Preparing Patients for Oral Immunotherapy (PPOINT): International Delphi consensus for procedural preparation and consent

BACKGROUND

Despite the promise of oral immunotherapy (OIT) to treat food allergies, this procedure is associated with potential risk. There is no current agreement about what elements should be included in the preparatory or consent process.

OBJECTIVE

We developed consensus recommendations about the OIT process considerations and patient-specific factors that should be addressed before initiating OIT and developed a consensus OIT consent process and information form.

METHODS

We convened a 36-member Preparing Patients for Oral Immunotherapy (PPOINT) panel of allergy experts to develop a consensus OIT patient preparation, informed consent process, and framework form. Consensus for themes and statements was reached using Delphi methodology, and the consent information form was developed.

RESULTS

The expert panel reached consensus for 4 themes and 103 statements specific to OIT preparatory procedures, of which 76 statements reached consensus for inclusion specific to the following themes: general considerations for counseling patients about OIT; patient- and family-specific factors that should be addressed before initiating OIT and during OIT; indications for initiating OIT; and potential contraindications and precautions for OIT. The panel reached consensus on 9 OIT consent form themes: benefits, risks, outcomes, alternatives, risk mitigation, difficulties/challenges, discontinuation, office policies, and long-term management. From these themes, 219 statements were proposed, of which 189 reached consensus, and 71 were included on the consent information form.

CONCLUSION

We developed consensus recommendations to prepare and counsel patients for safe and effective OIT in clinical practice with evidence-based risk mitigation. Adoption of these recommendations may help standardize clinical care and improve patient outcomes and quality of life.

Information needs of patients considering oral immunotherapy for food allergy

While the historic management of food allergy includes avoidance strategies and allergic reaction treatment, oral immunotherapy (OIT) approaches have become more commonly integrated into therapeutic approaches. International guidelines, phase 3 trials and real-world experience have supported the implementation of this procedure. However, OIT is an elective, rarely curative procedure with inherent risks that necessitates an increased degree of health literacy for the patients and families. Families assume the responsibility of amateur healthcare providers to ensure the daily safe administration of the allergenic food. As such, it is incumbent upon physicians to ensure that families are prepared for this role. A thorough educational and shared decision-making approach is necessary during the counselling and consent process to adequately inform the families. Educated discussion about the efficacy and patient-centred effectiveness, therapeutic alternatives and family goals is required to align physician and patient expectations. A frank discussion about the struggles, practical challenges, risks and contraindications can help to develop an understanding of the risk mitigation strategies employed to maintain safety. Physicians should develop a proactive approach to educate families about this, at times, burdensome procedure. This educational approach should encourage ongoing support starting prior to consent through the maintenance visits. By preparing families for their unique management role, physicians can help ensure the safe and successful integration of OIT into the therapeutic offering for the management of food allergies.

Diffusion tensor imaging reveals changes in microstructural integrity along compressed nerve roots that correlate with chronic pain symptoms and motor deficiencies in elderly stenosis patients

Age-related degenerative changes in the lumbar spine frequently result in nerve root compression causing severe pain and disability. Given the increasing incidence of lumbar spinal disorders in the aging population and the discrepancies between the use of current diagnostic imaging tools and clinical symptoms, novel methods of nerve root assessment are needed. We investigated elderly patients with stenosis at L4-L5 or L5-S1 levels. Diffusion tensor imaging (DTI) was used to quantify microstructure in compressed L5 nerve roots and investigate relationships to clinical symptoms and motor neurophysiology. DTI metrics (i.e. FA, MD, AD and RD) were measured at proximal, mid and distal segments along compressed (i.e. L5) and intact (i.e. L4 or S1) nerve roots. FA was significantly reduced in compressed nerve roots and MD, AD and RD were significantly elevated in the most proximal segment of the nerve root studied. FA was significantly correlated with electrophysiological measures of root function: minimum F-wave latency and peripheral motor conduction time (PMCT). In addition, FA along the compressed root also correlated with leg pain and depression score. There was also a relationship between RD and anxiety, leg pain and disability score and AD correlated with depression score. Taken together, these data show that DTI metrics are sensitive to nerve root compression in patients with stenosis as a result of age-related lumbar degeneration. Critically, they show that the changes in microstructural integrity along compressed L5 nerve roots are closely related to a number of clinical symptoms associated with the development of chronic pain as well as neurophysiological assessments of motor function. These inherent relationships between nerve root damage and phenotype suggest that the use DTI is a promising method as a way to stratify treatment selection and predict outcomes.

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DTI can be used to quantify lumbar spinal nerve root compression in elderly patients.

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Diffusion parameters correlate with functional neurophysiology and clinical symptoms.

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DTI has the potential to be used to predict treatment outcomes.

Frequency-dependent top-down modulation of temporal summation by anodal transcranial direct-current stimulation of the primary motor cortex in healthy adults

BACKGROUND

Transcranial direct-current stimulation (tDCS) applied over the primary motor cortex has been shown to be effective in the treatment of a number of chronic pain conditions. However, there is a lack of understanding of the top-down analgesic mechanisms involved.

METHOD

In this study, we investigated the effects of tDCS on the facilitation of subjective sensory and pain scores using a transcutaneous electrically evoked measure of temporal summation. In this randomized, blinded, cross-over study healthy subjects received a single stimulus given at 0.9× pain threshold (pTh) over the L5 dermatome on the lateral aspect of the right leg, followed by a train of 5 stimuli given at 0.5, 1, 5 and 20 Hz before and after 20 min of sham or anodal tDCS (2 mA) applied over the primary motor cortex. Ratings of sensation and pain intensity were scored on a visual analogue scale (VAS).

RESULTS

Temporal summation leading to pain only occurred at higher frequencies (5 and 20 Hz). Sham or real tDCS had no effect over temporal summation evoked at 5 Hz; however, there was a significant analgesic effect at 20 Hz. Sham or real tDCS had no effect over acute, single stimuli-evoked responses.

CONCLUSION

These results indicate that anodal tDCS applied to the primary motor cortex preferentially modulates temporal summation induced by high-frequency electrical stimulation-induced pain. The inhibitory effects of tDCS appear to be dynamic and dependent on the degree of spinal cord excitability and may explain the higher analgesic efficacy in patients with moderate to severe chronic pain symptoms.

SIGNIFICANCE

The analgesic effects of tDCS are dependent on spinal cord excitability. This work provides insight into top-down modulation during acute pain and temporal summation. This knowledge may explain why tDCS has a higher analgesic efficacy in chronic pain patients.

Endogenous analgesic action of the pontospinal noradrenergic system spatially restricts and temporally delays the progression of neuropathic pain following tibial nerve injury

Pontospinal noradrenergic neurons form part of an endogenous analgesic system that suppresses acute pain, but there is conflicting evidence about its role in neuropathic pain. We investigated the chronology of descending noradrenergic control during the development of a neuropathic pain phenotype in rats following tibial nerve transection (TNT). A lumbar intrathecal cannula was implanted at the time of nerve injury allowing administration of selective α-adrenoceptor (α-AR) antagonists to sequentially assay their effects upon the expression of allodynia and hyperalgesia. Following TNT animals progressively developed mechanical and cold allodynia (by day 10) and subsequently heat hypersensitivity (day 17). Blockade of α₂-AR with intrathecal yohimbine (30 μg) revealed earlier ipsilateral sensitization of all modalities while prazosin (30 μg, α₁-AR) was without effect. Established allodynia (by day 21) was partly reversed by the re-uptake inhibitor reboxetine (5 μg, i.t.) but yohimbine no longer had any sensitising effect. This loss of effect coincided with a reduction in the descending noradrenergic innervation of the ipsilateral lumbar dorsal horn. Yohimbine reversibly unmasked contralateral hindlimb allodynia and hyperalgesia of all modalities and increased dorsal horn c-fos expression to an innocuous brush stimulus. Contralateral thermal hyperalgesia was also reversibly uncovered by yohimbine administration in a contact heat ramp paradigm in anaesthetised TNT rats. Following TNT there is an engagement of inhibitory α₂-AR-mediated noradrenergic tone which completely masks contralateral and transiently suppresses the development of ipsilateral sensitization. This endogenous analgesic system plays a key role in shaping the spatial and temporal expression of the neuropathic pain phenotype after nerve injury.

Joint laminate degradation assessed by reflected ultrasound from the cartilage surface and osteochondral junction

The ability to quantify and qualify the progression of joint degeneration is becoming increasingly important in surgery. This paper examines the patterns of relative ultrasound reflection from normal, artificially and naturally degraded cartilage-on-bone, particularly investigating the potential of the ratio of reflection coefficients from the surface and osteochondral junction in distinguishing normal from osteoarthritic tissue. To this end, the reflection coefficients from the articular surface and osteochondral junction of normal cartilage-on-bone samples were calculated and compared to samples after the removal of proteoglycans, disruption of the collagen meshwork, delipidization of the articular surface and mechanical abrasion. Our results show that the large variation across normal and degraded joint samples negates the use of an isolated bone reflection measurement and to a lesser extent, an isolated surface reflection. The relative surface to bone reflections, calculated as a ratio of reflection coefficients, provided a more consistent and statistically significant (p < 0.001) method for distinguishing each type of degradation, especially osteoarthritic degradation, and due to the complementary relationship between surface and bone reflections was found to be an effective method for distinguishing degraded from normal tissue in the osteoarthritic joint, independent of the site of initiation of the osteoarthritic process.

Nucleus- and species-specific properties of the slow (<1 Hz) sleep oscillation in thalamocortical neurons

The slow (<1 Hz) rhythm is an electroencephalogram hallmark of resting sleep. In thalamocortical neurons this rhythm correlates with a slow (<1 Hz) oscillation comprising recurring UP and DOWN membrane potential states. Recently, we showed that metabotropic glutamate receptor activation brings about an intrinsic slow oscillation in thalamocortical neurons of the cat dorsal lateral geniculate nucleus in vitro which is identical to that observed in vivo. The aim of this study was to further assess the properties of this oscillation and compare them with those observed in thalamocortical neurons of three other thalamic nuclei in the cat (ventrobasal complex, medial geniculate body; ventral lateral nucleus) and two thalamic nuclei in rats and mice (lateral geniculate nucleus and ventrobasal complex). Slow oscillations were evident in all of these additional structures and shared several basic properties including, i) the stereotypical, rhythmic alternation between distinct UP and DOWN states with the UP state always commencing with a low-threshold Ca2+ potential, and ii) an inverse relationship between frequency and injected current so that slow oscillations always increase in frequency with hyperpolarization, often culminating in delta (delta) activity at approximately 1-4 Hz. However, beyond these common properties there were important differences in expression between different nuclei. Most notably, 44% of slow oscillations in the cat lateral geniculate nucleus possessed UP states that comprised sustained tonic firing and/or high-threshold bursting. In contrast, slow oscillations in cat ventrobasal complex, medial geniculate body and ventral lateral nucleus thalamocortical neurons exhibited such UP states in only 16%, 11% and 10% of cases, respectively, whereas slow oscillations in the lateral geniculate nucleus and ventrobasal complex of rats and mice did so in <12% of cases. Thus, the slow oscillation is a common feature of thalamocortical neurons that displays clear species- and nuclei-related differences. The potential functional significance of these results is discussed.

Properties and origin of spikelets in thalamocortical neurones in vitro

Spikelets, or fast prepotentials as they are frequently referred to, are a common feature of the electrophysiology of central neurones and are invariably correlated with the presence of electrotonic coupling via gap junctions. Here we report that in the presence of the metabotropic glutamate receptor agonists, trans-ACPD or DHPG, thalamocortical neurones of the cat dorsal lateral geniculate nucleus maintained in vitro exhibit stereotypical spikelets that possess similar properties to those described in other brain areas. These spikelets were routinely observed in the presence of antagonists of fast chemical synaptic transmission, were resistant to the application of a variety of voltage-dependent Ca(2+) channel blockers but were abolished by tetrodotoxin. In addition, spikelets were reversibly blocked by the putative gap junction blocker carbenoxolone and were nearly always accompanied by dye-coupling. These results indicate that thalamocortical neurones may be electrotonically coupled via gap junctions with spikelets representing attenuated action potentials from adjoining cells. We suggest that the presence of electrotonic communication between thalamocortical neurones would have major implications for the understanding of both physiological (Steriade et al., 1993; Sillito et al., 1994; Alonso et al., 1996; Neuenschwander and Singer, 1996; Weliky and Katz, 1999) and pathological (Steriade and Contreras, 1995; Pinault et al., 1998) synchronised electrical activity in the thalamus.

Serial fetal lung volume measurement using three-dimensional ultrasound

OBJECTIVE

To establish reference intervals for fetal lung growth.

DESIGN

Longitudinal observational study.

SUBJECTS

Fifty-eight women with initially uncomplicated singleton pregnancies were recruited from the antenatal population of a teaching hospital. Four women were excluded from the final analysis because of complications arising in their pregnancy.

METHODS

Each subject was serially scanned at monthly intervals. At each visit lung volume was measured using an ultrasound-based computerized three-dimensional imaging system. Multilevel models were used to determine conditional and unconditional reference intervals.

RESULTS

Reference intervals for fetal lung growth were derived. Fetal lung volume increases in a non-linear way with gestation.

CONCLUSIONS

Our computerized system has the capacity to be used in conjunction with any standard two-dimensional ultrasound scanner in order to measure volume. Lung volume measurement may be useful in predicting pulmonary hypoplasia.

On the putative contribution of GABA(B) receptors to the electrical events occurring during spontaneous spike and wave discharges

Cortical and thalamic neurones play a major role in the generation/expression of spike and wave discharges (SWDs), the main electroencephalographic (EEG) feature of absence seizures. The detailed mechanisms leading to this paroxysmal EEG activity, however, are still poorly understood. We have now made in vivo intracellular recordings from layer V cortical neurones of the facial motor cortex and from thalamocortical (TC) neurones of the ventroposteromedial and ventroposterolateral nuclei in a well established model of this disease: the Genetic Absence Epilepsy Rats from Strasbourg (GAERS). The main feature of the intracellularly recorded activity of TC neurones during spontaneous SWDs was the presence of rhythmic sequences of synaptic potentials consisting of an EPSP closely followed by 2-6 IPSPs. These rhythmic sequences were superimposed on a small tonic hyperpolarization that lasted for the whole duration of the SWD and was still present at potentials close to -85 mV. The rhythmic IPSPs, on the other hand, had a reversal potential of -68 mV, and always appeared as depolarizing events when recording with KCl-filled electrodes at -55 mV. Low frequency electrical stimulation of the corresponding cortical area evoked in TC neurones a short and a long lasting IPSP, whose waveforms were reminiscent of a GABA(A) and a GABA(B) IPSP, respectively. The main feature of the intracellular activity recorded in cortical neurones during spontaneous SWDs was the presence of rhythmic depolarizations. Their frequency was similar to the one of SWDs in the EEG, and was not affected by DC injection. The amplitude of the rhythmic depolarizations, however, increased following steady hyperpolarization of the neurone by DC injection. An increase in the apparent input resistance of cortical neurones was observed during SWDs compared to the inter-SWDs periods. Low frequency electrical stimulation of the contralateral striatum evoked in cortical neurones a short and a long lasting IPSP, whose waveforms were reminiscent of a GABA(A) and a GABA(B) IPSP, respectively. Our data indicate that there are no rhythmic GABA(B) IPSPs and low threshold Ca2+ potentials in GAERS TC neurones during SWDs, but rhythmic sequences of EPSP/IPSPs superimposed on a tonic hyperpolarization that might represent a long lasting GABA(B) IPSP. Further experiments are required to clarify the nature of the voltage waveform and the increase in input resistance observed in cortical neurones during spontaneous SWDs in GAERS.

All thalamocortical neurones possess a T-type Ca2+ 'window' current that enables the expression of bistability-mediated activities

1. The existence of a non-negligible steady-state ('window') component of the low threshold, T-type Ca2+current (IT) and an appropriately large ratio of IT to ILeak conductance (i.e. gT/gLeak) have been shown to underlie a novel form of intrinsic bistability that is present in about 15 % of thalamocortical (TC) neurones. 2. In the present experiments, the dynamic clamp technique was used to introduce into mammalian TC neurones in vitro either an artificial, i.e. computer-generated, IT in order to enhance endogenous IT, or an artificial inward ILeak to decrease endogenous ILeak. Using this method, we were able to investigate directly whether the majority of TC neurones appear non-bistable because their intrinsic ionic membrane properties are essentially different (i.e. presence of a negligible IT 'window' component), or simply because they possess a gT or gLeak conductance that is insufficiently large or small, respectively. 3. The validity of the dynamic clamp arrangement and the accuracy of artificial IT were confirmed by (i) recreating the low threshold calcium potential (LTCP) with artificial IT following its block by Ni2+ (0.5-1 mM), and (ii) blocking endogenous LTCPs with an artificial outward IT. 4. Augmentation of endogenous IT by an artificial analog or introduction of an artificial inward ILeak transformed all non-bistable TC neurones to bistable cells that expressed the full array of bistability-mediated behaviours, i.e. input signal amplification, slow oscillatory activity and membrane potential bistability. 5. These results demonstrate the existence of a non-negligible IT 'window' component in all TC neurones and suggest that rather than being a novel group of neurones, bistable cells are merely representative of an interesting region of dynamical modes in the (gT, gLeak) parameter space that may be expressed under certain physiological or pathological conditions by all TC neurones and other types of excitable cells that possess an IT 'window' component with similar biophysical properties.

Dynamic clamp study of Ih modulation of burst firing and delta oscillations in thalamocortical neurons in vitro

The dynamic clamp technique was used in thalamocortical neurons of the rat and cat dorsal lateral geniculate nucleus in vitro to investigate the effects of the hyperpolarization-activated cation current, Ih, and of its neuromodulation on burst firing and delta oscillations. Specific block of endogenous Ih using 4-(N-ethyl-N-phenylamino)-1,2-dimethyl-6-(methylamino)pyridinium chloride (ZD7288) (300 microM) abolished the depolarizing "sag" response to negative current steps, markedly increased the latency and shortened the duration of the low-threshold Ca2+ potentials, and decreased the number of action potentials in the burst evoked by the low-threshold Ca2+ potential. Subsequent introduction of artificial Ih using the dynamic clamp re-instated the "sag" and all the original properties of the low-threshold Ca2+ potential. In the absence of ZD7288, introduction of artificial outward Ih with the intention of abolishing endogenous Ih removed the depolarizing "sag" and produced similar effects on the low-threshold Ca2+ potentials as those observed during the pharmacological block of Ih. Application of ZD7288 to thalamocortical neurons displaying delta oscillations led to a reduction in the voltage range of their existence or to a complete cessation of this behaviour. A subsequent introduction of artificial Ih re-enabled the generation of delta oscillations. In the presence of ZD7288, physiologically relevant positive shifts in the voltage-dependence of artificial Ih increased the amplitude and duration of the low-threshold Ca2+ potential and increased the likelihood of delta oscillations while negative shifts had opposite effects. These results highlight the important difference between the dependence of burst firing and oscillations on membrane potential and their dependence on the properties of Ih, and demonstrate that the modulation by Ih of low-threshold Ca2+ potentials and burst firing in thalamocortical neurons, as well as the ability of these neurons to generate delta oscillations, is more elaborate than previously described.

Analysis and biophysical interpretation of bistable behaviour in thalamocortical neurons

Thalamocortical neurons display a wide spectrum of activity patterns that are the expressions of the non-linear interactions between the various voltage-gated ion channels. Here, we show how bistable behaviour can emerge in these neurons, and how it is brought about by the steady-state residual ("window") component of IT, the low-threshold Ca2+ current. In particular, we present results that describe the dependence of bistability on two system parameters: the injected current and the leakage conductance. In addition, we provide a biophysical interpretation of these results by means of the properties of the electrical circuit representing the neuron membrane.

The 'window' component of the low threshold Ca2+ current produces input signal amplification and bistability in cat and rat thalamocortical neurones

1. The mechanism underlying a novel form of input signal amplification and bistability was investigated by intracellular recording in rat and cat thalamocortical (TC) neurones maintained in slices and by computer simulation with a biophysical model of these neurones. 2. In a narrow membrane potential range centred around -60 mV, TC neurones challenged with small (10-50 pA), short (50-200 ms) current steps produced a stereotyped, large amplitude hyperpolarization (> 20 mV) terminated by the burst firing of action potentials, leading to amplification of the duration and amplitude of the input signal, that is hereafter referred to as input signal amplification. 3. In the same voltage range centred around -60 mV, single evoked EPSPs and IPSPs also produced input signal amplification, indicating that this behaviour can be triggered by physiologically relevant stimuli. In addition, a novel, intrinsic, low frequency oscillation, characterized by a peculiar voltage dependence of its frequency and by the presence of plateau potentials on the falling phase of low threshold Ca2+ potentials, was recorded. 4. Blockade of pure Na+ and K+ currents by tetrodotoxin (1 microM) and Ba2+ (0.1-2.0 mM), respectively, did not affect input signal amplification, neither did the presence of excitatory or inhibitory amino acid receptor antagonists in the perfusion medium. 5. A decrease in [Ca2+]o (from 2 to 1 mM) and an increase in [Mg2+]o (from 2 to 10 mM), or the addition of Ni2+ (2-3 mM), abolished input signal amplification, while an increase in [Ca2+]o (from 2 to 8 mM) generated this behaviour in neurones where it was absent in control conditions. These results indicate the involvement of the low threshold Ca2+ current (IT) in input signal amplification, since the other Ca2+ currents of TC neurones are activated at potentials more positive than -40 mV. 6. Blockade of the slow inward mixed cationic current (Ih) by 4-(N-ethyl-N-phenylamino)-1,2-dimethyl-6-(methylamino)-pyrimidinium++ + chloride (ZD 7288)(100-300 microM) did not affect the expression of the large amplitude hyperpolarization, but abolished the subsequent repolarization to the original membrane potential. In this condition, therefore, input signal amplification was replaced by bistable membrane behaviour, where two stable membrane potentials separated by 15-30 mV could be switched between by small current steps. 7. Computer simulation with a model of a TC neurone, which contained only IT, Ih, K+ leak current (ILeak) and those currents responsible for action potentials, accurately reproduced the qualitative and quantitative properties of input signal amplification, bistability and low frequency oscillation, and indicated that these phenomena will occur at some value of the injected DC if, and only if, the 'window' component of IT (IT,Window) and the leak conductance (gLeak) satisfy the relation (dIT,Window/dV)max > gLeak. 8. The physiological implications of these findings for the electroresponsiveness of TC neurones are discussed, and, as IT is widely expressed in the central nervous system, we suggest that 'window' IT will markedly affect the integrative properties of many neurones.

On the nature of anomalous rectification in thalamocortical neurones of the cat ventrobasal thalamus in vitro

1. Intracellular sharp electrode current clamp and discontinuous single electrode voltage clamp recordings were made from thalamocortical neurones (n = 57) of the cat ventrobasal thalamus in order to investigate the mechanism underlying anomalous rectification. 2. Under current clamp conditions, voltage-current (V-I) relationships in a potential range of -55 to -110 mV demonstrated anomalous rectification with two components: fast rectification, which controlled the peak of negative voltage deviations, and time-dependent rectification. Time-dependent rectification was apparent as a depolarizing sag generated during the course of negative voltage deviations, was first formed at potentials in the range -60 to -70 mV, and was sensitive to 3 mM Cs+ (n = 6). Similarly, under voltage clamp conditions, instantaneous and steady-state I-V relationships demonstrated anomalous rectification. A slowly activating inward current with an activation threshold in the range of -65 to -70 mV formed time-dependent rectification. This current was sensitive to Cs+ (3 mM) (n = 3) and had properties similar to the slow inward mixed cationic current (Ih). 3. 4-(N-Ethyl-N-phenylamino)-1,2-dimethyl-6-(methylamino)-pyrimidinium++ + chloride (ZD 7288) (100-300 microM) irreversibly blocked time-dependent rectification mediated by Ih (n = 23 of 25 neurones), and led to a hyperpolarization of the resting membrane potential (6.8 +/- 0.5 mV). In the presence of ZD 7288, V-I and I-V relationships, exhibited fast anomalous rectification, first activated from potential more negative than -80 mV. 4. Ba2+ (100 microM) (n = 8), in the continuous presence of ZD 7288, reversibly linearized peak V-I and instantaneous I-V relationships over a potential range of -70 to -120 mV, and led to a membrane depolarization (13.3 +/- 4.2 mV) or tonic inward current (192 +/- 36 pA). 5. The co-application of ZD 7288 and Ba2+ revealed a depolarizing sag in negative voltage deviations under current clamp conditions, or a large inward current with kinetics two to three times slower than those of Ih under voltage clamp conditions. This novel form of time-dependent rectification was first apparent at potentials more negative than about -85 mV, was sensitive to 5 mM Cs+ (n = 4), and is termed Ih,slow. Ih,slow tail currents reversed between -65.3 and -56.6 mV (with potassium acetate electrodes, n = 3) or -57.6 and -50.3 mV (with KCl electrodes, n = 3). 6. Computer simulations confirmed that the pattern of anomalous rectification in thalamocortical neurones of the cat ventrobasal thalamus is mediated by the concerted action of Ih and a Ba(2+)-sensitive current with properties similar to an inwardly rectifying K+ current (IKIR).

In vitro estimation of foetal liver volume using ultrasound, x-ray computed tomography and magnetic resonance imaging

Sixteen formalin-fixed foetal livers were scanned in vitro using a new system for estimating volume from a sequence of multiplanar 2D ultrasound images. Three different scan techniques were used (radial, parallel and slanted) and four volume estimation algorithms (ellipsoid, planimetry, tetrahedral and ray tracing). Actual liver volumes were measured by water displacement. Twelve of the sixteen livers also received x-ray computed tomography (CT) and magnetic resonance (MR) scans and the volumes were calculated using voxel counting and planimetry. The percentage accuracy (mean +/- SD) was 5.3 +/- 4.7%, -3.1 +/- 9.6% and -0.03 +/- 9.7% for ultrasound (radial scans, ray volumes), MR and CT (voxel counting) respectively. The new system may be useful for accurately estimating foetal liver volume in utero.

The accuracy of a new system for estimating organ volume using ultrasound

A new system is described for estimating volume from a series of multiplanar 2D ultrasound images. Ultrasound images are captured using a personal computer video digitizing card and an electromagnetic localization system is used to record the pose of the ultrasound images. The accuracy of the system was assessed by scanning four groups of ten cadaveric kidneys on four different ultrasound machines. Scan image planes were oriented either radially, in parallel or slanted at 30 degrees to the vertical. The cross-sectional images of the kidneys were traced using a mouse and the outline points transformed to 3D space using the Fastrak position and orientation data. Points on adjacent region of interest outlines were connected to form a triangle mesh and the volume of the kidneys estimated using the ellipsoid, planimetry, tetrahedral and ray tracing methods. There was little difference between the results for the different scan techniques or volume estimation alogorithms, although, perhaps as expected, the ellipsoid results were the least precise. For radial scanning and ray tracing, the mean and standard deviation of the percentage errors for the four different machines were as follows: Hitachi EUB-240, -3.0 +/- 2.7%; Tosbee RM3, -0.1 +/- 2.3%; Hitachi EUB-415, 0.2 +/- 2.3%; Acuson, 2.7 +/- 2.3%.

Estimation of fetal lung volume using enhanced 3-dimensional ultrasound: a new method and first result

OBJECTIVE

To measure fetal lung volume using a computer based, enhanced, 3-dimensional ultrasound imaging system.

DESIGN

An observational study.

SETTING

The Fetal Medicine Unit at Guys Hospital, London.

PARTICIPANTS

Twenty healthy women with a singleton pregnancy between 24 and 36 weeks of gestation were scanned on one occasion during pregnancy using an ultrasound based 3-dimensional imaging system. All delivered at term with weights above the 10th centile for gestation.

RESULTS

Total lung volume increased exponentially with gestational age. Right lung volume measured consistently greater than left lung volume.

CONCLUSIONS

The use of this new enhanced 3-dimensional imaging system allows for estimations of fetal lung volume. Preliminary data confirm that fetal lung volume, measured by a computerised 3-dimensional ultrasound imaging system increased exponentially with gestational age. The use of this system has obvious application in the further study of lung growth in utero and possible clinical application in disease states where fetal lung growth may be impaired.

Application of a new discreet form of Gauss' theorem for measuring volume

Volume measurements are useful in many branches of science and medicine. They are usually accomplished by acquiring a sequence of cross sectional images through the object using an appropriate scanning modality, for example x-ray computed tomography (CT), magnetic resonance (MR) or ultrasound (US). In the cases of CT and MR, a dividing cubes algorithm can be used to describe the surface as a triangle mesh. However, such algorithms are not suitable for US data, especially when the image sequence is multiplanar (as it usually is). This problem may be overcome by manually tracing regions of interest (ROIs) on the registered multiplanar images and connecting the points into a triangular mesh. In this paper we describe and evaluate a new discreet form of Gauss' theorem which enables the calculation of the volume of any enclosed surface described by a triangular mesh. The volume is calculated by summing the vector product of the centroid, area and normal of each surface triangle. The algorithm was tested on computer-generated objects, US-scanned balloons, livers and kidneys and CT-scanned clay rocks. The results, expressed as the mean percentage difference +/- one standard deviation were 1.2 +/- 2.3, 5.5 +/- 4.7, 3.0 +/- 3.2 and -1.2 +/- 3.2% for balloons, livers, kidneys and rocks respectively. The results compare favourably with other volume estimation methods such as planimetry and tetrahedral decomposition.

Heating characteristics of a 434 MHz transurethral system for the treatment of BPH and interstitial thermometry

A system is described for delivering transurethral hyperthermia to the prostate. The system used a helical coil antennae powered by a 434 MHz generator. The antennae was housed in a disposable 22 Ch Foley catheter with water passed down the centre of the winding of the antennae and returned between the antennae and inner wall of the catheter. The flow rate of the circulating water could be varied. The position of the antennae was adjustable with respect to the balloon, essentially altering the length of the antennae. Urethral wall temperature was measured with a thermocouple passed down a small tube moulded into the outer wall of the catheter. Rectal temperature was measured using thermocouples placed in grooves machined into a custom made perspex rectal applicator. A computer program displayed the temperature and controlled the power to the generator. The SAR around the catheter was measured in a polyacrylamide gel phantom. However this does not take into account the effects blood flow and thermal conduction which may have important clinical implications. In order to investigate the actual temperature within the prostate during treatment, a group of patients underwent intraprostatic thermometry.

Volume estimation from multiplanar 2D ultrasound images using a remote electromagnetic position and orientation sensor

A system is described for calculating volume from a sequence of multiplanar 2D ultrasound images. Ultrasound images are captured using a video digitising card (Hauppauge Win/TV card) installed in a personal computer, and regions of interest transformed into 3D space using position and orientation data obtained from an electromagnetic device (Polhemus, Fastrak). The accuracy of the system was assessed by scanning 10 water filled balloons (13-141 mL), 10 kidneys (147-200 mL) and 16 fetal livers (8-37 mL) in water using an Acuson 128XP/10 (5 MHz curvilinear probe). Volume was calculated using the ellipsoid, planimetry, tetrahedral and ray tracing methods and compared with the actual volume measured by weighing (balloons) and water displacement (kidneys and livers). The mean percentage error for the ray tracing method was 0.9 +/- 2.4%, 2.7 +/- 2.3%, 6.6 +/- 5.4% for balloons, kidneys and livers, respectively. So far the system has been used clinically to scan fetal livers and lungs, neonate brain ventricles and adult prostate glands.

Microwave hyperthermia in benign prostatic hypertrophy: a controlled clinical trial

OBJECTIVE

To compare the effects of microwave hyperthermia in benign prostatic hypertrophy (BPH) to sham treatment.

PATIENTS AND METHODS

The trial included 96 patients with proven symptomatic bladder outflow obstruction (BOO) caused by BPH. Patients underwent a full subjective and objective assessment (including urodynamics) before inclusion and again 3 and 6 months later. They were randomly assigned to receive 1 h of microwave hyperthermia or a sham treatment. Of the 96 patients, 93 were assessed at 3 months and 62 at 6 months after treatment.

RESULTS

There was no statistically significant difference in the objective measures of BOO between the treated and control groups of patients. There was an improvement of approximately 40% in all the subjective measures, but there was no significant difference between the treated and control groups.

CONCLUSION

Microwave hyperthermia, within the parameters defined in this trial, resulted in no significant difference from sham treatment in subjective or objective outcome.

Computer planning of stereotactic iodine-125 seed brachytherapy for recurrent malignant gliomas

At St Thomas' Hospital, we have developed a computer program on a Titan graphics supercomputer to plan the stereotactic implantation of iodine-125 seeds for the palliative treatment of recurrent malignant gliomas. Use of the Gill-Thomas-Cosman relocatable frame allows planning and surgery to be carried out at different hospitals on different days. Stereotactic computed tomography (CT) and positron emission tomography (PET) scans are performed and the images transferred to the planning computer. The head, tumour and frame fiducials are outlined on the relevant images, and a three-dimensional model generated. Structures which could interfere with the surgery or radiotherapy, such as major vessels, shunt tubing etc., can also be outlined and included in the display. Catheter target and entry points are set using a three-dimensional cursor controlled by a set of dials attached to the computer. The program calculates and displays the radiation dose distribution within the target volume for various catheter and seed arrangements. The CT co-ordinates of the fiducial rods are used to convert catheter co-ordinates from CT space to frame space and to calculate the catheter insertion angles and depths. The surgically implanted catheters are after-loaded the next day and the seeds left in place for between 4 and 6 days, giving a nominal dose of 50 Gy to the edge of the target volume. 25 patients have been treated so far.

3-D reconstruction of an ancient Egyptian mummy using X-ray computer tomography

Computer tomography has been used to image and reconstruct in 3-D an Egyptian mummy from the collection of the British Museum. This study of Tjentmutengebtiu, a priestess from the 22nd dynasty (945-715 BC) revealed invaluable information of a scientific, Egyptological and palaeopathological nature without mutilation and destruction of the painted cartonnage case or linen wrappings. Precise details on the removal of the brain through the nasal cavity and the viscera from the abdominal cavity were obtained. The nature and composition of the false eyes were investigated. The detailed analysis of the teeth provided a much closer approximation of age at death. The identification of materials used for the various amulets including that of the figures placed in the viscera was graphically demonstrated using this technique.

Voxel-based localization in frame-based and frameless stereotaxy and its accuracy

The problem of accurate stereotactic localization and registration of targets in computed tomography (CT) data sets is addressed, in particular the effect of using a single transformation matrix to map voxel coordinates onto stereotactic coordinates. An algebraic approach to the calculation of stereotactic target coordinates in tomographic data acquired with conventional stereotactic localizers is presented. The volume transformation matrix (VTM) is discussed, which is useful for the registration of volumetric data sets, and also corresponds to the rigid body transformation matrix used in many so-called frameless registration methods. The VTM can lead to accuracy degradation, in particular due to patient movement during scanning. Simulations were performed and CT data sets acquired with patients fitted with the CRW or the GTC stereotactic localizer were analyzed. Comparison of STM- and VTM-derived stereotactic coordinates shows an average overall registration error of 0.1 mm for anesthetized patients and in the range 0.6-1.4 mm for nonanesthetized patient. Accuracy maps are described that enable the user to visualize the registration error in relation to the data. It is shown that the effect of fiducial point localization error and patient movement for VTM-based localization is minimized when all available fiducials in the region of interest are used. The significance of these results is discussed, and methods are proposed to minimize these effects for frame-based and frameless registration methods.

Technical note: a technique for measuring the surface area of articular cartilage in acetabular fractures

The aim of this study was to develop a reliable technique for measuring the area of a curved surface from an axial computed tomography (CT) scan and to apply this clinically in the measurement of articular cartilage surface area in acetabular fractures. The method used was a triangulation algorithm. In order to determine the accuracy of the technique, areas of hemispheres of known size were measured to give the percentage error in area measurement. Seven such hemispheres were machined into a Perspex block and their area measured geometrically, and also from CT scans by means of the triangulation algorithm. Scans of 1, 2 and 4 mm slice thickness and separation were used. The error varied with slice thickness and hemisphere diameter. It was shown that the 2 mm slice thickness provides the most accurate area measurement, while 1 mm cuts overestimate and 4 mm cuts underestimate the area. For a hemisphere diameter of 5 cm, which is of similar size to the acetabulum, the error was -11.2% for 4 mm cuts, +4.2% for 2 mm cuts and +5.1% for 1 mm cuts. As expected, area measurement was more accurate for larger hemispheres. This method can be applied clinically to quantify acetabular fractures by measuring the percentage area of intact articular cartilage. In the case of both column fractures, the percentage area of secondary congruence can be determined. This technique of quantifying acetabular fractures has a potential clinical application as a prognostic factor and an indication for surgery in the long term.

Survival following interstitial brachytherapy for recurrent malignant glioma

The treatment of recurrent malignant glioma is difficult and at present largely disappointing. Furthermore the results of any treatment modality need to be interpreted with knowledge regarding patient selection and timing of treatment. The results of interstitial brachytherapy using iodine-125 in 23 patients are presented. There were no operative complications. Median survival time from tumour recurrence and implantation was 36 and 25 weeks respectively. Karnofsky Performance Status (KPS) was significantly associated with survival, though patient age, original tumour histology, prior chemotherapy, and time to recurrence were not. Treatment does confer modest survival benefit as compared to controls, but our results are not as impressive as others. Reasons for this finding are discussed.

Radiation risks to personnel and public during the treatment of malignant glioma using interstitial brachytherapy

125I seeds are used in brachytherapy for the treatment of malignant gliomas. The use of such radioactive sources is associated with a certain radiological hazard to both personnel and members of the public. This hazard should be quantified so that the ALARA principle of radiological protection may be implemented satisfactorily. A study was undertaken to derive isodose rate contours in the vicinity of an anthropomorphic phantom with 125I seeds positioned at typical tumour sites within the cranial cavity. These contours are illustrated for seed positions appropriate to deep and superficial temporal tumours. Results indicate that the annual doses to personnel and public should not exceed those recommended by the International Commission on Radiological Protection.

4-hydroxyandrostenedione: a new treatment for postmenopausal patients with breast cancer

We have evaluated 4-hydroxyandrostenedione, a specific inhibitor of aromatase, as treatment for breast cancer in a phase I dose-ranging study and a phase II study of the best-tolerated dose. 168 postmenopausal patients with locally advanced and metastatic breast cancer were treated intramuscularly. 19% of patients attained a complete or partial response but 26% of those who completed at least 4 weeks treatment responded. Side-effects were least in the group receiving 250 mg every 2 weeks. 13% of patients experienced local discomfort due to the injection and 5% had other side-effects. Serum oestradiol fell to 42.4 and 26.5% of baseline at 7 days after the start of treatment with the 250 mg and 500 mg dose, respectively. We conclude that 4-hydroxyandrostenedione at 250 mg every 2 weeks is a safe and effective form of treatment for postmenopausal patients with metastatic breast cancer.