The Patient's perspective: A review of the results from a radiotherapy patient experience survey in the North-West of England

INTRODUCTION

A patient experience survey was undertaken for patients completing radiotherapy at the three Northwest of England Radiotherapy Providers.

METHODS

A previously reported National Radiotherapy Patient Experience Survey was adapted and undertaken in the Northwest of England. Quantitative data was analysed to establish trends. Frequency distribution was applied to appraise the number of participants selecting each of the pre-determined responses. Thematic analysis of free text responses was conducted.

RESULTS

The questionnaire received 653 responses from the 3 providers across seven departments. Thematic analysis revealed 3 themes; logistics, information and operational.

CONCLUSION

The results indicate that the majority of patients are satisfied with their treatment and care. Patients' responses indicate areas for improvements. Expectancy theory states that an individual's satisfaction is related to the difference between expected service and the service received. Consequently, when reviewing services and developing improvement it is important to understand patients' expectations^. This regional survey starts to capture what people receiving radiotherapy expect from the service and the professionals delivering their treatment.

IMPLICATIONS FOR PRACTICE

This survey responses make a case for reviewing the information provision pre and post radiotherapy. This includes clarifying the understanding of consent for treatment including the intended benefits and potential late effects. There is an argument to offer information sessions prior to radiotherapy to achieve more relaxed and informed patients. A recommendation from this work is for the radiotherapy community undertake a national radiotherapy patient experience survey, facilitated via the 11 Radiotherapy ODNs. A national radiotherapy survey has multiple benefits to inform improvements in practice. This includes benchmarking services against national averages. This approach is aligned with the principles of the service specification in terms of reducing variation and increasing quality.

Avasopasem manganese (GC4419) protects against cisplatin-induced chronic kidney disease: An exploratory analysis of renal metrics from a randomized phase 2b clinical trial in head and neck cancer patients

Head and neck squamous cell carcinoma (HNSCC) patients treated with high-dose cisplatin concurrently with radiotherapy (hdCis-RT) commonly suffer kidney injury leading to acute and chronic kidney disease (AKD and CKD, respectively). We conducted a retrospective analysis of renal function and kidney injury-related plasma biomarkers in a subset of HNSCC subjects receiving hdCis-RT in a double-blinded, placebo-controlled clinical trial (NCT02508389) evaluating the superoxide dismutase mimetic, avasopasem manganese (AVA), an investigational new drug. We found that 90 mg AVA treatment prevented a significant reduction in estimated glomerular filtration rate (eGFR) three months as well as six and twelve months after treatment compared to 30 mg AVA and placebo. Moreover, AVA treatment may have allowed renal repair in the first 22 days following cisplatin treatment as evidenced by an increase in epithelial growth factor (EGF), known to aid in renal recovery. An upward trend was also observed in plasma iron homeostasis proteins including total iron (Fe-blood) and iron saturation (Fe-saturation) in the 90 mg AVA group versus placebo. These data support the hypothesis that treatment with 90 mg AVA mitigates cisplatin-induced CKD by inhibiting hdCis-induced renal changes and promoting renal recovery.

Reporting of tobacco use and tobacco-related analyses in cancer cooperative group clinical trials: a systematic scoping review

BACKGROUND

Continued smoking after a diagnosis of cancer negatively impacts cancer outcomes, but the impact of tobacco on newer treatments options is not well established. Collecting and evaluating tobacco use in clinical trials may advance understanding of the consequences of tobacco use on treatment modalities, but little is known about the frequency of reporting and analysis of tobacco use in cancer cooperative clinical trial groups.

PATIENTS AND METHODS

A comprehensive literature search was conducted to identify cancer cooperative group clinical trials published from January 2017-October 2019. Eligible studies evaluated either systemic and/or radiation therapies, included ≥100 adult patients, and reported on at least one of: overall survival, disease/progression-free survival, response rates, toxicities/adverse events, or quality-of-life.

RESULTS

A total of 91 studies representing 90 trials met inclusion criteria with trial start dates ranging from 1995 to 2015 with 14% involving lung and 5% head and neck cancer patients. A total of 19 studies reported baseline tobacco use; 2 reported collecting follow-up tobacco use. Seven studies reported analysis of the impact of baseline tobacco use on clinical outcomes. There was significant heterogeneity in the reporting of baseline tobacco use: 7 reported never/ever status, 10 reported never/ex-smoker/current smoker status, and 4 reported measuring smoking intensity. None reported verifying smoking status or second-hand smoke exposure. Trials of lung and head and neck cancers were more likely to report baseline tobacco use than other disease sites (83% versus 6%, P < 0.001).

CONCLUSIONS

Few cancer cooperative group clinical trials report and analyze trial participants' tobacco use. Significant heterogeneity exists in reporting tobacco use. Routine standardized collection and reporting of tobacco use at baseline and follow-up in clinical trials should be implemented to enable investigators to evaluate the impact of tobacco use on new cancer therapies.

699 EMBEDDING A FRAILTY TEAM AND UNIT INTO WYTHENSHAWE HOSPITAL’S EMERGENCY DEPARTMENT

Introduction

Evaluation of Wythenshawe Hospital’s Acute Frailty Service in January–June 2019 demonstrated slow referrals times and poor identification of frail patients due to inaccurate Clinical Frailty Scoring (CFS) at emergency department triage. This project presents the results of ongoing quality assessment of our service between June 2019–January 2021, following two quality improvement (QI) interventions.

Aims: To evaluate our service’s ability to deliver early identification and intervention for complex frail patients via Complex Geriatric Assessment (CGA), as set out in National and Regional Frailty standards.(1,2). -To improve and maintain better outcomes for patients accessing our frailty service.

Method

Intervention1 (July’19): Specialist frailty nurses relocated to ED. Dedicated frailty clinical fellows and Consultant geriatrician input 0900–1700 weekdays. Intervention2 (Sep’20): Short-stay frailty unit opened. Junior clinical fellow cover increased (0900–1900 weekdays and 0900–1700 weekends). 299 patients seen at intervals between Jun’19-Jan’21 analysed using electronic records and completed CGA proformas.

Results

Pre-intervention Intervention1 Intervention2 June’19(n = 22) July’19(n = 198) Nov’19(n = 25) Sep’20(n = 26) Jan’21(n = 28) Time from triage-to-CGA (mins) (CI 95%)* 372.0 ± 178.2 56.0 83.4 ± 31.0 72.9 ± 35.7 48.4 ± 20.0 Discharge(%): Same day 22.7 39.4 21.7 36.0 25.0 < 72 hr(cumulative) 72.7 63.6 47.8 68.0 57.1 Ave. length of stay(days)(CI95%) 10.4 ± 5.9 20.6 20.0 ± 8.7 7.1 ± 3.4 5.4 ± 2.1 Readmission <30 days(%) 30.0 9.0 17.4 12.5 25.0 CGA Quality(%) CFS completion 100 96.0100 89.3 ReSPECT discussion 29.3 64.0 61.5 67.9 Full medication review 46.5 96.0 80.8 89.3 Therapy assessment 85.5 92.0 92.3 89.3 *patients triaged between 0800–1700.

Conclusion

Since Intervention1, Wythenshawe frailty service has sustained a reduction in triage-to-CGA time, maintained high percentages of same-day and < 72 hr discharges, and sustained high rates of CFS completion and therapy assessments. Following intervention2, average length of stay reduced. Increased readmission rates in Jan’21 were impacted by COVID-19. Additional interventions targeted at reducing readmission rates and increasing ReSPECT discussions should be implemented. 1. Greater Manchester Frailty Collaborative and Network, 2019. 2. Same-day acute frailty service, NHS improvement, 2019.

Comparison of multimodal analgesia with thoracic epidural after transthoracic oesophagectomy

BACKGROUND

Thoracic epidural analgesia (TEA) has been regarded as the standard of care after oesophagectomy for pain control, but has several side-effects. Multimodal (intrathecal diamorphine, paravertebral and rectus sheath catheters) analgesia (MA) may facilitate postoperative mobilization by reducing hypotensive episodes and the need for vasopressors, but uncertainty exists about whether it provides comparable analgesia. This study aimed to determine whether MA provides comparable analgesia to TEA following transthoracic oesophagectomy.

METHODS

Consecutive patients undergoing oesophagectomy for cancer between January 2015 and December 2018 were grouped according to postoperative analgesia regimen. Propensity score matching (PSM) was used to account for treatment selection bias. Pain scores at rest and on movement, graded from 0 to 10, were used. The incidence of hypotensive episodes and the requirement for vasopressors were evaluated.

RESULTS

The study included 293 patients; 142 (48.5 per cent) received TEA and 151 (51.5 per cent) MA. After PSM, 100 patients remained in each group. Mean pain scores were significantly higher at rest in the MA group (day 1: 1.5 versus 0.8 in the TEA group, P = 0.017; day 2: 1.7 versus 0.9 respectively, P = 0.014; day 3: 1.2 versus 0.6, P = 0.047). Fewer patients receiving MA had a hypotensive episode (25 per cent versus 45 per cent in the TEA group; P = 0.003) and fewer required vasopressors (36 versus 53 per cent respectively; P = 0.016). There was no significant difference in the overall complication rate (71.0 versus 61.0 per cent; P = 0.136).

CONCLUSION

MA is less effective than TEA at controlling pain, but this difference may not be clinically significant. However, fewer patients experienced hypotension or required vasopressor support with MA; this may be beneficial within an enhanced recovery programme.

Pulse shape discrimination and exploration of scintillation signals using convolutional neural networks

We demonstrate the use of a convolutional neural network to perform neutron-gamma pulse shape discrimination, where the only inputs to the network are the raw digitised silicon photomultiplier signals from a dual scintillator detector element made of 6Li F:ZnS(Ag) scintillator and PVT plastic. A realistic labelled dataset was created to train the network by exposing the detector to an AmBe source, and a data-driven method utilising a separate photomultiplier tube was used to assign labels to the recorded signals. This approach is compared to the charge integration and continuous wavelet transform methods and a simpler artificial neural net. It is found to provide superior levels of discrimination, achieving an area under the curve of 0.996 ± 0.003. We find that the neural network is capable of extracting interpretable features directly from the raw data. In addition, by visualising the high-dimensional representations of the network with the t-SNE algorithm, we discover that not only is this method robust to minor mislabeling of the training dataset but that it is possible to identify an underlying substructure within the signals that goes beyond the original labelling. This technique could be utilised to explore and cluster complex, raw detector data in a novel way that may reveal more insights than standard analysis methods.

Cigarette-smoking characteristics and interest in cessation in patients with head-and-neck cancer

Purpose

Many patients diagnosed with head-and-neck cancer are current or former smokers. Despite the well-known adverse effects of smoking, continuation of smoking during cancer treatment is associated with reduced efficacy of that treatment and with cancer recurrence. In the present study, we examined smoking characteristics in patients with head-and-neck cancer near the time of cancer treatment.

Methods

A prospective cohort of patients with head-and-neck cancer who attended a dental oncology clinic before receiving cancer treatment at a regional cancer centre were invited to participate in a study that involved completing an interviewer-administered questionnaire to assess smoking characteristics, intention to quit, motivation to quit, and strategies perceived to potentially aid in successful cessation.

Results

The study enrolled 493 ever-smokers, with a response rate of 96.1% and a self-reported current smoker rate of 37.1% (n = 183). Most of the current smokers reported high nicotine dependence, with 84.7% (n = 155) indicating a time to first cigarette of 30 minutes or less. Most had previously attempted to quit smoking (77.0%), and many had prior unsuccessful quit attempts before resuming smoking again. Most were interested in quitting smoking (85.8%), and many (70.5%) were seriously considering quitting smoking within the subsequent 30 days.

Conclusions

Patients with head-and-neck cancer reported high nicotine dependence and high interest in cessation opportunities near the time of treatment for cancer. Those results might provide support for provision of smoking cessation opportunities.

A multicentre, randomised trial comparing schedules of G-CSF (filgrastim) administration for primary prophylaxis of chemotherapy-induced febrile neutropenia in early stage breast cancer

BACKGROUND

The optimal duration of filgrastim as primary febrile neutropenia (FN) prophylaxis in early breast cancer patients is unknown, with 5, 7 or 10 days being commonly prescribed. This trial evaluates whether 5 days of filgrastim was non-inferior to 7/10 days.

PATIENTS AND METHODS

In this randomised, open-label trial, early breast cancer patients who were to receive filgrastim as primary FN prophylaxis were randomly allocated to 5 versus 7 versus 10 days of filgrastim for all chemotherapy cycles. A protocol amendment in November 2017 allowed subsequent patients (N = 324) to be randomised to either 5 or 7/10 days. The primary outcome was a composite of either FN or treatment-related hospitalisations. Secondary outcomes included chemotherapy dose reductions, delays and discontinuations. Analyses were carried out by per protocol (primary) and intention-to-treat, and the non-inferiority margin was set at 3% for the risk of having FN and/or hospitalisation per cycle of chemotherapy.

RESULTS

Patients (N = 466) were randomised to receive 5 (184, 39.5%), or 7/10 (282, 60.5%) days of filgrastim. In our primary analysis, the difference in risk of either FN or treatment-related hospitalisation per cycle was -1.52% [95% confidence interval (CI): -3.22% to 0.19%] suggesting non-inferiority of a 5-day filgrastim schedule compared with 7/10-days. The difference in events per cycle for FN was 0.11% (95% CI: -1.05 to 1.27) while for treatment-related hospitalisations it was -1.68% (95% CI: -2.73% to -0.63%). The overall proportions of patients having at least one occurrence of either FN or treatment-related hospitalisation were 11.8% and 14.96% for the 5- and 7/10-day groups, respectively (risk difference: -3.17%, 95% CI: -9.51% to 3.18%).

CONCLUSION

Five days of filgrastim was non-inferior to 7/10 days. Given the cost and toxicity of this agent, 5 days should be considered standard of care. CLINICALTRIALS.

GOV REGISTRATION

NCT02428114 and NCT02816164.

Multimodal analgesia using intrathecal diamorphine, and paravertebral and rectus sheath catheters are as effective as thoracic epidural for analgesia post-open two-phase esophagectomy within an enhanced recovery program

Thoracic epidural (TE) analgesia has been the standard of care for transthoracic esophagectomy patients since the 1990s. Multimodal anesthesia using intrathecal diamorphine, local anesthetic infusion catheters (LAC) into the paravertebral space and rectus sheaths and intravenous opioid postoperatively represent an alternative option for postoperative analgesia. While TE can provide excellent pain control, it may inhibit early postoperative recovery by causing hypotension and reducing mobilization. The aim of this study is to determine whether multimodal analgesia with LAC was effective with respect to adequate pain management, and compare its impact on hypotension and mobility. Patients receiving multimodal LAC analgesia were matched using propensity score matching to patients undergoing two-phase trans-thoracic esophagectomy with a TE over a two-year period (from January 2015 to December 2016). Postoperative endpoints that had been evaluated prospectively, including pain scores on movement and at rest, inotrope or vasoconstrictor requirements, and hypotension (systolic BP < 90 mmHg), were compared between cohorts. Out of 14 patients (13 male) that received LAC were matched to a cohort of 14 patients on age, sex, and comorbidity. Mean and maximum pain scores at rest and movement on postoperative days 0 to 3 were equivalent between the groups. In both cohorts, 50% of patients had a pain score of more than 7 on at least one occasion. Fewer patients in the LAC group required vasoconstrictor infusion (LAC: 36% vs. TE: 57%, P = 0.256) to maintain blood pressure or had episodes of hypotension (LAC: 43% vs. TE: 79%, P = 0.05). The LAC group was more able to ambulate on the first postoperative day (LAC: 64% vs. TE: 43%, P = 0.14) but these differences were not statistically significant. Within the epidural cohort, three patients had interruption of epidural due to dislodgement or failure of block compared to no disruption in the multimodal local anesthesia catheters group (P = 0.05). Therefore, multimodal anesthesia using spinal diamorphine with combined paravertebral and rectus sheath local anesthetic catheters appears to provide comparable pain relief post two-phase esophagectomy and may provide more reliable and safe analgesia than the current standard of care.

Assessing long-term neuroinflammatory responses to encephalopathy using MRI approaches in a rat endotoxemia model

Sepsis-associated encephalopathy (SAE) induces neuroinflammation, which is associated with cognitive impairment (CI). CI is also correlated with aging. We used contrast-enhanced magnetic resonance imaging (MRI), perfusion MRI, and MR spectroscopy to assess long-term alterations in BBB permeability, microvascularity, and metabolism, respectively, in a rat lipopolysaccharide-induced SAE model. Free radical-targeted molecular MRI was used to detect brain radical levels at 24 h and 1 week post-LPS injection. CE-MRI showed increased Gd-DTPA uptake in LPS rat brains at 24 h in cerebral cortex, hippocampus, thalamus, and perirhinal cortex regions. Increased MRI signal intensities were observed in LPS rat brains in cerebral cortex, perirhinal cortex, and hippocampus regions 1 week post-LPS. Long-term BBB dysfunction was detected in the cerebral cortex at 6 weeks post-LPS. Increased relative cerebral blood flow (rCBF) in cortex and thalamus regions at 24 h, decreased cortical and hippocampal rCBF at 6 weeks, decreased cortical rCBF at 3 and 12 weeks, and increased thalamus rCBF at 6 weeks post-LPS, were detected. MRS indicated that LPS-exposed rat brains had decreased: NAA/Cho metabolite ratios at 1, 3, 6, and 12 weeks; Cr/Cho at 1, 3, and 12 weeks; and Myo-Ins/Cho at 1, 3, and 6 weeks post-LPS. Free radical imaging detected increased radical levels in LPS rat brains at 24 h and 1 week post-LPS. LPS-exposed rats were compared to saline-treated controls. We clearly demonstrated BBB dysfunction, impaired vascularity, and decreased brain metabolites, as measures of long-term neuroinflammatory indicators, as well as increased free radicals in a LPS-induced rat SAE model.

Evaluation of magnetic resonance imaging abnormalities in juvenile onset neuropsychiatric systemic lupus erythematosus

The aim of this study was to describe the abnormalities identified with conventional MRI in children with neuropsychiatric systemic lupus erythematosus (NPSLE). This was single-centre (Great Ormond Street Hospital, London) retrospective case series of patients with juvenile NPSLE seen in 2003-2013. Brain MR images of the first episode of active NPSLE were reviewed. All patients fulfilled the 1999 ACR case definitions for NPSLE syndromes. Presenting neuropsychiatric manifestations, immunological findings and treatment are reported. Results are expressed as median and ranges or percentages. Fisher's exact test was used to identify clinical predictors of abnormal MRI. A total of 27 patients (22 females), median age 11 years (4-15), were identified. Presenting clinical symptoms included the following: headaches (85.1 %), mood disorder/depression (62.9 %), seizures (22.2 %), acute psychosis (18.5 %), cognitive dysfunction (14.8 %), movement disorder (14.8 %), acute confusional state (14.8 %), aseptic meningitis (7.4 %), demyelinating syndrome (3.7 %), myelopathy (3.7 %), dysautonomia (3.7 %) and cranial neuropathy (3.7 %). The principal MR findings were as follows: (1) absence of MRI abnormalities despite signs and symptoms of active NPSLE (59 %); (2) basilar artery territory infarction (3 %); (3) focal white matter hyperintensities on T2-weighted imaging (33 %); (4) cortical grey matter lesions (3 %); and (5) brain atrophy (18.5 %). The presence of an anxiety disorder strongly associated with abnormal MRI findings (p = 0.008). In over half the children with NPSLE, no conventional MRI abnormalities were observed; white matter hyperintensities were the most commonly described abnormalities. Improved MR techniques coupled with other alternative diagnostic imaging modalities may improve the detection rate of brain involvement in juvenile NPSLE.

Letter to the Editor: On "Advantages and disadvantages of stiffness instructions when studying postural control" by C.T. Bonnet: You just can't win: Advantages and disadvantages of the postural stability requirement

In the examination of postural control, instructions to stand as still as possible are common and promote a relatively unnatural sway pattern. The validity of the stability requirement is discussed in the present commentary in response to the discussion initiated by Cedrick T. Bonnet. The advantages of using the stability requirement include: evaluating unbiased postural control, reducing variability in postural sway, manipulating focus of attention, examining the ability to maintain an upright stance, and ecological validity of testing. The disadvantages include: constraining natural postural sway, increasing the complexity of the control condition, promoting an internal focus of attention, and reducing the ability to detect exploratory behaviour. After evaluating the aforementioned advantages and disadvantages, the present commentary suggests that researchers should strive to provide specific instructions to maintain feet, arm and eye position without specifically requiring participants to reduce their postural sway.

Disrupted nitric oxide signaling due to GUCY1A3 mutations increases risk for moyamoya disease, achalasia and hypertension

Moyamoya disease (MMD) is a progressive vasculopathy characterized by occlusion of the terminal portion of the internal carotid arteries and its branches, and the formation of compensatory moyamoya collateral vessels. Homozygous mutations in GUCY1A3 have been reported as a cause of MMD and achalasia. Probands (n = 96) from unrelated families underwent sequencing of GUCY1A3. Functional studies were performed to confirm the pathogenicity of identified GUCY1A3 variants. Two affected individuals from the unrelated families were found to have compound heterozygous mutations in GUCY1A3. MM041 was diagnosed with achalasia at 4 years of age, hypertension and MMD at 18 years of age. MM149 was diagnosed with MMD and hypertension at the age of 20 months. Both individuals carry one allele that is predicted to lead to haploinsufficiency and a second allele that is predicted to produce a mutated protein. Biochemical studies of one of these alleles, GUCY1A3 Cys517Tyr, showed that the mutant protein (a subunit of soluble guanylate cyclase) has a significantly blunted signaling response with exposure to nitric oxide (NO). GUCY1A3 missense and haploinsufficiency mutations disrupt NO signaling leading to MMD and hypertension, with or without achalasia.

Diagnostic accuracy and limitations of post-mortem MRI for neurological abnormalities in fetuses and children

AIM

To compare the diagnostic accuracy of non-invasive cerebral post-mortem magnetic resonance imaging (PMMRI) specifically for cerebral and neurological abnormalities in a series of fetuses and children, compared to conventional autopsy.

MATERIALS AND METHODS

Institutional ethics approval and parental consent was obtained. Pre-autopsy cerebral PMMRI was performed in a sequential prospective cohort (n = 400) of fetuses (n = 277; 185 ≤ 24 weeks and 92 > 24 weeks gestation) and children <16 years (n = 123) of age. PMMRI and conventional autopsy findings were reported blinded and independently of each other.

RESULTS

Cerebral PMMRI had sensitivities and specificities (95% confidence interval) of 88.4% (75.5 to 94.9), and 95.2% (92.1 to 97.1), respectively, for cerebral malformations; 100% (83.9 to 100), and 99.1% (97.2 to 99.7) for major intracranial bleeds; and 87.5% (80.1 to 92.4) and 74.1% (68 to 79.4) for overall brain pathology. Formal neuropathological examination was non-diagnostic due to maceration/autolysis in 43/277 (16%) fetuses; of these, cerebral PMMRI imaging provided clinically important information in 23 (53%). The sensitivity of PMMRI for detecting significant ante-mortem ischaemic injury was only 68% (48.4 to 82.8) overall.

CONCLUSIONS

PMMRI is an accurate investigational technique for identifying significant neuropathology in fetuses and children, and may provide important information even in cases where autolysis prevents formal neuropathological examination; however, PMMRI is less sensitive at detecting hypoxic-ischaemic brain injury, and may not detect rarer disorders not encountered in this study.

In vivo targeted molecular magnetic resonance imaging of free radicals in diabetic cardiomyopathy within mice

Free radicals contribute to the pathogenesis of diabetic cardiomyopathy. We present a method for in vivo observation of free radical events within murine diabetic cardiomyopathy. This study reports on in vivo imaging of protein/lipid radicals using molecular MRI (mMRI) and immuno-spin trapping (IST) in diabetic cardiac muscle. To detect free radicals in diabetic cardiomyopathy, streptozotocin (STZ)-exposed mice were given 5,5-dimethyl-pyrroline-N-oxide (DMPO) and administered an anti-DMPO probe (biotin-anti-DMPO antibody-albumin-Gd-DTPA). For controls, non-diabetic mice were given DMPO (non-disease control), and administered an anti-DMPO probe; or diabetic mice were given DMPO but administered a non-specific IgG contrast agent instead of the anti-DMPO probe. DMPO administration started at 7 weeks following STZ treatment for 5 days, and the anti-DMPO probe was administered at 8 weeks for MRI detection. MRI was used to detect a significant increase (p < 0.001) in MRI signal intensity (SI) from anti-DMPO nitrone adducts in diabetic murine left-ventricular (LV) cardiac tissue, compared to controls. Regional increases in MR SI in the LV were found in the apical and upper-left areas (p < 0.01 for both), compared to controls. The biotin moiety of the anti-DMPO probe was targeted with fluorescently-labeled streptavidin to locate the anti-DMPO probe in excised cardiac tissues, which indicated elevated fluorescence only in cardiac muscle of mice administered the anti-DMPO probe. Oxidized lipids and proteins were also found to be significantly elevated (p < 0.05 for both) in diabetic cardiac muscle compared to controls. It can be concluded that diabetic mice have more heterogeneously distributed radicals in cardiac tissue than non-diabetic mice.

SOX3 deletion in mouse and human is associated with persistence of the craniopharyngeal canal

CONTEXT

SOX3 is an early developmental transcription factor involved in pituitary development. In humans, over- and underdosage of SOX3 is associated with X-linked hypopituitarism with variable phenotypes ranging from isolated GH deficiency (GHD) to panhypopituitarism, with or without mental retardation and, in most cases, with reported pituitary imaging, an ectopic/undescended posterior pituitary.

PATIENT

We present a young patient with hemophilia B and developmental delay who had a 2.31-Mb deletion on Xq27 including SOX3, F9, and eight other contiguous genes. He developed GH and gonadotropin deficiency, whilst his thyroid function was in the low normal range. Magnetic resonance imaging revealed a eutopic posterior pituitary and the unusual finding of a persistent craniopharyngeal canal that has not previously been described in patients with congenital hypopituitarism.

OBJECTIVE AND METHODS

To establish whether loss of SOX3 can account for the human phenotype, we examined in detail the hypothalamo-pituitary region of neonatal Sox3 null mice.

RESULTS

Consistent with the patient's phenotype, Sox3 null mice exhibit a ventral extension of the anterior pituitary that penetrates, and generates a mass beneath, the sphenoid bone. This suggests that the defect results from abnormal induction of Rathke's pouch, leading to a persistent connection between Rathke's pouch and the oral ectoderm.

CONCLUSIONS

Our observations expand the spectrum of phenotypes observed in association with altered SOX3 dosage and may affect the approach to genetic screening. Screening for SOX3 should be advised not only for hypopituitary patients with an ectopic posterior pituitary, but also for those with a structurally normal pituitary and additional findings, including clefts and a persistent craniopharyngeal canal, with or without mental retardation.

The utility of atlas-assisted segmentation in the male pelvis is dependent on the interobserver agreement of the structures segmented

OBJECTIVE

To investigate the relationship between the ability of atlas-based autosegmentation to reduce outlining time in the male pelvis (body, bladder, rectum, femoral heads, prostate and seminal vesicles) and the interobserver agreement in the delineation of these structures. To examine any increase of the interobserver agreement with the use of an autosegmentation tool.

METHODS

We created atlases in the ABAS™ system v. 2.0 (Elekta, Crawley, UK) and recorded the time to delineate the above structures on eight patients with and without its aid. We also measured the interobserver agreement in the structure definitions using several metrics [Dice's similarity coefficient (DSC), mean distance to conformity, percentage volume difference] with and without the aid of ABAS.

RESULTS

There is a high degree of correlation between the time saving with the use of ABAS and the degree of interobserver agreement (r = 0.90 for DSC). This indicates that for structures where the interobserver agreement is low (DSC < 0.65), the ABAS does not reduce outlining time. We found that the interobserver agreement is increased with ABAS only for the prostate.

CONCLUSION

Outlining time saved in the male pelvis is highly correlated with the interobserver agreement of the structures. Only for the prostate does the use of ABAS significantly reduce the amount of interobserver variation in contouring.

ADVANCES IN KNOWLEDGE

The use of autosegmentation software increases the outlining time for structures where the interobserver agreement is low. Any increase in the interobserver agreement in contouring with the aid of such software may be limited to those structures where there is currently mid-range agreement between observers.