Fractionated stereotactic radiotherapy of intracranial postoperative cavities after resection of brain metastases - Clinical outcome and prognostic factors

Background and Purpose

After surgical resection of brain metastases (BM), radiotherapy (RT) is indicated. Postoperative stereotactic radiosurgery (SRS) reduces the risk of local progression and neurocognitive decline compared to whole brain radiotherapy (WBRT). Aside from the optimal dose and fractionation, little is known about the combination of systemic therapy and postoperative fractionated stereotactic radiotherapy (fSRT), especially regarding tumour control and toxicity.

Methods

In this study, 105 patients receiving postoperative fSRT with 35 Gy in 7 fractions performed with Cyberknife were retrospectively reviewed. Overall survival (OS), local control (LC) and total intracranial brain control (TIBC) were analysed via Kaplan-Meier method. Cox proportional hazards models were used to identify prognostic factors.

Results

Median follow-up was 20.8 months. One-year TIBC was 61.6% and one-year LC was 98.6%. Median OS was 28.7 (95%-CI: 16.9-40.5) months. In total, local progression (median time not reached) occurred in 2.0% and in 20.4% radiation-induced contrast enhancements (RICE) of the cavity (after median of 14.3 months) were diagnosed. Absence of extracranial metastases was identified as an independent prognostic factor for superior OS (p = <0.001) in multivariate analyses, while a higher Karnofsky performance score (KPS) was predictive for longer OS in univariate analysis (p = 0.041). Leptomeningeal disease (LMD) developed in 13% of patients.

Conclusion

FSRT after surgical resection of BM is an effective and safe treatment approach with excellent local control and acceptable toxicity. Further prospective randomized trials are needed to establish standardized therapeutic guidelines.

Instabilität des Kniegelenks – medial oder anteromedial?

Hintergrund

Verletzungen des medialen Bandkomplexes gehören zu den häufigsten Knieverletzungen. Sie heilen zwar meist mit konservativer Therapie problemlos aus, persistierende Instabilitäten erhöhen aber die Belastung der Kreuzbänder und benötigen speziell bei deren Beteiligung eine adäquate Therapie.

Anatomie und Biomechanik

Der mediale Seitenbandkomplex besteht im Wesentlichen aus dem oberflächlichen Seitenband (sMCL), welches der primäre Stabilisator gegen Valgus ist, dem tiefen Seitenband (dMCL) mit dessen schräg verlaufendem ventralem Anteil (AML), die nur sekundäre Stabilisatoren gegen Valgus darstellen, aber primär gegen Außenrotation stabilisieren, und dem hinteren Schrägband (POL), das in vollständiger Streckung gegen Valgus sowie gegen Innenrotation stabilisiert.

Therapie

Chronische Instabilitäten bzw. höhergradige Verletzungen mit Dislokation der Bandstümpfe oder multiligamentäre Verletzungen bedürfen einer operativen Versorgung. Im Akutstadium zeigen Avulsionsverletzungen bei anatomischer Refixation gutes Heilungspotenzial, während bei intraligamentären Verletzungen zusätzlich zur Naht der Bandanteile eine Augmentation mit Sehnenmaterial empfohlen wird. Bei chronischen Instabilitäten ist die Differenzierung des Instabilitätsmusters ausschlaggebend für die Wahl der Rekonstruktionstechnik (reine sMCL-Rekonstruktion oder kombinierte Rekonstruktion von sMCL und AML). In beiden Fällen kommt die hier beschriebene Technik mit flachem Transplantat der Anatomie näher als bei konventionellen Verfahren.

Diskussion

Rekonstruktionstechniken unter Verwendung flacher Sehnentransplantate, die alle betroffenen Bandanteile adressieren, haben sich biomechanisch als sehr effektiv erwiesen, komplexe mediale Instabilitäten suffizient zu behandeln. Ob diese auch klinisch überlegen sind, werden zukünftige klinische Studien zeigen müssen.

Man against machine reloaded: performance of a market-approved convolutional neural network in classifying a broad spectrum of skin lesions in comparison with 96 dermatologists working under less artificial conditions

BACKGROUND

Convolutional neural networks (CNNs) efficiently differentiate skin lesions by image analysis. Studies comparing a market-approved CNN in a broad range of diagnoses to dermatologists working under less artificial conditions are lacking.

MATERIALS AND METHODS

One hundred cases of pigmented/non-pigmented skin cancers and benign lesions were used for a two-level reader study in 96 dermatologists (level I: dermoscopy only; level II: clinical close-up images, dermoscopy, and textual information). Additionally, dermoscopic images were classified by a CNN approved for the European market as a medical device (Moleanalyzer Pro, FotoFinder Systems, Bad Birnbach, Germany). Primary endpoints were the sensitivity and specificity of the CNN's dichotomous classification in comparison with the dermatologists' management decisions. Secondary endpoints included the dermatologists' diagnostic decisions, their performance according to their level of experience, and the CNN's area under the curve (AUC) of receiver operating characteristics (ROC).

RESULTS

The CNN revealed a sensitivity, specificity, and ROC AUC with corresponding 95% confidence intervals (CI) of 95.0% (95% CI 83.5% to 98.6%), 76.7% (95% CI 64.6% to 85.6%), and 0.918 (95% CI 0.866-0.970), respectively. In level I, the dermatologists' management decisions showed a mean sensitivity and specificity of 89.0% (95% CI 87.4% to 90.6%) and 80.7% (95% CI 78.8% to 82.6%). With level II information, the sensitivity significantly improved to 94.1% (95% CI 93.1% to 95.1%; P < 0.001), while the specificity remained unchanged at 80.4% (95% CI 78.4% to 82.4%; P = 0.97). When fixing the CNN's specificity at the mean specificity of the dermatologists' management decision in level II (80.4%), the CNN's sensitivity was almost equal to that of human raters, at 95% (95% CI 83.5% to 98.6%) versus 94.1% (95% CI 93.1% to 95.1%); P = 0.1. In contrast, dermatologists were outperformed by the CNN in their level I management decisions and level I and II diagnostic decisions. More experienced dermatologists frequently surpassed the CNN's performance.

CONCLUSIONS

Under less artificial conditions and in a broader spectrum of diagnoses, the CNN and most dermatologists performed on the same level. Dermatologists are trained to integrate information from a range of sources rendering comparative studies that are solely based on one single case image inadequate.

[Artificial intelligence and smartphone program applications (Apps) : Relevance for dermatological practice]

ADVANTAGES OF ARTIFICIAL INTELLIGENCE (AI)

With responsible, safe and successful use of artificial intelligence (AI), possible advantages in the field of dermato-oncology include the following: (1) medical work can focus on skin cancer patients, (2) patients can be more quickly and effectively treated despite the increasing incidence of skin cancer and the decreasing number of actively working dermatologists and (3) users can learn from the AI results. POTENTIAL DISADVANTAGES AND RISKS OF AI USE: (1) Lack of mutual trust can develop due to the decreased patient-physician contact, (2) additional time effort will be necessary to promptly evaluate the AI-classified benign lesions, (3) lack of adequate medical experience to recognize misclassified AI decisions and (4) recontacting a patient in due time in the case of incorrect AI classifications. Still problematic in the use of AI are the medicolegal situation and remuneration. Apps using AI currently cannot provide sufficient assistance based on clinical images of skin cancer.

REQUIREMENTS AND POSSIBLE USE OF SMARTPHONE PROGRAM APPLICATIONS

Smartphone program applications (apps) can be implemented responsibly when the image quality is good, the patient's history can be entered easily, transmission of the image and results are assured and medicolegal aspects as well as remuneration are clarified. Apps can be used for disease-specific information material and can optimize patient care by using teledermatology.

Dermatofluoroskopie – Ist angeregtes Melanin anregend?

Die Technologie der Dermatofluoroskopie beruht auf einer selektiven Anregung der Melaninfluoreszenz durch stufenweise 2-Photonen-Absorption. Hierbei wird das Melanin in einer Spektralregion angeregt, in der keine andere Hautkomponente absorbiert. Dadurch wird die Melaninfluoreszenz erstmals messbar. Unter Verwendung dieser Technik wird die Läsion Punkt für Punkt abgetastet. Die Fluoreszenzsignale werden dann mithilfe eines auf künstlicher Intelligenz basierten Algorithmus analysiert und das Ergebnis Score-basiert dargestellt. In Studien zeigte die Dermatofluoroskopie eine hohe diagnostische Genauigkeit mit guter Sensitivität und Spezifität. Das Medizinprodukt DermaFC® der Klasse IIa ist seit 2017 CE-zertifiziert und für den Einsatz als Diagnoseunterstützung bei melanozytären melanomverdächtigen Läsionen zugelassen. Nicht geeignet ist die Dermatofluoroskopie bei schwach pigmentierten Läsionen sowie schlecht zugänglichen Lokalisationen.

Kids N Fitness: A Group-based Pediatric Weight Management Curriculum Adapted for a Clinical Care Model

BACKGROUND

The current AAP clinical practice guidelines for the management of pediatric obesity recommend a structured, comprehensive, multi-disciplinary clinical intervention. However, there is a gap in the current literature on standardized curriculums for implementation of such programs. The objective of the present study is to adapt an evidenced-based, family- centered, weekly, weight management curriculum that addresses nutritional, physical activity and behavioral topics for a clinical care model at a tertiary care children's hospital.

METHODS

The curriculum was adapted for use in six individual sessions offered monthly by a multidisciplinary team, including a health educator, physician, dietitian, physical therapist and psychologist. Each provider offered specific feedback and curriculum adaptation based on their specialty. All team members completed training with scheduled treatment fidelity monitoring during implementation. To evaluate the effectiveness of the adapted curriculum, 60 adolescents, ages 14-18 years, with overweight or obesity, and at least one family member, will complete the six month intervention. The primary outcome is mean change in zBMI and %BMIp95 at six month and 18 months. Secondary outcomes include retention, satisfaction, effect on metabolic factors and activity level.

CONCLUSION

There is a paucity of literature on utilizing a standard curriculum in clinical weight management programs. Drawing from evidenced-based curriculum to strengthen clinical care creates an opportunity to improve existing clinical programs and potentially increase access and implementation of the current treatment recommendations for this high risk population.

Diagnostic performance of a deep learning convolutional neural network in the differentiation of combined naevi and melanomas

BACKGROUND

Deep learning convolutional neural networks (CNN) may assist physicians in the diagnosis of melanoma. The capacity of a CNN to differentiate melanomas from combined naevi, the latter representing well-known melanoma simulators, has not been investigated.

OBJECTIVE

To assess the diagnostic performance of a CNN when used to differentiate melanomas from combined naevi in comparison with dermatologists.

METHODS

In this study, a CNN with regulatory approval for the European market (Moleanalyzer-Pro, FotoFinder Systems GmbH, Bad Birnbach, Germany) was used. We attained a dichotomous classification (benign, malignant) in dermoscopic images of 36 combined naevi and 36 melanomas with a mean Breslow thickness of 1.3 mm. Primary outcome measures were the CNN's sensitivity, specificity and the diagnostic odds ratio (DOR) in comparison with 11 dermatologists with different levels of experience.

RESULTS

The CNN revealed a sensitivity, specificity and DOR of 97.1% (95% CI [82.7-99.6]), 78.8% (95% CI [62.8-89.1.3]) and 34 (95% CI [4.8-239]), respectively. Dermatologists showed a lower mean sensitivity, specificity and DOR of 90.6% (95% CI [84.1-94.7]; P = 0.092), 71.0% (95% CI [62.6-78.1]; P = 0.256) and 24 (95% CI [11.6-48.4]; P = 0.1114). Under the assumption that dermatologists use the CNN to verify their (initial) melanoma diagnosis, dermatologists achieve an increased specificity of 90.3% (95% CI [79.8-95.6]) at an almost unchanged sensitivity. The largest benefit was observed in 'beginners', who performed worst without CNN verification (DOR = 12) but best with CNN verification (DOR = 98).

CONCLUSION

The tested CNN more accurately classified combined naevi and melanomas in comparison with trained dermatologists. Their diagnostic performance could be improved if the CNN was used to confirm/overrule an initial melanoma diagnosis. Application of a CNN may therefore be of benefit to clinicians.

Man against machine: diagnostic performance of a deep learning convolutional neural network for dermoscopic melanoma recognition in comparison to 58 dermatologists

Background

Deep learning convolutional neural networks (CNN) may facilitate melanoma detection, but data comparing a CNN's diagnostic performance to larger groups of dermatologists are lacking.

Methods

Google's Inception v4 CNN architecture was trained and validated using dermoscopic images and corresponding diagnoses. In a comparative cross-sectional reader study a 100-image test-set was used (level-I: dermoscopy only; level-II: dermoscopy plus clinical information and images). Main outcome measures were sensitivity, specificity and area under the curve (AUC) of receiver operating characteristics (ROC) for diagnostic classification (dichotomous) of lesions by the CNN versus an international group of 58 dermatologists during level-I or -II of the reader study. Secondary end points included the dermatologists' diagnostic performance in their management decisions and differences in the diagnostic performance of dermatologists during level-I and -II of the reader study. Additionally, the CNN's performance was compared with the top-five algorithms of the 2016 International Symposium on Biomedical Imaging (ISBI) challenge.

Results

In level-I dermatologists achieved a mean (±standard deviation) sensitivity and specificity for lesion classification of 86.6% (±9.3%) and 71.3% (±11.2%), respectively. More clinical information (level-II) improved the sensitivity to 88.9% (±9.6%, P = 0.19) and specificity to 75.7% (±11.7%, P < 0.05). The CNN ROC curve revealed a higher specificity of 82.5% when compared with dermatologists in level-I (71.3%, P < 0.01) and level-II (75.7%, P < 0.01) at their sensitivities of 86.6% and 88.9%, respectively. The CNN ROC AUC was greater than the mean ROC area of dermatologists (0.86 versus 0.79, P < 0.01). The CNN scored results close to the top three algorithms of the ISBI 2016 challenge.

Conclusions

For the first time we compared a CNN's diagnostic performance with a large international group of 58 dermatologists, including 30 experts. Most dermatologists were outperformed by the CNN. Irrespective of any physicians' experience, they may benefit from assistance by a CNN's image classification.

Clinical trial number

This study was registered at the German Clinical Trial Register (DRKS-Study-ID: DRKS00013570; https://www.drks.de/drks_web/).

Erratum: First Dark Matter Constraints from a SuperCDMS Single-Charge Sensitive Detector [Phys. Rev. Lett. 121, 051301 (2018)]

This corrects the article DOI: 10.1103/PhysRevLett.121.051301.

An addiction model-based mobile health weight loss intervention in adolescents with obesity

BACKGROUND

Clinical approaches to treating childhood obesity can be expensive and poorly reimbursed, and often produce suboptimal results. It has been theorized that overeating may have addictive qualities, and a sizable number of adolescents with obesity endorse addictive habits. Interestingly, few weight management interventions have tested techniques founded in addiction medicine principles. We therefore performed a pilot study of an addiction model based mHealth weight loss intervention in adolescents.

METHODS

Adolescents with obesity were recruited from an multidisciplinary weight management clinic (EMPOWER). Adolescents without significant obesity comorbidities, who exhibited signs of addictive eating, based on the Yale Food Addiction Scale, were enrolled in a pilot study of an interactive, addiction-based, weight loss smartphone app with coaching (http://clinicaltrials.gov: NCT02689154). The app was designed to help subjects omit problem foods, avoid snacking and reduce meal size. A contemporary cohort of adolescents who completed the EMPOWER program were evaluated. Feasibility of recruitment, adherence, retention rates, BMI change and cost of intervention were examined.

RESULTS

Eighteen participants were recruited to app intervention. App participants had higher retention (100% vs. 37%) and lower total cost per patient ($855.15 vs. $1428.00) than the EMPOWER clinic participants. App participants exhibited a significant decrease in zBMI and %BMIp95 over the 6 months (p < 0.001 and p = 0.001), which was comparable to the age-matched EMPOWER program completers (p = 0.31 and p = 0.06).

CONCLUSIONS

An addiction medicine-based mHealth intervention targeted for adolescents was feasible to implement, resulted in high retention and adherence rates, and reduced zBMI and %BMIp95 in a more cost-effective manner than an in-clinic intervention.

Energy Management for Personalized Weight Reduction (EMPOWER) Program: Three-Year Outcome Data

BACKGROUND

The current consensus guidelines for management of pediatric obesity recommend clinic-based, family-centered, multi-disciplinary interventions. It is well reported that these programs often only lead to modest improvements in BMI status. The individual factors that differentiate which patient's BMI status will improve vs. worsen remains understudied. A retrospective cohort study was conducted to evaluate the outcomes of EMPOWER clinic and identify the participant specific characteristics that predicted BMI status improvement in this population.

METHODS

Youth who completed at least 6 visits in EMPOWER were included. Paired t-test was utilized to evaluate the mean change in zBMI, modified BMIz and %BMI_p95 from baseline to 6^th visit, and multivariate mixed effect models were utilized to analyze effect of baseline characteristics on change in BMI status.

RESULTS

92 participants were included in the analysis, 87% with severe obesity and 66% Hispanic. At the 6^th visit, there was a significant reduction in zBMI (-0.09 SD, p <0.001) and modified BMIz (-0.0003 SD, p = 0.04) with a small reduction in %BMI_p95 (-1.15 %, p = 0.20). Lower BMI status (p < 0.001) and absence of a comorbidity (p < 0.05) at baseline were predictors of BMI status improvement whereas age, gender, ethnicity, family history of obesity and insurance status were not significant predictors.

CONCLUSIONS

Given that implementation of the current guidelines for management of obesity in pediatrics only results in modest BMI status reduction, further investigation is required to understand how the determinants of obesity-related health outcomes can guide development of more innovative, effective interventions for this high risk population.

First Dark Matter Constraints from a SuperCDMS Single-Charge Sensitive Detector

We present the first limits on inelastic electron-scattering dark matter and dark photon absorption using a prototype SuperCDMS detector having a charge resolution of 0.1 electron-hole pairs (CDMS HVeV, a 0.93 g CDMS high-voltage device). These electron-recoil limits significantly improve experimental constraints on dark matter particles with masses as low as 1  MeV/c^{2}. We demonstrate a sensitivity to dark photons competitive with other leading approaches but using substantially less exposure (0.49 g d). These results demonstrate the scientific potential of phonon-mediated semiconductor detectors that are sensitive to single electronic excitations.

Diagnostic accuracy of dermatofluoroscopy in cutaneous melanoma detection: results of a prospective multicentre clinical study in 476 pigmented lesions

BACKGROUND

Early detection is a key factor in improving survival from melanoma. Today, the clinical diagnosis of cutaneous melanoma is based mostly on visual inspection and dermoscopy. Preclinical studies in freshly excised or paraffin-embedded tissue have shown that the melanin fluorescence spectra after stepwise two-photon excitation, a process termed dermatofluoroscopy, differ between cutaneous melanoma and melanocytic naevi. However, confirmation from a larger prospective clinical study is lacking.

OBJECTIVES

The primary end point of this study was to determine the diagnostic accuracy of dermatofluoroscopy in melanoma detection. Secondary end points included the collection of data for improving the computer algorithm that classifies skin lesions based on melanin fluorescence and the assessment of safety aspects.

METHODS

This was a prospective, blinded, multicentre clinical study in patients with pigmented skin lesions (PSLs) indicated for excision either to rule out or to confirm cutaneous melanoma. All included lesions underwent dermoscopy and dermatofluoroscopy in vivo before lesions were excised and subjected to histopathological examination.

RESULTS

In total, 369 patients and 476 PSLs were included in the final analysis. In 101 of 476 lesions (21·2%) histopathology revealed melanoma. The observed sensitivity of dermatofluoroscopy was 89·1% (90 of 101 melanomas identified), with an observed specificity of 44·8%. The positive and negative predictive values were 30·3% and 93·9%, respectively. No adverse events occurred.

CONCLUSIONS

Dermatofluoroscopy is a safe and accurate diagnostic method to aid physicians in diagnosing cutaneous melanoma. Limitations arise from largely amelanotic or regressing lesions lacking sufficient melanin fluorescence.

7q11.23 microduplication syndrome: neurophysiological and neuroradiological insights into a rare chromosomal disorder

BACKGROUND

The phenotypical consequence of the heterozygous chromosome 7q11.23 interstitial microdeletion is the Williams-Beuren syndrome, a very well-known genetic multi-systemic disorder. Much less is known about the reverse condition, the heterozygous interstitial microduplication of 7q11.23 region. The first molecular cytogenetic description was published in 2005, and only after several years were the reported patients numerous enough to attempt a description of a common phenotype.

METHOD

By using a broad multidisciplinary approach, we investigated 12 patients with this rare genetic anomaly. Ten of them harboured the duplication of the classical Williams-Beuren syndrome region and two a slightly larger duplication. Upon a detailed description of the clinical and psychological features, we used electroencephalography and magnetic resonance imaging to explore neurophysiological function and brain structures.

RESULTS

We analysed the clinical, psychological, neuroradiological and neurophysiological features of 12 yet-unpublished individuals affected by this rare genetic anomaly, focusing specifically on the last two aspects. Several structural abnormalities of the central nervous system were detected, like ventriculomegaly, hypotrophic cerebellum, hypotrophic corpus callosum and hypoplastic temporal lobes. Although only one of 12 individuals suffered from seizures during childhood, three others had abnormal electroencephalography findings prominent in the anterior brain regions, without any visible seizures to date.

CONCLUSION

Taken together, we enlarged the yet-underrepresented cohort in the literature of patients affected by 7q11.23 microduplication syndrome and shed further light on neuroradiological and neurophysiological aspects of this rare genetic syndrome.

Intra- and interobserver variability of image-based PASI assessments in 120 patients suffering from plaque-type psoriasis

BACKGROUND

The Psoriasis Area and Severity Index (PASI) is the standard for psoriasis severity assessment. However, PASI measurement is complex and subjective, frequently leading to a high intra- and interobserver variability. To date, the precise extent of variability in PASI measurements and its underlying causes remain unknown.

OBJECTIVE

To determine the inter- and intrarater variability of image-based PASI measurements by calculating Intra-Class-Correlation-Coefficients (ICCs) and to investigate the impact of the different PASI components and specific anatomic regions on the extent of variability.

METHODS

First, the methodology of 'image-based' vs. commonly used 'live' PASI measurements was validated in a pilot study. Next, in an observational cohort study, PASI scores of 120 patients affected by plaque psoriasis were prospectively evaluated by three formally trained physicians by means of total body images (TBI). Each observer independently performed two rounds of image-based PASI calculations in all patients at two different time points.

RESULTS

Overall, 720 image-based PASI scores were calculated with a mean PASI of 8.8 (range 0.7-34.8). An interrater variability with an ICC of 0.895 and mean absolute difference (MAD) of 3.3 PASI points were observed. Intrarater variability showed a mean ICC of 0.877 and a MAD of 2.2 points. When considering specific PASI components, the highest agreement was found for the assessment of the involved body surface area (BSA), while the lowest ICCs were calculated for severity scoring of 'scaling' and 'induration'. As BSA scores serve as a multiplier in the calculation of PASI, minor inaccuracies were capable of inducing a large share of variability.

CONCLUSION

The overall inter- and intrarater reliability of image-based PASI measurements in this study was good. However, physicians were formally trained and experienced, which frequently is not the case in a real-life clinical setting. Therefore, new strategies for higher standardization and objectivity of PASI calculations are needed.

Non-invasive tools for the diagnosis of cutaneous melanoma

BACKGROUND

While the excisional biopsy and histological examination of suspicious lesions remains the current gold standard for diagnosing cutaneous melanoma (CM), there is a demand for more objective and non-invasive examination methods that may support clinicians in their decision when to biopsy or not.

METHODS

This review is based on publications and guidelines retrieved by a selective search in PubMed and MEDLINE and focused on non-invasive diagnostic strategies for detecting melanoma.

RESULTS

Ten different non-invasive techniques were compared with regard to applicability, status of development, and resources necessary for introduction into clinical routine (dermoscopy, sequential digital dermoscopy, total body photography, computer-aided multispectral digital analysis, electrical impedance spectroscopy, Raman spectroscopy, reflectance confocal microscopy, multiphoton tomography, stepwise two-photon-laser spectroscopy, quantitative dynamic infrared imaging). In an effort to create a classification based on our analyses, we suggest to differentiate i) tools for screening of patients in daily clinical routine, ii) tools for examination of a restricted number of preselected lesions that produce an automated diagnostic score, iii) tools for examination of a restricted number of preselected lesions at specialized centers requiring extensive training, iv) devices at an experimental stage of development.

CONCLUSION

None of the discussed examination techniques is able to provide a definite and final diagnosis or to completely replace the histopathological examination. Up to date, the need for fully automated devices offering a complete skin cancer screening has not been satisfied.

Melanomas vs. nevi in high-risk patients under long-term monitoring with digital dermatoscopy: do melanomas and nevi already differ at baseline?

BACKGROUND

What lesions to select for a most efficient dermatoscopic monitoring of patients with multiple nevi remains an unresolved issue.

OBJECTIVE

To compare the grade of atypia of melanomas and nevi of the same patient at baseline.

METHODS

Prospective observational study using 236 dermatoscopic baseline images (59 quartets from 59 patients, each including one melanoma detected during follow-up and three nevi). Dermatologists (n = 26) were asked to assess the 'grade of dermatoscopic atypia' on a numerical scale and to identify the melanomas.

RESULTS

On average, each dermatologist identified 24 of 59 melanomas (40%, range: 11-37). The number of correct picks was greater for dermatologists with moderate (mean: 28) or high (mean: 28) experience compared to beginners (mean 17; P < 0.001). In three of the 59 sets, none of the 26 dermatologists identified the melanoma. The mean grade of dermatoscopic atypia was 2.5 for nevi (95% CI: 2.4-2.6) and 3.0 for melanomas (95% CI: 2.9-3.1, P < 0.001).

LIMITATIONS

Rating dermatologists were informed that each quartet of images included one melanoma creating substantial deviation from a real-life situation.

CONCLUSION

A significant proportion of melanomas detected during follow-up cannot be differentiated from nevi at baseline. This necessitates the additional inclusion of less atypical lesions for monitoring.

Pain management in photodynamic therapy using a nitrous oxide/oxygen mixture: a prospective, within-patient, controlled clinical trial

BACKGROUND

Photodynamic therapy is an effective treatment for actinic keratoses. Nevertheless, severe pain during the procedure is a serious adverse effect, which leads to interruption or even termination. Complete pain relief remains a difficult challenge.

OBJECTIVE

To evaluate the effect of a nitrous oxide/oxygen mixture on pain intensity during photodynamic therapy.

METHODS

This clinical trial has been designed as a prospective, single-centre, explorative, controlled, observational study.

RESULTS

We were able to detect a significant overall pain reduction of 55.2% after application of a nitrous oxide/oxygen mixture by means of an intra-individual comparison. Furthermore, the total number of therapy interruption significantly decreased by 82% after the inhalation analgesia. Additionally, treatment satisfaction ranged from 'extremely to very satisfied'.

CONCLUSIONS

This study shows that analgesia by means of a nitrous oxide/oxygen mixture is a very effective and well-tolerated method for achieving significant pain reduction during photodynamic therapy.

[Impact of Self-Reported Fatigue on ACL Injuries in Alpine Skiing: A Sex Comparison]

INTRODUCTION

In recreational alpine skiing, about one third of all injuries affect the knee joint, and the most common diagnosis in adult male and female skiers is a tear of the anterior cruciate ligament (ACL), which makes up 15 - 21 % of all injuries. General preventive recommendations to reduce the incidence of ski injuries include avoiding fatigue. However, it seems unclear to what extent ACL injuries in male and female recreational skiers are related to perceived fatigue.

METHODS

This study was conducted as a prospective questionnaire-based investigation in two Austrian ski injury clinics during the five winter seasons between 2009/2010 and 2013/2014. In total, 588 skiers (67.9 % females) with a mean age of 42.1 ± 10.9 years were interviewed about demographics, skiing ability, skiing behaviour, fitness, day and time of accident, skiing duration and perceived fatigue at the moment of accident.

RESULTS

ACL injured males reported a significantly higher skiing ability and fitness level as well as a more risky behaviour on ski slopes compared to females. About one third of males and females injured their ACL within the first day of the ski trip and about 57 % within the first two days, with no sex differences. However, a significantly higher number of female skiers sustained an ACL injury during the first hour of skiing (28 vs. 17 %) as well as during the first two hours of skiing compared to males (52 vs. 44 %). About 81 % of males and females felt no fatigue or just a trace of fatigue in their legs at the time of accident, with no sex differences.

CONCLUSION

Based on the findings of this study, fatigue does not seem to be a major risk factor for an ACL injury among male and female recreational skiers.

LungTech, an EORTC Phase II trial of stereotactic body radiotherapy for centrally located lung tumours: a clinical perspective

Evidence supports stereotactic body radiotherapy (SBRT) as a curative treatment option for inoperable early stage non-small-cell lung cancer (NSCLC) resulting in high rates of tumour control and low risk of toxicity. However, promising results are mainly derived from SBRT of peripheral pulmonary lesions, whereas SBRT for the central tumours can lead to severe radiation sequelae owing to the spatial proximity to the serial organs at risk. Robust data on the tolerance of mediastinal structures to high-dose hypofractionated radiation are limited; furthermore, there are many open questions regarding the efficiency, safety and response assessment of SBRT in inoperable, centrally located early stage NSCLC, which are addressed in a prospective multicentre study [sponsored by the European Organization for Research and Treatment of Cancer (EORTC 22113-08113-LungTech)]. In this review, we summarize the current status regarding SBRT for centrally located early stage NSCLC that leads to the rationale of the LungTech trial. Outline and some essential features of the study with focus on a summary of current experiences in dose/fraction-toxicity coherences after SBRT to the mediastinal structures that lead to LungTech normal tissue constraints are provided.

Alpine Skiing With total knee ArthroPlasty (ASWAP): effect on tendon properties

The aim of this study was to investigate the effect of alpine skiing on patellar tendon properties in patients with total knee arthroplasty (TKA). Thirty-one adults (70.4 ± 4.7 years) with unilateral TKA were recruited 2.7 ± 0.9 years after surgery and assigned to an intervention (IG) or a control group (CG). The IG underwent a 12-week guided skiing program. Tendon stiffness, Young's modulus, and cross-sectional area (CSA) were measured before and after the intervention. In both groups, mean tendon CSA was 28% (P < 0.001) larger in the operated (OP) than in the non-operated (NOP) leg at baseline, without any difference in other tendon properties. After training, stiffness increased in the IG by 5.8% and 15.8%, respectively, in the OP and NOP legs. Likewise, mean CSA increased in the IG by 2.9% in the OP and 3.8% in the NOP leg, whereas no significant changes were found for the Young's modulus. None of the tendon parameters changed in the CG. Results indicate that patellar tendon structure and/or loading pattern are altered following TKA, but this tissue seems to retain its adaptation capacity. Further, alpine skiing appears to offer a suitable rehabilitation strategy for TKA patients.

Functional assessments for decision-making regarding return to sports following ACL reconstruction. Part II: clinical application of a new test battery

PURPOSE

The purpose of this study was to utilize a novel functional test system to facilitate determining the time of return to sports following ACL reconstruction.

METHODS

Sixty-nine patients with unilateral ACL reconstruction were included in this pilot study. All the patients performed a standardized test battery consisting of one- and two-legged stability tests, counter movement jumps, speedy jumps, plyometric jumps and a quick feed test. The first test was administered on average 170.7 ± 75.1 days post-operatively, and the retest was administered on average 239.1 ± 79.7 days post-operatively. The values of the subtests were compared with the normative data of healthy gender- and age-matched controls to determine the functional capacities of patients following ACL reconstruction.

RESULTS

After the first and second test, 15.9 and 17.4 % of the patients met the criteria for a "return to non-competitive sports". One patient fulfilled the criteria for a "return to competitive sports" after the second test battery. The most limiting factor was a poor LSI value of <90 % if the dominant leg was involved and <80 % if the non-dominant leg was involved.

CONCLUSION

This test battery demonstrates that, in terms of neuromuscular abilities, most patients, compared to healthy controls, are most likely not ready for a safe return to sports, even 8 months post-operatively. This should be considered in the future to determine when it is safe to return to sports and should avoid a premature return to competitive sports.

LEVEL OF EVIDENCE

III.

Incisional hernia rate 3 years after midline laparotomy

BACKGROUND

Incisional hernia is the most frequent long-term complication after visceral surgery, with an incidence of between 9 and 20 per cent 1 year after operation. Most controlled studies provide only short-term follow-up, and the actual incidence remains unclear. This study evaluated the incidence of incisional hernia up to 3 years after midline laparotomy in two prospective trials.

METHODS

Three-year follow-up data from the ISSAAC (prospective, multicentre, historically controlled) and INSECT (randomized, controlled, multicentre) trials focused on the rate of incisional hernia 1 and 3 years after surgery. Differences between the two groups were compared using t tests for continuous data and the χ2 test for categorical data.

RESULTS

Analysis of 775 patients included in the two trials suggested that the incisional hernia rate increased significantly from 12.6 per cent at 1 year to 22.4 per cent 3 years after surgery (P < 0.001), a relative increase of more than 60 per cent.

CONCLUSION

This follow-up of two trials demonstrated that 1 year of clinical follow-up for detection of incisional hernia is not sufficient; follow-up for at least 3 years should be mandatory in any study evaluating the rate of postoperative incisional hernia after midline laparotomy.

Whole-body CT for lymphoma staging: feasibility of halving radiation dose and risk by iterative image reconstruction

OBJECTIVES

Patients with lymphoma are at higher-risk of secondary malignancies mainly due to effects of cancer therapy as well as frequent radiological surveillance. We thus aimed to investigate the objective and subjective image quality as well as radiation exposure and risk of full-dose standard (FDS), full-dose iterative (FDI), and half-dose iterative (HDI) image reconstruction in patients with lymphoma.

MATERIAL AND METHODS

In 100 lymphoma patients, contrast-enhanced whole-body staging was performed on a dual-source CT. To acquire full-dose and half-dose CT data simultaneously, the total current-time product was equally distributed on both tubes operating at 120 kV. HDI reconstructions were calculated by using only data from one tube. Quantitative image quality was assessed by measuring image noise in different tissues of the neck, thorax, and abdomen. Overall diagnostic image quality was assessed using a 5-point Likert scale. Radiation doses and risks were estimated for a male and female reference person.

RESULTS

For all anatomical regions apart from the lungs image noise was significantly lower and the overall subjective image quality significantly better when using FDI and HDI instead of FDS reconstruction (p<0.05). For the half-dose protocol, the risk to develop a radiation-induced cancer was estimated to be less than 0.11/0.19% for an adult male/female.

CONCLUSIONS

Image quality of FDI and more importantly of HDI is superior to FDS reconstruction, thus enabling to halve radiation dose and risk to lymphoma patients.