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Doris Y P Leung,1 Diana Tze-Fan Lee,1 Iris F K Lee,1 Lai-Wah Lam,1 Susanna W Y Lee,2 May W M Chan,3 Yin-Ming Lam,4 Siu-Hung Leung,5 Pui-Chi Chiu,6 Nelly K F Ho,7 Ming-Fai Ip,8 May My Hui8 1The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong; 2Hospital Authority Head Office, 3Kowloon West Cluster, 4New Territories West Cluster, 5Kowloon East Cluster, 6United Christian Hospital, 7Kowloon Hospital, 8Tuen Mun Hospital, Hong Kong Hospital Authority, Kowloon, Hong Kong Introduction: Attendance at emergency departments and unplanned hospital readmissions are common for frail older patients after discharge from hospitals. A virtual ward service was piloted to deliver “hospital-at-home” services by community nurses and geriatricians to frail older patients immediately after their discharge from hospital to reduce emergency services utilization.Objectives: This study examined the impacts of the virtual ward service on changes in the patients’ emergency attendance and medical readmissions, and their quality of life (QOL).Methods: A matched-control quasi-experimental study was conducted at four hospitals, with three providing the virtual ward service (intervention) and one providing the usual community nursing care (control). Subjects in the intervention group were those who are at high risk of readmission and who are supported by home carers recruited from the three hospitals providing the virtual ward service. Matched control patients were those recruited from the hospital providing usual care. Outcome measures include emergency attendance and medical readmission in the past 90 days as identified from medical records, and patient-reported QOL as measured by the modified Quality-of-Life Concerns in the End of Life Questionnaire (Chinese version). Wilcoxon signed-rank tests compared the changes in the outcome variables between groups.Results: A total of 39 patients in each of the two groups were recruited. The virtual ward group showed a greater significant reduction in the number of unplanned emergency hospital readmissions (-1.41±1.23 versus -0.77±1.31; P=0.049) and a significant improvement in their overall QOL (n=18; 0.60±0.56 versus 0.07±0.56; P=0.02), but there was no significant difference in the number of emergency attendances (-1.51±1.25 versus -1.08±1.48; P=0.29).Conclusion: The study results support the effectiveness of the virtual ward service in reducing unplanned emergency medical readmissions and in improving the QOL in frail older patients after discharge. Keywords: elderly, emergency attendance, emergency medical readmission, emergency services utilization, quality of life, virtual ward

Purpose: Oral mucositis (OM) is one of the most prevalent and crippling treatment-related toxicities experienced by nasopharyngeal carcinoma (NPC) patients receiving radiotherapy (RT), posing a tremendous adverse impact on quality of life. This multi-center study aimed to develop and externally validate a multi-omic prediction model for severe OM., Methods: Four hundred and sixty-four histologically confirmed NPC patients were retrospectively recruited from two public hospitals in Hong Kong. Model development was conducted on one institution (n = 363), and the other was reserved for external validation (n = 101). Severe OM was defined as the occurrence of CTCAE grade 3 or higher OM during RT. Two predictive models were constructed: 1) conventional clinical and DVH features and 2) a multi-omic approach including clinical, radiomic and dosiomic features., Results: The multi-omic model, consisting of chemotherapy status and radiomic and dosiomic features, outperformed the conventional model in internal and external validation, achieving AUC scores of 0.67 [95% CI: (0.61, 0.73)] and 0.65 [95% CI: (0.53, 0.77)], respectively, compared to the conventional model with 0.63 [95% CI: (0.56, 0.69)] and 0.56 [95% CI: (0.44, 0.67)], respectively. In multivariate analysis, only the multi-omic model signature was significantly correlated with severe OM in external validation (p = 0.017), demonstrating the independent predictive value of the multi-omic approach., Conclusion: A multi-omic model with combined clinical, radiomic and dosiomic features achieved superior pre-treatment prediction of severe OM. Further exploration is warranted to facilitate improved clinical decision-making and enable more effective and personalized care for the prevention and management of OM in NPC patients., Competing Interests: Declarations. Conflict of interest: The authors have no relevant financial or non-financial interests to disclose. Ethics approval and consent to participate: The use of data was approved by the Research Ethics Committee (Kowloon Central/Kowloon East), reference number KC/KE-18–0085/ER-1, and the Joint Chinese University of Hong Kong-New Territories East Cluster Clinical Research Ethics Committee, reference number CRE-2022.689. Due to the retrospective nature of the study, patient consent to participate was waived., (© 2024. The Author(s).)

Introduction: Alongside the improved survival of nasopharyngeal cancer (NPC), late radiation toxicities are alarmingly hampering survivors' quality of life. A patient-reported symptom burden survey is lacking to address the unmet need for symptom management among local NPC survivors., Methods: A single-center cross-sectional survey was conducted on 211 NPC survivors who had completed radiation therapy for three to 120 months. We employed the Chinese version M. D. Anderson Symptom Inventory - Head & Neck Module (MDASI-HN-C), Functional Assessment of Cancer Therapy - Head & Neck (FACT-HN-C), and a question extracted from the Cancer Survivors' Unmet Needs Measure (CaSUN)., Results: Two hundred valid responses were collected. Participants suffered from at least four moderate to severe symptoms (mean = 4.84, SD = 4.99). The top five severe symptoms were dry mouth, mucus problems, difficulty swallowing or chewing, teeth or gum problems, and memory problems. MDASI-HN-C subscales were negatively correlated with the physical, emotional, functional, and HN-specific domains of the FACT-HN-C. The unmet need for symptom management was positively associated with symptom burden, either general symptoms (Adjusted odds ratio [OR adj ] = 1.566, 95% CI = 1.282 - 1.914, p < 0.001) or top-5 symptoms (OR adj = 1.379, 95% CI = 1.185 - 1.604, p < 0.001), while negatively associated with post-RT time (OR adj = 0.981, 95% CI [0.972, 0.991], p < 0.001)., Conclusion: Virtually all NPC survivors suffer from late toxicities, which interplay with survivors' perceptions intricately to affect their unmet needs for symptom management. Personalized supportive care strategies with regular assessments and stratifications are warranted., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Tam, Ching, Yip, Kwong, Chan, Wong and Lee.)

Objective: To compare and contrast the perceived care needs of children with life-limiting conditions (CLLC) from the perspectives of the children, parents and healthcare providers., Design: A qualitative case study method using semistructured interviews was employed with a within-case and across-case analysis. Themes and subthemes emerging from the cases were compared and contrasted in the across-case analysis to explore the similarities and variations in participant perceptions., Setting/participants: The setting was the paediatric departments of five regional hospitals in Hong Kong. Twenty-five sets of informants (CLLC-parent-healthcare provider) were recruited, with 65 individual interviews conducted., Results: A total of 3784 units of analysis were identified, resulting in three themes with subthemes. 'Living with the disease' (55.8%) occupied the largest proportion, followed by 'information and understanding about the disease' (27.4%), and 'care support and palliative care' (16.8%). Healthcare provider support mainly focused on physical concerns. Family and social support were present, but carer stress created tension between couples. Doctors were the primary source of medical information, but the parents had to seek further information via the internet and support from patient groups. There was a perceived need for better coordination and collaboration of care. The palliative care approach coordinated by nurses was seen as helpful in addressing the care needs of the CLLC., Conclusions: This original study identified the importance of palliative care with active engagement of parents which can address the service gap for CLLC., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Despite advances in head and neck cancer treatment, virtually all patients experience chemoradiation-induced toxicities. Oral mucositis (OM) and dysphagia are among the most prevalent and have a systemic impact on patients, hampering treatment outcome and harming quality of life. Accurate prediction of severe cases is crucial for improving management strategies and, ultimately, patient outcomes. This scoping review comprehensively maps the reported predictors and critically evaluates the performance, methodology, and reporting of predictive models for these conditions. A total of 174 studies were identified from database searches, with 73 reporting OM predictors, 97 reporting dysphagia predictors, and 4 reporting both OM and dysphagia predictors. These predictors included patient demographics, tumor classification, chemoradiotherapy regimen, radiation dose to organs-at-risk, genetic factors, and results of clinical laboratory tests. Notably, many studies only conducted univariate analysis or focused exclusively on certain predictor types. Among the included studies, numerous predictive models were reported: eight for acute OM, five for acute dysphagia, and nine for late dysphagia. The area under the receiver operating characteristic curve (AUC) ranged between 0.65 and 0.81, 0.60 and 0.82, and 0.70 and 0.85 for acute oral mucositis, acute dysphagia, and late dysphagia predictive models, respectively. Several areas for improvement were identified, including the need for external validation with sufficiently large sample sizes, further standardization of predictor and outcome definitions, and more comprehensive reporting to facilitate reproducibility.

Given the high death rate caused by high-risk prostate cancer (PCa) (>40%) and the reliability issues associated with traditional prognostic markers, the purpose of this study is to investigate planning computed tomography (pCT)-based radiomics for the long-term prognostication of high-risk localized PCa patients who received whole pelvic radiotherapy (WPRT). This is a retrospective study with methods based on best practice procedures for radiomics research. Sixty-four patients were selected and randomly assigned to training ( n = 45) and testing ( n = 19) cohorts for radiomics model development with five major steps: pCT image acquisition using a Philips Big Bore CT simulator; multiple manual segmentations of clinical target volume for the prostate (CTV prostate ) on the pCT images; feature extraction from the CTV prostate using PyRadiomics; feature selection for overfitting avoidance; and model development with three-fold cross-validation. The radiomics model and signature performances were evaluated based on the area under the receiver operating characteristic curve (AUC) as well as accuracy, sensitivity and specificity. This study's results show that our pCT-based radiomics model was able to predict the six-year progression-free survival of the high-risk localized PCa patients who received the WPRT with highly consistent performances (mean AUC: 0.76 (training) and 0.71 (testing)). These are comparable to findings of other similar studies including those using magnetic resonance imaging (MRI)-based radiomics. The accuracy, sensitivity and specificity of our radiomics signature that consisted of two texture features were 0.778, 0.833 and 0.556 (training) and 0.842, 0.867 and 0.750 (testing), respectively. Since CT is more readily available than MRI and is the standard-of-care modality for PCa WPRT planning, pCT-based radiomics could be used as a routine non-invasive approach to the prognostic prediction of WPRT treatment outcomes in high-risk localized PCa.

Introduction: The COVID-19 pandemic has impacted children and adolescents' physical activity (PA), sleeping patterns, and psychological and behavioral health. Yet, little is known about the differences between those in countries with various economic statuses., Methods: Articles published from database inception through 16 March 2022 were retrieved using CINAHL Complete, Cochrane Library, EMBASE, Medline, PubMed, and PsycINFO. High-quality studies that reported the number of participants with parameters associated with PA, sleeping patterns, and psychological and behavioral problems in young people aged under 18 years during the pandemic were included. We referenced the Canadian 24-Hour Movement Guidelines for PA and sleep duration to provide the event rate for young people who were not compliant with the guidelines. The event rate of young people who had decreased sleep quality and experienced psychological and behavioral problems were also investigated. A subgroup analysis was conducted to identify the differences in those in countries with diverse economic statuses. Funnel plot analysis and Egger's test were also conducted to identify any risk of publication bias., Result: A total of 66 studies with 1,371,168 participants aged between 0 and 18 years, involving 27 countries, were included. During the pandemic, we identified that 41% (95% CI: 39%, 43%; I 2  = 96.62) and 43% (95% CI: 34%, 52%; I 2  = 99.42) of young people did not meet the PA and sleep duration recommendation guidelines. In addition, 31% (95% CI: 28%, 35%; I 2  = 99.66) of young people had decreased their sleep quality. Yet, no significant difference was found across countries with different economic statuses. However, the event rates of participants with psychological and behavioral problems were 32% (95% CI: 28%, 36%; I 2  = 99.85) and 19% (95% CI: 14%, 25%; I 2  = 99.72), respectively. In addition, the rate of psychological problems was more severe in those who live in lower middle-income countries ( p  < 0.001), while the rate of behavioral problems was more severe in those who live in high-income countries ( p  = 0.001)., Discussion: During the pandemic, the discouragement of PA, poor sleep quality, and high risk of psychological and behavioral problems are concerning. A large number of young people did not comply with the recommendation guidelines. Timely implementation of recovery plans is critical to address the adverse effects on young people., Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display&#95;record.php?RecordID=309209, identifier CRD42022309209., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Peng, Reeves, Lee, Chung, Hui, Leung and Pang.)

Modern medicine is reliant on various medical imaging technologies for non-invasively observing patients' anatomy. However, the interpretation of medical images can be highly subjective and dependent on the expertise of clinicians. Moreover, some potentially useful quantitative information in medical images, especially that which is not visible to the naked eye, is often ignored during clinical practice. In contrast, radiomics performs high-throughput feature extraction from medical images, which enables quantitative analysis of medical images and prediction of various clinical endpoints. Studies have reported that radiomics exhibits promising performance in diagnosis and predicting treatment responses and prognosis, demonstrating its potential to be a non-invasive auxiliary tool for personalized medicine. However, radiomics remains in a developmental phase as numerous technical challenges have yet to be solved, especially in feature engineering and statistical modeling. In this review, we introduce the current utility of radiomics by summarizing research on its application in the diagnosis, prognosis, and prediction of treatment responses in patients with cancer. We focus on machine learning approaches, for feature extraction and selection during feature engineering and for imbalanced datasets and multi-modality fusion during statistical modeling. Furthermore, we introduce the stability, reproducibility, and interpretability of features, and the generalizability and interpretability of models. Finally, we offer possible solutions to current challenges in radiomics research., (© 2023. The Author(s).)

Objective: High-risk prostate cancer (PCa) is often treated by prostate-only radiotherapy (PORT) owing to its favourable toxicity profile compared to whole-pelvic radiotherapy. Unfortunately, more than 50% patients still developed disease progression following PORT. Conventional clinical factors may be unable to identify at-risk subgroups in the era of precision medicine. In this study, we aimed to investigate the prognostic value of pre-treatment planning computed tomography (pCT)-based radiomic features and clinical attributes to predict 5-year progression-free survival (PFS) in high-risk PCa patients following PORT., Materials and Methods: A total of 176 biopsy-confirmed PCa patients who were treated at the Hong Kong Princess Margaret Hospital were retrospectively screened for eligibility. Clinical data and pCT of one hundred eligible high-risk PCa patients were analysed. Radiomic features were extracted from the gross-tumour-volume (GTV) with and without applying Laplacian-of-Gaussian (LoG) filter. The entire patient cohort was temporally stratified into a training and an independent validation cohort in a ratio of 3:1. Radiomics (R), clinical (C) and radiomic-clinical (RC) combined models were developed by Ridge regression through 5-fold cross-validation with 100 iterations on the training cohort. A model score was calculated for each model based on the included features. Model classification performance on 5-year PFS was evaluated in the independent validation cohort by average area-under-curve (AUC) of receiver-operating-characteristics (ROC) curve and precision-recall curve (PRC). Delong's test was used for model comparison., Results: The RC combined model which contains 6 predictive features (tumour flatness, root-mean-square on fine LoG-filtered image, prostate-specific antigen serum concentration, Gleason score, Roach score and GTV volume) was the best-performing model (AUC = 0.797, 95%CI = 0.768-0.826), which significantly outperformed the R-model (AUC = 0.795, 95%CI = 0.774-0.816) and C-model (AUC = 0.625, 95%CI = 0.585-0.665) in the independent validation cohort. Besides, only the RC model score significantly classified patients in both cohorts into progression and progression-free groups regarding their 5-year PFS (p< 0.05)., Conclusion: Combining pCT-based radiomic and clinical attributes provided superior prognostication value regarding 5-year PFS in high-risk PCa patients following PORT. A large multi-centre study will potentially aid clinicians in implementing personalised treatment for this vulnerable subgroup in the future., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Ching, Lam, Lam, Lui, Kwong, Lo, Chan, Cai, Leung and Lee.)

Purpose: Radiation dermatitis (RD) is a common, unpleasant side effect of patients receiving radiation therapy. In clinical practice, the severity of RD is graded manually through visual inspection, which is labor intensive and often leads to large interrater variations. To overcome these shortcomings, this study aimed to develop an automatic RD assessment based on deep learning (DL) techniques that could efficiently assist the RD severity classification in clinical application., Methods and Materials: A total of 1205 photographs of the head and neck region were collected from patients with nasopharyngeal carcinoma (NPC) undergoing radiation therapy. The severity of RD in these photographs was graded by 5 qualified assessors based on the Radiation Therapy Oncology Group guidance. An end-to-end RD grading framework was developed by combining a DL-based segmentation network and a DL-based RD severity classifier, which are used for segmenting the neck region from the camera-captured photographs and grading, respectively. U-Net was used for segmentation and another convolutional neural network classifier (DenseNet-121) was applied to RD severity classification. Dice similarity coefficient was used to evaluate the performance of segmentation. Severity classification was evaluated by several metrics, including overall accuracy, precision, recall, and F1 score., Results: Results of segmentation showed that the averaged dice similarity coefficients were 91.2% and 90.8% for front and side view, respectively. For RD severity classification, the overall accuracy of test photographs was 83.0%. Our method accurately classified 90.5% of grade 0, 67.2% of grade 1, 93.8% of grade 2, and 100% of above grade 2 cases. The overall prediction performance was comparable with human assessors. There was no significant difference in accuracy when using manually or automatically segmented regions (P = .683)., Conclusions: We have successfully demonstrated a DL-based method for automatic assessment of RD severity in patients with NPC. This method holds great potential for efficient and effective assessing and monitoring of RD in patients with NPC., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Vasovagal reaction (VVR) compromises donor safety and reduces the subsequent return rates. Performing applied muscle tension (AMT) during phlebotomy may reduce the incidence of VVR. However, the effectiveness of performing AMT after phlebotomy to reduce delayed VVR remains unclear. With ethics approval, 12 young, first-time donors (YFTD) were recruited to study the effects on stroke volume (SV), cardiac output (CO) and systemic vascular resistance (SVR) while performing AMT from needle insertion to end of recovery. Measurements from 12 matched control YFTD were used for comparison. Pre-donation anxiety and VVR severity were assessed. Compared to controls, donors who performed AMT had higher SV (Control: 57 mL vs. AMT: 69 mL, p = 0.045), higher CO (Control: 3.7 L·min -1 vs. AMT: 5.2 L·min -1 , p = 0.006) and lower SVR (Control: 1962 dyn·s·cm -5 vs. AMT: 1569 dyn·s·cm -5 , p = 0.032) during mid-phlebotomy. During recovery, the AMT group retained higher SV, higher CO and lower SVR than the control, but not reaching statistical significance. Practicing AMT during recovery resulted in sustained haemodynamic improvements beyond the donation period, despite the reduction in delayed VVR was insignificant compared to the control group. A larger sample size is needed to validate the effectiveness of performing AMT after donation to mitigate delayed VVR.

The rapid spread of the coronavirus disease 2019 (COVID-19) into a global pandemic caught the world unprepared. Previously effective measures for containing disease outbreaks were overwhelmed, necessitating strict controls such as lockdowns or curfews. Among the disease control interventions, community mass masking was one of the highly controversial issues with differing opinions on its indications or effectiveness from different health authorities around the world. Regions where community mass masking was timely introduced were associated with lower transmission rates, and more effective disease control. In this article, we discuss the evidence on the effectiveness, and rationale for community mass masking to prevent the COVID-19 transmission. Areas for further research to define the role of mass masking in light of the COVID-19 pandemic will be suggested. This would help policy makers in formulating mass masking policies., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Tam, Tam, Law, Khaw and Lee.)

The novel coronavirus disease (COVID-19), has become the most critical global health challenge in recent history. With SARS-CoV-2 infection, there was an unexpectedly high and specific prevalence of olfactory and taste disorders (OTDs). These high rates of hyposmia and hypogeusia, initially reported as up to 89% in European case series, led to the global inclusion of loss of taste and/or smell as a distinctive feature of COVID-19. However, there is emerging evidence that there are striking differences in the rates of OTDs in East Asian countries where the disease first emerged, as compared to Western countries (15.8 vs. 60.9%, p -value < 0.01). This may be driven by either variations in SARS-CoV-2 subtypes presenting to different global populations or genotypic differences in hosts which alter the predisposition of these different populations to the neuroinvasiveness of SARS-CoV-2. We also found that rates of OTDs were significantly higher in objective testing for OTDs as compared to subjective testing (73.6 vs. 60.8%, p -value = 0.03), which is the methodology employed by most studies. Concurrently, it has also become evident that racial minorities across geographically disparate world populations suffer from disproportionately higher rates of COVID-19 infection and mortality. In this mini review, we aim to delineate and explore the varying rates of olfactory and taste disorders amongst COVID-19 patients, by focusing on their underlying geographical, testing, ethnic and socioeconomic differences. We examine the current literature for evidence of differences in the olfactory and gustatory manifestations of COVID-19 and discuss current pathophysiological hypotheses for such differences., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Kumar, Lee, Lock and Keong.)

Introduction: Community face mask use during the coronavirus disease 2019 (COVID-19) pandemic has considerably differed worldwide. Generally, Asians are more inclined to wear face masks during disease outbreaks. Hong Kong has emerged relatively unscathed during the initial outbreak of COVID-19, despite its dense population. Previous infectious disease outbreaks influenced the local masking behaviour and response to public health measures. Thus, local behavioural insights are important for the successful implementation of infection control measures. This study explored the behaviour and attitudes of wearing face masks in the community during the initial spread of COVID-19 in Hong Kong., Methods: We observed the masking behaviour of 10 211 pedestrians in several regions across Hong Kong from 1 to 29 February 2020. We supplemented the data with an online survey of 3199 respondents' views on face mask use., Results: Among pedestrians, the masking rate was 94.8%; 83.7% wore disposable surgical masks. However, 13.0% wore surgical masks incorrectly with 42.5% worn too low, exposing the nostrils or mouth; 35.5% worn 'inside-out' or 'upside-down'. Most online respondents believed in the efficacy of wearing face mask for protection (94.6%) and prevention of community spread (96.6%). Surprisingly, 78.9% reused their mask; more respondents obtained information from social media (65.9%) than from government websites (23.2%)., Conclusions: In Hong Kong, members of the population are motivated to wear masks and believe in the effectiveness of face masks against disease spread. However, a high mask reuse rate and errors in masking techniques were observed. Information on government websites should be enhanced and their accessibility should be improved., Competing Interests: All authors have disclosed no conflicts of interest.

Background: Norepinephrine is an effective vasopressor during spinal anaesthesia for Caesarean delivery. However, before it can be fully recommended, possible adverse effects on neonatal outcome should be excluded. We aimed to test the hypothesis that umbilical arterial cord pH is at least as good (non-inferior) when norepinephrine is used compared with phenylephrine for treatment of hypotension., Methods: We enrolled 668 subjects having elective and non-elective Caesarean delivery under spinal or combined spinal-epidural anaesthesia in this randomised, double-blind, two-arm parallel, non-inferiority clinical trial. Arterial blood pressure was maintained using norepinephrine 6 μg ml -1 or phenylephrine 100 μg ml -1 according to the practice of the anaesthetist, either prophylactically or therapeutically, as an infusion or bolus. The primary outcome was umbilical arterial pH with a chosen non-inferiority margin of 0.01 units., Results: Of 664 subjects (531 elective and 133 non-elective) who completed the study, umbilical arterial cord blood was analysed for 351 samples from 332 subjects in the norepinephrine group and 343 samples from 332 subjects in the phenylephrine group. Umbilical arterial pH was non-inferior in the norepinephrine group (mean, 7.289; 95% confidence interval [CI], 7.284-7.294) compared with the phenylephrine group (mean, 7.287; 95% CI, 7.281-7.292) (mean difference between groups, 0.002; 95% CI, -0.005 to 0.009; P=0.017). Subgroup analysis confirmed the non-inferiority of norepinephrine for elective cases but was inconclusive for non-elective cases., Conclusions: Norepinephrine was non-inferior to phenylephrine for neonatal outcome assessed by umbilical arterial pH. These results provide high-quality evidence supporting the fetal safety of norepinephrine in obstetric anaesthesia., Clinical Trial Registration: ChiCTR-IPR-15006235., (Copyright © 2020 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Photobiomodulation (PBM) using low-level laser therapy (LLLT) is a treatment that is increasingly used in oncology. Studies reported enhancement of wound healing with reduction in pain, tissue swelling and inflammatory conditions such as radiation dermatitis, oral mucositis, and lymphedema. However, factors such as wavelength, energy density and irradiation frequency influence the cellular mechanisms of LLLT. Moreover, the effects of LLLT vary according to cell types. Thus, controversy arose as a result of poor clinical response reported in some studies that may have used inadequately planned treatment protocols. Since LLLT may enhance tumor cell proliferation, these will also need to be considered before clinical use. This review aims to summarize the current knowledge of the cellular mechanisms of LLLT by considering its effects on cell proliferation, metabolism, angiogenesis, apoptosis and inflammation. With a better understanding of the cellular mechanisms, bridging findings from laboratory studies to clinical application can be improved., (Copyright © 2020 Tam, Tam, Ramkumar, Khaw, Law and Lee.)

Cardiac output (CO) monitoring is useful for sports performance training, but most methods are unsuitable as they are invasive or hinder performance. The performance of PhysioFlow (PF), a portable noninvasive transthoracic bioimpedance CO monitor, was evaluated and compared with a reference Doppler CO monitor, USCOM, using a head-up tilt (HUT) test. With ethics committee approval, 20 healthy well-trained athletes were subjected to HUT in a fixed order of 0°, 70°, 30°, and 0° for 3 min each. Simultaneous hemodynamic measurements using PF and USCOM were made 30 s after a change in HUT and analyzed using t tests, ANOVA, and mountain plots. Heart rate (HR) and stroke volume (SV) from both monitors changed according to physiological expectation of tilt, but PF measurements of SV were higher with a positive bias (PF vs. USCOM, 0°: 87.3 vs. 54.0 mL, P < 0.001; 70°: 76.5 vs. 39.5 mL, P < 0.001; 30°: 81.4 vs. 50.1 mL, P < 0.001; 0°: 88.3 vs. 57.1 mL, P < 0.001). Relative changes in SV (∆SV) after each tilt measured using PF were lower with a negative bias (PF vs. USCOM, 0° to 70°: -12.3% vs. -26.3%, P = 0.002; 70° to 30°: +6.4% vs. +31.2%, P < 0.001; 30° to 0°: +9.2% vs. +15.8%, P = 0.280). CO measurements using PF at 70° were erroneous. Compared with USCOM, PF overestimated SV measurements but underestimated the ∆SV between HUT. Accuracy of the PF deteriorated at 70°, implying a gravitational influence on its performance. These findings suggested that the suitability of PF for sports use is questionable. NEW & NOTEWORTHY The use of impedance cardiography to monitor physiological changes in sports is rarely reported. Using head-up tilt test, we evaluated a portable noninvasive impedance cardiography device (PhysioFlow) by comparing it with a reference Doppler monitor (USCOM). Accuracy in tracking hemodynamic changes deteriorated with higher tilt, implying a gravitational influence on its performance. Stroke volume measurements were overestimated, but the changes were underestimated. Despite its convenient physical features, the suitability of PhysioFlow for sports use is questionable.

This study evaluated the morphological changes of the lower limb and associated hemodynamic responses to different lower-body compression pressures (COMPs) in physically active, healthy individuals at rest. Each of the 32 participants underwent three trials with three different degrees of lower-body compression applied: "Low" (2.2±1.4 mmHg), "Medium" (12.9±3.9 mmHg), and "High" (28.8±8.3 mmHg). In each COMP, a cross-sectional area of leg muscles (CSA muscle ), subcutaneous fat (CSA fat ), superficial vessels (SupV), deep arteries (DA), and deep veins (DV) at the calf, knee, and thigh levels were measured using magnetic resonance imaging (MRI). Additionally, blood pressure (BP), heart rate (HR), cardiac output (CO), stroke volume (SV), and systemic vascular resistance (SVR) were measured using Doppler ultrasound (USCOM ® ). With High COMP, calf CSA muscle and SupV were smaller (p<0.01), whereas DA and DV were larger (p<0.05). Calf CSA fat , however, was similar among all COMPs. There were no major changes in CSA muscle and CSA fat at knee and thigh levels. CO (3.2±0.9 L/min) and SV (51.9±16.4 mL) were higher (p<0.05) only with High COMP, but other hemodynamic variables showed no significant changes across different COMPs. The High COMP at the lower limb induces leg morphological changes and increases associated hemodynamic responses of physically active healthy individuals at rest., Competing Interests: The authors declare no conflicts of interest., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Traumatic brain injury (TBI) is a common presentation to the pediatric emergency department. Understanding factors that predict outcomes will be useful in clinical decision-making and prognostication. The objective of this study was to identify important clinical parameters predictive of outcomes in pediatric TBI patients who underwent surgery., Materials and Methods: This retrospective study included 43 pediatric TBI patients who underwent surgery from January 2011 to January 2017. Clinical parameters, including presenting signs and symptoms, mechanism of injury, intracranial pressure (ICP), need for inotropes, and computed tomography findings were collected. Outcomes were assessed using the Glasgow outcome score (GOS) based on the latest follow-up. Outcomes were divided into favorable (GOS 4-5) and unfavorable (GOS 1-3)., Results: Surgery was performed in 43 patients. The mean age was 9.6 ± 4.9. The mean follow-up period was 31 weeks. Thirty (70%) patients had favorable outcome and 13 (30%) had unfavorable outcome. On univariate analysis, mechanism of injury, vomiting, Glasgow coma scale score, pupil size and reactivity, hypotension, inotropic use, need for blood transfusion, and raised ICP (all P < 0.005) were significantly associated with outcomes. On step-wise logistic regression, only raised ICP (odds ratio [OR] = 35.6, P = 0.008) and hypotension (OR = 26.1, P = 0.01) were found to be statistically significant., Conclusion: The present study suggests that the majority of pediatric TBI patients who required neurosurgical intervention have favorable outcomes. Closer attention should be paid to raised ICP and hypotension as they were strong predictors of unfavorable outcomes. These findings also help manage expectations of patients' family and clinicians., Competing Interests: There are no conflicts of interest.

Objectives: While previous studies have demonstrated an ergogenic effect of sport compression garments in exercise performance and recovery, the possible underlying mechanisms remain unclear. Claims for improved venous return from wearing sport compression garments with a low compression pressure remain unproven. The aim of this study was to determine the pressure profile exerted by low-pressure sports compression tights, and to investigate using a non-invasive Doppler ultrasound cardiac output monitor (USCOM), whether the compression applied will influence haemodynamic responses during an orthostatic challenge., Design: A randomized-crossover design., Methods: Thirty-three healthy participants (18 male and 15 female) underwent two trials, each consisting of lying supine and 70° head-up tilt wearing either a low-pressure sports compression tights (CT) or track pants (CON). Stroke volume (SV) and cardiac output (CO) were measured non-invasively using USCOM; heart rate (HR) and non-invasive blood pressure were measured, and systemic vascular resistance (SVR) was derived., Results: The SV and CO was lower at 70° head-up tilt than in supine but wearing CT attenuated the decline in SV (25.9±11.6cm 3 CT vs. 35.9±11.4cm 3 CON, p<0.001), CO (1.1±0.7 Lmin -1 CT vs. 1.4±0.6 Lmin -1 CON, p<0.05), HR (8.8±8.4 beatmin -1 CT vs. 15.9±9.7 beatmin -1 CON, p<0.001) and SVR (740±504dscm -5 CT vs. 961±560dscm -5 CON, p<0.005). The mean arterial pressure (3.3±4.1mmHg CT vs. 3.6±4.5mm Hg CON, p>0.05) was similar in both trials., Conclusions: Healthy individuals wearing low-pressure sports compression tights experienced less severe haemodynamic disturbance such as decreases in CO, SV, HR and SVR during an orthostatic challenge., (Copyright © 2017 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

Background: The use of norepinephrine for maintaining blood pressure (BP) during spinal anesthesia for cesarean delivery has been described recently. However, its administration by titrated manually controlled infusion in this context has not been evaluated., Methods: In a double-blinded, randomized controlled trial, 110 healthy women having spinal anesthesia for elective cesarean delivery were randomly allocated to 1 of 2 groups. In group 1, patients received an infusion of 5 µg/mL norepinephrine that was started at 30 mL/h (2.5 µg/min) immediately after intrathecal injection and then manually adjusted within the range 0-60 mL/h (0-5 µg/min), according to values of systolic BP measured noninvasively at 1-minute intervals until delivery, with the objective of maintaining values near baseline. In group 2, no prophylactic vasopressor was given, and a bolus of 1 mL norepinephrine 5 µg/mL (5 µg) was given whenever systolic BP decreased to <80% of the baseline value. The study protocol was continued until delivery. The primary outcomes of the study were the incidence of hypotension and the overall stability of systolic BP control versus baseline compared using performance error calculations. In addition, the incidence and timing of hypotension were further compared using survival analysis., Results: Three patients were excluded from the analysis. Nine patients (17%) in group 1 had 1 or more episodes of hypotension versus 35 (66%) in group 2 (P < .001). Performance error calculations showed that on average, systolic BP was maintained closer to baseline (P < .001) in group 1. Survival curve analysis showed a significant difference between groups (log-rank test P < .001). Four patients in each group had a recorded heart rate <60 beats/min (P = .98). Despite a much greater rate of administration of norepinephrine in group 1 (median, 61.0 [interquartile range, 47.0-72.5] µg) versus group 2 (5.0 [0-18.1] µg) (P < .001), there was no difference in neonatal outcome as assessed by Apgar scores and umbilical cord blood gas analysis., Conclusions: In patients having spinal anesthesia for elective cesarean delivery, a manually titrated infusion of 5 µg/mL of norepinephrine was effective for maintaining BP and decreasing the incidence of hypotension, with no detectable detrimental effect on neonatal outcome. Further investigation of the use of dilute norepinephrine infusions for routine use in obstetric patients is suggested.

Introduction: Radiotherapy of nasopharyngeal carcinoma patients with parapharyngeal space (PPS) involvement may deliver high dose to the parotid gland. This study evaluated parotid gland changes during and up to 3 months after radiotherapy., Methods: Kilovoltage computed tomography (CT) scans of head and neck region of 39 nasopharyngeal carcinoma patients with PPS involvement were performed at pre-radiotherapy, 10th, 20th and 30th fractions and 3 months after treatment. The parotid glands were contoured in pre-radiotherapy planning CT scan and in subsequent scans. Dice similarity coefficient (DSC), percentage volume change and centroid movement between the planning CT and the subsequent CTs were obtained from the contouring software. In addition, the distance between medial and lateral borders of parotid glands from the mid-line at various time intervals were also measured., Results: The ipsilateral parotid gland received a mean dose of about 5 Gy higher than the contralateral side. The mean DSC and parotid volume decreased by more than 30% at 20th fraction and reached the minimum at 30th fraction. Partial recovery was observed at 3 months after treatment. The centroid displacement followed a similar pattern, which moved medially and superiorly by an average of 0.30 cm and 0.18 cm, respectively, at 30th fraction. The changes in ipsilateral gland were slightly greater than the contralateral side., Conclusions: Substantial volume change and medial movement of parotid gland were observed with slightly greater magnitude in the ipsilateral side. Adaptive radiotherapy was suggested at around 15th to 20th fraction so as to optimise the original dose distribution of the plan., (© 2017 The Authors. Journal of Medical Radiation Sciences published by John Wiley & Sons Australia, Ltd on behalf of Australian Society of Medical Imaging and Radiation Therapy and New Zealand Institute of Medical Radiation Technology.)

Background: We previously described the use of closed-loop feedback computer-controlled infusion of phenylephrine for maintaining blood pressure (BP) during spinal anesthesia for cesarean delivery. In this study, we report a modified system in which phenylephrine is delivered by intermittent boluses rather than infusion. We hypothesized that the use of computer-controlled boluses would result in more precise control of BP compared with infusions., Methods: Two hundred fourteen healthy patients having spinal anesthesia for elective cesarean delivery were randomized to have their systolic BP maintained by phenylephrine administered by computer-controlled continuous infusion or computer-controlled intermittent boluses. From induction of anesthesia until the time of uterine incision, a noninvasive BP monitor was set to cycle at 1-minute intervals. In the infusion group, the infusion rate was automatically adjusted after each BP measurement using a previously described algorithm. In the bolus group, the algorithm was modified so that the mass of drug that would have been delivered over 1 minute was instead injected as a rapid intravenous bolus after each BP measurement. The precision of BP control was assessed using performance error calculations and compared between groups, with the primary outcome defined as median absolute performance error, and the latter being a measure of inaccuracy showing an average of the magnitudes of the differences of measured BP values above or below the target values., Results: The precision of BP control was greater, as shown by smaller values for median absolute performance error, in the bolus group (median 4.38 [quartiles 3.22, 6.25] %) versus the infusion group (5.39 [4.12, 7.04] %, P = .008). In the bolus group, phenylephrine consumption was smaller; this was associated with smaller values for median performance error compared with the continuous infusion group (P < .001), which indicates that values for systolic BP, averaged over time, were slightly lower in the bolus group. There were no differences in cardiac output, nausea or vomiting, or neonatal outcome between groups., Conclusions: We confirmed the hypothesis that BP control was more precise when computer-controlled phenylephrine was delivered using intermittent boluses rather than continuous infusion. However, the difference between groups was small and was not associated with any difference in clinical outcomes. In the infusion group, greater doses of phenylephrine were delivered, which was related to the time taken for the noninvasive BP monitor to complete measurements. The use of intermittent boluses may be a useful alternative in the design of closed-loop vasopressor systems.

Objective: To investigate the effect of "breathing control" on sonographic diaphragmatic excursion., Method: A prospective, randomized, assessor-blinded study design involving 20 physiotherapy students; ten with knowledge of the breathing control technique (Group BC) and ten without (Group CON). All participants were asked to perform a Chester step test. Group BC performed BC, while Group CON adopted their own breathing pattern during recovery after the step test. Respiratory rate and sonographic parameters of the diaphragm including diaphragmatic excursion, speed of diaphragmatic contraction (slope of contraction), and inspiratory time were recorded before and after the step test., Results: All baseline data were similar for both groups except age. Respiratory rate at 1 min post-step test was higher in Group CON (24.6±4.9 bpm) compared to Group BC (15.6 ± 3.8 bpm) (p < 0.001). Post-step test sonographic evaluation demonstrated an increase in diaphragmatic excursion with a significant time and group interaction (F (4,72) = 5.499, p = 0.005). Post hoc analysis revealed that the diaphragmatic excursion was significantly higher in Group BC compared to Group CON at first, second and third minute post-step test. Time and group interactions were not significant in inspiration time (F (4,72) = 2.459, p = 0.082) nor the slope of contraction (F (4,72) = 0.655, p = 0.582)]., Conclusion: Post-exercise diaphragmatic excursion was higher in participants applying BC. Non-invasive ultrasonography is able to promote objective evaluation of the relationship between breathing techniques and diaphragmatic function.