece in HN treatment, it would be practical to consider a mouthpiece margin of 1 mm to avoid beam range errors if ions pass through the mouthpiece.

Predicting tolerability of high-dose fentanyl buccal tablets in cancer patients.

BACKGROUND & AIMS: Fentanyl buccal tablets (FBTs) are a rapid-onset opioid indicated for breakthrough cancer pain (BTcP) and FBT titration is needed to optimize BTcP management. We aimed to predict which patients could tolerate a high dose of FBT (400 µg or more at a time). METHODS: A retrospective analysis was performed to assess the final FBT dose. The final FBT doses were compared according to the clinical features. The prediction accuracy of patients tolerant of 400 µg or higher FBT was compared using the area under the receiver operating characteristic (ROC) curves. A risk scoring model based on the odds ratio (OR) was developed from the final multivariable model, and patients were assigned into two groups: low tolerance (0-1 point) and high tolerance (2-3 points). RESULTS: Among 131 patients, the most frequently effective dose of FBT was 200 µg (54%), followed by 100 µg (30%). The median value of morphine equivalent daily doses (MEDD) was 60 mg/day, and the most common daily use was 3-4 times/day. In multivariable analysis, male sex, younger age, and use of FBTs three or more times per day were independently associated with high-dose FBT. According to the risk scoring model, the patients with a final FBT of 400 µg or higher were significantly more in the high tolerance group (17%) compared to the low tolerance group (3%; p = 0.023). CONCLUSIONS: According to the dose relationship between the final FBT dose and the clinical features, three factors (sex, age, daily use of FBT) were independently associated with the final dose of FBT. Our risk score model could help predict tolerance to high-dose FBT and guide the titration plan for BTcP.

Beta-adrenergic receptor blockers and hepatocellular carcinoma survival: a systemic review and meta-analysis.

INTRODUCTION: Preclinical data have revealed that beta-adrenergic stimulation can affect the growth and progression of different types of malignancies. Beta-adrenergic receptor blockers have been associated with improved survival in patients with many types of cancer. We performed a meta-analysis to investigate the association between beta-blocker use and hepatocellular carcinoma (HCC) prognosis. METHODS: In this meta-analysis, a full search was conducted using PubMed, the Cochrane library and Embase to identify all relevant studies published up to May 2021. Available hazard ratios (HRs) were extracted for overall survival (OS), cancer-specific survival (CSS) and pooled using a random-effects meta-analysis. RESULTS: Four studies involving 7252 patients with HCC met the inclusion criteria and were included in the systemic review. Three studies that reported OS data of 5148 patients were included in the meta-analysis. The random-effects model showed that beta-blocker use was associated with significantly improved OS in HCC (HR = 0.69, 95% CI = 0.54-0.88, P = 0.0031), without significant heterogeneity (I2 = 41%; Q = 6.42, P = 0.18). CONCLUSION: This meta-analysis suggested that beta-blocker use can be associated with prolonged OS of patients with HCC.

Machine learning for prediction of postoperative nausea and vomiting in patients with intravenous patient-controlled analgesia.

BACKGROUND: Postoperative nausea and vomiting (PONV) is a still highly relevant problem and is known to be a distressing side effect in patients. The aim of this study was to develop a machine learning model to predict PONV up to 24 h with fentanyl-based intravenous patient-controlled analgesia (IV-PCA). METHODS: From July 2019 and July 2020, data from 2,149 patients who received fentanyl-based IV-PCA for analgesia after non-cardiac surgery under general anesthesia were applied to develop predictive models. The rates of PONV at 1 day after surgery were measured according to patient characteristics as well as anesthetic, surgical, or PCA-related factors. All statistical analyses and computations were performed using the R software. RESULTS: A total of 2,149 patients were enrolled in this study, 337 of whom (15.7%) experienced PONV. After applying the machine-learning algorithm and Apfel model to the test dataset to predict PONV, we found that the area under the receiver operating characteristic curve using logistic regression was 0.576 (95% confidence interval [CI], 0.520-0.633), k-nearest neighbor was 0.597 (95% CI, 0.537-0.656), decision tree was 0.561 (95% CI, 0.498-0.625), random forest was 0.610 (95% CI, 0.552-0.668), gradient boosting machine was 0.580 (95% CI, 0.520-0.639), support vector machine was 0.649 (95% CI, 0.592-0.707), artificial neural network was 0.686 (95% CI, 0.630-0.742), and Apfel model was 0.643 (95% CI, 0.596-0.690). CONCLUSIONS: We developed and validated machine learning models for predicting PONV in the first 24 h. The machine learning model showed better performance than the Apfel model in predicting PONV.

Oxygen reserve index guided fraction of inspired oxygen titration to reduce hyperoxemia during laparoscopic gastrectomy: A randomized controlled trial.

BACKGROUND: The usefulness of the oxygen reserve index (ORi) in reducing hyperoxemia remains unclear. We designed this study to investigate whether fraction of inspired oxygen (FiO2) adjustment under a combination of ORi and peripheral oxygen saturation (SpO2) guidance can reduce intraoperative hyperoxemia compared to SpO2 alone. METHODS: In this prospective, double-blind, randomized controlled study, we allocated patients scheduled for laparoscopic gastrectomy to the SpO2 group (FiO2 adjusted to target SpO2 ≥ 98%) or the ORi-SpO2 group (FiO2 adjusted to target 0 < 0 ORi < .3 and SpO2 ≥ 98%). The ORi, SpO2, FiO2, arterial partial pressure of oxygen (PaO2), and incidence of severe hyperoxemia (PaO2 ≥ 200 mm Hg) were recorded before and 1, 2, and 3 hours after surgical incision. Data from 32 and 30 subjects in the SpO2 and ORi-SpO2 groups, respectively, were analyzed. RESULTS: PaO2 was higher in the SpO2 group (250.31 ± 57.39 mm Hg) than in the ORi-SpO2 group (170.07 ± 49.39 mm Hg) 1 hour after incision (P < .001). PaO2 was consistently higher in the SpO2 group than in the ORi-SpO2 group, over time (P = .045). The incidence of severe hyperoxemia was higher in the SpO2 group (84.4%) than in the ORi-SpO2 group (16.7%, P < .001) 1 hour after incision. Higher FiO2 was administered to the SpO2 group [52.5 (50-60)] than the ORi-SpO2 group [40 (35-50), P < .001] 1 hour after incision. SpO2 was not different between the 2 groups. CONCLUSION: The combination of ORi and SpO2 guided FiO2 adjustment reduced hyperoxemia compared to SpO2 alone during laparoscopic gastrectomy.

Clinical outcomes according to intentionality of acute pesticide poisoning in South Korea: Retrospective observation study.

Objectives: To investigate if intentional pesticide intake could have different clinical outcomes compared to unintentional poisoning, and whether acute alcohol consumption correlated with intentional poisoning. METHODS: The retrospective observational study was conducted in South Korea and comprised data from the Emergency Department-based Injury In-depth Surveillance Registry of all adults with pesticide poisoning from 2009 to 2017. The primary outcome was overall mortality. Adjusted odds ratios with 95% confidence intervals of the exposures on clinical outcomes were calculated. Data was analysed using SAS 9.4. RESULTS: Among the 7,320 patients, intentional poisoning had higher odds of overall mortality (adjusted odds ratio: 1.88; 95% confidence interval: 1.56-2.25) and major adverse outcomes (adjusted odds ratio: 2.64; 95% confidence interval: 2.32-2.99), while acute alcohol consumption showed a higher incidence of intentional poisoning (adjusted odds ratio: 2.43; 95% confidence interval: 2.11-2.80). CONCLUSIONS: Intentional poisoning showed higher mortality rate and major adverse outcomes. It is important to consider host factors before poisoning, such as acute alcohol consumption, which may contribute to the clinical outcomes of pesticide poisoning cases.

Inadvertent Transfer of Murine VL30 Retrotransposons to CAR-T Cells.

For more than a decade, genetically engineered autologous T-cells have been successfully employed as immunotherapy drugs for patients with incurable blood cancers. The active components in some of these game-changing medicines are autologous T-cells that express viral vector-delivered chimeric antigen receptors (CARs), which specifically target proteins that are preferentially expressed on cancer cells. Some of these therapeutic CAR expressing T-cells (CAR-Ts) are engineered via transduction with γ-retroviral vectors (γ-RVVs) produced in a stable producer cell line that was derived from murine PG13 packaging cells (ATCC CRL-10686). Earlier studies reported on the copackaging of murine virus-like 30S RNA (VL30) genomes with γ-retroviral vectors generated in murine stable packaging cells. In an earlier study, VL30 mRNA was found to enhance the metastatic potential of human melanoma cells. These findings raise biosafety concerns regarding the possibility that therapeutic CAR-Ts have been inadvertently contaminated with potentially oncogenic VL30 retrotransposons. In this study, we demonstrated the presence of infectious VL30 particles in PG13 cell-conditioned media and observed the ability of these particles to deliver transcriptionally active VL30 genomes to human cells. Notably, VL30 genomes packaged by HIV-1-based vector particles transduced naïve human cells in culture. Furthermore, we detected the transfer and expression of VL30 genomes in clinical-grade CAR-T cells generated by transduction with PG13 cell-derived γ-retroviral vectors. Our findings raise biosafety concerns regarding the use of murine packaging cell lines in ongoing clinical applications.