Impact of the COVID-19 Pandemic on Outcomes for Patients with Lung Cancer Receiving Curative-intent Radiotherapy in the UK

AIMS

Previous work found that during the first wave of the COVID-19 pandemic, 34% of patients with lung cancer treated with curative-intent radiotherapy in the UK had a change to their centre's usual standard of care treatment (Banfill et al. Clin Oncol 2022;34:19-27). We present the impact of these changes on patient outcomes.

MATERIALS AND METHODS

The COVID-RT Lung database was a prospective multicentre UK cohort study including patients with stage I-III lung cancer referred for and/or treated with radical radiotherapy between April and October 2020. Data were collected on patient demographics, radiotherapy and systemic treatments, toxicity, relapse and death. Multivariable Cox and logistic regression were used to assess the impact of having a change to radiotherapy on survival, distant relapse and grade ≥3 acute toxicity. The impact of omitting chemotherapy on survival and relapse was assessed using multivariable Cox regression.

RESULTS

Patient and follow-up forms were available for 1280 patients. Seven hundred and sixty-five (59.8%) patients were aged over 70 years and 603 (47.1%) were female. The median follow-up was 213 days (119, 376). Patients with stage I-II non-small cell lung cancer (NSCLC) who had a change to their radiotherapy had no significant increase in distant relapse (P = 0.859) or death (P = 0.884); however, they did have increased odds of grade ≥3 acute toxicity (P = 0.0348). Patients with stage III NSCLC who had a change to their radiotherapy had no significant increase in distant relapse (P = 0.216) or death (P = 0.789); however, they did have increased odds of grade ≥3 acute toxicity (P < 0.001). Patients with stage III NSCLC who had their chemotherapy omitted had no significant increase in distant relapse (P = 0.0827) or death (P = 0.0661).

CONCLUSION

This study suggests that changes to radiotherapy and chemotherapy made in response to the COVID-19 pandemic did not significantly affect distant relapse or survival. Changes to radiotherapy, namely increased hypofractionation, led to increased odds of grade ≥3 acute toxicity. These results are important, as hypofractionated treatments can help to reduce hospital attendances in the context of potential future emergency situations.

Ultra-Widefield OCT Angiography

Optical Coherence Tomography Angiography (OCTA), a functional extension of OCT, has the potential to replace most invasive fluorescein angiography (FA) exams in ophthalmology. So far, OCTA's field of view is however still lacking behind fluorescence fundus photography techniques. This is problematic, because many retinal diseases manifest at an early stage by changes of the peripheral retinal capillary network. It is therefore desirable to expand OCTA's field of view to match that of ultra-widefield fundus cameras. We present a custom developed clinical high-speed swept-source OCT (SS-OCT) system operating at an acquisition rate 8-16 times faster than today's state-of-the-art commercially available OCTA devices. Its speed allows us to capture ultra-wide fields of view of up to 90 degrees with an unprecedented sampling density and hence extraordinary resolution by merging two single shot scans with 60 degrees in diameter. To further enhance the visual appearance of the angiograms, we developed for the first time a three-dimensional deep learning based algorithm for denoising volumetric OCTA data sets. We showcase its imaging performance and clinical usability by presenting images of patients suffering from diabetic retinopathy.

Changes in the Management of Patients having Radical Radiotherapy for Lung Cancer during the First Wave of the COVID-19 Pandemic in the UK

AIMS

In response to the COVID-19 pandemic, guidelines on reduced fractionation for patients treated with curative-intent radiotherapy were published, aimed at reducing the number of hospital attendances and potential exposure of vulnerable patients to minimise the risk of COVID-19 infection. We describe the changes that took place in the management of patients with stage I-III lung cancer from April to October 2020.

MATERIALS AND METHODS

Lung Radiotherapy during the COVID-19 Pandemic (COVID-RT Lung) is a prospective multicentre UK cohort study. The inclusion criteria were: patients with stage I-III lung cancer referred for and/or treated with radical radiotherapy between 2nd April and 2nd October 2020. Patients who had had a change in their management and those who continued with standard management were included. Data on demographics, COVID-19 diagnosis, diagnostic work-up, radiotherapy and systemic treatment were collected and reported as counts and percentages. Patient characteristics associated with a change in treatment were analysed using multivariable binary logistic regression.

RESULTS

In total, 1553 patients were included (median age 72 years, 49% female); 93 (12%) had a change to their diagnostic investigation and 528 (34%) had a change to their treatment from their centre's standard of care as a result of the COVID-19 pandemic. Age ≥70 years, male gender and stage III disease were associated with a change in treatment on multivariable analysis. Patients who had their treatment changed had a median of 15 fractions of radiotherapy compared with a median of 20 fractions in those who did not have their treatment changed. Low rates of COVID-19 infection were seen during or after radiotherapy, with only 21 patients (1.4%) developing the disease.

CONCLUSIONS

The COVID-19 pandemic resulted in changes to patient treatment in line with national recommendations. The main change was an increase in hypofractionation. Further work is ongoing to analyse the impact of these changes on patient outcomes.

Alcohol Consumption and Incident Cataract Surgery in Two Large UK Cohorts

Purpose

To examine the association of alcohol consumption and type of alcoholic beverage with incident cataract surgery in 2 large cohorts.

Design

Longitudinal, observational study.

Participants

We included 469 387 participants of UK Biobank with a mean age of 56 years and 23 162 participants of European Prospective Investigation of Cancer (EPIC)-Norfolk with a mean age of 59 years.

Methods

Self-reported alcohol consumption at baseline was ascertained by a touchscreen questionnaire in UK Biobank and a food-frequency questionnaire in EPIC-Norfolk. Cases were defined as participants undergoing cataract surgery in either eye as ascertained via data linkage to National Health Service procedure statistics. We excluded participants with cataract surgery up to 1 year after the baseline assessment visit or those with self-reported cataract at baseline. Cox proportional hazards models were used to examine the associations of alcohol consumption with incident cataract surgery, adjusted for age, sex, ethnicity, Townsend deprivation index, body mass index (BMI), smoking, and diabetes status.

Main Outcome Measures

Incident cataract surgery.

Results

There were 19 011 (mean cohort follow-up of 95 months) and 4573 (mean cohort follow-up of 193 months) incident cases of cataract surgery in UK Biobank and EPIC-Norfolk, respectively. Compared with nondrinkers, drinkers were less likely to undergo cataract surgery in UK Biobank (hazard ratio [HR], 0.89; 95% confidence interval [CI], 0.85–0.93) and EPIC-Norfolk (HR, 0.90; 95% CI, 0.84–0.97) after adjusting for covariables. Among alcohol consumers, greater alcohol consumption was associated with a reduced risk of undergoing cataract surgery in EPIC-Norfolk (P < 0.001), whereas a U-shaped association was observed in the UK Biobank. Compared with nondrinkers, subgroup analysis by type of alcohol beverage showed the strongest protective association with wine consumption; the risk of incident cataract surgery was 23% and 14% lower among those in the highest category of wine consumption in EPIC-Norfolk and UK Biobank, respectively.

Conclusions

Our findings suggest a lower risk of undergoing cataract surgery with low to moderate alcohol consumption. The association was particularly apparent with wine consumption. We cannot exclude the possibility of residual confounding, and further studies are required to determine whether this association is causal in nature.

Biomarker-estimated flavan-3-ol intake is associated with lower blood pressure in cross-sectional analysis in EPIC Norfolk

Flavan-3-ols are a group of bioactive compounds that have been shown to improve vascular function in intervention studies. They are therefore of great interest for the development of dietary recommendation for the prevention of cardio-vascular diseases. However, there are currently no reliable data from observational studies, as the high variability in the flavan-3-ol content of food makes it difficult to estimate actual intake without nutritional biomarkers. In this study, we investigated cross-sectional associations between biomarker-estimated flavan-3-ol intake and blood pressure and other CVD risk markers, as well as longitudinal associations with CVD risk in 25,618 participants of the European Prospective Investigation into Cancer (EPIC) Norfolk cohort. High flavan-3-ol intake, achievable as part of an habitual diet, was associated with a significantly lower systolic blood pressure (- 1.9 (- 2.7; - 1.1) mmHg in men and - 2.5 (- 3.3; - 1.8) mmHg in women; lowest vs highest decile of biomarker), comparable to adherence to a Mediterranean Diet or moderate salt reduction. Subgroup analyses showed that hypertensive participants had stronger inverse association between flavan-3-ol biomarker and systolic blood pressure when compared to normotensive participants. Flavanol intake could therefore have a role in the maintenance of cardiovascular health on a population scale.

Evaluation of (-)-epicatechin metabolites as recovery biomarker of dietary flavan-3-ol intake

Data from dietary intervention studies suggest that intake of (−)-epicatechin mediates beneficial vascular effects in humans. However, population-based investigations are required to evaluate associations between habitual intake and health and these studies rely on accurate estimates of intake, which nutritional biomarkers can provide. Here, we evaluate a series of structurally related (−)-epicatechin metabolites (SREM), particularly (−)-epicatechin-3′-glucuronide, (−)-epicatechin-3′-sulfate and 3′-O-methyl-(−)-epicatechin-5-sulfate (SREM_B), as flavan-3-ol and (−)-epicatechin intake. SREM_B in urine proved to be a specific indicator of (−)-epicatechin intake, showing also a strong correlation with the amount of (−)-epicatechin ingested (R²: 0.86 (95% CI 0.8l; 0.92). The median recovery of (−)-epicatechin as SREM_B in 24 h urine was 10% (IQR 7–13%) and we found SREM_B in the majority of participants of EPIC Norfolk (83% of 24,341) with a mean concentration of 2.4 ± 3.2 µmol/L. Our results show that SREM_B are suitable as biomarker of (−)-epicatechin intake. According to evaluation criteria from IARC and the Institute of Medicine, the results obtained support use of SREM_B as a recovery biomarker to estimate actual intake of (−)-epicatechin.

Prediction of acute myeloid leukaemia risk in healthy individuals

The incidence of acute myeloid leukaemia (AML) increases with age and mortality exceeds 90% when diagnosed after age 65. Most cases arise without any detectable early symptoms and patients usually present with the acute complications of bone marrow failure1. The onset of such de novo AML cases is typically preceded by the accumulation of somatic mutations in preleukaemic haematopoietic stem and progenitor cells (HSPCs) that undergo clonal expansion2,3. However, recurrent AML mutations also accumulate in HSPCs during ageing of healthy individuals who do not develop AML, a phenomenon referred to as age-related clonal haematopoiesis (ARCH)4-8. Here we use deep sequencing to analyse genes that are recurrently mutated in AML to distinguish between individuals who have a high risk of developing AML and those with benign ARCH. We analysed peripheral blood cells from 95 individuals that were obtained on average 6.3 years before AML diagnosis (pre-AML group), together with 414 unselected age- and gender-matched individuals (control group). Pre-AML cases were distinct from controls and had more mutations per sample, higher variant allele frequencies, indicating greater clonal expansion, and showed enrichment of mutations in specific genes. Genetic parameters were used to derive a model that accurately predicted AML-free survival; this model was validated in an independent cohort of 29 pre-AML cases and 262 controls. Because AML is rare, we also developed an AML predictive model using a large electronic health record database that identified individuals at greater risk. Collectively our findings provide proof-of-concept that it is possible to discriminate ARCH from pre-AML many years before malignant transformation. This could in future enable earlier detection and monitoring, and may help to inform intervention.

Evaluation at scale of microbiome-derived metabolites as biomarker of flavan-3-ol intake in epidemiological studies

The accurate assessment of dietary intake is crucial to investigate the effect of diet on health. Currently used methods, relying on self-reporting and food composition data, are known to have limitations and might not be suitable to estimate the intake of many bioactive food components. An alternative are nutritional biomarkers, which can allow an unbiased assessment of intake. They require a careful evaluation of their suitability, including: (a) the availability of a precise, accurate and robust analytical method, (b) their specificity (c) a consistent relationship with actual intake. We have evaluated human metabolites of a microbiome-derived flavan-3-ol catabolite, 5-(3',4'-dihydroxyphenyl)-[gamma]-valerolactone (gVL), as biomarker of flavan-3-ol intake in large epidemiological studies. Flavan-3-ols are widely consumed plant bioactives, which have received considerable interest due to their potential ability to reduce CVD risk. The availability of authentic standards allowed the development of a validated high-throughput method suitable for large-scale studies. In dietary intervention studies, we could show that gVL metabolites are specific for flavan-3-ols present in tea, fruits, wine and cocoa-derived products, with a strong correlation between intake and biomarker (Spearman's r = 0.90). This biomarker will allow for the first time to estimate flavan-3-ol intake and further investigation of associations between intake and disease risk.

Hot or not? The 10% rule in sentinel lymph node biopsy for malignant melanoma revisited

BACKGROUND

The surgeon needs a practical rule to follow when deciding whether to excise a lymph node during sentinel node biopsy (SLNB). The "10% rule" dictates that all nodes with a radiation count of greater than 10% of the hottest node and all blue nodes should be removed, and this study observes the effects of following this rule in SLNB in melanoma.

METHODS

We reviewed the records of 665 patients with primary melanoma who underwent sentinel lymph node over a 5-year period (2007-2011).

RESULTS

2064 nodes were identified in 898 nodal basins in 665 patients. 141 (21%) patients had at least one positive sentinel node. 105 positive nodal basins were identified in which more than one sentinel node was removed. In 18 of these, a less radioactive node was positive for tumour when the most radioactive node was negative. Of 175 positive nodes 157 (90%) contained blue dye staining. For cases in which the positive sentinel node was not the hottest node, the positive node had apparent blue dye staining in all 18 cases (100%), and was the second hottest node in the basin.

CONCLUSION

In this series removing just the hottest node and all blue nodes would not have missed a single positive basin and would have resulted in a 38% reduction in the number of nodes removed compared to those taken following the 10% rule, without changing the staging in any patient.

Results of a national training programme in sentinel lymph node biopsy for breast cancer

BACKGROUND

New Start, a structured, validated, multidisciplinary training programme in sentinel lymph node biopsy (SLNB), was established to allow the introduction and rapid transfer of appropriate knowledge and technical skills to ensure safe and competent practice across the UK.

METHODS

Multidisciplinary teams attended a theory/skills laboratory course, following which they performed 30 consecutive SLNBs, either concurrently with their standard axillary staging procedure (training model A) or as stand-alone SLNB (training model B). SLNB was performed according to a standard protocol using the combined technique of isotope ((99m) Tc-labelled albumin colloid) and blue dye. An accredited New Start trainer mentored the first five procedures in the participant's hospital, or all 30 if stand-alone. Validation standards for model A and B were a localization rate of at least 90 per cent. In addition, for model A only, in which a minimum of ten patients were required to be node-positive, a false-negative rate (FNR) of 10 per cent or less was required.

RESULTS

From October 2004 to December 2008, 210 SLNB-naive surgeons, in 103 centres, performed 6685 SLNB procedures. The overall sentinel lymph node (SLN) localization rate was 98·9 (95 per cent confidence interval 98·6 to 99·1) per cent (6610 of 6685) and the FNR 9·1 (7·9 to 10·5) per cent (160 of 1757). The FNR was related to nodal yield, ranging from 14·8 per cent for one node and declining to 9·7, 6·6, 4·7 and 4·1 per cent for two, three, four and more than four SLNs respectively. No learning curve was identified for localization or FNR.

CONCLUSION

The programme successfully trained a wide range of UK breast teams to perform safe SLNB and suggested that a standard injection protocol and structured multidisciplinary training can abolish learning curves.

Sources of pre-analytical variations in yield of DNA extracted from blood samples: analysis of 50,000 DNA samples in EPIC

The European Prospective Investigation into Cancer and nutrition (EPIC) is a long-term, multi-centric prospective study in Europe investigating the relationships between cancer and nutrition. This study has served as a basis for a number of Genome-Wide Association Studies (GWAS) and other types of genetic analyses. Over a period of 5 years, 52,256 EPIC DNA samples have been extracted using an automated DNA extraction platform. Here we have evaluated the pre-analytical factors affecting DNA yield, including anthropometric, epidemiological and technical factors such as center of subject recruitment, age, gender, body-mass index, disease case or control status, tobacco consumption, number of aliquots of buffy coat used for DNA extraction, extraction machine or procedure, DNA quantification method, degree of haemolysis and variations in the timing of sample processing. We show that the largest significant variations in DNA yield were observed with degree of haemolysis and with center of subject recruitment. Age, gender, body-mass index, cancer case or control status and tobacco consumption also significantly impacted DNA yield. Feedback from laboratories which have analyzed DNA with different SNP genotyping technologies demonstrate that the vast majority of samples (approximately 88%) performed adequately in different types of assays. To our knowledge this study is the largest to date to evaluate the sources of pre-analytical variations in DNA extracted from peripheral leucocytes. The results provide a strong evidence-based rationale for standardized recommendations on blood collection and processing protocols for large-scale genetic studies.

Abstract P1-01-01: Learning Sentinel Node Biopsy in the UK: Results of the NEW START Training Program

Background: NEW START-a structured, validated multi-professional surgical training programme, was established to allow rapid transfer of appropriate knowledge and technical skills to ensure safe and competent practice of sentinel lymph node biopsy (SLNB) across the UK.

Methods: Multi-professional teams attended a theory/skills-lab course delivering a standardized educational package, following which they performed SLNB in 30 consecutive patients, either concurrently with their standard axillary staging procedure — mentorship training model-or as stand-alone SLNB — apprenticeship training model. An accredited NEW START trainer mentored the first 5 procedures in the participants’ hospital, or all 30 if stand-alone. Validation standards were a localization rate of ≥90% and in the mentorship program where a minimum of 10 cases were node positive, a false-negative rate of ≥10%. SLNB was performed according to a standardised protocol using the combined technique of isotope (0.05-0.1ml of 99mTc-albumin colloid — Nanocoll®) and blue dye (Patent blue V) injected into the tumour quadrant peri-areolar tissue. Isotope was injected intra-dermally and static scintigraphic images were obtained, blue dye was injected sub-dermally after anaesthetic induction.

Results: From October 2004 to December 2008, 210 SLNB naive surgeons, in 103 centres, performed 6,685 SLNB procedures of which 31% (2,098/6,685) were node positive. The mentorship training model was followed in 87% (5,849/6,685). Scintigraphy identified axillary lymph node drainage in 85% (5,564/6,511) with an overall SLN localization rate of 98.9% (6,610/6,685, 95% CI 98.6% to 99.1%). Node positivity was higher (P&lt;0.001) for failed (58.7%, 44/75) than successful (31.1%, 2054/6610) localizations. The mentorship false negative rate (FNR) was 8.9% (163/1821, 95% CI 7.7% to 10.4%). The median SLN yield was 2.0 (range 1-11).

SLN localization and FNR improved with surgeon caseload so that after 20 procedures the FNR fell below 10% but no statistically significant learning curve was identified. The FNR patients who had one SLN harvested was 14.8%. The FNR rate declined to 9.4%, 6.3%, 4.5% and 4.0% for those patients with 2, 3, 4 and more than 4 SLNs removed.

Conclusion: NEW START demonstrates that a standardized injection protocol and structured multi-professional training can abolish learning curves so ensuring patient safety during national adoption of a new technique. Tumor quadrant injection using both isotope and dye has a high localization rate and low false-negative rate. Failed localization indicates higher probability of axillary nodal involvement. It is not necessary to remove more than 4 SLNs to achieve a FNR of less than 5%.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-01-01.

Mycoplasma Mastitis: A Review of Transmission and Control

The Mycoplasma sp. that cause mastitis are simple, cell wall-less, bacteria that can colonize and cause diseases in other extramammary sites in the bovine. Prevalence of mycoplasma mastitis appears to be increasing in many locations throughout the world. The best method to identify this group of pathogens is through direct culture on mycoplasma agar media. However, limitations with this culture procedure are the duration of culture, 10 days, special conditions required and thus added expense, and the lack of primary specificity to distinguish between true pathogens and commensal organisms. Thus culture of bulk tank milk samples has been advocated as a primary screening method to determine the mycoplasma status of a herd. This monitoring system is reasonably successful but the sensitivity of detection of Mycoplasma sp. in bulk tank milk is affected by a significant minority of cows that might shed the organism at levels below the threshold of detection. Contagious mastitis control procedures have been effective in controlling outbreaks of mycoplasma mastitis. Yet new methods of control might be warranted, methods that may prevent the outbreak. Current data suggests that a significant number of new outbreaks may occur via internal or animal-to-animal transmission of mycoplasma mastitis pathogens from asymptomatic carriers.

Bulk tank milk analysis: factors associated with appearance of Mycoplasma sp. in milk

Factors associated with the presence of Mycoplasma sp. in bulk tank milk samples were evaluated from 664 herds during 2.25 years. Milk quality components were not strongly related to the presence of Mycoplasma sp. in bulk tank milk. The presence of other contagious mastitis pathogens, Staphylococcus aureus and Streptococcus agalactiae, was also not related to the presence of mycoplasma, suggesting that the aetiology and transmission of mycoplasma mastitis were different from transmission of other contagious mastitis pathogens. The occurrence of the first isolation of mycoplasma from a bulk tank was not correlated to season of the year. Mycoplasma in bulk tank milk samples were more likely to be found in herds shipping more milk, an indirect measure of herd size. This suggests that larger herds are more likely to have mycoplasma mastitis. However, the first appearance of mycoplasma mastitis in a bulk tank sample was followed by a sample without this pathogen in more than 60% of herds. Mycoplasma sp. was not detected in any herd a year after first isolation. These findings suggest that this pathogen could be controlled and eliminated from herds.

Modelling Viscosity and Mass Fraction of Bitumen-Diluent Mixtures

Abstract

The viscosity model is an important component in enhanced oil recovery packages and, for pure bitumen, several accurate models are available. In this study, a simple correlation presented in an earlier publication is extended to predict the viscosity of bitumen-diluent mixtures, as well as the mass fraction required to reduce bitumen viscosity to pumping viscosity.

In developing the viscosity model, viscosities of pure bitumen and diluent were used as the endpoints, and the diluent mass fraction was raised to a power of "n" (a viscosity reduction parameter) to account for the sharp drop in bitumen viscosity with ncrease in diluent mass fraction. The model was developed with 99 data points from three different bitumens and five diluents; spanning a viscosity range of 10 -1−1 to 106 mm2/s.

The model was used to recalculate the viscosity and mass fraction values, and results compared with similar correlations by Cragoe and Chirinos. The best match was obtained with our correlation, with overall average absolute deviations of 12﹪ and 5﹪ for viscosity and mass fraction predictions, respectively. Predictions on data not used in developing the model showed an excellent match between experimental and predicted values, with an overall average absolute deviation of below 10﹪ for viscosities of mixtures at 25 °CDATA[C, 60.3 °CDATA[C, and 82.6 °CDATA[C.

Introduction

In the recovery of bitumen, viscosity reduction becomes important, both below and above the ground. The addition of a liquid diluent is thought to break down or weaken the intermolecular forces which create high viscosity in bitumen(1). The effect is so dramatic that the addition of even 5﹪ diluent can cause a viscosity reduction in excess of 80%; thus, facilitating the in situ recovery and pipe line transportation of bitumen.

The knowledge of the bitumen-diluent viscosity is highly important, since without it, calculations in upgrading process, in situ recovery, well simulation, heat transfer, fluid flow, and a variety of other engineering problems would be difficult or impossible to solve. This paper presents the development of a simple correlation to predict the viscosity of binary mixtures of bitumen-diluent in any proportion.

Experimental

The data used for the development of the correlation was

TABLE 1: Bitumen data at 30 °CDATA[C. Available In Full Paper.

TABLE 2: Diluent data at 30 °CDATA[C. Available In Full Paper.

obtained from Wallace et al.(2) and Wallace and Henry(3). The data consisted of a total of 99 points obtained from three bitumens and five diluents, respectively, listed in Tables 1 and 2.

Each of these bitumen samples was diluted at 30 °CDATA[C to 5, 10, 25, 50 and 75 weight ﹪ diluent with each of the diluents. After mixing, the samples were reweighed, and any weight loss was attributed to solvent evaporation. The diluent weight fractions were adjusted accordingly, and the viscosities of the mixtures measured. For a detailed account of experimental procedures, refer to Wallace and Henry(3).

Correlation Development

Many correlations have been developed to predict the viscosity characteristics of bitumen-diluent mixtures(1 -6). While several have been successful in making these predictions, most are cumbersome to use.

Gantry angulation in brain CT: dosage implications, effect on posterior fossa artifacts, and current international practice

The aim of this study was first to determine the effect of use of different scan planes at computed tomography (CT) of the brain on lens radiation dose and on severity of posterior fossa artifact. Twenty patients requiring nonenhanced and contrast material-enhanced brain CT scanning were selected. Each was scanned with two different beam angulations, one passing through the eyes and one avoiding them, and the resulting radiation doses were measured. Angling of the beam to avoid the orbit reduced the dose by 87%, while the severity of posterior fossa artifacts was not significantly different. Second, the implications of these results was assessed by means of an international questionnaire survey of current scanning technique. Only 32% of the respondents routinely avoided the eye during brain CT. No single scan plane was accepted by the respondents as being superior in terms of minimizing posterior fossa artifact. The authors conclude that the potential exists for a reduction in lens dose after reappraisal of radiologic practice in brain CT.

A gamma camera method to monitor the use of degradable starch microspheres in hepatic arterial chemotherapy

A gamma camera method to quantify the haemodynamic effects of degradable starch microspheres (DSM) in intra arterial hepatic therapy is described. Results are presented from ten patients with colorectal liver metastases. Intra hepatic arterio venous shunting was present in 1 patient prior to DSM and in 2 subjects after three 300 mg DSM fractions. DSM reduced the rate of flow of injectate to the lung in all cases. Conversely, an increased rate of flow of injectate to gut or spleen occurred with 300 mg fractions of DSM in 7/9 cases. Lower dose DSM fractions are indicated. At 2-3 min after DSM injection the mean fraction of the activity retained in the liver was 0.22. A DSM induced enhancement of tumour relative to normal tissue perfusion was obtained in four out of five tumour regions identified. All indices showed a wide variation between patients and between individual DSM doses, and the high incidence of extra hepatic shunting confirms the need for monitoring when using intra arterial microspheres.

Fatal pulmonary transfusion reaction to plasma containing donor HLA antibody

A 55-year-old woman with common variable immunodeficiency and mild chronic obstructive lung disease received 3 units of plasma as immunoglobulin replacement therapy. During the administration of the final unit, her temperature rose 1 degree C, with no other observable symptoms. Fifteen minutes later she developed shortness of breath without nausea, vomiting, rash, or pruritus. In 30 min she lost consciousness, was breathless, and cyanotic. Resuscitative efforts failed. Autopsy failed to pinpoint a cause of death. There was no evidence of ABO or Rh incompatibility, bacterial contamination, or hemolysis. There were no neutrophil, platelet or IgA antibodies detectable in the patient or the 3 plasma donors. There were no lymphocytotoxic HLA antibodies in the patient or two of the plasma donors. The third donor had HLA-B35 lymphocytotoxic antibodies that did not agglutinate or aggregate neutrophils. The patient's HLA type was A2, A3; B35, B40. Lymphocytotoxic crossmatches using lymphocytes of the patient were positive with plasma from the third donor but negative with the other two. An eluate prepared from post-mortem lung parenchymal tissue was cytotoxic to 7 of 8 panel lymphocytes positive for the HLA-B35 antigen but not with cells lacking B35. The implicated plasma donor was healthy with a history of 6 pregnancies. This case report illustrates the potential hazard of transfusion of plasma containing HLA antibodies.

Pulmonary permeability in coeliac disease and inflammatory bowel disease

Respiratory disease and subclinical pulmonary abnormalities are recognised complications of both coeliac disease (CD) and inflammatory bowel disease (IBD) but the pathogenesis of the lung disease remains uncertain. We have studied lung function, including permeability measured by clearance of inhaled technetium-99m diethylene triamine pentaacetic acid in 25 patients with IBD, 18 patients with CD on a gluten-free diet, and in 20 normal controls, all without respiratory symptoms. In IBD there was evidence of obstruction to airflow (mean forced expiratory volume in 1 s/forced vital capacity equals 75.8%, control 81%; p less than 0.05) but no change in pulmonary permeability (half-time clearance equals 70.3 vs. 69.2 min). In CD airflow was not significantly different from control (forced expiratory volume in 1 s/forced vital capacity equals 80%) but there was an increase in pulmonary permeability (half-time clearance equals 48.9 min; p less than 0.01). These findings suggest that the mechanisms of lung disease in CD differs from that in IBD and supports the hypothesis of a common mucosal defect in lung and small intestine in CD allowing increased permeability.

Measures of the inflammatory response in cryptogenic fibrosing alveolitis

Cryptogenic fibrosing alveolitis (CFA) is characterized by interstitial fibrosis and parenchymal inflammation. Eleven patients with CFA (10 proved by lung biopsy) were followed over 2 yr using clinical symptoms, radiographic change, and pulmonary function tests to adjust their treatment. Lung lavage, positron camera (PET) measurements of regional extravascular lung density (Dev), pulmonary blood volume (Vb), and the metabolic rate for 18F-deoxyglucose (MRglc), clearance of 99mTc-diethylenetriaminepentacetate (99mTc-DTPA) aerosol, and lung uptake of 67Ga were measured initially and at the end of the first year to give a profile of the inflammatory response. Compared with normal subjects, there was an increased percentage of neutrophils and eosinophils in the lung lavage, increased Dev (p less than 0.002) with no significant difference in Vb, increased MRglc (p less than 0.02), 99mTc-DTPA clearance (p less than 0.002), and 67Ga uptake (p less than 0.02). The smallest increases in Dev were seen in the two patients with most destruction shown by lung biopsy. There were inverse correlations between Dev and both FVC and TLC, but a direct correlation between Vb and transfer factor. 99mTc-DTPA clearance changed concordantly with clinical status and radiographic and respiratory function changes during the first year. If glucose utilization (MRglc) remained in the normal range between the initial and first yearly assessment, the patient improved or remained stable during the second year as shown by clinical status and radiographic and respiratory function measurements. If it rose or remained high, the patient's condition deteriorated.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of methacholine induced bronchoconstriction on the pulmonary distribution and plasma pharmacokinetics of inhaled sodium cromoglycate in subjects with normal and hyperreactive airways

Inhalation treatment may be less effective in the presence of bronchoconstriction because of the reduced penetration of drugs into the airways. The effect of bronchoconstriction on the lung deposition and plasma pharmacokinetics of inhaled sodium cromoglycate was examined. Ten subjects attended the laboratory on three occasions. On the first occasion a bronchial provocation test was performed to determine the concentration of methacholine required to reduce the forced expiratory volume in one second (FEV1) by 20% (PC20). On the two subsequent occasions subjects inhaled either saline or their PC20 methacholine, followed five minutes later by an aerosol containing sodium cromoglycate and stannous phytate labelled with technetium-99m. Twenty minutes later a gamma emission lung scan was performed to determine the intrathoracic deposition of the nebulised aerosol. The central:peripheral (C:P) ratio of lung deposition was then calculated. Measurements of FEV1 were made and blood samples taken for analysis of plasma sodium cromoglycate concentration at intervals for four hours. Methacholine led to a 23.4% (SEM 0.6%) lower FEV1 and a 2.8 times higher C:P ratio than those observed after saline. There was a direct correlation between log PC20 methacholine and the increase in the C:P ratio (r = 0.81). Despite these changes with methacholine, the plasma pharmacokinetics of inhaled sodium cromoglycate were not significantly different after methacholine and after saline, except that the maximum concentration achieved (Cmax) was increased. These observations suggest that the area of cromoglycate deposition and the anatomical site are less important in determining the plasma pharmacokinetics of cromoglycate than is the total dose delivered to the lung.

Corticosteroid treatment in pulmonary sarcoidosis: do serial lavage lymphocyte counts, serum angiotensin converting enzyme measurements, and gallium-67 scans help management?

Thirty two patients with persisting pulmonary sarcoidosis fulfilling defined criteria for treatment were managed according to a standard clinical protocol. In this an attempt was made to achieve and maintain maximal radiographic and physiological improvement with individually titrated doses of corticosteroids. Lavage cell counts, serum angiotensin converting enzyme (SACE) determinations, and gallium-67 scans were planned at standard intervals but were not used in management decisions. The study analysed serial measurements in relation to changes in the clinical measurements. Twelve patients' radiographs showed complete clearing, seven cleared partially, and 13 had partial clearing with evidence of fibrosis. There was no predictive value in the initial lavage lymphocyte counts or the SACE or gallium measurements. Notably, in seven patients, substantial radiographic improvement was observed when the initial lavage lymphocyte counts were normal. Higher initial lavage neutrophil counts (p less than 0.02), higher initial radiographic profusion scores (p less than 0.02), and lower vital capacity (p less than 0.01) and carbon monoxide transfer factor (p less than 0.05) were related to incomplete clearing. A repeat study of the patients when their radiograph had cleared maximally showed that the levels of lavage lymphocytes, SACE, and gallium tended to fall, but frequently remained raised even in the presence of a normal radiograph or vital capacity or both. On the other hand, however, most of the patients with a normal lavage lymphocyte count showed persisting abnormality of the radiograph, lung function measurements, SACE, and gallium scan (or of at least one of these indices). The interrelationships between changes in clinical indices (radiograph, vital capacity, and transfer factor) and in lavage lymphocyte counts, SACE, and gallium scans showed that concordance was fairly poor in each comparison; lavage lymphocytes showed a greater major discordance than did the other pairs of measurements. Symptom free patients with normal or stable radiographic appearances have been followed for many months and have shown no clinical deterioration despite abnormal lavage lymphocyte counts, SACE, and gallium scans. Radiographic relapse, within the criteria defined, was seen in only four patients during the study; this was reflected in the gallium counts in three and in SACE and lavage lymphocyte counts measurements in two. It is concluded that serial lavage lymphocyte counts, serum angiotensin converting enzyme measurements, and gallium-67 scans are not consistently more sensitive methods by which to monitor patients with sarcoidosis during treatment than are serial measurements of high quality radiographs and results of standard lung function tests.

Changes in neutrophil aggregation and chemotaxis response during 18-hour cold storage

Providing neutrophil transfusions to septic neonatal patients with depleted neutrophil reserves can be troublesome and require unscheduled blood donations. Buffy coats from stored whole blood are a potential source of neutrophils provided they remain viable during the interval between the whole blood collection and the buffy coat production. This study determined neutrophil function during storage of whole blood at 4 degrees C for 18 hours. Whole blood pH, hematocrit, platelet, and white cell counts remained unchanged. Chemotactic response to formyl methionyl leucyl penylalanine (FMLP) declined from 172.5 +/- 29 units (mean +/- SD) to 125 +/- 48 at 9 hours and 63.6 +/- 48 (p less than 0.05) at 18 hours. Aggregation response to FMLP remained normal for 9 hours but dropped to 15.5 percent of normal after 18 hours. Neutrophil response to cytaxins was maintained for at least 9 hours during storage of whole blood at 4 degrees C but seriously declined within 18 hours. Limiting 4 degrees C storage of whole blood to 9 hours prior to preparing buffy coats may provide flexibility needed for urgent provision of neutrophil transfusions.

Successful retransplantation of bone marrow following failure of initial engraftment in a patient with aplastic anemia

Histobompatible sibling bone marrow was transplanted to a patient withsevere aplastic anemia. The first transplant failed, but a second transplantfrom the same donor was successfully performed with a new and more potentimmunosuppressive regimen. Successful retransplantation after marrow graftrejection is now possible.