Shortening the preparation time of the single prolonged breath-hold for radiotherapy sessions

Objective: Single prolonged breath-holds of >5 min can be obtained in cancer patients. Currently, however, the preparation time in each radiotherapy session is a practical limitation for clinical adoption of this new technique. Here, we show by how much our original preparation time can be shortened without unduly compromising breath-hold duration. Methods: 44 healthy subjects performed single prolonged breath-holds from 60% O2 and mechanically induced hypocapnia. We tested the effect on breath-hold duration of shortening preparation time (the durations of acclimatization, hyperventilation and hypocapnia) by changing these durations and or ventilator settings. Results: Mean original breath-hold duration was 6.5 ± 0.2 (standard error) min. The total original preparation time (from connecting the facemask to the start of the breath-hold) was 26 ± 1 min. After shortening the hypocapnia duration from 16 to 5 min, mean breath-hold duration was still 6.1 ± 0.2 min (ns vs the original). After abolishing the acclimatization and shortening the hypocapnia to 1 min (a total preparation time now of 9 ± 1 min), a mean breath-hold duration of >5 min was still possible (now significantly shortened to 5.2 ± 0.6 min, p < 0.001). After shorter and more vigorous hyperventilation (lasting 2.7 ± 0.3 min) and shorter hypocapnia (lasting 43 ± 4 s), a mean breath-hold duration of >5 min (5.3 ± 0.2 min, p < 0.05) was still possible. Here, the final total preparation time was 3.5 ± 0.3 min. Conclusions: These improvements may facilitate adoption of the single prolonged breath-hold for a range of thoracic and abdominal radiotherapies especially involving hypofractionation. Advances in knowledge: Multiple short breath-holds improve radiotherapy for thoracic and abdominal cancers. Further improvement may occur by adopting the single prolonged breath-hold of >5 min. One limitation to clinical adoption is its long preparation time. We show here how to reduce the mean preparation time from 26 to 3.5 min without compromising breath-hold duration

Safely achieving single prolonged breath-holds of > 5 minutes for radiotherapy in the prone, front crawl position

Objective: Breast cancer radiotherapy is increasingly delivered supine with multiple, short breath-holds. There may be heart and lung sparing advantages for locoregional breast cancer of both prone treatment and in a single breath-hold. We test here whether single prolonged breath-holds are possible in the prone, front crawl position. Methods: 19 healthy volunteers were trained to deliver supine, single prolonged breath-holds with pre-oxygenation and hypocapnia. We tested whether all could achieve the same durations in the prone, front crawl position. Results: 19 healthy volunteers achieved supine, single prolonged breath-holds for mean of 6.2 ± 0.3 min. All were able to hold safely for the same duration while prone (6.1 ± 0.2 min ns. by paired ANOVA). With prone, the increased weight on the chest did not impede chest inflation, nor the ability to hold air in the chest. Thus, the rate of chest deflation (mean anteroposterior deflation movement of three craniocaudally arranged surface markers on the spinal cord) was the same (1.2 ± 0.2, 2.0 ± 0.4 and 1.2 ± 0.4 mm/min) as found previously during supine prolonged breath-holds. No leakage of carbon dioxide or air was detectable into the facemask. Conclusion: Single prolonged (>5 min) breath-holds are equally possible in the prone, front crawl position. Advances in knowledge: Prolonged breath-holds in the front crawl position are possible and have the same durations as in the supine position. Such training would therefore be feasible for some patients with breast cancer requiring loco-regional irradiation. It would have obvious advantages for hypofractionation.

Conditioned Variation in Heart Rate During Static Breath-Holds in the Bottlenose Dolphin (Tursiops truncatus)

Previous reports suggested the existence of direct somatic motor control over heart rate (fH) responses during diving in some marine mammals, as the result of a cognitive and/or learning process rather than being a reflexive response. This would be beneficial for O2 storage management, but would also allow ventilation-perfusion matching for selective gas exchange, where O2 and CO2 can be exchanged with minimal exchange of N2. Such a mechanism explains how air breathing marine vertebrates avoid diving related gas bubble formation during repeated dives, and how stress could interrupt this mechanism and cause excessive N2 exchange. To investigate the conditioned response, we measured the fH-response before and during static breath-holds in three bottlenose dolphins (Tursiops truncatus) when shown a visual symbol to perform either a long (LONG) or short (SHORT) breath-hold, or during a spontaneous breath-hold without a symbol (NS). The average fH (ifHstart), and the rate of change in fH (difH/dt) during the first 20 s of the breath-hold differed between breath-hold types. In addition, the minimum instantaneous fH (ifHmin), and the average instantaneous fH during the last 10 s (ifHend) also differed between breath-hold types. The difH/dt was greater, and the ifHstart, ifHmin, and ifHend were lower during a LONG as compared with either a SHORT, or an NS breath-hold (P &lt; 0.05). Even though the NS breath-hold dives were longer in duration as compared with SHORT breath-hold dives, the difH/dt was greater and the ifHstart, ifHmin, and ifHend were lower during the latter (P &lt; 0.05). In addition, when the dolphin determined the breath-hold duration (NS), the fH was more variable within and between individuals and trials, suggesting a conditioned capacity to adjust the fH-response. These results suggest that dolphins have the capacity to selectively alter the fH-response during diving and provide evidence for significant cardiovascular plasticity in dolphins.

Investigation of the BOLD-Based MRI Signal Time Course During Short Breath-Hold Periods for Estimation of the Cerebrovascular Reactivity

For the prognosis of stroke, patients with moyamoya disease (MMD) require the estimation of remaining cerebrovascular reactivity. For this purpose, CO2-triggered BOLD fMRI by use of short breath-hold periods seems to be a highly available alternative to nuclear medicine methods. Too long breath-hold periods are difficult to perform, too short breath-hold periods do not lead to sufficient BOLD signal changes. We aimed to investigate the required minimum breath-hold duration to detect distinct BOLD signals in the tissue of healthy subjects to find out how long the minimum breath-hold duration in clinical diagnostics of MMD should be. A prospective study was performed. Fourteen healthy subjects underwent fMRI during end-expiration breath-hold periods of different duration (3, 6, 9, and 12 s). Additionally, we compared the influence of paced and self-paced breathing altering the breath-hold periods. Data of a patient with MMD was evaluated to investigate whether the tested procedure is suitable for clinical use. Significant global BOLD signal increases were detected after breath-hold periods of 6, 9, and 12 s. The signals were significantly higher after breath-hold periods of 9 s than after 6 s, while not when the duration was extended from 9 to 12 s. Furthermore, we found additional BOLD signal changes before the expected signal increases, which could be avoided by paced respiratory instructions. This investigation indicates that end-expiration breath-hold period of at least 9 s might be used to measure the cerebrovascular reactivity. This time period resulted in distinct BOLD signal changes and could be performed easily.

Magnetic resonance cholangiopancreatography with compressed sensing at 1.5 T: clinical application for the evaluation of branch duct IPMN of the pancreas

Objectives To evaluate magnetic resonance cholangiopancreatography (MRCP) with compressed sensing (CS) for the assessment of branch duct intraductal papillary mucinous neoplasm (BD-IPMN) of the pancreas. For this purpose, conventional navigator-triggered (NT) sampling perfection with application-optimized contrast using different flip angle evolutions (SPACE) MRCP was compared with various CS-SPACE-MRCP sequences in a clinical setting. Methods A total of 41 patients (14 male, 27 female, mean age 68 years) underwent 1.5-T MRCP for the evaluation of BD-IPMN. The MRCP protocol consisted of the following sequences: conventional NT-SPACE-MRCP, CS-SPACE-MRCP with long (BHL, 17 s) and short single breath-hold (BHS, 8 s), and NT-CS-SPACE-MRCP. Two board-certified radiologists evaluated image quality, duct sharpness, duct visualization, lesion conspicuity, confidence, and communication with the main pancreatic duct in consensus using a 5-point scale (1–5), with higher scores indicating better quality/delineation/confidence. Maximum intensity projection reconstructions and originally acquired data were used for evaluation. Wilcoxon signed-rank test was used to compare the intra-individual difference between sequences. Results BHS-CS-SPACE-MRCP had the highest scores for image quality (3.85 ± 0.79), duct sharpness (3.81 ± 1.05), and duct visualization (3.81 ± 1.01). There was a significant difference compared with NT-CS-SPACE-MRCP (p < 0.05) but no significant difference to the standard NT-SPACE-MRCP (p > 0.05). Concerning diagnostic quality, BHS-CS-SPACE-MRCP had the highest scores in lesion conspicuity (3.95 ± 0.92), confidence (4.12 ± 1.08), and communication (3.8 ± 1.06), significantly higher compared with NT-SPACE-MRCP, BHL-SPACE-MRCP, and NT-CS-SPACE-MRCP (p = <0.05). Conclusions MRCP with CS 3D SPACE for the evaluation of BD-IPMN at 1.5 T provides the best results using a short breath-hold sequence. This approach is feasible and an excellent alternative to standard NT 3D MRCP sequences. Key Points • 1.5-T MRCP with compressed sensing for the evaluation of branch duct IPMN is a feasible method. • Short breath-hold sequences provide the best results for this purpose.

The iatrogenic elevation of neutrophils possibly aggravates lung injury after COVID-19 infection: A case report

Background: Coronavirus disease-2019 (COVID-19) caused by SARS-CoV-2 is a rapidly escalating epidemic in most of countries. Symptom of COVID-19 usually present as the normal or decrease of leucocytes and the decrease of lymphocytes, which may be the body’s response for SARS-CoV-2 infection. However, it is unknown that whether rising leukocytes, especially neutrophils, will aggravate lung injury in COVID-19. Here we report a case of aggravated lung injury induced by rising neutrophils with the usage of recombinant human granulocyte stimulating factor (GSF) for the first time.Case presentation: A patient aged 46 years old was infected with SARS-CoV-2 without hypoxemia on admission, but his leucocytes decreased gradually after admission. After following injected with recombinant human granulocyte stimulating factor(GSF) 150 μg , the absolute value of leucocytes reached to 32.81×109 /L, and neutrophils were 31.57×109/L. Then, the patient’s condition deteriorated rapidly and he appeared a series of symptoms, such as short breath, hemoptysis, hypoxemia, increased range of lung lesions and secondary acute respiratory distress syndrome (ARDS). However, those symptoms were alleviated and leucocytes recover to normal level gradually after stopping recombinant human GSF treatment. Eventually, Re-examination of CT showed that lung lesions were absorbed significantly and he was cured and discharged from hospital.Conclusion: This case report showed that iatrogenic increase of leucocytes (especially neutrophils) may worsen lung injury and leucocyte increasing agents were used with caution in the early stage of COVID-19 patients. At the same time, the phenomenon remains to be further confirmed in the future study.

A Quarter of a Century of Czech Political History: Stability through "Cautious" Nanopolitics

The key events of the 25-year political history of the Czech Republic are considered: the 1998 Opposition Agreement between the two leading forces – the Civic Democratic Party (ODS) and the Czech Social Democratic Party (CSDP); the emergence of ANO 2011 (Action of Dissatisfied Citizens); the Patent of Tolerance concluded in 2018 between the ANO 2011 and the Communist Party of Bohemia and Moravia. The concept of "nanopolitics" is introduced to designate domestic and foreign policy actions which make minor moves with major implications for the country's political course and attract international attention. The local short breath policy associated with these actions might have long-term consequences, including global ones. The demolition in April 2020 in Prague of the monument to its liberator Marshal Ivan Konev is one of the examples of this kind of policy.

Analysis of Dust and NO2 Level in the Ambient Air and Sweeper’s Respiratory Complaints in Purabaya Bus Station Sidoarjo

The air pollution can be impact for people’s health who doing an activity in bus station. The study aims to analyze the levels of dust and NO2 in ambient air and the sweeper’s respiratory complaints in Purabaya’s Bus Station. This was a observational study with cross sectional design. The population are 34 subjects that was all sweepers in Purabaya’s Bus Station using purposive sampling. Measurements of dust and NO2 level in the Bus Station’s arrival and departure in the morning, afternoon, and evening. The variables in this study are the dust and NO2 level, individual charactheristics are age, length of work in a day, work period over the years, use Personal Protective Equipment (masks), and respiratory complaints such us cough, phelgm, shor t breath, and fast breath. Data were analyzed descriptively. The results indicate that dust and NO2 level was high and inappropriate the standard of Peraturan Gubernur Jawa Timur No. 10 tahun 2009 with an average concentrations are 2,946 mg/m3 and 165,93 μg/m3. The respiratory complain such as cough (94,1%), phelgm (35,3%), short breath (35,3%), and fast breath (85,3%). It’s recommended for sweepers to use mask while working, Manager of Bus Station should be monitors of ambient air quality and medical checking for sweeper’s workers.