Identifying exceptional malaria occurrences in the absence of historical data in South Sudan: a method validation

Background

Detecting unusual malaria events that may require an operational intervention is challenging, especially in endemic contexts with continuous transmission such as South Sudan. Médecins Sans Frontières (MSF) utilises the classic average plus standard deviation (AV+SD) method for malaria surveillance. This and other available approaches, however, rely on antecedent data, which are often missing.

Objective

To investigate whether a method using linear regression (LR) over only 8 weeks of retrospective data could be an alternative to AV+SD.

Design

In the absence of complete historical malaria data from South Sudan, data from weekly influenza reports from 19 Norwegian counties (2006-2015) were used as a testing data set to compare the performance of the LR and the AV+SD methods. The moving epidemic method was used as the gold standard. Subsequently, the LR method was applied in a case study on malaria occurrence in MSF facilities in South Sudan (2010-2016) to identify malaria events that required a MSF response.

Results

For the Norwegian influenza data, LR and AV+SD methods did not perform differently (P > 0.05). For the South Sudanese malaria data, the LR method identified historical periods when an operational response was mounted.

Conclusion

The LR method seems a plausible alternative to the AV+SD method in situations where retrospective data are missing.

Muscle Derived Stem Cells Stimulate Muscle Myofiber Repair and Counteract Fat Infiltration in a Diabetic Mouse Model of Critical Limb Ischemia

Background

Critical Limb Ischemia (CLI) affects patients with Type 2 Diabetes (T2D) and obesity, with high risk of amputation and post-surgical mortality, and no effective medical treatment. Stem cell therapy, mainly with bone marrow mesenchymal, adipose derived, endothelial, hematopoietic, and umbilical cord stem cells, is promising in CLI mouse and rat models and is in clinical trials. Their general focus is on angiogenic repair, with no reports on the alleviation of necrosis, lipofibrosis, and myofiber regeneration in the ischemic muscle, or the use of Muscle Derived Stem Cells (MDSC) alone or in combination with pharmacological adjuvants, in the context of CLI in T2D.

Methods

Using a T2D mouse model of CLI induced by severe unilateral femoral artery ligation, we tested: a) the repair efficacy of MDSC implanted into the ischemic muscle and the effects of concurrent intraperitoneal administration of a nitric oxide generator, molsidomine; and b) whether MDSC may partially counteract their own repair effects by stimulating the expression of myostatin, the main lipofibrotic agent in the muscle and inhibitor of muscle mass.

Results

MDSC: a) reduced mortality, and b) in the ischemic muscle, increased stem cell number and myofiber central nuclei, reduced fat infiltration, myofibroblast number, and myofiber apoptosis, and increased smooth muscle and endothelial cells, as well as neurotrophic factors. The content of myosin heavy chain 2 (MHC-2) myofibers was not restored and collagen was increased, in association with myostatin overexpression. Supplementation of MDSC with molsidomine failed to stimulate the beneficial effects of MDSC, except for some reduction in myostatin overexpression. Molsidomine given alone was rather ineffective, except for inhibiting apoptosis and myostatin overexpression.

Conclusions

MDSC improved CLI muscle repair, but molsidomine did not stimulate this process. The combination of MDSC with anti-myostatin approaches should be explored to restore myofiber MHC composition.

Modification and validation of an analytical source model for external beam radiotherapy Monte Carlo dose calculations

PURPOSE

A dose calculation tool, which combines the accuracy of the dose planning method (DPM) Monte Carlo code and the versatility of a practical analytical multisource model, which was previously reported has been improved and validated for the Varian 6 and 10 MV linear accelerators (linacs). The calculation tool can be used to calculate doses in advanced clinical application studies. One shortcoming of current clinical trials that report dose from patient plans is the lack of a standardized dose calculation methodology. Because commercial treatment planning systems (TPSs) have their own dose calculation algorithms and the clinical trial participant who uses these systems is responsible for commissioning the beam model, variation exists in the reported calculated dose distributions. Today's modern linac is manufactured to tight specifications so that variability within a linac model is quite low. The expectation is that a single dose calculation tool for a specific linac model can be used to accurately recalculate dose from patient plans that have been submitted to the clinical trial community from any institution. The calculation tool would provide for a more meaningful outcome analysis.

METHODS

The analytical source model was described by a primary point source, a secondary extra-focal source, and a contaminant electron source. Off-axis energy softening and fluence effects were also included. The additions of hyperbolic functions have been incorporated into the model to correct for the changes in output and in electron contamination with field size. A multileaf collimator (MLC) model is included to facilitate phantom and patient dose calculations. An offset to the MLC leaf positions was used to correct for the rudimentary assumed primary point source.

RESULTS

Dose calculations of the depth dose and profiles for field sizes 4 × 4 to 40 × 40 cm agree with measurement within 2% of the maximum dose or 2 mm distance to agreement (DTA) for 95% of the data points tested. The model was capable of predicting the depth of the maximum dose within 1 mm. Anthropomorphic phantom benchmark testing of modulated and patterned MLCs treatment plans showed agreement to measurement within 3% in target regions using thermoluminescent dosimeters (TLD). Using radiochromic film normalized to TLD, a gamma criteria of 3% of maximum dose and 2 mm DTA was applied with a pass rate of least 85% in the high dose, high gradient, and low dose regions. Finally, recalculations of patient plans using DPM showed good agreement relative to a commercial TPS when comparing dose volume histograms and 2D dose distributions.

CONCLUSIONS

A unique analytical source model coupled to the dose planning method Monte Carlo dose calculation code has been modified and validated using basic beam data and anthropomorphic phantom measurement. While this tool can be applied in general use for a particular linac model, specifically it was developed to provide a singular methodology to independently assess treatment plan dose distributions from those clinical institutions participating in National Cancer Institute trials.

Gold and Hydroxyapatite Nano-Composite Scaffolds for Anterior Cruciate Ligament Reconstruction: In Vitro Characterization

Current anterior cruciate ligament (ACL) graft replacement materials often fail due to the lack of biological integration. While many newly developed extracellular matrix based scaffolds show good biocompatibility they often do not entice cellular remodeling and the rebuilding of a functional ligament. We have proposed the conjugation of gold nanoparticles (AuNP) and hydroxyapatite nanoparticles (nano-HAp) to acellular tissue to enhance cell attachment and proliferation while maintaining an improved degradation resistance and open microstructure. We are the first to investigate the double conjugation of AuNP and nano-HAp onto decellularized tissue to improve the tissue remodeling response. Decellularized porcine diaphragm was crosslinked with two types of nano-HAp and amine-functionalized AuNP with 1-ethyl-3-(3-dimethlaminopropyl) carbodiimide (EDC) crosslinker. Scaffolds were characterized using electron microscopy, differential scanning calorimetry, and fibroblast assays. Results demonstrated that scaffolds with nano-HAp have increased thermal stability at low levels of crosslinking. The open microstructure of the scaffold was not compromised allowing for cell migration while still providing increased degradation resistance. The addition of < 200 nm nano-HAp decreased cell viability compared to scaffolds without nanoparticles, but the addition of AuNP to scaffolds showed enhanced cell viability in the presence of < 200 nm nano-HAp. The addition of < 40 nm nano-HAp showed an increase in cell viability compared to scaffolds crosslinked without nanoparticles. It is concluded that attaching AuNP and < 40nm nano-HAp to extracellular matrices may improve overall properties.

Perfluoroalkyl substances measured in breast milk and child neuropsychological development in a Norwegian birth cohort study

Perfluoroalkyl substances (PFASs) are chemicals with potential neurotoxic effects although the current evidence is still limited. This study investigated the association between perinatal exposure to perfluorooctanesulfonic acid (PFOS) and perfluorooctanoic acid (PFOA) and neuropsychological development assessed at 6, 12 and 24 months. We measured PFOS and PFOA in breast milk samples collected one month after delivery by mothers of children participating in the HUMIS study (Norway). Cognitive and psychomotor development was measured at 6 and at 24 months using the Ages and Stages Questionnaire (ASQ-II). Behavioral development was assessed using the infant-toddler symptom checklist (ITSC) at 12 and at 24 months. Weighted logistic regression and weighted negative binomial regression models were applied to analyze the associations between PFASs and ASQ-II and ITSC, respectively. The median concentration of PFOS was 110 ng/L, while the median for PFOA was 40 ng/L. We did not detect an increased risk of having an abnormal score in ASQ-II at 6 months or 24 months. Moreover, no consistent increase in behavioral problems assessed at 12 and 24 months by ITSC questionnaire was detected. We observed no association between perinatal PFOS and PFOA exposure and early neuropsychological development. Further longitudinal studies are needed to confirm the effects of these compounds on neuropsychological development in older children.

Prevalence and causes of vision loss in Southeast Asia and Oceania: 1990-2010

BACKGROUND

To assess prevalence and causes of vision impairment in Southeast Asia and Oceania in 1990 and 2010.

METHODS

Based on a systematic review of medical literature, prevalence of moderate and severe vision impairment (MSVI; presenting visual acuity <6/18 but ≥3/60 in the better eye) and blindness (presenting visual acuity <3/60) was estimated for 1990 and 2010.

RESULTS

In Oceania, the age-standardised prevalence of blindness and MSVI did not decrease significantly (1.3% to 0.8% and 6.6% to 5.1%) respectively, but in Southeast Asia, blindness decreased significantly from 1.4% to 0.8%, a 43% decrease. There were significantly more women blind (2.18 million) compared with men (1.28 million) in the Southeast Asian population in 2010, but no significant gender differences in MSVI in either subregion. Cataract was the most frequent cause of blindness in Southeast Asia and Oceania in 1990 and 2010. Uncorrected refractive error, followed by cataract, macular degeneration, glaucoma and diabetic retinopathy were the most common causes for MSVI in 1990 and 2010. With the increasing size of the older population, there have been relatively small increases in the number of blind (2%), and with MSVI (14%) in Southeast Asia, whereas increases have been greater in Oceania of 14% for blindness and of 31% for MSVI.

CONCLUSIONS

The prevalence of blindness has reduced significantly from 1990 to 2010, with moderate but non-significant lowering of MSVI. Cataract and uncorrected refractive error are the main causes of vision impairment and blindness; cataract continues as the main cause of blindness, but at lower proportions.

Dosimetric effects of jaw tracking in step-and-shoot intensity-modulated radiation therapy

The purpose of this work was to determine the dosimetric benefit to normal tissues by tracking the multi‐leaf collimator (MLC) apertures with the photon jaws in step‐and‐shoot intensity‐modulated radiation therapy (IMRT) on the Varian 2100 platform. Radiation treatment plans for ten thoracic, three pediatric, and three head and neck cancer patients were converted to plans with the jaws tracking each segment's MLC apertures, and compared to the original plans in a commercial radiation treatment planning system (TPS). The change in normal tissue dose was evaluated in the new plan by using the parameters V5, V10, and V20 (volumes receiving 5, 10 and 20 Gy, respectively) in the cumulative dose‐volume histogram for the following structures: total lung minus gross target volume, heart, esophagus, spinal cord, liver, parotids, and brainstem. To validate the accuracy of our beam model, MLC transmission was measured and compared to that predicted by the TPS. The greatest changes between the original and new plans occurred at lower dose levels. In all patients, the reduction in V20 was never more than 6.3% and was typically less than 1%; the maximum reduction in V5 was 16.7% and was typically less than 3%. The variation in normal tissue dose reduction was not predictable, and we found no clear parameters that indicated which patients would benefit most from jaw tracking. Our TPS model of MLC transmission agreed with measurements with absolute transmission differences of less than 0.1% and, thus, uncertainties in the model did not contribute significantly to the uncertainty in the dose determination. We conclude that the amount of dose reduction achieved by collimating the jaws around each MLC aperture in step‐and‐shoot IMRT is probably not clinically significant.

PACS numbers: 87.55.D‐ 87.55.de 87.55.dk

Assessment of shoulder position variation and its impact on IMRT and VMAT doses for head and neck cancer

Background

For radiotherapy of the head and neck, 5-point mask immobilization is used to stabilize the shoulders. Still, the daily position of the shoulders during treatment may be different from the position in the treatment plan despite correct isocenter setup. The purpose of this study was to determine the interfractional displacement of the shoulders relative to isocenter over the course of treatment and the associated dosimetric effect of this displacement.

Methods

The extent of shoulder displacements relative to isocenter was assessed for 10 patients in 5-point thermoplastic masks using image registration and daily CT-on-rails scans. Dosimetric effects on IMRT and VMAT plans were evaluated in Pinnacle based on simulation CTs modified to represent shoulder shifts between 3 and 15 mm in the superior-inferior, anterior-posterior, and right-left directions. The impact of clinically observed shoulder shifts on the low-neck dose distributions was examined.

Results

Shoulder motion was 2-5 mm in each direction on average but reached 20 mm. Superior shifts resulted in coverage loss, whereas inferior shifts increased the dose to the brachial plexus. These findings were generally consistent for both IMRT and VMAT plans. Over a course of observed shifts, the dose to 99% of the CTV decreased by up to 101 cGy, and the brachial plexus dose increased by up to 72 cGy.

Conclusions

he position of the shoulder affects target coverage and critical structure dose, and may therefore be a concern during the setup of head and neck patients, particularly those with low neck primary disease.

The clinical impact of the couch top and rails on IMRT and arc therapy

The clinical impact of the Varian Exact Couch on dose, volume coverage to targets and critical structures, and tumor control probability (TCP) has not been described. Thus, we examined their effects on IMRT and arc therapy. Five clinical prostate patients were planned with both 6 MV eight-field IMRT and 6 MV two-arc RapidArc techniques using the Eclipse treatment planning system. These plans neglected treatment couch attenuation, as is a common clinical practice. Dose distributions were then recalculated in Eclipse with the inclusion of the Varian Exact Couch (imaging couch top) and the rails in varying configurations. The changes in dose and coverage were evaluated using the dose-volume histograms from each plan iteration. We used a TCP model to calculate losses in tumor control resulting from not accounting for the couch top and rails. We also verified dose measurements in a phantom. Failure to account for the treatment couch and rails resulted in clinically unacceptable dose and volume coverage losses to the targets for both IMRT and RapidArc. The couch caused average prescription dose losses (relative to plans that ignored the couch) to the prostate of 4.2% and 2.0% for IMRT with the rails out and in, respectively, and 3.2% and 2.9% for RapidArc with the rails out and in, respectively. On average, the percentage of the target covered by the prescribed dose dropped to 35% and 84% for IMRT (rails out and in, respectively) and to 18% and 17% for RapidArc (rails out and in, respectively). The TCP was also reduced by as much as 10.5% (6.3% on average). Dose and volume coverage losses for IMRT plans were primarily due to the rails, while the imaging couch top contributed most to losses for RapidArc. Both the couch top and rails contribute to dose and coverage losses that can render plans clinically unacceptable. A follow-up study we performed found that the less attenuating unipanel mesh couch top available with the Varian Exact couch does not cause a clinically impactful loss of dose or coverage for IMRT but still causes an unacceptable loss for RapidArc. Therefore, both the imaging or mesh couch top and the rails should be accounted for in arc therapy. The imaging couch top should be accounted for in IMRT treatment planning or the mesh top can be used, which would not need to be accounted for, and the rails should be moved to avoid the beams during treatment.

An empirical model of diagnostic x-ray attenuation under narrow-beam geometry

PURPOSE

The purpose of this study was to develop and validate a mathematical model to describe narrow-beam attenuation of kilovoltage x-ray beams for the intended applications of half-value layer (HVL) and quarter-value layer (QVL) estimations, patient organ shielding, and computer modeling.

METHODS

An empirical model, which uses the Lambert W function and represents a generalized Lambert-Beer law, was developed. To validate this model, transmission of diagnostic energy x-ray beams was measured over a wide range of attenuator thicknesses [0.49-33.03 mm Al on a computed tomography (CT) scanner, 0.09-1.93 mm Al on two mammography systems, and 0.1-0.45 mm Cu and 0.49-14.87 mm Al using general radiography]. Exposure measurements were acquired under narrow-beam geometry using standard methods, including the appropriate ionization chamber, for each radiographic system. Nonlinear regression was used to find the best-fit curve of the proposed Lambert W model to each measured transmission versus attenuator thickness data set. In addition to validating the Lambert W model, we also assessed the performance of two-point Lambert W interpolation compared to traditional methods for estimating the HVL and QVL [i.e., semi-logarithmic (exponential) and linear interpolation].

RESULTS

The Lambert W model was validated for modeling attenuation versus attenuator thickness with respect to the data collected in this study (R2 > 0.99). Furthermore, Lambert W interpolation was more accurate and less sensitive to the choice of interpolation points used to estimate the HVL and/or QVL than the traditional methods of semilogarithmic and linear interpolation.

CONCLUSIONS

The proposed Lambert W model accurately describes attenuation of both monoenergetic radiation and (kilovoltage) polyenergetic beams (under narrow-beam geometry).

Gain and offset calibration reduces variation in exposure-dependent SNR among systems with identical digital flat-panel detectors

PURPOSE

The conditions under which vendor performance criteria for digital radiography systems are obtained do not adequately simulate the conditions of actual clinical imaging with respect to radiographic technique factors, scatter production, and scatter control. Therefore, the relationship between performance under ideal conditions and performance in clinical practice remains unclear. Using data from a large complement of systems in clinical use, the authors sought to develop a method to establish expected performance criteria for digital flat-panel radiography systems with respect to signal-to-noise ratio (SNR) versus detector exposure under clinical conditions for thoracic imaging.

METHODS

The authors made radiographic exposures of a patient-equivalent chest phantom at 125 kVp and 180 cm source-to-image distance. The mAs value was modified to produce exposures above and below the mAs delivered by automatic exposure control. Exposures measured free-in-air were corrected to the imaging plane by the inverse square law, by the attenuation factor of the phantom, and by the Bucky factor of the grid for the phantom, geometry, and kilovolt peak. SNR was evaluated as the ratio of the mean to the standard deviation (SD) of a region of interest automatically selected in the center of each unprocessed image. Data were acquired from 18 systems, 14 of which were tested both before and after gain and offset calibration. SNR as a function of detector exposure was interpolated using a double logarithmic function to stratify the data into groups of 0.2, 0.5, 1.0, 2.0, and 5.0 mR exposure (1.8, 4.5, 9.0, 18, and 45 microGy air KERMA) to the detector.

RESULTS

The mean SNR at each exposure interval after calibration exhibited linear dependence on the mean SNR before calibration (r2=0.9999). The dependence was greater than unity (m = 1.101 +/- 0.006), and the difference from unity was statistically significant (p <0.005). The SD of mean SNR after calibration also exhibited linear dependence on the SD of the mean SNR before calibration (r2 = 0.9997). This dependence was less than unity (m = 0.822 +/- 0.008), and the difference from unity was also statistically significant (p < 0.005). Systems were separated into two groups: systems with a precalibration SNR higher than the median SNR (N = 7), and those with a precalibration SNR lower than the median SNR (N= 7). Posthoc analysis was performed to correct for expanded false positive results. After calibration, the authors noted differences in mean SNR within both high and low groups, but these differences were not statistically significant at the 0.05 level. SNR data from four additional systems and one system from those previously tested after replacement of its detector were compared to the 95% confidence intervals (CI) calculated from the postcalibration SNR data. The comparison indicated that four of these five systems were consistent with the CI derived from the previously tested 14 systems after calibration. Two systems from the paired group that remained outside the CI were studied further. One system was remedied with a grid replacement. The nonconformant behavior of the other system was corrected by replacing the image receptor.

CONCLUSIONS

Exposure-dependent SNR measurements under conditions simulating thoracic imaging allowed us to develop criteria for digital flat-panel imaging systems from a single manufacturer. These measurements were useful in identifying systems with discrepant performance, including one with a defective grid, one with a defective detector, and one that had not been calibrated for gain and offset. The authors also found that the gain and offset calibration reduces variation in exposure-dependent SNR performance among the systems.

WHO guidelines for the programmatic management of drug-resistant tuberculosis: 2011 update

The production of guidelines for the management of drug-resistant tuberculosis (TB) fits the mandate of the World Health Organization (WHO) to support countries in the reinforcement of patient care. WHO commissioned external reviews to summarise evidence on priority questions regarding case-finding, treatment regimens for multidrug-resistant TB (MDR-TB), monitoring the response to MDR-TB treatment, and models of care. A multidisciplinary expert panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to develop recommendations. The recommendations support the wider use of rapid drug susceptibility testing for isoniazid and rifampicin or rifampicin alone using molecular techniques. Monitoring by sputum culture is important for early detection of failure during treatment. Regimens lasting ≥ 20 months and containing pyrazinamide, a fluoroquinolone, a second-line injectable drug, ethionamide (or prothionamide), and either cycloserine or p-aminosalicylic acid are recommended. The guidelines promote the early use of antiretroviral agents for TB patients with HIV on second-line drug regimens. Systems that primarily employ ambulatory models of care are recommended over others based mainly on hospitalisation. Scientific and medical associations should promote the recommendations among practitioners and public health decision makers involved in MDR-TB care. Controlled trials are needed to improve the quality of existing evidence, particularly on the optimal composition and duration of MDR-TB treatment regimens.

Use of a matchline dosimetry analysis tool (MDAT) to quantify dose homogeneity in the region between abutting tangential and supraclavicular radiation fields

In this work, we develop and test a matchline dosimetry analysis tool (MDAT) to examine the dose distribution within the abutment region of two or more adjoining radiotherapy fields that employ different blocking mechanisms and geometries in forming a match. This objective and quantitative tool uses calibrated radiographic film to measure the dose in the abutment region, and uses a frequency distribution of area versus dose (a dose‐area histogram) to visualize the spatial dose distribution. We tested the MDAT's clinical applicability and parameters by evaluating the dose between adjacent photon fields incident on a flat phantom using field‐matching techniques employing collimator‐jaw and multileaf collimator (MLC) configurations. Additionally, we evaluated the dose in the abutment regions of four different clinical tangential‐breast and supraclavicular matching techniques using various combinations of collimator and MLC matches. Using the MDAT tool, it was determined that a 1 cm abutment region width (centered about the theoretical matchline between fields) is the most appropriate width to determine dose homogeneity in a field matching region. Using the MDAT, both subtle and large differences were seen between fields that used MLCs to form the match, compared to flat edge devices such as collimators and external cerrobend blocks. We conclude that the MDAT facilitates a more precise evaluation of the distribution of dose within the region of abutment of radiotherapy fields.

PACS number: 87.55.dk

Pretreatment Verification of IMSRT Using Electronic Portal Imaging and Monte Carlo Calculations

The use of an amorphous silicon electronic portal imaging device (EPID) and Monte Carlo calculations were investigated for pretreatment fluence verification in intensity modulated stereotactic radiotherapy (IMSRT). Monte Carlo calculations were performed using BEAM, a general purpose Monte Carlo code to simulate radiation beams from radiotherapy units. The dose distribution to the EPID phosphor was calculated by BEAM and then converted to pixel value using a pixel calibration curve. The calibration correlated calculated pixel dose to the measured pixel value for a range of open fields. Points within the region bounded by the photon jaws were extracted for comparison. Criteria for successful verification were 5% local percent difference in high dose regions, 1 mm distance to agreement in high gradient regions, or 2% of the Monte Carlo calculated central axis pixel value in low dose regions. Software was written to quantitatively compare the measured and calculated EPID images. Successful verification of the modulated field required that ≥ 95% of compared points fall within the comparison criteria. Dose response of the EPID was found to be linear with Monte Carlo calculated doses over the dose ranges examined in this work Comparison of the measured and calculated EPID dose distributions showed good agreement with 97% of the points passing criteria. The sensitivity of the methodology to detect field shaping errors was tested by introducing positioning errors in segments of the modulated field. These sensitivity tests indicate that the comparison software designed for this work can detect a 1 mm positioning error in a single segment of the composite IMSRT field. It should be noted, however, that the work presented here is a proof of concept and currently not a clinically viable QA tool. It represents a limited evaluation using a single IMSRT field, and verification of additional fields will be required for a comprehensive evaluation of the described methods before broad conclusions can be drawn. Additionally, the results of this work are subject to the comparison criteria that were used. Clinical implementation of the proposed technique should be evaluated for the specific institutional criteria where it will be employed.

Role of fluorescence in situ hybridization in sequencing the tomato genome

The tomato (Solanum lycopersicum L.) genome is being sequenced by a consortium of laboratories in 10 countries. Seventy-seven percent of the tomato genome (DNA) is located in repeat-rich, gene-poor, pericentric heterochromatin, while 23% of the genome is located in repeat-poor, gene-rich, distal euchromatin. It is estimated that approximately 90% of tomato's nuclear genes can be characterized by limiting the sequencing effort to euchromatin while avoiding the problems involved in sequencing the repetitive DNA in heterochromatin. Sequencing is being performed on tomato nuclear DNA cloned into bacterial artificial chromosome (BAC) vectors. Fluorescence in situ hybridization (FISH) is used to help direct the sequencing effort by cytologically demonstrating the location of selected BACs on tomato chromosomes. While mitotic metaphase chromosomes are too short and compact for this purpose, long pachytene chromosomes are ideal. BACs localized in euchromatin can be used confidently as anchors for the assembly of BAC contigs that extend through the euchromatic length of each chromosome arm. Another important role for FISH is identification of BACs near telomeres and near borders with pericentric heterochromatin to indicate that sequencing should not extend much further. This role of FISH is enhanced by our ability to estimate base pair distances between localized BACs and these chromosomal features. Finally, it is noteworthy that when BAC-FISH is combined with chromosomal in situ suppression (CISS) hybridization to block repeats and localize single/low copy sequences, the great majority of BACs localize to single sites. This observation is consistent with tomato being an ancient diploid.

Pediatric organ dose measurements in axial and helical multislice CT

An anthropomorphic pediatric phantom (5-yr-old equivalent) was used to determine organ doses at specific surface and internal locations resulting from computed tomography (CT) scans. This phantom contains four different tissue-equivalent materials: Soft tissue, bone, brain, and lung. It was imaged on a 64-channel CT scanner with three head protocols (one contiguous axial scan and two helical scans [pitch = 0.516 and 0.984]) and four chest protocols (one contiguous axial scan and three helical scans [pitch = 0.516, 0.984, and 1.375]). Effective mA s [= (tube current x rotation time)/pitch] was kept nearly constant at 200 effective mA s for head and 290 effective mA s for chest protocols. Dose measurements were acquired using thermoluminescent dosimeter powder in capsules placed at locations internal to the phantom and on the phantom surface. The organs of interest were the brain, both eyes, thyroid, sternum, both breasts, and both lungs. The organ dose measurements from helical scans were lower than for contiguous axial scans by 0% to 25% even after adjusting for equivalent effective mA s. There was no significant difference (p > 0.05) in organ dose values between the 0.516 and 0.984 pitch values for both head and chest scans. The chest organ dose measurements obtained at a pitch of 1.375 were significantly higher than the dose values obtained at the other helical pitches used for chest scans (p < 0.05). This difference was attributed to the automatic selection of the large focal spot due to a higher tube current value. These findings suggest that there may be a previously unsuspected radiation dose benefit associated with the use of helical scan mode during computed tomography scanning.

Monte Carlo study shows no significant difference in second cancer risk between 6- and 18-MV intensity-modulated radiation therapy

PURPOSE

To evaluate the photon and neutron out-of-field dose equivalents from 6- and 18-MV intensity-modulated radiation therapy (IMRT) and to investigate the impact of the differences on the associated risk of induced second malignancy using a Monte Carlo model.

METHODS AND MATERIALS

A Monte Carlo model created with MCNPX was used to calculate the out-of-field photon dose and neutron dose equivalent from simulated IMRT of the prostate conducted at beam energies of 6 and 18MV. The out-of-field dose equivalent was calculated at the locations of sensitive organs in an anthropomorphic phantom. Based on these doses, the risk of secondary malignancy was calculated based on organ-, gender-, and age-specific risk coefficients for a 50-year-old man.

RESULTS

The Monte Carlo model predicted much lower neutron dose equivalents than had been determined previously. Further analysis illuminated the large uncertainties in the neutron dose equivalent and demonstrated the need for better determination of this value, which plays a large role in estimating the risk of secondary malignancies. The Monte Carlo calculations found that the differences in the risk of secondary malignancies conferred by high-energy IMRT versus low-energy IMRT are minimal and insignificant, contrary to prior findings.

CONCLUSIONS

The risk of secondary malignancy associated with high-energy radiation therapy may not be as large as previously reported, and likely should not deter the use of high-energy beams. However, the large uncertainties in neutron dose equivalents at specific locations within the patient warrant further study so that the risk of secondary cancers can be estimated with greater accuracy.

Influence of source parameters on large-field electron beam profiles calculated using Monte Carlo methods

The purpose of this paper was to study the source model for a Monte Carlo simulation of electron beams from a medical linear accelerator. In a prior study, a non-divergent Gaussian source with a full-width at half-maximum (FWHM) of 0.15 cm was successful in predicting relative dose distributions for electron beams with applicators. However, for large fields with the applicator removed, discrepancies were found between measured and calculated profiles, particularly in the shoulder region. In this work, the source was changed to a divergent Gaussian spatial distribution and the FWHM parameter was varied to produce better agreement with measured data. The influence of the FWHM source parameter on profiles was observed at multiple locations in the simulation geometry including in-air fluence profiles at a 95 cm source-to-surface distance (SSD), percent depth dose profiles and off-axis profiles (OARs) in a water phantom for two SSDs, 80 and 100 cm. For a 6 MeV 40 x 40 cm(2) OAR profile, discrepancies in the shoulder region were reduced from 15% to 4% using a FWHM value of 0.45 cm. The optimal FWHM values for the other energies were 0.45 cm for 9 MeV, 0.22 for 12 MeV, 0.25 for 16 MeV and 0.2 cm for 20 MeV. Although this range of values was larger than measured focal spot sizes reported by other researchers, using the increased FWHM values improved the fit at most locations in the simulation geometry, giving confidence that the model could be used with a variety of SSDs and field sizes.

A Monte Carlo model for out-of-field dose calculation from high-energy photon therapy

As cancer therapy becomes more efficacious and patients survive longer, the potential for late effects increases, including effects induced by radiation dose delivered away from the treatment site. This out-of-field radiation is of particular concern with high-energy radiotherapy, as neutrons are produced in the accelerator head. We recently developed an accurate Monte Carlo model of a Varian 2100 accelerator using MCNPX for calculating the dose away from the treatment field resulting from low-energy therapy. In this study, we expanded and validated our Monte Carlo model for high-energy (18 MV) photon therapy, including both photons and neutrons. Simulated out-of-field photon doses were compared with measurements made with thermoluminescent dosimeters in an acrylic phantom up to 55 cm from the central axis. Simulated neutron fluences and energy spectra were compared with measurements using moderated gold foil activation in moderators and data from the literature. The average local difference between the calculated and measured photon dose was 17%, including doses as low as 0.01% of the central axis dose. The out-of-field photon dose varied substantially with field size and distance from the edge of the field but varied little with depth in the phantom, except at depths shallower than 3 cm, where the dose sharply increased. On average, the difference between the simulated and measured neutron fluences was 19% and good agreement was observed with the neutron spectra. The neutron dose equivalent varied little with field size or distance from the central axis but decreased with depth in the phantom. Neutrons were the dominant component of the out-of-field dose equivalent for shallow depths and large distances from the edge of the treatment field. This Monte Carlo model is useful to both physicists and clinicians when evaluating out-of-field doses and associated potential risks.

Flow cytometry after bromodeoxyuridine labeling to measure S and G2+M phase durations plus doubling times in vitro and in vivo

This protocol describes methods for calculating the proliferative parameters of cell populations. The basis of the technique is to label cells, either in vitro or in vivo, with halogenated thymidine analogs, such as bromodeoxyuridine (BrdU). Bivariate DNA-BrdU flow cytometry is used to analyze the BrdU-labeled and unlabeled cells. The enumeration of specific cohorts of cells that either have or have not divided in the interval between labeling and cell/tissue sampling permits the calculation of the potential doubling time (T(pot)) of the population, plus the durations of DNA synthesis (T(S)) and the G2+M phase (T(G2+M)) of the cell cycle. The method provides information that is not otherwise available, namely inhibition of DNA synthesis and the separate evaluation of cell-cycle effects in BrdU-labeled and unlabeled subpopulations. Ethanol-fixed samples take 1 d to prepare and stain, and reliable parameter estimates might be obtained from measurements made at a single time point after labeling.

Uncertainty of Calculated Risk Estimates for Secondary Malignancies After Radiotherapy

PURPOSE

The significance of risk estimates for fatal secondary malignancies caused by out-of-field radiation exposure remains unresolved because the uncertainty in calculated risk estimates has not been established. This work examines the uncertainty in absolute risk estimates and in the ratio of risk estimates between different treatment modalities.

METHODS AND MATERIALS

Clinically reasonable out-of-field doses and calculated risk estimates were taken from the literature for several prostate treatment modalities, including intensity-modulated radiotherapy (IMRT), and were recalculated using the most recent risk model. The uncertainties in this risk model and uncertainties in the linearity of the dose-response model were considered in generating 90% confidence intervals for the uncertainty in the absolute risk estimates and in the ratio of the risk estimates.

RESULTS

The absolute risk estimates of fatal secondary malignancy were associated with very large uncertainties, which precluded distinctions between the risks associated with the different treatment modalities considered. However, a much smaller confidence interval exists for the ratio of risk estimates, and this ratio between different treatment modalities may be statistically significant when there is an effective dose equivalent difference of at least 50%. Such a difference may exist between clinically reasonable treatment options, including 6-MV IMRT versus 18-MV IMRT for prostate therapy.

CONCLUSION

The ratio of the risk between different treatment modalities may be significantly different. Consequently risk models and associated risk estimates may be useful and meaningful for evaluating different treatment options. The calculated risk of secondary malignancy should be considered in the selection of an optimal treatment plan.

Calculating percent depth dose with the electron pencil-beam redefinition algorithm

In the present work, we investigated the accuracy of the electron pencil‐beam redefinition algorithm (PBRA) in calculating central‐axis percent depth dose in water for rectangular fields. The PBRA energy correction factor C(E) was determined so that PBRA‐calculated percent depth dose best matched the percent depth dose measured in water. The hypothesis tested was that a method can be implemented into the PBRA that will enable the algorithm to calculate central‐axis percent depth dose in water at a 100‐cm source‐to‐surface distance (SSD) with an accuracy of 2% or 1‐mm distance to agreement for rectangular field sizes ≥2×2 cm. Preliminary investigations showed that C(E), determined using a single percent depth dose for a large field (that is, having side‐scatter equilibrium), was insufficient for the PBRA to accurately calculate percent depth dose for all square fields ≥2×2 cm. Therefore, two alternative methods for determining C(E) were investigated. In Method 1, C(E), modeled as a polynomial in energy, was determined by fitting the PBRA calculations to individual rectangular‐field percent depth doses. In Method 2, C(E) for square fields, described by a polynomial in both energy and side of square W [that is, C=C(E,W)], was determined by fitting the PBRA calculations to measured percent depth dose for a small number of square fields. Using the function C(E, W), C(E) for other square fields was determined, and C(E) for rectangular field sizes was determined using the geometric mean of C(E) for the two measured square fields of the dimension of the rectangle (square root method). Using both methods, PBRA calculations were evaluated by comparison with measured square‐field and derived rectangular‐field percent depth doses at 100‐cm SSD for the Siemens Primus radiotherapy accelerator equipped with a 25×25‐cm applicator at 10 MeV and 15 MeV. To improve the fit of C(E) and C(E, W) to the electron component of percent depth dose, it was necessary to modify the PBRA's photon depth dose model to include dose buildup. Results showed that, using both methods, the PBRA was able to predict percent depth dose within criteria for all square and rectangular fields. Results showed that second‐ or third‐order polynomials in energy (Methods 1 and 2) and in field size (Method 2) were typically required. Although the time for dose calculation using Method 1 is approximately twice that using Method 2, we recommend that Method 1 be used for clinical implementation of the PBRA because it is more accurate (most measured depth doses predicted within approximately 1%) and simpler to implement.

PACS number: 87.53.Fs

Determination of output factors for small proton therapy fields

Current protocols for the measurement of proton dose focus on measurements under reference conditions; methods for measuring dose under patient-specific conditions have not been standardized. In particular, it is unclear whether dose in patient-specific fields can be determined more reliably with or without the presence of the patient-specific range compensator. The aim of this study was to quantitatively assess the reliability of two methods for measuring dose per monitor unit (DIMU) values for small-field treatment portals: one with the range compensator and one without the range compensator. A Monte Carlo model of the Proton Therapy Center-Houston double-scattering nozzle was created, and estimates of D/MU values were obtained from 14 simulated treatments of a simple geometric patient model. Field-specific D/MU calibration measurements were simulated with a dosimeter in a water phantom with and without the range compensator. D/MU values from the simulated calibration measurements were compared with D/MU values from the corresponding treatment simulation in the patient model. To evaluate the reliability of the calibration measurements, six metrics and four figures of merit were defined to characterize accuracy, uncertainty, the standard deviations of accuracy and uncertainty, worst agreement, and maximum uncertainty. Measuring D/MU without the range compensator provided superior results for five of the six metrics and for all four figures of merit. The two techniques yielded different results primarily because of high-dose gradient regions introduced into the water phantom when the range compensator was present. Estimated uncertainties (approximately 1 mm) in the position of the dosimeter in these regions resulted in large uncertainties and high variability in D/MU values. When the range compensator was absent, these gradients were minimized and D/MU values were less sensitive to dosimeter positioning errors. We conclude that measuring D/MU without the range compensator present provides more reliable results than measuring it with the range compensator in place.

A Monte Carlo model for calculating out-of-field dose from a varian 6 MV beam

Dose to the patient outside of the treatment field is important when evaluating the outcome of radiotherapy treatments. However, determining out-of-field doses for any particular treatment plan currently requires either time-consuming measurements or calculated estimations that may be highly uncertain. A Monte Carlo model may allow these doses to be determined quickly, accurately, and with a great degree of flexibility. MCNPX was used to create a Monte Carlo model of a Varian Clinac 2100 accelerator head operated at 6 MV. Simulations of the dose out-of-field were made and measurements were taken with thermoluminescent dosimeters in an acrylic phantom and with an ion chamber in a water tank to validate the Monte Carlo model. Although local differences between the out-of-field doses calculated by the model and those measured did exceed 50% at some points far from the treatment field, the average local difference was only 16%. This included a range of doses as low as 0.01% of the central axis dose, and at distances in excess of 50 cm from the central axis of the treatment field. The out-of-field dose was found to vary with field size and distance from the central axis, but was almost independent of the depth in the phantom except where the dose increased substantially at depths less than dmax. The relationship between dose and kerma was also investigated, and kerma was found to be a good estimate of dose (within 3% on average) except near the surface and in the field penumbra. Our Monte Carlo model was found to well represent typical Varian 2100 accelerators operated at 6 MV.

Growth Characteristics of Calves Fed an Intensified Milk Replacer Regimen with Additional Lactoferrin

The objective of this study was to evaluate the effect of lactoferrin addition to milk replacer varying in crude protein (CP) on dry matter intake, growth, and days medicated. Thirty-four Holstein heifer calves were assigned to 4 treatments in a 2 x 2 factorial arrangement of treatments in a randomized complete block design. Treatments were as follows: 562 g daily of a nonmedicated conventional milk replacer (20% CP:20% fat) feeding regimen with or without 1 g of supplemental bovine lactoferrin (n = 9 for both treatments) or a nonmedicated intensified milk replacer feeding regimen (28% CP:20% fat) fed on a metabolizable energy basis (0.2 Mcal/kg BW(0.75)) from d 2 to 9, and at 0.27 Mcal/kg BW(0.75) from d 10 to 42 with or without 1g supplemental bovine lactoferrin (n = 8 for both treatments). Calves were fed pelleted starter (25% CP) in 227.5-g increments beginning on d 2 and had free access to water. Calves remained on the study for 14 d postweaning. Dry matter intake was determined daily. Growth measurements were taken weekly. Blood samples were taken twice weekly for determination of blood urea N. On d 10 of life, calves were subjected to a xylose challenge. Calves on conventional treatments ate more starter preweaning, during weaning, and postweaning. Preweaning, intensively fed calves had higher dry matter intakes. Weights of intensified-fed calves were greater at weaning. Intensified milk replacer-fed calves had greater average daily gain preweaning and overall and higher gain:feed ratios preweaning, but conventionally fed calves had higher gain:feed ratios during weaning. Intensified milk replacer-fed calves had greater hip heights during weaning and postweaning and greater heart girths preweaning, weaning, and postweaning. Days medicated were greater preweaning and overall for intensified-fed calves. There were no differences among treatments for xylose absorption. Calves on conventional treatments had increased blood urea nitrogen concentrations preweaning. There were no effects of lactoferrin on any experimental variable. Intensified milk replacer-fed calves consumed less starter but had higher average daily gains overall and larger frames and greater BW than conventionally fed calves. An intensified milk replacer feeding regimen promotes faster growth during the preweaning period when compared with calves fed conventional treatments, but supplemental bovine lactoferrin was not beneficial under these experimental conditions.

Quantification of bleomycin-induced murine lung damage in vivo with micro-computed tomography

RATIONALE AND OBJECTIVES

We explored noninvasive, in vivo cone-beam microcomputed tomography (micro-CT) to visualize and quantify fibrotic and inflammatory damage over the entire lung volume of mice.

MATERIALS AND METHODS

We used bleomycin to induce pulmonary damage in vivo and compared the results from micro-CT with histologic measurements. Ten C57BL/6 mice were given 5 U/kg bleomycin intratracheally. Seven surviving mice were scanned with micro-CT before administration of bleomycin, and again before sacrifice. The resulting images were analyzed for lung volume measurements. After the final scan, all lungs were examined histologically and pulmonary damage was quantified. Damaged lung tissue regions were matched between micro-CT images and histologic sections for each mouse.

RESULTS

The percent lung damage calculated from micro-CT and histology were correlated (r(2) = 0.49, r = 0.64 with P = 0.12), and the means of their respective distributions were not different (P > 0.05).

CONCLUSION

This study shows that micro-CT is a promising alternative to predicting lung damage caused by bleomycin. CT image volumes of the thorax allow for global tissue sampling, which may be useful when following nonuniform lung damage that can occur from intratracheal administration of bleomycin.

Cell cycle kinetic dysregulation in HIV-infected normal lymphocytes

BACKGROUND

Viruses alter cellular gene transcription and protein binding at many steps critical for cell cycle regulation to optimize the milieu for productive infection. Reasoning that virus-host cell interactions would result in perturbations of cell cycle kinetics, measurement of the duration of the phases of the cell cycle in normal T lymphocytes infected with human immunodeficiency virus (HIV) was undertaken.

METHODS

Flow cytometric measurement of bromodeoxyuridine-labeled and DNA content-stained cells at multiple points through the cell cycle allowed estimation of the fraction of cells in each phase, the potential doubling-time, and the durations of S and G(2)/M phases. Separate analysis of the HIV(+) and HIV(-) populations within the infected cultures was performed based on intracellular, anti-HIV core p24 antibody labeling. A novel mathematical model, which accounted for cell loss, was developed to estimate cell cycle phases.

RESULTS

(a) S phase was prolonged in the HIV-1(SF2)-infected cells compared with control. (b) This delay in S phase was due to delay in the population of cells not expressing HIV-1 antigens (p24 negative). (c) Accumulation of cells in G(2)/M phase was confirmed in HIV-1-infected cultures and was proportional to the level of infection as measured by p24 fluorescent intensity. However, all mock and HIV-1-infected populations predicted to proceed through cell division demonstrated similar G(2)/M-phase durations. (c) Potential doubling times were longer in the infected cultures; in contrast, the p24(+) subpopulations accounted for this delay. This suggests an isolated delay in the G(0)/G(1) phase for that population of cells.

CONCLUSIONS

Multiple phases of host cell cycle durations were affected by HIV-1(SF2) infection in this in vitro model, suggesting novel HIV-1 pathogenesis mechanisms. Prolonged S-phase durations in HIV-1 infected/p24(-) and G(0)/G(1)-phase durations in HIV-1 infected/p24(+) subpopulations require further study to identify mechanistic pathways.

Estimating cell death in G2M using bivariate BrdUrd/DNA flow cytometry

BACKGROUND

In an accompanying paper (Asmuth et al.) it was found necessary to include cell death explicitly to estimate parameters of cell proliferation. The use of bivariate flow cytometry to estimate the phase durations and the doubling times of cells labeled with thymidine analogues is well established. However, these methods of analysis do not consider the possibility of cell death. This report demonstrates that estimating cell death in G(2)/M is possible.

METHODS

Mathematical models for the experimental quantities, the fraction of labeled undivided cells, the fraction of labeled divided cells, and the relative movement were developed. These models include the possibility that, of the cells with G(2)/M DNA content, only a certain fraction will divide, with the remainder dying after some time T(R). Simulation studies were conducted to test the possibility of using simple methods to estimate phase durations and cell death rates.

RESULTS

Cell death alters the estimates of phase transit times in a rather complex manner that depends on the lifetime of the doomed cells. However, it is still possible to obtain estimates of the phase durations of cells in S and G(2)/M and the death rates of cells in G(2)/M.

CONCLUSIONS

The methods presented herein provide a new way to characterize cell populations that includes cell death rates and common measurements of cell proliferation.

Out-of-field photon and neutron dose equivalents from step-and-shoot intensity-modulated radiation therapy

PURPOSE

To measure the photon and neutron out-of-treatment-field dose equivalents to various organs from different treatment strategies (conventional vs. intensity-modulated radiation therapy [IMRT]) at different treatment energies and delivered by different accelerators.

METHODS AND MATERIALS

Independent measurements were made of the photon and neutron out-of-field dose equivalents resulting from one conventional and six IMRT treatments for prostate cancer. The conventional treatment used an 18-MV beam from a Clinac 2100; the IMRT treatments used 6-MV, 10-MV, 15-MV, and 18-MV beams from a Varian Clinac 2100 accelerator and 6-MV and 15-MV beams from a Siemens Primus accelerator. Photon doses were measured with thermoluminescent dosimeters in a Rando phantom, and neutron fluence was measured with gold foils. Dose equivalents to the colon, liver, stomach, lung, esophagus, thyroid, and active bone marrow were determined for each treatment approach.

RESULTS

For each treatment approach, the relationship between dose equivalent per MU, distance from the treatment field, and depth in the patient was examined. Photon dose equivalents decreased approximately exponentially with distance from the treatment field. Neutron dose equivalents were independent of distance from the treatment field and decreased with increasing tissue depth. Neutrons were a significant contributor to the out-of field dose equivalent for beam energies > or =15 MV.

CONCLUSIONS

Out-of-field photon and neutron dose equivalents can be estimated to any point in a patient undergoing a similar treatment approach from the distance of that point to the central axis and from the tissue depth. This information is useful in determining the dose to critical structures and in evaluating the risk of associated carcinogenesis.

The calculated risk of fatal secondary malignancies from intensity-modulated radiation therapy

PURPOSE

Out-of-field radiation doses to normal tissues may be associated with an increased risk of secondary malignancies, particularly in long-term survivors. Step-and-shoot intensity-modulated radiation therapy (IMRT), an increasingly popular treatment modality, yields higher out-of-field doses than do conventional treatments, because of an increase in required monitor units (beam-on time).

METHODS

We used published risk coefficients (NRCP Report 116) and out-of-field dose equivalents to multiple organ sites to estimate a conservative maximal risk of fatal secondary malignancy associated with 6 IMRT approaches and 1 conventional external-beam approach for prostate cancer.

RESULTS

Depending on treatment energy, the IMRT treatments required 3.5-4.9 times as many monitor units to deliver as did the conventional treatment. The conservative maximum risk of fatal second malignancy was 1.7% for conventional radiation, 2.1% for IMRT using 10-MV X-rays, and 5.1% for IMRT using 18-MV X-rays. Intermediate risks were associated with IMRT using 6-MV X-rays: 2.9% for treatment with the Varian accelerator and 3.7% for treatment with the Siemens accelerator, as well as using 15-MV X-rays: 3.4% (Varian) and 4.0% (Siemens).

CONCLUSION

The risk of fatal secondary malignancy differed substantially between IMRT and conventional radiation therapy for prostate cancer, as well as between different IMRT approaches. Perhaps this risk should be considered when choosing the optimal treatment technique and delivery system for patients who will undergo prostate radiation.

Endovascular Repair or Surveillance of Patients with Small AAA

OBJECTIVE

To compare the outcome of patients with small abdominal aortic aneurysms (AAA) treated in a prospective trial of endovascular aneurysm repair (EVAR) to patients randomized to the surveillance arm of the UK Small Aneurysm Trial.

METHOD

All patients with small AAA (< or = 5.5 cm diameter) treated with a stent graft (EVARsmall) in the multicenter AneuRx clinical trial from 1997 to 1999 were reviewed with follow up through 2003. A subgroup of patients (EVARmatch) who met the age (60-76 years) and aneurysm size (4.0-5.5 cm diameter) inclusion criteria of the UK Small Aneurysm Trial were compared to the published results of the surveillance patient cohort (UKsurveil) of the UK Small Aneurysm Trial (NEJM 346:1445, 2002). Endpoints of comparison were aneurysm rupture, fatal aneurysm rupture, operative mortality, aneurysm related death and overall mortality. The total patient years of follow-up for EVAR patients was 1369 years and for UK patients was 3048 years. Statistical comparisons of EVARmatch and UKsurveil patients were made for rates per 100 patient years of follow up (/100 years) to adjust for differences in follow-up time.

RESULTS

The EVARsmall group of 478 patients comprised 40% of the total number of patients treated during the course of the AneuRx clinical trial. The EVARmatch group of 312 patients excluded 151 patients for age < 60 or > 76 years and 15 patients for AAA diameter < 4 cm. With the exception of age, there were no significant differences between EVARsmall and EVARmatch in pre-operative factors or post-operative outcomes. In comparison to the UKsurveil group of 527 patients, the EVARmatch group was slightly older (70 +/- 4 vs. 69 +/- 4 years, p = 0.009), had larger aneurysms (5.0 +/- 0.3 vs. 4.6 +/- 0.4 cm, p < 0.001), fewer women (7 vs. 18%, p < 0.001), and had a higher prevalence of diabetes and hypertension and a lower prevalence of smoking at baseline. Ruptures occurred in 1.6% of EVARmatch patients and 5.1% of UKsurveil patients; this difference was not significant when adjusted for the difference in length of follow up. Fatal aneurysm rupture rate, adjusted for follow up time, was four times higher in UKsurveil (0.8/100 patient years) than in EVARmatch (0.2/100 patient years, p < 0.001); this difference remained significant when adjusted for difference in gender mix. Elective operative mortality rate was significantly lower in EVARmatch (1.9%) than in UKsurveil (5.9%, p < 0.01). Aneurysm-related death rate was two times higher in UKsurveil (1.6/100 patient years) than in EVARmatch (0.8/100 patient years, p = 0.03). All-cause mortality rate was significantly higher in UKsurveil (8.3/100 patient years) than in EVARmatch (6.4/100 patient years, p = 0.02).

CONCLUSIONS

It appears that endovascular repair of small abdominal aortic aneurysms (4.0-5.5 cm) significantly reduces the risk of fatal aneurysm rupture and aneurysm-related death and improves overall patient survival compared to an ultrasound surveillance strategy with selective open surgical repair.

Retrospective analysis of 2D patient-specific IMRT verifications

We performed 858 two-dimensional (2D) patient-specific intensity modulated radiotherapy verifications over a period of 18 months. Multifield, composite treatment plans were measured in phantom using calibrated Kodak EDR2 film and compared with the calculated dose extracted from two treatment planning systems. This research summarizes our findings using the normalized agreement test (NAT) index and the percent of pixels failing the gamma index as metrics to represent the agreement between measured and computed dose distributions. An in-house dose comparison software package was used to register and compare all verifications. We found it was important to use an automatic positioning algorithm to achieve maximum registration accuracy, and that our automatic algorithm agreed well with anticipated results from known phantom geometries. We also measured absolute dose for each case using an ion chamber. Because the computed distributions agreed with ion chamber measurements better than the EDR2 film doses, we normalized EDR2 data to the computed distributions. The distributions of both the NAT indices and the percentage of pixels failing the gamma index were found to be exponential distributions. We continue to use both the NAT index and percent of pixels failing gamma with 5%/3 mm criteria to evaluate future verifications, as these two metrics were found to be complementary. Our data showed that using 2%/2 mm or 3%/3 mm criteria produces results similar to those using 5%/3 mm criteria. Normalized comparisons that have a NAT index greater than 45 and/or more than 20% of the pixels failing gamma for 5%/3 mm criteria represent outliers from our clinical data set and require further analysis. Because our QA verification results were exponentially distributed, rather than a tight grouping of similar results, we continue to perform patient-specific QA in order to identify and correct outliers in our verifications. The data from this work could be useful as a reference for other clinics to indicate anticipated trends in 2D verifications under various conditions.

Dosimetric accuracy of Kodak EDR2 film for IMRT verifications

Patient-specific intensity-modulated radiotherapy (IMRT) verifications require an accurate two-dimensional dosimeter that is not labor-intensive. We assessed the precision and reproducibility of film calibrations over time, measured the elemental composition of the film, measured the intermittency effect, and measured the dosimetric accuracy and reproducibility of calibrated Kodak EDR2 film for single-beam verifications in a solid water phantom and for full-plan verifications in a Rexolite phantom. Repeated measurements of the film sensitometric curve in a single experiment yielded overall uncertainties in dose of 2.1% local and 0.8% relative to 300 cGy. 547 film calibrations over an 18-month period, exposed to a range of doses from 0 to a maximum of 240 MU or 360 MU and using 6 MV or 18 MV energies, had optical density (OD) standard deviations that were 7%-15% of their average values. This indicates that daily film calibrations are essential when EDR2 film is used to obtain absolute dose results. An elemental analysis of EDR2 film revealed that it contains 60% as much silver and 20% as much bromine as Kodak XV2 film. EDR2 film also has an unusual 1.69:1 silver:halide molar ratio, compared with the XV2 film's 1.02:1 ratio, which may affect its chemical reactions. To test EDR2's intermittency effect, the OD generated by a single 300 MU exposure was compared to the ODs generated by exposing the film 1 MU, 2 MU, and 4 MU at a time to a total of 300 MU. An ion chamber recorded the relative dose of all intermittency measurements to account for machine output variations. Using small MU bursts to expose the film resulted in delivery times of 4 to 14 minutes and lowered the film's OD by approximately 2% for both 6 and 18 MV beams. This effect may result in EDR2 film underestimating absolute doses for patient verifications that require long delivery times. After using a calibration to convert EDR2 film's OD to dose values, film measurements agreed within 2% relative difference and 2 mm criteria to ion chamber measurements for both sliding window and step-and-shoot fluence map verifications. Calibrated film results agreed with ion chamber measurements to within 5 % /2 mm criteria for transverse-plane full-plan verifications, but were consistently low. When properly calibrated, EDR2 film can be an adequate two-dimensional dosimeter for IMRT verifications, although it may underestimate doses in regions with long exposure times.

Input parameter sensitivity analysis and comparison of quantification models for continuous arterial spin labeling

The regional cerebral blood flow (rCBF) values determined using continuous arterial spin labeling (CASL) are subject to several sources of variability, including natural physiologic variations, sensitivity to the input parameters, and the use of different quantification models. To date, a thorough analysis of the impact of input parameters and the choice of quantification model has not been performed. These sources of variability were investigated through computer simulations using bootstrap techniques on actual CASL data. Coefficients of variation for representative single voxels were 6.7% for gray matter and 29% for white matter, and for eight-voxel regions of interest they were 4.5% for gray matter and 23% for white matter. Comparison of nine CASL quantification models showed differences in gray matter rCBF values of up to 42%. An analysis of the sensitivity of the rCBF to input parameters for each of the nine quantification models demonstrated that accurate quantification of the inversion efficiency, tissue and arterial blood longitudinal relaxation times, and transit times were critical in calculating precise rCBF values. The large potential variations in rCBF and the effect of the choice of quantification model suggest that interpreting absolute rCBF values in CASL studies can be challenging and requires great care.

Detection of IMRT delivery errors using a quantitative 2D dosimetric verification system

We investigated the feasibility of detecting intensity modulated radiotherapy delivery errors automatically using a scalar evaluation of two-dimensional (2D) transverse dose measurement of the complete treatment delivery. Techniques using the gamma index and the normalized agreement test (NAT) index were used to parametrize the agreement between measured and computed dose distributions to seven different scalar metrics. Simulated verifications with delivery errors calculated using a commercially available treatment planning system for 9 prostate and 7 paranasal sinus cases were compared to 433 clinical verifications. The NAT index with 5% and 3 mm criteria that included cold areas outside the planning target volume detected the largest percent of delivery errors. Assuming a false positive rate of 5%, it was able to detect 88% of beam energy changes, 94% of a different patient's plan being delivered, 25% of plans with one beam's collimator rotated by 90 degrees, 81% of rotating one beam's gantry angle by 10 degrees, and 100% of omitting the delivery of one beam. However, no instances of changing one beam's monitor unit setting by 10% or shifting the isocenter by 5 mm were detected. Although the phantom shift could not be detected by the small change it made in the dose distribution, our autopositioning algorithm clearly identified the spatial anomaly. Using tighter 3 %/2 mm criteria or combining dose and distance disagreements in an either/or fashion resulted in poorer delivery error detection. The mean value of the 2D gamma index distribution was less sensitive to delivery errors than the other scalar metrics studied. Although we found that scalar metrics do not have sufficient delivery error detection rates to be used as the sole clinical analysis technique, manually examining 2D dose comparison images would result in a near 100% detection rate while performing an ion chamber measurement alone would only detect 54% of these errors.

Improving conformational searches by geometric screening

MOTIVATION

Conformational searches in molecular docking are a time-consuming process with wide range of applications. Favorable conformations of the ligands that successfully bind with receptors are sought to form stable ligand-receptor complexes. Usually a large number of conformations are generated and their binding energies are examined. We propose adding a geometric screening phase before an energy minimization procedure so that only conformations that geometrically fit in the binding site will be prompted for energy calculation.

RESULTS

Geometric screening can drastically reduce the number of conformations to be examined from millions (or higher) to thousands (or lower). The method can also handle cases when there are more variables than geometric constraints. An early-stage implementation is able to finish the geometric filtering of conformations for molecules with up to nine variables in 1 min. To the best of our knowledge, this is the first time such results are reported deterministically.

CONTACT

mzhang@mdanderson.org.

Evaluation of a contour-alignment technique for CT-guided prostate radiotherapy: an intra- and interobserver study

PURPOSE

The recent introduction of integrated CT/linear accelerator systems may mean that daily CT localization can become a reality in the clinic, possibly allowing further dose escalation to the prostate while limiting unwanted doses to the rectum and bladder. However, the implementation of CT localization is currently impeded by the lack of precise and robust techniques to align the treatment plan with the daily CT images. The purpose of this study was to evaluate a manual alignment technique, in which the gross target volume contours are overlaid on the daily CT images and then shifted to match the structures visible in the images.

METHODS AND MATERIALS

A total of 28 CT image sets were taken before the standard delivery of intensity-modulated radiotherapy for prostate cancer for 2 patients. Seven observers (four radiation oncologists and three medical physicists) manually shifted the gross target volume contours from the treatment plan to best match the daily CT images. One observer repeated the process 1 week later to evaluate intraobserver variations. The experiment was then repeated, but the CT images from the original treatment plan were used as a reference to reduce interobserver uncertainty when aligning the contours. The shifts in prostate position found by different observers, both with and without reference data, were evaluated using a factorial analysis of variance to determine the standard errors of measurement for the intra- and interobserver uncertainty (SEM(intra) and SEM(inter), respectively). The differences in the SEM for the two groups of observers (radiation oncologists and medical physicists), the two alignment techniques (with and without reference information), and the two patients were evaluated using the t test at 90% confidence levels.

RESULTS

With no reference information, the SEM(inter) using one patient data set (Patient 1) was 0.8 mm, 2.0 mm, and 2.2 mm in the right-left (RL), anterior-posterior (AP), and superior-inferior (SI) directions, respectively. The use of the treatment plan as a reference reduced the SEM(inter) to 0.7 mm, 1.0 mm, and 1.6 mm in the RL, AP, and SI directions, respectively. In Patient 2, localization of the prostate was more difficult; the best SEM(inter) achieved with this patient was 0.8 mm, 1.9 mm, and 2.0 mm in the RL, AP, and SI directions, respectively. The SEM(intra) values with Patient 1 were also slightly better than with Patient 2. When reference data were used, the SEM(intra) value was 0.5 mm, 0.7 mm, and 0.5 mm for Patient 1 and 0.6 mm, 1.0 mm, and 0.7 mm for Patient 2 in the RL, AP, and SI directions, respectively. Despite the larger than expected interobserver variation reported here, the SEM(inter) was smaller than the typical day-to-day variation in prostate position. The contour alignment technique may still be useful to aid daily prostate localization or in a correction scheme to minimize the effect of target positional error.

CONCLUSION

The interobserver uncertainties associated with aligning the gross target volume contours with daily CT images were sufficiently small that this method may be used for daily CT localization of the prostate. The use of a reference image is important to improve the consistency among different users in this technique.

Cellular kinetics of murine lung: model system to determine basis for radioprotection with keratinocyte growth factor

PURPOSE

Normal tissue toxicity remains a dose limitation for cancer radiotherapy and chemoradiotherapy. Growth factors offer a novel means of mitigating normal tissue radiotoxicity. In particular, keratinocyte growth factor (rHuKGF), whose proliferative activity is restricted to epithelial cells, holds promise on the basis of the findings of preclinical models of epithelial cytoprotection and the clinical developments to date. We report the radioprotection of murine lung by an increase in tissue cellularity after rHuKGF-induced proliferation.

METHODS AND MATERIALS

Flow cytometric and image analysis techniques after bromodeoxyuridine labeling were used to estimate proliferative parameters. Our specialized analytical methods measure not only labeling indexes, but also the durations of S and G(2)+M phases, potential doubling times, and the net cell production rate. Image analysis techniques were used to identify the specific cell types that were proliferating (type II pneumocytes).

RESULTS

Lung labeling index control values (0.5%) rose to a maximum (5.5%) at 3 days after intratracheal rHuKGF, returning to normal by Day 7. The potential doubling time fell from 66 days to 4.4 days. The net cell production rate rose from a control value of 1%/d to >15%/d by Day 3. This resulted in a nearly twofold increase in alveolar epithelial cellularity, which remained significantly elevated on Day 7. Saline-treated control animals exhibited no significant changes in the proliferative parameter values or cellularity. On the basis of these data, mice were irradiated, solely to the thorax, with ranges of single doses of 250 kVp X-rays 7 days after either intratracheal administration of 5 mg/kg rHuKGF or phospate-buffered saline. This interval was chosen because the proliferative response of the type II cells was finished but the cellularity of the lung remained increased. Pretreatment with rHuKGF extended the latent period before onset of pneumonitis after all radiation doses. rHuKGF treatment 7 days before thoracic irradiation significantly protected against pneumonitis (median effective dose 13.7 Gy, 95% confidence limit 13.4-14.0) compared with the control pretreatment with phosphate-buffered saline (median effective dose 12.8 Gy, 95% confidence limit 12.6-13.1).

CONCLUSION

The data showed that an increase in tissue cellularity, caused by rHuKGF treatment before irradiation, protected the lung from damage due to pneumonitis.

Chromosomal localization of three vacuolar-H+ -ATPase 16 kDa subunit (ATP6V0C) genes in the murine genome

Vacuolar-H(+)-ATPase (V-H-ATPase) is a large multimeric protein composed of at least 12 distinct subunits. The 16-kDa hydrophobic proteolipid subunit (ATP6V0C; ATPase, H(+ )transporting, lysosomal 16 kDa, V0 subunit C) plays a central role in H(+) transport across cellular membranes. We have mapped three ATP6V0C genes (Atp6v0c, Atp6v0c-ps1 and Atp6voc-ps2) in the murine genome. Atp6v0c-ps1 and Atp6v0c-ps2 map to Chromosomes 7 and 6, respectively. Atp6v0c maps to Chromosome 17, closely linked to the Tsc2 locus and D17Mit55. This region of Chromosome 17 in mouse is homologous with chromosome 16 in human where the ATP6V0C gene is localized.

The use of an extra-focal electron source to model collimator-scattered electrons using the pencil-beam redefinition algorithm

Currently, the pencil-beam redefinition algorithm (PBRA) utilizes a single electron source to model clinical electron beams. In the single-source model, the electrons appear to originate from a virtual source located near the scattering foils. Although this approach may be acceptable for most treatment machines, previous studies have shown dose differences as high as 8% relative to the given dose for small fields for some machines such as the Varian Clinac 1800. In such machines collimation-scattered electrons originating from the photon jaws and the applicator give rise to extra-focal electron sources. In this study, we examined the impact of modeling an additional electron source to better account for the collimator-scattered electrons. The desired dose calculation accuracy in water throughout the dose distribution is 3% or better relative to the given dose. We present here a methodology for determining the electron-source parameters for the dual-source model using a minimal set of data, that is, two central-axis depth-dose curves and two off-axis profiles. A Varian Clinac 1800 accelerator was modeled for beam energies of 20 and 9 MeV and applicator sizes of 15 x 15 and 6 x 6 cm2. The improvement in the accuracy of PBRA-calculated dose, evaluated using measured two-dimensional dose distributions in water, was characterized using the figure of merit, FA3%, which represents the fractional area containing dose differences greater than 3%. For the 15 x 15 cm2 field the evaluation was restricted to the penumbral region, and for the 6 x 6 cm2 field the central region of the beam was included as it was impacted by the penumbra. The greatest improvement in dose accuracy was for the 6 x 6 cm2 applicator. At 9 MeV, FA3% decreased from 15% to 0% at 100 cm SSD and from 34% to 4% at 110 cm SSD. At 20 MeV, FA3% decreased from 17% to 2% at 100 cm SSD and from 41% to 10% at 110 cm SSD. In the penumbra of the 15 x 15 cm2 applicator, the improvement was less, but still significant. At 9 MeV, FA3% changed from 11% to 1% at 100 cm SSD and from 10% to 12% at 110 cm SSD. At 20 MeV, FA3% decreased from 12% to 8% at 100 cm SSD and from 14% to 5% at 110 cm SSD. Results demonstrate that use of a dual-source beam model can provide significantly improved accuracy in the PBRA-calculated dose distribution that was not achievable with a single-source beam model when modeling the Varian Clinac 1800 electron beams. Time of PBRA dose calculation was approximately doubled; however, dual-source beam modeling of newer accelerators (e.g., the Varian Clinac 2100) may not be necessary because of less impact of collimator-scattered electrons on dosimetry.

PTV margin determination in conformal SRT of intracranial lesions

The planning target volume (PTV) includes the clinical target volume (CTV) to be irradiated and a margin to account for uncertainties in the treatment process. Uncertainties in miniature multileaf collimator (mMLC) leaf positioning, CT scanner spatial localization, CT-MRI image fusion spatial localization, and Gill-Thomas-Cosman (GTC) relocatable head frame repositioning were quantified for the purpose of determining a minimum PTV margin that still delivers a satisfactory CTV dose. The measured uncertainties were then incorporated into a simple Monte Carlo calculation for evaluation of various margin and fraction combinations. Satisfactory CTV dosimetric criteria were selected to be a minimum CTV dose of 95% of the PTV dose and at least 95% of the CTV receiving 100% of the PTV dose. The measured uncertainties were assumed to be Gaussian distributions. Systematic errors were added linearly and random errors were added in quadrature assuming no correlation to arrive at the total combined error. The Monte Carlo simulation written for this work examined the distribution of cumulative dose volume histograms for a large patient population using various margin and fraction combinations to determine the smallest margin required to meet the established criteria. The program examined 5 and 30 fraction treatments, since those are the only fractionation schemes currently used at our institution. The fractionation schemes were evaluated using no margin, a margin of just the systematic component of the total uncertainty, and a margin of the systematic component plus one standard deviation of the total uncertainty. It was concluded that (i) a margin of the systematic error plus one standard deviation of the total uncertainty is the smallest PTV margin necessary to achieve the established CTV dose criteria, and (ii) it is necessary to determine the uncertainties introduced by the specific equipment and procedures used at each institution since the uncertainties may vary among locations.

Gene expression in the developing mouse retina by EST sequencing and microarray analysis

Retinal development occurs in mice between embryonic day E11.5 and post-natal day P8 as uncommitted neuroblasts assume retinal cell fates. The genetic pathways regulating retinal development are being identified but little is understood about the global networks that link these pathways together or the complexity of the expressed gene set required to form the retina. At E14.5, the retina contains mostly uncommitted neuroblasts and newly differentiated neurons. Here we report a sequence analysis of an E14.5 retinal cDNA library. To date, we have archived 15 268 ESTs and have annotated 9035, which represent 5288 genes. The fraction of singly occurring ESTs as a function of total EST accrual suggests that the total number of expressed genes in the library could approach 27 000. The 9035 ESTs were categorized by their known or putative functions. Representation of the genes involved in eye development was significantly higher in the retinal clone set compared with the NIA mouse 15K cDNA clone set. Screening with a microarray containing 864 cDNA clones using wild-type and brn-3b (-/-) retinal cDNA probes revealed a potential regulatory linkage between the transcription factor Brn-3b and expression of GAP-43, a protein associated with axon growth. The retinal EST database will be a valuable platform for gene expression profiling and a new source for gene discovery.