Experiences and perspectives on the optimal timing for initiating advance care planning in patients with mild to moderate dementia: A meta-synthesis

BACKGROUND

Advance care planning is typically initiated during the last six months of a patient's life. However, due to the progressive decline in the decision-making process in individuals with dementia, their involvement in advance care planning is limited to the early stages of the disease. Currently, there is no consensus on the optimal timing for initiating advance care planning for people with dementia, and a comprehensive review of the literature addressing this matter is lacking.

OBJECTIVE

To explore the experiences and perspectives of people with dementia, their family caregivers, and health care professionals with regard to the optimal timing for initiating advance care planning.

DESIGN

A meta-synthesis was conducted.

DATA SOURCE

The following eight electronic databases were searched: PubMed, Embase, Web of Science, Cochrane Library, CINAHL and CNKI, WanFang and Vip.

REVIEW METHODS

This review uses thematic synthesis to systematically synthesize qualitative evidence and report findings according to The Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) and the Joanna Briggs Institute Manual for Evidence Synthesis. Study selection and data extraction were conducted independently by two researchers, and quality was evaluated using the Joanna Briggs Institute's Qualitative Research Standard Assessment tool.

FINDINGS

Twenty-one studies were selected for this review. This review involved an overarching theme: The utilization of pivotal elements to transition from delayed initiation to comprehensive implementation. Three themes emerge, including the prerequisites for initiating advance care planning, not ready to start advance care planning and struggling along narrow roads. For health care professionals, the selection of an opportune moment to initiate advance care planning for people with dementia is not only a challenge but also a crucial prerequisite for the successful implementation of advance care planning. Health care professionals' experience, attitude toward advance care planning, trust relationship with patients, cultural differences among people with dementia and their caregivers, and economic disparities all influence health care professionals' judgment of the timing for initiating advance care planning.

CONCLUSIONS

Determining the optimal timing for initiating advance care planning is a complex process that requires a comprehensive consideration of the realities faced by health care professionals, people with dementia and their caregivers. Therefore, it is imperative to provide relevant training to health care professionals to ensure the successful implementation of advance care planning.

The impact of delayed tracheostomy on critically ill patients receiving mechanical ventilation: a retrospective cohort study in a chinese tertiary hospital

OBJECTIVES

The timing of tracheostomy for critically ill patients on mechanical ventilation (MV) is a topic of controversy. Our objective was to determine the most suitable timing for tracheostomy in patients undergoing MV.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

One thousand eight hundred eighty-four hospitalisations received tracheostomy from January 2011 to December 2020 in a Chinese tertiary hospital.

METHODS

Tracheostomy timing was divided into three groups: early tracheostomy (ET), intermediate tracheostomy (IMT), and late tracheostomy (LT), based on the duration from tracheal intubation to tracheostomy. We established two criteria to classify the timing of tracheostomy for data analysis: Criteria I (ET ≤ 5 days, 5 days < IMT ≤ 10 days, LT > 10 days) and Criteria II (ET ≤ 7 days, 7 days < IMT ≤ 14 days, LT > 14 days). Parameters such as length of ICU stay, length of hospital stay, and duration of MV were used to evaluate outcomes. Additionally, the outcomes were categorized as good prognosis, poor prognosis, and death based on the manner of hospital discharge. Student's t-test, analysis of variance (ANOVA), Mann-Whitney U test, Kruskal-Wallis test, Chi-square test, and Fisher's exact test were employed as appropriate to assess differences in demographic data and individual characteristics among the ET, IMT, and LT groups. Univariate Cox regression model and multivariable Cox proportional hazards regression model were utilized to determine whether delaying tracheostomy would increase the risk of death.

RESULTS

In both of two criterion, patients with delayed tracheostomies had longer hospital stays (p < 0.001), ICU stays (p < 0.001), total time receiving MV (p < 0.001), time receiving MV before tracheostomy (p < 0.001), time receiving MV after tracheostomy (p < 0.001), and sedation durations. Similar results were also found in sub-population diagnosed as trauma, neurogenic or digestive disorders. Multinomial Logistic regression identified LT was independently associated with poor prognosis, whereas ET conferred no clinical benefits compared with IMT.

CONCLUSIONS

In a mixed ICU population, delayed tracheostomy prolonged ICU and hospital stays, sedation durations, and time receiving MV. Multinomial logistic regression analysis identified delayed tracheostomies as independently correlated with worse outcomes.

TRIAL REGISTRATION

ChiCTR2100043905. Registered 05 March 2021. http://www.chictr.org.cn/listbycreater.aspx.

Survival Benefit with Re-resection and Optimal Time to Re-resection in Gallbladder Cancer: a National Cancer Database Study

PURPOSE

Gallbladder cancer is often diagnosed incidentally after cholecystectomy. Most patients will then undergo re-resection for potential residual disease; however, overall survival (OS) benefit data in this scenario is variable. This National Cancer Database analysis (NCDB) compared OS in patients with T1b-T3 gallbladder cancer who underwent re-resection and evaluated if time to resection impacts OS.

METHODS

We reviewed the NCDB for patients who received initial cholecystectomy for gallbladder cancer and were subsequently eligible for re-resection based on tumor stage (T1b-T3 disease). Patients with re-resection were subdivided into four cohorts based on time to re-resection: 0-4 weeks, 5-8 weeks, 9-12 weeks, and > 12 weeks. We used a Cox proportional hazards ratio to identify factors associated with worse survival and logistic regression to evaluate characteristics associated with re-resection. OS was calculated using Kaplan Meier curves.

RESULTS

A total of 791 (5.82%) patients received re-resection. Cox proportional hazards analysis showed a comorbidity score of 1 was associated with worse survival. Patients with higher comorbidity scores and treatment at comprehensive community, integrated, or academic cancer programs were less likely to undergo re-resection. Re-resection showed significantly improved OS [HR 0.87; 95 CI 0.77-0.98; p = 0.0203]. Improved survival was appreciated when re-resection was completed at 5-8 weeks [HR 0.67; CI 0.57-0.81], 9-12 weeks [HR 0.64; CI 0.52-0.79], or > 12 weeks [HR 0.61; CI 0.47-0.78] compared to 0-4 weeks.

CONCLUSION

Optimal timing to re-resection in gallbladder cancer supports previous data showing benefit at > 4 weeks. However, there was no significant survival difference as to whether re-resection was completed at 5-8 weeks, 9-12 weeks, or > 12 weeks post initial cholecystectomy.

Evaluating the Optimal Time Between Diagnosis and Surgical Intervention for Early-Stage Lung Cancer

INTRODUCTION

There is no consensus on the optimal timing for lung cancer surgery. We aim to evaluate the impact of timing of surgical intervention. We hypothesize delay in intervention is associated with worse overall survival and higher pathologic upstaging in early-stage lung cancer.

METHODS

We identified patients with cT1/2N0M0 nonsmall cell lung cancer in the National Cancer Database from 2004 to 2018. Patients were categorized by time to surgery groups: early (<26 d), average (26-60 d), and delayed (61-365 d). Primary outcome was overall survival and secondary outcome was pathologic upstaging. Multivariate models and survival analyses were used to determine factors associated with time from diagnosis to surgery, pathologic upstaging, and overall survival.

RESULTS

In multivariate model, advanced age, non-Hispanic Black patients, nonprivate insurance, low median income and education, and treatment at low-volume facilities were less likely to undergo early intervention and compared to the average group were more likely to receive delayed intervention. Pathologic upstaging was more likely in the delayed group (odds ratio 1.11, 1.07-1.14) compared to early group (odds ratio 0.96, 0.93-0.99). Early intervention was associated with improved overall survival (hazard ratio 0.93, 0.91-0.95), while delayed intervention was associated with inferior survival (hazard ratio 1.11, 1.09-1.14).

CONCLUSIONS

Expeditious surgical intervention is associated with lower rates of pathologic upstaging and improved overall survival in early-stage lung cancer. Delays in surgery are associated with social and economic factors, suggesting disparities in access to surgery. Lung cancer surgery should be performed as quickly as possible to maximize oncologic outcomes.

Optimal timing of influenza vaccination among patients with acute myocardial infarction - Findings from the IAMI trial

Influenza vaccination reduces the risk of adverse cardiovascular events.The IAMI trial randomly assigned 2571 patients with acute myocardial infarction (AMI) to receive influenza vaccine or saline placebo during their index hospital admission. It was conducted at 30 centers in 8 countries from October 1, 2016 to March 1, 2020. In this post-hoc exploratory sub-study, we compare the trial outcomes in patients receiving early season vaccination (n = 1188) and late season vaccination (n = 1344).The primary endpoint wasthe composite of all-cause death, myocardial infarction (MI), or stent thrombosis at 12 months. Thecumulative incidence of the primary and key secondary endpoints by randomized treatment and early or late vaccination was estimated using the Kaplan-Meier method. In the early vaccinated group, the primary composite endpoint occurred in 36 participants (6.0%) assigned to influenza vaccine and 49 (8.4%) assigned to placebo (HR 0.69; 95% CI 0.45 to 1.07), compared to 31 participants (4.7%) assigned to influenza vaccine and 42 (6.2%) assigned to placebo (HR 0.74; 95% CI 0.47 to 1.18) in the late vaccinated group (P = 0.848 for interaction on HR scale at 1 year). We observed similar estimates for the key secondary endpoints of all-cause death and CV death. There was no statistically significant difference in vaccine effectiveness against adverse cardiovascular events by timing of vaccination. The effect of vaccination on all-cause death at one year was more pronounced in the group receiving early vaccination (HR 0.50; 95% CI, 0.29 to 0.86) compared late vaccination group (HR 0.75; 35% CI, 0.40 to 1.40) but there was no statistically significant difference between these groups (Interaction P = 0.335). In conclusion,there is insufficient evidence from the trial to establish whether there is a difference in efficacy between early and late vaccinationbut regardless of vaccination timing we strongly recommend influenza vaccination in all patients with cardiovascular diseases.

Factors Associated with Dialysis Initiation in Patients with Predialysis Arteriovenous Fistula

INTRODUCTION

A large proportion of patients initiated hemodialysis with a central vein catheter rather than a permanent vascular access which was recommended by guidelines. One major barrier was the paucity of evidence regarding the optimal timing of vascular access creation in predialysis patients.

METHODS

Our study prospectively enrolled 300 patients undergoing predialysis arteriovenous fistula (AVF) creation in our center from 2015 to 2018. Cox proportional hazard regression was performed to identify which demographic and clinical factors were associated with the initiation of hemodialysis after AVF surgery. A receiver operating characteristic area under the curve (AUC) was used to assess the predictive power of preoperative factors for the likelihood of hemodialysis initiation.

RESULTS

Overall, 163 (54.3%), 214 (71.3%), and 275 (91.7%) patients initiated hemodialysis within 3 months, 6 months, and 1 year, respectively, after AVF creation. The median time between AVF creation and hemodialysis start was 71.5 days. Using multivariate Cox regression analysis, three factors were associated with hemodialysis initiation within 1 year: serum phosphorus (HR = 1.407, p = 0.021), diabetic kidney disease (DKD) (HR = 1.429, p = 0.039), and cystatin C (HR = 1.179, p = 0.009). Cystatin C alone had a moderate predictive value for dialysis initiation (AUC = 0.746; p < 0.001), whereas the full model had a higher predictive value (AUC = 0.800; p < 0.001).

CONCLUSION

DKD, serum cystatin C, and phosphorus at access surgery were associated with hemodialysis initiation within 1 year of the predialysis AVF creation. Our findings provide a basis for a more customized approach to planning AVF placement in patients with chronic kidney disease.

The optimal timing between neoadjuvant therapy and surgery of breast cancer: A brief systematic review of the literature

Neoadjuvant therapy is a cornerstone of some early and locally advanced breast cancer treatment. The use of neoadjuvant chemotherapy, in fact, allows to obtain numerous advantages, including allowing a more conservative intervention, evaluating the in vivo response to therapy, modulating the intensity of subsequent treatments based on the degree of response to therapy and allowing to surgery with information on genetics. However, at the end of neoadjuvant cytotoxic therapy it is not possible to carry out surgery immediately, as a certain amount of time is required for recovery from toxicity, especially haematological, due to the systemic therapy itself. At the same time, it is intuitive that too much time must not pass between the end of neoadjuvant therapy and surgery. The goal of this systematic literature review is to summarize the most relevant literature data on this topic, selected and extracted according to the methodology of systematic reviews.

Effectiveness of methylprednisolone therapy in patients with a high-risk common type of COVID-19 pneumonia: a retrospective cohort study

The optimal timing of glucocorticoid treatment for coronavirus disease 2019 (COVID-19) pneumonia is uncertain. We evaluated the clinical outcomes of methylprednisolone therapy (MPT) for patients with a high-risk common type (HRCT) COVID-19 pneumonia. We conducted a multicenter retrospective cohort study in Northeast China. A comparison was performed between the standard treatment (SDT) group and the SDT + MPT group to determine the efficacy of methylprednisolone in treating HRCT COVID-19 pneumonia. We collected the medical records of 403 patients with HRCT COVID-19 pneumonia (127 in the SDT + MPT group and 276 in the SDT group). None of the patients had received mechanical ventilation or died. Furthermore, there were no side effects associated with MPT. Patients in the SDT + MPT group treated with methylprednisolone received an intravenous injection for a median interval of five days (interquartile range of 3 to 7 days). The trends in lymphocyte count, C-reactive protein, interleukin 6, lactic acid dehydrogenase, respiratory rate, SpO2, PaO2, D-dimer and body temperature were similar between the SDT + MPT and SDT groups. The results for the SDT + MPT group seemed to improve faster than those for the SDT group; however, the results were not statistically significant. Clinical outcomes revealed that the average hospitalized days and the rate of progression to severe type COVID-19 pneumonia in both the SDT + MPT group and the SDT group were 14.56 ± 0.57 days versus 16.55 ± 0.3 days (p = 0.0009) and 21.26% (27/127) versus 32.4% (89/276) (p = 0.0247), respectively. The 16-day nucleic acid negative rate was higher in the SDT + MPT group than in the SDT group, 81.73% (104/127) versus 65.27% (180/276) (p = 0.0006). MPT effectively prevents patients with HRCT COVID-19 pneumonia from progressing to the severe stage.

Comparison of clinical outcomes of tracheotomy in patients with acute cervical spinal cord injury at different timing

Respiratory failure is the leading cause of early death after acute CSCI. Tracheotomy is an effective approach to reduce mortality and improve the clinical outcomes. However, the optimal timing for tracheotomy remains controversial. Hence, the study aimed to compare the clinical outcomes of tracheotomy in patients with acute cervical spinal cord injury (CSCI) at different timing. A retrospectively review was performed of acute CSCI patients who underwent tracheotomy in the intensive care unit of Haian Hospital between January 2014 and June 2019. 124 CSCI patients were included and stratified into three groups based on the timing of tracheotomy: early group (≤4 days from initial intubation), medium group (4-10 days from initial intubation), and late group (≥10 days from initial intubation). The clinical outcomes and functional outcomes were analyzed. No significant intergroup differences in baseline characteristics were observed. The late group needed significantly longer duration of mechanical ventilation, longer ICU stay, and suffered higher ICU mortality, higher pneumonia after tracheotomy than the early and medium groups. More patients in the early and medium groups successfully weaned from mechanical ventilation. The early and medium groups achieved better improvement of JOA and NDI scores than the late group at one year after surgery and at the final follow-up. Early to medium term tracheotomy may lead to better clinical and functional outcomes in patients with acute CSCI who require prolonged mechanical ventilation.

Non-life-threatening ailments and rational patience when expected treatment outcomes are continuously improving

The time at which a rational patient chooses to undergo an elective medical procedure for a non-life-threatening ailment is contemplated. The resulting model is purposely uncomplicated but general, and accounts for several basic factors that might affect such a decision. One such factor is that a patient cannot know with certainty the degree to which the medical procedure will be successful. Even so, patients have information about the expected outcome of the procedure and its risk, and about how the expected outcome and risk are affected by medical technological progress and surgeon experience. The effect of changes in exogenous variables on the timing of the medical procedure and on patient expected lifetime utility are investigated. It is shown that risk averse and prudent patients behave in an unambiguous manner in response to changes in all of the exogenous variables.

Surgical strategy and optimal timing of tracheostomy in patients with COVID-19: Early experiences in Japan

OBJECTIVE

Tracheostomy is an important surgical procedure for coronavirus disease-2019 (COVID-19) patients who underwent prolonged tracheal intubation. Surgical indication of tracheostomy is greatly affected by the general condition of the patient, comorbidity, prognosis, hospital resources, and staff experience. Thus, the optimal timing of tracheostomy remains controversial.

METHODS

We reviewed our early experience with COVID-19 patients who underwent tracheostomy at one tertiary hospital in Japan from February to September 2020 and analyzed the timing of tracheostomy, operative results, and occupational infection in healthcare workers (HCWs).

RESULTS

Of 16 patients received tracheal intubation with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, five patients (31%) received surgical tracheostomy in our hospital. The average consultation time for surgical tracheostomy was 7.4 days (range, 6 - 9 days) from the COVID-19 team to the otolaryngologist. The duration from tracheal intubation to tracheostomy ranged from 14 to 27 days (average, 20 days). The average time of tracheostomy was 27 min (range, 17 - 39 min), and post-wound bleeding occurred in only one patient. No significant differences in hemoglobin (Hb) levels were found between the pre- and postoperative periods (mean: 10.2 vs. 10.2 g/dl, p = 0.93). Similarly, no difference was found in white blood cell (WBC) count (mean: 12,200 vs. 9,900 cells /µl, p = 0.25). After the tracheostomy, there was no occupational infection among the HCWs who assisted the tracheostomy patients during the perioperative period.

CONCLUSION

We proposed a modified weaning protocol and surgical indications of tracheostomy for COVID-19 patients and recommend that an optimal timing for tracheostomy in COVID-19 patients of 2 - 3 weeks after tracheal intubation, from our early experiences in Japan. An experienced multi-disciplinary tracheostomy team is essential to perform a safe tracheostomy in patients with COVID-19 and to minimize the risk of occupational infection in HCWs.

Optimal Timing of First Abdominal Radiography after Gastrografin Administration for Small Bowel Obstruction

BACKGROUND

Water-soluble contrast agent (WSCA) administration is commonly used to evaluate adhesive small bowel obstruction (SBO) either via a challenge or follow-through study. This analysis aimed to determine optimal timing to first abdominal radiograph after WSCA administration.

MATERIALS AND METHODS

A post hoc review of the Eastern Association for the Surgery of Trauma SBO database was used to compare data from two institutions using different methodologies, either the small bowel follow through method or the challenge method, from March 2015-January 2018. The primary outcome was timing of contrast into the colon. Outcomes were also analyzed. A multivariate regression analysis controlled for age, sex, body mass index, previous SBO admissions, and abdominal surgeries.

RESULTS

A total of 236 patients met inclusion and exclusion criteria (A, 119; B, 117). There were minor demographic differences between cohorts and no significant differences between institutions regarding the confirmed presence of WSCA in the colon, rates of operative intervention, length of operation, hospital length of stay, or 30-d readmission rates.Institution A, where the challenge method was practiced, had 95 (80%) patients with contrast to colon overall; four of 95 (4%) patients had confirmed contrast to colon at or before 7 h, and 89 of 95 (94%) patients had confirmed contrast to colon between 7.1 and 10 h. Institution B, where the small bowel follow through method was practiced, had 94 (80%) patients with contrast to colon overall; 73 of 94 (78%) patients had confirmed contrast to colon at or before 7 h, and 15 of 94 (16%) patients had confirmed contrast to colon between 7.1 and 10 h.

CONCLUSIONS

Either method is effective for evaluation of SBO. Adding a radiograph at 4 h is feasible, could promote earlier disposition, be conducted as part of an emergency department protocol, and possibly allow for the selection of patients who are candidates for outpatient treatment.

Plate removal without loss of correction after open-wedge high tibial osteotomy is possible when posterior cortex bone union reaches osteotomy gap center even in incompletely filled gaps

PURPOSE

The study aimed to evaluate the optimal timing for plate removal after open-wedge high tibial osteotomy (OWHTO) without loss of correction and to investigate risk factors for loss of correction after plate removal. The study presents the hypothesis that plate removal without loss of correction was possible when gap filling reached zone 2 (25-50%) on anteroposterior radiographs.

METHODS

Ninety-one patients (101 knees) who underwent OWHTO using the TomoFix^® plate were enrolled. Plate removal was performed at an average 16.4 ± 5.4 months after OWHTO. Clinical evaluation included plate-related symptoms, the Japanese Orthopedic Association Knee Score (JOA score), and Oxford Knee Score (OKS). Radiological outcomes, including the hip-knee-ankle angle (HKA), weight-bearing line ratio (WBLR), medial proximal tibial angle (MPTA), and posterior tibial slope (PTS), were evaluated preoperatively, at plate removal and at 1 year after plate removal. Computed tomography (CT) was performed at plate removal to evaluate the flange bone union, progression rates of gap filling, and posterior cortex bone union. In addition, the risk factors for loss of correction after plate removal were evaluated.

RESULTS

At plate removal, 63 (62.4%) knees had plate-related symptoms (mild, 56 knees; moderate, 7 knees; severe, 0). After plate removal, the JOA score did not change, whereas OKS further improved; six knees developed loss of correction. On CT evaluation at plate removal, the flange bone union was achieved in all cases; the progression rates of gap filling and posterior cortex bone union were 47.0% ± 16.6% and 62.8% ± 16.5%, respectively. A posterior cortex union rate of < 43.3% was the only predictor for loss of correction after plate removal (odds ratio: 1.38, P < 0.01).

CONCLUSIONS

Plate removal without loss of correction after OWHTO was possible when bone union of the posterior cortex reached the center of the osteotomy gap even in incompletely filled gaps.

LEVEL OF EVIDENCE

Therapeutic case series, Level IV.

Defining "early" cranioplasty to achieve lower complication rates of bone flap failure: resorption and infection

BACKGROUND

Although cranioplasty (CP) is a frequently performed and simple procedure, complications are common, particularly bone flap resorption and infection. The timing of surgery is as an important contributory factor, but the optimal timing has not been clearly determined.

OBJECTIVE

We retrospectively investigated bone flap resorption and surgical site infection after CP to determine the optimal timing of surgery for reduction of complications.

METHODS

The study enrolled 126 patients who underwent decompressive craniectomy (DC) and subsequent CP. Patients with bone flap resorption or surgical site infection were analyzed as the "complication" group. Receiver operating characteristic curve analysis was performed and the Youden index was used to dichotomize "early CP" and "late CP" groups. Univariate and multivariate survival analyses were performed.

RESULTS

The complication group included 42 patients. The Youden index was used to identify a cutoff value for the DC-CP interval of > 44 days, and this was used to define early (< 45 days) and late (≥ 45 days) CP. Late CP was a significant risk factor in univariate and multivariate Cox regression analyses.

CONCLUSION

This study showed that early CP before 45 days after DC is associated with a lower rate of bone flap resorption and surgical site infection than late CP.

What a Difference a Stochastic Process Makes: Epidemiological-Based Real Options Models of Optimal Treatment of Disease

The real options approach has been used within environmental economics to investigate the impact of uncertainty on the optimal timing of control measures to minimise the impacts of invasive species, including pests and diseases. Previous studies typically model the growth in infected area using geometric Brownian motion (GBM). The advantage of this simple approach is that it allows for closed form solutions. However, such a process does not capture the mechanisms underlying the spread of infection. In particular the GBM assumption does not respect the natural upper boundary of the system, which is determined by the maximum size of the host species, nor the deceleration in the rate of infection as this boundary is approached. We show how the stochastic process describing the growth in infected area can be derived from the characteristics of the spread of infection. If the model used does not appropriately capture uncertainty in infection dynamics, then the excessive delay before treatment implies that the full value of the option to treat is not realised. Indeed, when uncertainty is high or the disease is fast spreading, ignoring the mechanisms of infection spread can lead to control never being deployed. Thus the results presented here have important implications for the way in which the real options approach is applied to determine optimal timing of disease control given uncertainty in future disease progression.

LED light stress induced biomass and fatty acid production in microalgal biosystem, Acutodesmus obliquus

Microbial algal system can serve as a potential source for the production of much high value bioproducts and biofuels. The quality and intensity of light are the key elements to optimize the production of algal biomass and fatty acid contents. This study presents the effect of differential LED flashing light conditions on the growth of microalgae, Acutodesmus obliquus. The induced light stress was optimized for its biomass and fatty acid content. The microalgae are exposed to various frequency of intermittent LED flashing light (blue and red lights) at three different phases in the 18 day cell growth (log, lag and stationary phase). The frequency of light flashing rate was adjusted to 120, 10, 5, 3.75, and 1 times per min. The effect of light stress on growth and fatty acids composition of A. obliquus induced an increase in algae growth and fatty acid production. Different optimal timing for light stress was subjected to elucidate the effect of light stress on algae growth and fatty acid production. The results showed an increase in the algae growth (1.2mg/L of chl a content) under light stress condition at FT10 (flashing time, 10 times per min) from the initial day (log phase) compared with the control experiment (0.4 mg/L of chl a content). However, the total fatty acids (71 mg/g) and volumetric FAME production (9.4 ml/l) level was found to be significant under FT5 (flashing time, 5 times per min), adopting flashing light from day 10 (stationary phase). TEM studies also revealed the deposition of lipid to be largest in the 18 day old cells under flashing light (FT5) condition, representing maximum accumulation of lipids bodies (up to 770 nm diameter in particle size) occupying approximately 42% of the total area of the cell.

Optimal Timing of Whole-Brain Radiation Therapy Following Craniotomy for Cerebral Malignancies

BACKGROUND

For patients with cerebral metastases that are limited in number, surgical resection followed by whole-brain radiation therapy is the standard of care. In addition, for high-grade gliomas, maximal surgical resection followed by local radiotherapy is considered the optimal treatment. Radiation is known to impair wound healing, including healing of surgical incisions. Radiotherapy shortly after surgical resection would be expected to minimize the opportunity for tumor regrowth or progression. Owing to these competing interests, the purpose of this study was to shed light on the optimal timing of radiotherapy after surgical resection of brain metastasis or high-grade gliomas.

METHODS

A review of the literature was conducted on the following topics: radiation and wound healing, corticosteroid use and wound healing, radiotherapy for tumor control for cerebral metastases and high-grade gliomas, and whole-brain radiation therapy or focal radiotherapy after craniotomy with focus on the timing of radiotherapy after surgery.

RESULTS

In animal models, wound integrity and healing was less impaired by radiotherapy administered 1 week after surgery. In humans, this timing would be expected to be significantly longer, on the order of several weeks.

CONCLUSIONS

Given the limited literature, insufficient conclusions can be drawn. However, animal data suggest a period of at least 1 week (but it is likely several weeks in humans) is necessary for reconstitution of wound strength before initiation of radiation therapy. A randomized prospective study is recommended to understand better the effect of the timing of radiation therapy following surgical intervention for brain metastasis or high-grade gliomas.

A decrease in the size of ground glass nodules may indicate the optimal timing for curative surgery

OBJECTIVES

Although ground glass nodules (GGNs) are generally considered to grow slowly to a large size, their natural progression remains unclear, and a decrease in tumor size has been reported in a few previous studies. The study aimed to retrospectively review the radiologic and pathological characteristics of resected ground glass nodules (GGNs) followed with chest computed tomography (CT) for at least a year before surgery to clarify the natural progression of GGNs.

PATIENTS AND METHODS

The chest CT cans and clinical charts of 32 GGNs in 31 patients who underwent pulmonary resection between January 2006 and March 2013 were retrospectively reviewed. The definitions of pure GGNs and part-solid nodules were based on the tumor shadow disappearance rate. The tumor size was measured twice, and the mean size was used for evaluation.

RESULTS

The mean GGN size before surgery was 15.2 mm, and the median follow-up period before surgery was 21 months. In the follow-up period, 15 (58%) of 26 pure GGNs at the initial CT remained pure GGNs at the last CT. However, a solid component appeared in the remaining 11 tumors (42%) of the 26 initial pure GGNs. Furthermore, 1 GGN of the 15 GGNs that remained pure and 10 of the 11 GGNs with solid component also showed a size decrease. In addition, 6 part-solid nodules were observed at the initial CT. Of these, 3 showed a decrease in size during follow-up. Overall, 47% of the GGNs showed a size reduction on follow-up chest CT.

CONCLUSIONS

A size reduction was observed in nearly half of the GGNs and suggested the progression to an invasive adenocarcinoma. When a mild collapse of the GGNs is observed, a careful follow-up is necessary to identify a solid component. Tumor size decreases may represent the optimal timing of pulmonary resection for curative treatment.