Post partum infections: A review for the non-OBGYN

The epidemiology of infections in the puerperium (post partum period) is not well understood and remains underestimated because surveillance systems are often limited to the acute care setting. The most common source of persistent fever after delivery is genital tract infection for which diagnosis remains mostly clinical and antibiotic treatment empiric. This review will emphasize surgical site infections (SSIs) and endometritis. Septic thrombo-phlebitis, mastitis, urinary tract infections and rare infections will be covered in less detail. Puerperal sepsis will not be reviewed.

Deformable image registration for temporal subtraction of chest radiographs

PURPOSE

Temporal subtraction images constructed from image registration can facilitate the visualization of pathologic changes. In this study, we propose a deformable image registration (DIR) framework for creating temporal subtraction images of chest radiographs.

METHODS

We developed a DIR methodology using two different image similarity metrics, varying flow (VF) and compressible flow (CF). The proposed registration method consists of block matching, filtering, and interpolation. Specifically, corresponding point pairs between reference and target images are initially determined by minimizing a nonlinear least squares formulation using grid-searching optimization. A two-step filtering process, including least median of squares filtering and backward matching filtering, is then applied to the estimated point matches in order to remove erroneous matches. Finally, moving least squares is used to generate a full displacement field from the filtered point pairs.

RESULTS

We applied the proposed DIR method to 10 pairs of clinical chest radiographs and compared it with the demons and B-spline algorithms using the five-point rating score method. The average quality scores were 2.7 and 3 for the demons and B-spline methods, but 3.5 and 4.1 for the VF and CF methods. In addition, subtraction images improved the visual perception of abnormalities in the lungs by using the proposed method.

CONCLUSION

The VF and CF models achieved a higher accuracy than the demons and the B-spline methods. Furthermore, the proposed methodology demonstrated the ability to create clinically acceptable temporal subtraction chest radiographs that enhance interval changes and can be used to detect abnormalities such as non-small cell lung cancer.

Comparison of 4-dimensional computed tomography ventilation with nuclear medicine ventilation-perfusion imaging: a clinical validation study

PURPOSE

Four-dimensional computed tomography (4DCT) ventilation imaging provides lung function information for lung cancer patients undergoing radiation therapy. Before 4DCT-ventilation can be implemented clinically it needs to be validated against an established imaging modality. The purpose of this work was to compare 4DCT-ventilation to nuclear medicine ventilation, using clinically relevant global metrics and radiologist observations.

METHODS AND MATERIALS

Fifteen lung cancer patients with 16 sets of 4DCT and nuclear medicine ventilation-perfusion (VQ) images were used for the study. The VQ-ventilation images were acquired in planar mode using Tc-99m-labeled diethylenetriamine-pentaacetic acid aerosol inhalation. 4DCT data, spatial registration, and a density-change-based model were used to compute a 4DCT-based ventilation map for each patient. The percent ventilation was calculated in each lung and each lung third for both the 4DCT and VQ-ventilation scans. A nuclear medicine radiologist assessed the VQ and 4DCT scans for the presence of ventilation defects. The VQ and 4DCT-based images were compared using regional percent ventilation and radiologist clinical observations.

RESULTS

Individual patient examples demonstrate good qualitative agreement between the 4DCT and VQ-ventilation scans. The correlation coefficients were 0.68 and 0.45, using the percent ventilation in each individual lung and lung third, respectively. Using radiologist-noted presence of ventilation defects and receiver operating characteristic analysis, the sensitivity, specificity, and accuracy of the 4DCT-ventilation were 90%, 64%, and 81%, respectively.

CONCLUSIONS

The current work compared 4DCT with VQ-based ventilation using clinically relevant global metrics and radiologist observations. We found good agreement between the radiologist's assessment of the 4DCT and VQ-ventilation images as well as the percent ventilation in each lung. The agreement lessened when the data were analyzed on a regional level. Our study presents an important step for the integration of 4DCT-ventilation into thoracic clinical practice.

Pre-radiotherapy FDG PET predicts radiation pneumonitis in lung cancer

BACKGROUND

A retrospective analysis is performed to determine if pre-treatment [18 F]-2-fluoro-2-deoxyglucose positron emission tomography/computed tomography (FDG PET/CT) image derived parameters can predict radiation pneumonitis (RP) clinical symptoms in lung cancer patients.

METHODS AND MATERIALS

We retrospectively studied 100 non-small cell lung cancer (NSCLC) patients who underwent FDG PET/CT imaging before initiation of radiotherapy (RT). Pneumonitis symptoms were evaluated using the Common Terminology Criteria for Adverse Events version 4.0 (CTCAEv4) from the consensus of 5 clinicians. Using the cumulative distribution of pre-treatment standard uptake values (SUV) within the lungs, the 80th to 95th percentile SUV values (SUV(80) to SUV(95) were determined. The effect of pre-RT FDG uptake, dose, patient and treatment characteristics on pulmonary toxicity was studied using multiple logistic regression.

RESULTS

The study subjects were treated with 3D conformal RT (n=23), intensity modulated RT (n=64), and proton therapy (n=13). Multiple logistic regression analysis demonstrated that elevated pre-RT lung FDG uptake on staging FDG PET was related to development of RP symptoms after RT. A patient of average age and V(30) with SUV(95)=1.5 was an estimated 6.9 times more likely to develop grade ≥ 2 radiation pneumonitis when compared to a patient with SUV(95)=0.5 of the same age and identical V(30). Receiver operating characteristic curve analysis showed the area under the curve was 0.78 (95% CI=0.69 - 0.87). The CT imaging and dosimetry parameters were found to be poor predictors of RP symptoms.

CONCLUSIONS

The pretreatment pulmonary FDG uptake, as quantified by the SUV(95), predicted symptoms of RP in this study. Elevation in this pre-treatment biomarker identifies a patient group at high risk for post-treatment symptomatic RP.

Modeling lung deformation: a combined deformable image registration method with spatially varying Young's modulus estimates

PURPOSE

Respiratory motion introduces uncertainties in tumor location and lung deformation, which often results in difficulties calculating dose distributions in thoracic radiation therapy. Deformable image registration (DIR) has ability to describe respiratory-induced lung deformation, with which the radiotherapy techniques can deliver high dose to tumors while reducing radiation in surrounding normal tissue. The authors' goal is to propose a DIR method to overcome two main challenges of the previous biomechanical model for lung deformation, i.e., the requirement of precise boundary conditions and the lack of elasticity distribution.

METHODS

As opposed to typical methods in biomechanical modeling, the authors' method assumes that lung tissue is inhomogeneous. The authors thus propose a DIR method combining a varying intensity flow (VF) block-matching algorithm with the finite element method (FEM) for lung deformation from end-expiratory phase to end-inspiratory phase. Specifically, the lung deformation is formulated as a stress-strain problem, for which the boundary conditions are obtained from the VF block-matching algorithm and the element specific Young's modulus distribution is estimated by solving an optimization problem with a quasi-Newton method. The authors measure the spatial accuracy of their nonuniform model as well as a standard uniform model by applying both methods to four-dimensional computed tomography images of six patients. The spatial errors produced by the registrations are computed using large numbers (>1000) of expert-determined landmark point pairs.

RESULTS

In right-left, anterior-posterior, and superior-inferior directions, the mean errors (standard deviation) produced by the standard uniform FEM model are 1.42(1.42), 1.06(1.05), and 1.98(2.10) mm whereas the authors' proposed nonuniform model reduces these errors to 0.59(0.61), 0.52(0.51), and 0.78(0.89) mm. The overall 3D mean errors are 3.05(2.36) and 1.30(0.97) mm for the uniform and nonuniform models, respectively.

CONCLUSIONS

The results indicate that the proposed nonuniform model can simulate patient-specific and position-specific lung deformation via spatially varying Young's modulus estimates, which improves registration accuracy compared to the uniform model and is therefore a more suitable description of lung deformation.

A new approach for the characterization of proliferative cells in cestodes

Cestodes show a remarkable proliferative capability that sustains the constant growth and differentiation of proglottids essential for their lifestyle. It is believed that a separate population of undifferentiated stem cells (the so-called germinative cells) are the only cells capable of proliferation during growth and development. The study of this particular cell subpopulation is hampered by the current lack of methods to isolate it. In this work, we developed a reproducible flow cytometry and cell sorting method to quantify and isolate the proliferating cells in the tetrathyridia larvae of the model cestode Mesocestoides corti, based on the DNA content of the cells. The isolated cells display the typical germinative cell morphology, and can be used for RNA isolation with a yield in the ng to μg range. We expect that this approach may facilitate the characterization of the germinative cells in M. corti and other model tapeworms.

Prediction of extracapsular disease with multiparametric magnetic resonance imaging in high risk localized prostate cancer patient

OBJECTIVES

To assess the usefulness of multiparametric magnetic resonance imaging (MRI) in the staging of patients with localized prostate cancer (PC) and high risk of extracapsular disease (ECD).

METHODS

Retrospective study including 30 patients with localized PC and high risk of ECD. Pathologist and radiologist established an ECD suspicion according to the evaluation of the prostatic biopsy specimens and the multiparametric MRI analysis, respectively. Radical prostatectomy (RP) specimen analysis was used as a definitive confirmatory reference. Kappa (k)test was used to assess the degree of consistency between the initial suspicion provided by both specialists and the reference RP specimen.

RESULTS

When the prostatic gland was analyzed as a single unit, the pathological evaluation of the biopsy specimens did not correctly detect the risk of ECD in 46.6% of the patients (14/30; 10 FN; k=-0.035, 95%CI [-0.29-0.36]), while multiparametric MRI did not do in 36% of the cases (11/30, 9 FP; k=0.27, 95%CI [-0.03-0.61]). Whereas, if each side of the prostate (i.e. right and left) was considered as an independent observation, the pathologist wrongly predicted the risk of ECD in 35% of the cases (21/60; 18 FN; k=0.19, 95%CI [-0.03-0.40]), while the radiologist erred only in 18.3% of the cases (11/60; 7 FN and 4 FP; k=0, 61, 95%CI [0.40-0.81]).

CONCLUSIONS

Data from our experience suggest an added value of multiparametric MRI in the clinical staging of localized PC in cases of high risk of ECD. Multiparametric MRI may be used as a helpful tool in the surgical planning and the decision-making process regarding the management of this entity.

Role of TNF in sickness behavior and allodynia during the acute phase of Chagas' disease

Chagas disease, caused by the intracellular protozoan Trypanosoma cruzi, is associated with inflammation, discomfort and pain during the acute phase. The influence of TNF-α (tumor necrosis factor) in this disease outcome is controversial. In this way, the aim of this work was to determine the role of the TNF-α blocker etanercept in the pain, discomfort, and survival during the Chagas' acute phase of mice experimentally infected with a wild virulent strain of T. cruzi. The infection with this wild strain was responsible for a severe visceral inflammation and said parasite showed a tropism in peritoneal fluid cells. Etanercept was able to restore spontaneous vertical and horizontal activities during the second week after infection and to abolish mechanical allodynia during the first week after infection. Finally, etanercept delayed the mortality without any effect on the parasitemia rates. This is the first report that correlates sickness behavior and allodynia with TNF-α and suggests that this cytokine may play an important role in the physiopathology of the acute phase.

A reference dataset for deformable image registration spatial accuracy evaluation using the COPDgene study archive

Landmark point-pairs provide a strategy to assess deformable image registration (DIR) accuracy in terms of the spatial registration of the underlying anatomy depicted in medical images. In this study, we propose to augment a publicly available database (www.dir-lab.com) of medical images with large sets of manually identified anatomic feature pairs between breath-hold computed tomography (BH-CT) images for DIR spatial accuracy evaluation. Ten BH-CT image pairs were randomly selected from the COPDgene study cases. Each patient had received CT imaging of the entire thorax in the supine position at one-fourth dose normal expiration and maximum effort full dose inspiration. Using dedicated in-house software, an imaging expert manually identified large sets of anatomic feature pairs between images. Estimates of inter- and intra-observer spatial variation in feature localization were determined by repeat measurements of multiple observers over subsets of randomly selected features. 7298 anatomic landmark features were manually paired between the 10 sets of images. Quantity of feature pairs per case ranged from 447 to 1172. Average 3D Euclidean landmark displacements varied substantially among cases, ranging from 12.29 (SD: 6.39) to 30.90 (SD: 14.05) mm. Repeat registration of uniformly sampled subsets of 150 landmarks for each case yielded estimates of observer localization error, which ranged in average from 0.58 (SD: 0.87) to 1.06 (SD: 2.38) mm for each case. The additions to the online web database (www.dir-lab.com) described in this work will broaden the applicability of the reference data, providing a freely available common dataset for targeted critical evaluation of DIR spatial accuracy performance in multiple clinical settings. Estimates of observer variance in feature localization suggest consistent spatial accuracy for all observers across both four-dimensional CT and COPDgene patient cohorts.

Use of 4-dimensional computed tomography-based ventilation imaging to correlate lung dose and function with clinical outcomes

PURPOSE

Four-dimensional computed tomography (4DCT)-based ventilation is an emerging imaging modality that can be used in the thoracic treatment planning process. The clinical benefit of using ventilation images in radiation treatment plans remains to be tested. The purpose of the current work was to test the potential benefit of using ventilation in treatment planning by evaluating whether dose to highly ventilated regions of the lung resulted in increased incidence of clinical toxicity.

METHODS AND MATERIALS

Pretreatment 4DCT data were used to compute pretreatment ventilation images for 96 lung cancer patients. Ventilation images were calculated using 4DCT data, deformable image registration, and a density-change based algorithm. Dose-volume and ventilation-based dose function metrics were computed for each patient. The ability of the dose-volume and ventilation-based dose-function metrics to predict for severe (grade 3+) radiation pneumonitis was assessed using logistic regression analysis, area under the curve (AUC) metrics, and bootstrap methods.

RESULTS

A specific patient example is presented that demonstrates how incorporating ventilation-based functional information can help separate patients with and without toxicity. The logistic regression significance values were all lower for the dose-function metrics (range P=.093-.250) than for their dose-volume equivalents (range, P=.331-.580). The AUC values were all greater for the dose-function metrics (range, 0.569-0.620) than for their dose-volume equivalents (range, 0.500-0.544). Bootstrap results revealed an improvement in model fit using dose-function metrics compared to dose-volume metrics that approached significance (range, P=.118-.155).

CONCLUSIONS

To our knowledge, this is the first study that attempts to correlate lung dose and 4DCT ventilation-based function to thoracic toxicity after radiation therapy. Although the results were not significant at the .05 level, our data suggests that incorporating ventilation-based functional imaging can improve prediction for radiation pneumonitis. We present an important first step toward validating the use of 4DCT-based ventilation imaging in thoracic treatment planning.

Effect of universal MODS access on pulmonary tuberculosis treatment outcomes in new patients in Peru

SETTING

Primary health care centres in Callao, Peru.

OBJECTIVES

To evaluate the effect of universal access to the microscopic-observation drug susceptibility (MODS) assay on treatment outcomes in new and primary multidrug-resistant tuberculosis (MDR-TB) patients and on the process of drug susceptibility testing (DST).

DESIGN

Retrospective review of tuberculosis (TB) registers and clinical records before (2007) and after (2009) the introduction of MODS in 2008.

RESULTS

There were 281 patients in each cohort. Favourable treatment outcomes for 2007 (81%) and 2009 (77%) cohorts were similar. There was an increase in loss to follow-up (from 6% to 10%, P = 0.04) and a reduction in failure rates (from 4% to 0.4%, P = 0.01) in the 2009 compared with the 2007 cohort. In new MDR-TB cases (n = 22), a favourable treatment outcome was improved (from 46% to 82%, P = 0.183) in the 2009 cohort. DST coverage improved (from 24% to 74%, P < 0.001), and a significant reduction in time to diagnosis of drug-susceptible (from 118 to 33 days, P < 0.001) and MDR-TB (from 158 to 52 days, P =30.003) was observed in the 2009 cohort.

CONCLUSION

Universal access to MODS increased DST coverage, reduced the time required to obtain DST results and was associated with reduced failure rates. MODS can make an important contribution to TB management and control in Peru.

The Role of Lung Lobes in Radiation Pneumonitis and Radiation-Induced Inflammation in the Lung: A Retrospective Study

OBJECTIVE

We examined the relative response to radiation of the upper lung lobes (UL) versus lower lung lobes (LL) of normal lung tissue using normalized [¹⁸F]-fluorodeoxyglucose (FDG) uptake per radiation dose received per lung voxel in patients treated with either photons or protons and tested for correlation of the radiation response with clinical pneumonitis.

METHODS

Seventy-five patients (photon (n = 51) or proton (n = 24)) treated for esophageal cancer from November 1, 2003 to May 15, 2011 who received restaging FDG-positron emission tomography (PET) imaging 1 to 3 months after chemoradiation were selected. UL and LL were contoured using the major fissure as the boundary, with the right middle lobe being included in the right UL structure. Pneumonitis toxicity was scored using the Common Terminology Criteria for Adverse Events, version 4.0 based on the consensus of 5 clinicians.

RESULTS

LL had a higher mean dose (15.6 Gy vs. 10.4 Gy, p<0.001), higher mean standard uptake value (SUV) (0.78 vs. 0.56, p=0.001) and SUV in low dose regions (0.80 vs. 0.66 for 10 to 20 Gy, p=0.001), and lower mean dose response (0.015 vs. 0.019, p=0.003) compared to the UL. The mean dose ratio of UL vs. LL (p < 0.001), and SUV in the region of lung receiving 0-10 Gy (p=0.04), but not the dose response ratio of UL vs. LL (p=0.53) correlated with symptomatic pneumonitis.

CONCLUSION

Upper lung lobes had a greater pulmonary metabolic radiation response than lower lung lobes. Greater dose to UL relative to LL and higher SUV in the low dose region (10-20 Gy) on post-treatment PET correlated with symptomatic pneumonitis.