Therapeutic and prophylactic effects of radiation therapy in the management of recurrent granulation tissue induced tracheal stenosis: a review on the role of Endobronchial brachytherapy and external beam radiation therapy.

PURPOSE: Granulation tissue-induced tracheal stenosis (mainly secondary to intubation or lung transplantation) is one of the most common etiologies of benign airway obstructions. Recurrence rates after standard treatment options (surgical resection and/or endobronchial interventions) can inadvertently worsen the stricture through the stimulation of more granulation tissue generation (via increased fibroblast activity and roliferation). Low-dose radiotherapy could be a promising tool to prevent granulation tissue formation after surgery and/or endobronchial interventions regarding its established role in the treatment of keloids or hypertrophic scars, two benign diseases with similar a pathophysiology to tracheal stenosis. This study reviews case reports and small series that used endobronchial brachytherapy (EBBT) or external beam radiotherapy (EBRT) for the management of refractory granulation tissue-induced tracheal stenosis after surgery and/or endobronchial interventions. METHODS AND MATERIALS: Case reports and series (published up to October 2022) that reported outcomes of patients with recurrent granulation tissue-induced tracheal stenosis (after surgery and/or endobronchial interventions) treated by EBBT or EBRT (in definitive or prophylactic settings) were eligible. RESULTS: Sixteen studies (EBBT: nine studies including 69 patients, EBRT: seven studies including 32 patients) were reviewed. The pooled success rate across all studies was 74% and 97% for EBBT and EBRT, respectively. CONCLUSIONS: Radiation therapy appears to be effective in the management of selected patients with recurrent/refractory tracheal stenosis. Response to this treatment is usually good, but further studies with a larger number of patients and long-term followup are necessary to determine the optimal technique, dose, and timing of radiation therapy, late complications, the durability of response, and criteria for patient selection.

Predictors of poor cosmesis in breast cancer patients treated with adjuvant whole breast radiation therapy plus high-dose-rate interstitial brachytherapy boost after breast conservation surgery.

Purpose: To identify patient, tumor, and treatment-related factors, which predict cosmesis in breast cancer survivors treated with adjuvant whole breast irradiation (WBI) plus high-dose-rate (HDR) multicatheter interstitial brachytherapy (MIBT) boost after breast conservation surgery. Material and methods: At least 12 months after completion of radiotherapy, cosmetic outcomes were measured both objectively with BCCT.core software (using a front view digital photograph), and subjectively according to Harvard's criteria. MIBT dose fractionation regimen was 13.6 Gy/4 fractions (bid). To evaluate the correlation between cosmetic scores and dose-volume histogram (DVH) parameters, WBI and MIBT plans were retrospectively analyzed, and ipsilateral skin and breast biologically equivalent dosimetric indices were recorded (α/ß = 3 Gy). A multivariate ordinal logistic regression model was used for statistical analysis. Results: Twenty-eight consecutive patients were enrolled into this study. The median time from completion of radiation therapy to cosmesis scoring was 18 months. In evaluation with BCCT.core software, no patient was scored as excellent. Cosmesis was good in 18%, fair in 50%, and poor in 32% of patients. According to Harvard's scale, 10.5% of patients had excellent cosmesis, and 43%, 28.5%, and 18% of patients had good, fair, and poor scores, respectively. In univariate analysis, patients with higher absolute MIBT V29Gy (cc), those treated with irradiation of regional lymphatics (odds ratio ≈ 5), and patients with larger breast volumes had statistically significant lower Harvard's scores. In the multivariate model, none of the mentioned factors remained statistically significant, except for a trend for poorer cosmesis in patients with higher absolute MIBT V29Gy (p-value = 0.066). Conclusions: Based on the results of this study, MIBT breast V29Gy, regional nodal irradiation, and larger breast volumes are the potential factors, which could predict cosmesis.

Evaluation of rectal volume correlation with dosimetric parameters during optimized intracavitary high-dose-rate brachytherapy in cervical cancer.

PURPOSE: Brachytherapy (BRT) is a cornerstone in cervical cancer treatment, with the ultimate goal to maximize the tumor dose while sparing organs at risk (OARs), such as rectum. Several studies evaluated the effect of rectal volume on rectal doses, but the results are inconsistent. This study aimed to evaluate the rectal volume and dose-volume histogram (DVH) relationship in high-dose-rate (HDR) brachytherapy in locally advanced cervical cancer. MATERIAL AND METHODS: Planning computed tomography of 65 patients who underwent HDR brachytherapy boost as a component of definitive radiotherapy from March 2016 to February 2018 were reviewed. OARs and target volume were re-delineated by a single physician to decrease interobserver variation. Two sets of plan were generated; in the first set, the dose was prescribed to point A with Manchester system loading pattern, while in the second set, the dose was prescribed to high-risk clinical target volume (HR-CTV) D90 with inverse planning optimization. The DVH values for rectum, sigmoid, and HR-CTV were generated and correlated with rectal or sigmoidal volume variation. RESULTS: Dose to 2cc (D2cc), 1cc (D1cc), and 0.1cc (D0.1cc) of rectum and sigmoid showed a significant decrease in optimization vs. point A planning (p < 0.0001). HR-CTV D90 coverage was significantly higher in optimization vs. point A planning (p = 0.041). Rectal volume showed a significant correlation with D2cc (rs, 0.302, p = 0.014), D1cc (rs, 0.310, p = 0.012), and D0.1cc (rs, 0.283, p = 0.02) of rectum in optimization planning. CONCLUSIONS: Larger rectal volumes are associated with higher rectal dose parameters during HDR brachytherapy using inverse planning optimization. This method spares OAR, while producing reasonable HR-CTV D90. Prospective studies are needed to find appropriate technique of rectal volume reduction.

Sedative and Analgesic Effects of Entonox Gas Compared with Midazolam and Fentanyl in Synchronized Cardioversion.

The purpose of this study was to determine if the Entonox gas could cause adequate analgesic and sedative effects in patients who need cardioversion. In this randomized not blinded clinical trial, the sedative and analgesic effects of midazolam and fentanyl were compared with Entonox. Eligible patients who need synchronized cardioversion because of dysrhythmia were randomly divided into two groups. The first group received intravenous midazolam and fentanyl; the second group received Entonox through a blower-dependent mask. Onset and end of sedation, sedation level, and pain score were recorded. There were nonsignificant differences between the two groups (22 patients in each group) regarding age, gender, weight, sedation level, and frequency and level of shock. The pain score recorded in the first group was 5.05 ± 1.32, and 3.9 ± 0.7 in the second group (P = 0.002). Furthermore, sedation duration and time to full recovery consciousness were shorter in the second group (P < 0.001). In the first group, seven patients needed additional doses to induce and maintain sedation. In addition, as a result of apnoea, four patients required airway support. None of them occurred in the second group. Entonox is a suitable medication in rapid cardioversion, as it has minimal side effects and adequate analgesic and sedative effects.

The efficacy of intranasal desmopressin as an adjuvant in the acute renal colic pain management.

The aim of this study was to compare analgesic effect of intramuscular (IM) sodium diclofenac and intranasal desmopressin combination with IM sodium diclofenac alone in patients with acute renal colic. In this randomized double-blind clinical trial, all patients aged 18 to 55 years who were diagnosed as acute renal colic and met the inclusion and exclusion criteria were randomized into two groups to receive 40 µg intranasal desmopressin spray and 75 mg IM sodium diclofenac combination (Group A) or 75 mg IM sodium diclofenac alone (Group B). The pain score of patients was assessed using a visual analogue scale (VAS) at baseline, 15, 30, 45, and 60 minutes after administration. Of all 159 patients who were assessed for eligibility finally, the results of 120 patients were analyzed. There was no significant difference regarding age and gender between two groups. The baseline VAS score was not significantly different between two groups (P = 0.44). The Mean ± SD scores of two groups reduced 15 minutes after drug administration, but this decrease was significantly more in Group A compared with Group B (P = 0.02). This pattern continued in minutes 30, 45, and 60 of drug administration. Our results showed that desmopressin could be used as an effective adjuvant in acute renal colic pain management.

Comparison of clinical efficacy of intravenous acetaminophen with intravenous morphine in acute renal colic: a randomized, double-blind, controlled trial.

The aim of this study was to compare the clinical efficacy of intravenous acetaminophen with intravenous morphine in acute renal colic pain management. In this double-blind controlled trial, patients aged 18-55 years, diagnosed with acute renal colic, who met the inclusion and exclusion criteria, were randomized into two groups. First, using the visual analogue scale (VAS), intensity of pain was assessed in both groups. Then, one gram of intravenous acetaminophen or 0.1 mg/kg morphine was infused in 100 mL normal saline to either acetaminophen or morphine group. Intensity of pain was reassessed in 15, 30, 45, and 60 minutes according to VAS criteria. Finally, data from 108 patients were analyzed, 54 patients in each group. No significant difference was observed between the two groups in regard to sex (P = 0.13), mean age (P = 0.54), and baseline visual analogue score (P = 0.21). A repeated measure analysis of variance revealed that the difference between the two treatments was significant (P = 0.0001). The VAS reduction at primary endpoint (30 min after drug administration) was significantly higher in the acetaminophen group than in the morphine group (P = 0.0001). This study demonstrated that intravenous acetaminophen could be more effective than intravenous morphine in acute renal colic patients' pain relief.

An overview of thunderstorm-associated asthma outbreak in southwest of Iran.

The aim of this study was to report the characteristics and treatment strategies of all patients with acute bronchospasm who were presented to the emergency departments of Ahvaz, Iran, following the occurrence of a thunderstorm on November 2, 2013. A total of 2000 patients presenting with asthma attacks triggered by thunderstorm were interviewed and an initial questionnaire was completed for each individual. After twenty days, patients were asked to complete a supplementary questionnaire, but only 800 of them accepted to do so. The majority of subjects was aged 20-40 years (60.5%) and had no history of asthma in most cases (60.0%). The symptoms had started outdoors for 60.0% of the participants. In most patients, the onset of the condition was on November 2. Short-acting ß 2-agonist (salbutamol) and aminophylline were the most commonly prescribed medications in the emergency department. Upon the second interview, 85.3% of the patients were still symptomatic. Overall, 63.6% did not have a follow-up visit after hospital discharge, although all of them were referred to the specialist. The findings of the present study suggest that thunderstorm-associated asthma could affect young adults with no gender priority, with or without asthma history, which put a strain on emergency medical services.

The efficacy of nebulized furosemide and salbutamol compared with salbutamol alone in reactive airway disease: a double blind randomized, clinical trial.

We undertook this randomized clinical trial to investigate whether adding furosemide to salbutamol could improve the peak expiratory flow rate (PEFR) and clinical signs of reactive airway disease (RAD) patients. Eligible 18- to 55-year-old patients were randomly divided into intervention and control groups. Patients received 5 mg of nebulized salbutamol and 40 mg of nebulized furosemide in the intervention group and 5 mg of nebulized salbutamol alone in the control group. Patients in both groups received 100 mg of methylprednisolone intravenously stat. Severity of the RAD was estimated before and 45 minutes after treatment in both groups. PEFR was estimated before treatment and at 15, 30, and 45 minutes later. Ninety patients were enrolled, 45 in each group. There were no significant differences between two groups regarding gender, mean age, and normalized PEFR. The baseline mean PEFR was not significantly different between groups (P = 0.58). A repeated measure analysis of variance revealed that the differences between the two treatments was significant (P = 0.0001) and the behavior of two treatments was not similar across the time (P = 0.001). Comparison of clinical severity of acute RAD revealed no significant differences between groups at the end of the trial (0.06). This study showed that adding nebulized furosemide to salbutamol in RAD patients improved PEFR.