We present a rare case of a 39-year-old female with extramedullary relapse of acute myeloid leukaemia (AML) isolated to the left eye 2 months post allogeneic haematopoietic stem cell transplant. She initially presented with painless left eye erythema, swelling, and visual impairment. Initial ophthalmology review revealed conjunctival chemosis, raised intraocular pressure, and serous retinal detachments. She was initially treated for suspected orbital cellulitis with intravenous antibiotic and antifungal therapy but clinically progressed so was then treated with intravenous corticosteroids. One week later, she progressed to angle-closure glaucoma with development of a hypopyon and an enlarging subconjunctival mass. She proceeded to urgent subconjunctival biopsy and drainage of subretinal fluid which confirmed extramedullary relapse of AML. Notably, further investigation found no evidence of bone marrow or central nervous system relapse. She proceeded to localized radiotherapy with gradual resolution of the subconjunctival mass and serous retinal detachment and was for consideration of donor lymphocyte infusions and azacitidine therapy; unfortunately, she developed respiratory sepsis and passed away despite maximal efforts. This case represents a rare and unusual presentation of isolated ocular extramedullary relapse of AML and emphasises the importance of early ophthalmology involvement and tissue biopsy when there is high clinical suspicion of the disease.

Objective To systematically review the effect of intrathecal baclofen pump insertion in children with cerebral palsy (CP) with respect to scoliosis.Methods A systematic literature search was conducted in PubMed, Embase, Cochrane Library, and Google Scholar databases up to June 2022. The inclusion criteria were as follows: (1) studies with a quantitative study design; (2) studies with a study group of children with CP; (3) studies comparing scoliosis in children with and without an intrathecal baclofen pump; and (4) studies with Cobb's angle as a parameter.Results Of the 183 studies found, four studies, all of which were retrospective comparative studies, met the aforementioned inclusion criteria. All studies were homogeneous (I2=0%, p=0.53) and intrathecal baclofen pump insertion accelerated the progression of scoliosis (standard mean difference=0.27; 95% confidence interval=0.07-0.48).Conclusion Intrathecal baclofen pumps have been used to alleviate spasticity in children with CP, thus aiding their daily activities and movements. However, their advantages and disadvantages should be reviewed after sufficient time considering the pumps' negative effect on the course of scoliosis.

Objective: To systematically review the effects of protein supplementation in older adults with sarcopenia.Methods: A systematic literature search was conducted in PubMed, Cochrane Library, and Embase databases until May 2023. The inclusion criteria were as follows: (1) randomized controlled trials with a quantitative study design; (2) studies with a study group of older adults with sarcopenia; (3) studies comparing muscle mass, muscle strength, and performance of older adults with sarcopenia after protein supplementation; and (4) studies published up to May 2023.Results: Six retrospective comparative studies, including 715 patients, met the inclusion criteria. The nutritional supplementation group exhibited significant improvement in appendicular skeletal muscle mass (standardized mean difference [SMD]=0.41; 95% confidence interval [CI], 0.24–0.58; p<0.001; I2=1%), while handgrip strength (SMD=0.37; 95% CI, -0.32–1.07; p=0.29; I2=94%) and Short Physical Performance Battery (SPPB) (SMD=0.35; 95% CI, -0.47–1.18; p=0.40; I2=94%) showed a tendency for improvement.Conclusion: Nutritional supplementation with protein increased appendicular muscle mass in older adults with sarcopenia and improved handgrip strength and SPPB scores.

The survival rate of children admitted in the neonatal intensive care unit (NICU) after birth is on the increase; hence, proper evaluation and care of their neurodevelopment has become an important issue. Neurodevelopmental assessments of individual domains regarding motor, language, cognition, and sensory perception are crucial in planning prompt interventions for neonates requiring immediate support and rehabilitation treatment. These assessments are essential for identifying areas of weakness and designing targeted interventions to improve future functional outcomes and the quality of lives for both the infants and their families. However, initial stratification of risk to select those who are in danger of neurodevelopmental disorders is also important in terms of cost-effectiveness. Efficient and robust functional evaluations to recognize early signs of developmental disorders will help NICU graduates re-ceive interventions and enhance functional capabilities if needed. Several age-dependent, domain-specific neurodevelopmental assessment tools are available; therefore, this review summarizes the characteristics of these tools and aims to develop multidimensional, stan-dardized, and regular follow-up plans for NICU graduates in Korea.

BACKGROUND:Children with physical or brain disabilities experience several functional impairments and declining health complications that must be considered for adequate medical support. This study investigated the current medical service utilization of children expressing physical or brain disabilities in South Korea by analyzing medical visits, expenses, and comorbidities.METHODS:We used a database linked to the National Rehabilitation Center of South Korea to extract information on medical services utilized by children with physical or brain disabilities, the number of children with a disability, medical visits for each child, medical expenses per visit, total medical treatment cost, copayments by age group, condition severity, and disability type.RESULTS:Brain disorder comorbidities significantly differed between those with mild and severe disabilities. Visits per child, total medical treatment cost, and copayments were higher in children with severe physical disabilities; however, medical expenses per visit were lower than those with mild disabilities. These parameters were higher in children with severe brain disabilities than in mild cases. Total medical expenses incurred by newborns to three-year-old children with physical disorders were highest due to increased visits per child. However, medical expenses per visit were highest for children aged 13-18.CONCLUSION:Medical service utilization varied by age, condition severity, and disability type. Severe cases and older children with potentially fatal comorbidities required additional economic support. Therefore, a healthcare delivery system for children with disabilities should be established to set affordable medical costs and provide comprehensive medical services based on disability type and severity.

Background The antitumor effects of natural killer cells, helper T cells, and cytotoxic T cells after cancer surgery were reported previously. This study hypothesized that propofol-based anesthesia would have fewer harmful effects on immune cells than volatile anesthetics–based anesthesia during colorectal cancer surgery. Methods In total, 153 patients undergoing colorectal cancer surgery were randomized and included in the analysis. The primary outcome was the fraction of circulating natural killer cells over time in the propofol and sevoflurane groups. The fractions of circulating natural killer, type 1, type 17 helper T cells, and cytotoxic T cells were investigated. The fractions of CD39 and CD73 expressions on circulating regulatory T cells were investigated, along with the proportions of circulating neutrophils, lymphocytes, and monocytes. Results The fraction of circulating natural killer cells was not significantly different between the propofol and sevoflurane groups until 24 h postoperatively (20.4 ± 13.4% vs. 20.8 ± 11.3%, 17.9 ± 12.7% vs. 20.7 ± 11.9%, and 18.6 ± 11.6% vs. 21.3 ± 10.8% before anesthesia and after 1 and 24 h after anesthesia, respectively; difference [95% CI], –0.3 [–4.3 to 3.6], –2.8 [–6.8 to 1.1], and –2.6 [–6.2 to 1.0]; P = 0.863, P = 0.136, and P = 0.151 before anesthesia and after 1 and 24 h, respectively). The fractions of circulating type 1 and type 17 helper T cells, cytotoxic T cells, and CD39+ and CD73+ circulating regulatory T cells were not significantly different between the two groups. The neutrophil to lymphocyte ratio in both groups remained within the normal range and was not different between the groups. Conclusions Propofol-based anesthesia was not superior to sevoflurane-based anesthesia in terms of alleviating suppression of immune cells including natural killer cells and T lymphocytes during colorectal cancer surgery. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Purpose: We systematically reviewed the short-term effects of hippotherapy and therapeutic horseback riding (THR) on lower-limb muscle spasticity in children with cerebral palsy (CP). Methods: PubMed, EMBASE, Cochrane Library, and Google Scholar databases were searched for relevant quantitative studies. Treatment effects were coded using the Ashworth scale (AS) or modified Ashworth scale (MAS) in pre- and posttreatment evaluations. Of the 73 studies identified initially, 7 met the inclusion criteria. Results: Treatment was associated with positive effects on lower-limb muscle spasticity, as supported by the AS or MAS scores. However, repeated trials did not show a statistically significant difference from a single trial (Q = 2.95, P = .086). Conclusion: Hippotherapy and THR can be used to treat lower-limb muscle spasticity in children with CP. However, repeated sessions did not show a better effect in reducing spasticity. What this adds to the evidence: This is the first meta-analysis to confirm that hippotherapy or THR can reduce lower-limb muscle spasticity in children with CP in the short term, but long-term effects on function still require further studies.

Postoperative acute kidney injury (AKI) is associated with increased mortality and morbidity in patients undergoing surgeries performed under general anesthesia. There are several models that predict postoperative AKI risk, but most are single center studies that need external validation.

Background: This study was designed to investigate the effect of cluster differentiation (CD)39 and CD73 inhibitors on the expresion of tumour-associated macrophages (TAMs), M1- versus M2-tumour phenotypes in mice with colon cancer. Methods: An in vivo study of co-culture with colon cancer cells and immune cells from the bone marrow (BM) of mice was performed. After the confirmation of the effect of polyoxotungstate (POM-1) as an inhibitor of CD39 on TAMs, the mice were randomly divided into a control group without POM-1 and a study group with POM-1, respectively, after subcutaneous injection of CT26 cells. On day 14 after the injection, the mice were sacrificed, and TAMs were evaluated using fluorescence-activated cell sorting. Results: In the in vivo study, the co-culture with POM-1 significantly increased the apoptosis of CT26 cells. The cell population from the co-culture with POM-1 showed significant increases in the expression of CD11b+ for myeloid cells, lymphocyte antigen 6 complex, locus C (Ly6C+) for monocytes, M1-tumour phenotypes from TAMs, and F4/80+ for macrophages. In the in vivo study, tumour growth in the study group with POM-1 was significantly limited, compared with the control group without POM-1. The expressions of Ly6C+ and major histocompatibility complex class II+ for M1-tumour phenotypes from TAMs on F4/80+ from the tumour tissue in the study group had significantly higher values compared with the control group. Conclusion: The inhibition of CD39 with POM-1 prevented the growth of colon cancer in mice, and it was associated with the increased expression of M1-tumour phenotypes from TAMs in the cancer tissue.

Several studies have documented reductions in left ventricular (LV) global longitudinal strain (GLS) using advanced echocardiographic techniques[1, 2] acutely following left tangential breast radiotherapy(RT), with a persistent reduction at 12 months[3]. This strain reduction is greatest in the apical region, coinciding with the greatest incident radiation dose [4]. This study aims to determine changes in longitudinal strain at the left ventricular segmental level as per the American Heart Association 18 segment model [5] at 6 weeks and 12 months following left tangential breast RT Twenty-three left-sided breast cancer patients were recruited prospectively between October 2015 and October 2016 (mean age 60 years (38-76)), with n=20 patient datasets used in current analysis. All patients received tangential breast radiotherapy alone. No patients received chemotherapy. Transthoracic echocardiography was performed at baseline pre RT, 6 weeks, and 12 months post RT. Paired t-tests were used to compare pre RT values with 6 week and 12 month post RT results, with a p value of <0.05 considered significant. Standard 2D echocardiographic measurements, mean heart dose, and mean segmental dose calculated from a novel contouring technique [4] were recorded. Mean heart dose was 2.7Gy (1.5-3.9Gy). At each ventricular region, segments composing the anterior and lateral walls received higher mean radiation segmental doses. Relative reduction in strain across regional segments corresponded visually to differential doses across said segments. At 6 weeks post RT, reduction in segmental longitudinal strain was seen in segments 5 (-18.9 vs -16.55 p=0.05), 13 (-28.8 vs -24.5 p=0.01) and 16(-24.5 vs -21.5 p=0.04). Significant reduction in GLS was seen at 12 months post RT (- 21.9 vs -19.8 p<.0.01). At 12 months post RT, segment 5 remained reduced, with reductions now in segments 11 (-19.7 vs -16.7 p<0.01), 12 (-19.6 vs -15.7 p=0.03), 17(-26.8 vs -26.2 p=<0.01), and 18 (-23.7 vs -25.4 p=0.03) (see table 1). Segment 13 trended to significance at 12 months (-28.8 vs -25.2 p=0.068). GLS was reduced at 12 months consistent with previous results. Significant reductions in longitudinal strain were seen the mid and apical anterior and lateral segments at some time point following exposure to RT. This study suggests a potential dose response relationship between incident radiation dose and reduction in longitudinal strain at the segmental level.Abstract 2104; Table 1Region of LVComponent of LV WallLV SegmentAverage Mean radiation dose (Gy)Significant reduction at 6 weeksSignificant reduction at 12 monthsBasalAnterior12.5Septal22.131.4Inferior41.1Lateral51.3xx61.9MidAnterior78.7Septal85.192.4Inferior102.0Lateral112.4x124.5xApicalAnterior1331.2xSeptal1420.9158.5Inferior166.5xLateral1710.4x1823.1xX denote significant reductions in longitudinal strain at 6 weeks, and 12 months post RT. Open table in a new tab

Objective To investigate if the extent of lumbar segmental motion is correlated with the recovery process in the form of pain intensity in patients with acute single level lumbar disc herniation (LDH). Methods A retrospective review of medical records was performed on patients presented with acute low back pain from January 2011 to December 2017. With prerequisites of undergoing both lumbar spine magnetic resonance imaging and functional radiography, patients with etiologies other than single level LDH were excluded. A total of 46 patients were selected, including 27 patients with disc herniation at L4-5 level and 19 patients at L5-S1 level. Pearson correlation analysis of pain intensity against segmental range of motion (sROM) and percentage of sROM of each lumbar segment was performed at the initial evaluation point and follow-ups. Results Serial documentation of pain intensity and functional radiography exhibited an inverse correlation between changes in visual analogue scale (VAS) and sROM in single level LDH at L4-5 level (r=-0.69, p<0.05). In addition, percentage of sROM showed a negative correlation with pain intensity at the aforementioned segment (r=-0.74, p<0.05). Initial pain intensity was also inversely correlated to sROM of the affected segment (r=-0.83, p<0.01 at L4-5; r=-0.82, p<0.05 at L5-S1). Conclusion Improvement in sagittal mobility of the affected segment in LDH adequately reflected mitigation of low back pain during the recovery process. This conjunction could illustrate that the involved segment is overcoming natural immobilization, evidently demonstrating an inverse relationship between initial pain intensity and limitation of sagittal range of motion.

S1171ESTRO 37parameters between strategies (Wilcoxon's signed rank test; α=0.05). ResultsStrategy A reduced the underestimation of the reconstructed displacement significantly by on average 1.3% (range: 0%-4%) of the true motion amplitude, compared with strategy B. The average RC improved significantly by 1.3% from 94.2 % to 95.5 % when adopting strategy A; The average IBV remained the same, 1.6 mm.The average S was virtually the same for both strategies A (0.85) and B (0.86) (Figure 2). ConclusionHalf-size amplitude binning reduced the reconstructed motion underestimation with no loss in 4DMRI quality compared with equal-size amplitude binning.

Reduction in left ventricular global and segmental myocardial strain following tangential radiotherapy (RT) for left sided breast cancer treatment has been demonstrated using advanced echocardiographic techniques. This study aimed to determine if cardiac MRI (CMR), a more sensitive and precise imaging modality, could detect similar changes in segmental myocardial strain as per the American Heart Association(AHA) 16 segment model of the left ventricle in left sided breast cancer patients, and correlate this to RT dose. For 21 patients receiving left-sided breast RT, two serial CMR scans were obtained; immediately prior, and 4-6 weeks following RT. Single breath-hold Steady-State Free Precession (SSFP) Cine 2, 3, 4 chamber and short axis views were acquired, and using cvi42 tissue tracking software, two independent readings of 2D and 3D strain values were obtained, with the average being used for analysis. A linear mixed effects model was used to account for potential clustering of values between patients and segments. Multiple RT dosimetric values (including mean, max, V25) of each segment were calculated and their relationship with delta 2D/3D strain values explored. Median age was 59 years (range 38-76 years). Comprehensive nodal treatment using modified wide tangents using a deep inspiration breath hold technique (n=1) and the remainder received tangential breast radiation alone (n=20). No patient received chemotherapy. Two patients received 50Gy in 25 fractions, with 19/21 receiving 42.4Gy in 16 fractions. Median mean heart dose was 2.6Gy (1.5-3.9Gy). No difference was found between any pre and post RT strain parameters. These results are summarised in the table below.Abstract TU_12_3436: Table 1Strain ParameterPre-RT MeanPost-RT MeanDifference95% CIRadial 2D (Short Axis)54.5950.23-3.43[-8.8, 1.9]Circumference 2D (Short Axis)-23.11-22.150.73[-0.51, 2.0]Radial 2D (Long Axis)48.5647.460.07[-3.7, 3.8]Longitudinal 2D (Long Axis)-22.45-22.27-0.08[-0.80, 0.63]Radial 3D40.7737.85-2.17[-7.4, 3.1]Circumference 3D-20.05-19.200.72[-0.62, 2.1]Longitudinal 3D-19.49-18.920.47[-0.79, 1.7]Note the calculated differences are modelled quantities taking into account patients as a random effect and missing data. Therefore values in Difference column are not equal to pre RT mean minus post RT mean. When correlated with several radiation measures, there were no significant relationships between any radiation parameters and change in serial strain. Open table in a new tab Note the calculated differences are modelled quantities taking into account patients as a random effect and missing data. Therefore values in Difference column are not equal to pre RT mean minus post RT mean. When correlated with several radiation measures, there were no significant relationships between any radiation parameters and change in serial strain. No differences in left ventricular segmental strain were detected using CMR 4-6 weeks following left-sided breast radiotherapy, nor was there a clear relationship between RT dose and delta strain. Changes below the threshold of CMR detection given the lower temporal scanning resolution of CMR cannot be excluded. Longer term follow-up of this cohort will help determine if more delayed effects of radiation on LV function become manifest.