Effects of bradycardia, hypoxemia and early intubation on bronchopulmonary dysplasia in very preterm infants: An observational study.

BACKGROUND: Bronchopulmonary dysplasia (BPD) is the most common pulmonary complication in preterm infants. OBJECTIVES: The study aimed to explore the effects of bradycardia, hypoxemia, and early intubation on BPD in very preterm infants. METHODS: This is a prospective observational cohort study. Preterm infants with a mean gestational age of 28.67 weeks were recruited from two level III neonatal intensive care units (NICUs) in Taiwan. Continuous electrocardiography was used to monitor heart rates and oxygen saturation (SpO2). Infants were monitored for heart rates of <100 beats per minute and SpO2 levels of <90 % lasting for 30 s. Generalized estimating equations were used to analyze the effects of bradycardia, hypoxemia, and early intubation on BPD in very preterm infants. Model fit was visually assessed using receiver operating characteristic curve analysis. RESULTS: Bradycardia, hypoxemia, and early intubation significantly increased the odds of BPD among the preterm infants (N = 39) during NICU stay; the odds ratios for bradycardia, hypoxemia, and early intubation for BPD versus non-BPD were 1.058, 1.013, and 29.631, respectively (all p < 0.05). A model combining bradycardia, hypoxemia, and early intubation accurately predicted BPD development (area under the curve = 0.919). CONCLUSIONS: Bradycardia, hypoxemia, and early intubation significantly increased the odds of BPD among very preterm infants during NICU stay. The model combining bradycardia, hypoxemia, and early intubation accurately predicted BPD development.

Population-Based Prognostic Models for Head and Neck Cancers Using National Cancer Registry Data from Taiwan.

PURPOSE: This study aims to raise awareness of the disparities in survival predictions among races in head and neck cancer (HNC) patients by developing and validating population-based prognostic models specifically tailored for Taiwanese and Asian populations. METHODS: A total of 49,137 patients diagnosed with HNCs were included from the Taiwan Cancer Registry (TCR). Six prognostic models, divided into three categories based on surgical status, were developed to predict both overall survival (OS) and cancer-specific survival using the registered demographic and clinicopathological characteristics in the Cox proportional hazards model. The prognostic models underwent internal evaluation through a tenfold cross-validation among the TCR Taiwanese datasets and external validation across three primary racial populations using the Surveillance, Epidemiology, and End Results database. Predictive performance was assessed using discrimination analysis employing Harrell's c-index and calibration analysis with proportion tests. RESULTS: The TCR training and testing datasets demonstrated stable and favorable predictive performance, with all Harrell's c-index values ≥ 0.7 and almost all differences in proportion between the predicted and observed mortality being < 5%. In external validation, Asians exhibited the best performance compared with white and black populations, particularly in predicting OS, with all Harrell's c-index values > 0.7. CONCLUSIONS: Survival predictive disparities exist among different racial groups in HNCs. We have developed population-based prognostic models for Asians that can enhance clinical practice and treatment plans.

Time variation of high-risk groups for liver function deteriorations within fluctuating long-term liver function after hepatic radiotherapy in patients with hepatocellular carcinoma.

PURPOSE: The purpose of this study is to find essential risk factors associated with liver function (LF) deteriorations within fluctuating long-term LF and their time-varying effects in patients with hepatocellular carcinoma (HCC) receiving hepatic radiotherapy and to identify high-risk groups for adverse LF deteriorations and their changes over time in facilitating the prevention of hepatic decompensation and the improvement of survival. MATERIALS AND METHODS: A total of 133 HCC patients treated by hepatic radiotherapy were enrolled. A study design was conducted to convert posttreatment long-term LF with fluctuating levels over time to recurrent LF events using defined upgrades in a grading scale. The hazard ratios (HR) of pretreatment biochemical, demographic, clinical, and dosimetric factors in developing posttreatment LF events were estimated using the Cox model. Methodologies of the counting process approach, robust variance estimation, goodness-of-fit testing based on the Schoenfeld residuals, and time-dependent covariates in survival analysis were employed to handle the correlation within subjects and evaluate the time-varying effects during long-term follow-up. RESULTS: Baseline LF score before radiotherapy and gender were significant factors. Initial HR in developing LF events was 1.17 (95% CI 1.11-1.23; P < 0.001) for each increase of baseline LF score and kept almost constant over time (HR, 1.00; 95% CI 1.00-1.01; P = 0.065). However, no difference was observed regarding initial hazards for gender (HR, 1.00; 95% CI 0.64-1.56; P = 0.994), but the hazard for women got higher monthly over time compared with men (HR, 1.04; 95% CI 1.01-1.07; P = 0.006). CONCLUSIONS: High-risk groups for adverse LF deteriorations after hepatic radiotherapy may change over time. Patients with poor baseline LF are vulnerable from the beginning. Women require prevention strategies and careful monitoring for deteriorations at a later stage.

Critical Factors of Dose Distribution in Breast Cancer Tomotherapy With Metallic Port Breast Tissue Expander: Image Correction, Delivery Mode, and Volume Impact.

Objectives: Breast reconstruction helps patients enhance their body image after mastectomy. Metallic ports in tissue expanders lead to dose attenuation during radiotherapy. Tissue expander volume shifts the metallic port position, possibly causing various dose alterations. This study aimed to evaluate the impact of the MAGNA-SITETM tissue expander volume on tomotherapy. Methods: Boluses and MAGNA-SITETM were placed on a Rando phantom to simulate the tissue expander under the pectoralis major. Computed tomography simulation images were transformed through replacing the electron density of (a) metallic artifact region only (Image metallic port) and (b) metallic port and artifact regions (Image Homo). Planning was calculated using fixed-beam and helical-mode techniques. Radiation was delivered with different volumes of the tissue expander. Results: Integrated 997 dose points were calculated. Planning with Image metallic port provided a calculated dose significantly closer to a realistic dose. The percentage of doses achieving the prescribed dose was significantly higher in the helical mode. In layer 2, the 100-mL tissue expander had a significantly lower measurement dose than all other volumes. Volume 150 mL had the highest increase in the measured dose difference from the plan dose at layer 2. Volume 250 mL had the highest percentage of measurement doses passing the 5% dose difference from plan dose. The coldest dose areas were noted in layers 1 and 2, especially in the metallic port-direct image mode. The average dose reduction of the measured cold areas was 6.03 ± 1.94%. Conclusion: Dose distribution was affected by the volume of the metallic port tissue expander. Tomotherapy with proper image heterogeneity correction and helical mode can reduce the attenuation from the metallic port. A tissue expander volume of 150 to 250 mL is suitable. Patients with high risk at the chest wall should be evaluated carefully to avoid underdosing. Radiation oncologists should closely cooperate with plastic surgeons to optimize treatment for each patient.

Risk of work-related injury in workers with obstructive sleep apnea: A systematic review and meta-analysis.

The objective of this study is to elucidate the relationship between obstructive sleep apnea (OSA) and the risk of work-related injuries (WRIs), synthesize the latest clinical evidence and conduct a systematic review and meta-analysis adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA 2020). Observational studies published before April 2020 in PubMed, Cochrane library, PsycINFO, Scopus, Google Scholar and Web of Science were included. Random-effects Mantel-Haenszel meta-analysis was performed. A total of 15 studies with 21,507 participants were included. Prespecified subgroup analyses based on study design and the characteristics of the enrollees were conducted. Overall, workers with OSA had 1.64-fold increased odds of being involved in WRIs compared to their counterparts (OR = 1.64, 95% CI = 1.24-2.16, p = 0.0005). In addition to the professional drivers that have been studied in the past, such a trend also existed in the general working population (OR = 1.68, 95% CI = 1.14-2.49, p = 0.01). We also found that workers with excessive daytime sleepiness (Epworth Sleepiness Scale score >10) had a 1.68-fold increased risk of WRIs compared to those with lower ESS scores (OR = 1.68, 95% CI = 1.22-2.30, p = 0.002). This study verified that OSA workers had a higher risk of WRIs, and such correlations do not show obvious differences in subgroups with different sample sizes, OSA diagnosis methods, job types or definitions of WRI. Based on the association between OSA and WRIs identified in our study, further studies investigating the protective effects of early identification and management of OSA on WRIs are warranted.

Half-beam volumetric-modulated arc therapy in adjuvant radiotherapy for gynecological cancers.

PURPOSE: The purpose of this study is to introduce half-beam volumetric-modulated arc therapy (HVMAT), an innovative treatment planning technique from our work, for reducing dose to the organs at risk (OAR) during adjuvant radiotherapy for gynecological cancers. METHODS AND MATERIALS: Seventy-two treatment plans of 36 patients with gynecological cancers receiving adjuvant radiotherapy were assessed. Among them, 36 plans were designed using HVMAT and paired with the other 36 traditional volumetric-modulated arc therapy (VMAT) plans for each patient. The main uniqueness of the HVMAT designs was that it consisted of two opposite-shielded half-beam fields rotated inversely in two coplanar arcs, collocating with the specially-devised avoidance structures to enhance the control of the OAR doses. The dose distributions in HVMAT and VMAT were evaluated and compared using the random effects model. RESULTS: The ratios of OAR doses in HVMAT compared with VMAT showed a comprehensive OAR dose reduction when using HVMAT (V20Gy : bladder, 0.92; rectum, 0.95; V30Gy : bowel, 0.91; femoral heads, 0.66), except for the ilium (V30Gy : 1.12). The overall mean difference for each OAR across V40Gy , V30Gy , V20Gy , and bowel V15Gy was statistically significant (almost all p < 0.001). In addition, HVMAT promoted a better conformity index, homogeneity index, D2% , and V107% of the planning target volume (all p < 0.001). CONCLUSIONS: HVMAT is capable of generating deep double-concave dose distributions with the advantage of reducing dose to several OARs simultaneously. It is highly recommended for pelvic irradiation, especially for treating gynecological cancers in adjuvant radiotherapy.

Calling nurses to care for burn victims after color-dust explosion.

BACKGROUND: Healthcare professionals follow codes of ethics, making them responsible for providing holistic care to all disaster victims. However, this often results in ethical dilemmas due to the need to provide rapid critical care while simultaneously attending to a complex spectrum of patient needs. These dilemmas can cause negative emotions to accumulate over time and impact physiological and psychological health, which can also threaten nurse-patient relationships. AIM: This study aimed to understand the experience of nurses who cared for burn victims of the color-dust explosion and the meaning of ethical relationships between nurse and patient. RESEARCH DESIGN: A qualitative descriptive study using a phenomenological approach. PARTICIPANTS AND RESEARCH CONTEXT: Clinical nurses who provided care to the patients of the Formosa color-dust explosion of 2015 were selected by purposive sampling (N = 12) from a medical center in Taiwan. Data were collected using individual in-depth semi-structured interviews. Audiotaped interviews were transcribed and analyzed using Colaizzi's method. ETHICAL CONSIDERATIONS: This study was approved by the institutional review board of the study hospital. All participants provided written informed consent. FINDINGS: Three main themes described the essence of the ethical dilemmas experienced by nurses who cared for the burn-injured patients: (1) the calling must be answered, (2) the calling provoked my feelings, and (3) the calling called out my strengths. CONCLUSIONS: Healthcare providers should recognize that nurses believed they had an ethical responsibility to care for color-dust explosion burn victims. Understanding the feelings of nurses during the care of patients and encouraging them to differentiate between the self and the other by fostering patient-nurse relationships based on intersubjectivity could help nurses increase self-care and improve patient caregiving.

Long-term clinical outcomes of patients receiving proton beam therapy for caudate lobe hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) located in the caudate lobe (caudate HCC) is rare; however, patients with this type of tumour have poorer prognoses than those with HCC in other segments. Despite many published reports on the clinical usefulness of proton beam therapy (PBT) for HCC, data on the clinical outcomes of patients undergoing PBT for caudate HCC remain scarce. Therefore, the present study aimed to investigate the outcomes of this group of patients. Thirty patients with caudate HCC who underwent definitive PBT between February 2002 and February 2014 were retrospectively analysed. The total irradiation doses ranged from 55 to 77 (median 72.6) Gy relative biological dose. The median follow-up period was 37.5 (range, 3.0-152.0) months. The overall survival (OS) rates at one, three and five years were 86.6%, 62.8% and 46.1%, respectively. According to univariate and multivariate analyses, Child-Pugh A (P < 0.01), having a single tumour (P = 0.02) and a low serum alpha-fetoprotein level (AFP; P < 0.01) were significant factors predicting longer survival. The local control (LC) rates at one, three and five years were 100%, 85.9% and 85.9%, respectively, while the corresponding progression-free survival (PFS) rates were 65%, 27.5% and 22%, respectively. No grade 3 or worse adverse events were observed. PBT is effective and safe for the treatment of caudate HCC, and should therefore be considered a feasible option for intervention in patients with this disease.

Meaning of critical traumatic injury for a patient's body and self.

BACKGROUND: Patients with a traumatic injury often require intensive care for life-saving treatments. Physical suffering and emotional stress during critical care can be alleviated by ethical caring provided by nurses. The relationship between body and self are fundamentally inseparable. Nurses need to understand the impacts of traumatic injury on a patient's body and self. AIM: To understand the meaning of traumatic injury for body and self for patients receiving intensive care. RESEARCH DESIGN: A qualitative descriptive study using Giorgi's phenomenological approach. PARTICIPANTS AND RESEARCH CONTEXT: Patients receiving intensive care for physical trauma were selected by purposive sampling (N = 15) from a medical center in Taiwan. Individual in-depth, face-to-face audiotaped interviews, guided by semi-structured questions, were used to collect data. Each interview lasted 30-60 min. Audiotaped interviews were transcribed and analyzed. ETHICAL CONSIDERATIONS: This study was approved by the Institutional Review Board of the medical center. FINDINGS: The impact of the experience of traumatic injury on participants' body and self was described by three main themes: (1) Searching for the meaning of the injured body, (2) Feeling trapped in the bed, and (3) The carer and the cared-for. DISCUSSION AND CONCLUSION: The implications of the three themes described in the findings are as follows: Trauma as a source of meaning; Body and self are mutually limiting or mutually enabling; and Ethical relationships. The experience of needing intensive care following a traumatic injury on the body and self was dynamic and mutual. The experience of the injury changed the relationship between body and self, and gave new meaning to life. Nurses play a crucial role in continuity of care by understanding the meaning of a traumatic injury for patient's body and self that facilitates ethical care and recovery from injury.

Capacity of proton beams in preserving normal liver tissue during proton beam therapy for hepatocellular carcinoma.

Unirradiated liver volume (ULV) preservation rate is an important factor associated with radiation-induced liver disease (RILD) in patients with hepatocellular carcinoma (HCC) undergoing proton beam therapy (PBT). The purpose of this study is to identify the predictors for ULV preservation and quantify the capacity of proton beams in normal liver sparing during PBT. We reviewed planning data of 92 patients with single intrahepatic HCC tumors undergoing PBT. The potential clinical and planning factors that may affect ULV preservation were involved in multiple linear regression for ULV preservation rate. The significant factors were determined to be predictors and their influences were quantified. The median ULV preservation rate was 62.08%. All the assessed clinical factors showed significant effects on ULV preservation rate: clinical target volume (CTV), P < 0.001; portal vein tumor thrombosis (PVTT), P = 0.010; left lobe tumor, P = 0.010. In contrast, none of the planning factors demonstrated significance. The coefficients of significant factors in multiple linear regression were 60.85 for intercept, -0.02 for CTV, -9.01 for PVTT and 8.31 for left lobe tumors. The capacity of proton beams to spare normal liver tissue during PBT for HCC is mainly affected by clinical factors. The baseline of the ULV preservation rate is 60.85%, decreasing 0.02% with each milliliter of CTV increase and 9.01% for tumors with PVTT, and increasing 8.31% for tumors limited to the left lobe. Further clinical studies should be carried out to correlate our dosimetric findings with clinical outcomes.

Arabidopsis chloroplast J protein DJC75/CRRJ mediates nitrate-promoted seed germination in the dark.

BACKGROUND AND AIMS: Nitrate can stimulate seed germination of many plant species in the absence of light; however, the molecular mechanism of nitrate-promoted seed germination in the dark remains largely unclear and no component of this pathway has been identified yet. Here, we show that a plastid J-domain protein, DJC75/CRRJ, in arabidopsis (Arabidopsis thaliana) is important for nitrate-promoted seed germination in the dark. METHODS: The expression of DJC75 during imbibition in the dark was investigated. The seed germination rate of mutants defective in DJC75 was determined in the presence of nitrate when light cues for seed germination were eliminated by the treatment of imbibed seeds with a pulse of far-red light to inactivate phytochrome B (phyB), or by assaying germination in the dark with seeds harbouring the phyB mutation. The germination rates of mutants defective in CRRL, a J-like protein related to DJC75, and in two chloroplast Hsp70s were also measured in the presence of nitrate in darkness. KEY RESULTS: DJC75 was expressed during seed imbibition in the absence of light. Mutants defective in DJC75 showed seed germination defects in the presence of nitrate when light cues for seed germination were eliminated. Mutants defective in CRRL and in two chloroplast Hsp70s also exhibited similar seed germination defects. Upregulation of gibberellin biosynthetic gene GA3ox1 expression by nitrate in imbibed phyB mutant seeds was diminished when DJC75 was knocked out. CONCLUSIONS: Our data suggest that plastid J-domain protein DJC75 regulates nitrate-promoted seed germination in the dark by upregulation of expression of the gibberellin biosynthetic gene GA3ox1 through an unknown mechanism and that DJC75 may work in concert with chloroplast Hsp70s to regulate nitrate-promoted seed germination. DJC75 is the first pathway component identified for nitrate-promoted seed germination in the dark.

Small bowel dose in subserosal tandem insertion during cervical cancer brachytherapy.

Cervical cancer patients may sometimes experience subserosal tandem insertions during brachytherapy, which can lead to increased but unnoticed irradiations to the small bowel (SB). In this study, we aimed to quantify and further predict individual SB dose increase and to increase focus on the SB in subserosal tandem insertions. Images and dosimetry data of cervical cancer brachytherapy with subserosal insertion (SI) were reviewed. The percentage increases in the SB dose compared with intracavitary insertion (II) at 8 points of D(x)cc with 10 cc intervals were assessed. SI was classified into anterior and posterior SI according to the insertion site. The differences in minimum distance from the tandem tip to the SB on the axial view between these 2 insertions were tested using the Mann-Whitney test. The distance and D(x)cc were involved in the individual dose increase model by linear regression as prediction factors. A total of 27 insertions were evaluated, including 8 insertions with SI and 19 insertions with II. The median percentage increases in the normalized SB dose for all SI showed a logarithmic trend with a 55.4% increase at the hotspot. In contrast to posterior SI, anterior SI demonstrated a more significantly logarithmic trend, which featured highly increased doses at the hotspot (79.1% for the absolute SB dose and 137.8% for the normalized SB dose). The prediction models can predict the percentage dose increases in SI: Increased D(x)cc [%] = 31.370 - 7.865 ln(distance) - 3.949 ln(x) (absolute SB dose), and Increased D(x)cc [%] = 55.618 - 18.591 ln(distance) - 7.232 ln(x) (normalized SB dose). We developed prediction models for individual SB dose increase in SI in our study. SB hotspots in anterior SI require greater attention during cervical cancer brachytherapy. The models are new ones and are given for the first time.

Radiation Dose in the Uterine Perforation by Tandem in 3-Dimensional Cervical Cancer Brachytherapy.

Cervical cancer patients may sometimes experience different types of uterine perforation by a tandem during brachytherapy. The purpose of this study was to address possibly different management strategies regarding different tandem positions from a dosimetry aspect by evaluating radiation doses delivered to organs-at-risk (OAR) in order to help medical professionals handle different types of uterine perforation. Images and dosimetry data in cervical cancer brachytherapy with uterine perforation were reviewed. Uterine perforation was classified into anterior and posterior perforation according to their tandem positions. Radiation doses received by OAR, including D2cc and D1cc of the bladder, rectum, and sigmoid colon, were statistically compared with nonperforation. The doses of high-risk clinical target volume (HR-CTV) of cervical tumor and bilateral point A were also compared in order to assure that the plans had not compromised the treatment efficacy. A total of 21 applications were assessed, including 5 with anterior perforation, 4 with posterior perforation, and 12 without perforation. In anterior perforation, the bladder was the only organ that received a significantly increased dose about 30% at D2cc and D1cc. However, in posterior perforation, multiple OAR received significantly excessive doses: approximately 30% for the bladder, 37% for the rectum, and 100% for the sigmoid colon. The OAR dose assessment was based on a statistically equivalent cervical tumor dose. Different management strategies are possible for anterior vs posterior perforation during brachytherapy due to different detrimental extents on OAR dosimetry. The bladder warrants more attention in anterior perforation, without compromising target coverage in treatment planning. On the other hand, repositioning may be considered in posterior perforation due to relatively massive OAR detriments. This concept is a new one and is given for the first time.

Tangent-based volumetric modulated arc therapy for advanced left breast cancer.

PURPOSE: To introduce the benefits of tangent-based volumetric modulated arc therapy (TVMAT), an innovative radiotherapy planning technique, compared with traditional volumetric modulated arc therapy (VMAT) for advanced left breast cancer needing nodal irradiation. MATERIALS AND METHODS: Twenty-three patients with advanced left breast cancer who had received modified radical mastectomy (MRM) and needed adjuvant radiotherapy including nodal irradiation were assessed. Among 23 radiotherapy treatment plans, 17 plans were designed by using TVMAT technique and 6 plans were designed by using traditional VMAT. The main difference of TVMAT from VMAT was that the area of avoidance sector within specific degrees of angle that had no monitor unit (MU) delivery was used in the arc planning, including a total of 5 sectors in 5 partial arcs. The dosimetries of planning target volume (PTV), right breast, bilateral lungs, and heart between TVMAT and VMAT were compared. RESULTS: The conformity index (CI) and homogeneity index (HI) of PTV between two groups were statistically equivalent (CI: 0.98 ± 0.02 and 0.98 ± 0.03, P = 0.431; HI: 0.12 ± 0.03 and 0.11 ± 0.05, P = 0.177), which indicated that the treatment efficacy of the plans regarding TVMAT was compatible with VMAT. However, all neighboring organs at risk (OAR) showed a great percentage of reduction in mean doses (right breast: 53.1%, right lung: 37.7%, left lung: 8.8%, heart: 21.2%) and low dose parameters (V10: right breast: 72.3%, right lung: 86.1%, left lung: 12.5%, heart: 25.1%; V5: right breast: 56.5%, right lung: 28.3%, left lung: 12.7%, heart: 18.2%) by using TVMAT. CONCLUSION: TVMAT greatly decreases the radiation doses delivered to the OAR with maintained therapeutic efficacy. It is highly recommended for treating breast cancer, especially for difficult cases with left side disease needing nodal irradiation.

Dosimetric analysis of tangent-based volumetric modulated arc therapy with deep inspiration breath-hold technique for left breast cancer patients.

BACKGROUND: Tangent-based intensity modulated radiation therapy (TIMRT) is a common adjuvant radiotherapy strategy for breast cancer patients. This study compared the dosimetric characteristics of tangent-based volumetric modulated arc therapy (TVMAT) and TIMRT for left breast cancer patients during deep inspiration breath-hold (DIBH) and free breathing (FB) techniques. METHODS: Fourteen patients with left breast cancer after breast-conserving surgery were included. The first arc started at 331.8-353.6 degrees and stopped at 281.8-315.0 degrees. The third arc started at 123.2-149.1 degrees and stopped at 88.0-96.0 degrees. The second and fourth arcs were reverse arcs of first and third arcs. DIBH-TIMRT inversing plans were generated using opposing tangential fields. Wilcoxon signed rank test and Spearman correlation were used to examine the significance of dose difference. RESULTS: Compared with FB-TVMAT, the mean heart dose of DIBH-TVMAT plans was reduced from 7.9 Gy to 3.2 Gy (p < 0.001). The average left lung volume receiving 30 Gy or more (V30Gy) was reduced from 12.9 to 5.7% (p < 0.001). DIBH-TVAMT plans resulted in a lower mean dose to the contralateral breast and lung (2 Gy and 0.7 Gy vs 3.4 Gy and 1.5 Gy, respectively) as compared to FB-TVMAT plans. Compared with DIBH-TIMRT, the average left lung V30Gy of DIBH-TVMAT plans was reduced from 8.5 to 5.7% (p = 0.031). As for low-dose areas, exposure of the left lung, right breast, heart and right lung volume with 10 Gy or more was not significantly different between the IMRT- and VMAT-plans. CONCLUSIONS: DIBH-TVMAT for left breast cancer treatment retains treatment plan quality similar to the DIBH-IMRT technique without compromising dose restrictions to the heart, right breast and right lung. DIBH-TVMAT increased left lung protection but still had higher V5Gy to right breast and substantially higher V5Gy to heart. For left breast cancer patients receiving treatment with the DIBH technique, DIBH-TVMAT provides better treatment quality and is a safe and feasible treatment strategy.

Quantitative analysis of respiration-induced motion of each liver segment with helical computed tomography and 4-dimensional computed tomography.

BACKGROUND: To analyze the respiratory-induced motion of each liver segment using helical computed tomography (helical CT) and 4-dimensional computed tomography (4DCT), and to establish the individual segment expansion margin of internal target volume (ITV) to facilitate target delineation of tumors in different liver segments. METHODS: Twenty patients who received radiotherapy with CT-simulation scanning of the whole liver in both helical CT and 10-phase-gated 4DCT were investigated, including 2 patients with esophagus cancer, 4 with lung cancer, 10 with breast cancer, 2 with liver cancer, 1 with thymoma, and 1 with gastric diffuse large B-cell lymphoma (DLBCL). For each patient, 9 representative points were drawn on the helical CT images of liver segments 1, 2, 3, 4a, 4b, 5, 6, 7, and 8, respectively, and adaptively deformed to 2 phases of the 4DCT images at the end of inspiration (phase 0 CT) and expiration (phase 50 CT) in the treatment planning system. Using the amplitude of each point between phase 0 CT and phase 50 CT, we established quantitative data for the respiration-induced motion of each liver segment in 3-dimensional directions. Moreover, using the amplitude between the original helical CT and both 4DCT images, we rendered the individual segment expansion margin of ITV for hepatic target delineation to cover more than 95% of each tumor. RESULTS: The average amplitude (mean ± standard deviation) was 0.6 ± 3.0 mm in the left-right (LR) direction, 2.3 ± 2.4 mm in the anterior-posterior (AP) direction, and 5.7 ± 3.4 mm in the superior-inferior (SI) direction, respectively. All of the segments moved posteriorly and superiorly during expiration. Segment 7 had the largest amplitude in the SI direction, at 8.6 ± 3.4 mm. Otherwise, the segments over the lateral side, including segments 2, 3, 6, and 7, had greater excursion in the SI direction compared to the medial segments. To cover more than 95% of each tumor, the required expansion margin of ITV in the LR, AP, and SI directions were at least 2.5 mm, 2.5 mm, and 5.0 mm on average, respectively, with variations between different segments. CONCLUSIONS: The greatest excursion occurred in liver segment 7, followed by the segments over the lateral side in the SI direction. The individual segment expansion margin of ITV is required to delineate targets for each segment and direction.

Psychometric Testing of Two Chinese-Version Scales on Attitudes Toward and Caregiving Behaviors for End-of-Life Patients and Families.

The study purpose was to examine the validities and reliabilities of the Chinese-versions Frommelt Attitudes Toward Care of the Dying Scale (Attitudes Scale) and Caregiving Behaviors Scale for End-of-Life Patients and Families (Behaviors Scale). The scales were tested in a convenience sample of 318 nurses with ≥6 months work experience at three hospitals. Cronbach's alphas of the Attitudes and Behaviors Scales were .90 and .96, respectively. Each scale had Kaiser-Meyer-Olkin index >.85 and Bartlett's test of sphericity >4000 ( p < .001). Attitudes Scale loaded on three factors: respecting and caring for dying patients and families, avoiding care of the dying, and involving patients and families in end-of-life care. The Behaviors Scale loaded on two factors: supporting dying patients and families, and helping families cope with grief. Factor loadings for both scales were ≥.49. Both Attitudes and Behaviors Scales are reliable and valid for evaluating nurses' attitudes and caregiving behaviors for the dying.

Effects of Aromatherapy Massage on Pregnant Women's Stress and Immune Function: A Longitudinal, Prospective, Randomized Controlled Trial.

OBJECTIVES: This study's aims are to examine the effects of aromatherapy massage on women's stress and immune function during pregnancy. METHODS: This longitudinal, prospective, randomized controlled trial recruited 52 healthy pregnant women from a prenatal clinic in Taipei using convenience sampling. The participants were randomly assigned to the intervention (n = 24) or control (n = 28) group using Clinstat block randomization. The intervention group received 70 min of aromatherapy massage with 2% lavender essential oil every other week (10 times in total) for 20 weeks; the control group received only routine prenatal care. In both groups, participants' salivary cortisol and immunoglobulin A (IgA) levels were collected before and after the intervention group received aromatherapy massage (every month from 16 to 36 weeks gestation) and were analyzed using enzyme-linked immunosorbent assay. RESULTS: The pregnant women in the intervention group had lower salivary cortisol (p < 0.001) and higher IgA (p < 0.001) levels immediately after aromatherapy massage than those in the control group, which did not receive massage treatment. Comparing the long-term effects of aromatherapy massage on salivary IgA levels between groups at different times, the study found that the pretest salivary IgA levels at 32 (p = 0.002) and 36 (p < 0.001) weeks gestational age (GA) were significantly higher than the pretest IgA at 16 weeks GA (baseline). CONCLUSIONS: This study presented evidence that aromatherapy massage could significantly decrease stress and enhance immune function in pregnant women. The findings can guide clinicians or midwives in providing aromatherapy massage to women throughout the pregnancy.

Prostatic urethral angle might be a predictor of treatment efficacy of α-blockers in men with lower urinary tract symptoms.

PURPOSE: We investigated the association of the prostatic urethral angle (PUA) with peak urinary flow rate (Qmax) and the severity of lower urinary tract symptoms (LUTS) on the aging male. We also evaluated the effect of the PUA on the treatment efficacy of tamsulosin on men with LUTS. MATERIALS AND METHODS: The records were obtained from a prospective database for first-visit male patients with LUTS in the outpatient department of our institution. These patients underwent a detailed physical examination and taking of medical history. A transrectal ultrasound was performed on these patients. The prostate size, length of intravesical prostatic protrusion (IPP), PUA, and International Prostate Symptom Score (IPSS) of the patients were evaluated. Uroflowmetry and a bladder scan for residual urine were also performed on every patient. Tamsulosin 0.2 mg per day was prescribed. The IPSS and uroflowmetry were reevaluated after they had received treatment for 3 months. RESULTS: A total of 178 patients were included, and 149 of them completed this cohort study. The mean PUA was 48.32°±13.74°. The mean prostate volume was 39.19±20.87 mL, and the mean IPP was 5.67±7.85 mm. On multivariate linear regression analysis, the PUA was independently associated with the IPSS (P<0.001), Qmax (P=0.004), post-treatment IPSS change (P=0.032), and post-treatment Qmax change (P<0.001). However, the prostate volume and IPP were not associated with these clinical items. CONCLUSION: The PUA is significantly associated with Qmax and IPSS in men with LUTS. The PUA is also inversely correlated with changes in Qmax and IPSS after tamsulosin treatment. Namely, the PUA might be a predictor for the treatment efficacy of α-blockers in aging men with LUTS.

Cannabinoid receptor 1 promotes hepatic lipid accumulation and lipotoxicity through the induction of SREBP-1c expression in zebrafish.

The activated cannabinoid receptor 1 (CB1R) is exclusively responsible for food intake and weight gain and regulates several pathological features associated with obesity in mammals. However, the precise role of CB1R in non-mammalian model systems is poorly understood. To investigate the functions of CB1R in zebrafish liver, we conditionally expressed CB1R proteins using a liver-specific Tet(off) transgenic system. In this study, we found hepatic lipid accumulation in CB1R transgenic zebrafish (CB) without doxycycline treatment (-Dox) and a suppression of CB1R expression, resulting in the loss of lipid accumulation in the livers of CB fish that received doxycycline treatment (+Dox). Oil Red O (ORO)-stained hepatocytes were predominant in the liver buds of CB-Dox larvae, indicating that CB1R functionally promotes lipid accumulation during CB hepatogenesis. More than 73 % of CB-Dox adults showed increased lipid content, which leads, in turn, to steatosis. Liver histology and ORO staining of CB-Dox hepatocytes also indicated the accumulation of fatty droplets in the CB liver samples, consistent with the specific pathological features of liver steatosis or steatohepatitis. We also found that hepatic CB1R overexpression accompanies the stimulation of the lipogenic transcription factor SREBP-1c and its target enzymes, acetyl coenzyme-A carboxylase-1 (ACC1) and fatty acid synthase (FAS), and increases de novo fatty acid synthesis. This study is the first to report CB1R as a potential hepatic stimulator for zebrafish liver steatosis.