Deep Parasternal Intercostal Plane Block for Intraoperative Pain Control in Cardiac Surgical Patients for Sternotomy: A Prospective Randomized Controlled Trial

OBJECTIVES

Sternotomy pain is common after cardiac surgery. The deep parasternal intercostal plane (DPIP) block is a novel technique that provides analgesia to the anterior chest wall. The aim of this study was to investigate the analgesic effect of bilateral DPIP blocks on intraoperative pain control in cardiac surgery.

DESIGN

This is a double-blinded, prospective randomized controlled trial (Oct 2020-Dec 2022).

SETTINGS

This study was conducted in a single institution, which is an academic university hospital.

PARTICIPANTS

Eighty-six elective cardiac surgical patients with median sternotomy were recruited.

INTERVENTIONS

Patients were randomly divided into DPIP or control group. Either 20ml 0.25% levobupivacaine or 0.9% normal saline was injected for the DPIP under ultrasound guidance after induction of general anaesthesia.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was intraoperative opioids consumption and hemodynamic changes at sternotomy. Secondary outcomes included postoperative morphine consumption, postoperative pain and time to tracheal extubation. Intraoperative opioids requirement was reduced from a median (IQR) intravenous morphine equivalence of 21.4mg (13.8-24.3mg) in control group to 9.5mg (7.3-11.2mg) in the DPIP group (P<0.001). Hemodynamic parameters were more stable in DPIP group at sternotomy, as evidenced by lower percentage increase in systolic, diastolic and mean arterial blood pressure from baseline. No difference was observed in time to tracheal extubation, postoperative morphine consumption, postoperative pain score and spirometry.

CONCLUSIONS

Bilateral DPIP block provides effective intraoperative analgesia and opioid-sparing. It may be included as part of the multimodal analgesia for enhanced recovery in cardiac surgery.

Clinical Outcomes of Breast-Conserving Surgery with Synchronous 50-kV X-ray Intraoperative Partial Breast Irradiation in Patients Aged 64 Years or Older with Low-Risk Breast Cancer

Background

Breast-conserving surgery with synchronous 50-kV X-ray intraoperative radiation therapy (TARGIT-IORT) is a convenient form of partial breast irradiation; however, the existing literature supports a wide range of local control rates.

Objectives

We investigated the treatment effectiveness and toxic effects of TARGIT-IORT in a patient cohort aged 64 years or older with low-risk breast cancer.

Design

Retrospective analysis.

Methods

Patients who received breast-conserving surgery with synchronous TARGIT-IORT at a single institution from 2016 to 2019 were reviewed. Additional whole breast irradiation was recommended at the discretion of the treating radiation oncologist. Baseline patient demographics and treatment details were recorded. Acute and chronic toxicities, measured using the Common Terminology Criteria for Adverse Events version 3.0 or 4.0 and breast cosmetic outcomes, using the Harvard Cosmesis score, were recorded. Locoregional recurrence, distant metastasis, and overall survival were recorded, and 5-year rates were estimated using the Kaplan-Meier method.

Results

61 patients were included with a median follow-up of 3.5 years and median age of 72 years. Eight (13%) patients received additional whole breast irradiation, and fifty-four (89%) received adjuvant hormone therapy. There were no local, regional, or distance recurrences. One patient died of complications from COVID-19 infection. Grade 2 + acute and chronic toxicities were observed in 6 (12%) and 7 (14%) patients, respectively. One patient experienced a grade 3 acute toxicity. Cosmetic outcome was "excellent" or "good" in 45 (92%) patients.

Conclusions

Breast TARGIT-IORT was well tolerated and conferred excellent disease control in this cohort of patients with low-risk breast cancer. While continued follow-up is required, TARGIT-IORT may be an appropriate treatment option for this population.

Breast Irradiation Is Well Tolerated in Carriers of a Pathogenic ATM Variant

PURPOSE

There are mixed and limited data regarding radiation therapy (RT) tolerance in carriers of a germline pathogenic or likely pathogenic (P/LP) ATM variant. We investigated RT-related toxic effects in carriers of an ATM variant who received treatment for breast cancer.

METHODS AND MATERIALS

We identified 71 patients treated with adjuvant RT for breast cancer who were carriers of a variant in ATM: 15 were classified as P/LP and 56 classified as variants of unknown significance (VUS). We additionally identified 205 consecutively treated patients during a similar timeframe who were either confirmed ATM wild type or had no prior genetic testing. RT plans were reviewed. Acute and chronic toxic effects were evaluated using Common Terminology Criteria for Adverse Events version 4.0 criteria. Fisher's exact tests for count data were performed to compare toxic effects between the cohorts (P/LP vs VUS vs control). Wilcoxon rank-sum testing was performed to assess for differences in patient characteristics.

RESULTS

The median toxicity follow-up was 19.4 months; median follow-up for the subcohorts was 13.3 months (P/LP), 12.6 months (VUS), and 23.3 months (control). There were no significant differences in radiation plan heterogeneity, receipt of a boost, or size of breast/chest wall planning target volume. There was greater use of hypofractionated RT in the control cohort (P = .023). After accounting for patient- and treatment-related factors that may affect toxic effects, we found no significant differences with respect to acute dermatitis, hyperpigmentation, moist desquamation, breast/chest wall pain, or breast edema. Additionally, we found no significant differences with respect to chronic breast/chest wall pain, induration, telangiectasia, or cosmetic outcome.

CONCLUSIONS

RT as part of the management of breast cancer was well tolerated in carriers of a P/LP ATM variant, with toxic effect profiles that were similar to those seen in patients without known ATM mutations. High rates of excellent or good cosmesis were observed in carriers of a P/LP ATM variant who underwent breast conservation.

Near-Surface Dose Correlates With Moist Desquamation and Unplanned Reconstructive Surgery in Patients With Implant-Based Reconstruction Receiving Postmastectomy Radiation Therapy

Purpose

Postmastectomy radiation therapy (PMRT) reduces disease recurrence in appropriately selected patients but may compromise implant-based reconstruction. We investigated whether near-surface dose correlates with radiation-related toxic effects in these patients.

Methods and Materials

Patients receiving PMRT at a single institution from 2016 to 2019 were retrospectively reviewed. Patient demographics and treatment information were collected. Three near-surface structures were retrospectively generated, bound by the chest wall tangent beam as well as the skin surface and the skin-3 mm contour (SR3), skin surface and skin-5 mm contour (SR5), or skin-5 and skin-10 mm contours. Dosimetric analysis of these near-surface contours was performed in 2 Gy intervals. Univariate and multivariate analyses were used to identify predictors of moist desquamation, grade 2+ chest wall pain, use of opiate pain medication, unplanned reconstructive surgery, and implant failure. Logistic regression for each outcome and near-surface contour was performed for receiver-operator area under the curve (AUC) analysis and the Youden J Statistic was used to determine the optimal threshold for each dosimetric parameter.

Results

Of 126 patients reviewed, 109 met the study's eligibility criteria. Median follow-up was 2.3 years. Twenty-five patients (23%) underwent unplanned reconstructive surgery, and 10 (9.2%) experienced implant failure. Among clinical variables, low body mass index and history of smoking predicted unplanned surgery on univariate and multivariate analyses, and moist desquamation predicted grade 2+ chest wall pain. The top dosimetric parameters by AUC for moist desquamation, grade 2+ chest wall pain, use of opiates, unplanned reconstructive surgery, and implant failure were SR5 D10 cc (AUC = 0.701, optimal threshold 57.8 Gy, P < .001), SR3 D10 cc (AUC = 0.600, optimal threshold 56.8 Gy, P = .079), SR5 D10 cc (AUC = 0.642, optimal threshold 57.3 Gy, P = .041), SR3 V44 Gy (AUC = 0.711, optimal threshold 81%, P = .001), and SR3 V44 Gy (AUC = 0.688, optimal threshold 82%, P = .052), respectively.

Conclusions

Near-surface dose correlates with moist desquamation and unplanned reconstructive surgery after PMRT. Further evaluation of prospective optimization of dosimetric parameters related to SR3 and SR5 should be considered.

[Visual analysis of the current research status and hotspots of electric burns at home and abroad]

Objective: To analyze the literature on electric burns published at home and abroad, and to explore the research hotspots and frontiers of electric burns. Methods: The bibliometric method was used. The Chinese and English literature related to electric burns published in China National Knowledge Infrastructure, Wanfang database, VIP database and the core collection of Web of Science database from January 1, 2013 to December 31, 2022 were searched respectively, and the CiteSpace 6.2.R2 software was used for analysis. The number of papers, authors, countries, and institutions of Chinese and English literature were counted respectively, and the co-occurrence analysis of keywords and mutation analysis and cluster analysis on the basis of the co-occurrence analysis were conducted, besides, the clustering time line figure was obtained after the keywords were sorted by time to explore the current research status and the evolution process of hotspots in the field of electric burns. Results: A total of 398 English papers were retrieved from the core collection of Web of Science database, and a total of 523 Chinese papers were retrieved from China National Knowledge Infrastructure, Wanfang database, and VIP database after duplicate check. From 2013 to 2022, the number of English literature published in the field of electric burns showed a steadily upward trend, and the number of published Chinese literature showed a downward trend and tended to be stable. In Chinese literature, a total of 302 authors as the first author published papers related to electric burns, with 17 core authors published ≥3 papers; in English literature, a total of 320 authors as the first author published papers related to electric burns. Researches on electric burns were carried out in 65 countries, with United States having the most cooperation with other countries and the largest number of papers published. A total of 512 institutions at home and abroad published papers related to electric burns, and the institutions with the largest number of Chinese and English papers were Shanghai Electric Power Hospital in China (n=14) and Hallym University in Korea (n=11), respectively. A total of 1 176 Chinese keywords and 1 068 English keywords were included for co-occurrence analysis after excluding keywords related to the searching words. The top three keywords in frequency in Chinese literature were surgical flap, wound repair, and nursing, and the top three keywords in frequency in English literature were management, epidemiology, and children. Ten clusters were obtained by keyword analysis in Chinese literature, and the largest cluster was wound healing, followed by clinical effects and surgical flaps. Seven clusters were obtained by keyword analysis in English literature, and the largest cluster was reconstructive surgical procedures, followed by chronic pain and shock. The persistent clusters in Chinese literature were wound healing and clinical outcomes, etc., and the prominent nodes in the recent two years were surgical timing, limb electric burns, and hypertrophic scars; the persistent clusters in English literature were reconstructive surgical procedures and chronic pain, etc., and the prominent nodes in the recent two years were predictors and burn management, etc. In Chinese literature, the keyword with the longest duration of mutation (2017-2021) was wrist electric burns, and the keyword with the highest intensity of mutation was flap repair; in English literature, the keyword with the longest duration of the mutation (2019-2022) was voltage, and the keyword with the highest intensity of mutation was prevention. Conclusions: There are similarities and differences in the research directions and hotspots of electric burns at home and abroad. Surgical flap repair is a common research hotspot at home and abroad. At present, domestic research focuses on wound healing, wrist electric burns, and other aspects, while international research focuses on treatment management, epidemiology, reconstruction, and other aspects.

Tumor Voxel Dose-Response Matrix Prediction Using Deep Learning

PURPOSE/OBJECTIVE(S)

Tumor voxel dose-response matrix (DRM) can be assessed using a series of FDG-PET/CT feedback images acquired during radiotherapy. Predicting the tumor voxel DRM earlier is crucial for effectively implementing adaptive treatment management. However, it is also challenging due to FDG uptake dynamic fluctuation in tumor cells. This study investigated the feasibility of predicting tumor voxel DRM during the early treatment weeks using the advanced deep learning (DL) technique.

MATERIALS/METHODS

Serial FDG-PET/CT images were acquired at the pretreatment (pre-Tx), the 2nd and 4th treatment weeks during standard chemo-radiotherapy (35 × 2 Gy) from each of the 50 patients with head and neck squamous cell carcinomas (HNSCC). The reference value of tumor voxel DRM (DRMref), representing the average metabolic change ratio during the treatment, was determined using a linear regression performed on the standard uptake values (SUV)s obtained at the pre-Tx (SUV0), the 2nd (SUV2) and the 4th (SUV4) treatment weeks following deformable PET/CT image registration. A DL model, 3D residual-Unet with a total of 3.4 million parameters, was trained to predict the tumor voxel DRMref with using the SUV0 and SUV2 matrices as inputs. The performance of the DL model was evaluated using 10-fold cross-validation and was compared to that of a linear regression (LR) model determined on the SUV0 and SUV2 matrices.

RESULTS

The mean (SD) of the tumor voxel DRMref was 0.46 (0.2) over all 34612 tumor voxels. The predicted tumor voxel DRM was 0.5 (0.38) and 0.46 (0.15) for the LR model and the DL model, respectively. For those resistant voxels (23.7% of all tumor voxels) with a DRMref > 0.6, the DRM deviation was 0.13 (0.4) and -0.11 (0.13) for the LR model and the DL model, respectively. For those sensitive voxels (76.3%) with a DRMref ≤ 0.6, the DRM deviation was 0.01 (0.23) and 0.03 (0.08) for the LR model and the DL model, respectively.

CONCLUSION

The proposed DL model can predict the tumor voxel DRM with a single FDG-PET feedback image acquired during the 2nd treatment week of radiotherapy for HNSCC patients. The prediction accuracy was improved compared to that of the LR model with a substantial reduction in the variances of the prediction errors. This work demonstrates the great potential of utilizing DL techniques to improve the efficiency of tumor response assessment and adaptive treatment management.

[Mechanism of intestinal injury induced by WNT2B high-expressed fibroblasts in Crohn's disease]

Objective: To explore the mechanism of intestinal tissue damage induced by macrophages activated by WNT2B high-expressed fibroblasts. Methods: This study involved biological information analysis, pathological tissue research and cell experimental research. The biological information of the colon tissue from the children with inflammatory bowel disease in previous study was analyzed again with single-cell sequencing. The pathological tissues were collected by colonoscopy from 10 children with Crohn's disease treated in the Department of Gastroenterology of Guangzhou Women and Children's Medical Center from July 2022 to September 2022. According to the findings of colonoscopy, tissues with obvious inflammation or ulceration were classified as the inflammatory group, while tissues with slight inflammation and no ulceration were classified as the non-inflammatory group. HE staining was performed to observe the pathological changes of the colon tissues. Macrophage infiltration and CXCL12 expression were detected by immunofluorescence. In terms of cell experiments, fibroblasts transfected with WNT2B plasmid or empty plasmid were co-cultured with salinomycin treated or non-treated macrophages, respectively; the expression of proteins through Wnt classical pathway were detected by western blotting. Macrophages treated with SKL2001 were used as the experimental group, and those with phosphate buffer as the control group. The expression and secretion of CXCL12 in macrophages were detected by quantitative Real-time PCR and enzyme-linked immunosorbent assay (ELISA). T-test or rank sum test were used for the comparison between groups. Results: Single-cell sequencing analysis suggested that macrophages were the main cells in inflammatory bowel disease colon tissue, and there was interaction between WNT2B high-expressed fibroblasts and macrophages. HE staining of the 10 patients ((9.3±3.8) years old, 7 males and 3 females) showed that the pathological score of colon tissue in the inflammatory group was higher than that in the non-inflammatory group (4 (3, 4) vs. 2 (1, 2) points, Z=3.05, P=0.002). Tissue immunofluorescence indicated that the number of infiltrating macrophages in the inflammatory group was significantly higher than that in the non-inflammatory group under high power field of view (72.8±10.4 vs.8.4±3.5, t=25.10, P<0.001), as well as the number of cells expressing CXCL12 (14.0±3.5 vs. 4.7±1.9, t=14.68, P<0.001). In cell experiments, western blotting suggested an elevated level of glycogen synthase kinase-3β phosphorylation in macrophages co-cultured with fibroblast transfected with WNT2B plasmid, and salinmycin could reverse this change. Real-time PCR suggested that the transcription level of CXCL12 in the experimental group was higher than that in the control group (6.42±0.04 vs. 1.00±0.03, t=183.00, P<0.001), as well as the expression and secretion of CXCL12 by ELISA ((465±34) vs. (77±9) ng/L, t=13.21, P=0.006). Conclusion: WNT2B high-expressed fibroblasts can secrete WNT2B protein and activate the Wnt classical signaling pathway thus enhancing the expression and secretion of CXCL12 in macrophages, inducing the development of intestinal inflammation of Crohn's disease.

[Efficacy and safety of endoscopic diaphragm incision in children with congenital duodenal diaphragm]

Objective: To explore the efficacy and safety of endoscopic diaphragm incision in pediatric congenital duodenal diaphragm. Methods: Eight children with duodenal diaphragm treated by endoscopic diaphragm incision in the Department of Gastroenterology of Guangzhou Women and Children's Medical Center from October 2019 to May 2022 were enrolled in this study. Their clinical data including general conditions, clinical manifestations, laboratory and imaging examinations, endoscopic procedures and outcomes were retrospectively analyzed. Results: Among the 8 children, 4 were males and 4 females. The diagnosis was confirmed at the age of 6-20 months; the age of onset was 0-12 months and the course of disease was 6-18 months. The main clinical manifestations were recurrent non-biliary vomiting, abdominal distension and malnutrition. One case complicated with refractory hyponatremia was first diagnosed with atypical congenital adrenal hyperplasia in the endocrinology department. After treatment with hydrocortisone, the blood sodium returned to normal, but vomiting was recurrent. One patient underwent laparoscopic rhomboid duodenal anastomosis in another hospital but had recurred vomiting after the operation, who was diagnosed with double duodenal diaphragm under endoscope. No other malformations were found in all the 8 cases. The duodenal diaphragm was located in the descending part of the duodenum, and the duodenal papilla was located below the diaphragm in all the 8 cases. Three cases had the diaphragm dilated by balloon to explore the diaphragm opening range before diaphragm incision; the other 5 had diaphragm incision performed after probing the diaphragm opening with guide wire. All the 8 cases were successfully treated by endoscopic incision of duodenal diaphragm, with the operation time of 12-30 minutes. There were no complications such as intestinal perforation, active bleeding or duodenal papilla injury. At one month of follow-up, their weight increased by 0.4-1.5 kg, with an increase of 5%-20%. Within the postoperative follow-up period of 2-20 months, all the 8 children had duodenal obstruction relieved, without vomiting or abdominal distension, and all resumed normal feeding. Gastroscopy reviewed at 2-3 months after the operation in 3 cases found no deformation of the duodenal bulbar cavity, and the mucosa of the incision was smooth, with a duodenal diameter of 6-7 mm. Conclusion: Endoscopic diaphragm incision is safe, effective and less invasive in pediatric congenital duodenal diaphragm, with favorable clinical applicability.

Development and Validation of an Integrated Healthy Workplace Management Model in Taiwan

Background

Impacts of exposure are generally monitored and recorded after injuries or illness occur. Yet, absence of conventional after-the-effect impacts (i.e., lagging indicators), tend to focus on physical health and injuries, and fail to inform if workers are not exposed to safety and health hazards. In contrast to lagging indicators, leading indicators are proactive, preventive, and predictive indexes that offer insights how effective safety and health. The present study is to validate an extended Voluntary Protection Programs (VPP) that consists of six leading indicators.

Methods

Questionnaires were distributed to 13 organizations (response rate = 93.1%, 1,439 responses) in Taiwan. Cronbach α, multiple linear regression and canonical correlation were used to test the reliability of the extended Voluntary Protection Programs (VPP) which consists of six leading indicators (safe climate, transformational leadership, organizational justice, organizational support, hazard prevention and control, and training). Criteria-related validation strategy was applied to examine relationships of six leading indicators with six criteria (perceived health, burnout, depression, job satisfaction, job performance, and life satisfaction).

Results

The results showed that the Cronbach's α of six leading indicators ranged from 0.87 to 0.92. The canonical correlation analysis indicated a positive correlation between the six leading indicators and criteria (1st canonical function: correlation = 0.647, square correlation = 0.419, p < 0.001).

Conclusions

The present study validates the extended VPP framework that focuses on promoting safety and physical and mental health. Results further provides applications of the extended VPP framework to promote workers' safety and health.

[Analysis of solitary rectal ulcer syndrome in 7 children]

Objective: To analyze the clinical features, treatment and prognosis of solitary rectal ulcer syndrome (SRUS) in children. Methods: The clinical data of 7 children who were diagnosed with SRUS in Department of Gastroenterology in Guangzhou Women and Children' Medical Center from January 2019 to December 2021 were retrospectively analyzed. The clinical data including general demographics, clinical presentations, endoscopic and histologic features, treatment and outcome were extracted from hospital medical records. Results: The 7 patients were all males, and the age of onset was 6-12 years. The course before diagnosis was 2-36 months. The most common symptom was rectal bleeding (6 cases) and most common findings at initial colonoscopy were ulcer in 3 cases and protuberance in 4 cases, both located only in rectum. The intestinal histopathology of 5 cases showed characteristic fibromuscular obliteration of lamina propria. Five children were treated with mesalamine granules or suppositories, and 2 cases underwent local excision. The follow-up lasted for 5-24 months and found symptoms relieved in 5 cases, improved in 1 case, and no remission in 1 case. Colonoscopy after the treatment was performed in 5 children, among whom 2 cases achieved mucosal healing. Conclusions: SRUS in children is mainly presented with rectal bleeding, and has characteristic histological change of ulcer and protuberance in endoscopy. Pathology is crucial for diagnosis and differential diagnosis. Both the medical and surgical treatment are effective for SRUS.

Workplace bullying as an organizational problem: Spotlight on people management practices

Though workplace bullying is conceptualized as an organizational problem, there remains a gap in understanding the contexts in which bullying manifests-knowledge vital for addressing bullying in practice. In three studies, we leverage the rich content contained within workplace bullying complaint records to explore this issue then, based on our discoveries, investigate people management practices linked to bullying. First, through content analysis of 342 official complaints lodged with a state health and safety regulator (over 5,500 pages), we discovered that the risk of bullying primarily arises from ineffective people management in 11 different contexts (e.g., managing underperformance, coordinating working hours, and entitlements). Next, we developed a behaviorally anchored rating scale to measure people management practices within a refined set of nine risk contexts. Effective and ineffective behavioral indicators were identified through content analysis of the complaints data and data from 44 critical incident interviews with subject matter experts; indicators were then sorted and rated by two independent samples to form a risk audit tool. Finally, data from a multilevel multisource study of 145 clinical healthcare staff nested in 25 hospital wards showed that the effectiveness of people management practices predicts concurrent exposure to workplace bullying at individual level beyond established organizational antecedents, and at the team level beyond leading indicator psychosocial safety climate. Overall, our findings highlight where the greatest risk of bullying lies within organizational systems and identifies effective ways of managing people within those contexts to reduce the risk, opening new avenues for bullying intervention research and practice. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Proton Therapy for Breast Cancer: A Consensus Statement From the Particle Therapy Cooperative Group Breast Cancer Subcommittee

Radiation therapy plays an important role in the multidisciplinary management of breast cancer. Recent years have seen improvements in breast cancer survival and a greater appreciation of potential long-term morbidity associated with the dose and volume of irradiated organs. Proton therapy reduces the dose to nontarget structures while optimizing target coverage. However, there remain additional financial costs associated with proton therapy, despite reductions over time, and studies have yet to demonstrate that protons improve upon the treatment outcomes achieved with photon radiation therapy. There remains considerable heterogeneity in proton patient selection and techniques, and the rapid technological advances in the field have the potential to affect evidence evaluation, given the long latency period for breast cancer radiation therapy recurrence and late effects. In this consensus statement, we assess the data available to the radiation oncology community of proton therapy for breast cancer, provide expert consensus recommendations on indications and technique, and highlight ongoing trials' cost-effectiveness analyses and key areas for future research.

Pre-existing Vestibular Symptoms Are Associated With Acute Vestibular Symptoms After Gamma Knife Therapy for Vestibular Schwannoma

OBJECTIVE

To identify pretreatment variables associated with the development of acute vestibular symptoms after Gamma Knife (GK) treatment for Vestibular Schwannoma (VS).

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary neurotology referral center.

PATIENTS

Patients treated with GK radiosurgery for VS between March 2007 and March 2017 were considered for this study. Patients with neurofibromatosis type II, previous VS surgery, follow-up less than 6 months, or the lack of T2 magnetic resonance imaging (MRI) sequences from the day of treatment were excluded.

MAIN OUTCOME MEASURES

The presence of acute vestibular symptoms arising within 6 months after GK was the main outcome variable. Tumor, patient, and treatment characteristics were gathered from the medical record.

RESULTS

In total, 98 patients met inclusion criteria. The incidence of acute vestibular symptoms occurring within 6 months after GK treatment was 46.9%. Post-GK vestibular symptoms were reported at a significantly higher frequency among subjects who had reported vestibular symptoms before their treatment (p = 0.001). Tumor size was not associated with a propensity to develop acute vestibular symptoms (p = 0.397). The likelihood of receiving a referral to vestibular rehabilitation services was not significantly different among patients with larger versus smaller tumor size, as defined by 1.6 cm and 1.4 cm thresholds (p = 0.896, p = 0.654).

CONCLUSIONS

Inquiries aimed at revealing a history of vestibular complaints may prove useful in counseling patients on the likelihood of experiencing acute vestibular symptoms after treatment of Vestibular Schwannoma with Gamma Knife therapy.

Pulsed radiation therapy for the treatment of newly diagnosed glioblastoma

BACKGROUND

Pulsed radiation therapy (PRT) has shown effective tumor control and superior normal-tissue sparing ability compared with standard radiotherapy (SRT) in preclinical models and retrospective clinical series. This is the first prospective trial to investigate PRT in the treatment of patients with newly diagnosed glioblastoma (GBM).

METHODS

This is a single-arm, prospective study. Patients with newly diagnosed GBM underwent surgery, followed by 60 Gy of PRT with concurrent temozolomide (TMZ). Each day, a 2-Gy fraction was divided into ten 0.2-Gy pulses, separated by 3-minute intervals. Patients received maintenance TMZ. Neurocognitive function (NCF) and quality of life (QoL) were monitored for 2 years using the Hopkins Verbal Learning Test‒Revised and the European Organisation for Research and Treatment of Cancer QLQ-C30 QoL questionnaire. Change in NCF was evaluated based on a minimal clinically important difference (MCID) threshold of 0.5 standard deviation.

RESULTS

Twenty patients were enrolled with a median follow-up of 21 months. Median age was 60 years. Forty percent underwent subtotal resection, and 60% underwent gross total resection. One patient had an isocitrate dehydrogenase (IDH)-mutated tumor. Median progression-free survival (PFS) and overall survival (OS) were 10.7 and 20.9 months, respectively. In a post-hoc comparison, median OS for the prospective cohort was longer, compared with a matched cohort receiving SRT (20.9 vs 14 mo, P = 0.042). There was no decline in QoL, and changes in NCF scores did not meet the threshold of an MCID.

CONCLUSIONS

Treatment of newly diagnosed GBM with PRT is feasible and produces promising effectiveness while maintaining neurocognitive function and QoL. Validation of our results in a larger prospective trial warrants consideration.

DNA Barcode Technology and Its Application Prospects in Forensic Medicine

Abstract

Traditional species identification has gone through five stages -- morphology, cytology, biochemistry, immunology and molecular biology. At present, the use of DNA technology for species identification has become a research hotspot. In the use of DNA for species identification, the presentation and application of DNA barcode is of epoch-making significance. With the successful application of new technology in species identification, forensic species identification has also made corresponding development, and is expected to play an important role in forensic related fields. This paper briefly describes the general situation and principles of DNA barcode technology as well as its advantages and limitations when applied to biological classification, and discusses the future significance and feasibility of DNA barcode technology in forensic applications, in order to provide new ideas for future forensic identification.

Omission of Axillary Lymph Node Dissection is Associated with Inferior Survival in Breast Cancer Patients with Residual N1 Nodal Disease Following Neoadjuvant Chemotherapy

BACKGROUND

The appropriateness of substituting sentinel lymph node dissection (SLND) and regional nodal irradiation (RNI) for axillary lymph node dissection (ALND) in patients with residual lymph node (LN) disease following neoadjuvant chemotherapy (NAC) is unknown. We used the National Cancer Database (NCDB) to compare survival following SLND and ALND in breast cancer patients with residual LN disease.

METHODS

We analyzed NCDB patients, treated between 2006 and 2014, with cT1-3, cN1, cM0 breast cancer and residual disease in 1-3 axillary LNs (ypN1) following NAC. Patients were grouped into those who received SLND (defined as removal of ≤ 4 LNs) and RNI, or ALND and RNI. Patients were matched for all patient, tumor, and treatment characteristics.

RESULTS

We identified 1313 eligible patients in the ALND group and 304 patients in the SLND group. For the matched cohorts, SLND was associated with significantly lower survival in both univariate and doubly robust multivariable analyses (MVA) (HR 1.7, 95% CI 1.3-2.2, P < 0.001 for MVA), with estimated 5-year OS of 71%, compared with 77% in the ALND group (P = 0.01). Exploratory subgroup analyses showed that SLND was comparable with ALND in patients with luminal A or B tumors with a single metastatic LN (HR 1.03, 95% CI 0.59-1.8, (P = 0.91).

CONCLUSIONS

Our analysis suggests that, while an ALND may not be needed for patients with limited residual nodal burden and biologically favorable tumors, SLND should not be routinely substituted for ALND in patients with ypN1 disease following NAC until its efficacy is confirmed by prospective trials.

Rates of rectal toxicity in patients treated with high dose rate brachytherapy as monotherapy compared to dose-escalated external beam radiation therapy for localized prostate cancer

BACKGROUND

Using a prospectively collected institutional database, we compared rectal toxicity following high dose rate (HDR) brachytherapy as monotherapy relative to dose-escalated external beam radiotherapy (EBRT) for patients with localized prostate cancer.

METHODS

2683 patients treated with HDR or EBRT between 1994 and 2017 were included. HDR fractionation was 38 Gy/4 fractions (n = 321), 24 Gy/2 (n = 96), or 27 Gy/2 (n = 128). EBRT patients received a median dose of 75.6 Gy in 1.8 Gy fractions [range 70.2-82.8 Gy], using either 3D conformal or intensity modulated radiotherapy (IMRT). EBRT patients underwent 3D image guidance via an off-line adaptive process.

RESULTS

Median follow-up was 7.5 years (7.4 years for EBRT and 7.9 years for HDR). 545 patients (20.3%) received HDR brachytherapy and 2138 (79.7%) EBRT. 69.1% of EBRT patients received IMRT. Compared to EBRT, HDR was associated with decreased rates of acute grade ≥2 diarrhea (0.7% vs. 4.5%, p < 0.001), rectal pain/tenesmus (0.6% vs. 7.9%, p < 0.001), and rectal bleeding (0% vs. 1.6%, p = 0.001). Rates of chronic grade ≥2 rectal bleeding (1.3% vs. 8.7%, p < 0.001) and radiation proctitis (0.9% vs. 3.3%, p = 0.001) favored HDR over EBRT. Rates of any chronic rectal toxicity grade ≥2 were 2.4% vs. 10.5% (p < 0.001) for HDR versus EBRT, respectively. In those treated with IMRT, acute and chronic rates of any grade ≥2 GI toxicity were significantly reduced but remained significantly greater than those treated with HDR.

CONCLUSIONS

In appropriately selected patients with localized prostate cancer undergoing radiation therapy, HDR brachytherapy as monotherapy is an effective strategy for reducing rectal toxicity.

Post-mastectomy radiotherapy is associated with improved overall survival in T3N0 patients who do not receive chemotherapy

BACKGROUND AND PURPOSE

There is limited retrospective evidence addressing the utility of post-mastectomy radiotherapy (PMRT) in patients with T3N0 breast cancer. We performed a retrospective analysis of the National Cancer Database (NCDB) comparing overall survival (OS) in T3N0 patients treated with mastectomy alone (MTX) or with PMRT.

MATERIALS AND METHODS

We performed a matched-cohort analysis of NCDB breast cancer patients with pT3N0 disease who did not receive NAC, or cT3N0 patients who received NAC treated between 2006 and 2014. Patients were matched for all available baseline characteristics using propensity scores with inverse probability of treatment weighting (IPTW) with stabilized weights.

RESULTS

We identified 13,901 eligible patients. In the pT3N0 cohort, median follow-up was 47 months for the MTX group and 50 months for the PMRT group. In the cT3N0 cohort, median follow-up was 44 months for the MTX group and 46 months for the PMRT group. OS was higher in pT3N0 patients treated with PMRT compared to MTX: 7-year OS of 74% vs. 65% (P < 0.001). Doubly robust multivariable analysis showed an association between PMRT and improved OS (HR 0.78, 95% CI 0.68-0.89, P < 0.001). There was no benefit to PMRT in patients who received adjuvant chemotherapy (AC). In the NAC cohort, PMRT did not change OS, with 7-year OS of 78% with MTX and 79% with PMRT. There was a trend of improved OS with PMRT in patients with residual disease in the breast and lymph nodes (HR 0.70, 95% CI 0.46-1.07).

CONCLUSION

PMRT improves OS in patients with pT3N0 disease, but the benefit appears limited to those who do not receive AC. PMRT does not improve OS in patients with cT3N0 disease who receive NAC, but there might be a benefit in patients with a poor response to chemotherapy. However, longer follow-up may be needed to make a definitive conclusion about the benefit of PMRT in patients who receive chemotherapy.

Mapping of Metastatic Level I Axillary Lymph Nodes in Patients with Newly Diagnosed Breast Cancer

PURPOSE

We examined the distribution of pretreatment nodal metastases to the level I axilla (Ax-L1) to assess the appropriateness of current breast atlases and provide guidelines in relationship to easily identifiable anatomic landmarks for accurate delineation of this lymph node (LN) basin.

METHODS AND MATERIALS

Patients with newly diagnosed breast cancer and biopsy-proven metastatic Ax-L1 LNs were identified. We related the location of each LN to its most adjacent rib and its distance from the bottom of the humeral head, axillary vessels, and a line connecting the anterior aspects of the pectoralis and latissimus dorsi muscles (P-L line). LNs were mapped onto a representative planning computed tomography scan, and their distribution was used to validate the current Radiation Therapy Oncology Group, European Society for Radiotherapy and Oncology, and Radiotherapy Comparative Effectiveness breast atlases. Furthermore, we examined metastases to a subregion encompassing the superolateral Ax-L1, irradiation of which correlates highly with lymphedema.

RESULTS

We identified 106 eligible patients with 107 biopsied LNs. All LNs fell between the second and fifth ribs (mean, 3.8 ± 0.56). Mean distance from the inferior aspect of the humeral head was 4.3 ± 1.6 cm (range, 0.3-8.4). Mean distance from the inferior aspect of the axillary vessels was 2.9 ± 1.5 cm (range, -0.6 to 5.4). Mean distance from the P-L line was 0.01 ± 1.9 cm (range, -2.2 to 2.4); negative and positive values denote medial or lateral to the P-L line. A Radiation Therapy Oncology Group-compliant Ax-L1 consensus contour, created from contours by 4 attending breast radiation oncologists, partially or fully missed 45% of mapped LNs. European Society for Radiotherapy and Oncology- and Radiotherapy Comparative Effectiveness-compliant Ax-L1 similarly missed 46% and 34% of mapped LNs, respectively. LNs were most frequently missed in the lateral direction. The superolateral Ax-L1 encompassed 9.3% of the mapped LNs.

CONCLUSIONS

A significant percentage of at-risk Ax-L1 tissue falls outside current contouring atlases. We propose expansion of the recommended Ax-L1 borders, most notably in the lateral direction.

Predictors of radiation necrosis in long-term survivors after Gamma Knife stereotactic radiosurgery for brain metastases

Background

The long-term risk of necrosis after radiosurgery for brain metastases is uncertain. We aimed to investigate incidence and predictors of radiation necrosis for individuals with more than 1 year of survival after radiosurgery for brain metastases.

Methods

Patients who had a diagnosis of brain metastases treated between December 2006 and December 2014, who had at least 1 year of survival after first radiosurgery were retrospectively reviewed. Survival was analyzed using the Kaplan-Meier estimator, and the incidence of radiation necrosis was estimated with death or surgical resection as competing risks. Patient and treatment factors associated with radiation necrosis were also analyzed.

Results

A total of 198 patients with 732 lesions were analyzed. Thirty-four lesions required salvage radiosurgery and 10 required salvage surgical resection. Median follow-up was 24 months. The estimated median survival for this population was 25.4 months. The estimated per-lesion incidence of radiation necrosis at 4 years was 6.8%. Medical or surgical therapy was required for 60% of necrosis events. Tumor volume and male sex were significant factors associated with radiation necrosis. The per-lesions incidence of necrosis for patients undergoing repeat radiosurgery was 33.3% at 4 years.

Conclusions

In this large series of patients undergoing radiosurgery for brain metastases, patients continued to be at risk for radiation necrosis throughout their first 4 years of survival. Repeat radiosurgery of recurrent lesions greatly exacerbates the risk of radiation necrosis, whereas treatment of larger target volumes increases the risk modestly.

Trimodality therapy for atypical teratoid/rhabdoid tumor is associated with improved overall survival: A surveillance, epidemiology, and end results analysis

BACKGROUND

Atypical teratoid/rhabdoid tumors (AT/RTs) are rare aggressive central nervous system tumors. The use of radiation therapy (RT) remains controversial, especially for patients younger than three years of age. The purpose of the current investigation is to robustly analyze the impact of RT among pediatric AT/RT patients using the Surveillance, Epidemiology, and End Results (SEER) database.

METHODS

SEER 18 Custom Data registries were queried for AT/RT (ICD-0-3 9508/3). A total of 190 pediatric AT/RT patients were identified, of whom 102 underwent surgery + chemotherapy and 88 underwent trimodality therapy. Univariate and multivariable analyses using Kaplan-Meier and Cox proportional hazards regression modeling were performed. Propensity-score matched analysis with inverse probability of treatment weighting was performed to account for indication bias. The landmark method was used to account for immortal time bias.

RESULTS

The majority of patients were <3 years old (75.8%). Patients <3 were more likely to be treated without RT as compared with older patients (62% vs 38%). Doubly robust MVA identified distant disease as a negative prognostic factor (HR 2.1, P = 0.003), whereas trimodality therapy was strongly protective (HR 0.39, P < 0.001). Infants (<1), toddlers (1-2), and older children (3+) all benefited from trimodality therapy, with largest benefit for infants (HR 0.34, P = 0.02) and toddlers (HR 0.31, P < 0.001).

CONCLUSION

The current study provides further evidence that trimodality therapy improves clinical outcomes among patients with AT/RT. This finding was most pronounced for younger patients; therefore, further studies are needed to confirm this finding in this vulnerable population.

The longitudinal study for the work-related factors to job performance among nurses in emergency department

To explore the relationship between baseline information, personal factors, working characteristics and job performance among nurses in emergency department in northern Taiwan.Two-hundred twenty-two nursing staff were interviewed repeated with structured questionnaires for data collection in 3 time points (From August to September, 2008, from February to March, 2009, and from November to December, 2009). The generalized estimating equation (GEE) is used to test the relationship between the domains of independent variables (baseline information, personal factors, working characteristics) and dependent variables (task performance, contextual performance).The mean age of participants is 30.1 ± 5.1 years. 50.0% are junior college or bachelor degrees. From the GEE model, biological protection (β = 0.17, P value = .002) and safety climate (β = 0.24, P value < .001) are significantly related to task performance. Contextual performance is strongly affected by safety climate (β = 0.15, P value < .001).To improve the job performance among nurses in emergency department, it should consider personal psychological and environmental factors.

Associations of health literacy with diabetic foot outcomes: a systematic review and meta-analysis

BACKGROUND

People with diabetes have low health literacy, but the role of the latter in diabetic foot disease is unclear.

AIM

To determine, through a systematic review and meta-analysis, if health literacy is associated with diabetic foot disease, its risk factors, or foot care.

METHODS

We searched PubMed, EMBASE, CINAHL, Web of Science, Scopus and Science Direct. All studies were screened and data extracted by two independent reviewers. Studies in English with valid and reliable measures of health literacy and published tests of association were included. Data were extracted on the associations between the outcomes and health literacy. Meta-analyses were performed using random effects models.

RESULTS

Sixteen articles were included in the systematic review, with 11 in the meta-analysis. In people with inadequate health literacy, the odds of having diabetic foot disease were twice those in people with adequate health literacy, but this was not statistically significant [odds ratio 1.99 (95% CI 0.83, 4.78); two studies in 1278 participants]. There was no statistically significant difference in health literacy levels between people with and without peripheral neuropathy [standardized mean difference -0.14 (95% CI -0.47, 0.18); two studies in 399 participants]. There was no association between health literacy and foot care [correlation coefficient 0.01 (95% CI -0.07, 0.10); seven studies in 1033 participants].

CONCLUSIONS

There were insufficient data to exclude associations between health literacy and diabetic foot disease and its risk factors, but health literacy appears unlikely to have a role in foot care. The contribution of low health literacy to diabetic foot disease requires definitive assessment through robust longitudinal studies.

How deep is the inflammation in chronic rhinosinusitis? Sinus wall thickness and blood eosinophilia

Various factors have been proposed to be related to refractory chronic rhinosinusitis (CRS). Treatment for refractory CRS is challenging for ear, nose, and throat (ENT) surgeons. The aim of the study was to determine the clinical features associated with the severity of CRS that may necessitate revision surgery by eliminating the bias of the surgeons technique using standardizing surgical procedures. Sinus wall thickness and blood eosinophilia, which may represent the depth of inflammation in CRS, are associated with the need for revision surgery. We found that, when the thickness of the postero-lateral maxillary sinus wall is more than 3.03 mm, there is an increased probability for a need for revision surgery. CRS patients with thickened sinus walls were found to have poorer outcomes. Further research is needed in order to justify this type of surgical procedure for CRS.

Dosimetric Evaluation of Incorporating Patient Geometric Variations Into Adaptive Plan Optimization Through Probabilistic Treatment Planning in Head and Neck Cancers

PURPOSE

Four-dimensional (4D) adaptive radiation therapy (ART) treatment planning is an alternative to the conventional margin-based treatment planning approach. In 4D ART, interfraction patient geometric variations, gathered from computed tomography (CT) or cone beam CT (CBCT) images acquired during the patient treatment course, are directly incorporated into the adaptive plan optimization using a probabilistic treatment planning method. The goal of the present planning study was to evaluate the dosimetric differences between 4D ART and conventional margin-based adaptive planning strategies for head and neck cancers. In addition, we examined whether the dose differences achieved with 4D ART would translate into clinically relevant toxicity reductions using the existing normal tissue complication probability (NTCP) models.

METHODS AND MATERIALS

For 18 head and neck cancer patients, the treatment plans were retrospectively generated for 4 different treatment strategies, including a solely image guided radiation therapy (IGRT) strategy (IGRT-only), 2 conventional adaptive treatment planning strategies using 3- and 0-mm planning target volume (PTV) margins, and the 4D ART strategy. In the IGRT-only strategy, a conventional 3-mm PTV margin treatment plan was applied for the entire treatment course. In the 2 conventional adaptive strategies, 2 new treatment plans were generated during the treatment course using diagnostic planning CT scans acquired after the 10th and 22nd fractions. The 4D ART followed the same adaptive schedule, except that the 4D adaptive plan was generated using 5 CBCT images acquired during the 5 most recent treatment fractions. For each strategy, the actual delivered dose for the entire treatment course was constructed by calculating the daily doses on 35 CBCT scans, deforming back to the pretreatment planning CT scan, and accumulating over all 35 fractions. The target coverage was evaluated using the percentage of target volume receiving ≥100% of the prescription dose (V_100%) and the minimum dose to 99% of the target volume (D₉₉). It was considered adequate if the V_100% was ≥95% and the dose deficit in D₉₉ was ≤2 Gy (with respect to the prescription dose). For each strategy, the dose received by the organs at risk (OARs) was also evaluated, and the corresponding NTCP values were subsequently calculated using 3 NTCP models.

RESULTS

Adequate target coverage was achieved for the primary clinical target volume (CTV1) and elective nodal CTV (CTV2) with a 3-mm PTV margin, regardless of adaptation. The 3-mm ART plan reduced the OAR mean dose by 1 to 2 Gy compared with the IGRT-only plan. The 0-mm ART plan further reduced the OAR dose by another 2 to 3 Gy at the expense of target coverage: 3 and 1 patient had V_100% <95%, and 6 and 5 patients had a >2 Gy dose deficit in D₉₉ for the CTV1 and CTV2, respectively. Use of 4D ART improved target coverage and attained OAR sparing similar to that with 0-mm ART. The number of patients with V_100% <95% and >2 Gy D₉₉ deficit decreased to 0 and 0 for CTV1 and 0 and 2 for CTV2, respectively. The NTCP calculations suggested that 4D ART could benefit a substantial portion of patients compared with IGRT-only because 17 and 12 patients had ≥5% and ≥10% NTCP reductions for parotid toxicity and 18 and 3 patients had ≥5% and ≥10% NTCP reductions for swallowing toxicity, respectively.

CONCLUSIONS

Compared with margin-based adaptive planning strategies, 4D ART provides a better balance between target coverage and OAR sparing. NTCP estimation predicted for theoretical clinical benefits that warrant further clinical validation.

Effect of salinity on medium- and low-pressure UV disinfection of Vibrio cholerae

The problem of biological invasions attributed to ballast water release is an ongoing problem that threatens ecosystems and human health. Ultraviolet (UV) radiation has been increasingly used for ballast water treatment mainly due to the advantages of short contact time and minimized harmful disinfection by products. In this study, the impact of salinity on the inactivation of Vibrio cholerae (NCTC 7253) was examined, and comparison of inactivation level and disinfection kinetics after medium-pressure (MP) (1 kW) and low-pressure (LP) (10 W) UV irradiation was made. MP UV exposure resulted in higher inactivation efficacy against V. cholerae than LP UV exposure especially at lower UV doses (≤3 mJ cm^-2) and salinity had a negative impact on both MP and LP UV disinfection, especially at higher UV doses (≥3 mJ cm^-2 for MP and ≥4 mJ cm^-2 for LP). To understand the mechanisms of salinity effect on V. cholerae, the enzyme-linked immunosorbent assay (ELISA) was employed to determine the number of cyclobutane pyrimidine dimers (CPDs), one major type of DNA damage. No significant effects of salinity were found at the CPDs level except for 3% artificial seawater after LP UV exposure case. It is imperative that site-specific conditions of salinity be taken into account in the design of UV reactors to treat V. cholerae and other species.

Kernohan-Woltman Notch Phenomenon Caused by Acute Traumatic Subdural Haematoma

A 27-year-old man suffered from right hemiparesis after a closed head injury. Computed tomography (CT) revealed a right hemisphere subdural haematoma with midline structure shifted to the left. The CT finding was believed to be mislabeled because the site of haematoma did not correlate with an ipsilateral hemiparesis. Magnetic resonance imaging revealed a right transtentorial uncal herniation and a small lesion within left cerebral peduncle, suggesting Kernohan-Woltman notch phenomenon (KWNP). KWNP has been rarely seen in patients with acute traumatic subdural haemorrhage. Anatomical small maximum tentorial notch width is the possible anatomical factor predisposing our patient to this phenomenon. (Hong Kong j.emerg.med. 2014;21:116-119)

The role of transformational leadership in workplace bullying

Purpose

The purpose of this paper is to examine the moderating role of transformational leadership on the relationship between job characteristics of both leaders and followers and workplace bullying within the workgroup. The central hypotheses were that, in a process of resource erosion, leaders’ task demands would be positively associated with workplace bullying in the workgroup, but that transformational leadership would moderate this effect, and the effect of followers’ autonomy on bullying.

Design/methodology/approach

Anonymous surveys were completed by 540 volunteer fire-fighters’ from 68 fire brigades and, separately, by 68 brigade captains.

Findings

The multi-level analyses show that leaders’ task demands positively predicted both bullying outcomes, after controlling for followers’ emotional demands and autonomy. Of most interest, transformational leadership moderated the influence of leaders’ task demands and followers’ autonomy on workplace bullying assessed by two approaches: self-labeling and behavioral experience. Further, a significant three-way interaction demonstrated that transformational leadership is actually associated with higher bullying as followers’ emotional demands increase under conditions wherein followers’ autonomy is constrained, but not when followers’ autonomy is high.

Practical implications

This study offers important practical implications in terms of leadership development in bullying prevention and reduction. For transformational leadership to be effective in reducing bullying at work, the situation must be matched to support this leadership style, or bullying could actually increase.

Originality/value

The study contributes to the research on workplace bullying by advancing the understanding of organizational factors that can influence bullying at work. The study also provides the first quantitative evidence of a relationship between the demands faced by leaders and the bullying experienced by members of the workgroup.

Geometric calibration and correction for a lens-coupled detector in x-ray phase-contrast imaging

A lens-coupled x-ray camera with a tilted phosphor collects light emission from the x-ray illuminated (front) side of phosphor. Experimentally, it has been shown to double x-ray photon capture efficiency and triple the spatial resolution along the phosphor tilt direction relative to the same detector at normal phosphor incidence. These characteristics benefit grating-based phase-contrast methods, where linear interference fringes need to be clearly resolved. However, both the shallow incident angle on the phosphor and lens aberrations of the camera cause geometric distortions. When tiling multiple images of limited vertical view into a full-field image, geometric distortion causes blurring due to image misregistration. Here, we report a procedure of geometric correction based on global polynomial transformation of image coordinates. The corrected image is equivalent to one obtained with a single full-field flat panel detector placed at the sample plane. In a separate evaluation scan, the position deviations in the horizontal and vertical directions were reduced from 0.76 and 0.028 mm, respectively, to 0.006 and 0.009 mm, respectively, by the correction procedure, which were below the 0.028-mm pixel size of the imaging system. In a demonstration of a phase-contrast imaging experiment, the correction reduced blurring of small structures.

Cloaking through cancellation of diffusive wave scattering

A new cloaking mechanism, which makes enclosed objects invisible to diffusive photon density waves, is proposed. First, diffusive scattering from a basic core-shell geometry, which represents the cloaked structure, is studied. The conditions of scattering cancellation in a quasi-static scattering regime are derived. These allow for tailoring the diffusivity constant of the shell enclosing the object so that the fields scattered from the shell and the object cancel each other. This means that the photon flow outside the cloak behaves as if the cloaked object were not present. Diffusive light invisibility may have potential applications in hiding hot spots in infrared thermography or tissue imaging.

Outcomes According to Breast Cancer Subtype in Patients Treated With Accelerated Partial Breast Irradiation

BACKGROUND

The purpose of the study was to determine outcomes for patients treated with accelerated partial breast irradiation (APBI) on the basis of breast cancer subtype (BCST).

PATIENTS AND METHODS

Our single-institution, institutional review board-approved APBI database was queried for patients who had complete testing results for the estrogen (ER), progesterone (PR), and HER2/neu receptors to determine outcomes for each BCST. Women were assigned as luminal A (LA), luminal B (LB), HER2, and basal BCST using their ER, PR, and HER2/neu receptor status. Degree of ER expression supplemented the receptor-based luminal BCST assignment. Two hundred seventy-eight patients had results for all 3 receptors (LA = 164 [59%], LB = 81 [29%], HER2 = 5 [2%], basal = 28 [10%]), which were submitted for analysis (ipsilateral breast tumor recurrence [IBTR], regional nodal failure, distant metastasis [DM], disease-free survival [DFS], cause-specific survival [CSS], and overall survival [OS]).

RESULTS

Median follow-up was 5.4 years (range, 0.1-12.4 years). Basal and HER2 subtype patients had higher histologic grades (Grade 3 = 75% vs. 10% LA/LB; P < .001), larger tumors (13.0 mm basal vs. 10.7 mm LA/LB; P = .059), and were more likely to receive chemotherapy (68% vs. 15% LA/LB; P < .001). Margin and nodal status were similar among BCSTs. At 5 years, IBTR rates were similar (1.8%, 2.9%, 0%, and 4.8%) for LA, LB, HER2, and basal subtypes, respectively (P = .62). DM was only seen in LA (2.9%) and LB (1.3%) (P = .83). DFS (95%-100%), CSS (97%-100%), and OS (80%-100%) were not statistically different (P = .97, .87, .46, respectively).

CONCLUSION

Five-year local control rates after breast-conserving surgery, APBI, and appropriate systemic therapy are excellent for luminal, HER2, and basal phenotypes of early-stage breast cancer; however, further study of receptor subtype effect on risk stratification in early-stage breast cancer is needed.

Using Social Exchange Theory to Distinguish Procedural from Interactional Justice

Organizational justice researchers have long debated the distinction between procedural and interactional justice. Recently, several researchers have proposed that procedural and interactional justice can be distinguished from one another using social exchange theory. In particular, procedural justice applies more to the exchange between the individual and employing organization, whereas interactional justice generally refers to the exchange between the individual and his or her supervisor. If this theory is correct, procedural justice should be more closely associated with reactions toward upper management and organizational policies, whereas interactional justice should be more closely associated with reactions toward one’s supervisor and job performance. These predictions were tested in a field study involving approximately 107 employees and their supervisors. Predictions were generally confirmed, though there were some unexpected findings.