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Background: Breast-conserving surgery (BCS) followed by adjuvant radiotherapy (RT) is a standard treatment for ductal carcinoma in situ (DCIS). A low-risk patient subset that does not benefit from RT has not yet been clearly identified. The DCISionRT test provides a clinically validated decision score (DS), which is prognostic of 10-year in-breast recurrence rates (invasive and non-invasive) and is also predictive of RT benefit. This analysis presents final outcomes from the PREDICT prospective registry trial aiming to determine how often the DCISionRT test changes radiation treatment recommendations., Methods: Overall, 2496 patients were enrolled from February 2018 to January 2022 at 63 academic and community practice sites and received DCISionRT as part of their care plan. Treating physicians reported their treatment recommendations pre- and post-test as well as the patient's preference. The primary endpoint was to identify the percentage of patients where testing led to a change in RT recommendation. The impact of the test on RT treatment recommendation was physician specialty, treatment settings, individual clinical/pathological features and RTOG 9804 like criteria. Multivariate logisitc regression analysis was used to estimate the odds ratio (ORs) for factors associated with the post-test RT recommendations., Results: RT recommendation changed 38% of women, resulting in a 20% decrease in the overall recommendation of RT (p < 0.001). Of those women initially recommended no RT (n = 583), 31% were recommended RT post-test. The recommendation for RT post-test increased with increasing DS, from 29% to 66% to 91% for DS <2, DS 2-4, and DS >4, respectively. On multivariable analysis, DS had the strongest influence on final RT recommendation (odds ratio 22.2, 95% confidence interval 16.3-30.7), which was eightfold greater than clinicopathologic features. Furthermore, there was an overall change in the recommendation to receive RT in 42% of those patients meeting RTOG 9804-like low-risk criteria., Conclusions: The test results provided information that changes treatment recommendations both for and against RT use in large population of women with DCIS treated in a variety of clinical settings. Overall, clinicians changed their recommendations to include or omit RT for 38% of women based on the test results. Based on published clinical validations and the results from current study, DCISionRT may aid in preventing the over- and undertreatment of clinicopathological 'low-risk' and 'high-risk' DCIS patients., Trial Registration: ClinicalTrials.gov identifier: NCT03448926 ( https://clinicaltrials.gov/study/NCT03448926 )., (© 2024. The Author(s).)

Purpose: Preservation surgery can halt the progress of joint degradation, preserving the life of the hip; however, outcome depends on the existing cartilage quality. Biochemical analysis of the hip cartilage utilizing MRI sequences such as delayed gadolinium-enhanced MRI of cartilage (dGEMRIC), in addition to morphological analysis, can be used to detect early signs of cartilage degradation. However, a complete, accurate 3D analysis of the cartilage regions and layers is currently not possible due to a lack of diagnostic tools., Methods: A system for the efficient automatic parametrization of the 3D hip cartilage was developed. 2D U-nets were trained on manually annotated dual-flip angle (DFA) dGEMRIC for femoral head localization and cartilage segmentation. A fully automated cartilage sectioning pipeline for analysis of central and peripheral regions, femoral-acetabular layers, and a variable number of section slices, was developed along with functionality for the automatic calculation of dGEMRIC index, thickness, surface area, and volume., Results: The trained networks locate the femoral head and segment the cartilage with a Dice similarity coefficient of 88 ± 3 and 83 ± 4% on DFA and magnetization-prepared 2 rapid gradient-echo (MP2RAGE) dGEMRIC, respectively. A completely automatic cartilage analysis was performed in 18s, and no significant difference for average dGEMRIC index, volume, surface area, and thickness calculated on manual and automatic segmentation was observed., Conclusion: An application for the 3D analysis of hip cartilage was developed for the automated detection of subtle morphological and biochemical signs of cartilage degradation in prognostic studies and clinical diagnosis. The segmentation network achieved a 4-time increase in processing speed without loss of segmentation accuracy on both normal and deformed anatomy, enabling accurate parametrization. Retraining of the networks with the promising MP2RAGE protocol would enable analysis without the need for B1 inhomogeneity correction in the future., (© 2022. The Author(s).)

Background: A performance improved project identified elderly trauma patients to have a disproportionate incidence of complications., Aims: The purpose of this study was to assess the efficacy of a small specialty care unit to decrease complications in patients who no longer warrant care in an intensive care unit (ICU)., Methods: A surgical post-acute treatment unit (SPA) was developed with focused attention to cognition, nutrition, respiration, and mobilization needs of patients who no longer had physiologic need for an intensive care unit environment, but were still in need of increased attention at the bedside., Results: While ICU and hospital lengths of stay were unchanged, patients placed in the SPA experienced less complications and required less unplanned ICU re-admissions., Discussion: Geriatric patients, especially the elderly, are not simply old adults. They have unique needs as a consequence of the aging process, which can be encompassed by four pillars of intercession: cognition, nutrition, respiration, and mobilization., Conclusions: By adapting a physical environment supported by bedside attention to address the interwoven needs of geriatric and elderly patients who no longer care in an ICU, complications and unplanned return admissions to the ICU can be decreased., Level of Evidence: III.

Purpose: To evaluate the accuracy and reliability of image-based safety analysis for robotic cochlear implantation (RCI) in an ex vivo assessment., Methods: The accuracy was evaluated in a study on 23 human temporal bones. For image analysis, a computer-assisted safety analysis based on intraoperative cone beam computed tomography was implemented. The method automatically segments the drill tunnel and predicts the distance between the tunnel and the facial nerve. In addition, the drilling error at the target is predicted. The predicted distances were compared with the actually drilled distances measured in postoperative high-resolution micro-computed tomography scans. The automatic method was compared to accuracies associated with a manual analysis of the image data., Results: The presented computerized image-based analysis enabled the proximity of the facial nerve to the drill trajectory to be predicted with an accuracy of 0.22 ± 0.15 mm and drilling error at the target to be predicted with an accuracy of 0.11 mm ± 0.08 during N = 19 RCI procedures. The manual assessment of facial nerve proximity was performed with an accuracy of 0.34 ± 0.20 mm by a trained clinical expert., Conclusion: The assessment of intraoperative CT-based imaging presents multiple benefits over alternative safety mechanisms including early detection and applicability even in cases of malformation of the mastoid. This work presents a computer-assisted approach to image analysis that enables procedure safety measurements to be reliably performed with superior accuracy to other proposed safety methodologies, at a safe distance from the facial nerve. Its application must, however, be considered in relation to associated costs (time, cost, irradiation) and the dependence of the measure on a reliable preoperative segmentation.

Purpose: A personalized estimation of the cochlear shape can be used to create computational anatomical models to aid cochlear implant (CI) surgery and CI audio processor programming ultimately resulting in improved hearing restoration. The purpose of this work is to develop and test a method for estimation of the detailed patient-specific cochlear shape from CT images., Methods: From a collection of temporal bone [Formula: see text]CT images, we build a cochlear statistical deformation model (SDM), which is a description of how a human cochlea deforms to represent the observed anatomical variability. The model is used for regularization of a non-rigid image registration procedure between a patient CT scan and a [Formula: see text]CT image, allowing us to estimate the detailed patient-specific cochlear shape., Results: We test the accuracy and precision of the predicted cochlear shape using both [Formula: see text]CT and CT images. The evaluation is based on classic generic metrics, where we achieve competitive accuracy with the state-of-the-art methods for the task. Additionally, we expand the evaluation with a few anatomically specific scores., Conclusions: The paper presents the process of building and using the SDM of the cochlea. Compared to current best practice, we demonstrate competitive performance and some useful properties of our method.

Diffuse intrinsic pontine glioma (DIPG) is a rare and deadly childhood malignancy. After 40 years of mostly single-center, often non-randomized trials with variable patient inclusions, there has been no improvement in survival. It is therefore time for international collaboration in DIPG research, to provide new hope for children, parents and medical professionals fighting DIPG. In a first step towards collaboration, in 2011, a network of biologists and clinicians working in the field of DIPG was established within the European Society for Paediatric Oncology (SIOPE) Brain Tumour Group: the SIOPE DIPG Network. By bringing together biomedical professionals and parents as patient representatives, several collaborative DIPG-related projects have been realized. With help from experts in the fields of information technology, and legal advisors, an international, web-based comprehensive database was developed, The SIOPE DIPG Registry and Imaging Repository, to centrally collect data of DIPG patients. As for April 2016, clinical data as well as MR-scans of 694 patients have been entered into the SIOPE DIPG Registry/Imaging Repository. The median progression free survival is 6.0 months (95% Confidence Interval (CI) 5.6-6.4 months) and the median overall survival is 11.0 months (95% CI 10.5-11.5 months). At two and five years post-diagnosis, 10 and 2% of patients are alive, respectively. The establishment of the SIOPE DIPG Network and SIOPE DIPG Registry means a paradigm shift towards collaborative research into DIPG. This is seen as an essential first step towards understanding the disease, improving care and (ultimately) cure for children with DIPG.

Background: Intraoperatively fabricated polymethylmethacrylate (PMMA) implants based on computer-designed moulds were used to improve cosmetic results after hard tissue replacement. To assess the implant's cosmetic and functional results we performed both subjective and objective assessments., Methods: This retrospective analysis was performed using a cohort of 28 patients who received PMMA implants between February 2009 and March 2012. The cosmetic and functional results were assessed using a patient questionnaire. Furthermore an objective volumetric subtraction score (0-100) was applied and implant thickness, as well as gaps and tiers, were measured., Results: Patients mainly judged their cosmetic result as "good". Two of the 28 patients found their cosmetic result unfavourable. The functional result and stability was mainly judged to be good. Measurements of implant thickness showed a very high correlation with the thickness of the contralateral bone. Volumetric subtraction led to a median quality of 80 on a scale from 0 to 100. Median gaps around the margins of the implant were 1.5 mm parietally, 1.7 mm frontally and 3.5 mm fronto-orbitally, and median tiers were 1.2 mm, 0 mm and 0 mm respectively. The overall rate of surgical revisions was 10.7 % (three patients). Two patients suffered from wound healing disturbances (7.1 %). The overall complication rate was comparable to other reports in the literature., Conclusions: Implantation of intraoperatively fabricated patient-specific moulded implants is a cost-effective and safe technique leading to good clinical results with a low complication rate.

Purpose: For the facilitation of minimally invasive robotically performed direct cochlea access (DCA) procedure, a surgical planning tool which enables the surgeon to define landmarks for patient-to-image registration, identify the necessary anatomical structures and define a safe DCA trajectory using patient image data (typically computed tomography (CT) or cone beam CT) is required. To this end, a dedicated end-to-end software planning system for the planning of DCA procedures that addresses current deficiencies has been developed., Methods: Efficient and robust anatomical segmentation is achieved through the implementation of semiautomatic algorithms; high-accuracy patient-to-image registration is achieved via an automated model-based fiducial detection algorithm and functionality for the interactive definition of a safe drilling trajectory based on case-specific drill positioning uncertainty calculations was developed., Results: The accuracy and safety of the presented software tool were validated during the conduction of eight DCA procedures performed on cadaver heads. The plan for each ear was completed in less than 20 min, and no damage to vital structures occurred during the procedures. The integrated fiducial detection functionality enabled final positioning accuracies of 0.15 ± 0.08 mm., Conclusions: Results of this study demonstrated that the proposed software system could aid in the safe planning of a DCA tunnel within an acceptable time.

Clinical suspicion, positive gram stains and cultures of the synovial fluid are the fundamental criteria for the diagnosis of bacterial arthritis. Bacterial arthritis may, however, show an oligosymptomatic clinical course and thus lead to a delay in diagnosis. The case records of 43 patients with bacterial arthritis were reviewed retrospectively. Rigors (20.9%), fever (40.5%), blood leucocytosis (41.8%) and a shift to the left of blood leucocytes (35%) were found in less than half of all examined patients. Positive cultures of the synovial fluid (71.4%) were far more frequent than positive blood cultures (23.5%). We conclude, that the absence of fever, rigors, blood leucocytosis and positive blood cultures does not rule out the possibility of bacterial arthritis.

In 95 Swiss patients with classical ankylosing spondylitis (AS) the tissue antigen HLA-B27 was present in 92.6%, compared with 7.7% in healthy Swiss blood donors. Assuming the prevalence of ankylosing spondylitis in Switzerland to be 1.9 promille, the chance of a Swiss carrier of HLA-B27 to develop a classical form of AS would be only some 2.2%. For diagnostic purposes, HLA typing thus seems to be of very little value, as among the 462 000 Swiss carriers of HLA-B27 there seem to exist no more than 10 800 classical cases with clinically manifest AS. Absence of HLA-B 27 does not exclude ankylosing spondylitis, as 7.4% of the classical cases are HLA-B27-negative. However, the crudely calculated risk to develop AS is 160 times smaller compared to a carrier HLA-B27. Corner stone of the diagnosis therefore remains careful case history and radiological features of a bilateral sacroileitis of at least grade II.

Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by, among other things, spinal and extraspinal manifestations. Two studies on the prevalence and clinical significance of hyperostotic spurs and ectopic ossifications in the pelvic area are presented. Spinal DISH seems to be a risk factor for the development of ectopic ossification, particularly in the postoperative course after total hip arthroplasty. Pain and reduced range of motion, however, are not obligatory consequences of these phenomena.

The nosological relationship between Polymyalgia rheumatica (PMR) and Cranial Arteritis has been studied by comparing 46 cases of PMR with 21 cases of cranial arteritis. Symptoms consistent with cranial arteritis were present in 83% of the PMR patients, but only 32% showed giant cell arteritis in the biopsy of temporal arteries. The difference is explained by the segmental involvement of the arteritis. The patients with cranial arteritis had symptoms of PMR in 48%. It is concluded, that PMR and cranial arteritis are both manifestations of the same disease. Temporary signs of generalized arteritis seem to occur often in PMR and may lead to fatal complications. PMR may last up to ten years. Because of the potential fatality of this disease, a temporal artery biopsy is indicated in every suspicious case in order to provide a sound basis for the required long term therapy with corticosteroids.

A family with known accumulation of ankylosing spondylitis (AS) was examined clinically, radiologically and by HLA tissue typing. Among 17 individuals of three generations there were four carriers of classical AS, all HLA-B27-positive. Five carriers of HLA-B27 were clinically and radiologically healthy, but three of them were below the age of 30, thus still being at risk of developing AS. The numerical relation between first degree relatives with and without HLA-B27 was 10:7. Genotype reconstruction of the great grandparents lead to the conclusion, that they were carriers of two different haplotype combinations, HLA-1/HLA-B27 and HLA-2/HLA-B27. Both haplotype combinations proved to be associated with AS. Among the offsprings of these great grandparents the combination of HLA-2 with HLA-B27 occurred in 3 of the 4 ankylosing spondylitics and in four of the six healthy HLA-B27-carriers. The question whether a haplotype combination of HLA-2 and HLA-B27 leads to an increased risk for AS cannot be decided without further systematic genotype determinations.

The question, whether HLA-B27-negative patients with classical ankylosing spondylitis (AS) belong to a separate nosological entity, was studied by a standardized analysis of 12 clinical, 8 radiological and 6 laboratory criteria in 95 cases, including 7 with HLA-B27-negativity, who reinforced international criteria for classical AS. The results showed neither definite clinical nor radiological, or laboratory differences between the HLA-B27 negative and positive group. We conclude, that existence or absence of the tissue antigen HLA-B27 has no influence on inflammatory activity of skeletal or soft tissue manifestations of the disease. The group of HLA-B27-negative patients who fulfill the criteria of classical AS does therefore not seem to form a separate nosological entity.

The effect of disodium cromoglycate (cromolyn) in preventing the pulmonary dysfunction caused by the inhalation of barn and hay dust was studied in 5 horses with confirmed chronic obstructive pulmonary disease (COPD). The horses were studied before (Con) and after exposure to hay and dust allergens (Expos) and after pretreatment with cromolyn followed by exposure (Cr-Expos). There was a significant reduction in PaO2 from 86.8 +/- 8.3 to 73.1 +/- 8.8 when the horses were exposed to hay and dust allergens. The PaO2 after pretreatment with cromolyn and exposures was 78.1 +/- 5.5. There were no significant changes in PaCO2, FRC, pH and A-aDO2 when the Con, Expos, and Cr-Expos periods were compared. There were significant increases in VE from a control value of 77.9 +/- 18.2 to 128.7 +/- 55.1 and 133.7 +/- 17.1 L/min during the exposures, which was due primarily to increases in respiratory frequency. Respiratory dead space (VD/VT) increased from 0.55 +/- 0.10 to 0.71 +/- 0.07 and 0.65 +/- 0.05, and alveolar ventilation (VA) remained constant. Pulmonary resistance (RL) and transpulmonary pressure (Ptr) increased from a control of 0.77 +/- 0.28 cm H2O/L/sec and 7.73 +/- 3.38 cm H2O to 2.93 +/- 1.01 and 20.17 +/- 4.81 during the Expos period and tidal volume (VT) fell from 7.5 +/- 1.0 to 5.7 +/- 1.3 L. The pre-treatment with cromolyn before exposures significantly reduced the increase in RL and Ptr and returned VT to Con levels.

The cardiorespiratory and metabolic responses to various levels of tethered-swimming were evaluated in 5 sedentary horses. Cardiac output (Q) and heart rate (HR) correlated highly (r = 0.89 and 0.94 respectively) with work effort (WE) expressed as kg pulled . kg body wt-1 . 10-2. While swimming, stroke volume (SV) was reduced at the lowest workloads, but increased with increasing WE so that at the highest workloads it had returned to the on-land standing SV. Pressures in the pulmonic as well as on both sides of the systemic circulation were considerably elevated by this form of exercise, although only mean carotid artery pressure (CAP) correlated highly (r = 0.83) with WE. During tethered-swimming plasma lactic acid (LA) rose exponentially from 1 to 10 mmol . 1-1 with increasing HR over the range 150-200 beats . min-1. Oxygen uptake (VO2) increased linearly (r = 0.95) from 25-112 ml . kg-1. min-1 over the We range of 3.0-7.8 kg pulled . kg body wt-1. 10-2. The aerobic capacity of the equine species would appear to be twice that of man. The greater increase in VO2 in the exercising horse cannot be explained solely on the basis of increases in Q. Therefore alterations in hematocrit, hemoglobin and oxygen extraction appear to play a more important role in the horse during exercise than they do in man.