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Clinical and Translational Radiation... May 2024Deep-inspirational breath hold (DIBH) is an option for heart protection in breast radiotherapy; we intended to study its individual benefit.
INTRODUCTION
Deep-inspirational breath hold (DIBH) is an option for heart protection in breast radiotherapy; we intended to study its individual benefit.
MATERIALS AND METHODS
3DCRT treatment planning was performed in a cohort of 103 patients receiving radiotherapy of the whole breast (WBI)/chest wall (CWI) ± nodal regions (NI) both under DIBH and free breathing (FB) in the supine position, and in the WBI only cases prone (n = 45) position, too. A series of patient-related and heart dosimetry parameters were analyzed.
RESULTS
The DIBH technique provided dramatic reduction of all heart dosimetry parameters the individual benefit, however, varied. In the whole population the best predictor of benefit was the ratio of ipsilateral lung volume (ILV)FB and ILVDIBH. In the WBI cohort 9-11 patients and 5-8 patients received less dose to selected heart structures with the DIBH and prone positioning, respectively; based on meeting various dose constraints DIBH was the only solution in 6-13 cases, and prone positioning in 5-6 cases. In addition to other excellent predictors, a small ILVFB or ILVDIBH with outstanding predicting performance (AUC ≥ 0.90) suggested prone positioning. Detailed analysis consistently indicated the outstanding performance of ILVFB and ILVDIBH in predicting the benefit of one over the other technique in lowering the mean heart dose (MHD), left anterior descending coronary artery (LAD) mean dose and left ventricle(LV)-V5Gy. The preference of prone positioning was further confirmed by anatomical parameters measured on a single CT scan at the middle of the heart. Performing spirometry in a cohort of 12 patients, vital capacity showed the strongest correlation with ILVFB and ILVDIBH hence this test could be evaluated as a clinical tool for patient selection.
DISCUSSION
Individual lung volume measures estimated by spirometry and anatomical data examined prior to acquiring planning CT may support the preference of DIBH or prone radiotherapy for optimal heart protection.
PubMed: 38550309
DOI: 10.1016/j.ctro.2024.100746 -
Critical Care Medicine Nov 2023
Topics: Humans; Prone Position; Respiratory Distress Syndrome; Patient Positioning; Respiration, Artificial
PubMed: 37902350
DOI: 10.1097/CCM.0000000000005978 -
Journal of Magnetic Resonance Imaging :... Sep 2023Diffusion-weighted imaging (DWI) may allow for breast cancer screening MRI without a contrast injection. Multishot methods improve prone DWI of the breasts but face...
BACKGROUND
Diffusion-weighted imaging (DWI) may allow for breast cancer screening MRI without a contrast injection. Multishot methods improve prone DWI of the breasts but face different challenges in the supine position.
PURPOSE
To establish a multishot DWI (msDWI) protocol for supine breast MRI and to evaluate the performance of supine vs. prone msDWI.
STUDY TYPE
Prospective.
POPULATION
Protocol optimization: 10 healthy women (ages 22-56), supine vs. prone: 24 healthy women (ages 22-62) and five women (ages 29-61) with breast tumors.
FIELD STRENGTH/SEQUENCE
3-T, protocol optimization msDWI: free-breathing (FB) 2-shots, FB 4-shots, respiratory-triggered (RT) 2-shots, RT 4-shots, supine vs. prone: RT 4-shot msDWI, T2-weighted fast-spin echo.
ASSESSMENT
Protocol optimization and supine vs. prone: three observers performed an image quality assessment of sharpness, aliasing, distortion (vs. T2), perceived SNR, and overall image quality (scale of 1-5). Apparent diffusion coefficients (ADCs) in fibroglandular tissue (FGT) and breast tumors were measured.
STATISTICAL TESTS
Effect of study variables on dichotomized ratings (4/5 vs. 1/2/3) and FGT ADCs were assessed with mixed-effects logistic regression. Interobserver agreement utilized Gwet's agreement coefficient (AC). Lesion ADCs were assessed by Bland-Altman analysis and concordance correlation (ρ ). P value <0.05 was considered statistically significant.
RESULTS
Protocol optimization: 4-shots significantly improved sharpness and distortion; RT significantly improved sharpness, aliasing, perceived SNR, and overall image quality. FGT ADCs were not significantly different between shots (P = 0.812), FB vs. RT (P = 0.591), or side (P = 0.574). Supine vs. prone: supine images were rated significantly higher for sharpness, aliasing, and overall image quality. FGT ADCs were significantly higher supine; lesion ADCs were highly correlated (ρ = 0.92).
DATA CONCLUSION
Based on image quality, supine msDWI outperformed prone msDWI. Lesion ADCs were highly correlated between the two positions, while FGT ADCs were higher in the supine position.
EVIDENCE LEVEL
2.
TECHNICAL EFFICACY
Stage 1.
Topics: Humans; Female; Prospective Studies; Prone Position; Diffusion Magnetic Resonance Imaging; Magnetic Resonance Imaging; Reproducibility of Results; Breast Neoplasms; Echo-Planar Imaging
PubMed: 36583628
DOI: 10.1002/jmri.28582 -
MedRxiv : the Preprint Server For... Feb 2024To elucidate the changes in cardiorespiratory dynamics during neuromuscular blockade and prone positioning and determine the associations between changes in...
OBJECTIVES
To elucidate the changes in cardiorespiratory dynamics during neuromuscular blockade and prone positioning and determine the associations between changes in cardiorespiratory dynamics following prone positioning and mortality.
DESIGN
Single center retrospective cohort study of patients admitted to the medical ICU between June 1, 2020 and September 1, 2022 who received prone positioning while mechanically ventilated.
RESULTS
Our final cohort consisted of 136 patients. Prone position was associated with an improvement in A-a gradient of 113 mmHg (95% CrI 78 - 149) between the pre-proning values and 10 hours post proning. Norepinephrine dose did not significantly change before and after prone positioning (Estimated difference: 0.04 mcg/min 95% CrI -1.00 - 1.07). For the outcome of 7-d mortality, there was a high probability that the baseline factors of increasing age, male sex, and higher baseline A-a gradient were associated with increased risk of death. Increased total vasopressor requirement and increased in PCO2 were associated with worse prognosis while a decrease in instantaneous heart rate and a decrease in heart rate variability were associated with improved prognosis.
CONCLUSION
The immediate changes in prone positioning primarily impact respiratory physiology, with limited influence on circulatory parameters. Predictors of short-term mortality after prone positioning include both respiratory and cardiovascular parameters suggesting that extrapulmonary effects, such as improvement in right ventricular heart function, might also contribute to the benefit of prone positioning.
PubMed: 38352571
DOI: 10.1101/2024.01.30.24301935 -
Nurse Education Today Sep 2023During the coronavirus pandemic (COVID -19), the use of prone positioning in critically ill patients with acute respiratory distress syndrome (ARDS) increased...
INTRODUCTION
During the coronavirus pandemic (COVID -19), the use of prone positioning in critically ill patients with acute respiratory distress syndrome (ARDS) increased substantially. As a result, clinicians had to (re)learn how to treat the patient in the prone position while preventing adverse events such as pressure ulcers, skin tears and moisture-associated skin damage.
AIM
The purpose of the study was to determine participants' learning needs related to patients in the prone position and the prevention of skin damage, such as pressure ulcers, and what they perceived as a positive or negative learning experience.
DESIGN
This study used a qualitative methodological framework and employed an exploratory design.
PARTICIPANTS
A purposive sample of clinicians (n = 20) with direct or indirect work experience with prone ventilated patients was recruited in Belgium and Sweden.
METHODS
Individual semi-structured interviews were conducted in Belgium and Sweden between February and August 2022. Data were analysed thematically using an inductive approach. The COREQ guideline was utilised to comprehensively report on the study.
FINDINGS
Two themes were identified: 'Adapting to a crisis' and 'How to learn', with the latter having two subthemes: 'balancing theory and practice' and 'co-creating knowledge'. Unexpected circumstances necessitated a personal adaption, a change in learning methods and a pragmatic adaptation of protocols, equipment and working procedures. Participants recognised a multifaceted educational approach which would contribute to a positive learning experience regarding prone positioning and skin damage prevention. The importance of poising theoretical teaching with practical hands-on training was highlighted with an emphasis on interaction, discussion, and networking between peers.
CONCLUSIONS
The study findings highlight learning approaches which may help inform the development of befitting educational resources for clinicians. Prone therapy for ARDS patients is not limited to the pandemic. Therefore, educational efforts should continue to ensure patient safety in this important area.
Topics: Humans; Prone Position; COVID-19; Pressure Ulcer; Belgium; Sweden; Respiratory Distress Syndrome
PubMed: 37302346
DOI: 10.1016/j.nedt.2023.105860 -
International Journal of Surgery... Apr 2024Various new positions for percutaneous nephrolithotomy (PCNL) were proposed to reduce the limitations of the traditional position. This study was aimed to evaluate the... (Meta-Analysis)
Meta-Analysis Comparative Study
OBJECTIVES
Various new positions for percutaneous nephrolithotomy (PCNL) were proposed to reduce the limitations of the traditional position. This study was aimed to evaluate the efficacy and safety of the different PCNL positions.
METHODS
PubMed, Embase, Web of Science, and the Cochrane Library were searched for relevant randomized controlled trials (RCTs) up to 18 April 2023. The authors collected five common surgical positions used for PCNL: oblique supine position (OSP), supine position (SP), flank position (FP), split-leg oblique supine/flank position (SLP), and prone position (PP). Paired and network meta-analysis were conducted to compare relevant outcomes, including complications, operative time, stone-free rates, hospital stay, and hemoglobin loss among these different positions.
RESULTS
The study included 17 RCTs with a total of 1841 patients. The result demonstrated that SLP significantly outperformed in terms of decreasing operation time (FP vs SLP MD- MD-41.65; OSP vs SLP MD 28.97; PP vs SLP MD 34.94), hospital stay, and hemoglobin loss. Ranking probabilities showed SLP had highest stone-free rate. Prone position was more likely to occur complications than others. Based on SMAA model, the benefit-risk analysis suggested the SLP was the optimal position in PCNL.
CONCLUSIONS
For PCNL, the split-leg, flank, supine, and OSPs are as secure as the prone position. Further RCTs are necessary to confirm the outstanding safety and efficacy of split-leg position. Besides, the position should be selected regard for the patient's demands, the surgeon's preference and learning curve.
Topics: Humans; Kidney Calculi; Length of Stay; Nephrolithotomy, Percutaneous; Network Meta-Analysis; Operative Time; Patient Positioning; Postoperative Complications; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 38445503
DOI: 10.1097/JS9.0000000000001130 -
Journal of Critical Care Feb 2024Neuromuscular blockers (NMBs) are often used during prone positioning to facilitate mechanical ventilation in COVID-19 related ARDS. However, their impact on oxygenation... (Observational Study)
Observational Study
PURPOSE
Neuromuscular blockers (NMBs) are often used during prone positioning to facilitate mechanical ventilation in COVID-19 related ARDS. However, their impact on oxygenation is uncertain.
METHODS
Multi-centre observational study of invasively ventilated COVID-19 ARDS adults treated with prone positioning. We collected data on baseline characteristics, prone positioning, NMB use and patient outcome. We assessed arterial blood gas data during supine and prone positioning and after return to the supine position.
RESULTS
We studied 548 prone episodes in 220 patients (mean age 54 years, 61% male) of whom 164 (75%) received NMBs. Mean PaO:FiO (P/F ratio) during the first prone episode with NMBs reached 208 ± 63 mmHg compared with 161 ± 66 mmHg without NMBs (Δ = 47 ± 5 mmHg) for an absolute increase from baseline of 76 ± 56 mmHg versus 55 ± 56 mmHg (p < 0.001). The mean P/F ratio on return to the supine position was 190 ± 63 mmHg in the NMB group versus 141 ± 64 mmHg in the non-NMB group for an absolute increase from baseline of 59 ± 58 mmHg versus 34 ± 56 mmHg (p < 0.001).
CONCLUSION
During prone positioning, NMB is associated with increased oxygenation compared to non-NMB therapy, with a sustained effect on return to the supine position. These findings may help guide the use of NMB during prone positioning in COVID-19 ARDS.
Topics: Adult; Female; Humans; Male; Middle Aged; COVID-19; Neuromuscular Blockade; Neuromuscular Diseases; Prone Position; Pulmonary Gas Exchange; Respiration, Artificial; Respiratory Distress Syndrome
PubMed: 37992464
DOI: 10.1016/j.jcrc.2023.154469 -
Annals of Medicine and Surgery (2012) Nov 2023Prone positioning is one type of postural lung recruitment manoeuvre that has been widely studied regarding the benefits and physiological changes of the...
INTRODUCTION
Prone positioning is one type of postural lung recruitment manoeuvre that has been widely studied regarding the benefits and physiological changes of the cardiorespiratory system. However, prone positioning is not very comfortable for the patients because they have to lie on their stomachs for a while when the oxygen therapy and other monitoring devices are still attached. Based on patient observations, some patients will change to more comfortable positions, namely using the right/left lateral decubitus position. The purpose of this research was to examine the physiological impact of prone and lateral decubitus position in non-intubated patients who were diagnosed with severe COVID-19.
METHODS
It was a prospective cohort study in subsequent people with severe COVID-19 who obtained a non-rebreathing mask or high-flow nasal cannula at a University Hospital between 1 June and 10 September 2021. The study lasted for a total of 2021 days and involved 48 patients. The patients assumed the prone positioning or lateral decubitus every morning and afternoon for 4 h and were measured for cardiorespiratory parameters and blood gas analysis. It has been reported in line with the STROCSS criteria.
RESULTS
Dynamic changes based on cardiorespiratory parameters and blood gas analysis parameters in patients with prone and lateral decubitus position in patients with severe COVID-19 receiving conventional oxygen therapy (via non-rebreathing mask) or high-flow nasal cannula did not show any significant difference.
CONCLUSION
The physiological effect of prone positioning and lateral decubitus in non-intubated patients with severe COVID-19 are similar. Accordingly, lateral decubitus can be an alternative for postural lung recruitment manoeuvres and warrants further randomized trials.
PubMed: 37915711
DOI: 10.1097/MS9.0000000000001317 -
PloS One 2024To conduct a volumetric and movement analysis of lung parenchyma in prone positioning using deep neural networks (DNNs).
PURPOSE
To conduct a volumetric and movement analysis of lung parenchyma in prone positioning using deep neural networks (DNNs).
METHOD
We included patients with suspected interstitial lung abnormalities or disease who underwent full-inspiratory supine and prone chest CT at a single institution between June 2021 and March 2022. A thoracic radiologist visually assessed the fibrosis extent in the total lung (using units of 10%) on supine CT. After preprocessing the images into 192×192×192 resolution, a DNN automatically segmented the whole lung and pulmonary lobes in prone and supine CT images. Affine registration matched the patient's center and location, and the DNN deformably registered prone and supine CT images to calculate the x-, y-, z-axis, and 3D pixel movements.
RESULTS
In total, 108 CT pairs had successful registration. Prone positioning significantly increased the left lower (90.2±69.5 mL, P = 0.000) and right lower lobar volumes (52.5±74.2 mL, P = 0.000). During deformable registration, the average maximum whole-lung pixel movements between the two positions were 1.5, 1.9, 1.6, and 2.8 cm in each axis and 3D plane. Compared to patients with <30% fibrosis, those with ≥30% fibrosis had smaller volume changes (P<0.001) and smaller pixel movements in all axes between the positions (P = 0.000-0.007). Forced vital capacity (FVC) correlated with the left lower lobar volume increase (Spearman correlation coefficient, 0.238) and the maximum whole-lung pixel movements in all axes (coefficients, 0.311 to 0.357).
CONCLUSIONS
Prone positioning led to the preferential expansion of the lower lobes, correlated with FVC, and lung fibrosis limited lung expansion during prone positioning.
Topics: Humans; Deep Learning; Prone Position; Pulmonary Fibrosis; Respiration; Lung
PubMed: 38422097
DOI: 10.1371/journal.pone.0299366 -
Journal of Endourology Jan 2024Despite increasing interest in reducing radiation doses during endoscopic stone surgery, there is conflicting evidence as to whether percutaneous nephrolithotomy (PCNL)...
Despite increasing interest in reducing radiation doses during endoscopic stone surgery, there is conflicting evidence as to whether percutaneous nephrolithotomy (PCNL) positioning (prone or supine) impacts radiation. We observed clinically that a patient placed prone on gel rolls had higher than expected radiation with intraoperative CT imaging and that gel rolls were visible on the coaxial imaging. We hypothesized that gel rolls directly increase radiation doses. Anthropomorphic experiments to simulate PCNL positions were performed using a robotic multiplanar fluoroscopy system (Artis Zeego Care+Clear, Siemens) and a 5-second coaxial imaging protocol (5s BODY). A fluoroscopy phantom was placed in various positions, including prone on a gel roll; prone on blankets of equal thickness; prone and supine directly on the table; and modified supine (MS) positions using a thin gel roll or rolled blanket. Impacts of C-arm direction and use of a 1 L saline bag were also evaluated. Measured dose area product (DAP) was compared for the groups. Measured DAP was found to increase by 146 μGy*m2 (287%) when prone on gel rolls compared with only 62.29 (23%) when placed on blankets of equal thickness, although the model likely both overstates the relative impact and understates the absolute impact that would be seen clinically. Measured DAP between experimental groups also varied considerably despite fluoroscopy time being held constant. Our experiments support our hypothesis that gel rolls directly increase radiation dose, which has not been previously reported, using an anthropomorphic model. Surgeons should consider radiolucent materials for positioning to limit radiation exposure to patients and the surgical team.
Topics: Humans; Nephrolithotomy, Percutaneous; Kidney Calculi; Patient Positioning; Prone Position; Supine Position; Radiation Exposure; Nephrostomy, Percutaneous; Treatment Outcome
PubMed: 37917095
DOI: 10.1089/end.2023.0251