Classification system for primary care provider eConsults about medications for older adults with frailty

BACKGROUND

Providing primary care for people with frailty can be challenging due to an increased risk of adverse outcomes and use of potentially inappropriate medications which may exacerbate characteristics of frailty. eConsult is a service where primary care providers can receive timely specialist advice for their patients through a secure web-based application. We aimed to develop a classification system to characterize medication-focused eConsult questions for older adults with frailty and assess its usability.

METHODS

A classification system was developed and refined over three cycles of improvement through a cross-sectional study of 35 cases categorized as medication-focused from cases submitted in 2019 for patients aged 65 or older with frailty through the Champlain BASE eConsult service (Ontario, Canada). The final classification system was then applied to each case.

RESULTS

The classification system contains 5 sections: (1) case descriptives; (2) intent and type of question; (3) medication recommendations and additional information in the response; (4) medication classification; and (5) potentially inappropriate medications. Among the 35 medication-focused cases, the most common specialties consulted were endocrinology (9 cases, 26%) and cardiology (5 cases, 14%). Medication histories were available for 29 cases (83%). Many patients were prescribed potentially inappropriate medications based on explicit tools (AGS Beers Criteria®, STOPPFall, Anticholinergic Cognitive Burden Scale, ThinkCascades) yet few consults inquired about these medications.

CONCLUSION

A classification system to describe medication-related eConsult cases for patients experiencing frailty was developed and applied to 35 eConsult cases. It can be applied to more cases to identify professional development opportunities and enhancements for eConsult services.

High Rate of Pulmonary Cement Embolism after Cement-Augmented Pedicle Screw Fixation: A 12-Year Single-Center Study

BACKGROUND

 The global trend toward increased life expectancy because of remarkable improvements in health care quality has drawn increased attention to osteoporotic fractures and degenerative spine diseases. Cement-augmented pedicle screw fixation has been established as the mainstay treatment for patients with poor bone quality. This study aimed to determine the number of patients with cement leakage and pulmonary cement embolism (PCE) as detected on thoracic computed tomography (CT), and to assess the potential risk factors for PCE.

METHODS

 Patients undergoing cement-augmented pedicle screw placement in our institution between May 2008 and December 2020 were included. Data regarding baseline characteristics, complications, and cement leakage rates were collected. Indications for the performance of a postoperative thoracic CT due to the suspicion of PCE were intra- or postoperative complications, or postoperative oxygen supplementation. Moreover, PCE was accidently diagnosed because the thoracic CT was performed for medical reasons other than the suspicion of PCE (tumor staging, severe pneumonia, or exacerbated chronic pulmonary obstructive disease).

RESULTS

 A total of 104 patients with a mean age of 72.8 years (standard deviation of 6.7) were included. Of 802 screws, 573 were cement augmented. Of the 104 patients, 44 (42.3%) underwent thoracic CT scans to diagnose PCE; additionally, 67 (64.4%) demonstrated cement leakage, of whom 27 developed PCE and 4 were symptomatic. Cement-augmented thoracic screws were a risk factor for PCE (odds ratio: 1.5; 95% confidence interval: 1.2-2.1; p = 0.004).

CONCLUSIONS

 This study showed a high prevalence of cement leakage after cement-augmented pedicle screw insertion, with a relatively frequent incidence of PCE, as tracked by thoracic CT scans. Cement-augmented thoracic screw placement was a unique risk factor for PCE.

Realization of the absorbed dose to water for 70 kV electronic brachytherapy sources for surface applications

Objective.The purpose of this work is to establish a primary standard for the absorbed dose to water for surface applications with 70 kV electronic brachytherapy sources and thereby to investigate several reference conditions with respect to applicability in metrology institutes, calibration labs and clinics.Approach.A primary standard for the absorbed dose to water for LDR-Seeds (ipFAC) was utilized. For this, the method of evaluation was modified to account for the different geometries in interstitial and surface brachytherapy and for the different energy distributions of the radiation fields, respectively. The correction factors required to determine the absorbed dose to water were evaluated using Monte Carlo (MC) simulations. MC-calculations were also used to estimate the uncertainties of this method.Main results.It could be shown that determining the absorbed dose to water in 1 cm depth below the surface of a water phantomDw(1 cm) is feasible with the ipFAC. Thereby the method to determineDw(1 cm) when the source is placed at 50 cm distance and the beam is collimated turns out to be more robust to variations in the directional emittance of the source than placing the source applicator assembly directly on the phantom.Significance.The first method features significantly lower uncertainties, 1.4% compared to 3.7% (both fork= 2), for the second one. However, a calibration based on a transfer chamber calibrated with the second method is more practical and easier to implement in clinical routine.

Ethical and societal aspects of radiological protection for offspring and next generations

PURPOSE

Over the last decade or so, ethical and societal aspects of radiological protection have received increasing attention. This is also reflected in the publications of the International Commission on Radiological Protection (ICRP). The current paper aims at identifying relevant ethical and societal topics which should receive attention in the context of radiological protection for offspring and next generations.

MATERIALS AND METHODS

We present a non-comprehensive review of the subject, based on presentation made at an ICRP workshop in Budapest in 2022. We first discuss the ethical values promoted by ICRP, and the application of these values in cases of (potential) pre-conceptual and prenatal radiation exposures. We then consider experience gained after the Fukushima accident indicating particular societal concerns about the health effects of such exposures.

RESULTS AND CONCLUSIONS

Beneficence/non-maleficence, prudence, justice and dignity, the "core values" of the system of radiological protection have special roles to play when heritable and/or in utero effects are to be considered. Prudence, in particular, must be taken account of in view of the fact that solid scientific data in humans are largely lacking in this area, and it is necessary to rely on insights from animal experiments as well as theoretical considerations. As regards societal considerations, the perception of risk among (potentially) affected populations needs to be taken seriously. Accountability, transparency, and inclusivity, the "procedural values" promoted by ICRP for the practical implementation of the system of radiological protection play a central role in overcoming skepticism and creating trust. Stakeholder involvement should emphasize cooperation and dialogue, which allows for the joint evaluation of an exposure situation by experts and affected people.

Radiological Features in Type II Odontoid Fractures in Older Adults After High- and Low-Energy Trauma

STUDY DESIGN

Retrospective study.

OBJECTIVES

Although type II odontoid fractures mainly occur due to high-energy trauma (HET), the number of odontoid type II fractures after low-energy trauma (LET) in the elderly is on the rise. However, there is a paucity of conclusive evidence on the relationship between trauma mechanism and cervical spine alignment in the elderly population. Consequently, we examined cervical alignment and osteoporotic and osteoarthritic patterns in elderly individuals (aged ≥65 years) with type II odontoid fractures.

METHODS

We retrospectively assessed cervical spine alignment in 76 elderly individuals who experienced type II odontoid fractures after HET (n = 36) and LET (n = 40) between 2005 and 2020. Osteoporotic and osteoarthritic changes on computed tomography and cervical alignment parameters on sagittal plane radiographs were examined.

RESULTS

Moderate and severe osteoporosis of the dens-body junction and osteoarthritis of the atlanto-odontoid joint were more prevalent in the LET than the HET group (P<.005). The anterior atlantodental interval (ADI) was significantly smaller in the LET group than in the HET group (.7 [.7] millimeter vs 1.2 [.8] mm; P=.003). An ADI equal 0 mm indicative for anterior fusion of C1/C2 was present in 37.5% of patients of the LET group. The C0-C2 angle, C1-C2 lordosis, and C2-C7 sagittal vertical axis were significantly different (HET vs LET: 33.2 [7.2]° vs 41.6 [11.4]°, P=.005; 28.1 [7.0]° vs 34.0 [8.0]°, P=.002; and 16.1 [11.1] millimeter vs 27.1 [12.4] mm, P=.008; respectively).

CONCLUSION

Significantly higher rates of osteoporotic and degenerative changes were observed after LET. Furthermore, previous cervical malalignment represents a risk factor for type II odontoid fractures after LET.

Interracial anatomical differences in the transsphenoidal approach to the sellar region

OBJECTIVE

Injury to vascular structures such as the internal carotid artery (ICA) is a rare but catastrophic complication of minimally invasive transsphenoidal surgery. Thorough preoperative planning, and knowledge of anatomical landmarks, such as the intercarotid distance (ICD) reduce this risk. Numerous anatomical studies have been conducted regarding the transsphenoidal approach, but none have taken racial disparities into account.

METHODS

Since differences of the cranium, especially of the skull base exist, we sought to analyze anatomical differences of the sellar region in thin sliced T2-weighted MRI scans of 187 (87 male and 100 female) Asian, African American and Caucasian patients provided by the 'Human Connectome Project' (HCP).

RESULTS

We found significant differences in the ICD between males and females across all races. Furthermore, we found that the ICD was up to 2.4 mm smaller in the Caucasian cohort compared to the African American/Asian cohort.

CONCLUSION

These findings indicate that racial disparities regarding the sellar anatomy should be considered in patients undergoing pituitary surgery.

Vancouver call for action to strengthen expertise in radiological protection worldwide

Ionising radiation has been used for over a century for peaceful purposes, revolutionising health care and promoting well-being through its application in industry, science, and medicine. For almost as long, the International Commission on Radiological Protection (ICRP) has promoted understanding of health and environmental risks of ionising radiation and developed a protection system that enables the safe use of ionising radiation in justified and beneficial practices, providing protection from all sources of radiation. However, we are concerned that a shortage of investment in training, education, research, and infrastructure seen in many sectors and countries may compromise society's ability to properly manage radiation risks, leading to unjustified exposure to or unwarranted fear of radiation, impacting the physical, mental, and social well-being of our peoples. This could unduly limit the potential for research and development in new radiation technologies (healthcare, energy, and the environment) for beneficial purposes. ICRP therefore calls for action to strengthen expertise in radiological protection worldwide through: (1) National governments and funding agencies strengthening resources for radiological protection research allocated by governments and international organisations, (2) National research laboratories and other institutions launching and sustaining long-term research programmes, (3) Universities developing undergraduate and graduate university programmes and making students aware of job opportunities in radiation-related fields, (4) Using plain language when interacting with the public and decision makers about radiological protection, and (5) Fostering general awareness of proper uses of radiation and radiological protection through education and training of information multipliers. The draft call was discussed with international organisations in formal relations with ICRP in October 2022 at the European Radiation Protection Week in Estoril, Portugal, and the final call announced at the 6th International Symposium on the System of Radiological Protection of ICRP in November 2022 in Vancouver, Canada.

Differences in mastoid pneumatization between Asians and Caucasians

BACKGROUND

Anatomical differences of the mastoid pneumatization in Asian and Caucasian patients must be considered when performing the retrosigmoid craniotomy since it may have implications to avoid specific complications such as cerebrospinal fluid infections or fistula.

METHODS

We selected cranial CT scans of 120 Asian and 120 Caucasian patients, who were treated at the Mitsui Memorial Hospital (Japan) and at the Heidelberg University Hospital (Germany). Mastoid pneumatization was classified according to the relationship of the mastoid air cells (MAC) to the sigmoid sinus (Type I - III). The risk of mastoid air cell opening through craniotomy increases from Type I to III. Comparative analyses between gender and ethnicities were performed using the Chi² Test and the independent T-Test and considered significant if p < 0.05.

RESULT

In Caucasians, Type III pneumatization was significantly overrepresented compared to Type II or I, compared to the Asian cohort (Type III:II:I in Caucasians = 60 %:26 %:14 %; in Asians = 28 %:43 %:29 %). Importantly, we found significant differences in pneumatization types between Caucasians and Asians in both gender subgroups (m: Type III 60 % vs 35 %; Type II 30 % vs 36.7 %; Type I 10 % vs 28.3 %, p = 0.008; f: Type III 60 % vs 23.3 %, Type II 21.7 % vs 48.3 %, Type III 18.3 % vs 28.3 %, p < 0.001; Chi² Test).

CONCLUSION

Caucasian patients are more prone to the opening of the mastoid air cells than Asian patients when performing a retrosigmoid craniotomy due to differences in the degree of mastoid pneumatization. This may help to avoid complications such as postoperative infections or cerebrospinal-fluid fistula.

Summary of the 2021 ICRP workshop on the future of radiological protection

The International Commission on Radiological Protection (ICRP) has embarked on a process to review and revise the current System of Radiological Protection ('the System'). To stimulate discussion, the ICRP published two open-access articles: one on aspects of the System that might require review, and another on research that might improve the scientific foundation of the System. Building on these articles, the ICRP organized a Workshop on the Future of Radiological Protection as an opportunity to engage in the review and revision of the System. This digital workshop took place from 14 October-3 November 2021 and included 20 live-streamed and 43 on-demand presentations. Approximately 1500 individuals from 100 countries participated. Based on the subjects covered by the presentations, this summary is organized into four broad areas: the scientific basis, concepts and application of the System; and the role of the ICRP. Some of the key topics that emerged included the following: classification of radiation-induced effects; adverse outcome pathway methodologies; better understanding of the dose-response relationship; holistic and reasonable approaches to optimization of protection; radiological protection of the environment; ethical basis of the System; clarity, consistency and communication of the System; application of the System in medicine and application of the principles of justification and optimization of protection.

Perspectives on tolerability and reasonableness

Judgements on tolerability and reasonableness are central to the optimisation of protection. There are currently several international developments regarding these key considerations which will contribute to the review and evolution of the system of radiological protection. The IRPA15 International Congress brought together the principal issues currently under discussion, and the outcome of these discussions is presented.

Thirteen-week nose-only inhalation exposures of propylene glycol aerosols in Sprague Dawley rats with a lung systems toxicology analysis

The objectives of this study were to increase PG exposure above concentrations tested by Suber et al. and use systems toxicology analysis of lung tissue to understand molecular events. Sprague Dawley rats were exposed to filtered air (sham), propylene glycol/water (PG/W; 90:10) or a propylene glycol/vegetable glycerin/water (PG/VG/W; 50:40:10) reference. The reference group was added at the high dose to observe any changes that might be associated with a carrier more in line with e-vapor products. Macroscopic examinations and terminal organ weights revealed no observations associated with exposure to PG/W or reference. Food consumption and body weights were unaffected by PG/W or reference when compared to sham. No exposure related alterations were observed in serum chemistry, hematology, coagulation, urinalysis or BALF cytology and clinical chemistry. Although clinical observations of dried red material around the nose in the high dose PG/W group were reported, histopathology showed no nasal hemorrhaging which was previously reported by Suber et al. Non-adverse PG/W and reference related findings of minimal mucous cell hyperplasia were noted in nasal cavity section II. No other exposure-related findings were noted in the primary or recovery necropsies. A systems toxicology analysis on lung tissue showed no statistically significant differentially expressed transcripts or proteins compared to the sham group. The endpoints measured from the PG/W high dose group did not differ significantly from those in the more common carrier PG/VG/W. As anticipated, exposure to PG aerosols was slightly irritating but well tolerated. Accordingly, the highest PG exposure (5 mg/L, 6 hrs/day) was regarded as the NOAEC, corresponding to a PG delivered dose of 1,152 mg/kg/day in rats.

Future technological developments in proton therapy - A predicted technological breakthrough

In the current spectrum of cancer treatments, despite high costs, a lack of robust evidence based on clinical outcomes or technical and radiobiological uncertainties, particle therapy and in particular proton therapy (PT) is rapidly growing. Despite proton therapy being more than fifty years old (first proposed by Wilson in 1946) and more than 220,000 patients having been treated with in 2020, many technological challenges remain and numerous new technical developments that must be integrated into existing systems. This article presents an overview of on-going technical developments and innovations that we felt were most important today, as well as those that have the potential to significantly shape the future of proton therapy. Indeed, efforts have been done continuously to improve the efficiency of a PT system, in terms of cost, technology and delivery technics, and a number of different developments pursued in the accelerator field will first be presented. Significant developments are also underway in terms of transport and spatial resolution achievable with pencil beam scanning, or conformation of the dose to the target: we will therefore discuss beam focusing and collimation issues which are important parameters for the development of these techniques, as well as proton arc therapy. State of the art and alternative approaches to adaptive PT and the future of adaptive PT will finally be reviewed. Through these overviews, we will finally see how advances in these different areas will allow the potential for robust dose shaping in proton therapy to be maximised, probably foreshadowing a future era of maturity for the PT technique.

POS1209 SUCCESSFUL TREATMENT OF SEVERE COVID-19 PNEUMONIA AND CYTOKINE RELEASE WITH SIMULTANEOUS TOCILIZUMAB AND ANAKINRA WITH ONE-MONTH FOLLOW-UP

Background:

Severe and life threating COVID-19 pneumonia is often characterized by local and systemic immune-mediated hyperinflammation At the early disease stage activated monocytes are migrating to the lung and cause the typical opac infiltrates, which lead to an reduction of oxygen uptake. These pathophysiological observations and the fact that corticosteroids are so far the only drug, which has shown significant improvement, was the rationale use this combination anti-inflammatory drugs in severe Covid-19 disease. Interleukin (IL)-6 and IL-1 blockade alone, respectively showed contradictory results in severe COVID-19 pneumonia that might be related to the differences is patient populations (early vs. late stage) and to the fact that blockade of just one cytokine might be not sufficient against the cytokine storm.

Objectives:

Here we report results of an open-label treatment with a combination of an IL-6 receptor blocker tocilizumab and an IL-1 receptor antagonist anakinra in patients with early (up to 10 days since symptom onset) severe COVID-19 pneumonia with evidence of cytokine release.

Methods:

Adult patients with, according to World Health Organisation criteria, severe to critical COVID-19 infection associated pneumonia and cytokine release, requiring oxygen supplementation and evidence of rapid deterioration and decrease of oxygen saturation to ≤ 95% hospitalized between May 2020 and December 2020 were treated with tocilizumab 8 mg/ kg up to 800 mg intravenously and anakinra 100 to 300 mg for 3 to 5 days, starting at the same day. We excluded patients with a symptom duration of > 10 days, patients with evidence of bacterial infection, indicated by an elevated procalcitonin serum level, patients with severe pre-existing lung disease such as severe COPD or heart failure of > II according to the NYHA classification and patients > 80 years. Laboratory parameters and chest CT were performed on initial presentation and one month after treatment. A semi-quantitative CT score was calculated based on the extent of lobar pneumonia involvement (0:0%; 1, < 5%; 2:5-25%; 3:26-50%; 4:51-75%; 5, > 75%; range 0-5; global score 0-25) for each time point.

Results:

15 patients with severe to critical COVID-19 pneumonia and signs of cytokine release, mean age 55 (range 31-79) years, all male, with a mean symptom duration of 6 (range 4-10) days were treated. Mean oxygen saturation was 86% (range 76-95%) before initiating therapy. Mean ferritin was 1297 µg/l (range 347 – 2734), mean IL-6 112 ng/L (range 2.2 – 607.4) and CRP 82.4 mg/L (range 36.4 – 125). In all patients we were able to prevent them from intubation and mechanic ventilation, none of our patients died. Fife patients did not need to be referred to the intensive care unit at all, while 9 patients received noninvasive ventilation and high-flow nasal oxygen support. All patients showed typical imaging features of COVID-19 pneumonia at baseline (BL) according to the Radiological Society of North America (RSNA) chest CT classification system. The mean of the global chest CT severity score at BL was 13 (range 7-20) and decreased to 6 (range 0-16) within 1 month which corresponded to a mean reduction of 58%. Chronic fibrotic pulmonary changes were not seen in any patient at BL and after 1 month mild changes were observed in 6 patients. One patient experienced lower abdominal pain, urinary tract infection, gastrointestinal bleeding due to antrum ulcers Forrest III, in another patient atrial fibrillation, urinary tract infection and apoplexy were observed.

Conclusion:

In our case series, all patients treated with the combination tocilizumab and anakinra recovered fast and sustained without major infectious side effects, indicating that early interruption of cytocine release might be very effective and safe in preventing patients from mechanical ventilation, death and long-term damage.

Image 1: Chest CT of a patient with active COVID-19 infection before and one month after treatment with a combination of tocilizumab and anakinra

Disclosure of Interests:

Hildrun Haibel Speakers bureau: Abbive, Novartis, Janssen, Pfizer, Roche, Consultant of: Janssen, Novartis, Roche, Janis Lucas Vahldiek: None declared, Stefan Angermair: None declared, Michael Schumann: None declared, Britta Siegmund Speakers bureau: Abbvie, CED Service GmbH, Falk, Ferring, Janssen, Novartis and Takeda as a representative of Charité – Universitätsmedizin Berlin, Consultant of: Abbvie, Arena, BMS, Boehringer, Celgene, Falk, Janssen, Lilly, Pfizer, Prometheus, Takeda representative of Charité – Universitätsmedizin Berlin, Grant/research support from: Pfizer, Denis Poddubnyy Speakers bureau: AbbVie, Bristol-Myers Squibb, Lilly, MSD, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Biocad, Gilead, GlaxoSmithKline, Eli Lilly, MSD, Novartis, Pfizer, Samsung Bioepis, and UCB, Grant/research support from: AbbVie, Eli Lilly, MSD, Novartis, and Pfizer, Thomas Schneider: None declared.

International collaboration for blood safety: The French-African experience

Blood safety is a non-negotiable issue worldwide, specifies the World Health Organization (WHO). Africa is both an entity and a multiplicity of situations within and cross-borders. Indeed, most African countries have recent borders and political organizations, after gaining independence in the 60's. Many such countries have maintained various types of links and cooperation programs with former European countries of influence, e.g. France and Belgium among others, which is the case for several countries from the francophone Central and West Africa. Besides, borders do not delineate ethnic groups as many of them migrate, with spread North to South and East to West across several countries, each having representations, ethnologically speaking. Transfusion is an essential supportive healthcare that requires medicine, technicity and logistics. Cooperation can be provided to Francophone Africa though at the expense of recruiting donors upon criteria that do not completely overlap with e.g. those put forward in France and other high-income countries, despite WHO claims for the universal model of Voluntary Non-Remunerated Blood Donation system. Next, the patient profile in intertropical Africa-of which the various francophone African countries-stringently differs from the profile now seen in France, with its younger (but strongly social network-connected) populations and the importance of anemia of all causes but frequently infectious in nature. The frequency of antigens defining blood groups also significantly differs from that in France and the rest of Europa. Last, the carriage of blood transmissible infectious pathogens in sick but also apparently healthy populations seriously complicates the build up of suitable blood component inventory. In the present review, we discuss the universality of blood donation, the specificities of inter-continent cooperation and report on experiences of such cooperation. The French Blood Establishment EFS has taken over earlier initiatives of regional blood services and provides technology and scientific transfer and support to many countries for several decades; the National Institute for Blood transfusion, an education and research institute, has set up collaborative research in several domains but mostly in the domain of blood transmissible infections. We next also present a theoretical view of support named ALEASE, that can be pursued, based on collaborative experiences carried out in the Mediterranean Northern and Eastern areas. ALEASE promotes benchmark between participants. If there is general agreement that cooperation between economically wealthy countries and low-income, developing, countries in the domain of blood and blood transfusion safety, promotion of blood donation, blood component manufacturing, transfusion technology, hemovigilance, etc., tools to achieve this goal can be periodically reviewed based on specific needs for countries and professionals. That also comprise of adapted, sometimes specific, education programs.

A Fay-Herriot Model for Estimating Subjective Cognitive Decline among Military Veterans

BACKGROUND

Although studies have examined the geographic distribution of dementia among the general population in order to develop geographically targeted interventions, no studies have examined the geographic distribution of subjective cognitive decline (SCD) among military veterans specifically.

OBJECTIVES

To map the geographic distribution of subjective cognitive decline from 2011-2019 in the United States among military veterans.

DESIGN

Cross-sectional.

SETTING

United States.

PARTICIPANTS

Individuals reporting previous service in the United States Armed Forces.

MEASUREMENTS

Using 2011 Behavioral Risk Factor Surveillance System (BRFSS) data, which is last year for which geocoded SCD data is publicly available, we estimated the survey-weighted county-level prevalence of veteran SCD for counties with >30 veterans (43 counties in 7 states). We then developed a Fay-Herriot small area estimation linear model using auxiliary data from the Census, with county-level veteran-specific covariates including % >65 years old, % female, % college educated, and median income. Following model validation, we created beta-weighted predictions of veteran SCD for all USA counties for 2011-2019 using relevant time-specific Census auxiliary data. We provide choropleth maps of our predictions.

RESULTS

Results of our model on 43 counties showed that county-level rates of SCD were significantly associated with all auxiliary variables except annual income (F = 1.49, df = 4, 38). Direct survey-weighted rates were correlated with model-predicted rates in 43 counties (Pearson r = 0.32). Regarding predicted rates for the entire USA, the average county-level prevalence rate of veteran SCD in 2011 was 13.83% (SD = 7.35), but 29.13% in 2019 (SD = 14.71) - although variation in these rates were evident across counties.

CONCLUSIONS

SCD has increased since 2011 among veterans. Veterans Affairs hospitals should implement plans that include cognitive assessments, referral to resources, and monitoring patient progress, especially in rural areas.

NAA is a Marker of Disability in Secondary-Progressive MS: A Proton MR Spectroscopic Imaging Study

BACKGROUND AND PURPOSE

The secondary progressive phase of multiple sclerosis is characterised by disability progression due to processes that lead to neurodegeneration. Surrogate markers such as those derived from MRI are beneficial in understanding the pathophysiology that drives disease progression and its relationship to clinical disability. We undertook a 1H-MRS imaging study in a large secondary progressive MS (SPMS) cohort, to examine whether metabolic markers of brain injury are associated with measures of disability, both physical and cognitive.

MATERIALS AND METHODS

A cross-sectional analysis of individuals with secondary-progressive MS was performed in 119 participants. They underwent ¹H-MR spectroscopy to obtain estimated concentrations and ratios to total Cr for total NAA, mIns, Glx, and total Cho in normal-appearing WM and GM. Clinical outcome measures chosen were the following: Paced Auditory Serial Addition Test, Symbol Digit Modalities Test, Nine-Hole Peg Test, Timed 25-foot Walk Test, and the Expanded Disability Status Scale. The relationship between these neurometabolites and clinical disability measures was initially examined using Spearman rank correlations. Significant associations were then further analyzed in multiple regression models adjusting for age, sex, disease duration, T2 lesion load, normalized brain volume, and occurrence of relapses in 2 years preceding study entry.

RESULTS

Significant associations, which were then confirmed by multiple linear regression, were found in normal-appearing WM for total NAA (tNAA)/total Cr (tCr) and the Nine-Hole Peg Test (ρ = 0.23; 95% CI, 0.06-0.40); tNAA and tNAA/tCr and the Paced Auditory Serial Addition Test (ρ = 0.21; 95% CI, 0.03-0.38) (ρ = 0.19; 95% CI, 0.01-0.36); mIns/tCr and the Paced Auditory Serial Addition Test, (ρ = -0.23; 95% CI, -0.39 to -0.05); and in GM for tCho and the Paced Auditory Serial Addition Test (ρ = -0.24; 95% CI, -0.40 to -0.06). No other GM or normal-appearing WM relationships were found with any metabolite, with associations found during initial correlation testing losing significance after multiple linear regression analysis.

CONCLUSIONS

This study suggests that metabolic markers of neuroaxonal integrity and astrogliosis in normal-appearing WM and membrane turnover in GM may act as markers of disability in secondary-progressive MS.

Enhanced Dispersion and Mechanical Behavior of Polypropylene Composites Compounded Using Extension-Dominated Extrusion

The process of dispersing filler in polymer matrix is vital to the behavior of polymer composites. The current study involves understanding the extent of dispersion of filler by only varying the nature of mixing during the process. Identical polymer composite materials are processed via two different kinds of mixing sections on the screw in a twin-screw extruder, differing in the type and amount of stress they impose on the filler agglomerate. An aggressive (900) Kneading Block (KB) mixing section is compared with recently developed Extensional Mixing Elements (EMEs), which impart extension dominated mixing while KB imparts shear dominated mixing. Various EME geometries of different levels of aggressiveness were computationally studied and validated. Composites obtained from KB are compared with composites processed using five different EME geometries. Three composites of Polypropylene (PP) filled with carbon black, graphene nano platelets and carbon nanotubes were studied independently. Composites processed through EMEs display about an order of magnitude better dispersion of filler agglomerate over the composites processed through KB. In addition, enhanced modulus and yield stress is observed for composites processed through EMEs. An improvement of 63% to 266% in the strain achieved for EME processed composites is seen under biaxial film stretching.

Cav2.3 R-type calcium channels: from its discovery to pathogenic de novo CACNA1E variants: a historical perspective

So-called pharmacoresistant (R-type) voltage-gated Ca²⁺ channels are structurally only partially characterized. Most of them are encoded by the CACNA1E gene and are expressed as different Ca_v2.3 splice variants (variant Ca_v2.3a to Ca_v2.3e or f) as the ion conducting subunit. So far, no inherited disease is known for the CACNA1E gene but recently spontaneous mutations leading to early death were identified, which will be brought into focus. In addition, a short historical overview may highlight the development to understand that upregulation during aging, easier activation by spontaneous mutations or lack of bioavailable inorganic cations (Zn²⁺ and Cu²⁺) may lead to similar pathologies caused by cellular overexcitation.

Free-running cardiac magnetic resonance fingerprinting: Joint T1/T2 map and Cine imaging

PURPOSE

To develop and evaluate a novel non-ECG triggered 2D magnetic resonance fingerprinting (MRF) sequence allowing for simultaneous myocardial T₁ and T₂ mapping and cardiac Cine imaging.

METHODS

Cardiac MRF (cMRF) has been recently proposed to provide joint T₁/T₂ myocardial mapping by triggering the acquisition to mid-diastole and relying on a subject-dependent dictionary of MR signal evolutions to generate the maps. In this work, we propose a novel "free-running" (non-ECG triggered) cMRF framework for simultaneous myocardial T₁ and T₂ mapping and cardiac Cine imaging in a single scan. Free-running cMRF is based on a transient state bSSFP acquisition with tiny golden angle radial readouts, varying flip angle and multiple adiabatic inversion pulses. The acquired data is retrospectively gated into several cardiac phases, which are reconstructed with an approach that combines parallel imaging, low rank modelling and patch-based high-order tensor regularization. Free-running cMRF was evaluated in a standardized phantom and ten healthy subjects. Comparison with reference spin-echo, MOLLI, SASHA, T₂-GRASE and Cine was performed.

RESULTS

T₁ and T₂ values obtained with the proposed approach were in good agreement with reference phantom values (ICC(A,1) > 0.99). Reported values for myocardium septum T₁ were 1043 ± 48 ms, 1150 ± 100 ms and 1160 ± 79 ms for MOLLI, SASHA and free-running cMRF respectively and for T₂ of 51.7 ± 4.1 ms and 44.6 ± 4.1 ms for T₂-GRASE and free-running cMRF respectively. Good agreement was observed between free-running cMRF and conventional Cine 2D ejection fraction (bias = -0.83%).

CONCLUSION

The proposed free-running cardiac MRF approach allows for simultaneous assessment of myocardial T₁ and T₂ and Cine imaging in a single scan.

Applying science to pressing conservation needs for penguins

More than half of the world's 18 penguin species are declining. We, the Steering Committee of the International Union for Conservation of Nature Species Survival Commission Penguin Specialist Group, determined that the penguin species in most critical need of conservation action are African penguin (Spheniscus demersus), Galápagos penguin (Spheniscus mendiculus), and Yellow-eyed penguin (Megadyptes antipodes). Due to small or rapidly declining populations, these species require immediate scientific collaboration and policy intervention. We also used a pairwise-ranking approach to prioritize research and conservation needs for all penguins. Among the 12 cross-taxa research areas we identified, we ranked quantifying population trends, estimating demographic rates, forecasting environmental patterns of change, and improving the knowledge of fisheries interactions as the highest priorities. The highest ranked conservation needs were to enhance marine spatial planning, improve stakeholder engagement, and develop disaster-management and species-specific action plans. We concurred that, to improve the translation of science into effective conservation for penguins, the scientific community and funding bodies must recognize the importance of and support long-term research; research on and conservation of penguins must expand its focus to include the nonbreeding season and juvenile stage; marine reserves must be designed at ecologically appropriate spatial and temporal scales; and communication between scientists and decision makers must be improved with the help of individual scientists and interdisciplinary working groups.

In vitro and in vivo phosphorylation of the Cav2.3 voltage-gated R-type calcium channel

During the recording of whole cell currents from stably transfected HEK-293 cells, the decline of currents carried by the recombinant human Cav2.3+β3 channel subunits is related to adenosine triphosphate (ATP) depletion after rupture of the cells. It reduces the number of functional channels and leads to a progressive shift of voltage-dependent gating to more negative potentials (Neumaier F., et al., 2018). Both effects can be counteracted by hydrolysable ATP, whose protective action is almost completely prevented by inhibition of serine/threonine but not tyrosine or lipid kinases. These findings indicate that ATP promotes phosphorylation of either the channel or an associated protein, whereas dephosphorylation during cell dialysis results in run-down. Protein phosphorylation is required for Ca_v2.3 channel function and could directly influence the normal features of current carried by these channels. Therefore, results from in vitro and in vivo phosphorylation of Ca_v2.3 are summarized to come closer to a functional analysis of structural variations in Ca_v2.3 splice variants.

The impact of local control on overall survival after stereotactic body radiotherapy for liver and lung metastases from colorectal cancer: a combined analysis of 388 patients with 500 metastases

BACKGROUND

The aim of this analysis was to model the effect of local control (LC) on overall survival (OS) in patients treated with stereotactic body radiotherapy (SBRT) for liver or lung metastases from colorectal cancer.

METHODS

The analysis is based on pooled data from two retrospective SBRT databases for pulmonary and hepatic metastases from 27 centers from Germany and Switzerland. Only patients with metastases from colorectal cancer were considered to avoid histology as a confounding factor. An illness-death model was employed to model the relationship between LC and OS.

RESULTS

Three hundred eighty-eight patients with 500 metastatic lesions (lung n = 209, liver n = 291) were included and analyzed. Median follow-up time for local recurrence assessment was 12.1 months. Ninety-nine patients with 112 lesions experienced local failure. Seventy-one of these patients died after local failure. Median survival time was 27.9 months in all patients and 25.4 months versus 30.6 months in patients with and without local failure after SBRT. The baseline risk of death after local failure exceeds the baseline risk of death without local failure at 10 months indicating better survival with LC.

CONCLUSION

In CRC patients with lung or liver metastases, our findings suggest improved long-term OS by achieving metastatic disease control using SBRT in patients with a projected OS estimate of > 12 months.

Flat Bands, Indirect Gaps, and Unconventional Spin-Wave Behavior Induced by a Periodic Dzyaloshinskii-Moriya Interaction

Periodically patterned metamaterials are known for exhibiting wave properties similar to the ones observed in electronic band structures in crystal lattices. In particular, periodic ferromagnetic materials are characterized by the presence of bands and band gaps in their spin-wave spectrum at tunable GHz frequencies. Recently, the fabrication of magnets hosting Dzyaloshinskii-Moriya interactions has been pursued with high interest since properties, such as the stabilization of chiral spin textures and nonreciprocal spin-wave propagation, emerge from this antisymmetric exchange coupling. In this context, to further engineer the magnon band structure, we propose the implementation of magnonic crystals with periodic Dzyaloshinskii-Moriya interactions, which can be obtained, for instance, via patterning of periodic arrays of heavy metal wires on top of an ultrathin magnetic film. We demonstrate through theoretical calculations and micromagnetic simulations that such systems show an unusual evolution of the standing spin waves around the gaps. We also predict the emergence of indirect gaps and flat bands, effects that depend on the strength of the Dzyaloshinskii-Moriya interaction. Such phenomena, which have been previously observed in different systems, are observed here simultaneously, opening new routes towards engineered metamaterials for spin-wave-based devices.

The role of experts in postaccident recovery: lessons learnt from Chernobyl and Fukushima

Following a nuclear accident, a major dilemma for affected people is whether to stay or leave the affected area, or, for those who have been evacuated, whether or not to return to the decontaminated zones. Populations who have to make such decisions have to consider many parameters, one of which is the radiological situation. Feedback from Chernobyl and Fukushima has demonstrated that involvement and empowerment of the affected population is a way to provide them with the necessary elements to make informed decisions and, if they decide to return to decontaminated areas, to minimise exposure by contributing to the development of a prudent attitude and vigilance towards exposure. However, involving stakeholders in postaccident management raises the question of the role of experts and public authorities in supporting the inhabitants who have to make decisions about their future. Based on experiences in Chernobyl and Fukushima, this paper will discuss various principles that have to be taken into account by experts and public authorities about their role and position when dealing with stakeholders in a postaccident recovery process.

ICRP Publication 138: Ethical Foundations of the System of Radiological Protection

Abstract –

Despite a longstanding recognition that radiological protection is not only a matter of science, but also ethics, ICRP publications have rarely addressed the ethical foundations of the system of radiological protection explicitly. The purpose of this publication is to describe how the Commission has relied on ethical values, either intentionally or indirectly, in developing the system of radiological protection with the objective of presenting a coherent view of how ethics is part of this system. In so doing, it helps to clarify the inherent value judgements made in achieving the aim of the radiological protection system as underlined by the Commission in Publication 103. Although primarily addressed to the radiological protection community, this publication is also intended to address authorities, operators, workers, medical professionals, patients, the public, and its representatives (e.g. NGOs) acting in the interest of the protection of people and the environment. This publication provides the key steps concerning the scientific, ethical, and practical evolutions of the system of radiological protection since the first ICRP publication in 1928. It then describes the four core ethical values underpinning the present system: beneficence/ non-maleficence, prudence, justice, and dignity. It also discusses how these core ethical values relate to the principles of radiological protection, namely justification, optimisation, and limitation. The publication finally addresses key procedural values that are required for the practical implementation of the system, focusing on accountability, transparency, and inclusiveness. The Commission sees this publication as a founding document to be elaborated further in different situations and circumstances.

Seasonal plasticity in photoprotection modulates UV-induced hsp gene expression in copepods from a clear lake

Zooplankton from clear alpine lakes is exposed to stressful levels of solar UV radiation (UVR). As these pelagic organisms experience high UVR and large changes in solar radiation conditions between ice-free and ice-cover periods, they have evolved various strategies to minimize UVR exposure and damage. Here, we studied the relation between photoprotection levels (mycosporine-like amino acids, carotenoids), antioxidant capacities, and gene expression of heat shock proteins (hsps) as indicator of stress in the copepod Cyclops abyssorum tatricus during the course of a year. Expression of hsp60, hsp70, and hsp90 was measured in the field (baseline expression [BE]) and after UVR exposure in the laboratory. The BE differed among genes and seasons (hsp60: high during summer, hsp70 and hsp90: high during the ice-cover period). The gene expression of hsp70 was upregulated after exposure to UVR (up to 5.2-fold change), while hsp60 and hsp90 were only constitutively expressed. A strong seasonal pattern was found in the photoprotective compounds and antioxidant capacities, with highest levels during the ice-free period. The extent of upregulation of hsp70 gene expression increased with decreasing photoprotection levels and peaked 24 h post UVR exposure (9.6-fold change) at the time of lowest photoprotection (February). Our data suggest that hsp70 gene expression is modulated by seasonal plasticity in photoprotection. This ability of adequate stress response is essential for survival in highly variable ecosystems such as alpine lakes.

Racial Differences in the Anatomy of the Posterior Fossa: Neurosurgical Considerations

OBJECTIVE

Racial differences in anatomy of the cranium exist but have not been specifically considered in neurosurgical access planning. We sought to find differences in the anatomy of the posterior fossa in a cohort study consisting of Asian, African American, and Caucasian patients.

METHODS

Magnetic resonance imaging data of 60 Asian, 57 African American, and 70 Caucasian individuals were obtained from the Human Connectome Project. Measurements were done in axial, coronal, and sagittal planes in T2-weighted thin-sliced images. P values were calculated using 2-tailed Student t test. P < 0.05 was considered significant.

RESULTS

We measured distance in millimeters from the z values (craniocaudal axis) from the internal acoustic meatus to the transition of the transverse sinus into the sigmoid sinus. We discovered significant differences across all races. Our results show that the junction of the transverse to sigmoid sinus is lowest in Caucasians followed by Asians and African Americans.

CONCLUSIONS

Significant differences in anatomy have practical implications in the retrosigmoid approach to the cerebellopontine angle. Based on our findings, the junction of the transverse sinus with the sigmoid sinus can differ up to 0.5 cm in the craniocaudal axis depending on race. As neuronavigation is not standard to the approach to the cerebellopontine angle, the study aimed to provide the neurosurgeon operating in the retrosigmoid area additional knowledge to avoid sinus injury with subsequent complications, such as blood loss, sinus occlusion, or air embolism.

The work programme of NERIS in post-accident recovery

NERIS is the European platform on preparedness for nuclear and radiological emergency response and recovery. Created in 2010 with 57 organisations from 28 different countries, the objectives of the platform are to: improve the effectiveness and coherency of current approaches to preparedness; identify further development needs; improve 'know how' and technical expertise; and establish a forum for dialogue and methodological development. The NERIS Strategic Research Agenda is now structured with three main challenges: (i) radiological impact assessments during all phases of nuclear and radiological events; (ii) countermeasures and countermeasure strategies in emergency and recovery, decision support, and disaster informatics; and (iii) setting up a multi-faceted framework for preparedness for emergency response and recovery. The Fukushima accident has highlighted some key issues for further consideration in NERIS research activities, including: the importance of transparency of decision-making processes at local, regional, and national levels; the key role of access to environmental monitoring; the importance of dealing with uncertainties in assessment and management of the different phases of the accident; the use of modern social media in the exchange of information; the role of stakeholder involvement processes in both emergency and recovery situations; considerations of societal, ethical, and economic aspects; and the reinforcement of education and training for various actors. This paper emphasises the main issues at stake for NERIS for post-accident management.

The SBRT database initiative of the German Society for Radiation Oncology (DEGRO): patterns of care and outcome analysis of stereotactic body radiotherapy (SBRT) for liver oligometastases in 474 patients with 623 metastases

BACKGROUND

The intent of this pooled analysis as part of the German society for radiation oncology (DEGRO) stereotactic body radiotherapy (SBRT) initiative was to analyze the patterns of care of SBRT for liver oligometastases and to derive factors influencing treated metastases control and overall survival in a large patient cohort.

METHODS

From 17 German and Swiss centers, data on all patients treated for liver oligometastases with SBRT since its introduction in 1997 has been collected and entered into a centralized database. In addition to patient and tumor characteristics, data on immobilization, image guidance and motion management as well as dose prescription and fractionation has been gathered. Besides dose response and survival statistics, time trends of the aforementioned variables have been investigated.

RESULTS

In total, 474 patients with 623 liver oligometastases (median 1 lesion/patient; range 1–4) have been collected from 1997 until 2015. Predominant histologies were colorectal cancer (n = 213 pts.; 300 lesions) and breast cancer (n = 57; 81 lesions). All centers employed an SBRT specific setup. Initially, stereotactic coordinates and CT simulation were used for treatment set-up (55%), but eventually were replaced by CBCT guidance (28%) or more recently robotic tracking (17%). High variance in fraction (fx) number (median 1 fx; range 1–13) and dose per fraction (median: 18.5 Gy; range 3–37.5 Gy) was observed, although median BED remained consistently high after an initial learning curve. Median follow-up time was 15 months; median overall survival after SBRT was 24 months. One- and 2-year treated metastases control rate of treated lesions was 77% and 64%; if maximum isocenter biological equivalent dose (BED) was greater than 150 Gy EQD2Gy, it increased to 83% and 70%, respectively. Besides radiation dose colorectal and breast histology and motion management methods were associated with improved treated metastases control.

CONCLUSION

After an initial learning curve with regards to total cumulative doses, consistently high biologically effective doses have been employed translating into high local tumor control at 1 and 2 years. The true impact of histology and motion management method on treated metastases control deserve deeper analysis. Overall survival is mainly influenced by histology and metastatic tumor burden.