Imaging Recommendations for Diagnosis, Staging, and Management of Oral Cancer

Oral cavity cancers contribute to a majority of cancers in India. Clinical examination alone cannot determine the deeper extent of the disease; therefore, need for cross-sectional imaging including computed tomography and magnetic resonance imaging becomes indispensable for pre-treatment evaluation to decide optimal plan of management. Oral cavity squamous cell cancers (OSCC) can be treated with surgery alone, whereas deep muscle, neurovascular, osseous, or nodal involvement on imaging suggests advanced disease that requires a combination of surgery, radiation, and/or chemotherapy. Because of the complex anatomy of the oral cavity and its surrounding structures, imaging is crucial for locoregional staging and early detection of distant metastases. Imaging plays indispensable role not only in diagnosis but also in planning the management. An optimal guideline paper for developing countries like India is lacking that not only helps standardize the management but will also assist oncologists make reasonable decisions and reduce the unnecessary imaging. This imaging guideline paper will discuss the optimal imaging in diagnosis and management OSCC for Indian subcontinent.

Multisystem Imaging Recommendations/Guidelines: In the Pursuit of Precision Oncology

With an increasing rate of cancers in almost all age groups and advanced screening techniques leading to an early diagnosis and longer longevity of patients with cancers, it is of utmost importance that radiologists assigned with cancer imaging should be prepared to deal with specific expected and unexpected circumstances that may arise during the lifetime of these patients. Tailored integration of preventive and curative interventions with current health plans and global escalation of efforts for timely diagnosis of cancers will pave the path for a cancer-free world. The commonly encountered circumstances in the current era, complicating cancer imaging, include coronavirus disease 2019 infection, pregnancy and lactation, immunocompromised states, bone marrow transplant, and screening of cancers in the relevant population. In this article, we discuss the imaging recommendations pertaining to cancer screening and diagnosis in the aforementioned clinical circumstances.

Imaging Guidelines and Recommendations for Diagnosis, Surveillance, and Management of Pediatric CNS and Spinal Tumors

Central nervous system (CNS) tumors are the second most common cause of cancer in children when incidence rates of cancer are estimated according to the Indian population dynamics based on 2011 consensus. As per the estimates, CNS tumors account for 20.1% of cancer burden in children aged between 0 and 14 years and 16.8% when 0 to 19 years age group is considered. The most common pediatric brain tumors are astrocytoma and medulloblastoma followed by other embryonal tumors, craniopharyngioma, and ependymal tumors. The incidence of CNS tumors in children from India is similar to the western high-income countries, other than slightly higher incidence of craniopharyngioma in Indian children.

Prognostic Value of Radiological Extranodal Extension Detected by Computed Tomography for Predicting Outcomes in Patients With Locally Advanced Head and Neck Squamous Cell Cancer Treated With Radical Concurrent Chemoradiotherapy

Objective

Extra Nodal Extension (ENE) assessment in locally advanced head and neck cancers (LAHNCC) treated with concurrent chemo radiotherapy (CCRT) is challenging and hence the American Joint Committee on Cancer (AJCC) N staging. We hypothesized that radiology-based ENE (rENE) may directly impact outcomes in LAHNSCC treated with radical CCRT.

Materials and Methods

Open-label, investigator-initiated, randomized controlled trial (RCT) (2012–2018), which included LAHNSCC planned for CCRT. Patients were randomized 1:1 to radical radiotherapy (66–70 grays) with concurrent weekly cisplatin (30 mg/m²) [cisplatin radiation arm (CRT)] or same schedule of CRT with weekly nimotuzumab (200 mg) [nimotuzumab plus CRT (NCRT)]. A total of 536 patients were accrued and 182 were excluded due to the non-availability of Digital Imaging and Communications in Medicine (DICOM) computed tomography (CT) data. A total of 354 patients were analyzed for rENE. Metastatic nodes were evaluated based on five criteria and further classified as rENE as positive/negative based on three-criteria capsule irregularity with fat stranding, fat invasion, and muscle/vessel invasion. We evaluated the association of rENE and disease-free survival (DFS), loco-regional recurrence-free survival (LRRFS), and overall survival (OS).

Results

A total of 244 (68.9%) patients had radiologically metastatic nodes (rN), out of which 140 (57.3%) had rENE. Distribution of rENE was balanced in the two study groups CRT or NCRT (p-value 0.412). The median follow-up period was 39 months (ranging from 35.5 to 42.8 months). Complete response (CR) was seen in 204 (57.6%); incomplete response (IR), i.e., partial response plus stable disease (PR + SD), in 126 (35.6%); and progressive disease (PD) in 24 (6.8%). rENE-positive group had poor survival compared to rENE-negative group 3-year OS (46.7% vs. 63.6%), poor DFS (48.8% vs. 87%), and LRRFS (39.9% vs. 60.4%). rENE positive had 1.71 times increased risk of IR than rENE negative. Overall stage, site, clinical metastatic node (cN), response, and rENE were the significant factors for predicting OS, DFS, and LRRFS on univariate analysis. After making adjustment on multivariate analysis, rENE was an independent prognostic factor for DFS and trending to be significant for OS.

Conclusion

Pre-treatment rENE is an independent prognostic marker for survival in patients with LAHNSCC treated radically with CCRT that can be used as a potential predictive marker for response to treatment and hence stratify patients into responders vs. non-responders. We propose the mahajan rENE grading system applicable on CT, magnetic resonance imaging, positron emission tomography–contrast-enhanced CT, and ultrasound.

Prognostic Impact of Pattern of Mandibular Involvement in Gingivo-Buccal Complex Squamous Cell Carcinomas: Marrow and Mandibular Canal Staging System

Purpose

To study the pattern of mandibular involvement and its impact on oncologic outcomes in patients with gingivo-buccal complex squamous cell carcinoma (GBC-SCC) and propose a staging system based on the pattern of bone involvement (MMC: Marrow and mandibular canal staging system) and compare its performance with the 8th edition of the American Joint Committee on Cancer (AJCC8).

Methods

This retrospective observational study included treatment-naïve GBC-SCC patients who underwent preoperative computed tomography (CT) imaging between January 1, 2012, and March 31, 2016, at a tertiary care cancer center. Patients with T4b disease with high infratemporal fossa involvement, maxillary erosion, and follow-up of less than a year were excluded. The chi-square or Fisher’s exact test was used for descriptive analysis. Kaplan–Meier estimate and log-rank test were performed for survival analysis. Multivariate analysis was done using Cox regression analysis after making adjustments for other prognostic factors. p-Value <0.05 was considered as significant. Based upon the survival analysis with different patterns of bone invasion, a new staging system was proposed “MMC: Marrow and mandibular canal staging system”. “Akaike information criterion” (AIC) was used to study the relative fitted model of the various staging (TNM staging—AJCC8) with respect to survival parameters.

Results

A total of 1,200 patients were screened; 303 patients were included in the study. On radiology review, mandibular bone was involved in 62% of patients. The pattern of bone involvement was as follows: deep cortical bone erosion (DCBE) in 23%, marrow in 34%, and marrow with the mandibular canal in 43% of patients. Patients with DCBE and no bone involvement (including superficial cortical) had similar survival [disease-free survival (DFS) and locoregional recurrence-free survival (LRRFS)], and this was significantly better than those with marrow with or without mandibular canal involvement (for both DFS and LRRFS). Patients with DCBE were staged using the MMC, and when compared with the AJCC8, the MMC system was better for the prediction of survival outcomes, as AIC values were lower compared with those of the AJCC8. There was a significant association (p = 0.013) between the type of bone involvement and the pattern of recurrence.

Conclusions

For GBC-SCC, only marrow with or without mandibular canal involvement is associated with poorer survival outcomes. As compared with the AJCC8, the proposed Mahajan et al. MMC staging system downstages DCBE correlates better with survival outcomes.

Role of imaging in surgical decision making in young knee osteoarthrosis

Osteoarthrosis is the most common form of knee arthritis, characterized by pain and discomfort from primarily articular cartilage wear. Traditionally in its end stage, it has been treated with total knee arthroplasty, a permanent process with a life span of ten to fifteen years and challenges with revision. With an increasing longevity and epidemic of obesity that the population is facing, naturally, we are seeing more and more patients with osteoarthrosis at a younger age. This makes it imperative to extend the life of the native knee by conservative measures, injections of steroid, hyaluronic acid, or biologicals and finally a slew of surgical alternatives ranging from joint realignment to partial and total joint replacement. Besides the clinical presentation, decisions are made based on joint alignment, extent and degree of cartilage wear and the status of the subchondral bone. Imaging plays an invaluable role in surgical decision making. In this article, we will discuss how imaging is used in our practice during decision making for the management of the young osteoarthritic knee.

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Prevalence of knee osteoarthrosis is increasing in younger population.

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Surgical treatment of osteoarthrosis at a younger age has its own challenges of need to return to higher levels of physical activity and longer life expectancy.

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Osteoarthrosis is now considered a whole organ dynamic disease.

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Imaging plays an important role in decision making in treatment and management of osteoarthrosis.

Prognostic Significance of EMVI in Rectal Cancer in a Tertiary Cancer Hospital in India

Background  Presence of extramural venous invasion (EMVI) is a poor prognostic factor for rectal cancer as per literature. However, India-specific data are lacking.

Aim  The aim of the study is to determine the prognostic significance of EMVI in locally advanced rectal cancer on baseline MRI.

Materials and Methods  We retrospectively reviewed 117 MRIs of operable non-metastatic locally advanced rectal cancers in a tertiary cancer institute. Three dedicated oncoradiologists determined presence or absence of EMVI, and its length and thickness, in consensus. These patients were treated as per standard institutional protocols and followed up for a median period of 37 months (range: 2–71 months). Kaplan-Meier curves (95% CI) were used to determine disease-free survival (DFS), distant-metastases free survival (DMFS), and overall survival (OS). Univariate analysis was performed by comparing groups with log-rank test.

Results  EMVI positive cases were 34/114 (29%). More EMVI-positive cases developed distant metastasis compared with EMVI-negative cases (14/34–41% vs. 22/83–26%). The difference, however, was not statistically significant ( p  = 0.146). After excluding signet-ring cell cancers ( n  = 14), EMVI showed significant correlation with DMFS ( p  = 0.046), but not with DFS or OS. The median thickness and length of EMVI was 6 and 14 mm, respectively in patients who developed distant metastasis, as compared with 5 and 11 mm in those who did not, although this difference was not statistically significant.

Conclusion  EMVI is a predictor of distant metastasis in locally advanced non-metastatic, non-signet ring cell rectal cancers. EMVI can be considered another high-risk feature to predict distant metastasis.

Role of ultrasound-guided decompression in management of mucoid degeneration of the anterior cruciate ligament

OBJECTIVE

To assess the effectiveness of ultrasound-guided decompression in managing symptomatic mucoid degeneration of the anterior cruciate ligament (ACL).

MATERIALS AND METHODS

Retrospective analysis of 55 patients who underwent ultrasound-guided ACL mucoid degeneration decompression between July 2013 and August 2019. Subjective satisfaction scores were gathered immediately post-procedure for all 55 patients; follow-up satisfaction scores (scale of 0-10, 10 being excellent) were gathered telephonically for 46 patients (83.6%) up to 63 months post-procedure. Follow-up duration of each patient was classified as short (1-6 months), intermediate (7-12 months), or long (more than 12 months) post-procedure. Forty-five patients (81.8%) MRI were retrospectively analyzed and classified into cystic (n = 13, 28.9%), mucoid (n = 11, 24.4%), or mucoid-cystic (21, 46.7%) types. Multivariate logistic regression was used to identify associations between follow-up satisfaction score, follow-up duration, patient age, and type of ACL degeneration.

RESULTS

All patients had immediate marked post-procedure improvement, with excellent (>7/10) satisfaction scores. Forty-six of 55 patients were telephonically followed up: 21 (45.6%) short-term interval, 18 (39.1%) intermediate term, and 7 (15.2%) long-term. Thirty (65.22%) patients had excellent and eight (17.4%) patients had average satisfaction scores at follow-up. Eight (17.4%) patients had poor post-procedure satisfaction scores within six months. There were no significant associations between immediate or follow-up satisfaction score and duration of follow-up, age of patient, or type of ACL degeneration.

CONCLUSION

Ultrasound-guided aspiration, fenestration, and injection are an effective, safe, minimally invasive and radiation-free technique for management of mucoid degeneration of ACL with excellent immediate- and long-term results.

Role of Radiographs and Ultrasound in Diagnosing Calcific Tendinitis and Periarthritis in the Wrist and Hand with Ultrasound-Guided Barbotage as Management Tool

Aim  To demonstrate the role of radiographs and ultrasound (USG) in the diagnosis of calcific tendinitis and periarthritis in the wrist and hand and the efficacy of USG-guided barbotage for its management. Materials and Methods  A retrospective chart review was performed in six patients who presented with acute-onset pain in the wrist and hand varying from 3 days to 2 weeks. Four patients had tenderness over pisiform and two patients had pain along the lateral aspect of the wrist and thumb. Radiographs and USG revealed calcific focus corresponding to the site of pain. USG-guided calcific barbotage and injection was performed for the same and pain relief was assessed immediately and through telephonic follow-up at 6 months using subjective satisfaction score. Data were analyzed using Microsoft Excel 2013. Results  Four patients with tenderness over pisiform had flexor carpi ulnaris calcific tendinitis and two patients with pain along the lateral aspect of the wrist and thumb had first metacarpophalangeal calcific periarthritis and abductor pollicis brevis calcific tendinitis on radiographs as well as USG. In post-USG-guided calcific barbotage and injection, all patients had significant immediate and 6 months delayed relief in symptoms with excellent satisfaction scores. Conclusion  Acute calcific tendinitis/periarthritis is a benign and self-limiting inflammatory condition. Radiographs are extremely helpful in identifying calcific focus. Ultrasonography in experienced hands is the best modality to identify, confirm the symptomatic calcific focus, and perform USG-guided intervention. USG-guided calcific barbotage is the simplest, quickest, and effective way to treat this condition and avoid compromised functional capacity.

Accuracy of MRI for nodal restaging in rectal cancer: a retrospective study of 166 cases

AIM

Assessing metastatic mesorectal nodal involvement is a challenge in rectal cancer, especially in the post chemoradiation setting. We aim to assess the accuracy of MRI for nodal restaging and the validity of SAR criteria (≥ 5 mm size being metastatic).

MATERIALS AND METHODS

This was an IRB-approved retrospective study of 166 patients with locally advanced rectal cancers, operated after neoadjuvant treatment. Two dedicated oncoradiologists reviewed the 166 post-chemoradiation presurgical MRIs in consensus. Nodal size and morphology (shape, margins, and signal intensity) were noted. The most accurate cut-off for size for predicting positive pN status was determined using the Youden index.

RESULTS

MRI understaged 30/166 (18%) and overstaged 40/166 (24%) patients using the SAR criteria. The most accurate cut-off for node size was 5.5 mm, with a sensitivity of 75%, specificity of 60.2%, PPV of 40.7%, NPV of 86.9% (95% CI:78-92.5%), accuracy of 64.2%, and area under the curve (AUC) 0.657 (95% CI-0.524-0.79). Morphological characteristics were not significant to determine involvement, with positive nodes including 42% of round and 31% of oval nodes, 40% of heterogeneous and 45% of homogeneous nodes, and 31% irregularly marginated and 46% nodes with regular margins being positive on pathology. MRI was accurate in predicting pathology for mucinous nodes in 9/29 (31%) cases. Seven cases which were yN2 on MRI and yN0 on pathology demonstrated mucinous changes on MRI and had acellular mucin on histopathology.

CONCLUSIONS

MRI has good negative predictive value, poor positive predictive value and moderate accuracy in nodal restaging. The cut-off of 5.5 mm demonstrated in our study is close to the SAR cut-off of 5 mm in the post-treatment setting. MRI accuracy is lower in patients with mucinous nodes.

Multidisciplinary brain metastasis clinic: is it effective and worthwhile?

Background

Management of brain metastasis is a complex multidisciplinary venture. Hence, we started a multidisciplinary brain metastasis clinic for the opinion on difficult brain metastasis cases. This is the review of the impact of this clinic on the treatment decisions.

Methods

The brain metastasis clinic (BMC) was started in April 2018 and meets once a week. Data of patients discussed between 27th April 2018 and 28th June 2019 were included for this analysis. Treatment decision made by clinicians (before sending the patient to the BMC) was compared with the decisions made in BMC. The decisions were broken on a predefined proforma as the intent of treatment (curative or palliative), modalities planned (surgery, radiation, chemotherapy) and type of therapy planned (details of each therapy) in each modality were collected both pre and post BMCs. In addition, compliance of the respective physicians to BMC decision was also calculated. SPSS version 20 was used for analysis. Descriptive statistics were performed.

Results

Ninety-nine patients were discussed in this time period. The median age was 51 (range 17–68) years. The gender distribution was 70 males (70.7%) and 29 females (29.3%). Lung was the predominant site of malignancy (79, 79.8%). Thirty-one patients (31.3%) had EGFR TKI domain activating mutation, while 17 (17.2%) had anaplastic lymphoma kinase (ALK) rearrangement. The treatment plan was changed in 46 patients (46.5%). The intent of treatment was changed from palliative to curative in 5%. Change in the treatment plan with respect to surgery in 9.1%, radiation in 37.4%, chemotherapy in15.2%, targeted therapy in 22.9% and intrathecal in 6.1% patients, respectively. The compliance with the BMC decision in patients in whom it was changed was 84.8% (39, n = 46).

Conclusion

Multidisciplinary management of difficult brain metastasis cases in specialised clinics has a significant impact on treatment decisions.

Reverse swing-M, phase 1 study of repurposing mebendazole in recurrent high-grade glioma

BACKGROUND

Relapsed high-grade glioma has dismal outcomes. Mebendazole has shown promising activity against glioma in in-vitro and in-vivo studies. Hence, we undertook a phase 1 study to repurpose mebendazole in the treatment of glioblastoma.

METHODS

We conducted a phase 1 study (accelerated titrated design 4) of mebendazole in patients with recurrent glioblastoma (GBM). Patients eligible for re-irradiation were enrolled in arm A1 (radiation with concurrent temozolomide 75 mg/m2 daily during the course of radiation+mebendazole) while patients who were ineligible were enrolled in either arm B1 (CCNU 110 mg/m2 day 1, every 6 weekly + mebendazole) or arm C1 (temozolomide 200 mg/m2 day 1-5, every 4 weekly + mebendazole). The primary endpoint of phase 1 was to identify the MTD of mebendazole in each combination.

FINDINGS

11 patients were enrolled in the whole study. MTD of mebendazole was not reached in arm A1 and C1 and hence the recommended dose for phase 2 was 1600 mg TDS (4800 mg) per day. The MTD of mebendazole in combination with CCNU was 1600 mg TDS (4800 mg) per day and the dose recommended for phase 2 was 800 mg TDS (2400 mg) per day. The three most common adverse events seen in the study were anemia (n = 9, 81.8%), nausea (n = 7, 63.6%), and fatigue (n = 6, 55.5%).

INTERPRETATION

The recommended phase 2 dose of mebendazole is 1600 mg TDS with temozolomide and temozolomide-radiation combination while the dose of 800 mg TDS needs to be used with single-agent CCNU.

Prognostic value of radiological extranodal extension detected by computed tomography for predicting outcomes in head and neck squamous cell cancer patients treated with radical chemoradiotherapy

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Background: As per the AJCC 8th edition ENE/ECS is the most important predictor for N staging of HNSCC and is one of the key predictor of outcomes. Because ENE/ECS is based on pathological findings after surgery and it is difficult to predict outcomes for locally advanced squamous head and neck cancer (LASHNC) treated radically with CCRT. We hypothesized that ENE assessed by CT imaging (rENE) may directly correlate with outcomes in LASHNC treated radically with CCRT. Methods: This open-label, investigator-initiated, phase 3, randomized trial was conducted from 2012 to 2018. Adult patients with LASHNC who were fit for radical chemoradiation were randomized 1:1 to receive either radical radiotherapy (66-70 grays) with concurrent weekly cisplatin (30 mg/m2) (CRT) or the same schedule of CRT with weekly nimotuzumab (200 mg) (NCRT). 536 patients were accrued,182 were excluded due to non-availability DICOM CT scan, 354 patients were analysed for rENE (based on 6 criterion for metastasis and 3 for rENE). Near equal distribution of patients was achieved in CRT arm (170 patients) and NCRT arm (184 patients). There were 181 (51.1%) oropharynx and 173(48.9%) larynx and hypopharynx patients. We evaluated association of radiological ENE and clinical outcomes.The endpoints were disease-free survival (DFS), duration of locoregional control (LRC), and overall survival (OS). Results: There were 244(68.9%) patients with radiologically metastatic nodes, out of which 140(57.3%) had rENE. There was no significant association between rENE and CRT (p value 0.3) or NCRT (p value 0.412). The median follow-up was 33.0 months (95%CI 30.7-35.2 months). Complete response was achieved in 204 (57.6%) cases, PR/SD in 126(35.6%) cases and PD in 24(6.8%) cases. rENE positive patients had poor overall 3-year survival (46.7%), poor DFS (48.8%) and LRC (39.9%) than rENE negative cases (63.6%, 87%, 60.4%). rENE positive cases had 1.71 times increase chances of incomplete response than rENE negative cases. Overall stage, clinical positive node, response, rENE and site were the only significant factors for predicting OS, DFS and LRC. Conclusions: In conclusion, pre-treatment rENE can be regarded as an independent prognostic factor for survival (OS, DFS, LRC) in patients with LASHNC treated radically with CCRT. Pre-treatment rENE is not only associated with CCRT response but is also associated with poor prognosis and hence rENE, as an imaging biomarker, can stratify responder’s vs non-responders. Clinical trial information: CTRI/2014/09/004980 .

LGBT adolescents in America: Depression, discrimination and suicide

Introduction

The mental health of Adolescents in America is a major concern for the field of psychiatry. In particular, Lesbian, Gay, Bisexual and Transgender (LGBT) adolescents are at higher risk of adverse mental health outcomes. This is largely attributed to “minority stress” and from outright bullying and discrimination. In this presentation, this link between bullying and depression will be explored.

Objectives

By the end of this presentation, the audience will be able to better understand the link between anti-LGBT bullying and mental illness and identify the ways to help their patients.

Methods

This presentation is informed by a literature search from PubMed In addition, it is informed by a symposium previously done at the American Psychiatric Association (APA) annual meeting in 2014.

Results

There is clear evidence in the literature that bullying of LGBT adolescents is pervasive. In addition, LGBT people are more likely to be depressed than their heterosexual counterparts. This combination has led to 4-5 times higher rates of attempted suicide by LGBT adolescents. Having Gay-Straight Alliances in schools, supportive teachers and school administrators, and broader anti-discrimination legislation has a protective effect on this.

Conclusion

LGBT adolescents are exposed to more stress by being a minority in society and by being explicitly bullied and discriminated against. This can lead to depression in some of these adolescents, and can also lead to suicide in the most vulnerable among them. There are proven ways to reduce these risks, and psychiatrists have a role to play in advocating for these reforms.

Disclosure of interest

The author has not supplied his declaration of competing interest.

Imaging in oral cancers: A comprehensive review

This review aims at simplifying the relevant imaging anatomy, guiding the optimal imaging method and highlighting the key imaging findings that influence prognosis and management of oral cavity squamous cell carcinoma (OSCC). Early OSCC can be treated with either surgery alone while advanced cancers are treated with a combination of surgery, radiotherapy and/or chemotherapy. Considering the complex anatomy of the oral cavity and its surrounding structures, imaging plays an indispensable role not only in locoregional staging but also in the distant metastatic work-up and post treatment follow-up. Knowledge of the anatomy with understanding of common routes of spread of cancer, allows the radiologist to accurately determine disease extent and augment clinical findings to plan appropriate therapy. This review aims at simplifying the relevant imaging anatomy, guiding the optimal imaging method and highlighting the key imaging findings that influence prognosis and management.

Proton-driven plasma wakefield acceleration in AWAKE

In this article, we briefly summarize the experiments performed during the first run of the Advanced Wakefield Experiment, AWAKE, at CERN (European Organization for Nuclear Research). The final goal of AWAKE Run 1 (2013-2018) was to demonstrate that 10-20 MeV electrons can be accelerated to GeV energies in a plasma wakefield driven by a highly relativistic self-modulated proton bunch. We describe the experiment, outline the measurement concept and present first results. Last, we outline our plans for the future. This article is part of the Theo Murphy meeting issue 'Directions in particle beam-driven plasma wakefield acceleration'.

Experimental Observation of Proton Bunch Modulation in a Plasma at Varying Plasma Densities

We give direct experimental evidence for the observation of the full transverse self-modulation of a long, relativistic proton bunch propagating through a dense plasma. The bunch exits the plasma with a periodic density modulation resulting from radial wakefield effects. We show that the modulation is seeded by a relativistic ionization front created using an intense laser pulse copropagating with the proton bunch. The modulation extends over the length of the proton bunch following the seed point. By varying the plasma density over one order of magnitude, we show that the modulation frequency scales with the expected dependence on the plasma density, i.e., it is equal to the plasma frequency, as expected from theory.

Experimental Observation of Plasma Wakefield Growth Driven by the Seeded Self-Modulation of a Proton Bunch

We measure the effects of transverse wakefields driven by a relativistic proton bunch in plasma with densities of 2.1×10^{14} and 7.7×10^{14}  electrons/cm^{3}. We show that these wakefields periodically defocus the proton bunch itself, consistently with the development of the seeded self-modulation process. We show that the defocusing increases both along the bunch and along the plasma by using time resolved and time-integrated measurements of the proton bunch transverse distribution. We evaluate the transverse wakefield amplitudes and show that they exceed their seed value (<15  MV/m) and reach over 300  MV/m. All these results confirm the development of the seeded self-modulation process, a necessary condition for external injection of low energy and acceleration of electrons to multi-GeV energy levels.

Acceleration of electrons in the plasma wakefield of a proton bunch

High-energy particle accelerators have been crucial in providing a deeper understanding of fundamental particles and the forces that govern their interactions. To increase the energy of the particles or to reduce the size of the accelerator, new acceleration schemes need to be developed. Plasma wakefield acceleration^1–5, in which the electrons in a plasma are excited, leading to strong electric fields (so called ‘wakefields’), is one such promising acceleration technique. Experiments have shown that an intense laser pulse^6–9 or electron bunch^10,11 traversing a plasma can drive electric fields of tens of gigavolts per metre and above—well beyond those achieved in conventional radio-frequency accelerators (about 0.1 gigavolt per metre). However, the low stored energy of laser pulses and electron bunches means that multiple acceleration stages are needed to reach very high particle energies^5,12. The use of proton bunches is compelling because they have the potential to drive wakefields and to accelerate electrons to high energy in a single acceleration stage¹³. Long, thin proton bunches can be used because they undergo a process called self-modulation^14–16, a particle–plasma interaction that splits the bunch longitudinally into a series of high-density microbunches, which then act resonantly to create large wakefields. The Advanced Wakefield (AWAKE) experiment at CERN^17–19 uses high-intensity proton bunches—in which each proton has an energy of 400 gigaelectronvolts, resulting in a total bunch energy of 19 kilojoules—to drive a wakefield in a ten-metre-long plasma. Electron bunches are then injected into this wakefield. Here we present measurements of electrons accelerated up to two gigaelectronvolts at the AWAKE experiment, in a demonstration of proton-driven plasma wakefield acceleration. Measurements were conducted under various plasma conditions and the acceleration was found to be consistent and reliable. The potential for this scheme to produce very high-energy electron bunches in a single accelerating stage²⁰ means that our results are an important step towards the development of future high-energy particle accelerators^21,22.

Electron acceleration to very high energies is achieved in a single step by injecting electrons into a ‘wake’ of charge created in a 10-metre-long plasma by speeding long proton bunches.

Roles of "Wanting" and "Liking" in Motivating Behavior: Gambling, Food, and Drug Addictions

The motivation to seek out and consume rewards has evolutionarily been driven by the urge to fulfill physiological needs. However in a modern society dominated more by plenty than scarcity, we tend to think of motivation as fueled by the search for pleasure. Here, we argue that two separate but interconnected subcortical and unconscious processes direct motivation: "wanting" and "liking." These two psychological and neuronal processes and their related brain structures typically work together, but can become dissociated, particularly in cases of addiction. In drug addiction, for example, repeated consumption of addictive drugs sensitizes the mesolimbic dopamine system, the primary component of the "wanting" system, resulting in excessive "wanting" for drugs and their cues. This sensitizing process is long-lasting and occurs independently of the "liking" system, which typically remains unchanged or may develop a blunted pleasure response to the drug. The result is excessive drug-taking despite minimal pleasure and intense cue-triggered craving that may promote relapse long after detoxification. Here, we describe the roles of "liking" and "wanting" in general motivation and review recent evidence for a dissociation of "liking" and "wanting" in drug addiction, known as the incentive sensitization theory (Robinson and Berridge 1993). We also make the case that sensitization of the "wanting" system and the resulting dissociation of "liking" and "wanting" occurs in both gambling disorder and food addiction.

Primary hepatic angiosarcoma

Primary hepatic angiosarcoma is a rare, aggressive tumor; composed of spindle or pleomorphic cells that line, or grow into, the lumina of pre-existing vascular spaces like sinusoids and terminal hepatic venules; with only about 200 cases diagnosed annually worldwide but it is the most common primary malignant mesenchymal tumor of the liver in adults and accounts for 2% of all primary hepatic malignancies. HAS occurs in association with known chemical carcinogens, but 75% of the tumors have no known etiology. Patients present with vague symptoms like abdominal pain, weight loss, fatigue or an abdominal mass. Hepatic angiosarcoma is usually multicentric and involves both lobes, entire liver may also found to be involved. CD31 is the most reliable marker. These tumors lack specific features on imaging, so, pathological diagnosis is necessary. There are no established treatment guidelines because of low frequency and aggressive nature of tumor, chemotherapy is only palliative, liver resection is indicated for solitary mass and liver transplant is contraindicated. The aim of this article is to comprehensively review all the available literature and to present detailed information and an update on primary hepatic angiosarcoma.

Performance analysis of newly developed point-of-care hemoglobinometer (TrueHb) against an automated hematology analyzer (Sysmex XT 1800i) in terms of precision in hemoglobin measurement

INTRODUCTION

The aim of this study was to evaluate the performance of the newly developed handheld hemoglobinmeter (TrueHb) by comparing its performance against and an automated five-part hematology analyzer, Sysmex counter XT 1800i (Sysmex).

METHODS

Two hundred venous blood samples were subjected through their total hemoglobin evaluation on each device three times. The average of the three readings on each device was considered as their respective device values, that is, TrueHb values and Sysmex values. The two set of values were comparatively analyzed. The repeatability of the performance of TrueHb was also evaluated against Sysmex values.

RESULTS

The scatter plot of TrueHb values and Sysmex values showed linear distribution with positive correlations (r = 0.99). The intraclass correlation (ICC) values between the two set of values was found to be 0.995. Regression coefficients through origin, β, was found to be 0.995, with 95% confidence intervals (CI) ranging between 0.9900 and 1.0000. The mean difference in Bland-Altman plots of TrueHb values against the Sysmex values was found to be -0.02, with limits of agreement between -0.777 and 0.732 g/dL. Statistical analysis suggested good repeatability in results of TrueHb, having a low mean CV of 2.22, against 4.44, that of Sysmex values, and 95% confidence interval of 1.99-2.44, against 3.85-5.03, that of Sysmex values.

CONCLUSION

These results suggested a strong positive correlation between the two measurements devices. It is thus concluded that TrueHb is a good point-of-care testing tool for estimating hemoglobin.

Idiopathic collapsing glomerulopathy: A clinicopathologic analysis of 30 cases

Collapsing glomerulopathy (CG) is a distinct clinicopathologic entity associated with various infections, medications and acute ischemia. There have been few scattered reports of CG from India. This study aimed at evaluating the clinicopathologic features of idiopathic CG in Indian patients with comparison between adult-onset and childhood CG. This study included all cases of idiopathic CG diagnosed over a period of 4 years (2006-2009). Appropriate clinical details and laboratory findings were retrieved. Renal biopsies were reviewed and detailed pathologic features assessed. Statistical analysis was performed to compare various features between adult-onset and childhood CG. Over these 4 years, 30 cases of idiopathic CG were diagnosed. Of these, 11 were children. Childhood CG cases had longer duration of symptoms and lower serum urea and creatinine levels compared with adult patients. In renal histology, tubular atrophy and interstitial fibrosis was frequent in our cases. Pediatric cases of CG showed a higher proportion of segmental glomerulosclerosis. On clinical follow-up, nine of the 30 patients progressed to end-stage renal disease and these included two pediatric patients. Idiopathic CG is a significant cause of renal dysfunction in both pediatric and adult patients. Childhood and adult-onset CG differ in few clinicopathologic features. Early and accurate diagnosis of CG is imperative for appropriate management of these patients.

Detection of subclinical peste des petits ruminants virus infection in experimental cattle

The present study was undertaken to investigate the possible involvement of cattle in the epidemiology of peste des petits ruminants (PPR) as subclinical carriers. Cattle were exposed experimentally to PPR virus (PPRV) infection or placed in contact with PPR infected goats. Clinical samples including heparinized/EDTA blood, plasma, peripheral blood monocyte cells (PBMCs) and clotted blood (for serum) were collected periodically from 21 days post infection (dpi) to 397 dpi (21, 45, 50, 57, 65, 95, 111, 119, 148, 190, 203 and 397 dpi) and tested for PPRV antigen, nucleic acid and antibody. Exposed cattle seroconverted and maintained PPRV specific haemagglutinin antibodies and detectable PPRV antigen/nucleic acid in blood, plasma and PBMCs from 21 to 397 dpi. PPRV was recovered from blood and PBMC collected from experimental animals at 21 dpi, initially in B95a cells and then adapted to Vero cells. The study indicated that PPRV can infect cattle subclinically and PPRV antigen/nucleic acid persist in cattle for at least 397 days.

Detection of New Delhi metallo-beta-lactamase and extended-spectrum beta-lactamase genes in Escherichia coli isolated from mastitic milk samples

In this study, eight Escherichia coli isolates were obtained from milk samples of dairy cattle suffering from clinical/subclinical mastitis. Isolates were characterized for antimicrobial resistance traits and virulence genes. Results revealed that one isolate was harbouring New Delhi metallo-beta-lactamase gene (blaNDM ). Cloning and sequencing of the PCR amplicon confirmed the identity of the gene (GenBank accession no. KC769583) having 100% homology with blaNDM-5 (GenBank accession no. JN104597.1), and this isolate was susceptible to colistin, chloramphenicol and tetracycline only. Moreover, another isolate carried extended-spectrum beta-lactamase (ESBL) gene - blaCTX-M , and all isolates possessed blaTEM gene. Of the eight isolates, only one isolate was positive for shiga toxin gene (stx2), and none were harbouring stx1 gene. Occurrence of New Delhi metallo-beta-lactamase (blaNDM ) in one E. coli isolate and ESBL genes in other isolates poses a potential threat to human health following possible entry and spread through food chain.