Accuracy and precision of cone-beam computed tomography guided intensity modulated radiation therapy

PURPOSE

To assess the accuracy and precision of cone-beam computed tomography (CBCT)-guided intensity modulated radiation therapy (IMRT).

METHODS AND MATERIALS

A 7-field intensity modulated radiation therapy plan was constructed for an anthropomorphic head phantom loaded with a custom cassette containing radiochromic film. The phantom was positioned on the treatment table at 9 locations: 1 "correct" position and 8 "misaligned" positions along 3 orthogonal axes. A commercial kilovoltage cone-beam computed tomography (kV-CBCT) system (VolumeView, Elekta AB, Stockholm, Sweden) was then used to align the phantom prior to plan delivery. The treatment plan was delivered using the radiation therapy delivery system (Infinity; Elekta AB) 3 times for each of the 9 positions, allowing film measurement of the delivered dose distribution in 3 orthogonal planes. Comparison of the planned and delivered dose profiles along the major axes provided an estimate of the accuracy and precision of CBCT-guided IMRT.

RESULTS

On average, targeting accuracy was found to be within 1 mm in all 3 major anatomic planes. Over all 54 measured dose profiles, the means and standard errors of the displacement of the center of the field between the measured and calculated profiles for each of the right-left, anterior-posterior, and superior-inferior axes were +0.08 ± 0.07 mm, +0.60 ± 0.08 mm, and +0.78 ± 0.16 mm, respectively. Agreement between planned and measured 80% profiles was less than 0.4 mm on either side along the right-left axis. A systematic shift of the measured profile of slightly less than 1 mm in anterior and superior directions was noted along the anterior-posterior and superior-inferior axes, respectively.

CONCLUSIONS

Submillimeter targeting accuracy can be achieved using a commercial kV-CBCT IGRT system.

AAPM Medical Physics Practice Guideline 2.a: Commissioning and quality assurance of X-ray-based image-guided radiotherapy systems

The American Association of Physicists in Medicine (AAPM) is a nonprofit professional society whose primary purposes are to advance the science, education, and professional practice of medical physics. The AAPM has more than 8,000 members and is the principal organization of medical physicists in the United States.

The AAPM will periodically define new practice guidelines for medical physics practice to help advance the science of medical physics and to improve the quality of service to patients throughout the United States. Existing medical physics practice guidelines will be reviewed for the purpose of revision or renewal, as appropriate, on their fifth anniversary or sooner.

Each medical physics practice guideline represents a policy statement by the AAPM, has undergone a thorough consensus process in which it has been subjected to extensive review, and requires the approval of the Professional Council. The medical physics practice guidelines recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guidelines and technical standards by those entities not providing these services is not authorized.

Fusion genes and their discovery using high throughput sequencing

Fusion genes are hybrid genes that combine parts of two or more original genes. They can form as a result of chromosomal rearrangements or abnormal transcription, and have been shown to act as drivers of malignant transformation and progression in many human cancers. The biological significance of fusion genes together with their specificity to cancer cells has made them into excellent targets for molecular therapy. Fusion genes are also used as diagnostic and prognostic markers to confirm cancer diagnosis and monitor response to molecular therapies. High-throughput sequencing has enabled the systematic discovery of fusion genes in a wide variety of cancer types. In this review, we describe the history of fusion genes in cancer and the ways in which fusion genes form and affect cellular function. We also describe computational methodologies for detecting fusion genes from high-throughput sequencing experiments, and the most common sources of error that lead to false discovery of fusion genes.

Comparison of action levels for patient-specific quality assurance of intensity modulated radiation therapy and volumetric modulated arc therapy treatments

PURPOSE

To perform a comprehensive and systematic comparison of fixed-beam IMRT and volumetric modulated arc therapy (VMAT) patient-specific QA measurements for a common set of geometries using typical measurement methods.

METHODS

Fixed-beam IMRT and VMAT plans were constructed for structure set geometries provided by AAPM Task Group 119. The plans were repeatedly delivered across multiple measurement sessions, and the resulting dose distributions were measured with (1) radiochromic film and ionization chamber and (2) a commercial two-dimensional diode array. The resulting QA measurements from each delivery technique were then analyzed, compared, and tested for statistically significant differences.

RESULTS

Although differences were noted between QA results for some plans, neither modality showed consistently better agreement of measured and planned doses: of the 22 comparisons, IMRT showed better QA results in 11 cases, and VMAT showed better QA results in 11 cases. No statistically significant differences (p < 0.05) between IMRT and VMAT QA results were found for point doses measured with an ionization chamber, planar doses measured with radiochromic film, or planar doses measured with a two-dimensional diode array.

CONCLUSIONS

These results suggest that it is appropriate to apply patient-specific QA action levels derived from fixed-beam IMRT to VMAT.

Potential of discrete Gaussian edge feathering method for improving abutment dosimetry in eMLC-delivered segmented-field electron conformal therapy

PURPOSE

The purpose of this work was to investigate the potential of discrete Gaussian edge feathering of the higher energy electron fields for improving abutment dosimetry in the planning volume when using an electron multileaf collimator (eMLC) to deliver segmented-field electron conformal therapy (ECT).

METHODS

A discrete (five-step) Gaussian edge spread function was used to match dose penumbras of differing beam energies (6-20 MeV) at a specified depth in a water phantom. Software was developed to define the leaf eMLC positions of an eMLC that most closely fit each electron field shape. The effect of 1D edge feathering of the higher energy field on dose homogeneity was computed and measured for segmented-field ECT treatment plans for three 2D PTVs in a water phantom, i.e., depth from the water surface to the distal PTV surface varied as a function of the x-axis (parallel to leaf motion) and remained constant along the y-axis (perpendicular to leaf motion). Additionally, the effect of 2D edge feathering was computed and measured for one radially symmetric, 3D PTV in a water phantom, i.e., depth from the water surface to the distal PTV surface varied as a function of both axes. For the 3D PTV, the feathering scheme was evaluated for 0.1-1.0-cm leaf widths. Dose calculations were performed using the pencil beam dose algorithm in the Pinnacle(3) treatment planning system. Dose verification measurements were made using a prototype eMLC (1-cm leaf width).

RESULTS

1D discrete Gaussian edge feathering reduced the standard deviation of dose in the 2D PTVs by 34, 34, and 39%. In the 3D PTV, the broad leaf width (1 cm) of the eMLC hindered the 2D application of the feathering solution to the 3D PTV, and the standard deviation of dose increased by 10%. However, 2D discrete Gaussian edge feathering with simulated eMLC leaf widths of 0.1-0.5 cm reduced the standard deviation of dose in the 3D PTV by 33-28%, respectively.

CONCLUSIONS

A five-step discrete Gaussian edge spread function applied in 2D improves the abutment dosimetry but requires an eMLC leaf resolution better than 1 cm.

Target localization accuracy in a respiratory phantom using BrainLAB ExacTrac and 4DCT imaging

This study evaluated the accuracy of measuring the motion of an internal target using four‐dimensional computed tomography (4DCT) scanning and the BrainLAB ExacTrac X‐ray imaging system. Displacements of a metal coil implanted in a commercial respiratory phantom were measured in each system and compared to the known motion. A commercial respiratory motion phantom containing a metal coil as a surrogate target was used. Phantom longitudinal motions were sinusoidal with a 4.0 second period and amplitudes ranging from 5–25 mm. We acquired 4DCT and ExacTrac images of the coil at specified respiratory phases and recorded the coordinates of the coil ends. Coil displacement relative to the 0% phase (full‐inhale) position were computed for the ExacTrac and 4DCT imaging systems. Coil displacements were compared to known displacements based on the phantom's sinusoidal motion. Coil length distortion due to 4DCT phase binning was compared to the known physical length of the coil (31 mm). The maximum localization error for both coil endpoints for all motion settings was 3.5 mm for the 4DCT and 0.8 mm for the ExacTrac gating system. Coil length errors measured on the 4DCT were less than 0.8 mm at end inhale/exhale phases, but up to 8.3 mm at mid‐inhalation phases at the largest motion amplitude (25 mm). Due to the fast image acquisition time (100 ms), no coil distortion was observable in the ExacTrac system. 4DCT showed problems imaging the coil during mid‐respiratory phases of higher velocity (phases 20%–30% and 70%–80%) due to distortion caused by residual motion within the 4DCT phase bin. The ExacTrac imaging system was able to accurately localize the coil in the respiratory phantom over all phases of respiration. For our clinic, where end‐respiration phases from 4DCT may be used for treatment planning calculations, the ExacTrac system is used to measure internal target motion. With the ExacTrac system, planning target size and motion uncertainties are minimized, potentially reducing internal target volume margins in gated radiotherapy.

PACS number: 87.56.‐v

Verification of calculated skin doses in postmastectomy helical tomotherapy

PURPOSE

To verify the accuracy of calculated skin doses in helical tomotherapy for postmastectomy radiation therapy (PMRT).

METHODS AND MATERIALS

In vivo thermoluminescent dosimeters (TLDs) were used to measure the skin dose at multiple points in each of 14 patients throughout the course of treatment on a TomoTherapy Hi·Art II system, for a total of 420 TLD measurements. Five patients were evaluated near the location of the mastectomy scar, whereas 9 patients were evaluated throughout the treatment volume. The measured dose at each location was compared with calculations from the treatment planning system.

RESULTS

The mean difference and standard error of the mean difference between measurement and calculation for the scar measurements was -1.8% ± 0.2% (standard deviation [SD], 4.3%; range, -11.1% to 10.6%). The mean difference and standard error of the mean difference between measurement and calculation for measurements throughout the treatment volume was -3.0% ± 0.4% (SD, 4.7%; range, -18.4% to 12.6%). The mean difference and standard error of the mean difference between measurement and calculation for all measurements was -2.1% ± 0.2% (standard deviation, 4.5%: range, -18.4% to 12.6%). The mean difference between measured and calculated TLD doses was statistically significant at two standard deviations of the mean, but was not clinically significant (i.e., was <5%). However, 23% of the measured TLD doses differed from the calculated TLD doses by more than 5%.

CONCLUSIONS

The mean of the measured TLD doses agreed with TomoTherapy calculated TLD doses within our clinical criterion of 5%.

A simple, rapid method for enumerating total viable and metabolically active bacteria in groundwater

We report here a new staining procedure which uses both the enzymatic dehydrogenation of 2-(p-iodophenyl)-3-p-(nitrophenyl)-5 phenyltetrazolium chloride to a pink intracellular formazan and the DNA-specific fluorochrome 4',6'-diamidino-2-phenylindole. Application of this staining procedure to cells concentrated on filters and then transferred to microscope slides by the filter-transfer-freeze technique has proven valuable for statistically accurate enumeration of the total viable and metabolically active cells in groundwaters.

Response of an antarctic lake heterotrophic community to high dissolved oxygen

The upper waters of Lake Hoare, Antarctica, contain dissolved oxygen at about three times the normal saturation (>/=42 mg liter). The response of the heterotrophic plankton community to this high dissolved oxygen was evaluated by the criteria of CFU and d-[U-C]glucose assimilated-respired. High dissolved oxygen was not inhibitory to d-[U-C]glucose assimilation-respiration compared with normal atmospheric dissolved oxygen in Lake Hoare water. The d-[U-C]glucose was assimilated and respired optimally at 12 degrees C in Lake Hoare. The d-[U-C]glucose assimilated-respired in the upper saturated atmospheric dissolved oxygen waters of Mountain Lake, Va., was inhibited in contrast to Lake Hoare (P < 0.05). CFU formation was inhibited in both lakes. CFU represent <1% of the fluorochrome-stained direct counts in Lake Hoare. Lake Hoare planktobacteria are smaller than the planktobacteria in Mountain Lake. ATP size fractionation revealed that 39% of the ATP biomass was <0.5 mum in Lake Hoare.

Factors affecting high-oxygen survival of heterotrophic microorganisms from an antarctic lake

We sought to determine factors relating to the survival of heterotrophic microorganisms from the high-dissolved-oxygen (HDO) waters of Lake Hoare, Antarctica. This lake contains perpetual HDO about three times that of normal saturation (40 to 50 mg liter). Five isolates, one yeast and four bacteria, were selected from Lake Hoare waters by growth with the membrane filter technique with oxygen added to yield dissolved concentrations 14 times that in situ, 175 mg liter. One bacterial isolate was obtained from the microbial mat beneath the HDO waters. This organism was isolated at normal atmospheric oxygen saturation. The bacteria were gram-negative rods, motile, oxidase positive, catalase positive, and superoxide dismutase positive; they contained carotenoids. The planktonic isolates grew in media containing 10 mg of Trypticase soy (BBL Microbiology Systems)-peptone (2:1) liter but not at 10 g liter. Under low-nutrient levels simulating Lake Hoare waters (10 mg liter), two of the planktonic isolates tested were not inhibited by HDO. Growth inhibition by HDO increased as nutrient concentration was increased. A carotenoid-negative mutant of one isolate demonstrated a decreased growth rate, maximal cell density, and increased cell lysis in the death phase under HDO compared with the parent strain. The specific activity of superoxide dismutase was increased by HDO in four of the five bacterial isolates. The superoxide dismutase was of the manganese type on the basis of inhibition and electrophoretic studies. The bacterial isolates from Lake Hoare possess several adaptations which may aid their survival in the HDO waters, as well as protection due to the oligotrophic nature of the lake.

Evaluation of a commercial flatbed document scanner and radiographic film scanner for radiochromic EBT film dosimetry

The purpose of this study was to quantify the performance and assess the utility of two different types of scanners for radiochromic EBT film dosimetry: a commercial flatbed document scanner and a widely used radiographic film scanner. We evaluated the Epson Perfection V700 Photo flatbed scanner and the Vidar VXR Dosimetry Pro Advantage scanner as measurement devices for radiochromic EBT film. Measurements were made of scan orientation effects, response uniformity, and scanner noise. Scanners were tested using films irradiated with eight separate 3×3 cm2 fields to doses ranging from 0.115–5.119 Gy. ImageJ and RIT software was used for analyzing the Epson and Vidar scans, respectively. For repeated scans of a single film, the measurements in each dose region were reproducible to within ±0.3% standard deviation (SD) with both scanners. Film‐to‐film variations for corresponding doses were measured to be within ±0.4% SD for both Epson scanner and Vidar scanners. Overall, the Epson scanner showed a 10% smaller range of pixel value compared to the Vidar scanner. Scanner noise was small: ±0.3% SD for the Epson and ±0.2% for the Vidar. Overall measurement uniformity for blank film in both systems was better than ±0.2%, provided that the leading and trailing 2 cm film edges were neglected in the Vidar system. In this region artifacts are attributed to the film rollers. Neither system demonstrated a clear measurement advantage. The Epson scanner is a relatively inexpensive method for analyzing radiochromic film, but there is a lack of commercially available software. For a clinic already using a Vidar scanner, applying it to radiochromic film is attractive because commercial software is available. However, care must be taken to avoid using the leading and trailing film edges.

PACS number: 87.55.Qr

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

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

Acute toxicity of whole-pelvis IMRT in 87 patients with localized prostate cancer

PURPOSE

To assess the acute toxicity profile of whole pelvis IMRT (WP-IMRT) for localized prostate cancer.

MATERIALS

Eighty seven patients treated with definitive WP-IMRT at UTMB from May 2002 to November 2006 were retrospectively reviewed. Treatment consisted of two sequential phases, WP-IMRT to 54 Gy at 1.8 Gy per fraction to the pelvic nodes and seminal vesicles and 60 Gy at 2 Gy to the prostate, and a separate external beam boost, 3DCRT or IMRT, to bring the dose to the prostate to 76 Gy. Acute toxicity was prospectively scored weekly during treatment and at 3 month follow-up according to CTC v2.0 for 10 genitourinary (GU) and gastrointestinal (GI) domains. The proportion of patients experiencing a given level of peak acute toxicity at a given point is reported.

RESULTS

Treatment was feasible with delivered doses to PTVs not significantly lower than planned ones and with only two patients experiencing treatment gaps longer than 5 days. About 2/3 and 1/10 of the patients experienced peak grade 2 and grade 3 reactions at least once during RT, respectively. Frequency/urgency (Grade 2+: 37.9%) and diarrhea (36.7%) were the most prevalent symptoms followed by proctitis (21.8%) and dysuria (16.1%). GI reactions were generally shorter lasting compared to GU ones which accumulated progressively during treatment. At 3 months, almost half of the patients were asymptomatic and most of observed reactions (89.2%) were mild, with GI ones more likely to be fully resolved (92.5%) than GU ones (68.7%, chi(2), p=0.001).

CONCLUSION

Our approach is dosimetrically and clinically feasible with intense, but transient, acute toxicity.

Does Treatment of the Pelvic Nodes with IMRT Increase Late Rectal Toxicity over Conformal Prostate-Only Radiotherapy to 76 Gy?

PURPOSE

To compare late rectal toxicity rates after three-dimensional conformal radiotherapy to the prostate alone (P-3D-CRT) and whole-pelvis intensity-modulated radiotherapy along with a prostate boost (WP-IMRT/PB) to the same nominal total dose to the prostate.

PATIENTS AND METHODS

68 patients treated with conformal radiotherapy to the prostate only to 76 Gy at the National Institute for Cancer Research, Genoa, Italy, represented the first group (P-3D-CRT). The second group consisted of 45 patients treated at the University of Texas Medical Branch (UTMB), Galveston, TX, USA, with IMRT covering the pelvic nodes and seminal vesicles to 54 Gy at 1.8 Gy per fraction and the prostate to 60 Gy in the same 30 fractions. A separate phase boosted the prostate to 76 Gy (WP-IMRT/PB). Major aspects of planning were remarkably similar at both institutions leaving the inclusion or not of pelvic nodes as the main treatment-related difference between the two groups. Late rectal toxicity was prospectively scored according to the RTOG scale. All patients have a 12-month minimum follow-up, and mean follow-up, similar in both groups, is 25.9 months (SD [standard deviation]: 8.4 months).

RESULTS

At 2 years, the estimated cumulative incidence of grade 2 late rectal toxicity is 6%+/-4% for WP-IMRT/PB and 21.2%+/-6% for P-3D-CRT (p=0.06). The difference became significant (HR [hazard ratio]=0.1, 95% CI [confidence interval]: 0.0-0.6; p=0.01) at multivariate analysis. None of the patients developed grade 3+ toxicity.

CONCLUSION

Despite the larger treated volume, WP-IMRT/PB allows more rectal sparing than P-3D-CRT.

PTV margin determination in conformal SRT of intracranial lesions

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

Periprosthetic bone mineral density changes with femoral components of differing design philosophy

We measured the bone mineral density in 22 patients with the cylindrical stemmed cobalt-chrome AML prosthesis (collared) and in 22 patients with the tapered stem titanium CLS prosthesis (collarless). DEXA scanning was undertaken at a mean of 40 months in the AML and 52 months in the CLS group from the time of implant insertion. In both groups the greatest mean loss of BMD was found in Gruen zone 7 and the least change in Gruen zone 5. In all zones the BMD loss was greater in the AML group but only statistically significant in zones 6 (P<0.05) and 7 (P<0.01). Although numerous factors affect BMD changes around cementless implants, this study suggests that less bone loss can be associated with the titanium CLS stem.

Humic and fulvic acids stimulate the growth of Mycobacterium avium

Mycobacterium avium, an environmental, opportunistic pathogenic mycobacterium, has been isolated frequently and in high numbers from waters in Finland and from acid, brown water swamps of the southeastern coastal USA. M. avium has also been recovered in high numbers from Finnish drinking water and frequently isolated from Finnish AIDS patients. Boreal forests and brown water swamps are similar in that they are rich in humic and fulvic acids and of low pH and dissolved oxygen. Growth of representative isolates of M. avium in natural water was stimulated markedly by the addition of humic and fulvic acids. Further, the M. avium isolates grew at pH levels as low at 4.0 and at oxygen levels equal to 4% of atmospheric levels. The high numbers of M. avium in boreal waters and brown water swamps are likely due to their ability to proliferate in those humic- and fulvic-rich, acidic, micro-aerobic environments.

Migration of the uncemented CLS acetabular component

The migration of uncemented press-fit CLS (Cementless Total Hip Replacement System) acetabular cups was measured retrospectively from standard anteroposterior pelvic radiographs using a digitizer and software specifically developed for this study. A radiographic and clinical review also were undertaken. There were 96 patients in the study group. The mean follow-up for radiographic review was 2.23 years, and the mean follow-up for clinical review was 3 years. Migration was measured in the cranial and medial directions. Mean migration of the cup at 2 years was 1.35 mm in the cranial direction and 2.15 mm in the medial direction. Radiographic appearances altered little over the study period. Fifty-five (57.3%) patients demonstrated bone ingrowth onto the prosthesis, predominantly in DeLee and Charnley zone 1. Twenty-one patients demonstrated nonprogressive sclerotic lines; no lucent lines were encountered. Statistical analysis showed a significant correlation between acetabular ingrowth and reduced cup migration in the medial direction (P = .011 at 5 years). There was no statistical relationship between migration of the cup and radiographic features or clinical outcome.

Migration of the uncemented CLS femoral component

The migration of uncemented CLS (Cementless Total Hip Replacement System) femoral stems was measured retrospectively from standard anteroposterior pelvic radiographs using a digitizer and software specifically designed for this study. The study population was comprised of 117 patients with 126 uncemented CLS femoral stems. All radiographs were reviewed and the incidence of thigh pain obtained by means of a questionnaire. The mean clinical follow-up was 3 years and the mean follow-up for radiographic review was 2.77 years. The mean femoral stem migration was 2 mm at 2 years and 3.66 mm at 7 years. Radiographic features varied little with no specific predictive features in patients with excessive early migration or those who complained of thigh pain. There was no statistical relationship between the presence of thigh pain and femoral stem migration.

Percutaneous transluminal angioplasty of the abdominal aorta

PURPOSE

To determine the long-term results of percutaneous transluminal angioplasty (PTA) of focal infrarenal abdominal aortic stenoses.

PATIENTS AND METHODS

Over a 10-year period, 15 focal infrarenal abdominal aortic stenoses were treated with PTA in 14 patients (13 women and one man; mean age, 53.2 years; range, 43-78 years).

RESULTS

The initial technical success rate was 100%. Clinical patency, as defined by continued absence or improvement in symptoms after PTA, was achieved in 14 of the 15 angioplasty procedures (93%) with a mean duration of clinical follow-up of 4.3 years (range, 0.6-9.8 years) in the 14 patients. Long-term noninvasive follow-up demonstrated continued patency of the angioplasty site in 11 of 11 patients available for study. The mean ankle-arm index in these 11 patients was 0.95 (range, 0.9-1.0) at a mean follow-up of 4.8 years (range, 0.6-9.8 years). There was no significant morbidity or mortality associated with the angioplasty procedures.

CONCLUSION

In view of the high degree of technical success and the excellent long-term patency, we believe that PTA should be considered a primary method of treatment in properly selected patients with focal abdominal aortic stenoses.

Current status and extended applications of intravascular stents

The introduction of several novel techniques and mechanical devices to interventional radiology has expanded the range of therapies for a variety of medical disorders. Intravascular metallic stents have received widespread acclaim and may possess the most potential of all the newest devices available to the interventionist. The addition of metallic stents to the percutaneous therapeutic arsenal provides the interventionist with a device that can resist the elastic recoil of a stenotic vessel or support a newly created vascular tract. Peripheral artery metallic stent placement holds great promise for the treatment of selected patients; other applications of stents, including transjugular intrahepatic portosystemic stent shunts are likely to have a great impact in patient management. We review the techniques, appropriate indications, and recent clinical results of vascular stents for percutaneous intervention and therapy.

Epidemiology of infection by nontuberculous mycobacteria. Mycobacterium avium, Mycobacterium intracellulare, and Mycobacterium scrofulaceum in acid, brown-water swamps of the southeastern United States and their association with environmental variables

Mycobacterium avium, Mycobacterium intracellulare, and Mycobacterium scrofulaceum (MAIS) organisms were isolated and identified from waters, soils, aerosols, and droplets ejected from water collected from four geographically separate aquatic environments (Okefenokee Swamp, GA; Dismal Swamp, VA; Claytor Lake, VA; and Cranberry Glades, WV) during several seasons. Recovery of MAIS was significantly higher from waters, soils, and aerosols collected from the two acid, brown-water swamps located in the southeastern coastal plain. High MAIS numbers correlated with warmer temperature, low pH, low dissolved oxygen, high soluble zinc, high humic acid, and high fulvic acid. This research, in relation to previous findings for the geographic distribution and physiologic ecology of MAIS, supports the conclusion that waters, soils, and aerosols of the acid, brown-water swamps of the southeastern United States coastal plain represent major environmental sources likely connected with the higher incidence of human infection in this region.

Complications associated with the use of the gamma nail

At Kingston Hospital, the Gamma nail has only been used for the fixation of unstable intertrochanteric and subtrochanteric fractures of the femur. There have been 28 cases; 21 required distal locking. Of these, there were intraoperative difficulties in nine.

Unusual bony lesions of histiocytosis X in a patient previously treated for Hodgkin's disease

We present an unusual case of multifocal Histiocytosis X in a 78-year-old man treated for Hodgkin's Disease 33 and 24 years previously. The Hodgkin's Disease at first involved cervical nodes and 9 years later axillary and inguinal nodes and was treated by radiotherapy. Chronic destructive lesions developed in the femora and pelvis and bone biopsies showed a curious mixture of fibroblastic tissue and foamy macrophages. These lesions eventually resulted in pathological fractures of the femoral necks, and bilateral hip replacements were required seven years after initial detection of the bony lesions. There was a focal infiltrate of S-100 protein positive histiocytic cells containing Birbeck granules in the femoral heads. There was radioisotopic and radiological evidence of other skeletal lesions. The association between Histiocytosis X and Hodgkin's Disease is recognised but rare and its significance is discussed.

Epidemiology of infection by nontuberculous mycobacteria. VIII. Absence of mycobacteria in chicken litter

Overlap in the geographic distributions of (1) higher frequencies of persons reacting to antigens prepared from the Mycobacterium avium, M. intracellulare, and M. scrofulaceum (MAIS) group; (2) higher frequencies of isolation from natural waters and soils; (3) higher densities of farms producing broilers (chicken) in the southeastern United States raises the question of whether MAIS organisms occur abundantly in chicken litter (pine bark shavings containing avian fecal material) and whether litter may be a potential source of animal or human infection through its subsequent use as a fertilizer or feed supplement. We show here that potentially pathogenic mycobacteria were seldom recovered from chicken litter containing avian fecal material. Further, litter appears bactericidal to these organisms in that less than 1% of cells inoculated survived more than 6 wk, probably because of the high pH of litters.

Epidemiology of infection by nontuberculous mycobacteria. VII. Absence of mycobacteria in southeastern groundwaters

Using the fluorochrome auramine-O, direct microscopic counts of log phase cells of Mycobacterium avium, M. intracellulare, and M. scrofulaceum (MAIS) group showed excellent correlations with viable spread-plate counts. Accordingly, an enumeration of total acid-fast and MAIS cells by stain and culture (respectively) in groundwaters from three United States regions that differ in their incidence of human infection by MAIS was undertaken. Of 30 state-monitored, undisinfected wells, 11 were in Georgia coastal plain (high incidence), 10 were in the Virginia coastal plain (intermediate incidence), and 9 were in Montgomery County, Virginia (low incidence). Total acid-fast cells ranged widely between 280 to 5,367 per ml among the groundwaters, and with one exception showed no correlations or trends between regions of different incidence of human infection, or to total bacterial cell counts or colony-forming units. The exception was that the proportions of acid-fast cells relative to total cells were higher in the Georgia groundwaters. However, despite the relatively high auramine-O counts, few mycobacteria were recovered by culture. Of 12 wells yielding mycobacteria, 9 yielded rapidly growing and 4 slowly growing mycobacteria. Only one well in Montgomery County, Virginia (region of low incidence) yielded a MAIS isolate, albeit at low density. This research supports the conclusion that clean groundwaters are unlikely sources of MAIS infection in humans in the southeastern United States.

Oxygen budget of a perennially ice-covered Antarctic lake

A bulk O2 budget for Lake Hoare, Antarctica, is presented. Five years of seasonal data show the lake to be persistently supersaturated with O2. Oxygen is carried into the lake in glacial meltstreams and is left behind when this water is removed as ice by ablation and sublimation. A diffusive loss of O2 from the lake through the summer moat is suggested. Measured values of the total O2 in the water column indicate that the time scale of O2 turnover is much longer than a year. Based on these results we suggest that the amount of O2 in the water does not change significantly throughout the year and that the lake is also supersaturated with N2.

Cryoconite holes on glaciers

Cryoconite holes are water-filled depressions on the surface of glaciers. They contain microbial communities and may contribute to glacial wastage and biological colonization of ice-free areas.

Epidemiology of infection by nontuberculous mycobacteria. V. Numbers in eastern United States soils and correlation with soil characteristics

Organisms of the Mycobacterium avium, M. intracellulare, and M. scrofulaceum (MAIS) group were recovered in significant numbers from 63 soil samples collected from the floodplains of 4 major rivers in the eastern United States: Hudson (NY), James (VA), Savannah (GA, SC), and Tombigbee (AL, MS). The mean numbers of M. avium-intracellulare, M. scrofulaceum, and MAIS-intermediate biovars recovered increased significantly from the Hudson to the James to the Tombigbee and Savannah soil samples, agreeing reasonably well with previous findings on MAIS distribution in eastern U.S. waters and with the geographic distribution of naval recruits reacting to PPD-B and PPD-G, which is higher in the southeastern United States. From the Savannah and Tombigbee rivers, soils were collected throughout their lengths. The number of total MAIS and biovars recovered from the different soil sites varied widely and showed no obvious trends. However, statistical analysis revealed a highly significant correlation between high numbers of MAIS recovered and high acidity of the soils. Other soil characteristics, such as high total organic matter, high conductivity, and reduced moisture, were only weakly, if at all, correlated with high MAIS numbers. Whereas the general distribution of MAIS in these soils of the Northeast (NY), mid-Atlantic (VA), and Southeast (GA, SC, AL, and MS) might explain the geographic distribution of the naval recruits reacting to PPD-B and PPD-G, the distribution of MAIS in soils along the stretches of the 2 southeastern rivers was not correlated with the county-by-county frequency of PPD-B reactive naval recruits in Georgia, South Carolina, Alabama, and Mississippi.

Recovery and survival of nontuberculous mycobacteria under various growth and decontamination conditions

The survival of microorganisms of the Mycobacterium avium, M. intracellulare, and M. scrofulaceum (MAIS) complex was evaluated after various soil and water decontamination regimens. Survival was reduced by growing cells in natural waters compared with laboratory media and by inclusion of malachite green in media as an antifungal agent. Decontamination with benzalkonium chloride, while reducing survival significantly less than 1% NaOH, failed to eliminate many fungi. Recovery from soil was further reduced by transfer losses and by irreversible cell adsorption onto particulates.

In vitro susceptibility of human and environmental isolates of Mycobacterium avium, M. intracellulare, and M. scrofulaceum to heavy-metal salts and oxyanions

Because of the widespread distribution of Mycobacterium intracellulare and M. scrofulaceum in southeastern U.S. waters, the susceptibility of members of these species to heavy-metal salts and oxyanions was investigated. Isolates with abnormally high tolerance to mercuric chloride or cadmium chloride were identified.

Epidemiology of infection by nontuberculous mycobacteria. IV. Preferential aerosolization of Mycobacterium intracellulare from natural waters

We report here the first laboratory studies simulating the conditions for natural aerosolization of Mycobacterium intracellulare and M. scrofulaceum and estimate the yields for this pathway of transfer of pathogenic mycobacteria from water to air; M. intracellulare and M. scrofulaceum were both concentrated in droplets ejected from cell suspensions of densities comparable to those found in natural freshwaters (100 to 2,000 colony-forming units per ml). The enrichment factor (defined as the concentration of cells per droplet volume divided by the concentration of cells in the bulk suspension per equivalent volume) for M. intracellulare isolates ranged from 68 to 15,000, with an average of 2,922; for M. scrofulaceum it ranged from 35 to 550, with an average of 177. One factor responsible for the greater aerosolization of M. intracellulare was their aggregation. However, after vortexing, M. intracellulare were still aerosolized more (enrichment factor, 325) than M. scrofulaceum. Increasing salt concentrations enriched the aerosolization of both species, but the number of organisms transferred from water to air did not increase proportionately because the salt decreased the droplet volume. Other waterborne pathogens such as Legionella pneumophila were also enriched and transferred from water to air, indicating that this pathway for possible infection of humans may also be significant for other respiratory diseases.

Sensitivity of an oligotrophic lake planktonic bacterial community to oxygen stress

Dissolved oxygen at approximately four times normal saturation (42 mg liter) inhibited the growth and metabolism of summer planktonic bacteria in the surface water of alpine oligotrophic Mountain Lake (Giles County, Va.). Data were derived from growth of CFU on membrane filters, d-[U-C]glucose incorporation into the extractable lipid of these CFU, and respiration and assimilation of d-[U-C]glucose by lake water samples. Statistically significant (alpha < 0.05) differences were not detected in either CFU or C incorporation in lipid when superoxide dismutase (30 U ml) or catalase (130 U ml) was added to the medium. Thus, exogenous oxygen by-products apparently are not responsible for the observed inhibition of growth and metabolism.

Uric acid utilization by Mycobacterium intracellulare and Mycobacterium scrofulaceum isolates

Forty-nine human and environmental isolates of Mycobacterium intracellulare and Mycobacterium scrofulaceum were tested for their ability to grow on uric acid and a number of its degradation products. Nearly all (88 to 90%) strains used uric acid or allantoin as a sole nitrogen source; fewer (47 to 69%) used allantoate, urea, or possibly ureidoglycollate. Enzymatic activities of one representative isolate demonstrated the existence of a uric acid degradation pathway resembling that in other aerobic microorganisms.

Chlorophylla and adenosine triphosphate levels in Antarctic and temperate lake sediments

Analysis of adenosine triphosphate (ATP) from surficial sediment layers in two antarctic lakes and two temperate lakes showed a high degree of similarity in spite of differences between trophic state, mictic state, or geographic location. Adenosine triphosphate was found at all levels sampled in temperate lake sediment cores but occasionally was present only in surficial layers of antarctic cores. Surficial sediment layers from antarctic lakes contained high chlorophylla (Chla) levels due to the extensive benthic algal mats which occur there. In some antarctic cores, Chla was detectable in deep, old mat layers, whereas Chla was not found in any of the temperate lake cores. Antarctic lake sediments appear to be unique environments where Chla molecules can remain intact for long periods of time due to low light, temperature, and microbial activity. As such, these lakes are important natural laboratories where a long history of microbial interactions can be studied without metazoan perturbation effects. Although there was much variability in concentration of Chla and ATP between samples, there appears to be no relationship between Chla or ATP levels to mictic or trophic states of the lakes. These data suggest that sediment microbial communities may be independent of environmental and biological properties of the overlying water masses.

Recent experience in the epidemiology of disease caused by atypical mycobacteria

To obtain information on the epidemiology of mycobacteriosis, water and air samples collected along the East Coast of the United States were examined for mycobacteria. Mycobacterium avium-intracellulare-scrofulaceum (MAIS) were isolated from 25% of the water, samples, mostly those from South Carolina, Georgia, and the Gulf states. Mycobacterium kansasii and Mycobacterium marinum were not found, probably because of the detrimental effects of the NaOH used to decontaminate the samples. MAIS strains were found more often in estuaries than in fresh or ocean waters. The frequency of Mycobacterium intracellulare was relatively uniform along the entire coast, while Mycobacterium scrofulaceum predominated in the South. Only M. intracellulare was found in aerosol specimens, although both M. intracellulare and M. scrofulaceum were found in waters collected at the same sites.

Epidemiology of infection by nontuberculous Mycobacteria. III. Isolation of potentially pathogenic mycobacteria from aerosols

Nontuberculous mycobacteria (21 isolates), biochemically similar to those that are recovered from humans, were recovered from rainwater and from natural river waters and their aerosols in the area of Richmond, Virginia. Field experiments have confirmed the existence of a natural mechanism for the transfer of significant numbers of mycobacteria from water to air. These findings support the hypothesis that aerosolization of potentially pathogenic mycobacteria from waters of the southeastern United States may be a major pathway for human infection.