To investigate the relationship between the infection rate and the timing of replacement of temporary external fixators with internal fixation, and the timing of immediate or delayed internal fixation after removal of temporary external fixation in the staging treatment modality of open fractures of extremities.A retrospective analysis was performed on 122 cases of open fractures of extremities. External fixators were applied at the early stage and replaced with internal fixation when the condition of soft tissues improved and inflammatory indexes dropped to the normal range or showed a steady downward trend. Depending on the carrying time of external fixators after wound closure or healing, the patients were divided into three groups; the carrying time of groups A, B, and C was ≤ 14 days, 15–28 days, and > 28 days, respectively. Depending on the immediate or delayed internal fixation after removal of external fixator, patients were divided into group a  and group b .P < 0.05). The infection rates of different Gustilo–Anderson fractures were as follows: no cases of infection out of 10 cases with type I fracture (0%); two cases of infection out of 35 cases with type II fracture (5.7%); three cases of infection out of 36 cases with IIIa fracture (8.3%); five cases of infection out of 28 cases with IIIB fracture (17.9%); and five cases of infection out of 13 cases with IIIC fracture (38.5%). The differences among the five groups were statistically significant.The infection rates of groups A, B, and C were 6.5%, 5.9%, and 23.3%, respectively. The differences among the three groups were statistically significant (The occurrence of infection of open fractures of extremities is associated with the fracture severity (Gustilo classification). For open fractures of Gustilo types I and II, the final internal fixation should be placed as soon as possible when the recovery of general and local conditions is good and the infection is controlled. With the rapid development of social economy, open fractures of limbs caused by various trauma factors become increasingly common. Open fractures of extremities are usually the result of high-energy trauma, such as traffic accidents, falling accidents, and industrial accidents, so bone and soft tissue can be severely traumatized. Some patients also have extensive skin and soft tissue defects, accompanied by exposure, injury, or defect of muscles, tendons, bones, joints, vessels, and nerves. Their treatment is characterized by long cycles and great difficulties. Once infection occurs, repeated debridement is often required, which imposes heavy economic burden on individuals, families, and countries . Severe Despite the rapid development of modern medicine, the postoperative infection rate of open fractures remains high, and the postoperative limb function is poor, which seriously affects the quality of life. The methods to reduce the postoperative infection of open fractures have always been the focus of controversy.There are many factors influencing postoperative infection in open fractures, such as smoking history, diabetes mellitus, Gustilo typing,,duration of external fixator carrying time, etc. . Reuss ePostoperative infection after placing internal fixation is an important factor affecting the therapeutic effect. It is important to clarify how to reduce the incidence of postoperative infection and improve the therapeutic safety. To this end, we retrospectively analyzed 122 cases of open fractures of extremities admitted to two orthopedic centers from January 2017 to December 2019; analyzing the treatment of open fractures of extremities by sequential external fixator–internal fixation, we evaluated the relationship between postoperative infection and timing of external fixator replacement with internal fixation, and related factors, aiming to provide a reference for clinical treatment of open fractures.Case inclusion criteria were as follows: (1) age ≥ 15 years; (2) open fractures of extremities; (3) temporary external fixation of the fracture at phase I, replaced by internal fixation at phase II; (4) postoperative follow-up time ≥ 12 months; (5) complete clinical and imaging data available. Exclusion criteria were as follows: (1) patients’ choice of external fixators as the final treatment; (2) internal fixation at phase II after bone transport or bone lengthening surgery; (3) other infection foci in affected limbs during follow-up; (4) treatment with glucocorticoids or immunosuppressants for other diseases; (5) amputation due to limb necrosis caused by vascular injury during follow-up.Based on the above eligibility criteria, 122 cases were selected, including 82 males and 27 females. Among them, 13 patients had double fractures that met the inclusion criteria. The age range was 15–70 years, with an average of 40.8 years. Causes of injuries included traffic accidents (76 cases), high falls (20 cases), machine accidents (10 cases), crushing by heavy objects (9 cases), and other causes (7 cases). Considering Gustilo classification, there were 10 cases of type I, 35 cases of type II, 36 cases of type IIIa, 28 cases of type IIIb, and 13 cases of type IIIc fractures. Multiple fractures or multiple injuries occurred in 73 cases.All of the patients were treated with antibiotics and tetanus immunoglobulin soon after admission. The emergency surgery was performed using the orthopedic damage control concept. According to our experience, thorough debridement was done on open wounds at the early stage to remove contamination sources, foreign bodies, and ischemic inactivated tissues, but the remaining periosteal blood supply was retained as much as possible. Fracture reduction, correction of fracture shortening, rotation, and displacement, maintenance of fracture alignment, and installation of single-arm or combined external fixators were performed under fluoroscopy guidance. The fracture site stability was tested during the operation. If it was stable, cross-joint fixation was unnecessary. If not, cross-joint fixation was applied to increase stability. Limited internal fixation by Kirschner wire was applied depending on the fracture characteristics if necessary.Different treatments were selected depending on the wound conditions: (1) direct suture of tension-free wound; (2) coverage with vacuum sealing drainage (VSD) or KCI sponge at phase I, 4–7 days each time, for severe tension wounds or skin defects. According to the wound situation, patients with severe contamination, unclear boundaries of tissue necrosis, or wound infection received repeated debridement as needed. If the surrounding granulation tissue status was good, flap transposition, flap dissociation, and free skin graft were performed at phase II.When soft tissue swelling completely subsided, skin wrinkled, there were no local infection symptoms and signs, such as swelling and obvious inflammatory secretions in the wound, the general condition improved, and inflammatory indexes, such as white blood cells (WBCs), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and procalcitonin (pro-CT), decreased steadily or decreased to the normal range , 10. PatCarrying time of external fixators was measured from suture or repair time of open fracture wounds to internal fixation. Infection after internal fixation was defined as bone tissue infection with or without surrounding soft tissue infection after the replacement of external fixator with internal fixation due to pathogenic microbial contamination or low immunity of patients. For diagnostic criteria of bone infection, we referred to the consensus formulated by the International Association for Internal Fixation Research in 2017 [According to the carrying time of external fixators after wound closure or healing, the patients were divided into three groups ; the carrying time in groups A, B, and C was ≤ 14 days, 15–28 days, and > 28 days, respectively. Depending on immediate or delayed replacement with internal fixation, the cases were divided into two groups (a and b). In group a, internal fixation was placed immediately after removal of external fixators. In group b, internal fixation was delayed 5–7 days after removal of external fixators. The medical records of the patients were collected, and the corresponding imaging results and results of WBCs, CRP, ESR, and other inflammatory indices were collected simultaneously. The incidence of deep tissue infection (osteomyelitis) and efficacy were compared between the groups. Chi-square test or Fisher exact probability test was used to compare the incidence of infection after internal fixation placement between the groups.P > 0.05), which indicated the comparability of the groups , type II—5.7% 2/35), type IIIa—8.3% (3/36), type IIIb—17.9% (5/28), and type IIIC—38.5% (5/13). By comparing the postoperative infection rates of different types of Gustilo fractures after internal fixation placement, it was found that the postoperative infection rate increased with the increase in the severity of open fractures. The differences were statistically significant . The infection rates were 5.9% (1/17 cases) and 23.3% (10/43 cases) in the group with the carrying time of 15–28 days and that of > 28 days, respectively. With the extension of the carrying time of temporary external fixators, the postoperative infection rates of the three groups showed an overall increasing trend, and the differences among three groups were statistically significant, supporting the principle of replacing external fixators with final internal fixation for open fracture patients as soon as possible. We found a 6.5% infection rate (4/62 cases) in patients in whom external fixators had been removed within 14 days. The infection rate after 14 days was 18.3% (11/60). The comparison of the infection rates after internal fixation between the two groups showed a significant difference. In addition, the infection rate in patients in whom external fixators had been removed within 28 days was 6.3% (5/79); the infection rate after 28 days was 23.3% (10/43 cases), which was significantly different  in the immediate group and 18.5% (5/27) in the interval group, while there was no statistical difference in the comparison between the two groups (Table P > 0.05).We compared the infection rates of different temporary external fixator indwelling time under the same Gustilo classification. In mild injury (Gustilo I and II), the infection rate of group A was 0%, that of group B was 14.3%, and that of group C was 33.3%. The differences among the three groups were statistically significant Fig. . In GustOpen fractures of extremities with severe soft tissue injury are mostly caused by high-energy injury. There are no effective solutions for the infection risk caused by latent bacteria in deep tissues, and the risk of deep tissue infection (osteomyelitis) is high after operations. The combined treatment of fracture and soft tissue injury can ensure better prognoses. Early debridement, soft tissue coverage, and early fracture fixation are particularly important . HoweverDespite the data that planned conversion therapy is safe for severe open fractures of extremities, the best timing for internal fixation has not yet been thoroughly explored. Bhandari et al.  conducteIt is also controversial whether to apply internal fixation immediately after removal of temporary external fixators. Some scholars believe that when a temporary external fixator is retained for more than 14 days, after removing the temporary external fixator, the final internal fixation should be replaced only after the healing of nail path and after the inflammatory indices return to normal  , 33. NowIt has been reported , 42 thatThis study also has the following limitations: (1) It was not randomized, but retrospective study, so there was potential bias in the results. (2) The age of doctors on duty for emergency debridement after admission was uneven, and the operations were performed by doctors at different hospitals, which may have affected the results. (3) This study included Gustilo I and II open fractures. External fixation may be the preferred treatment for Gustilo–Anderson III fractures, and IF may be the preferred treatment for most type I open fractures. Therefore, it is questionable whether the Gustilo–Anderson I/II open fractures with injuries or fractures and Gustilo–Anderson III open fractures should be analyzed together. 4) There is a close correlation between indwelling time of temporary external fixator and injury degree, and the injury degree is an important factor in postoperative infection. In this study, the sample size of Gustilo III was insufficient, which prevented better comparison of the infection rates between different temporary external fixator indwelling times in Gustilo type IIIa and above. Therefore, we intend to further explore the relationship between the carrying time of temporary external fixators and infection in open fractures of Gustilo type IIIa and above.However, apart from these limitations, this study conducted in two orthopedic centers clarified that sequential external fixator–internal fixation staging treatment was safe and effective for open fractures of extremities. The main factor affecting postoperative infection of open fractures of extremities was the degree of limb injury, and the infection rate increased with increasing the degree of the injury. The indwelling time of temporary external fixators had a certain effect on the postoperative infection rate of mild open fractures; longer indwelling time of temporary external fixation was associated with a higher risk of postoperative infection. For open fractures of Gustilo IIIa and above, additional clinical investigation is needed to clarify whether the duration of temporary external fixator indwelling affects the postoperative infection rate.In summary, there are some difficulties in the treatment of open fractures of extremities. For open fractures with mild injury, the replacement of external fixator with internal fixation as early as possible on the basis of good infection control, soft tissue, and general conditions is conducive to reducing the risk of infection. Internal fixation can be applied immediately or delayed after removal of the external fixator, but the decision should be made based on the infection indices and the reaction of the nail path.


Delirium is common, distressing and associated with poor outcomes. Previous studies investigating the impact of delirium on cognitive outcomes have been limited by incomplete ascertainment of baseline cognition or lack of prospective delirium assessments. This study quantified the association between delirium and cognitive function over time by prospectively ascertaining delirium in a cohort aged ≥ 65 years in whom baseline cognition had previously been established.For 12 months, we assessed participants from the Cognitive Function and Ageing Study II-Newcastle for delirium daily during hospital admissions. At 1-year, we assessed cognitive decline and dementia in those with and without delirium. We evaluated the effect of delirium (including its duration and number of episodes) on cognitive function over time, independently of baseline cognition and illness severity.Eighty two of 205 participants recruited developed delirium in hospital (40%). One-year outcome data were available for 173 participants: 18 had a new dementia diagnosis, 38 had died. Delirium was associated with cognitive decline  and an increased risk of new dementia diagnosis at follow up (OR 8.8 [95% CI 1.9–41.4]). More than one episode and more days with delirium (>5 days) were associated with worse cognitive outcomes.Delirium increases risk of future cognitive decline and dementia, independent of illness severity and baseline cognition, with more episodes associated with worse cognitive outcomes. Given that delirium has been shown to be preventable in some cases, we propose that delirium is a potentially modifiable risk factor for dementia. Delirium increases risk of future cognitive decline.Longer duration, more severe delirium and more episodes of delirium were associated with worse cognitive outcomes.Delirium may be a potentially modifiable risk factor for dementia.Delirium is a sudden onset and fluctuating cognitive disorder, frequently precipitated by acute illness, which specifically affects attention and level of arousal. Delirium is highly distressing and common, affecting 1 in 4 older people in hospital . DeliriuThe degree to which delirium is associated with permanent changes in cognition is unclear because most studies  have not assessed prior cognitive function . In contIn order to address the relative contribution of acute and chronic factors in determining subsequent cognitive impairment, the Delirium and Cognitive Impact in Dementia (DECIDE) study aimed to measure the effect of delirium on cognition, independent of illness severity, in a population-based cohort study of incident dementia. A further objective was to quantify the association of other features of delirium, including number of episodes and duration, on cognitive outcomes.http://www.cfas.ac.uk/). All members of CFAS II-Newcastle live within the catchment area of the Newcastle Hospitals NHS Foundation Trust.The DECIDE study is a prospective sample nested within the Cognitive Function and Ageing Study II (CFAS-II) ,18. CFASSurviving members of CFAS II-Newcastle were contacted by CFAS prior to the start of the DECIDE study. Participants were provided with written information and given the opportunity to opt-out of further contact. All non-objecting members of CFAS-II Newcastle, with or without dementia, were eligible to participate in DECIDE if admitted to the Royal Victoria Infirmary or Freeman Hospital as an emergency or electively between 5 January 2016 and 5 January 2017. We were alerted to admissions by a Recurring Admission Patient Alert on the electronic records system. If the participant themselves lacked capacity, an appropriate personal consultee was requested to provide written confirmation of willingness to participate. Once recruited, participants were seen on each subsequent hospital admission during the study period. Participants were excluded if: they lacked capacity to consent and we were unable to identify or contact an appropriate personal consultee, they were receiving end of life care, they were being isolated for infection control reasons, they were expected to be in hospital for fewer than 24 h.Disturbance in attention was evaluated using months of the year backwards and digit span, and arousal was recorded using the Observational Scale of Level of Arousal and the modified Richmond Agitation and Sedation Scale  and a part-time research nurse. At monthly intervals throughout the study, we completed joint assessments of a sample of participants to optimise consistency between assessors. Training to deliver the standardised computerised interview at 1-year follow up was provided by the CFAS team based at University of Cambridge. They also had oversight of on-going quality control, using audio recording of interviews with consenting participants.t-test, Kruskall–Wallis test or chi-squared test depending on data type and distribution. We used multiple regression to determine whether delirium was associated with cognitive decline or dementia, independent of baseline cognition and illness severity along with other relevant confounders including age, education, sex, frailty, baseline cognition, time between baseline and follow up interviews and comorbidities. We used multiple regressions to estimate the effect of peak delirium severity, delirium duration and total number of episodes of delirium. We investigated patterns of missing data and delirium cases evaluated by the expert panel in sensitivity analyses. All statistical analyses were performed on STATA Version 15.We evaluated between groups differences using an independent Of the 1,751 CFAS II-Newcastle participants with baseline data, 1,328 were surviving and non-objecting at the start of the DECIDE study. During the year of recruitment, 363 (27·3%) were admitted to hospital, 280 were eligible for DECIDE and 205 were recruited (73·2%) . There wA total of 82 participants developed delirium in hospital during the study period (40%) and 24 participants had more than one episode of delirium (29%). For those who experienced delirium, the median total number of days with delirium during the study period was 3 days (IQR 6 days). Older age (OR 1·09 per year [95% CI 1·03–1·16]) and lower baseline cognition (OR 0.95 per MMSE point [95% CI 0·91–0.99]) were independently associated with delirium.One hundred and thirty five of 205 participants completed follow up interviews 1 year after hospital admission (65·9%), with 18 participants receiving a new diagnosis of dementia. A total of 38 participants had died prior to follow up (18·5%) and 32 refused follow up (15·6%) . Mean tiAn episode of delirium was associated with a markedly increased risk of incident dementia (OR 8.8 [95% CI 1.9–41.4]), independent of illness severity and baseline cognition, as well as age, sex, education, comorbidity, time between interviews and frailty . DeliriuSensitivity analyses showed that excluding the four delirium cases ascertained via consensus panel requiring a third assessor did not alter the overall results.In this prospective, population-based cohort study, we have shown for the first time that delirium is associated with a new diagnosis of dementia and cognitive decline, independent of baseline cognition and illness severity. Further, repeated episodes of delirium, more days with delirium and greater severity of delirium are associated with worse cognitive outcomes. Taken together, these findings suggest that increasing grades of delirium exposure  confer increased risk of dementia.A strength of DECIDE was the prospective delirium assessments using a standardised approach, including a consensus panel for borderline cases. However, not all participants were seen every day, which might not have captured all days with delirium, particularity given the fluctuating nature of the condition. We mitigated this using review of notes as part of the assessment . NestingThe magnitude and direction of these independent associations are similar to those found in previous studies in which delirium ascertainment was retrospective. The first used data from the original Cognitive Function and Ageing Study cohort (CFAS I) , and theThere are substantial clinical implications of this association between grades of delirium exposure and incident dementia and cognitive decline because delirium itself is modifiable, and in some cases preventable . This paaa-20-0850-File002_afaa244Click here for additional data file.


Suspension laryngoscopy is commonly used in operative laryngology. Although it is efficient and minimally invasive in most cases, it can lead to postoperative sore throat (POST) and cough. Because of intensive stimulation by the rigid metal suspension laryngoscope, procedures must be implemented under general anesthesia. Together, these factors increase the possibility of postoperative complications. Blocking the internal branch of the superior laryngeal nerve (SLN) is useful in inhibiting the endotracheal intubation stress response. Thus, we evaluated the efficacy of ultrasound-guided block of the internal branches of the superior laryngeal nerve to improve postoperative complications.n = 32) and without a block . Patients in group iSLNB received ultrasound-guided blocks of the internal branches of superior laryngeal nerve bilaterally . The primary outcome measures were the incidence and severity of sore throat and cough assessed 0.5, 2, 6, and 24 h after tracheal extubation. The secondary outcome measures were heart rate and mean arterial pressure on arrival in the operating room (T0), at endotracheal intubation (T1), upon insertion of the suspension laryngoscope (T2), 5 min after insertion (T3), at tracheal extubation (T4), and 5 min after extubation (T5). Blood glucose levels were measured at T0, T3, and T5.A total of 64 patients was scheduled for elective laryngeal cancer resection, and suspension laryngoscopic surgery was performed under general anesthesia with a block of the internal branch of the superior laryngeal nerve . Compared to the control group from T0–T5, except at T0, the iSLNB group had significantly lower heart rate and mean arterial pressure (P < 0.05). Compared to T0, at other time points, the heart rates in the control group were significantly increased (P < 0.05), and the mean arterial pressures at other time points in the iSLNB group were significantly lower than those at T0 (P < 0.05). The blood glucose levels at T3 and T5 in the iSLNB group were significantly reduced compared with those in the control group (P < 0.05).The incidence and severity of POST and cough in the iSLNB  group were significantly reduced within 6 h after extubation compared with those in the control group, regardless of whether swallowing was present (Ultrasound-guided block of the internal branch of the superior laryngeal nerve might effectively ameliorate postoperative complications secondary to suspension laryngoscopic surgery with endotracheal intubation under general anesthesia and improve hemodynamic stability.https://www.chictr.org.cn, identifier: ChiCTR2100049801. Transoral surgery is now an important strategy in the treatment of laryngeal–pharyngeal cancer because it is less invasive than traditional open procedures , in whicThe superior laryngeal nerve (SLN) is not a pure motor nerve  and has Currently, ultrasound is widely used in a multitude of clinical applications. With precise location of the target nerve and anatomic marks, ultrasound-guided nerve block brings potential advantages, including a higher success rate and shorter performance time; more importantly, ultrasound visualization can reduce relevant complications . TherefoSuperior laryngeal nerve block is now commonly used in endotracheal intubation and bronchoscopic maneuvers, which result in relatively transient stimulations, so SLNB performed by lidocaine injection is the first choice in these clinical applications , 15. Thehttps://www.chictr.org.cn, Yin Bao) on August 9, 2021, and the registration number was ChiCTR2100049801.This prospective randomized blind clinical trial was conducted after receiving the ethics committee approval (TRECKY-2021-139), and all enrolled patients signed written informed consent forms. The present study was registered prior to patient recruitment at the Chinese Clinical Trial Registry  patients with laryngeal cancer (T1-2N0M0) aged 35–65 years and the ability to cooperate with postoperative follow-up. All recruited patients received laryngeal cancer resection with a COThe patients were assigned into two groups using a random number generator: the control group (C group) and the ultrasound-guided iSLNB group (iSLNB group). Group allocation was concealed to blind both the patients and the investigators who collected and analyzed the patient data .2%), were performed continuously and recorded automatically at 5 min intervals. A bispectral index (BIS) monitor assessing the level of consciousness was also applied before general anesthesia induction. Anesthesia induction began with intravenous administration of 1 mg midazolam. Induction and maintenance of anesthesia were obtained with effect-site target control infusion of remifentanil and propofol. The target plasma effect-site concentration (Ce) values of propofol and remifentanil were set at 3–4 μg/ml and 3 ng/ml during induction, respectively. After loss of consciousness, cisatracurium (0.2 mg/kg) and 80 mg methylprednisolone were administered intravenously. After confirming muscle relaxation, endotracheal intubation was performed with a video laryngoscope, with a 6.5 mm internal diameter endotracheal tube for men and a 6.0 mm tube for women. Mechanical ventilation was performed with a tidal volume of 6–8 ml and respiratory rate of 10–15 per min to maintain PETCO2 35–45 mmHg. During anesthesia maintenance, the propofol target Ce was adjusted to keep the BIS between 40 and 60. Meanwhile, the remifentanil target Ce was titrated if HR and NIBP changed more than 20% of basic value. All patients completed tracheal extubation in the operating room and were transferred to the postanesthesia care unit after tracheal extubation.After presenting to the operating room, all the patients were monitored routinely. Electrocardiogram (ECG), heart rate (HR), non-invasive blood pressure (NIBP), and pulse oxygen saturation  was located over the submandibular area in a longitudinal orientation . The thyThe primary outcome measures were the incidence and severity of POST and cough, which were evaluated at 0.5, 2, 6, and 24 h after tracheal extubation by an investigator who was blinded to the patients' assignment. The secondary outcome measures included HR and mean arterial pressure (MAP) at five time points: upon arrival in the operating room (T0), at endotracheal intubation (T1), at suspension laryngoscope insertion (T2), 5 min after suspension laryngoscope insertion (T3), at tracheal extubation (T4), and 5 min after tracheal extubation (T5). Blood glucose levels were measured at T0, T3, and T5. At the same time, the total operative duration, tracheal extubation duration, and incidence of postoperative complications were recorded, such as choking cough, aspiration, and dyspnea. The duration of tracheal extubation refers to the length of time from the end of the operation to the removal of the endotracheal tube.The severity of POST and cough were assessed with a 4-grade scale  16); 0–; 0–16); Based on our pilot study, the incidence of POST when undergoing suspension laryngoscopic surgery was ~80%, and we hypothesized that iSLNB would reduce the risk of POST by 20%. Thus, the sample size was calculated with a power of 0.8 and alpha error of 0.05. At least 25 subjects per group were needed. Assuming a 5% dropout rate and to increase the credibility of this study, 64 patients were recruited (32 subjects for each group).t-tests or Mann–Whitney U-tests where appropriate. Hemodynamic data from different time points were analyzed by one-way ANOVA. Categorical variables were evaluated via the Pearson χ2 test or Fisher exact test, where appropriate. P < 0.05 was considered as significant.Statistical analysis was performed using the IBM SPSS version 21 for Windows . Continuous variables are expressed as the mean ± SD, and categorical variables are presented as numbers (percentages). The Kolmogorov–Smirnov test was used to evaluate the normality of continuous variables, the Levene's test was used to evaluate the equality of variances, and their differences were analyzed with independent P < 0.05).A total of 77 patients were recruited, and 64 patients completed this study. There were no significant differences between the two groups relative to these demographic parameters . AlthougAs shown in Compared to the C group, except at T0, the iSLNB group had significantly reduced HR and MAP .P < 0.05). Although the MAPs of the C group at different time points were not significantly different, the MAPs of the other time points were slightly increased compared with those at T0 (P > 0.05). The HR at T1 was significantly higher than those at T2 and T3 (P < 0.05), and the HR at T4 was significantly higher than those at T2, T3, and T5 (P < 0.05).In the C group, compared to basic HR (T0), the HRs at other time points were significantly increased (P < 0.05). The MAPs at other time points were significantly lower than that at T0 (P < 0.05).In the iSLNB group, the HRs at T1 and T4 were significantly higher than that at T2 (P < 0.05)  .In the present study, there were no other complications, such as dyspnea or choking cough.This study demonstrated that ultrasound-guided iSLNB with low concentration of ropivacaine could not only ameliorate the incidence and severity of POST and cough, but also stabilize the hemodynamics of patients undergoing endotracheal intubation, tracheal extubation, and insertion and maintenance of a rigid suspension laryngoscope.Postoperative sore throat is the most common complaint in patients undergoing laryngoscopic surgery , and it Superior laryngeal nerve block is known to have great value in laryngopharyngeal surgery . RecentlThe endotracheal intubation procedure can lead to sympathetic nervous system activation that causes an unstable hemodynamic response . In mostIn this study, the levels of blood glucose were significantly reduced by iSLNB. Blood glucose, as a metabolic substrate, is closely associated with the acute stress response . We specOur study demonstrated that HR and MAP after endotracheal intubation and tracheal extubation were slightly higher than those after suspension laryngoscope manipulation, although there was no significant difference among these data. These results were contrary to our primary hypothesis that stimulation caused by suspension laryngoscopy was much more intensive than that caused by endotracheal intubation or tracheal extubation. An explanation might be that endotracheal intubation was completed without iSLNB. However, it remained unclear why HR and MAP were higher during tracheal extubation than those after suspension laryngoscope manipulation; this result was unexpected.In our study, there are some limitations that should be considered when reviewing the results. For example, although this is a prospective randomized controlled study, it is a single-center trial with a small sample size, which inevitably lacks external validity. Second, lidocaine was used in most studies regarding SLNB, and we should add another group of lidocaine block to compare their different effects. Third, this study lacks long-term follow-up. All of these factors should be considered in future studies, which should have increased sample sizes and observations of long-term prognosis, for example, recrudescence, and mortality of tumors. Additionally, different volumes and concentrations of ropivacaine should be explored further to determine the optimal dose and concentration. Unsuitable nerve block might lead to severe complications ; therefoPostoperative sore throat and cough were the most frequent complications after suspension laryngoscopic surgery with endotracheal intubation, and these manipulations might cause cardiovascular responses secondary to sympathetic nerve system activation. The ultrasound-guided iSLNB could obviously ameliorate these complications and make hemodynamic changes more stable without major complications.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethics Committee of Beijing Tongren Hospital, Capital Medical University. The patients/participants provided their written informed consent to participate in this study.YB and JX designed this clinical trial and wrote the primary article. HW implemented all anesthesia protocols for the enrolled patients. YZ and QZ were responsible for these patients' treatment including operation. GW advised this trial and assisted with the writing in English. All authors contributed to the article and approved the submitted version.This work was supported by the Beijing Hospitals Authority Clinical Medicine Development of Special Funding Support, ZYLX202103.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


IntroductionLymph node involvement is the most important predictor of prognosis in oesophageal cancer. The present study describes our single-centre experience of lymphadenopathy in oesophageal carcinoma cases at a tertiary care centre in the Marathwada region of Maharashtra state in western India.MethodsThis descriptive study included 31 patients who were operated for oesophageal carcinoma at the State Cancer Hospital in Marathwada from August 2015 to September 2017. Thirty patients underwent three-field lymph node dissections, and one patient underwent Ivor Lewis surgery with two-field lymph node dissections. Three-field lymph node dissections were through a thoracotomy, followed by laparotomy and left cervical incision. The lymphatic metastases were categorised as (a) adjacent node metastases, (b) multiple levels of lymph node metastases, and (c) skip node metastases. The histopathological assessment of the removed specimen and lymph nodes was done. Pathologists evaluated the character and depth of the primary tumour and its invasion and node involvement. The location and numbers of positive and negative nodes were recorded.ResultsA total of 31 patients were included in the study, of which 17 had lymph node involvement. A total of 946 lymph nodes were dissected and examined, and the average number of lymph nodes removed per patient was 30.51. Among the 28 squamous cell carcinoma cases, lymph node involvement was found in 14 cases (50%) whereas, in adenocarcinoma, all the three cases showed lymph node involvement. In 11 cases of squamous cell carcinoma, thoracic lymph nodes were involved, whereas abdominal lymph nodes were involved in nine and cervical lymph nodes in two cases. Thoracic lymph nodes were involved in two cases of adenocarcinoma and abdominal lymph nodes were involved in one case of adenocarcinoma.ConclusionsSquamous cell carcinoma was the predominant type, and lymph node metastasis was observed in 50% of these cases. Thoracic lymph nodes were more commonly involved. Tumour staging T2 and T3 had an increasing percentage of lymph nodes involved. Lymph node involvement was more in moderately differentiated and undifferentiated oesophageal cancers. Oesophageal cancer is among the top three gastrointestinal malignancies in our country, and it has a poor prognosis. Lymphatic drainage of oesophagus runs along the oesophageal axis vertically and drains into cervical and abdominal lymph nodes. There is widespread lymph node metastasis observed in oesophageal cancer. The lymph node spread of oesophageal cancer is varied and correlates with T status, stage, grading, perineural invasion, length and width of the primary tumour and histopathology of the tumour. The status of lymph node involvement is the most important prognostic marker in oesophageal cancer -4. PostoThis descriptive study included 31 patients who were operated for oesophageal carcinoma at the State Cancer Hospital in Marathwada from August 2015 to September 2017. The Institutional Ethics Committee approved the study protocol. All patients diagnosed with carcinoma of the oesophagus, with surgery being their primary modality of treatment, were included after their informed consent for study participation. Exclusion criteria were metastasis to viscera, medically unfit or not willing for surgery. After collecting the preliminary data, a thorough history was taken in each case. A thorough general and physical examination was carried out for each patient to determine any associated disease and judge fitness for general anaesthesia and surgery.All routine investigations were carried out. Endoscopy and endoscopic biopsy were done to confirm the pathology. Radiological investigations such as chest x-ray, ultrasonography of the neck and the abdomen and contrast study of the neck, thorax and abdomen were done. Each patient was discussed in a multi-disciplinary team meeting and a plan of treatment was decided.Thirty patients underwent total transthoracic oesophagectomy with three-field lymph node dissection, and one patient underwent Ivor Lewis surgery with two-field lymph node dissections. Thus, 30 patients underwent three-field lymph node dissections, and one underwent two-field lymph node dissection. Three-field lymph node dissections were through a thoracotomy, followed by laparotomy and left cervical incision. A greater curvature gastric tube was pulled to the neck in 30 cases and thorax in 1 case for esophagogastric anastomosis. Right fourth intercostal thoracotomy was performed. Then the oesophagus with the tumour was removed along with adjoining tissues, i.e., both pleural surfaces, the pericardium and all the lympho-vascular tissues between the spine and oesophagus. The thoracic lymphatic duct was resected throughout its course in the posterior mediastinum, and so a complete dissection of the middle and lower mediastinal nodes, including the peri-oesophageal, para-hiatal, subcarinal and aortopulmonary window nodes, was done. The upper abdominal and retroperitoneal lymph nodes were removed. The left cervical incision was used to clear the superior mediastinal and the cervical lymph nodes. The nodes along the mediastinal course of recurrent laryngeal nerves, para-oesophageal nodes in the upper thorax, pretracheal nodes, tracheobronchial nodes, the lower cervical deep nodes postero-lateral to the carotid sheath and the supraclavicular nodes were removed. Lymph nodes >1 cm on the short-axis diameter were considered significant although all stations were dissected and sent for histopathological examination.Lymph node mappingLymphatic nodes were named as per the Japanese Esophageal Society guidelines for oesophageal diseases and divided into (a) cervical lymph nodes, (b) thoracic lymph nodes, and (c) abdominal lymph nodes .Two-field lymph node dissection involved the resection of lymph nodes within the mediastinal and abdominal lymph node stations. Right thoracotomy was done and the paraesophageal, bilateral intrathoracic recurrent laryngeal nerve chain nodes, subaortic arch nodes, subcarinal nodes, and bilateral pulmonary hilar nodes were dissected. The paracardial, celiac nodes, nodes along the left gastric artery, and common hepatic artery nodes were dissected through an upper midline laparotomy. Cervical collar incision was made and the cervical recurrent laryngeal nerve chain nodes, internal jugular nodes below the level of the cricoid cartilage, supraclavicular nodes, deep cervical nodes, and cervical para oesophageal nodes were dissected bilaterally.The location of oesophageal carcinoma was described as follows: (a) cervical oesophagus, 15-20 cm from incisors; (b) upper thoracic oesophagus, >20-25 cm from incisors; (c) middle thoracic oesophagus, >25-30 cm from incisors; (d) lower thoracic oesophagus, >30-40 cm from incisors.The pattern and extent of lymphatic spread was described as follows: (a) adjacent node metastases, same segment of the oesophageal lesion; (b) multiple levels of lymph node metastases, adjacent and other nodes; (c) skip node metastases in which adjacent nodes are uninvolved, but other levels are involved.Histopathological assessment of the removed specimen and lymph nodesEach group was assigned its localisation; they were fixed in 10% formalin, embedded in paraffin, stained with haematoxylin and eosin and examined by light microscopy. Pathologists evaluated the character and depth of primary tumour and its invasion and node involvement. The positive and negative node numbers and their locations were recorded. Postoperatively, the patient was kept electively intubated for one day and in ICU for four to five days and afterwards in the general ward. The hospital stay was 10-12 days. However, in the case of a postoperative complication, the hospital stay was prolonged.Among the 31 patients studied, lymph node involvement was found in 17 patients. The most common symptoms were dysphagia and weight loss.Out of 31 cases, 15 cases were given neoadjuvant chemotherapy before surgery, whereas 16 cases underwent surgery directly. Tables Table Table Table Table Lymphovascular and perineural invasion of the primary lesion was observed in seven cases. Of these, in six cases, the primary lesion was in the lower thoracic oesophagus, and the primary lesion was in the mid thoracic oesophagus in one case Table .Among squamous cell carcinoma cases, multiple lymph node involvements were observed in two and skip lymph node involvement (directly in the abdomen) in one out of eight cases of the middle thoracic oesophagus. Directly skip nodes in the abdomen were seen in two out of 18 cases of lower thoracic oesophagus carcinoma. Skip nodes to cervical lymph nodes were not seen. Multiple lymph node involvements were observed in two out of 18 cases of lower thoracic oesophagus carcinoma. In the two lower thoracic oesophageal adenocarcinoma cases, only thoracic lymph nodes were involved. Abdominal skip lymph nodes were observed in the single case of upper thoracic oesophageal adenocarcinoma. Table On analysis of cases with positive cervical lymph nodes, intraoperative assessment revealed more lymph node involvement as compared to the CT and histopathology findings. On CT with contrast, no cervical lymph node involvement was noticed, but 22.6% of cases showed cervical lymph node involvement intraoperatively, and 6.5% of cases showed cervical lymph node involvement on histopathology. Similarly, in the cases of involvement of thoracic lymph nodes, intraoperative findings revealed more lymph node involvement as compared to contrast CT. In the case of thoracic lymph nodes, 32.2% involvement was found on CT, 51.6% intraoperatively and 41.9% on histopathology. In the case of intra-abdominal lymph nodes, CT showed involvement in only 3.2% cases; intraoperatively 19.6% cases showed involvement and 32.6% cases were proved to be involved on histopathology. The accuracy of CT with histopathology for cervical lymph nodes was 0%, for thoracic lymph nodes was 76.9% and for abdominal lymph nodes was 30%. The average accuracy of CT with histopathology was 52% Table .In our study, complications were observed in four cases. There was recurrent laryngeal nerve injury in two cases, splenic artery injury in one case and thoracic lymphorrhea in one case.Figure In this study, 17 out of 31 patients were found to have lymph node involvement. The average number of lymph nodes removed per patient was 30.51. The lymph node counts are lower than reported in the literature. Kato et al. reported 74.9 (mean) nodes dissected and Nishihara et al. reported an average of 82 lymph nodes dissected in oesophageal carcinoma surgeries . In an IThere is a need for studies on the subject. Currently, an international research project is being carried out (TIGER study) involving oesophageal cancer institutes across the world to assess the lymph node status in carcinoma of oesophagus. This study aims to provide details for uniform classification and staging, which can help in designing tailor-made and patient-centred treatment options .Thus, in oesophageal carcinoma, lymphatic metastasis may develop by three routes: longitudinally along the submucosa plexus to regional and non-regional lymph nodes, perpendicularly through the muscularis propria to regional lymph nodes and to the thoracic duct and systemic venous plexus. Therefore, it might be logical to interpret that not only the mediastinal lymph nodes but also the cervical and upper abdominal group of lymph nodes are part of regional lymphatic drainage of oesophagus.LimitationsThis study is descriptive and single centre based, and the sample size was small. Follow-up is another limitation, and it does not provide the details of outcomes over a long period.Squamous cell carcinoma was the predominant type and lymph node metastasis was found in 50% cases. Lymph node involvement was more in moderately differentiated and undifferentiated oesophageal cancers. The utility of CT was found to be limited in diagnosing lymph node involvement. The varied presentation of the disease with respect to lymphatic spread and the prognostic impact should encourage further research on the topic so as to better understand and manage oesophageal cancer.


IntroductionThe radiotherapy of left-sided breast cancers is challenging because of neighboring critical organs, posing an increased risk of complications. Various radiation delivery techniques have been used to deliver the desired dose of radiation to the target area while keeping the doses to nearby structures within constraints.The main aim of this study is to quantify doses delivered to the organs at risk (OARs) including heart, left lung, spinal cord, and contralateral breast, and to the planning target volume (PTV) using Field-in-Field (FIF) and Volumetric Modulated Arc Therapy (VMAT).Patients and methodsA retrospective review of 15 left-sided breast cancer patients was done. All the patients underwent breast-conserving surgery and adjuvant radiation. For every patient, two different radiation treatment plans were formulated and compared for the PTV coverage and doses to OARs, including heart, ipsilateral lung, spinal cord, and contralateral breast.The radiation treatment techniques utilized for this purpose were FIF and VMAT. The homogeneity index (HI), and conformity index (CI) required for the treatment planning were also calculated. Data was analyzed using Statistical Package for the Social Sciences . An Independent T-test was used for statistical analysis.ResultsThe mean age was 41 years and the majority of them were stage II. Total nine patients were given 4005centi Gray (cGy) in 15 fractions (fr) followed by 10Gy boost, hence receiving a total dose of 5005cGy in 20fr. While remaining six patients were given a total dose 4005cGy in 15fr without any boost.All patients were hypofractionated and the dose was delivered at a rate of 267cGy per fr. The FIF technique utilized in breast cancer radiation significantly reduced the mean doses to OARs: mean heart dose (3.81cGy), ipsilateral lung dose (V16- 15cGy), mean contralateral breast dose (0.03cGy), and maximum spinal cord dose (0.18cGy); as compared to VMAT technique which delivered comparatively higher doses: mean heart dose (8.85cGy), ipsilateral lung dose (V16- 19.82cGy), mean contralateral breast dose (4.59cGy), and maximum spinal cord dose (7.14cGy).There was a significant mean difference between doses of OARs and all p-values were statistically significant (p<0.005). Moreover, the FIF technique also improves the dose distribution of PTV in terms of dose homogeneity. However, the conformity index is more enhanced with VMAT as opposed to FIF.ConclusionThe FIF technique is more advantageous than the VMAT planning technique because it provides better dose distribution in terms of PTV coverage and significantly lower doses to OARs in radiotherapy to left-sided breast cancer. Breast cancer is the most common cancer in females. According to Globocan statistics 2018, the worldwide burden of breast cancer is 11.6% . An overTraditionally, adjuvant radiation therapy to the breast was delivered with conventional tangential beams which include part of the anterior thoracic cavity, consequently increasing the doses to organs at risk (OARs), in particular heart and ipsilateral lung. These approaches delivered homogenous doses to the entire volume including OARs resulting in considerable normal tissue toxicity. Furthermore, It is also proven that breast cancer patients treated on the left side have a moderately increased risk of cardiac toxicity and morbidity . TherefoIn parallel, the advancements in external beam radiation treatment have revolutionized the delivery techniques to the whole breast and have improved radiation dose conformity, thereby limiting exposure to healthy tissue. As compared to conventional tangential fields, the computed tomography (CT)-based conformal tangential radiotherapy (CRT) in whole breast RT has significantly spared the doses to the OARs . AlthougSeveral researchers have narrated and compared the role of different radiation delivery techniques so that maximal dosimetric benefit and least harm to OARs can be achieved ,10. One At Shaukat Khanum Memorial Cancer Hospital and Research Centre (SKMCH&RC), we decided to plan left-sided breast cancer patients, who were booked for radiation therapy after BCS, on two different radiation planning techniques - FIF and VMAT - which are frequently used radiation planning techniques in our center. The purpose of this study was to evaluate dosimetric comparisons between FIF and VMAT radiation techniques with respect to doses to OARs, PTV, homogeneity, and conformity. The volume of data collected during this study will provide us a body of evidence to devise better radiation planning techniques for our breast cancer patients.We retrospectively analyzed 15 left-sided breast cancer patients who underwent BCS. Patients were simulated in head-first supine position and accessories including wing board and headrest were used to maintain a stable position throughout the treatment. Normal free-breathing planning CT scan without contrast was done from chin till diaphragm, with adjacent transverse slices spacing of 5mm. The CT dataset was shifted to the treatment planning system (TPS) .Target and normal tissue delineationThe contours of all the involved OARs including heart, ipsilateral lung, spinal cord, and contralateral breast were outlined by the treating physician as per Radiation Therapy Oncology Group (RTOG) contouring atlas guidelines. The cranial extent of the heart started 5mm below the pulmonary trunk crosses the midline, including the infundibulum of the right ventricle, the right atrium, and the right atrium auricle. The caudal border of the heart was at the level of the diaphragm, included the lowest border of the pericardium and left ventricle. The automated contouring trait of the TPS was used to generate body and lung contours.The volume of the contralateral breast was defined as the breast tissue encircled by the tangential line between the patient’s midline and the contralateral posterior border was defined as being at the same level as the treated breast. Clinical target volume (CTV) for the breast was delineated by the same radiation oncologist. CTV after breast-conserving therapy (BCT) included all remaining breast tissue and deep fascia excluding muscles and skin. CTV was defined superiorly at the level of second rib insertion, caudally at the level of loss of CT apparent breast tissue, medially sternal rib junction, laterally maxillary line excluding latissimus dorsi muscle, anteriorly skin and posteriorly excluding pectoralis muscle, ribs, and intercostal muscles.PTV was created by giving the isotropic margin of 10mm to the CTV. Anteriorly, the PTV was corrected for being 5mm inside the skin surface. All OARs, CTV, and PTV were outlined slice by slice on the CT image. After the final approval of all contours, two different radiation treatment plans (VMAT and FIF) were optimized by a medical physicist.Field-in-field radiotherapyIn this technique two equally weighted, opposing open tangential photon fields were created against breast PTV, using the same gantry angle as that of the conventional tangential field. In the FIF technique, the gantry angle for the medial tangent was approximately around 300 degrees. Similarly, the gantry angle for the lateral tangent was nearly 120 degrees. The minor variation between gantry angles of patients was according to the patient's tumor location and anatomy. We used five to six segments in one FIF plan, and the number of segments varies from patient to patient. Five to six very low weighted subfields were introduced in the main tangential field in order to decrease the number of hot spots (area of overdose) in the target volume and improve dose homogeneity. All subfields and main fields were merged into one portal. Figure Volumetric modulated arc therapyIn order to produce highly conformal dose distribution around breast PTV, two half-arc plans were generated. Within each arc, three parameters of cone-beam were continuously modulated including gantry rotation, dose rate, and multi-leaf collimators (MLCs) so that maximum homogeneity and conformity could be achieved. We achieved a 0.8cm margin between PTV and MLC after using a 1cm virtual bolus on the target volume. Approximately angle of arcs was between 301-179 degrees. In order to avoid secondary dose to normal tissue and hot spot areas, constraints were given to OARs, and target volume and final dose calculations were done. Figure Dosimetric evaluationIn this study, Varian Millennium 120 MLCs  were used. Patients were planned for a radical dose of 4005cGy in 15 fractions at 267cGy per fraction. Nine patients who were under 50 years were also given an additional boost dose of 1000cGy in five fractions at 200cGy per fraction.Radiation plans were generated by a senior medical physicist and a review of the radiation treatment plans was done by another senior qualified medical physicist to ensure safe and high-quality care. For the VMAT technique, radiation plans were normalized to 100% target mean dose while for the FIF technique, plans were normalized to field isocenter. The main aim was to cover 95% of the dose to 95% of the volume through both planning techniques. Dose volume histograms (DVHs) were also created for PTV and all OARs including heart, ipsilateral lung, contralateral breast, and spinal cord, and were compared for both radiation planning techniques in all patients. Dose homogeneity index (DHI) and conformity index (CI) were also calculated.Dose homogeneity index (DHI)Dose homogeneity index is defined as the ratio between the maximum dose in target volume and the reference isodose. It is calculated from the following formula:DHI = Imax/RI Where Imax = the maximum dose in the target and RI = reference isodose.Its ideal value is 1 and it increases as the plan becomes less homogenous.Conformity index (CI)Conformity index is defined as the ratio between the volume covered by the reference isodose, which according to the International Commission on Radiation Units and Measurements (ICRU) is isodose of 95%, and the target volume, designated as PTV. It is presented by the following equation:CI = Vri/TV Where Vri = volume covered by reference isodose and TV = target volumeThe ideal value of CI is 1, as it corresponds to the ideal dose coverage or high conformity. The value of CI greater than 1 indicates that the irradiated volume exceeds the target volume and partly covers the healthy tissue; similarly, its value less than 1 indicates that the target volume is partially radiated.The PTV doses were analyzed on the basis of the percent volumes receiving at least 95% of the prescribed dose (V95) and the percent volumes receiving 100% of the prescribed dose (V100). Similarly, the maximum point dose of the spinal cord, and the mean doses of the heart and contralateral breast for each plan were also compared. The percentage of the ipsilateral lung volume receiving 12, 16, and 30Gy, and, likewise, the percentage of the heart volume receiving 2 and 10Gy were also evaluated.Statistical analysisThe Statistical Package for Social Sciences (SPSS Statistics) version 23.0  was used for statistical analysis. Independent samples t-test was used for comparisons. A p-value of less than 0.05 was considered to be significant.The median age of the patients was 41 years. Patient and disease characteristics are displayed in (Table The comparison of plan parameters of FIF technique with VMAT for adjuvant radiation to left-sided breast cancer patients after lumpectomy is outlined in Table .The percentage volumes and standard deviation (SD) of the PTV (left breast) showed that there was no statistically significant difference in terms of the PTV volumes that received 95% of the prescribed dose (p=0.265) and PTV volumes that received 100% of the prescribed dose (p=0.927) when FIF and VMAT techniques were compared Figure .All patients who were planned on the FIF technique received significantly reduced mean doses to the OARs  as opposed to VMAT. When the mean percentage OAR volumes radiated with specified doses were compared between FIF and VMAT, results were in favor of the FIF technique Table .HeartThe required dose constraints for the heart was the mean heart dose <4Gy. The mean dose of heart achieved by FIF was 3.81Gy versus 8.85Gy by VMAT technique (p=0.024) which is a highly significant difference for left-sided breast cancer patients where it is very difficult to control heart doses. Similarly, the required dose constraints for the percentage heart volume receiving 10Gy and 2Gy were <5% and <30%, respectively. When the mean percentage heart volume receiving 10Gy and 2Gy were evaluated, the FIF technique allowed lower mean percentage values (V10) 9.76% and (V2) 27.54% as compared to the VMAT technique in which (V10) was 30.76% and (V2) 97.13% (p=0.000).Ipsilateral lungThe required dose constraints for the percentage ipsilateral lung volume receiving 12, 16, and 30Gy were 18%, 20%, and 25%, respectively. When the mean percentage volume of ipsilateral lung receiving 12, 16, and 30Gy was compared between two techniques, the values were significantly reduced with the FIF technique, with a statistically significant p-value for V12 and V16 (p=0.002 for V12 and p=0.036 for V16) Figure . With thSpinal cordThe maximum spinal cord doses achieved by FIF was 0.18Gy as compared to VMAT, in which it was 7.14Gy (p=0.000), again favoring FIF over VMAT.Contralateral breastThe mean dose received by the contralateral breast was 0.03Gy by FIF technique and 4.59Gy by VMAT technique with a statistically significant p-value (p=0.000) . Therefore, VMAT plans were more conformal as compared to FIF Figure .In this study, we have evaluated the plan parameters of two different radiation treatment planning techniques in left-sided breast cancer patients treated with breast conservation surgery and have discovered that the FIF technique is superior to VMAT in terms of dose homogeneity and delivering far fewer doses to OARs, specifically the heart. However, conformity is more pronounced with the VMAT technique.The standard-of-care treatment plan for breast cancer patients includes a tri-modality regimen consisting of systemic agents, surgery, and radiation. Over the period of time, due to advancements in radiation delivering and planning techniques, multiple three-dimensional CT-based whole-breast RT planning techniques have been established with the main aim of delivering fewer doses to OARs and maximizing the homogenous dose distribution in target volume ,12. The Multiple studies have mentioned the dosimetric comparison of VMAT with 3D conformal radiation techniques -21. WhenNormal tissue response after radiation delivery depends upon the volume of the tissue irradiated, which will be manifested in the form of organ dysfunction. Malfunctioning organs can be symptomatic or asymptomatic  . MultiplIn this study, we found that the FIF technique significantly reduced V12 and V16 values of the ipsilateral lung. Similarly, it is also noticed that the FIF technique remarkably improved the mean contralateral breast dose along with the maximum spinal cord dose when compared to the VMAT technique. Furthermore, heart dose, which is of more concern in left-sided breast cancer patients, is better attained by the FIF technique.Many published papers in the literature have stated the dosimetric comparison of both conventional and conformal radiation techniques for whole breast radiation -27. De NThe utilization of the FIF technique for whole breast radiation treatment is also advantageous. Haciislamoglu and colleagues compared FIF with VMAT in their study and reported that VMAT offers excellent target coverage and conformity; however, areas of low doses in the contralateral breast and other normal tissues were comparatively greater with VMAT than with FIF. They also concluded that due to lower mean OAR doses achieved through the FIF technique, the chances of long-term side effects are also lower in patients treated by FIF . Our resIn our study, we did not include other variables like body mass index (BMI), breast size, and risk of secondary cancers. However, it is a well-known fact that there is a major correlation between breast size and dose homogeneity . MoreoveIn conclusion, our study has demonstrated that the use of the FIF technique for whole breast radiation is more beneficial than VMAT as it offers better results in terms of target coverage, dose homogeneity, and lower doses to OARs. VMAT plan has a slight advantage of improving the CI of the PTV, but it may increase the dose to ipsilateral lung, heart, spinal cord, and contralateral breast. Therefore, the utilization of the VMAT technique for the radiotherapy of the left-sided breast cancer patients is not recommended.


The microbiome of the LS patients was dominated by possibly harmful bacteria including Lactobacillus iners, Streptococcus anginosus or Gardnerella vaginalis known to initiate direct or indirect damage by increasing defensin level production. Our observations highlight that correcting the composition of the microbiome may be applicable in supplementary LS therapy by targeting the restoration of the beneficial flora that does not increase hBD2-3 production.Human beta defensins (hBDs) may play an important role in the progression of lichen sclerosus (LS), due to their ability to induce excessive stimulation of extracellular matrix synthesis and fibroblast activation. The genetic ability of the individual to produce defensins, the presence of microbes influencing defensin production, and the sensitivity of microbes to defensins together regulate the formation of an ever-changing balance between defensin levels and microbiome composition. We investigated the potential differences in postmenopausal vaginal microbiome composition and vaginal hBD levels in LS patients compared to non-LS controls. LS patients exhibited significantly lower levels of hBD1 ( The overall prevalence of LS is estimated at 0.2%, and is observed in the male population less frequently than in the female population2. The genital form—which may present before the onset of puberty—is the most common in young girls, with atrophy of the skin and mucous membranes, in addition to bullous and hemorrhagic symptoms. As the chronic process of LS progresses, shrinkage of the connective tissue and scarring leads to pronounced narrowing of the vaginal opening with the affected surfaces being eroded and sensitive. Post-menopausal women are also commonly symptomatic. In fact, symptoms often worsen after the climacteric3.Lichen sclerosus (LS) is a chronic dermatosis of unknown origin, concentrated on the anogenital area compared to other cutaneous sites4. Auto-antibodies targeting extracellular matrix 1 (ECM1) protein have been demonstrated in women with anogenital LS significantly more frequently (74%) compared with 7% in controls5. However, ECM1 autoreactivity might be involved in disease progression, rather than in the initiation of the condition. ECM1 autoreactivity occurs more likely in patients, whose symptoms persisted for longer than 1 year and/or in those with more extensive disease presentations. Antibodies develop in patients with autoimmune diathesis due to chronic irritation of the genital epithelium6. It has been proposed that some microbial “irritants” indirectly play a role in autoimmune processes and that the postmenopausal change of vaginal microbiome may be linked to the progression of LS. Gardnerella vaginalis as a participant in the dysbiotic or Bacterial Vaginosis (BV) associated vaginal microbiome plays not only an indirect role but also a direct role in inhibiting wound healing with its secreted soluble products7.The possible causes of the disease include genetic predisposition, chronic irritation, infection and autoimmunity8. Lower relative mRNA expression of hBD1, but significantly higher hBD2 and hBD3 mRNA expression levels in LS patients, compared to healthy controls are observed9. Higher amounts of different hBDs in LS may change the appearance of the skin resembling pathological scarring, due to excessive stimulation of matrix synthesis and fibroblast activation. Pathogens of all sorts of infections induce production of ß defensins12. In turn, the increased levels of these peptides affects the composition of the surrounding bacterial flora due their selective antimicrobial activity14.Human β defensins (hBDs) belong to the group of cysteine-rich short-chain natural antibacterial peptides. β-defensins are subdivided into further subgroups: hBD1 is produced in the kidney, in the epithelial cells of the respiratory tract and in the female genital tract constitutively, while hBD2 and hBD3 are inducible, expressed in inflammatory diseases of the skin. In addition to their known antibacterial activity, they contribute to immunomodulatory and chemotactic effects in inflammatory processes, infections and wound healing15 two-thirds of postmenopausal healthy patients had a Streptococcus dominated microbiome, one-fifth of individuals had a Gardnerella dominated microbiome, while others belonged to L. crispatus or L. iners dominated clusters. Although the vaginal microbiome with the most optimal composition is dominated by L. crispatus, in many patients without clinical issues the proportion of other bacteria is higher. Therefore, if a pathological condition emerges, in a complex environment like the genital tract not only the bacterial composition has to be assessed, but a number of other factors.In the study of Glienwitz et al.The genetic ability of an individual to produce human defensins, the presence of microorganisms influencing defensin production in the surrounding environment of producer cells, and the sensitivity of microbes to defensins together regulate the formation of an ever-changing balance between defensin levels and microbiome composition. Menopause may be a time of reduced genital tract health, reflecting changes in the vaginal microbiome and mucosal environment.In our current study, we aimed to investigate postmenopausal vaginal microbiome and associated defensin levels in LS and control patients.p = 0.0003), while hBD2 (LS median: 1110 pg/mL and CTL median: 614 pg/mL) (p = 0.0359) and hBD3 levels (LS median: 2998 ng/mL and CTL median: 994.5 ng/mL) (p = 0.0002) were significantly elevated in the LS group, measured in 10 mL cervicovaginal lavage. Based on subjective evaluation, the most severe symptoms were in patient LS7, and the mildest in patients LS6, LS10, LS11, LS14. Patient LS1 had the highest global objective score and patient LS7 had the lowest. Günthert16 severity score was the highest in patients LS1 and LS9, and the lowest in LS2, LS7, LS11 and LS12. Although there are discrepancies between subjective and objective severity assessments, none of the scores show a relationship between severity and the microbiome-determining dominant bacterial genus. No significant correlations, or any trends were found between symptom severity score values and hBD levels in any given LS patient.Participants in both the LS 15) and control (8) groups were postmenopausal. All LS patients had a histologically confirmed illness for at least 9 years, and they all had subjective symptoms and objective signs at the time of the study . No statistical significant differences were found in microbial alpha diversity in the samples between LS and CTL patients by either metrics used to assess differences  and the control (3/8) groups . Aggregated by cohorts at genus level, the microbiome composition of LS cohort consisted of 35% Lactobacillus and 16% Streptococcus, while the control cohort contains 36% Lactobacillus and 12% Streptococcus  or Lactobacillus (p = 0.957) abundance between the LS and Control group at genus level. Moving on to the species-level analyses, a more striking difference was observed: among the Lactobacilli, L. iners species was present in an exceptionally high proportion in the LS group against the control group  .Regardless of whether the patients belonged to the LS or the control group, they were equally distributed among the ups Fig. a. There Lactobacillus. According to PERMANOVA analysis, significant differences among the LS and control were not observed at species level. If the LS and control groups were divided into additional cohorts based on lactobacillus dominance or polymicrobial property, the ß diversity of only lactobacillus-dominant control and LS cohort differed significantly by PERMANOVA analysis. For a complete analysis please consult Table Figure L. iners was the most common species with a relative abundance between 68–96%—with the exception of Lactobacillus u.s. and Pediococcus acidilactici—other notable species were not detected in the vaginal microbiome. The only exception was the LS9 sample, where both Gardnerella u.s. and Bifidobacterium u.s. were associated with L. iners. S. anginosus was frequently co-existing almost excusively with other Streptococcus sp., or Corynebacterium u.s. In the polymicrobial group, the most abundant species were Gardnerella u.s., Bifidobacterium u.s. and Atopobium vaginae frequently co-existing.Figure L. iners in the samples increased in parallel with hBD2 and hBD3 levels. However due to the high SD values, and low sample size significant differences were observed only between the lowest and highest hBD groups . Of note, the incidence of Streptococcus anginosus changed in an opposite direction to hBD2-3 levels, but the differences are not significant due to high SD. .LS patients were divided into 3 distinct groups, based on the levels of hBD2, hBD3, and median LS defensin values. The first cohort includes patients whose hBD2 and hBD3 levels were lower than the median values . The second cohort contains LS patients whose hBD2 or hBD3 levels were higher than the median values , and patients in the third cohort had higher levels of both inducible hBDs than the median values in the LS group . Figure 15 from the ideal microbiome dominated by L. crispatus, without any symptoms or disease. With increasing age, a number of individual factors and hormonal changes shape the microbiome that develops during menopause. LS is probably a multicausal disease in which individual genetic factors, microorganisms, and autoimmunity play roles in its formation and progression. There were patients in the healthy control group whose microbiome was Streptococcus-dominated or polymicrobial but did not have any pathological symptoms. Our working hypothesis is that potentially disease-causing bacteria, that form the microbiome of LS patients, are involved in the progression of this multicausal disease.All patients in the LS group had a positive diagnosis of Lichen sclerosus for at least 9 years, but at the time of sampling they presented themselves for examination because their symptoms had worsened. The vaginal microbiome of healthy women during menopause can be differentLactobacillus species are equally beneficial to the host. L. crispatus is the optimal species associated with vaginal health, whereas L. iners may be associated with the development of pathological conditions17. The most important virulence factors of L. iners are inerolysin, and AB-1 adhesine18. Inerolysin is a pore-forming cholesterol dependent cytolysin toxin, which interacts with the CD59 human cell surface receptor, and at the end of a multi-step process it induces perforation of the cell membrane and ultimately cell death19. The AB-1 adhesine attaches to human fibronectin18. Fibronectin is one of the extracellular matrix components whose expression and distribution are altered in lichen sclerosus20. Further altered components are tenascin, fibrinogen, biglycan, versacin and ECM-121. The alteration in these extracellular matrix components may be relevant to the initiation of scarring in LS and to the associated increased skin fragility20.Each of the bacteria predominantly present in LS patients has virulence factors that can worsen the prognosis of the disease. Not all vaginal S. anginosus is a pathogenic species, the predominant microorganism in patients with aerobic vaginitis. Successful binding of these bacteria to extracellular matrix proteins, like fibronectin, fibrinogen and laminin plays an important role in their pathogenesis22. The sag haemolysin of S. anginosus has been described to initiate vaginal epithelial cell lysis23.Gardnerella vaginalis and Atopobium vaginae are thought to be etiologic agents of bacterial vaginosis (BV). G. vaginalis is able to effectively displace lactobacilli and adhere to vaginal epithelial cells24, and has an increased propensity for biofilm formation25. Enzymes produced by G. vaginalis—vaginal sialidase or vaginolysin—promote the breakdown of the mucous layer and the vaginal epithelium26. Mature biofilm facilitates the adhesion of second colonizers, including A. vaginae27. A. vaginae induces a broad range of pro-inflammatory cytokines, chemokines, and antimicrobial peptides, including IL-1β, IL-6, IL-8, MIP-3α, hBD-2 and TNFα17. Some of the bacteria in the vaginal microbiome are known to play a role in enhancing antimicrobial peptide production: hBD2 levels are most strongly elevated in the presence of A. vaginae, P. bivia and L. iners without any effect on hBD1 production17.9 and co-workers measured significantly lower hBD1 mRNA expression, and higher hBD2 and hBD3 mRNA expressions in LS patients than in controls. In our study LS patients had significantly lower levels of hBD1 (p = 0.0003), and significantly higher levels of hBD2 (p = 0.0359) and hBD3 (p = 0.0002), compared to the control group. Also psoriasin, LL-37 and RNAse 7 were analysed in the above mentioned study, and measured a higher level of constitutively expressed psoriasin in LS patients but no differences between the levels of inducible LL-37 and RNAse 7 in LS patients and control groups. Further studies are needed to characterize the factors influencing the prevalence of bacterial species in a complex environment such as the vagina.GambichlerLactobacillus sp. in the vaginal microbiome28. During our study, the detected concentration of defensins overall was about 2 µg/mL in the 10 mL of lavage fluid; however, this may reflect a considerably higher concentration directly on the mucosal surface. It would be reasonable to speculate that the survival of different Lactobacillus species and other bacteria is largely affected by these amounts of different defensins. Antimicrobial peptide (AMP) susceptibility and the capability of different bacteria to induce the production of AMPs may explain the difference in the levels of defensins in LS patients and controls, and can affect the composition of the corresponding various microbiomes. In both the control and LS patient groups, the presence of L. iners in the microbiome was only observed at low hBD1 levels. Further studies are needed to investigate whether low hBD1 levels are a prerequisite for L. iners to exist in the vaginal microbiota. The low level of hBD1 in LS patients may explain the differences in Lactobacillus species present in patients, compared to controls. Based on our results, it appears that in LS patients, characterized by low hBD1 levels, a series of bacterial species are present, as opposed to the healthy flora dominated by only L. crispatus. Consequently, as hBD2 and hBD3 levels are increased, the total amounts of S. anginosus decreased and the presence of L. iners is increased.Increased levels of hBD2 and hBD3 levels were correlated with higher amounts of Limitations of this study are the small number of patients, the exclusive use of the 16S rRNA sequencing method, that provides species-level identification in only a few cases and the lack of proteomic analysis. This latter would highlight the importance and relationship of additional antibacterial peptides and bacterial products in patients diagnosed with LS.L. iners). Consideration should be given to supplement LS therapy with Lactobacillus-containing probiotics, or to restore the beneficial flora that does not induce the increase in hBD2-3 production, in order to improve the quality of life in patients affected by LS. It would be worthwhile to investigate whether higher levels of hBD1 are required for the colonization of beneficial lactoflora.In summary, we observed differences in both defensin levels and the microbial composition in the samples obtained from LS patients compared to the samples from non-LS patients. Although the differences were clearly observable, additional studies are warranted to explore the cause-and-effect relationship between defensin levels and the presence/absence of various microorganisms  postmenopausal women were recruited at the Department of Dermatology, Venerology and Dermatooncology of Semmelweis University between March 2018 and September 2018. Sample collection began following approval from the Ethics Committee of the Semmelweis University (SE TUKEB: 275/2017). All procedures performed in the studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards, and participants gave written informed consent for sample collection and analysis for research purposes.16. Subjective scores for pruritus, burning sensation and dyspareunia were quantified by interview, using a visual analogue scale . A global subjective score (GSS) was obtained by summing the scores of each symptom parameter (highest GSS = 30.) The following objective parameters were scored to evaluate clinical feature of the patients: (1) leukoderma (2) sclerosis (3) atrophy (4) fine wrinkling (5) lichenification (6) hyperkeratosis (7) erosion (8) oedema (9) erythema (10) purpuric lesions (11) itching-related excoriations (12) unilateral labial adhesion (13) bilateral labial adhesion. Each sign was scored using the following 4-point scale: 0 = absence, 1 = mild, 2 = moderate, 3 = severe. A global objective score (GOS) was obtained by summing the scores of each clinical parameter (highest GOS = 39). The Günthert score was calculated by measuring (1) erosion (2) hyperkeratosis (3) fissures (4) agglutination (5) stenosis (6) atrophy . The characteristics of the study participants are presented in Table The participants included women in an LS and a control (CTL) group. The LS group included n = 15 women, diagnosed with LS based on histological findings. Members of the LS group suffered from different active symptoms or refused them. The CTL group had n = 8 individuals, who were patients of the Department with other dermatological diseases , who voluntarily agreed to have their vaginal secretions examined. Only individuals (patients and controls), that were not taking antibiotics or immunosuppressive medications for any reason in the 3 months prior to sample collection were included in our study. Exclusion criteria for both groups were: positive history of sexually transmitted or recent genital infections, use of lactobacillus-containing suppository or gynecological intervention in the last 3 months. In all cases, the physical examination was preceded by the completion of a questionnaire on previous illnesses, their treatment and current complaints. The LS score classification was based on a subjective scoring of relevant symptoms, an objective score and the Günthert classificationukoderma  sclerosi29.For vaginal microbiome analysis, swab samples were collected by using the Puritan UniTranz-RT transport system . Cervicovaginal lavage was collected by washing the cervix and vagina with 10 mL of normal saline and supernatants were aliquotted and stored at − 80 °C for determination of defensin levelswww.cosmosid.com).DNA isolation was performed according to manufacturer’s protocol by the ZymoBIOMICS DNA Miniprep Kit . Concentration of genomic DNA was measured using a Qubit2.0 Fluorometer with Qubit dsDNA HS Assay Kit . Bacterial DNA was amplified with tagged primers covering the V3-V4 region of bacterial 16S rRNA gene. PCR and DNA purification were performed according to Illumina’s protocol. PCR product libraries were assessed using DNA 1000 Kit with Agilent 2100 Bioanalyzer . Equimolar concentrations of libraries were pooled and sequenced on an Illumina MiSeq platform , using MiSeq Reagent Kit v3 (600 cycles PE). In order to evaluate contribution of extraneous DNA from reagents, extraction negative controls and PCR negative controls were included in every run. To ensure reproducibility, each sample was independently extracted and sequenced twice. Isolated DNA samples were placed at − 80 °C until PCR amplification. Raw sequencing data were retrieved from the Illumina BaseSpace and uploaded to CosmosId Bioinformatics Platform for evaluation . All diluted standards, samples and blank wells were measured in duplicates.www.cosmosid.com).The levels of statistical significance for the difference between vaginal defensin levels , and bacterial taxa abundances—not normally distributed variables—measured in the LS and CTL groups was calculated by Mann–Whitney U test. The difference in the incidence of taxa was assessed by chi-square test. Statistical significance between cohorts were implemented using Wilcoxon rank sum testing for microbiome alpha diversity  and PERMANOVA analysis for Bray–Curtis PCoA beta diversity using the statistical analysis support application of CosmosID (CosmosID Metagenomics Cloud, app.cosmosid.com, CosmosID Inc., Supplementary Information 1.Supplementary Information 2.Supplementary Information 3.Supplementary Information 4.