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Purpose: The presence of women and people underrepresented in medicine (URiM) continues to be lower in radiation oncology (RO) than within the United States population, medical school graduates, and oncology fellowship applicants. The objective of this study was to identify demographics of matriculating medical students who are inclined to consider pursuing a residency in RO and identify barriers to entry that students may perceive before medical school training. Methods and Materials: A survey of incoming medical students at New York Medical College was distributed via e-mail and assessed demographic background information, interest in and awareness of oncologic subspecialties, and perceived barriers to RO. Results: Students of the incoming class of 2026 had a complete response rate of 72% (155 complete responses and 8 incomplete responses of 214 class members). Two-thirds of participants had prior awareness of RO, and half have considered pursuing an oncologic subspecialty, but less than one-fourth have ever previously considered a career in RO. Students responded that they need more education, clinical exposure, and mentorship to increase their chance of choosing RO. Male participants had 3.4 times the odds of having an acquaintance in the community tell them about the specialty and also had significantly greater interest in using advanced technologies. There were no URiM participants who had personal relationships with an RO physician compared with 6 (4.5%) non-URiM participants. The average response to “What is the likelihood that you will pursue a career in RO?” showed no significant difference between genders. Conclusions: All races and ethnicities scored a similar likelihood of pursuing a career in RO, which differs greatly from the current RO workforce. Responses emphasized the importance of education, mentorship, and exposure to RO. This study demonstrates the need for support of female and URiM students during medical school.

Category: Trauma Introduction/Purpose: Acute ankle fracture-dislocations require emergent reduction. Once the dislocation is successfully reduced, the ideal timing of operative fixation is not well understood. At our institution, a protocol enables patients who have a successful closed reduction in the Emergency Department (ED) to go home and return to the clinic to schedule surgery. We sought to describe the rate at which initial reduction is lost between the ED and clinic visits, and to identify factors associated with loss of reduction. Methods: We retrospectively reviewed all patients who were treated operatively for an ankle fracture from 2008-2012 at a single, Level 1 trauma center and identified 30 patients who had isolated, closed ankle fracture-dislocations that were successfully reduced and splinted in the ED. Adequate reduction was defined by achievement of congruent joint line with < 5mm medial clear space. If reduction was maintained at the clinic visit, surgery was scheduled electively, defining a success. However, if reduction was lost in the interim between ED and clinic visits the patient was admitted from clinic for urgent surgical stabilization, defining a failure. Results: Seventeen patients (57%) successfully maintained closed reduction and 13 (43%) experienced failure of closed reduction in the interim. Compared to the successful group, the failed group had significantly greater posterior malleolus (PM) fracture fragment size (5.1 mm vs. 3.0 mm, p = 0.029). When the ratio of PM fracture fragment size to complete articular surface was > 0.1, rate of failure was 65% compared to 18% when the ratio was ≤0.1 (p = 0.016). There were 2 major wound complications, both of which occurred in the group that failed reduction in the interim. Conclusion: Greater PM fracture fragment size is associated with higher rates of interim failure of closed reduction of closed ankle fracture-dislocations. Injuries with a large PM fracture fragment may warrant consideration of earlier operative intervention.

Category: Trauma Introduction/Purpose: Ankle fractures are among the most common injuries treated by Orthopaedic Surgeons. Complications following surgical treatment of ankle fractures have been well described, however less is known about the risk factors for postoperative wound complications specifically. The purpose of the present study was to evaluate the incidence of wound complications following open reduction and internal fixation of ankle fractures in obese and non-obese patients. Methods: We retrospectively identified 127 consecutive patients who underwent open reduction and internal fixation for an isolated, closed ankle fracture from 2008-2012. The age, sex, height, weight, diabetes status, and tobacco use of each patient were recorded. Time from injury to surgical fixation, use of external fixation, presence of initial dislocation, energy of mechanism, and injury pattern were also recorded. Patients’ records were reviewed to identify any postoperative wound complications. Complications were categorized as major or minor based on need for subsequent surgical intervention. Complication rates were compared between groups using the chi square test, and significant results were followed up with calculation of odds ratios and 95% confidence intervals using multivariate logistic regression. Results: The overall rate of wound complication was 18.9% (24/127), consisting of 6 major and 18 minor complications. The rate of wound complication of any type was significantly lower in obese patients at 11.7% (7/60) compared to 25.4% (17/67) in non- obese patients (P = 0.049). Obesity was associated with a significantly lower risk of developing a wound complication (OR 0.267, 95% CI 0.087 - 0.822), even when controlling for age, sex, diabetes status, tobacco use, surgical delay, external fixation, and injury pattern. No other covariates were associated with an increased risk of a wound infection. Conclusion: In the present study obese patients were less likely than non-obese patients to have a postoperative wound complication following internal fixation of an ankle fracture. Obesity may be protective against wound complications following surgical treatment of ankle fractures given the additional soft-tissue overlying the ankle.

Histopathology, which is the gold-standard for prostate cancer diagnosis, faces significant challenges. With prostate cancer ranking among the most common cancers in the United States and worldwide, pathologists experience an increased number for prostate biopsies. At the same time, precise pathological assessment and classification are necessary for risk stratification and treatment decisions in prostate cancer care, adding to the challenge to pathologists. Recent advancement in digital pathology makes artificial intelligence and learning tools adopted in histopathology feasible. In this review, we introduce the concept of AI and its various techniques in the field of histopathology. We summarize the clinical applications of AI pathology for prostate cancer, including pathological diagnosis, grading, prognosis evaluation, and treatment options. We also discuss how AI applications can be integrated into the routine pathology workflow. With these rapid advancements, it is evident that AI applications in prostate cancer go beyond the initial goal of being tools for diagnosis and grading. Instead, pathologists can provide additional information to improve long-term patient outcomes by assessing detailed histopathologic features at pixel level using digital pathology and AI. Our review not only provides a comprehensive summary of the existing research but also offers insights for future advancements., Competing Interests: None., (AJCEU Copyright © 2024.)

Previous work has reported the design of a novel thermobrachytherapy (TBT) balloon implant to deliver magnetic nanoparticle (MNP) hyperthermia and high-dose-rate (HDR) brachytherapy simultaneously after brain tumor resection, thereby maximizing their synergistic effect. This paper presents an evaluation of the robustness of the balloon device, compatibility of its heat and radiation delivery components, as well as thermal and radiation dosimetry of the TBT balloon. TBT balloon devices with 1 and 3 cm diameter were evaluated when placed in an external magnetic field with a maximal strength of 8.1 kA/m at 133 kHz. The MNP solution (nanofluid) in the balloon absorbs energy, thereby generating heat, while an HDR source travels to the center of the balloon via a catheter to deliver the radiation dose. A 3D-printed human skull model was filled with brain-tissue-equivalent gel for in-phantom heating and radiation measurements around four 3 cm balloons. For the in vivo experiments, a 1 cm diameter balloon was surgically implanted in the brains of three living pigs (40-50 kg). The durability and robustness of TBT balloon implants, as well as the compatibility of their heat and radiation delivery components, were demonstrated in laboratory studies. The presence of the nanofluid, magnetic field, and heating up to 77 °C did not affect the radiation dose significantly. Thermal mapping and 2D infrared images demonstrated spherically symmetric heating in phantom as well as in brain tissue. In vivo pig experiments showed the ability to heat well-perfused brain tissue to hyperthermic levels (≥40 °C) at a 5 mm distance from the 60 °C balloon surface.

Purpose: The presence of women and people underrepresented in medicine (URiM) continues to be lower in radiation oncology (RO) than within the United States population, medical school graduates, and oncology fellowship applicants. The objective of this study was to identify demographics of matriculating medical students who are inclined to consider pursuing a residency in RO and identify barriers to entry that students may perceive before medical school training., Methods and Materials: A survey of incoming medical students at New York Medical College was distributed via e-mail and assessed demographic background information, interest in and awareness of oncologic subspecialties, and perceived barriers to RO., Results: Students of the incoming class of 2026 had a complete response rate of 72% (155 complete responses and 8 incomplete responses of 214 class members). Two-thirds of participants had prior awareness of RO, and half have considered pursuing an oncologic subspecialty, but less than one-fourth have ever previously considered a career in RO. Students responded that they need more education, clinical exposure, and mentorship to increase their chance of choosing RO. Male participants had 3.4 times the odds of having an acquaintance in the community tell them about the specialty and also had significantly greater interest in using advanced technologies. There were no URiM participants who had personal relationships with an RO physician compared with 6 (4.5%) non-URiM participants. The average response to "What is the likelihood that you will pursue a career in RO?" showed no significant difference between genders., Conclusions: All races and ethnicities scored a similar likelihood of pursuing a career in RO, which differs greatly from the current RO workforce. Responses emphasized the importance of education, mentorship, and exposure to RO. This study demonstrates the need for support of female and URiM students during medical school., (© 2022 The Authors.)

Aim: Hyperthermia (HT) has been shown to improve clinical response to radiation therapy (RT) for cancer. Synergism is dramatically enhanced if HT and RT are combined simultaneously, but appropriate technology to apply treatments together does not exist. This study investigates the feasibility of delivering HT with RT to a 5-10mm annular rim of at-risk tissue around a tumor resection cavity using a temporary thermobrachytherapy (TBT) balloon implant., Methods: A balloon catheter was designed to deliver radiation from High Dose Rate (HDR) brachytherapy concurrent with HT delivered by filling the balloon with magnetic nanoparticles (MNP) and immersing it in a radiofrequency magnetic field. Temperature distributions in brain around the TBT balloon were simulated with temperature dependent brain blood perfusion using numerical modeling. A magnetic induction system was constructed and used to produce rapid heating (>0.2°C/s) of MNP-filled balloons in brain tissue-equivalent phantoms by absorbing 0.5 W/ml from a 5.7 kA/m field at 133 kHz., Results: Simulated treatment plans demonstrate the ability to heat at-risk tissue around a brain tumor resection cavity between 40-48°C for 2-5cm diameter balloons. Experimental thermal dosimetry verifies the expected rapid and spherically symmetric heating of brain phantom around the MNP-filled balloon at a magnetic field strength that has proven safe in previous clinical studies., Conclusions: These preclinical results demonstrate the feasibility of using a TBT balloon to deliver heat simultaneously with HDR brachytherapy to tumor bed around a brain tumor resection cavity, with significantly improved uniformity of heating over previous multi-catheter interstitial approaches. Considered along with results of previous clinical thermobrachytherapy trials, this new capability is expected to improve both survival and quality of life in patients with glioblastoma multiforme.

Hyperthermia holds great promise to advance immunotherapy in the treatment of cancer. Multiple trials have demonstrated benefit with the addition of hyperthermia to radiation or chemotherapy in the treatment of wide-ranging malignancies. Similarly, pre-clinical studies have demonstrated the ability of hyperthermia to enhance each of the 8 steps in the cancer-immunotherapy cycle including stimulation of tumor-specific immunity. While there has been an extensive recent focus on augmenting immunotherapy with radiation, surprisingly to date, there have been no clinical trials assessing the combination of hyperthermia with immunotherapy. The study of hyperthermia with immunotherapy is particularly compelling when considered in the context of a new treatment paradigm for this anti-neoplastic modality. Novel concepts include ease of treatment including elicitation of the tumor-specific response of not requiring whole tumor heating, potentially shorter treatment time, better treatment tolerance as opposed to other multi-agent approaches to immunotherapy and the ability to apply heat repeatedly with immunotherapies, unlike ionizing radiation. Several questions remained with regard to clinical integration which can be readily addressed with thoughtful clinical trial design building upon lessons learned at the bench and from clinical trials combining radiation and immunotherapy. Examples of promising avenues for clinical investigation of hyperthermia and immunotherapy including melanoma, bladder, and head and neck cancers are reviewed. In summary, there is a present convergence of factors in oncology that compel further investigation of the integration of hyperthermia with immunotherapy for the benefit of cancer patients.

Quality assurance (QA) guidelines are essential to provide uniform execution of clinical hyperthermia treatments and trials. This document outlines the clinical and technical consequences of the specific properties of interstitial heat delivery and specifies recommendations for hyperthermia administration with interstitial techniques. Interstitial hyperthermia aims at tumor temperatures in the 40-44 °C range as an adjunct to radiation or chemotherapy. The clinical part of this document imparts specific clinical experience of interstitial heat delivery to various tumor sites as well as recommended interstitial hyperthermia workflow and procedures. The second part describes technical requirements for quality assurance of current interstitial heating equipment including electromagnetic (radiative and capacitive) and ultrasound heating techniques. Detailed instructions are provided on characterization and documentation of the performance of interstitial hyperthermia applicators to achieve reproducible hyperthermia treatments of uniform high quality. Output power and consequent temperature rise are the key parameters for characterization of applicator performance in these QA guidelines. These characteristics determine the specific maximum tumor size and depth that can be heated adequately. The guidelines were developed by the ESHO Technical Committee with participation of senior STM members and members of the Atzelsberg Circle.

Over the past few decades there is growing appreciation for the role of chemotherapy in treatment of prostate cancer. Initial successful phase III randomized trials in castration resistant prostate cancer (CRPC) have led to additional successful trials in earlier presentations of disease. Given the established role of radiation in management of locally advanced disease and demonstrated efficacy of taxanes in treatment of prostate cancer, optimal combination of radiation and chemotherapy in this patient population has garnered increased attention. Successful phase III trials in this space have given additional stimulus to further exploring combination therapy with radiation. New directions include assessment of additional chemotherapeutic agents including cabazitaxel and PARP inhibitors as well as personalization of therapy with use of genomic testing and other emerging markers to guide therapeutic decisions., Competing Interests: Conflicts of Interest: The author has no conflicts of interest to declare.

Background: We sought to determine whether patients with high-volume, low-risk prostate cancer are suitable candidates for ultrasound-guided brachytherapy, monotherapy alone, without supplemental external beam radiation., Materials and Methods: The study cohort comprised 200 consecutive patients who received ultrasound.guided monotherapy from November 02, 1998 to March 26, 2010. Real.time intraoperative treatment planning was performed for all patients. 145. Gy with I125 was prescribed to the prostate with no margin. The primary endpoint was time to prostate-specific antigen. (PSA) failure using the phoenix definition. Cox multivariable regression analysis was used to determine the factors significantly associated with time to PSA failure., Results: Median follow-up was 59 months (range 1.2-146.8 months). The median PSA was 5.0 ng/ml. For the overall cohort, both 5- and 8-year PSA failure-free survival was 92.3% (95% confidence interval [95% CI]: 86.5-95.7%). Low-risk patients per the NCCN criteria had 5- and 8-year PSA failure-free survival of 93.6%. On cox multivariable analysis, only baseline PSA (adjusted hazard ratio: 1.29 [95% CI: 1.02-1.65], P = 0.036) was associated with outcome. Among patients with Conclusions: Our analysis indicates that patients with a high number of cores positive for cancer can be adequately treated with modern brachytherapy as monotherapy and be spared the additional morbidity and cost of supplemental external beam radiation or androgen deprivation therapy.

High-dose rate brachytherapy (HDR-BT) monotherapy and robotic arm (i.e., CyberKnife) stereotactic body radiation therapy (SBRT) are emerging technologies that have become popular treatment options for prostate cancer. Proponents of both HDR-BT monotherapy and robotic arm SBRT claim that these modalities are as efficacious as intensity-modulated radiation therapy in treating prostate cancer. Moreover, proponents of robotic arm SBRT believe it is more effective than HDR-BT monotherapy because SBRT is non-invasive, touting it as 'virtual HDR-BT.' We perform a comparative effective analysis of the two technologies. The tumor control rates and toxicities of HDR-BT monotherapy and robotic arm SBRT are promising. However, at present, it would be inappropriate to state that HDR-BT monotherapy and robotic arm SBRT are as efficacious or effective as other treatment modalities for prostate cancer, which have stronger foundations of evidence. Studies reporting on these technologies have relatively short follow-up time, few patients and are largely retrospective.

Background: Pain due to bone metastases is a common cause of cancer-related morbidity, with few options available for patients refractory to medical therapies and who do not respond to radiation therapy. This study assessed the safety and efficacy of magnetic resonance-guided focused ultrasound surgery (MRgFUS), a noninvasive method of thermal tissue ablation for palliation of pain due to bone metastases., Methods: Patients with painful bone metastases were randomly assigned 3:1 to receive MRgFUS sonication or placebo. The primary endpoint was improvement in self-reported pain score without increase of pain medication 3 months after treatment and was analyzed by Fisher's exact test. Components of the response composite, Numerical Rating Scale for pain (NRS) and morphine equivalent daily dose intake, were analyzed by t test and Wilcoxon rank-sum test, respectively. Brief Pain Inventory (BPI-QoL), a measure of functional interference of pain on quality of life, was compared between MRgFUS and placebo by t test. Statistical tests were two-sided., Results: One hundred forty-seven subjects were enrolled, with 112 and 35 randomly assigned to MRgFUS and placebo treatments, respectively. Response rate for the primary endpoint was 64.3% in the MRgFUS arm and 20.0% in the placebo arm (P < .001). MRgFUS was also superior to placebo at 3 months on the secondary endpoints assessing worst score NRS (P < .001) and the BPI-QoL (P < .001). The most common treatment-related adverse event (AE) was sonication pain, which occurred in 32.1% of MRgFUS patients. Two patients had pathological fractures, one patient had third-degree skin burn, and one patient suffered from neuropathy. Overall 60.3% of all AEs resolved on the treatment day., Conclusions: This multicenter phase III trial demonstrated that MRgFUS is a safe and effective, noninvasive treatment for alleviating pain resulting from bone metastases in patients that have failed standard treatments., (© The Author 2014. Published by Oxford University Press.)

Unlabelled: Patients with posttraumatic stress disorder (PTSD) frequently complain of sleep disturbances such as insomnia and nightmares. Evaluation of sleep disturbances is often difficult due to the subjective nature of the complaints. Polysomnography (PSG) and other sleep studies are generally not indicated in the evaluation of insomnia or nightmares associated with PTSD. Actigraphy, (electronic activity monitoring) has been used in research to evaluate sleep disturbances in patients with PTSD. We reviewed the literature on the use of actigraphy in evaluation of sleep problems in patients with PTSD., Methods: A literature search for articles on the topic was conducted on PubMed using the search algorithm (actigraphy[Title/Abstract] OR actigraphic[Title/Abstract]) AND PTSD[Title/Abstract]. Out of 11 search results, 9 studies in which application of actigraphy had relevance to the primary objective and outcome in PTSD patients with sleep problems were selected for review. We also handpicked one additional article from personal communication with our colleagues who have done some of these studies., Conclusion: Actigraphy has been used to evaluate circadian rhythm sleep disorders. Use of actigraphy in psychiatry clinics is uncommon. There is no data to support that there are specific actigraphic sleep related findings in PTSD patients. However, it can be a useful tool to complement the use of sleep diaries when assessing sleep and wake patterns in patients with PTSD.

External beam radiation therapy (EBRT) combined with brachytherapy (BT) is an attractive treatment option for select patients with clinically localized prostate cancer. Either low- or high-dose rate BT may be combined with EBRT ('LDR-BT boost,' 'HDR-BT boost,' respectively). HDR-BT boost has potential theoretical benefits over LDR-BT boost or external beam radiation therapy monotherapy in terms of radiobiology, radiophysics and patient convenience. Based on prospective studies in this review, freedom from biochemical failure (FFBF) rates at 5 years for low-, intermediate- and high-risk patients have generally been 85-100%, 68-97%, 63-85%, respectively; late Radiotherapy and Oncology Group Grades 3 and 4 genitourinary and gastrointestinal toxicities are seen in <8% of patients. HDR-BT boost is now a relatively well-established treatment modality for certain intermediate-risk and high-risk prostate cancer patients, though limitations exist in drawing conclusions from the currently published studies.

Objective: To assess whether awakenings from sleep and sleep duration in Post Traumatic Stress Disorder (PTSD) were related to demography, posttraumatic or depressive symptoms, subjective sleep quality, and daytime sleepiness., Methods: Sample consisted of 23 veterans with lifetime PTSD and current sleep disturbance not due to apnea or other diagnosable conditions. Data collection included demography, two weeks of actigraphy, Beck Depression Inventory, Posttraumatic Checklist, Clinical Assessment of Posttraumatic Symptoms, Pittsburgh Sleep Quality Index, and Epworth Sleepiness Scale., Results: The study revealed that awakenings increased with younger age. Variability in awakenings also increased with younger age (p = 0.002). More awakenings were associated with shorter sleep duration., Conclusions: These paradoxical observations regarding younger age and more awakening may be related to increased sleep symptoms early in the course and then gradual waning of posttraumatic symptoms over time, since awakenings tend to increase with age in normals (rather than decrease, as we observed).

Radiotherapy is used to treat approximately 50% of all cancer patients, with varying success. Radiation therapy has become an in-tegral part of modern treatment strategies for many types of cancer in recent decades, but is associated with a risk of long-term adverse effects. Of these side effects, car-diac complications are particularly relevant since they not only adversely affect quality of life but can also be potentially life-threat-ening. The dose of ionizing radiation that can be given to the tumor is determined by the sensitivity of the surrounding normal tissues. Strategies to improve radiotherapy therefore aim to increase the effect on the tumor or to decrease the effects on normal tissues, which must be achieved without sensitizing the normal tissues in the first approach and without protecting the tumor in the second approach. Hyperthermia is a potent sensitizer of cell killing by ionizing radiation (IR), which can be attributed to the fact that heat is a pleiotropic damaging agent, affecting multiple cell components to varying degrees by altering protein structures, thus influencing the DNA damage response. Hyperthermia induces heat shock protein 70 (Hsp70; HSPA1A) synthesis and enhances telomerase activity. HSPA1A expression is associated with radioresistance. Inactivation of HSPA1A and telomerase increases residual DNA DSBs post IR exposure, which correlates with increased cell killing, supporting the role of HSPA1A and telomerase in IR-induced DNA damage repair. Thus, hyperthermia influences several molecular parameters involved in sensitizing tumor cells to radiation and can enhance the potential of targeted radiotherapy. Therapy-inducible vectors are useful for conditional expression of therapeutic genes in gene therapy, which is based on the control of gene expression by conventional treatment modalities. The understanding of the molecular response of cells and tissues to ionizing radiation has lead to a new appreciation of the exploitable genetic alterations in tumors and the development of treatments combining pharmacological interventions with ionizing radiation that more specifically target either tumor or normal tissue, leading to improvements in efficacy.

Blastomycosis was once thought to be restricted to North America; it has rarely been found in the RSA. The first case reported in the RSA was associated with a diffuse pulmonary infiltrate and cavitation; the patient responded to amphotericin B.

Pneumocystis carinii pneumonia (PCP) has become one of the most important of the opportunistic pulmonary infections of the 1980s. In view of the rapidly expanding population of immunosuppressed patients, many more cases of PCP may be expected in the future. The history, microbiology, pathogenesis, pathology, clinical and laboratory features, diagnosis, treatment, course and prognosis of this disease are reviewed.

Toxic irreversible encephalopathic syndromes developed in 2 patients treated with lithium carbonate and haloperidol. Symptoms consisted of lethargy, fever, tremulousness, confusion, and extrapyramidal and cerebellar dysfunction, accompanied by leucocytosis and elevated serum enzyme, blood urea nitrogen, creatinine and fasting blood glucose levels. One patient suffered widespread irreversible brain damage; the other was left with persistent dyskinesias. Although causal factors have not been identified, this report and others in the literature suggest that diffuse irreversible encephalopathy may occasionally develop in individuals with abnormal brain sensitivity to the lithium carbonate/haloperidol combination. Evidence for this is based on the fact that in our patients and others mentioned in the literature the dosage and blood levels of lithium were not high.

A case of gonococcal arthritis-dermatitis syndrome is reported and discussed. A plea is made for a greater awareness of its occurrence since a high index of suspicion is often required to make the diagnosis.

Pneumocystis carinii pneumonia is today an opportunistic infection of major importance, occurring in immunosuppressed patients. Twelve cases of P. carinii pneumonia were seen by the Pulmonology Unit in Johannesburg between November 1984 and December 1985. The clinical presentation, laboratory and radiographic features, method of diagnosis, treatment, complications of therapy and outcome of these 12 cases are described.