2020 ASCO, 2023 NCCN, 2023 MASCC/ESMO, and 2019 CCO: a comparison of antiemetic guidelines for the treatment of chemotherapy-induced nausea and vomiting in cancer patients.

Chemotherapy-induced nausea and vomiting (CINV) is a common toxicity that may impair the quality of life of patients with various malignancies ranging from early to end stages. In light of frequent changes to the guidelines for optimal management of CINV, we undertook this narrative review to compare the most recent guidelines published by ASCO (2020), NCCN (2023), MASCC/ESMO (2023), and CCO (2019). The processes undertaken by each organization to evaluate existing literature were also described. Although ASCO, NCCN, MASCC/ESMO, and CCO guidelines for the treatment and prevention of CINV share many fundamental similarities, the literature surrounding low and minimal emetic risk regimens is lacking. Current data regarding adherence to these guidelines is poor and warrants further investigation to improve care.

A Systematic Review of Neurophysiology-Based Localization Techniques Used in Deep Brain Stimulation Surgery of the Subthalamic Nucleus.

OBJECTIVE: This systematic review is conducted to identify, compare, and analyze neurophysiological feature selection, extraction, and classification to provide a comprehensive reference on neurophysiology-based subthalamic nucleus (STN) localization. MATERIALS AND METHODS: The review was carried out using the methods and guidelines of the Kitchenham systematic review and provides an in-depth analysis on methods proposed on STN localization discussed in the literature between 2000 and 2021. Three research questions were formulated, and 115 publications were identified to answer the questions. RESULTS: The three research questions formulated are answered using the literature found on the respective topics. This review discussed the technologies used in past research, and the performance of the state-of-the-art techniques is also reviewed. CONCLUSION: This systematic review provides a comprehensive reference on neurophysiology-based STN localization by reviewing the research questions other new researchers may also have.

Mepitel Film for the prevention of acute radiation dermatitis in head and neck cancer: a systematic review and meta-analysis of randomized controlled trials.

PURPOSE: This systematic review and meta-analysis evaluates the efficacy of Mepitel Film in preventing acute radiation dermatitis (RD) in patients with head and neck cancer (HNC) across randomized controlled trials (RCTs). METHODS: Embase, MEDLINE, and Cochrane Central Register of Controlled Trials were searched on 5 March 2023 to identify relevant RCTs. RD assessment tools and outcomes were compared across studies. Pooled effect sizes and 95% confidence intervals (CI) were estimated based on random-effects analysis using RevMan 5.4. RESULTS: Three RCTs conducted between 2018 and 2020 were included. Mepitel Film decreased RD severity when compared to Sorbolene or Biafine but not when compared to mometasone. A per-protocol analysis of two of the trials revealed that, overall, Mepitel Film significantly reduced the incidence of grade 2-3 RD (odds ratio (OR), 0.24; 95% CI, 0.09-0.65; p = 0.005) and moist desquamation (OR, 0.21; 95% CI, 0.10-0.46; p < 0.0001) and decreased average patient, researcher, and combined components of the Radiation-Induced Skin Reaction Assessment Scale (the standardized mean difference (SMD) for patient ratings, - 2.56; 95% CI, - 3.15 to - 1.96, p < 0.00001; SMD for researcher ratings, - 3.47; 95% CI, - 6.63 to - 0.31, p = 0.03; SMD for combined scores, - 3.68; 95% CI, - 6.43 to - 0.92, p = 0.009). Noted issues with Mepitel Film included itchiness and poor adherence. CONCLUSION: While there were discrepancies across studies, Mepitel Film demonstrated a decrease in the incidence of grade 2-3 RD and moist desquamation. These findings emphasize the need for further examining Mepitel Film's efficacy across diverse patient groups and the importance of standardizing RD severity assessment methodologies and control arms.

Mepitel film for the prevention and treatment of acute radiation dermatitis in breast cancer: a systematic review and meta-analysis of randomized controlled trials.

PURPOSE: This systematic review and meta-analysis aimed to evaluate the efficacy of Mepitel film in preventing or treating acute radiation dermatitis (RD) in patients with breast cancer in randomized controlled trials (RCTs). METHODS: Embase, APA PsychInfo, Journals@Ovid Full Text, Ovid MEDLINE, PubMed, and Cochrane Trials were searched until December 12, 2022, to identify RCTs on the use of Mepitel film for preventing or treating acute RD from breast cancer radiotherapy. Per-protocol analysis was used to compare outcomes, calculate pooled effect sizes, odds ratio (OR), and 95% confidence intervals (CI), and to create forest plots using random effects analysis in RevMan 5.4. RESULTS: Three RCTs were included in this review. Mepitel film significantly reduced the incidence of grade 3 RD (OR 0.15 95% CI 0.06, 0.37, p<0.0001) and grade 2 or 3 RD (OR 0.16 95% CI 0.04, 0.65, p=0.01) as scored on either the CTCAE or the RTOG scale. Additionally, Mepitel film significantly reduced RISRAS mean scores assessed by patients and combined researcher and patient (standardized mean difference (SMD) -7.59, 95% CI -14.42, -0.76, p=0.03; SMD -15.36, 95% CI -30.01, -0.71 p=0.04) but not the researcher component of the assessment tool (SMD -17.55, 95% CI -36.94, 1.84, p=0.08). CONCLUSION: Mepitel film reduced the incidence of acute RD and improved patient-reported outcomes with minimal side effects, the main one being itchiness. Future research should assess the feasibility of Mepitel film with respect to specific patient-reported outcomes such as health-related quality of life issues associated with its use.

StrataXRT for the prevention of acute radiation dermatitis in breast cancer: a systematic review and meta-analysis of randomized controlled trials.

PURPOSE: To evaluate the overall efficacy of StrataXRT, a topical gel dressing, in preventing acute radiation dermatitis (RD) in breast cancer patients undergoing radiotherapy (RT). METHODS: A systematic search was conducted on April 25, 2023 in Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Randomized controlled trials (RCTs) assessing the effectiveness of StrataXRT in preventing acute RD in breast cancer patients undergoing adjuvant RT to the breast or chest wall with or without regional nodes were included. Pooled incidence odds ratio (OR) and 95% confidence interval (CI) were calculated using a random-effects model, with analysis and forest plots generated in RevMan v5.4. RESULTS: The analysis included three RCTs with a total of 189 patients assessed using per-protocol analysis. Two RCTs compared StrataXRT to standard of care, while the third compared it with Mepitel film and was reported separately. In the former RCTs, the odds ratio (OR) for developing acute grade 3 RD favored StrataXRT at 0.05 (95% CI, 0.01-0.22; P < 0.0001). The OR for developing acute grades 2-3 RD was 0.32 (95% CI, 0.03-3.18; P = 0.33). The RCT comparing StrataXRT with Mepitel film showed insignificant ORs for grade 3 and grades 2-3 RD. One RCT reported significantly lower erythema index (P = 0.008) and melanin index (P = 0.015) in StrataXRT patients. The use of StrataXRT did not raise additional safety concerns. CONCLUSION: StrataXRT may help prevent severe acute RD in breast cancer RT patients. Further high quality, large-scale studies are needed to confirm these findings.

Quality of life in patients with malignant spinal cord compression: a systematic review.

INTRODUCTION: Malignant spinal cord compression (MSCC) is an oncological emergency that may result in a devastating combination of malignancy and disability. Existing quality of life (QoL) questionnaires commonly used in MSCC literature (EORTC QLQ-C30, BM-22, Brief Pain Inventory, and Spine Oncology Study Group Outcomes) may not capture all the commonly reported symptoms and lack specificity to MSCC. The primary objective of this systematic review is to determine unmet patient needs and underreported QoL issues and compile a comprehensive list of QoL issues. The secondary objective of this review is to compile all existing QoL tools and questionnaires and determine whether any QoL issues are not addressed in the existing tools currently used in the literature. METHODS: A literature search was conducted on Ovid MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases between 1946 and February 6, 2023, to compile all QoL issues and existing questionnaires used to assess QoL in patients with MSCC. All study designs were included given that they discussed QoL issues specific to patients with MSCC. RESULTS: The results of this systematic review identified the most frequently discussed QoL issues in the literature studying MSCC. This included direct symptoms of MSCC such as back pain, paralysis, limb weakness/numbness, and urinary/bowel incontinence. Indirect symptoms coming from radiotherapy treatment such as dysphagia, painful swallowing, mouth pain, dry mouth, diarrhea, fatigue, and nausea/vomiting were also noted. Other symptoms resulting from corticosteroid treatment included difficulty sleeping, blurring of vision, weight gain, and mood disturbance. Patients also experienced psychosocial issues such as anxiety, depression, emotional distress, low self-esteem, concerns about dependence on others, concerns about getting home, and fear about their prognosis and future. CONCLUSION: This review highlights the QoL issues specific to patients with MSCC and QoL tools capturing these issues. Relevance of QoL issues identified in this systematic review must be prospectively validated by patients and healthcare professionals with experience in treating MSCC.

Quality of life issues in patients with bone metastases: A systematic review.

INTRODUCTION: Bones are frequent sites of metastatic disease, observed in 30-75% of advanced cancer patients. Quality of life (QoL) is an important endpoint in studies evaluating the treatments of bone metastases (BM), and many patient-reported outcome tools are available. The primary objective of this systematic review was to compile a list of QoL issues relevant to BM and its interventions. The secondary objective was to identify common tools used to assess QoL in patients with BM, and the QoL issues they fail to address. METHODS: A search was conducted on Ovid MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases between 1946 and 27 January 2023 with the keywords "bone metastases", "quality of life", and "patient reported outcomes". Specific QoL issues in original research studies and the QoL tools used were extracted. RESULTS: The review identified the QoL issues most prevalent to BM in the literature. Physical and functional issues observed in patients included pain, interference with ambulation and daily activities, and fatigue. Psychological symptoms, such as helplessness, depression, and anxiety were also common. These issues interfered with patients' relationships and social activities. Items not mentioned in existing QoL tools were related to newer treatments of BM, such as pain flare, flu-like symptoms, and jaw pain due to osteonecrosis. CONCLUSIONS: This systematic review highlights that QoL issues for patients with BM have expanded over time due to advances in BM-directed treatments. If they are relevant, additional treatment-related QoL issues identified need to be validated prospectively by patients and added to current assessment tools.

Detection and Reconstruction of Poor-Quality Channels in High-Density EMG Array Measurements.

High-density electromyography (HD-EMG) arrays allow for the study of muscle activity in both time and space by recording electrical potentials produced by muscle contractions. HD-EMG array measurements are susceptible to noise and artifacts and frequently contain some poor-quality channels. This paper proposes an interpolation-based method for the detection and reconstruction of poor-quality channels in HD-EMG arrays. The proposed detection method identified artificially contaminated channels of HD-EMG for signal-to-noise ratio (SNR) levels 0 dB and lower with ≥99.9% precision and ≥97.6% recall. The interpolation-based detection method had the best overall performance compared with two other rule-based methods that used the root mean square (RMS) and normalized mutual information (NMI) to detect poor-quality channels in HD-EMG data. Unlike other detection methods, the interpolation-based method evaluated channel quality in a localized context in the HD-EMG array. For a single poor-quality channel with an SNR of 0 dB, the F1 scores for the interpolation-based, RMS, and NMI methods were 99.1%, 39.7%, and 75.9%, respectively. The interpolation-based method was also the most effective detection method for identifying poor channels in samples of real HD-EMG data. F1 scores for the detection of poor-quality channels in real data for the interpolation-based, RMS, and NMI methods were 96.4%, 64.5%, and 50.0%, respectively. Following the detection of poor-quality channels, 2D spline interpolation was used to successfully reconstruct these channels. Reconstruction of known target channels had a percent residual difference (PRD) of 15.5 ± 12.1%. The proposed interpolation-based method is an effective approach for the detection and reconstruction of poor-quality channels in HD-EMG.

Childhood food allergy and food allergen sensitisation are associated with adult airways disease: A birth cohort study.

BACKGROUND: Childhood food allergy (FA) and food allergen sensitization (FAS) are associated with allergic airway disease(s) [AAD] (asthma and rhinitis) in childhood. However, the associations between childhood FA/FAS and AAD in adulthood are not well described. METHODS: We investigated the longitudinal relationship between childhood FA/FAS to common food allergens and AAD at 18 and 26 years, in the Isle of Wight birth cohort. Study subjects (N = 1456) were followed up at fixed time points from ages 1-26 years for FA/FAS status. AAD were evaluated from 4 years onwards. The associations between FA/FAS and AAD were assessed with univariate analyses and then multivariable logistic regression, adjusting for clinically relevant co-variates. RESULTS: Food allergy at 4 years was significantly associated with asthma at 18 years [adjusted odds ratio (aOR): 2.75, 95% CI: 1.53-4.92, p = .001] and 26 years (aOR: 2.62, 95% CI: 1.32-5.20, p = .006). Conversely, childhood FA was not associated with adulthood rhinitis whatsoever. While FAS at ages 4 and 10 were associated with both AAD, the associations between FAS and rhinitis were less robust relative to asthma. CONCLUSION: Childhood FA increased the odds of asthma during adulthood by nearly threefold. Additionally, childhood FAS was also associated with increased odds of asthma in adulthood. Conversely, FAS but not FA in childhood was associated with rhinitis in adulthood. We suggest that children with FA/FAS should be followed up to facilitate early detection and intervention of subsequent AAD, particularly asthma.

Impact of psychological impairment on quality of life and work impairment in severe asthma.

BACKGROUND: Psychological impairment, such as anxiety and depression, is common in severe asthma. However, the impact of psychological impairment on asthma-specific quality of life (ASQOL) and work impairment has not been assessed within Southeast-Asia. Furthermore, previous ASQOL questionnaires contained items overlapping with asthma control, making it challenging to isolate the relationship between psychological impairment with ASQOL and asthma control, respectively. OBJECTIVE: To evaluate the relationship between psychological impairment with ASQOL and work impairment in severe asthma. METHODS: This is a cross-sectional study of severe asthma at Singapore General Hospital. We assessed ASQOL, psychological impairment, work impairment and asthma control using validated questionnaires. An ASQOL questionnaire not containing items evaluating asthma symptoms was selected to reduce overlap with asthma control. Medical records were used to obtain other asthma characteristics and healthcare utilization patterns. RESULTS: Amongst 111 patients, 37% had psychological impairment based on Hospital Anxiety and Depression Scale. Poorer ASQOL was associated with anxiety (p = .013) after controlling for demographic characteristics, asthma control and comorbidities. Anxiety symptoms were associated with greater health concerns while depression symptoms were associated with sleep difficulty and physical limitations. Having depressive symptoms was associated with an additional 16% impairment of total work hours (p = .038). Psychological impairment was not associated with spirometry results or healthcare utilization. Ethnicity significantly predicted both ASQOL and work impairment. CONCLUSIONS: In severe asthma, patients with psychological impairment have poorer ASQOL and greater work impairment than those without psychological impairment. There is an urgent need to mitigate this problem.

Managing asthma in the COVID-19 pandemic and current recommendations from professional bodies: a review.

OBJECTIVE: To provide a summary of the management of asthma in the current COVID-19 pandemic by examining and comparing the recommendations from various professional bodies. DATA SOURCES AND STUDY SELECTION: Websites of known respiratory professional bodies were searched for COVID-19 guidance related to asthma. Subject matter experts were also consulted for useful resources. Resources that were targeted at healthcare professionals were included, while those targeting patients and the general public were excluded. RESULTS: There is currently little data to suggest that asthma protects from or increases the risk of COVID-19, nor is there any data to support strong recommendations for or against specific asthma treatments. Physicians should continue to manage asthma according to existing accepted asthma guidelines and recommendations. All prescribed medications, especially inhaled corticosteroids, should be continued, and, where indicated, oral corticosteroids and biologic therapies should still be used. Nebulizers and spirometry should be avoided where possible to reduce the risk of viral transmission. A detailed history should be taken to differentiate asthma exacerbations from COVID-19. CONCLUSION: Understanding similarities and differences among the recommendations of the various professional bodies will aid in medical decision-making in managing asthma in the COVID-19 pandemic. Health professionals should also consider the individual needs, preferences and values of their patients and the unique characteristics of their local healthcare systems.

The frequency and quality of delirium documentation in discharge summaries.

BACKGROUND: The National Institute for Health and Care Excellence recommends documenting all delirium episodes in the discharge summary using the term "delirium". Previous studies demonstrate poor delirium documentation rates in discharge summaries and no studies have assessed delirium documentation quality. The aim of this study was to determine the frequency and quality of delirium documentation in discharge summaries and explore differences between medical and surgical services. METHODS: This was a multi-center retrospective chart review. We included 110 patients aged ≥ 65 years identified to have delirium during their hospitalization using the Chart-based Delirium Identification Instrument (CHART-DEL). We assessed the frequency of any delirium documentation in discharge summaries, and more specifically, for the term "delirium". We evaluated the quality of delirium discharge documentation using the Joint Commission on Accreditation of Healthcare Organization's framework for quality discharge summaries. Comparisons were made between medical and surgical services. Secondary outcomes included assessing factors influencing the frequency of "delirium" being documented in the discharge summary. RESULTS: We identified 110 patients with sufficient chart documentation to identify delirium and 80.9 % of patients had delirium documented in their discharge summary ("delirium" or other acceptable term). The specific term "delirium" was reported in 63.6 % of all delirious patients and more often by surgical than medical specialties (76.5 % vs. 52.5 %, p = 0.02). Documentation quality was significantly lower by surgical specialties in reporting delirium as a diagnosis (23.5 % vs. 57.6 %, p < 0.001), documenting delirium workup (23.4 % vs. 57.6 %, p = 0.001), etiology (43.3 % vs. 70.4 %, p = 0.03), treatment (36.7 % vs. 66.7 %, p = 0.02), medication changes (44.4 % vs. 100 %, p = 0.002) and follow-up (36.4 % vs. 88.2 %, p = 0.01). CONCLUSIONS: The frequency of delirium documentation is higher than previously reported but remains subpar. Medical services document delirium with higher quality, but surgical specialties document the term "delirium" more frequently. The documentation of delirium in discharge summaries must improve to meet quality standards.

A mixed methods evaluation of a 4-week geriatrics curriculum in strengthening knowledge and comfort among orthopaedic surgery residents.

BACKGROUND: In 2014, the University of Toronto Faculty of Medicine implemented a 4-week "Orthogeriatrics" rotation for orthopaedic surgery residents. We sought to assess the rotation's impact on trainees' knowledge, attitudes, and behaviours toward caring for older adults, and explore areas for improvement. METHODS: We used a mixed methods concurrent triangulation design. The Geriatrics Clinical Decision-Making Assessment (GCDMA) and Geriatric Attitudes Scale (GAS) compared knowledge, attitudes, and behaviours between trainees who were or were not exposed to the curriculum. Rotation evaluations and semi-structured interviews with trainees and key informants explored learning experiences and the curriculum's impact on resident physician growth and development in geriatric competencies. RESULTS: Among trainees who completed the GCDMA (n = 19), those exposed to the rotation scored higher in knowledge compared to the unexposed cohort (14.4 ± 2.1 vs. 11.3 ± 2.0, p < 0.01). The following themes emerged from the qualitative analysis of 29 stakeholders: Increased awareness and comfort regarding geriatric medicine competencies, appreciation of the value of orthogeriatric collaboration, and suggestions for curriculum improvement. CONCLUSIONS: These results suggest that the Orthogeriatrics curriculum strengthens knowledge, behaviour, and comfort towards caring for older adults. Our study aims to inform further curriculum development and facilitate dissemination of geriatric education in surgical training programs across Canada and the world.

The circles of care game © - using gaming to teach interprofessional teamwork in clerkship.

The aim of this study was to gain insight into how online gaming can teach medical students about interprofessional collaborative practice and promote their development of interprofessional competencies prior to clerkship. This prospective cohort study involved third year medical students from the Schulich School of Medicine and Dentistry in London, Ontario, Canada who participated in the 'Circles of Care'© online board game. A total of 97 student reflections were obtained and subjected to conventional qualitative descriptive content analysis. The transcribed data were analyzed question by question and line by line. Themes evolved from four questions: (1) What surprised you the most about teamwork from this learning activity, (2) What did you learn about collaborative teamwork, (3) What will you take away from this learning event to use in your practice, and (4) Please comment on the value of using a game such as this one to develop your collaborative team practice. A total of seven themes emerged including: "Gaining insights", "What worked and what did not", "Openness to learning", "Comfort in sharing with others", "Commitment and skepticism", "Being a seeker", and "Continuum of value to learning and practice". Analysis of the student reflections illustrated the potential of using an online-based game to effectively introduce and teach interprofessional competencies to medical students.

Filaggrin mutations increase allergic airway disease in childhood and adolescence through interactions with eczema and aeroallergen sensitization.

BACKGROUND: Filaggrin loss-of-function (FLG-LOF) mutations are an established genetic cause of eczema. These mutations have subsequently been reported to increase the risk of aeroallergen sensitization and allergic airway disease. However, it is unclear whether FLG variants require both eczema and aeroallergen sensitization to influence airway disease development long-term outcomes. OBJECTIVE: To examine the effects of FLG-LOF mutations on allergic airway disease outcomes, with eczema and aeroallergen sensitization as intermediate variables, using the Isle of Wight birth cohort. METHODS: Study participants were evaluated at ages 1, 2, 4, 10 and 18 years to ascertain the development of allergic diseases (eczema, asthma and allergic rhinitis) and aeroallergen sensitization (determined by skin prick tests). FLG-LOF mutations were genotyped in 1150 subjects. To understand the complex associations between FLG mutations, intermediate variables (eczema and aeroallergen sensitization) and airway disease, path analysis was performed. RESULTS: There were significant total effects of FLG-LOF mutations on both asthma and allergic rhinitis at all ages as well as on aeroallergen sensitization up till 10 years old. In the filaggrin-asthma analysis, a direct effect of FLG-LOF mutations was observed on early childhood eczema (age 1 and 2 years) (relative risk (RR) 2.01, 95% CI: 1.74-2.31, P < .001), and all significant indirect pathways on asthma outcomes passed through eczema at these ages. In contrast, for the filaggrin-rhinitis model, FLG-LOF mutations exerted significant direct effects on early eczema as well as rhinitis at 10 years (RR 1.99; 95% CI: 1.72-2.29, P = .002). CONCLUSION: FLG-LOF mutations are a significant risk factor for later childhood asthma and rhinitis. However, the pathway to asthma is only through early childhood eczema while a direct effect was observed for childhood rhinitis.

Investigating the Effects of Motion Streaks on pQCT-Derived Leg Muscle Density and Its Association With Fractures.

Lower peripheral quantitative computed tomography (pQCT)-derived leg muscle density has been associated with fragility fractures in postmenopausal women. Limb movement during image acquisition may result in motion streaks in muscle that could dilute this relationship. This cross-sectional study examined a subset of women from the Canadian Multicentre Osteoporosis Study. pQCT leg scans were qualitatively graded (1-5) for motion severity. Muscle and motion streak were segmented using semi-automated (watershed) and fully automated (threshold-based) methods, computing area, and density. Binary logistic regression evaluated odds ratios (ORs) for fragility or all-cause fractures related to each of these measures with covariate adjustment. Among the 223 women examined (mean age: 72.7 ± 7.1 years, body mass index: 26.30 ± 4.97 kg/m2), muscle density was significantly lower after removing motion (p < 0.001) for both methods. Motion streak areas segmented using the semi-automated method correlated better with visual motion grades (rho = 0.90, p < 0.01) compared to the fully automated method (rho = 0.65, p < 0.01). Although the analysis-reanalysis precision of motion streak area segmentation using the semi-automated method is above 5% error (6.44%), motion-corrected muscle density measures remained well within 2% analytical error. The effect of motion-correction on strengthening the association between muscle density and fragility fractures was significant when motion grade was ≥3 (p interaction <0.05). This observation was most dramatic for the semi-automated algorithm (OR: 1.62 [0.82,3.17] before to 2.19 [1.05,4.59] after correction). Although muscle density showed an overall association with all-cause fractures (OR: 1.49 [1.05,2.12]), the effect of motion-correction was again, most impactful within individuals with scans showing grade 3 or above motion. Correcting for motion in pQCT leg scans strengthened the relationship between muscle density and fragility fractures, particularly in scans with motion grades of 3 or above. Motion streaks are not confounders to the relationship between pQCT-derived leg muscle density and fractures, but may introduce heterogeneity in muscle density measurements, rendering associations with fractures to be weaker.

Postoperative real-time electrocardiography monitoring detects myocardial ischemia: a case report.

PURPOSE: This case report outlines the utility and challenges of remote continuous postoperative electrocardiography ECG) monitoring, which is routed through a secure smartphone to provide real-time detection and management of myocardial ischemia. CLINICAL FEATURES: A 42-yr-old male with previous myocardial infarction and angioplasty underwent a radical prostatectomy. At three hours and 45 min postoperatively, remote real-time ECG monitoring was initiated upon the patient's arrival on a regular surgical ward. Monitor alerts were routed to a study clinician's smartphone. About six hours postoperatively, alarms were received and horizontal ST segment depressions were observed. A 12-lead ECG validated the ST segment changes, prompting initiation of a metoprolol iv and a red blood cell transfusion. Approximately seven hours and 30 min postoperatively, the ST segments normalized. The patient was discharged on postoperative day 3 and followed for four years without any sequelae. CONCLUSION: This case report illustrates the use of remote ECG monitoring and clinician response in real time with the use of a smartphone. With each alert, a small ECG strip is transmitted to the smartphone for viewing. In our view, this technology and management system provides a possible means to interrupt myocardial ischemic cascades in real time and prevent postoperative myocardial infarction.

The reliability of a segmentation methodology for assessing intramuscular adipose tissue and other soft-tissue compartments of lower leg MRI images.

OBJECTIVE: Determine the reliability of a magnetic resonance (MR) image segmentation protocol for quantifying intramuscular adipose tissue (IntraMAT), subcutaneous adipose tissue, total muscle and intermuscular adipose tissue (InterMAT) of the lower leg. MATERIALS AND METHODS: Ten axial lower leg MRI slices were obtained from 21 postmenopausal women using a 1 Tesla peripheral MRI system. Images were analyzed using sliceOmatic™ software. The average cross-sectional areas of the tissues were computed for the ten slices. Intra-rater and inter-rater reliability were determined and expressed as the standard error of measurement (SEM) (absolute reliability) and intraclass coefficient (ICC) (relative reliability). RESULTS: Intra-rater and inter-rater reliability for IntraMAT were 0.991 (95% confidence interval [CI] 0.978-0.996, p < 0.05) and 0.983 (95% CI 0.958-9.993, p < 0.05), respectively. For the other soft tissue compartments, the ICCs were all >0.90 (p < 0.05). The absolute intra-rater and inter-rater reliability (expressed as SEM) for segmenting IntraMAT were 22.19 mm(2) (95% CI 16.97-32.04) and 78.89 mm(2) (95% CI 60.36-113.92), respectively. CONCLUSION: This is a reliable segmentation protocol for quantifying IntraMAT and other soft-tissue compartments of the lower leg. A standard operating procedure manual is provided to assist users, and SEM values can be used to estimate sample size and determine confidence in repeated measurements in future research.

Radial endobronchial ultrasound in diagnosing peripheral lung lesions in a high tuberculosis setting.

BACKGROUND: Current data for the utility of radial endobronchial ultrasound (EBUS) in investigating peripheral lung lesions (PLLs) has been restricted to populations with low pulmonary tuberculosis (TB) incidence. The aim of this study was to assess the diagnostic utility of radial EBUS with guide sheath in the diagnosis of peripheral lung lesions in Singapore, a high TB incidence setting. METHODS: A post-hoc database analysis was performed. 123 consecutive patients with computed tomographic evidence of PLLs who underwent radial EBUS guided bronchoscopy were included. RESULTS: The final diagnosis was malignancy in 76 cases and benign in 44 cases. Radial EBUS guided bronchoscopy had a sensitivity of 65.8 % for malignancy, positive predictive value of 100 %, negative predictive value of 62.9 %, and a diagnostic accuracy of 82.5 %. 22 patients had a final diagnosis of pulmonary TB. The diagnostic sensitivity for pulmonary TB was 77.3 %, with a positive predictive value of 100 %, negative predictive value of 95.2 % and a diagnostic accuracy of 95.8 %. Overall, 58.8 % of pulmonary TB cases relied on histology to make an early diagnosis. CONCLUSION: Radial EBUS guided bronchosopy is useful in investigating PLLs in a high TB incidence setting. Our data also suggests that radial EBUS is a more rapid diagnosis technique for tuberculous lesions.