Treatment of In-stent Restenosis of the Internal Carotid Artery Using Drug-eluting Balloons

PURPOSE

In-stent restenosis (ISR) following internal carotid artery (ICA) stenting is relatively common with an estimated incidence of 5%. Treatment options include repeat angioplasty with conventional or drug-eluting balloons (DEB), repeat stent angioplasty and surgical intervention. Application of DEB in ISR of the coronary and peripheral arteries is an established method; however, data on DEB treatment of ICA ISR are sparse. In this work, results from a retrospective cohort of 45 patients harboring 46 ICA ISR lesions treated with DEB angioplasty are presented.

METHODS

Clinical, procedural and imaging data from DEB angioplasty treatment of 46 high-grade ICA ISR lesions in 45 patients, performed between 2013 and 2021 were collected. A single type of DEB (Elutax, Aachen Resonance, Aachen, Germany) was used in all procedures. Imaging follow-up was performed by regular Doppler ultrasound (DUS), verified by computed tomography angiography (CTA) in cases suspicious for a recurrent ISR.

RESULTS

Technical success was 100%. Intraprocedural and postprocedural complications were not encountered. Clinical follow-up was obtained in all patients. Recurrent stroke in the affected territory was not encountered. A recurrent ISR following DEB treatment was confirmed by DUS and CTA in 4/46 (8.7%) of the lesions and were retreated with DEB. A third recurrent ISR occurred in a single case (2%) and following a second DEB retreatment there were no signs of a fourth recurrence after 36 months follow-up.

CONCLUSION

The use of DEB angioplasty is a safe and effective treatment of ICA ISR lesions, yielding significantly better results compared to other modalities. Randomized multicenter studies are warranted.

Burnout and occupational stress among Hungarian radiographers working in emergency and non-emergency departments during COVID-19 pandemic

INTRODUCTION

The increased workload caused by the coronavirus pandemic may have had a significant impact on the mental health of radiographers. The aim of our study was to investigate burnout and occupational stress in radiographers working in emergency departments (ED) and non-emergency departments (NED).

METHODS

Quantitative, cross-sectional, descriptive research was carried out among radiographers working in the public health sector in Hungary. Due to the cross-sectional nature of our survey, there was no overlap between the ED and NED groups. For data collection, we used simultaneously the Maslach Burnout Inventory (MBI), the Effort-Reward Imbalance questionnaire (ERI), and our self-designed questionnaire.

RESULTS

We excluded incomplete questionnaires from our survey; finally, 439 responses were evaluated. Significantly higher scores for depersonalisation (DP; 8.43 (SD = 6.69) vs. 5.63 (SD = 4.21) and emotional exhaustion (EE; 25.07 (SD = 11.41) vs. 19.72 (SD = 11.72)) were observed in radiographers working in ED (p = 0.001; p = 0.001) when compared to NED. Male radiographers working in ED aged 20-29 and 30-39 years with experience of 1-9 years were more affected by DP (p ≤ 0.05). Worrying about one's own health had a negative effect on DP and EE (p ≤ 0.05). Having close friend with a COVID-19 infection had a negative effect on EE (p ≤ 0.05); not being infected with coronavirus, not being quarantined and relocating within the workplace had a positive effect on personal accomplishment (PA); radiographers who were 50 years or older with 20-29 years of experience were more affected by depersonalisation (DP); and those who worried about their health had significantly higher stress scores (p ≤ 0.05) in both ED and NED settings.

CONCLUSION

Male radiographers at the beginning of their careers were more affected by burnout. Employment in EDs had a negative impact on DP and EE.

IMPLICATIONS FOR PRACTICE

Our results support the implementation of interventions to counter the effects of occupational stress and burnout among radiographers working in ED.

Improved survival of non-small cell lung cancer patients after introducing patient navigation: A retrospective cohort study with propensity score weighted historic control

OnkoNetwork is a patient navigation program established in the Moritz Kaposi General Hospital to improve the timeliness and completeness of cancer investigations and treatment. The H2020 SELFIE consortium selected OnkoNetwork as a promising integrated care initiative in Hungary and conducted a multicriteria decision analysis based on health, patient experience, and cost outcomes. In this paper, a more detailed analysis of clinical impacts is provided in the largest subgroup, non-small cell lung cancer (NSCLC) patients. A retrospective cohort study was conducted, enrolling new cancer suspect patients with subsequently confirmed NSCLC in two annual periods, before and after OnkoNetwork implementation (control and intervention cohorts, respectively). To control for selection bias and confounding, baseline balance was improved via propensity score weighting. Overall survival was analyzed in univariate and multivariate weighted Cox regression models and the effect was further characterized in a counterfactual analysis. Our analysis included 123 intervention and 173 control NSCLC patients from early to advanced stage, with significant between-cohort baseline differences. The propensity score-based weighting resulted in good baseline balance. A large survival benefit was observed in the intervention cohort, and intervention was an independent predictor of longer survival in a multivariate analysis when all baseline characteristics were included (HR = 0.63, p = 0.039). When post-baseline variables were included in the model, belonging to the intervention cohort was not an independent predictor of survival, but the survival benefit was explained by slightly better stage distribution and ECOG status at treatment initiation, together with trends for broader use of PET-CT and higher resectability rate. In conclusion, patient navigation is a valuable tool to improve cancer outcomes by facilitating more timely and complete cancer diagnostics. Contradictory evidence in the literature may be explained by common sources of bias, including the wait-time paradox and adjustment to intermediate outcomes.

Correlation between Tissue Cellularity and Metabolism Represented by Diffusion-Weighted Imaging (DWI) and 18F-FDG PET/MRI in Head and Neck Cancer (HNC)

Simple Summary

We report on the correlation between the diffusion-weighted imaging (DWI) and the metabolic volume parameters derived from a PET scan, to determine the correlation between these parameters and the tumor cellularity in head and neck primary tumors. Our findings implied that there was no correlation between the information derived from the DWI and the information derived from the FDG metabolic parameters. Thus, both imaging techniques might play a complementary role in HNC diagnosis and assessment. This is significant because the treatment plan of patients with HNC should be well evaluated by using all the available diagnosis techniques, for a better understanding of how the tumor will react.

Abstract

Background: This study aimed to assess the association of 18F-Fluorodeoxyglucose positron-emission-tomography (18F-FDG/PET) and DWI imaging parameters from a primary tumor and their correlations with clinicopathological factors. Methods: We retrospectively analyzed primary tumors in 71 patients with proven HNC. Primary tumor radiological parameters: DWI and FDG, as well as pathological characteristics were analyzed. Spearman correlation coefficient was used to assess the correlation between DWI and FDG parameters, ANOVA or Kruskal–Wallis, independent sample t-test, Mann–Whitney test, and multiple regression were performed on the clinicopathological features that may affect the 18F- FDG and apparent-diffusion coefficient (ADC) of the tumor. Results: No significant correlations were observed between DWI and any of the 18F-FDG parameters (p > 0.05). SUVmax correlated with N-stages (p = 0.023), TLG and MTV correlated with T-stages (p = 0.006 and p = 0.001), and ADC correlated with tumor grades (p = 0.05). SUVmax was able to differentiate between N+ and N− groups (p = 0.004). Conclusions: Our results revealed a non-significant correlation between the FDG-PET and ADC-MR parameters. FDG-PET-based glucose metabolic and DWI-MR-derived cellularity data may represent different biological aspects of HNC.

Endovascular Recanalization of Tandem Internal Carotid Occlusions Using the Balloon-assisted Tracking Technique

PURPOSE

Tandem occlusive lesions are responsible for up to 20% of acute ischemic stroke cases and are associated with poor prognosis if complete recanalization cannot be achieved. Endovascular recanalization might be challenging due to difficulties in the safe passage of the occluded plaque at the origin of the internal carotid artery (ICA). The balloon-assisted tracking technique (BAT), where a partially deflated balloon is exposed out of the catheter tip to facilitate its passage through stenosed or spastic arterial segments was introduced by interventional cardiologists and the applicability of the technique has been recently proposed in the field of neurointervention as well. Here we describe our experience using the BAT technique in the endovascular recanalization of tandem occlusive lesions.

METHODS

Procedures were performed from June 2013 to December 2020 in a single center. Baseline clinical and imaging data, procedural and follow-up details and clinical outcomes were retrospectively collected.

RESULTS

In this study 107 patients, median age 66 years, median admission NIHSS 14 and median ASPECTS 8 were included. Successful recanalization of the ICA using the BAT technique was achieved in 100 (93%) and successful intracranial revascularization in 88 (82%) patients. There were no complications attributable to the BAT technique. Intraprocedural complications occurred in 9 (8%) patients. Emergent stenting was performed in 40 (37%) at the end of the procedure. Postprocedural adverse events (intracerebral hemorrhage [ICH], malignant infarction) occurred in 6 (5%) patients. Good clinical outcome at 3 months (modified Rankin scale [mRS] 0-2) was 54 (50%) and mortality 26 (24%). Delayed stent placement during follow-up occurred in 21 cases.

CONCLUSION

Application of BAT technique in tandem occlusions appears feasible, safe, and efficient. Further evaluation of this technique is awaited.

The role of hybrid FDG-PET/MRI on decision-making in presurgical evaluation of drug-resistant epilepsy

Background

When MRI fails to detect a potentially epileptogenic lesion, the chance of a favorable outcome after epilepsy surgery becomes significantly lower (from 60 to 90% to 20–65%). Hybrid FDG-PET/MRI may provide additional information for identifying the epileptogenic zone. We aimed to investigate the possible effect of the introduction of hybrid FDG-PET/MRI into the algorithm of the decision-making in both lesional and non-lesional drug-resistant epileptic patients.

Methods

In a prospective study of patients suffering from drug-resistant focal epilepsy, 30 nonlesional and 30 lesional cases with discordant presurgical results were evaluated using hybrid FDG-PET/MRI.

Results

The hybrid imaging revealed morphological lesion in 18 patients and glucose hypometabolism in 29 patients within the nonlesional group. In the MRI positive group, 4 patients were found to be nonlesional, and in 9 patients at least one more epileptogenic lesion was discovered, while in another 17 cases the original lesion was confirmed by means of hybrid FDG-PET/MRI. As to the therapeutic decision-making, these results helped to indicate resective surgery instead of intracranial EEG (iEEG) monitoring in 2 cases, to avoid any further invasive diagnostic procedures in 7 patients, and to refer 21 patients for iEEG in the nonlesional group. Hybrid FDG-PET/MRI has also significantly changed the original therapeutic plans in the lesional group. Prior to the hybrid imaging, a resective surgery was considered in 3 patients, and iEEG was planned in 27 patients. However, 3 patients became eligible for resective surgery, 6 patients proved to be inoperable instead of iEEG, and 18 cases remained candidates for iEEG due to the hybrid FDG-PET/MRI. Two patients remained candidates for resective surgery and one patient became not eligible for any further invasive intervention.

Conclusions

The results of hybrid FDG-PET/MRI significantly altered the original plans in 19 of 60 cases. The introduction of hybrid FDG-PET/MRI into the presurgical evaluation process had a potential modifying effect on clinical decision-making.

Trial registration

Trial registry: Scientific Research Ethics Committee of the Medical Research Council of Hungary. Trial registration number: 008899/2016/OTIG. Date of registration: 08 February 2016.

Additional Value of 18F-FDOPA Amino Acid Analog Radiotracer to Irradiation Planning Process of Patients With Glioblastoma Multiforme

PURPOSE

To investigate the added value of 6-(18F]-fluoro-L-3,4-dihydroxyphenylalanine (FDOPA) PET to radiotherapy planning in glioblastoma multiforme (GBM).

METHODS

From September 2017 to December 2020, 17 patients with GBM received external beam radiotherapy up to 60 Gy with concurrent and adjuvant temozolamide. Target volume delineations followed the European guideline with a 2-cm safety margin clinical target volume (CTV) around the contrast-enhanced lesion+resection cavity on MRI gross tumor volume (GTV). All patients had FDOPA hybrid PET/MRI followed by PET/CT before radiotherapy planning. PET segmentation followed international recommendation: T/N 1.7 (BTV1.7) and T/N 2 (BTV2.0) SUV thresholds were used for biological target volume (BTV) delineation. For GTV-BTVs agreements, 95% of the Hausdorff distance (HD95%) from GTV to the BTVs were calculated, additionally, BTV portions outside of the GTV and coverage by the 95% isodose contours were also determined. In case of recurrence, the latest MR images were co-registered to planning CT to evaluate its location relative to BTVs and 95% isodose contours.

RESULTS

Average (range) GTV, BTV1.7, and BTV2.0 were 46.58 (6-182.5), 68.68 (9.6-204.1), 42.89 (3.8-147.6) cm3, respectively. HD95% from GTV were 15.5 mm (7.9-30.7 mm) and 10.5 mm (4.3-21.4 mm) for BTV1.7 and BTV2.0, respectively. Based on volumetric assessment, 58.8% (28-100%) of BTV1.7 and 45.7% of BTV2.0 (14-100%) were outside of the standard GTV, still all BTVs were encompassed by the 95% dose. All recurrences were confirmed by follow-up imaging, all occurred within PTV, with an additional outfield recurrence in a single case, which was not DOPA-positive at the beginning of treatment. Good correlation was found between the mean and median values of PET/CT and PET/MRI segmented volumes relative to corresponding brain-accumulated enhancement (r = 0.75; r = 0.72).

CONCLUSION

18FFDOPA PET resulted in substantial larger tumor volumes compared to MRI; however, its added value is unclear as vast majority of recurrences occurred within the prescribed dose level. Use of PET/CT signals proved to be feasible in the absence of direct segmentation possibilities of PET/MR in TPS. The added value of 18FFDOPA may be better exploited in the context of integrated dose escalation.

Effect of rapid response system on hospital mortality, implemented by Somogy County Kaposi Mór Teaching Hospital

Összefoglaló. Bevezetés: Általánosságban elmondható, hogy a fekvőbeteg-ellátást nyújtó egészségügyi intézmények intenzív terápiás osztályain (ITO) jelennek meg a legsúlyosabb kórképekkel és a legmagasabb halálozási aránnyal bíró esetek, rendszerint megkésve. Eltérően az ITO-tól, más betegellátó osztályokon előfordulhat, hogy nem észlelik megfelelően és időben a betegek olyan állapotváltozásait, melyek előre jelzik például a szívleállást vagy a keringési rendszer várható összeomlását. Ennek kiküszöbölésére jelenthet megoldást az úgynevezett gyors reagálású rendszer (RRS), melynek segítségével csökkenthető a kórházon belüli mortalitás. Célkitűzés: A Somogy Megyei Kaposi Mór Oktató Kórház a teljes intézményre kiterjedően a 2016. évtől alkalmazza az RRS-t. A jelen tanulmány célja a kórházi mortalitás csökkentésével kapcsolatos első eredmények bemutatása. Módszer: Vizsgálatunkban az ITO-ra került betegek adatbázisán alapuló kereszttáblás, illetve nemparametrikus statisztikai módszereket alkalmaztuk. Eredmények: A statisztikai próbák eredményei alapján megállapítottuk, hogy az intenzív ellátás felvételi diagnózisai (légzési elégtelenség, neurológiai ok, reanimáció, szepszis, szív/keringési, egyéb ok) között statisztikailag igazolható eltérés tapasztalható (p = 3,815e-14) RRS alkalmazásával és a nélkül. Az RRS-sel felvettek között magasabb arányt képviseltek a légzési elégtelenséggel és szepszissel érkező, súlyosabb betegek, ugyanakkor kisebbnek bizonyult a reszuszcitáltak száma. Megbeszélés: Az RRS nélküli időszak 2,983%-os intézményi mortalitása az RRS-időszakban 2,932%-ra csökkent, azonban a beküldő osztályonkénti adatokban jelentős különbségeket tapasztaltunk. 21 fekvőbeteg-osztály közül 19 osztály esetén csökkent a mortalitás az RRS bevezetését követően. Következtetés: Arra a megállapításra jutottunk, hogy a nemzetközi szakirodalom alapján bevezetett RRS növelte az egészségügyi ellátás hatékonyságát, és ezáltal sikerült csökkenteni az intézményi szintű mortalitást. Orv Hetil. 2021; 162(20): 782-789.

SUMMARY

INTRODUCTION

In general, the cases with the most severe diseases and highest mortality rate are admitted to the intensive care units (ICU) usually late. Contrary to ICU, in other in-patient units it can happen that those changes in patients' condition, which pre-indicate, e.g., cardiac arrest or collapse of circulatory system, are not noticed properly and in time. To eliminate this, the so-called rapid response system (RRS) can be the solution, by the help of which hospital mortality can be reduced. Objectve: The RRS has been used all institution-wide in Somogy County Kaposi Mór Teaching Hospital from 2016. The aim of this study is to demonstrate the results concerning hospital mortality cutdown.

METHOD

Our analysis was based on ICU patients' database and we applied cross-tabulation and non-parametric statistical methods.

RESULTS

We appointed, that among admission diagnosises to ICU (respiration insufficiency, neurological reason, reanimation, sepsis, cardiac/circulatory condition, other), statistically verifiable discrepancy can be experienced (p = 3.815e-14) with using RRS or without it. Among those admitted via RRS, more severe patients with respiration insufficiency and septic conditions were represented in higher rate, while the number of the admitted ones after resuscitation has decreased.

DISCUSSION

Hospital mortality rate of 2.983% without using RRS decreased into 2.932% in the period of using RRS, though we observed remarkable differences in data of non-ICU in-patient departments. Mortality has reduced in 19 in-patient departments out of 21, after implementing RRS.

CONCLUSION

To sum it up, we identified that RRS implemented on the basis of international references has increased the efficiency of healthcare and owing to it, institution-level mortality has successfully decreased. Orv Hetil. 2021; 162(20): 782-789.

Pre-treatment PET/MRI based FDG and DWI imaging parameters for predicting HPV status and tumor response to chemoradiotherapy in primary oropharyngeal squamous cell carcinoma (OPSCC)

OBJECTIVES

To determine the feasibility of pre-treatment primary tumor FDG-PET and DWI-MR imaging parameters in predicting HPV status and the second aim was to assess the feasibility of those imaging parameters to predict response to therapy.

MATERIAL AND METHODS

We retrospectively analyzed primary tumors in 33 patients with proven OPSCC. PET/MRI was performed before and 6 months after chemo-radiotherapy for assessing treatment response. PET Standardized uptake value (SUVmax), total lesion glycolysis (TLG), metabolic tumor volume (MTV), and apparent diffusion coefficient (ADC) from pre-treatment measurements were assessed and compared to the clinicopathological characteristics (T stages, N stages, tumor grades, HPV and post-treatment follow up). HPV was correlated to the clinicopathological characteristics.

RESULTS

ADCmean was significantly lower in patients with HPV^+ve than HPV^-ev, (P = 0.001), cut off value of (800 ± 0.44*10^-3mm²/s) with 76.9% sensitivity, and 72.2% specificity is able to differentiate between the two groups. No significant differences were found between FDG parameters (SUVmax, TLG, and MTV), and HPV status, (P = 0.873, P = 0.958, and P = 0.817), respectively. Comparison between CR and NCR groups; ADCmean, TLG, and MTV were predictive parameters of treatment response, (P = 0.017, P = 0.013, and P = 0.014), respectively. HPV^+ve group shows a higher probability of lymph nodes involvement, (P = 0.006) CONCLUSION: Our study found that pretreatment ADC of the primary tumor can predict HPV status and treatment response. On the other hand, metabolic PET parameters (TLG, and MTV) were able to predict primary tumor response to therapy.

Creating a cross-sectional, CT and MR atlas of the Pannon minipig

PURPOSE

The purpose of this study was to create a detailed cross-sectional anatomical reference atlas of the Pannon minipig by correlating good resolution CT and MR images with high quality cross-sectional anatomical images. According to the authors knowledge, no detailed anatomical atlas is available for the minipig.

MATERIAL AND METHOD

An adult female minipig was utilized for this purpose. The animal was placed in a PVC half tube, and CT generated images of 0.6 mm slice thickness and MR images of 1.41 mm slice thickness were obtained. The images covered the whole body from the most rostral portion of the snout to the tip of the tail. The CT and MR scans were aligned with frozen anatomical sections prepared with an anatomical band saw from the same animal and significant structures were identified and labelled. The terminology employed has been referenced from the Nomina Anatomica Veterinaria 6th edition-2017.

FINDINGS AND CONCLUSIONS

The resulting atlas consists of 109 anatomical slices and the corresponding 109 CT and 109 MR scans (altogether 327 images) and the nomenclature list for each image. Although this publication contains limited images of the resulted atlas, it is a reference source for anatomy education and clinical sciences. We are of the opinion that more comprehensive and especially online available interactive atlases should be prepared using similar methodology.

Predictive value of PET/CT based metabolic information in the modern 3D based radiotherapy treatment of head and neck can-cer patients - single institute study

OBJECTIVE

The aim of the study was to evaluate the predictive value of pretreatment positron emission tomography (PET) standardized uptake value (SUVmax), standardized uptake value corrected for lean body mass (SULpeak) value, metabolic tumour volume (MTV) and total lesion glycolysis (TLG) parameters of the primary tumour assessed with PET/computed tomography (CT) in the clinical out-come in patients diagnosed with histopathologically confirmed head and neck squamous cell carcinoma.

MATERIALS AND METHODS

Retrospective evaluation was performed using PET/CT image datasets of 52 histologically proven head and neck cancer patients in 4 weeks' prior receiving definitive chemo-radiotherapy (CRT). Positron emission tomography /CT was performed before the CRT and 12 weeks after it for response evaluation. Image data was used for target volume delineation and for specify SUVmax, SULpeak, MTV and TLG parameters of the primary tumour. According to the results of the therapeutic response evaluation two patient subgroups were created in relation to the presence or absence of viable tumour. Metabolic data from pre-treatment PET/CT and therapeutic response were correlated using Kruskal-Wallis test.

RESULTS

After completion of the CRT in 24/52 (46%) cases viable residual tumour was detected on restaging PET/CT, while in 28/52 (54%) patients showed complete remission. For the therapeutic success prediction assessment, we could not find any significant correlation with pre-treatment SUVmax and SULpeak values (P>0.44, P>0.33). Total lesion glycolysis provided nearly significant difference (P=0.052) and MTV had shown significant difference (P=0.001) between the two patient subgroups statistically.

CONCLUSION

Simple metabolic data (SUVmax and SULpeak) from pretreatment fluorine-18-fluorodeoxyglucose (¹⁸F-FDG) PET/CT were unable to predict therapeutic response, while volumetric information containing MTV and TLG parameters proved to be more useful, thus their inclusion to risk stratification may also have additional value.

Predictive Value of Diffusion, Glucose Metabolism Parameters of PET/MR in Patients With Head and Neck Squamous Cell Carcinoma Treated With Chemoradiotherapy

Purpose: This study aims to evaluate the predictive value of the pretreatment, metabolic, and diffusion parameters of a primary tumor assessed with PET/MR on patient clinical outcomes.

Methods: Retrospective evaluation was performed using PET/MR image data sets acquired using the single tracer injection dual imaging of 68 histologically proven head and neck cancer patients 4 weeks before receiving definitive chemoradiotherapy (CRT). PET/MR was performed before the CRT and 12 weeks after the CRT for response evaluation. Image data (PET and MRI diffusion-weighted imaging [DWI]) was used to specify the maximum standard uptake value, the peak lean body mass corrected, SUV_max, the metabolic tumor volume, the total lesion glycolysis (SUV_max, SUL_peak, MTV, and TLG), and the mean apparent diffusion coefficient (ADC_mean) of the primary tumor. Based on the results of the therapeutic response evaluation, two patient subgroups were created: one with a viable tumor and another without. Metabolic and diffusion data, from the pretreatment PET/MR and the therapeutic response, were correlated using Spearman's correlation coefficient and Wilcoxon's test.

Results: After completing the CRT, a viable residual tumor was detected in 36/68 (53%) cases, and 32/68 (47%) patients showed complete remission. However, no significant correlation was found between the pretreatment parameter, ADC_mean (p = 0.88), and the therapeutic success. The PET parameters, SUV_max and SUL_peak, MTV, and TLG (p = 0.032, p = 0.01, p < 0.0001, p = 0.0004) were statistically significantly different between the two patient subgroups.

Conclusion: This study found that MRI-based (ADC_mean) data from FDG PET/MR pretreatment could not be used to predict therapeutic response although the PET parameters SUV_max, SUL_peak, MTV, and TLG proved to be more useful; thus, their inclusion in risk stratification may also be of additional value.

High Frequency and Intensity Rehabilitation in 641 Subacute Ischemic Stroke Patients

OBJECTIVES

To determine the effects of exergaming on quality of life (QoL), motor, and clinical symptoms in subacute stroke patients.

DESIGN

A pseudorandomized controlled trial, using a before-after test design.

SETTING

University hospital.

PARTICIPANTS

Subacute, ischemic stroke outpatients (N=3857), 680 of whom were randomized and 641 completed the study.

INTERVENTIONS

We determined the effects of 5 times a week twice daily (EX2; 50 sessions; n=286) and once daily (EX1; 25 sessions; n=272) exergaming and low-intensity standard care (control [CON]; 25 sessions; n=83) on clinical, mobility, blood pressure (BP), and QoL outcomes.

MAIN OUTCOME MEASURES

The primary outcome was Modified Rankin Scale. Secondary outcomes were activities of daily living, 5 aspects of health-related QoL, Beck Depression Inventory, 6-minute walk test (6MWT), Berg Balance Scale (BBS), and static balance (center of pressure).

RESULTS

During exercise, the peak heart rate was 134, 134, and 126 beats per minute in the EX2, EX1, and CON groups, respectively. mRS improved similarly in the EX2 (-1.8; effect size, d=-4.0) and EX1 (-1.4; d=-2.6) groups, but more than in the CON group (-0.7; d=-0.6). QoL, Barthel Index, BBS, 6MWT, and standing posturography improved more in the EX2 group and the same in the EX1 and CON groups. Systolic and diastolic resting BP decreased more in the EX2 and EX1 groups than in the CON group. The intervention effects did not differ between men (n=349) and women (n=292).

CONCLUSIONS

Twice daily compared with once daily high-intensity exergaming or once daily lower intensity standard care produced superior effects on clinical and motor symptoms, BP, and QoL in male and female subacute ischemic stroke participants.

Diffusion-Weighted Imaging (DWI) derived from PET/MRI for lymph node assessment in patients with Head and Neck Squamous Cell Carcinoma (HNSCC)

BACKGROUND

To determine the usefulness of Diffusion Weighted Imaging (DWI) derived from PET/MRI in discriminating normal from metastatic lymph nodes and the correlation between the metastatic lymph nodes with the grade and the localization of the primary tumor.

METHODS

Retrospective study of 90 lymph nodes from 90 subjects; 65 patients who had proven histopathological metastatic lymph nodes from (HNSCC) who had undergone 18F- PET/MRI for clinical staging and assessment and twenty-five lymph nodes were chosen from 25 healthy subjects. Apparent Diffusion Coefficient (ADC) map was generated from DWI with b values (0 and 800 s/mm2). ADC values of the metastatic lymph nodes were calculated and compared to the normal lymph nodes ADC values, ROC was used to determine the best cut-off values to differentiate between the two group. Metastatic lymph nodes ADC mean values were compared to primary tumor grade and localization.

RESULTS

ADCmean value of the metastatic lymph nodes in the overall sample (0.899 ± 0.98*10- 3 mm2/sec) was significantly lower than the normal lymph nodes' ADCmean value (1.267 ± 0.88*10- 3 mm2/sec); (P = 0.001). The area under the curve (AUC) was 98.3%, sensitivity and specificity were 92.3 and 98.6%, respectively, when using a threshold value of (1.138 ± 0.75*10- 3 mm2/sec) to differentiate between both groups. Significant difference was found between metastatic lymph nodes (short-axis diameter < 10 mm), ADCmean (0.898 ± 0.72*10- 3 mm2/sec), and the benign lymph nodes ADCmean, (P = 0.001). No significant difference was found between ADCmean of the metastatic lymph nodes < 10 mm and the metastatic lymph nodes > 10 mm, ADCmean (0.899 ± 0.89*10- 3 mm2/sec), (P = 0.967). No significant differences were found between metastatic lymph nodes ADCmean values and different primary tumor grades or different primary tumor localization, (P > 0.05).

CONCLUSION

DWI-ADC is an effective and efficient imaging technique in differentiating between normal and malignant lymph nodes, and might be helpful to discriminate sub-centimeters lymph nodes.

TRIAL REGISTRATION

The trial is registered in clinical trials under ID: NCT04360993 , registration date: 17/04/2020.

OAR sparing 3D radiotherapy planning supported by fMRI brain mapping investigations

The human brain as an organ has numerous functions; some of them can be visualized by functional imaging techniques (e.g., functional MRI [fMRI] or positron emission tomography). The localization of the appropriate activity clusters requires sophisticated instrumentation and complex measuring protocol. As the inclusion of the activation pattern in modern self-tailored 3D based radiotherapy has notable advantages, this method is applied frequently. Unfortunately, no standardized method has been published yet for the integration of the fMRI data into the planning process and the detailed description of the individual applications is usually missing. Thirteen patients with brain tumors, receiving fMRI based RT planning were enrolled in this study. The delivered dose maps were exported from the treatment planning system and processed for further statistical analysis. Two parameters were introduced to measure the geometrical distance Hausdorff Distance (HD), and volumetric overlap Dice Similarity Coefficient (DSC) of fMRI corrected and not corrected dose matrices as calculated by 3D planning to characterize similarity and/or dissimilarity of these dose matrices. Statistical analysis of bootstrapped HD and DSC data was performed to determine confidence intervals of these parameters. The calculated confidence intervals for HD and DSC were (5.04, 7.09), (0.79, 0.86), respectively for the 40 Gy and (5.2, 7.85), (0.74, 0.83), respectively for the 60 Gy dose volumes. These data indicate that in the case of HD < 5.04 and/or DSC > 0.86, the 40 Gy dose volumes obtained with and without fMRI activation pattern do not show a significant difference (5% significance level). The same conditions for the 60 Gy dose volumes were HD < 5.2 and/or DSC > 0.83. At the same time, with HD > 7.09 and/or DSC < 0.79 for 40 Gy and HD > 7.85 and/or DSC < 0.74 for 60 Gy the impact of fMRI utilization in RT planning is excessive. The fMRI activation clusters can be used in daily RT planning routine to spare activation clusters as critical areas in the brain and avoid their high dose irradiation. Parameters HD (as distance) and DSC (as overlap) can be used to characterize the difference and similarity between the radiotherapy planning target volumes and indicate whether the fMRI delivered activation patterns and consequent fMRI corrected planning volumes are reliable or not.

Benefits Of Timely Care In Pancreatic Cancer: A Systematic Review To Navigate Through The Contradictory Evidence

The evidence base of policies that improve the timeliness of cancer care is under ongoing debate. Pancreatic cancer is frequently diagnosed in a stage when curative therapy is not feasible; hence, it is an important target for timelier healthcare interventions. The objectives of our research were to identify all clinical studies on pancreatic cancer care delays via a systematic literature review, to assess the study methodologies for possible biases, to conclude on the available evidence, and to formulate research recommendations on evidence gaps. Nineteen studies were identified and eight reported multivariate analyses. Although many sources of bias shifted the results towards negative or paradoxical findings, a statistically significant association of shorter delays with better clinical outcomes was demonstrated in the majority of studies reporting multivariate analyses. Noninferiority analyses were not published. Further efforts to provide timely care for pancreatic cancer patients are encouraged, and studies on the associations of delay with patient experience and healthcare resource utilization are warranted.

[Possibilities of dose reduction during CT imaging by application of iterative image reconstruction]

Introduction and aim: In case of imaging modalities using ionizing radiation, radiation exposure of the patients is a vital issue. It is important to survey the various dose-reducing techniques to achieve optimal radiation protection while keeping image quality on an optimal level. Method: We reprocessed 105 patients' data prospectively between February and April 2017. The determination of the radiation dose was based on the effective dose, calculated by multiplying the dose-length product (DLP) and dose-conversation coefficient. In case of image quality we used signal-to-noise ratio (SNR) based on manual segmentation of region of interest (ROI). For statistical analysis, one sample t-test and Wilcoxon signed rank test were used. Results: Using iterative reconstruction, the effective dose was significantly lower (p<0.001) in both native and contrast-enhanced abdominal, contrast-enhanced chest CT scans and in the case of the total effective dose. At native and contrast-enhanced abdominal CT scans, the noise content of the images showed significantly lower (p<0.001) values for iterative reconstruction images. At contrast-enhanced chest CT scans there was no significant difference between the noise content of the images (p>0.05). Conclusion: Using iterative reconstruction, it was possible to achieve significant dose reduction. Since the noise content of the images was not significantly higher using the iterative reconstruction compared to the filtered back projection, further dose reduction can be achievable while preserving the optimal quality of the images. Orv Hetil. 2019; 160(35): 1387-1394.

[Burnout level among radiology department workers in Hungary]

Introduction: Burnout can have a wide negative impact on the quality and the effectiveness of the health care system. The aim of our research was to assess the burnout level of the radiology department workers in Hungary. Method: Our quantitative, cross-sectional, descriptive data collection lasted from June to September 2018 using an online questionnaire. Simple, non-random sampling was carried out among radiology department workers in Hungary. In addition to our self-made questionnaire which included socio-demographic and work-related questions, an internationally validated Maslach Burnout Inventory questionnaire was sent out. Results: After data cleaning, a total number of 404 (n = 404) respondents were included in the statistical analysis. The majority of the respondents works in county hospital, the average year spent in the healthcare system was 18.3 (SD 13,7). The sample's values at the depersonalization and emotional exhaustion dimension were slightly elevated in contrast to the average values. Educational level, age and years spent in the healthcare system had a significant influence on all the three dimensions of burnout (p≤0.05). The group of workers being 31-35 years old and the group of those who spent 16-20 years in the healthcare system are considered to be the most compromised groups in all the three dimensions of burnout. Respondents with master degree had significantly lower emotional exhaustion values than their colleagues. Conclusion: The increased value of the depersonalization and the emotional exhaustion can be an indicator for employers. Our results are similar like described in the international literature. Orv Hetil. 2019; 160(27): 1070-1077.

Body composition and venison quality of farmed red deer (Cervus elaphus) hinds reared on grass, papilionaceous or mixed pasture paddocks

Red deer (Cervus elaphus) hinds (n=3×10) of identical initial body weight (BW, ca. 68 kg) were reared on a monocotyledonous grass (G group), on a grass–papilionaceous (GP group) or on pure papilionaceous pasture each of 2 ha (P group) for 219 d. At the end of the experiment carcass tissue composition was assessed by means of computer tomography, slaughter value and meat quality were characterized and tissue – longissimus thoracis et lumborum (LTL), thigh and liver – samples were taken for fatty acid composition analysis. The primary aim was to assess nutrition-driven differences.

Hinds of group P provided higher final BW (101 kg vs. 90 and 91.9 kg in groups G and GP, respectively) and higher BW gain (32.6 kg during the total period vs. 22.4 and 22.1 kg). The carcass weight exceeded those of the other groups significantly (68.8 kg vs. 59.3 and 63.2 kg), while there was no difference among groups in the perirenal fat weight and red color tone (a*) of the LTL. Groups G and P differed significantly in the LTL weight (highest in P), its dripping loss (lowest in G), lightness (L; highest in P) and yellow color tone (b*).

In the thigh muscle, LTL and liver the highest proportion of fatty acid CLA9c11t was reached on the G pasture, and the same trend was true for docosahexaenoic acid (DHA , C22:6 n3) in the muscles. The n6 / n3 fatty acid ratio was the highest on the P pasture in the liver and both muscles. The liver incorporated the highest proportion of linoleic acid (C18:2 n6) and converted it rather effectively to arachidonic acid (C20:4 n6), coupled with the lowest α-linolenic acid presence.

In conclusion, concerning muscle mass production, group P proved to be the most advantageous pasture; meanwhile LTL meat quality factors (dripping loss, DHA proportion, pH, color) were more favorable on the G pasture.

Planning, implementation and operation of a personalized patient management system for subjects with first suspect of cancer (OnkoNetwork): system description based on a qualitative study

Background

OnkoNetwork is a recently established integrated care model with a personalized pathway system to manage patients with first suspect of a solid tumour in secondary care, that evolved as a regional initiative in Hungary. The primary aim of OnkoNetwork is the improvement of clinical outcomes via timely access to quality assured and defragmented healthcare services. The Horizon 2020 funded SELFIE project has selected OnkoNetwork for in-depth qualitative and quantitative evaluation. The aim of this study was to provide a qualitative evaluation of OnkoNetwork along the six components of the SELFIE conceptual framework: 1) service delivery, 2) leadership and governance, 3) workforce, 4) financing, 5) technologies and medical products, and 6) information and research.

Methods

Analysis of published and grey programme documentation, followed by 20 semi-structured interviews with representatives of programme initiators, general and financial managers, involved physicians and non-physician professionals, patients and their informal caregivers. Transcripts of all interviews were analysed by Mayring’s content analysis method by two independent researchers.

Results

This study yielded the first comprehensive description of the programme. OnkoNetwork is a blue dahila in Central and Eastern Europe, providing timely and quality-assured healthcare services for the target patients by personalized patient path monitoring and management in a financially sustainable manner without macro-level financing of its operation. Innovative professional roles were implemented for non-physicians and physicians, and a supporting information technology application was developed.

Conclusions

This paper provides a systematic description of OnkoNetwork on the six components of the SELFIE conceptual framework for integrated care in multimorbidity to understand how and why OnkoNetwork was implemented and cares (better) for its patients. Because integrated care models are designed and adjusted to their specific local needs and context, those few successful and sustainable models that were established in Central and Eastern European countries represent important benchmarks for other initiatives in this region. Experience with OnkoNetwork during its planning, implementation and operation including the description of key success factors and barriers as perceived by various stakeholder groups, may support the development of further integrated care models especially in countries with similar economic status and healthcare settings.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3957-9) contains supplementary material, which is available to authorized users.

[The predictive role of PET/CT imaging in clinical N and M staging and treatment decision process. Institutional experiences in Hungary]

INTRODUCTION AND AIM

The aim of our study was to investigate changes in clinical staging N (lymph node) and M (distant metastasis) in patients who receive PET/CT-based 3D radiotherapy within complex oncological treatment, and compare to conventional cross-sectional imaging staging technique. We also investigated the presence of PET/CT-detected second tumors and the effect of PET/CT on therapeutic decisions.

METHOD

From the 1st of January 2015 to the 30th of November 2016, 192 patients (n = 192) were treated with PET/CT-based radiation (109 head, 44 lung, 28 rectum and 11 cervical localization) in the Oncoradiology Institute of the Health Center of the University of Kaposvár. All patients received conventional cross-sectional and PET/CT imaging in accordance with the valid investigation protocol. The average time interval between the two cross-sectional investigations was 5.2 weeks. Clinical N and M staging was performed on the basis of the classification of the American Joint Committee on Cancer (AJCC) and the Union of International Cancer Control (UICC).

RESULTS

By analyzing the clinical stages N and M separately, based on the results of the PET/CT studies, the N stage was changed in 77 cases and the M stage changed in 31 cases. Overall, the PET/CT study resulted in higher clinical stages in 68 (35.4%) patients and lower clinical stages in 14 (7.3%) patients. The treatment plan was changed in 9% of the patients (n = 18) (definitive versus palliative treatment) and the extension of radiotherapy treatment target volume (PTV) was indicated in 20% of the patients (n = 39) due to the change in clinical lymph node status. PET/CT also detected secondary tumors in 15 (8%) patients.

CONCLUSION

Based on our results, the addition of PET/CT to conventional cross-sectional staging imaging permits a more accurate clinical classification of N and M stages and significantly influences therapeutic decisions. PET/CT imaging also provides a great help in detecting occult second tumors. The results of our Institute harmonize with the international data available in the literature. Orv Hetil. 2018; 159(39): 1593-1601.

A PET/MR képalkotás magyarországi klinikai alkalmazásának lehetőségei, első tapasztalatai

Abstract:

Hungary’s first and still only multimodality PET/MR device is operating in the Health Center of Kaposvár University. The aim of our review article is to present the current Hungarian PET/MR imaging application opportunities, our available initial experiences with this novel multimodality imaging technique in malignant and non-malignant diseases and further potential targeted clinical fields of use are also addressed. Orv Hetil. 2018; 159(34): 1375–1384.

A beállítási biztonsági margó nagyságának meghatározása fej-nyak daganatok 2D-2D és 3D képvezérelt intenzitásmodulált sugárkezelése esetén

Abstract:

Introduction: Image-guided intensity-modulated radiation therapy is essential for oncology treatment of head-and-neck cancer patients. Aim: MV-kV and CBCT modalities were compared in case of IGRT treatment for head-and-neck cancer patients. Setup error, setup margin (SM), imaging and evaluation times and imaging doses were analyzed. Method: Eight patients’ elective treatment was evaluated, 66 orthogonal MV-kV images and 66 CBCT series were acquired. Setup error measurement was based on bony manual image registration in three translational directions. Normality test and F-test were performed followed by the comparison with independent-samples T-test (p<0,05). The necessary target volume setup margin was calculated based on Van Herk’s equation. Imaging time and setup error determination time were measured. Imaging doses were estimated based on the literature. Results: No statistically significant difference was found between setup errors determined by MV-kV and CBCT (VRT: 0.5 mm, SD = 1.9 vs. 0.4 mm, SD = 2.1, p = 0.371; LNG: 0.2 mm, SD = 2.2 vs. –0.1 mm, SD = 2.2, p = 0.188; LAT: 0.2 mm, SD = 2.2 vs. 0.3 mm, SD = 2.1, p = 0.41). SM values were: VRT: 2.7 mm vs. 2.5 mm; LNG: 2.1 mm vs. 1.3 mm; LAT: 2.2 mm vs. 2.3 mm. Mean imaging time was 0.65 min (MV-kV) vs. 2.29 min (CBCT). Mean setup error determination time was 2.41 min for both modalities. Estimated imaging doses were 6.88 mGy (MV-kV) vs. 17.2 mGy (CBCT) per fraction. Conclusion: The bony anatomy derived image registration based translational setup error determination results in similar values either by MV-kV or by CBCT. Using 3 mm setup margin in all the directions might be adequate. Imaging time is less by MV-kV, significant difference in imaging doses did not appear. Using CBCT is generally suggested. MV-kV might be an alternative in case of need for shortened imaging time. Orv Hetil. 2018; 159(29): 1193–1200.

Matrix Metalloproteinase-2 Impairs Homing of Intracoronary Delivered Mesenchymal Stem Cells in a Porcine Reperfused Myocardial Infarction: Comparison With Intramyocardial Cell Delivery

Background

Intracoronary (IC) injection of mesenchymal stem cells (MSCs) results in a prompt decrease of absolute myocardial blood flow (AMF) with late and incomplete recovery of myocardial tissue perfusion. Here, we investigated the effect of decreased AMF on oxidative stress marker matrix metalloproteinase-2 (MMP-2) and its influence on the fate and homing and paracrine character of MSCs after IC or intramyocardial cell delivery in a closed-chest reperfused myocardial infarction (MI) model in pigs.

Methods

Porcine MSCs were transiently transfected with Ad-Luc and Ad-green fluorescent protein (GFP). One week after MI, the GFP-Luc-MSCs were injected either IC (group IC, 11.00 ± 1.07 × 10⁶) or intramyocardially (group IM, 9.88 ± 1.44 × 10⁶). AMF was measured before, immediately after, and 24 h post GFP-Luc-MSC delivery. In vitro bioluminescence signal was used to identify tissue samples containing GFP-Luc-MSCs. Myocardial tissue MMP-2 and CXCR4 receptor expression (index of homing signal) were measured in bioluminescence positive and negative infarcted and border, and non-ischemic myocardial areas 1-day post cell transfer. At 7-day follow-up, myocardial homing (cadherin, CXCR4, and stromal derived factor-1alpha) and angiogenic [fibroblast growth factor 2 (FGF2) and VEGF] were quantified by ELISA of homogenized myocardial tissues from the bioluminescence positive and negative infarcted and border, and non-ischemic myocardium. Biodistribution of the implanted cells was quantified by using Luciferase assay and confirmed by fluorescence immunochemistry. Global left ventricular ejection fraction (LVEF) was measured at baseline and 1-month post cell therapy using magnet resonance image.

Results

AMF decreased immediately after IC cell delivery, while no change in tissue perfusion was found in the IM group (42.6 ± 11.7 vs. 56.9 ± 16.7 ml/min, p = 0.018). IC delivery led to a significant increase in myocardial MMP-2 64 kD expression (448 ± 88 vs. 315 ± 54 intensity × mm², p = 0.021), and decreased expression of CXCR4 (592 ± 50 vs. 714 ± 54 pg/tissue/ml, p = 0.006), with significant exponential decay between MMP-2 and CXCR4 (r = 0.679, p < 0.001). FGF2 and VEGF of the bioluminescence infarcted and border zone of homogenized tissues were significantly elevated in the IM goups as compared to IC group. LVEF increase was significantly higher in IM group (0.8 ± 8.4 vs 5.3 ± 5.2%, p = 0.046) at the 1-month follow up.

Conclusion

Intracoronary stem cell delivery decreased AMF, with consequent increase in myocardial expression of MMP-2 and reduced CXCR4 expression with lower level of myocardial homing and angiogenic factor release as compared to IM cell delivery.

The Attrition and Migration Behaviour among Hungarian Radiographers

INTRODUCTION: Organizations are social systems where human resources are the most important factors. In recent years, healthcare employers have assigned a high priority to the recruitment of educated health professionals. The aim of our study was to identify the possible reasons behind the migration and attrition behaviour among Hungarian radiographers. We were interested whether the professional staff have ideas across borders which can be connected with attrition.MATERIAL & METHODS: In our cross-sectional retrospective study we used a self designed questionnaire and the Effort-Reward Imbalance (ERI) Questionnaire’s shortened version. Our target group were active radiographers with BSC radiography degree. The study sample counted 216 radiographers (n=216). For data analysis we used the SPSS 13.0. Variance analysis, paired sample T-test, Chi-square test, linear regression and descriptive statistics were used with the performed probability of 95% (p<0.05).RESULTS: 30.6% of responders (n=66) were considering working abroad, 40.3% (n=87) of responders remain in Hungary. At the age group of 20–30 we can observe significant relationship between the working opportunity abroad (p=0.001). The migration tendency was specific for radiographers with no children (n=54). We found a significant relationship between the working ability abroad and the radiographers’ years spent working in the healthcare system (p=0.008). 41.7% of respondents (n=90) think that it would be a favorable option to making a career change. We also found a significant relationship between the possibility of working abroad and the desire for higher wages and the lack of making career advancements as a radiographer (p=0.001; p=0.001).CONCLUSION: Correlation of our results with similar research was difficult because very few researchers put their interest into radiographers. In respect to other healthcare workers (eg.: nurses, physiotherapists) our result correlate well with the literature. Our research provides a broad view of the migration and attrition tendency among Hungarian radiographers and its underlying causes. According to our study changes should be implemented in the Hungarian system to keep the younger radiographers home.

Acute hepatic effects of low-dose fumonisin B(1) in rats

Adult male Wistar rats were enrolled in a study to test the acute hepatic effects of 50 mg/kg fumonisin B₁ in feed for 5 days. Fumonisin B₁ depressed growth and feed intake, and absolute and relative liver weight showed a significant increase. The proportions of C17:0, C18:3 n3, C22:5 n3 and C22:6 n3 fatty acids decreased in the hepatic phospholipid fraction. All proportional decreases modified the hepatocellular membrane lipids into a more rigid state. The fatty acid profile modifications were partly compensated for by endogenous glutathione (preventing the formation of conjugated dienes and trienes as initial phase lipid peroxidation indicators), while the enzymatic antioxidant defence system (glutathione peroxidase) was unaltered. In contrast, hepatic malondialdehyde, the cytotoxic product of end-phase lipid peroxidation showed a concentration increase even after 5 days of feeding. The results indicate a rather strong and rapid hepatic effect of FB₁, immediately impairing membrane phospholipids, even before the enzymatic antioxidant defence is activated.

Feed exposure to FB1 can aggravate pneumonic damages in pigs provoked by P. multocida

The possible interaction between Pasteurella multocida and the mycotoxin fumonisin B1 (FB1), recognised as one of the most often food/feed contaminant, was studied with the aim to evaluate whether and how FB1 can influence and/or complicate the development and severity of various pathological damages provoked by Pasteurella multocida in some internal organs of pigs. Heavier lung pathology was seen in pigs experimentally infected with Pasteurella multocida, when the same were exposed to 20ppm dietary levels of fumonisin B1 (FB1) as was assessed by gross pathology, pathomorphological examinations, clinical biochemistry and some immunological investigations. The most typical damages in FB1 treated pigs were the strong oedema in the lung and the slight oedema in the other internal organs and mild degenerative changes in the kidneys, whereas the typical pathomorphological findings in pigs infected with Pasteurella multocida was broncho-interstitial pneumonia. FB1 was found to aggravate pneumonic changes provoked by P. multocida in the cranial lobes of the lung and to complicate pneumonic damages with interstitial oedema in the lung. No macroscopic damages were observed in the pigs infected only with Pasteurella multocida. It can be concluded that the feed intake of FB1 in pigs may complicate or exacerbate the course of P. multocida serotype A infection.

[COMPUTED TOMOGRAPHIC EXAMINATION OF CRANIAL LESIONS, A PALEORADIOLOGICAL APPROACH]

BACKGROUND AND PURPOSE

Introducing the multidisciplinary paleoradiology research at the Institute of Diagnostic Imaging and Radiation Oncology of the Kaposvár University, highlighting the cases with potential central nervous system involvement--from the scanning methods to the 3D printing--in order to draw attention to the historical background and clinical aspects of certain pathological conditions.

METHODS

The authors developed the examination protocols for three different CT scanners. Among the examined archaeological remains cranial lesions were identified in 26 cases, from which 4 cases with potential central nervous system involvement are demonstrated. The scanning parameters and the advantages of secondary image reconstructions (multiplanar reconstruction, maximum intensity projection, three-dimensional volume rendering technique) are presented with the cases.

RESULTS

The authors demonstrate a case with destructive skull lesions due to syphilis from the 15th century AD, a condition rarely seen or even unknown nowadays in the modern world. With the CT images of the skull base fracture from the Iron Age, signs of healing could be verified. Using the CT images a non-invasive approach is presented in the case of the craniofacial osteosarcoma in order to visualize the local status and the direct intracranial propagation. Advantages of the 3D VRT reconstructions are shown in the case of unilateral coronal suture synostosis.

CONCLUSION

Paleoradiological CT examinations serve as a non-invasive, non-destructive tool for studying archaeological remains and artifacts. The special applications provided by the imaging modality contribute to the conventional paleopathological investigations.

[NEUROINTERVENTIONAL TREATMENT OF ACUTE ISCHEMIC STROKE: OUR EXPERIENCE IN KAPOSVAR, HUNGARY]

AIM OF THE STUDY

In the present study, we report procedural and mid-term functional outcome data on the first 50 neurointerventional treatments of acute ischemic stroke in the Kaposi Mór County Hospital, Kaposvár, Hungary.

MATERIALS AND METHODS

Endovascular recanalization of occluded large cervical and intracranial arteries was performed following an unsuccessful intravenous lysis or when intravenous lysis was contraindicated. A control cohort was retrospectively formed by analyzing data of 16 patients who has been unsuccesfully treated with iv. lysis before neurointervention was available in our hospital.

RESULTS AND CONCLUSION

Recanalization rate was 84% and major complication rate was 2% in the neurointerventional group. Mid-term good functional outcome, defined as mRS 0-2, was achieved in 44% in the neurointerventional and in 13% in the intravenous lysis group, after 11.5 and 39.7 months follow-up period, respectively. Subgroup analysis revealed patient age as the strongest predictive factor of good functional outcome. Our data shows that neurointerventional treatment of acute ischemic stroke gives substantially improved functional outcome, in accordance with the results of the recently published international randomized trials.

Characterization of Individuals Taking Part in Low Dose Computed Tomography (LDCT) Screening Program

In the past years the participation rate in conventional voluntary x-ray lung screening has been around 22 % in Somogy County in Hungary. Due to the high morbidity and mortality rates of lung cancer, low participation rate of the high risk individuals on the screening is a primary question in Hungary. To obtain an effectively high level of participation in our ongoing low dose CT screening program, we had to emphasize the benefits of participation for the targeted individuals. As a first step, our aim was to gather information on the aspects affecting the individuals' will for participation. We used the most accessible source of information: individuals over the age of 50, who attended the conventional voluntary lung screening, were approached to fill a questionnaire on their habits relating to smoking, health issues and their prior participation of lung screening. 1080 adults anonymously completed the questionnaire. Analyzing the results, beside other findings, we found a unique variable factor, which altered negatively the compliance for the screening: older individuals, who started participating in the screening in obligation to the health regulations, took part in the voluntary screening programs at a significantly lower rate. Our findings led us to better understanding the complexity of decision making affecting the individual's participation and attitudes toward health issues.

TRIAL REGISTRATION

IG/03833/2012.

A comparative pathological finding in pigs exposed to fumonisin B1 and/or Mycoplasma hyopneumoniae

A more complicated pathology was observed in female pigs infected with Mycoplasma hyopneumoniae, when the same were exposed to 20 ppm dietary levels of fumonisin B1 (FB1) starting 14 days before infection for a period of 42 days as was assessed by gross pathology and pathomorphological examinations or computed tomography, and also manifested by the strong deterioration of the pneumonic process in two pigs and the subsequent euthanizing of one pig. Typical damages in FB1-fed pigs were a strong oedema in the lung and slight oedema in the other internal organs and mild degenerative changes in the kidneys, whereas the typical pathomorphological changes in M. hyopneumoniae-infected pigs corresponded to the morphologic pattern of a catarrhal bronchointerstitial pneumonia more pronounced in the cranial and middle lobes or in the cranial third of the caudal lobe of the lung. The pigs treated by both pathogens (toxic and infectious) revealed strong oedematous changes in the interstitium of lung in addition to deteriorated and extended bronchointerstitial pneumonic process.

[Preliminary experiences with low-dose computed tomography for lung cancer screening in Hungary]

INTRODUCTION

Lung cancer has the highest mortality rate of all types of cancers both in developed countries and Hungary.

AIM

To obtain experience and facilitate the application of low-dose computed tomography-based lung cancer screening as a targeted public health screening procedure.

METHOD

Volunteers without thoracic complaints above the age of 40 years (n = 963) were screened for lung cancer using digital chest radiography and low-dose computed tomography.

RESULTS

Two lung cancers were found among the participants screened with digital chest radiography (0.2%). After informed consent, 173 individuals with normal chest radiography findings (n = 943) took the opportunity to voluntarily participate in low-dose computed tomography screening for lung cancer. After 3 or 12 months, 65 individuals had follow up control examinations based on the size and characteristics of the detected lesions. Among them, one participant was found to have lung cancer using low-dose computed tomography.

CONCLUSIONS

These results indicate that low-dose computed tomography-based lung cancer screening as a public health screening procedure can enhance the success of screening with 50% (from 0.2% to 0.3%). The cost-benefit ratio can be raised if chest radiography is performed prior to the low-dose computed tomography examination.

Application of computed tomography to assess the effect of egg yolk ratio on body composition in chickens of different genotype and gender at hatch and during the rearing period

1. Computed tomography was used for the in vivo determination of yolk ratio in 7000 domestic hen eggs, originated from two markedly different genotypes, in order to examine the effect of egg yolk ratio, gender and genotype on the development of hatched chicks. 2. Eggs with extremely low, average and extremely high yolk ratio were chosen for further investigation (n = 350 in each group in both genotypes). After incubating the selected eggs, hatched birds were reared and slaughtered at 11 weeks of age. 3. The yolk ratio of eggs significantly affected the body composition of the chickens at hatching and during rearing to 8-9 weeks of age. 4. Chickens of a genotype selected partly for weight gain had significantly higher live weight from hatching to the end of the rearing period and had better slaughter characteristics than those of the dual purpose TETRA-H genotype. 5. At hatching, only the dry matter content of the body was affected by the gender of the birds. The effect of gender on the live weight and body composition of chickens was evident from the 5th week of age to the time of slaughter. 6. It was concluded that eggs with a low yolk ratio were most beneficial for broiler production, because chickens hatched from these eggs had the highest slaughter weight and muscle index and the lowest fat index for their body mass.

Comparison of changes in production and egg composition in relation to in vivo estimates of body weight and composition of brown and white egg layers during the first egg-laying period

1. The aim of this study was to compare the changes in the production and in the body and egg composition of 45 TETRA SL brown egg layers and 45 TETRA BLANCA white egg layers during the first egg-laying period. 2. Changes in the body composition of the hens were followed in vivo by means of computed tomography (CT) four-weekly, between 20 and 72 weeks of age. The measurements covered the whole body of the hens using overlapping 10 mm slice thicknesses on a Siemens Somatom Emotion 6 multislice CT scanner. 3. The yolk, albumen and shell ratio of the eggs, produced on the days of the CT measurements by the hens, were determined and their composition was analysed chemically. 4. The body fat content of the hens increased continuously until 44 weeks of age and plateaued thereafter in both genotypes. However, the body fat content of the white egg layers was always higher than that of the brown egg layers. 5. The yolk ratio and the dry matter and crude fat content of the eggs of white egg layers were higher than the brown egg layers throughout the experiment. 6. Moderate correlations were observed in both genotypes between the body fat content of the hens and egg yolk ratio of their eggs.

Evaluation of experimental myocardial infarction models via electromechanical mapping and magnetic resonance imaging

The diagnostic characteristics of electromechanical mapping (EMM) were evaluated in porcine myocardial infarction (MI) models with the parallel application of cardiac magnetic resonance imaging (cMRI) from the aspect of different pathophysiology and localization. Balloon occlusion in the left anterior descending coronary artery (LAD balloon group) or coil deployment in the LAD (LAD coil group) or circumflex artery (Cx coil group) was applied percutaneously in 16 domestic pigs. Regional left ventricular viability data were captured via cMRI and EMM. The unipolar voltage (UV) value was significantly decreased in segments containing transmural and subendocardial late enhancement compared with viable segments in the LAD balloon, LAD coil, and Cx coil groups. Receiver operating characteristic analysis revealed area under the curve values of 0.809 and 0.691 in the LAD infarct territory, and 0.864 and 0.855 in the Cx infarct territory for the UV compared with cMRI viability results as transmural late enhancement or viable tissue and subendocardial late enhancement or viable tissue, respectively. In conclusion, the UV value detected the presence of scar tissue with differential transmural extent and which represented proper diagnostic features both in the reperfused and nonreperfused models. This data could provide additional benefit in the clinical use of EMM for diagnostic purposes.

Use of computed tomography and histopathologic review for lung lesions produced by the interaction between Mycoplasma hyopneumoniae and fumonisin mycotoxins in pigs

Mycoplasma hyopneumoniae has a primary role in the porcine respiratory disease complex (PRDC). The objective of this study was to determine whether fumonisin mycotoxins influence the character and/or the severity of pathological processes induced in the lungs of pigs by Mycoplasma hyopneumoniae. Four groups of pigs (n = 7/group) were used, one fed 20 ppm fumonisin B1 (FB1) from 16 days of age (group F), one only infected with M. hyopneumoniae on study day 30 (group M), and a group fed FB1 and infected with M. hyopneumoniae (group MF), along with an untreated control group (group C). Computed tomography (CT) scans of infected pigs (M and MF) on study day 44 demonstrated lesions extending to the cranial and middle or in the cranial third of the caudal lobe of the lungs. The CT images obtained on study day 58 showed similar but milder lesions in 5 animals from group M, whereas lungs from 2 pigs in group MF appeared progressively worse. The evolution of average pulmonary density calculated from combined pixel frequency values, as measured by quantitative CT, was significantly influenced by the treatment and the age of the animals. The most characteristic histopathologic lesion in FB1-treated pigs was pulmonary edema, whereas the pathomorphological changes in Mycoplasma-infected pigs were consistent with catarrhal bronchointerstitial pneumonia. FB1 aggravated the progression of infection, as demonstrated by severe illness requiring euthanasia observed in 1 pig and evidence of progressive pathology in 2 pigs (group MF) between study days 44 and 58.

Overview of large animal myocardial infarction models (review)

There are several experimental models for the in vivo investigation of myocardial infarction (MI) in small (mouse, rat) and large animals (dog, pig, sheep and baboons). The application of large animal models raises ethical concerns, the design of experiments needs longer follow-up times, requiring proper breeding and housing conditions, therefore resulting in higher cost, than in vitro or small animal studies. On the other hand, the relevance of large animal models is very important, since they mostly resemble to human physiological and pathophysiological processes. The first main difference among MI models is the method of induction (open or closed chest, e.g. surgical or catheter based); the second main difference is the presence or absence of reperfusion. The former (i.e. reperfused MI) allows the investigation of reperfusion injury and new catheter based techniques during percutaneous coronary interventions, while the latter (i.e. nonreperfused MI) serves as a traditional coronary occlusion model, to test the effects of new pharmacological agents and biological therapies, as cell therapy. The reperfused and nonreperfused myocardial infarction has different outcomes, regarding left ventricular function, remodelling, subsequent heart failure, aneurysm formation and mortality. Our aim was to review the literature and report our findings regarding experimental MI models, regarding the differences among species, methods, reproducibility and interpretation.

Integrating functional MRI information into conventional 3D radiotherapy planning of CNS tumors. Is it worth it?

The purpose of our study was to examine the potential benefits of integrating functional MRI (fMRI) information into the 3D-based planning process for central nervous system (CNS) malignancies. Between 01.01.2008 and 01.12.2009, ten patients with astrocytoma (both low and high-grade histological type) were enrolled in this study. Before the planning process, conventional CT planning, postoperative MR, and individual functional MRI examinations were conducted. For the functional MRI examination four types of conventional stimuli were applied: acoustic, visual, somatosensory, and numeric. To examine the potential benefits of using fMRI-based information, three different types of theoretical planning were applied and compared: 3D conformal plan without fMRI information, 3D conformal plan with fMRI information, and IMRT plan with fMRI information. DVH analysis and the NTCP model were used for plan comparison. When comparing planning methods, distance-related subgroups were generated and studied. By using the additional fMRI information, a significantly higher sparing effect can be achieved on these ORs (both with conventional 3D-based planning and IMRT). In cases when the OR-PTV distance is less than 1 cm, IMRT seems to be a significantly better choice than conventional 3D-based techniques. IMRT also has an additional sparing effect on the optic tract and brainstem, especially for locations close to the midline. Our results demonstrated that using fMRI information in conventional 3D-based treatment planning has the potential benefit of significant dose reduction for the critical organs, with no compromise in PTV coverage even when using conventional 3D planning. fMRI can be widely used in low-grade cases (long life expectancy, lower acute and late toxicity) and also in cases with high-grade astrocytomas or distant metastases (higher dose to PTV with better sparing of risk organs). In cases when the OR-PTV distance is less than 1 cm, IMRT should be the choice of treatment for a higher sparing effect on functional active areas. Longer imaging and clinical follow up are needed to confirm the real sparing effect on these functional areas.

Interaction of Bordetella bronchiseptica, Pasteurella multocida, and fumonisin B1 in the porcine respiratory tract as studied by computed tomography

The interaction of Bordetella bronchiseptica, toxigenic Pasteurella multocida serotype D, and the mycotoxin fumonisin B(1) (FB(1)) was studied. On day 0 of the experiment, 28 artificially reared 3-day-old piglets were divided into 4 groups (n = 7 each): a control group (A), a group fed FB(1) toxin (B), a group infected with the 2 pathogens (C), and a group infected with the 2 pathogens and fed FB(1) toxin (D). The B. bronchiseptica infection [with 10(6) colony-forming units (CFU)/mL] was performed on day 4 and the P. multocida infection (with 10(8) CFU/mL) on day 16. From day 16 a Fusarium verticillioides fungal culture (dietary FB(1) toxin content 10 mg/kg) was mixed into the feed of groups B and D. In groups C and D, clinical signs including mild serous nasal discharge, sneezing, panting, and hoarseness appeared from day 4, and then from day 16 some piglets had coughing and dyspnea as well. Computed tomography (CT) performed on day 16 demonstrated lung lesions attributable to colonization by B. bronchiseptica in the infected groups. By day 25 the number of piglets exhibiting lesions had increased, and the lesions appeared as well-circumscribed, focal changes characterized by a strong density increase in the affected areas of the lungs. The gross pathological findings confirmed the results obtained by CT. These results indicate that, when combined with dual infection by B. bronchiseptica and P. multocida, dietary exposure of pigs to FB(1) toxin raises the risk of pneumonia and increases the extent and severity of the pathological changes.