Assessment of therapy efficacy using animal models of tumorigenic cancer requires the ability to accurately measure changes in tumor volume over the duration of disease course. In order to be meaningful, in vivo tumor volume measurements by non-invasive techniques must correlate with tumor volume measurements from endpoint histological analysis. Tumor volume is frequently assessed by endpoint histological analyses approximating the tumor volume with geometric primitives such as spheroids and ellipsoids. In this study we investigated alternative techniques for quantifying histological volume measurements of tumors in a xenograft orthotopic mouse model of human glioblastoma multiforme, and compared these to in vivo tumor volume measurements based on magnetic resonance imaging (MRI) data. Two techniques leveraging three-dimensional (3D) image analysis methods were investigated. The first technique involves the reconstruction of a smoothed polygonal model representing the tumor volume from histological section images and is intended for accuracy and qualitative assessment of tumor burden by visualization, while a second technique which approximates the tumor volume as a series of slabs is presented as an abbreviated process intended to produce quantitatively similar volume measurements with a minimum of effort required on behalf of the investigator. New software (QuickVol) designed for use in the first technique, is also discussed. In cases where tumor growth is asymmetric and invasive, we found that 3D analysis techniques using histological section images produced volume measurements more consistent with in vivo volume measurements based on MRI data, than approximation of tumor volume using geometric primitives. Visualizations of the volumes represented by each of these techniques qualitatively support this finding, and suggest that future research using mouse models of glioblastoma multiforme (genetically engineered or xenograft) will benefit from the use of these or similar alternative tumor volume measurement techniques.

Introduction: Pharmacologic management of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is well-established. Our aim in the current study is to determine if therapy with a positive expiratory pressure (PEP) device with or without an oscillatory mechanism (OM) in addition to standard care results in a reduction in hospital length of stay (LOS) among patients hospitalized for AECOPD. Methods: Two studies were performed and are reported here. Study 1: Patients admitted with AECOPD and sputum production were enrolled in a prospective trial comparing PEP therapy versus Oscillatory PEP (OPEP) therapy. Study 2: A retrospective historical cohort, matched in a 2 to 1 manner by age, gender, and season of admission, was compared with the prospectively collected data to determine the effect of PEP ± OM versus standard care on hospital LOS. Results: In the prospective trial (Study 1; 91 subjects), median hospital LOS was 3.2 (95% CI 3.0-4.3) days in the OPEP group and 4.8 (95% CI 3.9-6.1) days in the PEP group (p=0.16). In fully adjusted models comparing the prospective trial data with the retrospective cohort (Study 2; 182 subjects), cases had a median hospital LOS of 4.2 days (95% CI 3.8-5.1) versus 5.2 days (95% CI 4.4-6.0) in controls, consistent with a shorter hospital LOS with adjunctive PEP±OM therapy versus standard care (p=0.04). Conclusion: Adjunctive therapy with a PEP device versus standard care may reduce hospital LOS in patients admitted for AECOPD. Although the addition of an OM component to PEP therapy suggests a further reduction in hospital LOS, comprehensive multicenter randomized controlled trials are needed to confirm these findings. Clinical trial registration number: NCT03094806.

An 87-year-old woman with end-stage renal disease, superior vena cava thrombosis, and anticoagulation therapy with warfarin presented with complaints of tongue swelling and hoarseness. There was no history of trauma. On physical examination, a large, soft, purple-red swelling involving the sublingual space consistent with a hematoma was visualized (Figure). Laboratory values revealed an international normalized ratio level of 8. Within 2 hours from presentation, the patient started complaining of difficulty breathing as the hematoma continued to enlarge, displacing her tongue superiorly and causing airway obstruction.For the diagnosis and teaching points, see page 47. To view the entire collection of Images in Emergency Medicine, visit www.annemergmed.com

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