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Background: During a previous study on intraoperative goal-directed haemodynamic treatment (GDHT) in elderly patients, cardiac performance did not improve as anticipated (ClinicalTrials.gov NCT01141894). We hypothesized that in this group, responsiveness to interventions could be predicted by individual patient characteristics.Methods: Data for the present study were collected during a previously performed, single-centre, open, randomized, and controlled parallel-group superiority trial in patients aged ≥70 yr undergoing hip-fracture surgery. Haemodynamic parameters were collected by the LiDCOplus™ monitor. The GDHT group received oxygen delivery-guided fluid challenges and dobutamine infusion. Management in the routine fluid treatment group was clinician guided without access to LiDCOplus™ readings. In the GDHT group, independent predictors were assessed by multiple logistic regression analyses of two outcomes: first fluid challenge response (defined as increase of stroke volume by ≥10%); and overall intervention response (maintenance of oxygen delivery at the end of surgery).Results: Data from 72 routine fluid treatment and 70 GDHT patients were analysed. Clinician-guided pre-anaesthesia fluid loading increased the stroke volume in 14% of patients, and 17% of patients increased or maintained oxygen delivery at the end of surgery. The GDHT-guided first and subsequent fluid challenges were associated with increased stroke volume in 39 and 9% of patients, respectively, and increased or maintained oxygen delivery was present in 47% of patients at the end of surgery. In the GDHT group, a baseline stroke volume index (<28 ml m(-2)) was an independent predictor of first fluid challenge response, and a baseline oxygen delivery index (<330 ml min(-1) m(-2)) was a predictor of maintained or increased oxygen delivery.Conclusions: Fewer patients responded to GDHT than anticipated. Our data suggest that individual characteristics could predict the haemodynamic responses.Clinical Trial Registration: NCT01141894. [ABSTRACT FROM AUTHOR]

Background Patients with proximal femoral fracture (PFF) are at high risk of postoperative complications. Goal-directed haemodynamic treatment (GDHT) in other high-risk surgical patients reduces postoperative complications. We aimed to compare effects of GDHT and routine fluid treatment (RFT) on postoperative outcomes after PFF surgery. Methods PFF patients (≥70 yr) were enrolled in this single-centre, open, randomized, controlled, parallel-group superiority trial with concealed allocation using computer-generated randomization. Treatments: (i) GDHT to attain oxygen delivery index >600 ml min−1 m−2 using fluids and dobutamine and (ii) a protocol-guided RFT. After 150 enrolled patients, the trial was stopped due to slow recruitment. The short-term primary outcome measure was the relative risk (RR) of postoperative complications; secondary measures were (i) administered fluid levels, (ii) vasopressor requirements, and (iii) haemodynamic responses. Results For the GDHT group, 74 and for the RFT group 75 patients were designated. The RR of postoperative complications (GDHT vs RFT) was 0.79 (95% confidence interval 0.54–1.16); the volumes of i.v. fluids decreased (1078 vs 1440 ml, P=0.01); fewer patients required treatment of hypotension (18.5% vs 75%, P<0.005); there were more patients with increased oxygen delivery at the end of operation (28% vs 8%, P=0.04), but the haemodynamic goal was achieved in only 27% of patients in the GDHT group. Conclusions The magnitude of risk reduction of postoperative complications is clinically relevant, but the trial was underpowered and the null hypothesis cannot be rejected. [ABSTRACT FROM PUBLISHER]

Few data are available on patients with multiple native valvular heart disease (VHD). To assess the characteristics, management, and survival of patients with multiple native VHD. Among the 5087 patients with ≥ 1 severe left-sided native VHD included in the EURObservational VHD II Survey, 3,571 had a single VHD (group A, 70.2%), 363 had one severe left-sided VHD with moderate VHD of the other ipsilateral valve (group B, 7.1%) and 1,153 patients (22.7%) had ≥ 2 severe native VHDs (left-sided and/or tricuspid regurgitation [TR], group C). Patients with multiple VHD (groups B and C) were more often women, had greater congestive heart failure and comorbidity, higher left-atrial volumes and pulmonary pressure, and lower ejection than group A patients (all P ≤ 0.003). During the survey period, 36.7% of group A (n = 1312), 26.7% of group B (n = 97), and 32.7% of group C (n = 377) underwent valvular intervention (P < 0.001). Six-month survival was better for group A than for group B (P = 0.0002) or C (P < 0.0001). After adjustment for age, sex, body-mass index and Charlson index, group B [adjusted HR(95%CI) = 1.62(1.10–2.38)] and group C [adjusted HR(95%CI) = 1.72(1.32–2.25)] experienced greater six-month mortality than group A. Group B and C patients were more often diagnosed with heart failure during the six-month follow-up than those of group A (both P < 0.001) (Fig. 1). Multiple VHD is common, encountered in nearly 30% of patients with left-sided native VHD, and associated with greater cardiac damage and leads to higher mortality and more heart failure at six months than single VHD, yet with lower rates of surgery. [ABSTRACT FROM AUTHOR]

Introduction Computerized Tomography (CT) scan provides Hounsfield Unit information (HU) and so Electronic Density (ED) which is necessary for planned dose treatment calculation in radiotherapy (RT). For prostate cancer and for delineation issues, MRI provides excellent soft tissue contrast compared to CT images and it is increasingly used for target delineation. Our project was first to develop our own algorithm conversion and image transformation between MRI signal intensity into HU and then to evaluate the algorithm on prostate clinical case as previous studies have obtained encouraging results [1] . Methods First, we set up MRI parameters (GE Signa 1.5 T, Lava Flex sequence) so that signal information matches CT-scan ones (Philips Big Bore). We selected 4 pelvic patients that were installed on a flat table to have a close installation to that of CT-scan. Using Matlab R2016a, we developed our own algorithm of conversion and image transformation between MRI signal intensity and HU using 3DSlicer 4.5 for specific density segmentation. MRI intensity signals for muscles and soft tissue were similar: we needed two conversion functions (soft tissues and bones). Images produced thanks to conversion functions were compared to real CT-scan images used for RT. We compared the depth dose profile of a 6MV field over 5 × 5 cm 2 targeting the prostate and a 6 MV Volumetric Modulated Arc (VMAT). VMAT dose distributions were compared in terms of Gamma Index criteria. Results Preliminary results gave distinct intervals function definition for different structures, which was similar to the Finish-Helsinki university hospital study [1,2] . We identified spongy bone and cortical bone (bone function), fat, muscle, urine and prostate (soft tissue). Those distinct intervals testified the accuracy of our image conversion to produce the pseudo-CT. Dose differences were less than 5% outside the build-up region between depth dose profiles of a 6MV beam. For the VMAT treatment plan, 99% of points passed the gamma criterion of 3% dose and 3 mm distance to agreement. Finally, the pseudo-CT produced using our model showed a small effect on dose differences compared to real CT images. Conclusions This study revealed promising results to the possibility of using specific sequences of MRI for dose calculation in RT. Taking into account the potential limitation of our work, further investigation could be necessary. It could be particularly interesting to increase the number of patients, to improve the acquisition conditions and to integrate the different uncertainties of the MRI in the model. Finally, we plan to study the potential and feasibility of this model for other localization such as lung and head&neck. [ABSTRACT FROM AUTHOR]

Résumé Objectif de l’étude Cette étude a consisté à évaluer l’erreur interobservateurs des recalages rigides par tomographie conique dans le cadre des traitements prostatiques avec modulation d’intensité. Matériels et méthodes Douze manipulateurs de radiothérapie ont effectué 286 recalages rigides par tomographie conique (osseux puis prostatiques). Les résultats des recalages ont été comparés à ceux obtenus par deux oncologues-radiothérapeutes. Pour chaque manipulateur, les écarts calculés par le logiciel ont été rapportés selon les trois axes. Une analyse statistique a permis de déterminer un seuil dans les trois directions en dessous duquel se situaient 95 % des observateurs. Une analyse de variance puis un test post hoc ont permis d’observer s’il existait une différence significative entre les observateurs et quels étaient les observateurs concernés. Résultats L’étude de recalage a montré que les écarts par rapport aux oncologues-radiothérapeutes, exprimés en termes du 95 e percentile, étaient : 2,1 mm dans l’axe droite–gauche, 3,5 mm dans celui craniocaudal et 7,3 mm dans celui antéropostérieur. Dans la direction la plus critique, antéropostérieure, 4 % des observateurs ont trouvé des écarts supérieurs à 8 mm, marge utilisée actuellement sans tomographie conique quotidienne. Le test de variance a révélé une valeur de p de moins de 0,05 uniquement sur l’axe craniocaudal et aucun des observateurs n’avait un écart significatif par rapport aux oncologues-radiothérapeutes. Conclusion Cette étude a confirmé l’intérêt d’un recalage tissulaire tridimensionnel pour les traitements prostatiques. L’étude a montré une bonne reproductibilité entre les observateurs. Cela a permis de justifier la tomographie conique quotidienne pour la localisation prostatique avec une possibilité de réduction des marges au volume cible prévisionnel dans les trois directions. Une évaluation de la délégation partielle des recalages aux manipulateurs a été mise en place. Purpose This work evaluated the interobserver variability in cone beam computed tomography (CBCT) registration for prostate cancers treated with intensity-modulated radiotherapy. Material and methods Twelve technologists realized 286 CBCT/CT registrations (bone registration followed by prostate to prostate registration). The registration results were compared to those obtained by two radiation oncologists (reference). Each technologist reported the shifts calculated by the software in all three axes. A statistical analysis allowed us to calculate the minimum threshold under which 95% of the observers found similar values. A variance analysis followed by the post hoc test were used to find differences in interobserver registration variability and determine whether any individual users performed registrations which differed significantly from those of the other users. Results The registration differences compared to the reference in the three directions in terms of 95th percentile are: 2.1 mm left–right, 3.5 mm target–gun, 7.3 mm anterior–posterior. In the posterior direction, 4% of the observers have found differences superior to 8 mm, margin used in routine without the use of a daily CBCT. The variance test revealed a P -value <0.05 only for target–gun and for all observers there was no significant difference compared to the reference. Conclusion This study confirmed the interest of a 3D tissue registration for prostate treatments. The registration study showed a good interobserver reproducibility. This showed the importance of a daily CBCT/CT registration in prostate treatment with the possibility of a planning target volume margin reduction in the three directions. An evaluation of a partial delegation of registration to technologists should be done by the radiation oncologists. [ABSTRACT FROM AUTHOR]

Background: We have previously reported that stroke volume is reduced in a majority of elderly patients undergoing surgical repair of hip fracture before and after intrathecal injection of anaesthetic. We aimed to investigate these observations further in a prospective study of elderly patients undergoing elective hip or knee arthroplasty under spinal anaesthesia.Methods: Patients ≥65 yr undergoing elective arthroplasty were monitored with LiDCOplus™ preoperatively (baseline), before and continuously for 45 min after spinal anaesthesia. Postspinal hypotension was defined as systolic blood pressure (bp) < 100 mm Hg or > 30% decrease from baseline. Associations between post-spinal hypotension and haemodynamic changes before (i.e. between baseline and before injection) spinal anaesthesia were analysed by logistic regression analysis.Results: Twenty patients with a mean age of 74 (range 66-89) yr were included. Stroke volume index decreased by 14% (95% CI 9.3%-19%) before spinal anaesthesia. When patients were categorised according to post-spinal hypotension (Y/N) the patterns of haemodynamic changes differed. In the hypotensive patients, cardiac index progressively decreased whereas it increased initially in the non-hypotensive patients. Reduction of cardiac index from baseline before spinal anaesthesia was associated with increased risk of hypotension: OR 0.79 (95% CI 0.60, 0.91). The predictive value of reduced cardiac index was good (AUC under ROC curve 0.91).Conclusions: A decrease in cardiac output from baseline before spinal anaesthesia and an inability to increase it after induction may be important features of postspinal hypotension in elderly patients. [ABSTRACT FROM AUTHOR]