Clinical Outcomes of Image-Guided Volumetric Modulated Arc Therapy for Total Body Irradiation

PURPOSE/OBJECTIVE(S)

Volumetric modulated arc therapy (VMAT)-based total body irradiation (TBI) with image guidance is a novel technique that is increasing in implementation. Compared to conventional TBI, VMAT-TBI offers favorable dose homogeneity, better organ-at-risk sparing, and enhanced patient comfort. However, whether these dosimetric advantages translate to improved clinical outcomes that justify the increased planning and delivery burden is not well understood. Only a single study of clinical outcomes of VMAT-TBI exists in the literature. We present the largest study to date of clinical outcomes of VMAT-TBI.

MATERIALS/METHODS

In this IRB-approved retrospective single-institution study, all patients treated with VMAT-TBI conditioning for allogeneic stem cell transplant, per the institution's published protocol, were identified. Dosimetric data were abstracted from the radiation oncology treatment planning system. Clinical data were abstracted from the electronic medical record. The primary outcome was six-month overall survival (6M OS) from the last day of TBI by Kaplan-Meier method.

RESULTS

Fifty-five patients (47 adult and 8 pediatric) were treated with VMAT-TBI between June 2020 and December 2022. All patients received conditioning chemotherapy with standard-dose TBI of 12 or 13.2 Gy in 8 twice-daily fractions. The PTV coverage (V95%) mean was 95.3% ± 1.2%. Mean lung dose was 9.5 Gy ± 0.6 for adult patients and 8.4 Gy ± 0.9 for pediatric patients. Mean lung dose rate was 18.0 cGy/min ± 4.4. Mean kidney dose was 5.9 Gy ± 0.6. Mean skin dose measured by MOSFET was 12.7 Gy ± 1.2. Median treatment time was 63 minutes (range: 53-104). Median follow-up was 7.7 months. At most recent follow-up, 78% of patients were alive. 6M OS was 82%. Common acute toxicities were fatigue (90.9% of patients, all grade 1-2), diarrhea (70.9%, all grade 1-2), nausea (76.4%, all grade 1-2), mucositis (60% grade 1-2, 12.7% grade 3, 1.8% grade 4, no grade 5), and xerostomia (54.5%, all grade 1). Mean pretreatment FEV1 was 98.3 percent of predicted (%p) ± 11.9%p and mean posttreatment FEV1 was 94.7%p ± 13.8%p. Mean pretreatment GFR was 101.4mL/min/1.73m² ± 17.4, mean 3-month posttreatment GFR was 92.4 ± 20.0, and mean 6-month posttreatment GFR was 97.5 ± 26.48. One patient experienced grade 2 pneumonitis; there were no other cases of pneumonitis. There were no acute grade 3+ toxicities aside from mucositis. Observed late toxicities were cataracts (7.3%, all grades 1-3) and hypothyroidism (12.7%, all grades 1-2). There were no grade 3+ late toxicities. Mild acute graft-versus-host disease (GVHD) was noted in 27.2% of patients and mild chronic GVHD was noted in 14.5% of patients, with no other cases of GVHD.

CONCLUSION

In the largest series to date, VMAT-TBI had excellent oncologic and toxicity outcomes. A randomized trial of VMAT-TBI versus standard TBI is warranted.

Impact of omitting post-transplant minidose-methotrexate doses in allogeneic hematopoietic cell transplantation

Given prophylactic methotrexate (MTX) is often held in the setting of toxicity we investigated the impact of omitting minidose-MTX dose(s). Outcomes were compared between patients who had 1-3 doses omitted and those who received all four planned doses of minidose-MTX. Of 370 consecutive patients, 50 had MTX dose(s) omitted. When MTX was omitted, initial management was mycophenolate mofetil (MMF; 36/50 patients) with or without corticosteroids (14/50 patients). Rates of grade 3-4 acute GVHD were similar between groups. Omission of minidose-MTX resulted in an increased risk of chronic GVHD (cGVHD; HR 2.27; p = .024) and decreased overall survival (HR 1.61; p = .024). However, other transplant-related outcomes were comparable. In summary, omission of minidose-MTX doses was not associated with an increased risk of acute GVHD when an alternative was added (e.g. MMF ± corticosteroids). This did not abrogate the increased risk of cGVHD or decreased overall survival.

Mitral valve dysfunction among sudden death victims

Funding Acknowledgements

Type of funding sources: None.

Introduction

Mitral dysfunction is a commonly found valvular abnormality in the US. The association between mitral dysfunction with sudden death is both complex and controversial.

Purpose

To assess mitral dysfunction as a potential risk factor for sudden death using medical and autopsy records in a population-based registry of sudden deaths.

Methods

From 2013-2015, out-of-hospital deaths aged 18-64 reported by Emergency Medical Services in Wake County, North Carolina were screened to adjudicate 399 sudden death victims. Medical records were available in 270 victims, echocardiograms in 53, and autopsies in 64. Echocardiogram reports of none/trace/trivial mitral insufficiency were compared to patients with mild, moderate, or severe insufficiency. Autopsy reports for thickened mitral leaflets, calcification, and redundancy were reviewed. Additionally, available echocardiograms from a control group of 1101 patients were reviewed for mitral insufficiency. Demographics and clinical comorbidities were assessed from medical and death records. Mean, t-tests, and a bivariate logistic regression were estimated, as appropriate.

Results

Of the 53 victims with echocardiograms, mean age was 53 years, 36 (65.5%) were male, and 21 (39.6%) were African-American. Victims with available echocardiograms were more likely to have congestive heart failure (41.8%), coronary artery disease (50.9%), and diabetes (47.3%) compared to victims without echocardiograms. None/trivial/trace insufficiency was present in 27 victims (50.9%), mild insufficiency in 18 (34.0%), and moderate-severe insufficiency in 8 (15.1%). There was no association between severity of mitral insufficiency with demographic covariates or comorbid conditions. The presence of structural mitral valve abnormalities, including thickened leaflets, calcification, and redundancy of the mitral valve, were present in only 8 (12.5%) of 64 victims with autopsies. In a control group of 1101 date-matched patients from the same county, 57 (4.8%) patients had an echocardiogram available. 14 (24.6%) of these patients had mild-moderate mitral insufficiency.

Conclusion

Mitral insufficiency and structural abnormalities of the mitral valve are often identified in echocardiograms or autopsies of sudden death victims. Living controls had approximately half the prevalence of mitral insufficiency, suggesting that mitral dysfunction and its associated comorbidities are associated with sudden death.

Noninvasive Monitoring of Mantle Cell Lymphoma by Immunoglobulin Gene Next-Generation Sequencing in a Phase 2 Study of Sequential Chemoradioimmunotherapy Followed by Autologous Stem-Cell Rescue

Limited information exists in mantle cell lymphoma (MCL) on the performance of next-generation sequencing–based assay of immunoglobulin gene rearrangements for minimal residual disease (MRD) assessment. Posttreatment peripheral blood samples were collected from 16 MCL patients and analyzed with the Adaptive Biotechnologies MRD assay, which identified early molecular relapse. We observed more sensitivity in the cellular versus acellular compartment.

Influence of hydrostatic pressure and sound amplitude on the ultrasound induced dispersion and de-agglomeration of nanoparticles

In most applications, nanoparticles are required to be in a well-dispersed state prior to commercialisation. Conventional technology for dispersing particles into liquids, however, usually is not sufficient, since the nanoparticles tend to form very strong agglomerates requiring extremely high specific energy inputs in order to overcome the adhesive forces. Besides conventional systems as stirred media mills, ultrasound is one means to de-agglomerate nanoparticles in aqueous dispersions. In spite of several publications on ultrasound emulsification there is insufficient knowledge on the de-agglomeration of nanoparticulate systems in dispersions and their main parameters of influence. Aqueous suspensions of SiO2-particles were stressed up to specific energies EV of 10(4) kJ/m3 using ultrasound. Ultrasonic de-agglomeration of nanoparticles in aqueous solution is considered to be mainly a result of cavitation. Both hydrostatic pressure of the medium and the acoustic amplitude of the sound wave affect the intensity of cavitation. Furthermore, the presence of gas in the dispersion medium influences cavitation intensity and thus the effectiveness of the de-agglomeration process. In this contribution both, the influence of these parameters on the result of dispersion and the relation to the specific energy input are taken into account. For this, ultrasound experiments were carried out at different hydrostatic pressure levels (up to 10 bars) and amplitude values (64-123 microm). Depending on the optimisation target (time, energy input,...) different parameters limit the dispersion efficiency and result. All experimental results can be explained with the specific energy input that is a function of the primary input parameters of the process.

A longitudinal study on effects of a six-week course for energy conservation for multiple sclerosis patients

Objective Fatigue management and energy conservation are effective strategies to minimize fatigue in multiple sclerosis (MS). Sustained results have not yet been reported.

Methods A fatigue management course was provided for 32 MS patients. They were tested prior to, directly after participation in the course and in a 7—9 month follow-up with the Fatigue Severity Scale, the MS-specific Fatigue Scale, the Modified Fatigue Impact Scale (MFIS), the Pittsburgh Sleep Quality Index and a self-rating scale for depression. The Expanded Disability Status Score (EDSS) and the MS functional composite (MSFC) were evaluated before and after participation in the course.

Results The total score and the Cognitive and Physical subscores of the MFIS showed significant improvements on both points of time. Scores in the Fatigue Severity Scale, MS-specific Fatigue Scale and Psychosocial Fatigue Impact Scale did not improve significantly. MS functional composite and EDSS remained unchanged after six weeks of course participation. Subjective sleep quality improved directly after participation in the course and after 7—9 months. The depression score decreased significantly to a normal level at the end of training and in the 7—9 month follow-up.

Conclusion Fatigue management enables MS patients to cope with their fatigue and energy more effectively. Follow-up evaluations showed stable results after 7—9 months. Multiple Sclerosis 2008; 14: 500—505. http://msj.sagepub.com

A meta-analysis for neurobehavioural effects due to electromagnetic field exposure emitted by GSM mobile phones

BACKGROUND AND OBJECTIVE

Numerous studies have investigated the potential effects of electromagnetic fields (EMFs) emitted by GSM mobile phones ( approximately 900 MHz to approximately 1800 MHz) on cognitive functioning, but results have been equivocal. In order to try and clarify this issue, the current study carried out a meta-analysis on 19 experimental studies.

DESIGN

Meta-analysis.

METHODS

Nineteen studies were taken into consideration. Ten of them were included in the meta-analysis as they fulfilled several minimum requirements; for example, single-blind or double-blind experimental study design and documentation of means and standard deviation of the dependent variables. The meta-analysis compared exposed with non-exposed subjects assuming that there is a common population effect so that one single effect size could be calculated. When homogeneity for single effect sizes was not given, an own population effect for each study and a distribution of population effects was assumed.

RESULTS

Attention measured by the subtraction task seems to be affected in regard to decreased reaction time. Working memory measured by the N-back test seems to be affected too: under condition 0-back target response time is lower under exposure, while under condition 2-back target response time increases. The number of errors under condition 2-back non-targets appears to be higher under exposure.

CONCLUSION

Results of the meta-analysis suggest that EMFs may have a small impact on human attention and working memory.

Unilaterale akrale Nekrosen als Abortivform einer palmoplantaren Erythrodysästhesie

Hand-foot syndrome is a common toxic side-effect, particularly during chemotherapy, with an incidence of 6-64% overall and 10-24% for capecitabine (Xeloda) monotherapy. Consequently, differential diagnostic considerations should include hand-foot syndrome when acral skin lesions appear, particularly during capecitabine monotherapy. The dosage should be reduced or therapeutic regimen changed. We present a unique patient who while on capecitabine developed unilateral acral necrosis which should be classified as a minor form of hand-foot syndrome.

Sleep spindle-related activity in the human EEG and its relation to general cognitive and learning abilities

Stage 2 sleep spindles have been previously viewed as useful markers for the development and integrity of the CNS and were more currently linked to 'offline re-processing' of implicit as well as explicit memory traces. Additionally, it had been discussed if spindles might be related to a more general learning or cognitive ability. In the present multicentre study we examined the relationship of automatically detected slow (< 13 Hz) and fast (> 13 Hz) stage 2 sleep spindles with: (i) the Raven's Advanced Progressive Matrices (testing 'general cognitive ability'); as well as (ii) the Wechsler Memory scale-revised (evaluating memory in various subdomains). Forty-eight healthy subjects slept three times (separated by 1 week) for a whole night in a sleep laboratory with complete polysomnographic montage. Whereas the first night only served adaptation and screening purposes, the two remaining nights were preceded either by an implicit mirror-tracing or an explicit word-pair association learning or (corresponding) control task. Robust relationships of slow and fast sleep spindles with both cognitive as well as memory abilities were found irrespectively of whether learning occurred before sleep. Based on the present findings we suggest that besides being involved in shaping neuronal networks after learning, sleep spindles do reflect important aspects of efficient cortical-subcortical connectivity, and are thereby linked to cognitive- and memory-related abilities alike.

Effects of macromolecular impurities and of crystallization method on the quality of eubacterial aspartyl-tRNA synthetase crystals

Although macromolecular purity is thought to be essential for the growth of flawless protein crystals, only a few studies have investigated how contaminants alter the crystallization process and crystal quality. Likewise, the outcome of a crystallization process may vary with the crystallization method. Here, it is reported how these two variables affect the crystallogenesis of aspartyl-tRNA synthetase from the eubacterium Thermus thermophilus. This homodimeric enzyme (Mr=130,000) possesses a multi-domain architecture and crystallizes either in a monoclinic or an orthorhombic habit. Minute amounts of protein impurities alter to a different extent the growth of each crystal form. The best synthetase crystals are only obtained when the crystallizing solution is either enclosed in capillaries or immobilized in agarose gel. In these two environments convection is reduced with regard to that existing in an unconstrained solution.

Factors influencing quality of life in multiple sclerosis patients: disability, depressive mood, fatigue and sleep quality

OBJECTIVES

In a series of 504 patients with multiple sclerosis (MS), quality of life (QOL) and its main clinical and demographic determinants were assessed in comparison with healthy individuals.

MATERIALS AND METHODS

A postal questionnaire with self-completed measures of disability (Expanded Disability Status Scale, EDSS), QOL (Quality of Life Index, QLI), depressive mood (Self-rating Depression Scale, SDS), fatigue severity (Fatigue Severity Scale, FSS) and sleep quality (Pittsburgh Sleep Quality Index, PSQI) was sent to this sample of MS patients.

RESULTS

Most patients were severely disabled; almost half were mildly to severely depressed, suffering from reduced sleep quality and/or fatigue. The multiple sclerosis patients had significantly lower QLI scores than healthy controls. EDSS and SDS scores were found to be predictors of global QLI score. Regarding the different QLI domains, mean SDS scores remained predictive for all QLI items, while mean EDSS, PSQI and FSS scores were only predictive for physical domains.

CONCLUSION

Our study clearly demonstrates that depressive mood is the main factor influencing QOL. The disability status, fatigue and reduced sleep quality have an impact mainly on physical domains of life quality.

From conventional crystallization to better crystals from space: a review on pilot crystallogenesis studies with aspartyl-tRNA synthetases

Aspartyl-tRNA synthetases were the model proteins in pilot crystallogenesis experiments. They are homodimeric enzymes of Mr approximately 125 kDa that possess as substrates a transfer RNA, ATP and aspartate. They have been isolated from different sources and were crystallized either as free proteins or in association with their ligands. This review discusses their crystallisability with emphasis to crystal quality and structure determination. Crystallization in low diffusivity gelled media or in microgravity environments is highlighted. It has contributed to prepare high-resolution diffracting crystals with better internal order as reflected by their mosaicity. With AspRS from Thermus thermophilus, the better crystalline quality of the space-grown crystals within APCF is correlated with higher quality of the derived electron density maps. Usefulness for structural biology of targeted methods aimed to improve the intrinsic physical quality of protein crystals is highlighted.

Structure of tetragonal hen egg-white lysozyme at 0.94 A from crystals grown by the counter-diffusion method

Very high quality crystals of tetragonal hen egg-white lysozyme were grown in the Advanced Protein Crystallization Facility (APCF) on board the Space Shuttle using a modified free-interface diffusion (FID) reactor designed ad hoc to have a longer diffusion path. This design allows the performance of true counter-diffusion experiments. Crystals were obtained under the classical chemical conditions defined 50 y ago with NaCl as a crystallizing agent and acetate pH 4.5 as a buffer. Counter-diffusion crystallization allows a "physical" instead of chemical optimization of growth conditions: indeed, this method screens for the best supersaturation conditions in a single trial and yields crystals of very high quality. A complete diffraction data set was collected at atomic resolution from one of these crystals using synchrotron radiation at the DESY-EMBL beamlines. The overall R(merge) on intensities in the resolution range 31-0.94 A was 5.2% and the data were 98.9% complete. Refinement was carried out with the programs CNS and SHELX97 to a final crystallographic R factor of 12.26% for 72 390 reflections. A mean standard uncertainty in the atomic positions of 0.024 A was estimated from inversion of blocked least-squares matrices. 22 side chains show alternate conformations and the loop 59-75 adopts in the same crystal packing two conformations that were observed for either triclinic or tetragonal lysozyme in previous high-resolution studies. In addition to 255 water molecules, the crystallizing agent (one hexacoordinated sodium ion and five chloride anions) participates in the ordered lysozyme hydration shell.

Growth kinetics, diffraction properties and effect of agarose on the stability of a novel crystal form of Thermus thermophilus aspartyl-tRNA synthetase-1

Growth kinetics and diffraction properties of monoclinic crystals of eubacterial Thermus thermophilus aspartyl-tRNA synthetase-1 (AspRS-1) prepared in the presence of polyethylene glycol and agarose are studied. Their solubility and two-dimensional phase diagram are compared with those of orthorhombic crystals which grow in the presence of sodium formate or ammonium sulfate. The growth mechanism of the novel crystals was monitored by atomic force microscopy. The gel stabilizes the crystal lattice under the cryogenic conditions used for structure determination at high resolution.