Fully automated analysis combining [18F]-FET-PET and multiparametric MRI including DSC perfusion and APTw imaging: a promising tool for objective evaluation of glioma progression.

PURPOSE: To evaluate diagnostic accuracy of fully automated analysis of multimodal imaging data using [18F]-FET-PET and MRI (including amide proton transfer-weighted (APTw) imaging and dynamic-susceptibility-contrast (DSC) perfusion) in differentiation of tumor progression from treatment-related changes in patients with glioma. MATERIAL AND METHODS: At suspected tumor progression, MRI and [18F]-FET-PET data as part of a retrospective analysis of an observational cohort of 66 patients/74 scans (51 glioblastoma and 23 lower-grade-glioma, 8 patients included at two different time points) were automatically segmented into necrosis, FLAIR-hyperintense, and contrast-enhancing areas using an ensemble of deep learning algorithms. In parallel, previous MR exam was processed in a similar way to subtract preexisting tumor areas and focus on progressive tumor only. Within these progressive areas, intensity statistics were automatically extracted from [18F]-FET-PET, APTw, and DSC-derived cerebral-blood-volume (CBV) maps and used to train a Random Forest classifier with threefold cross-validation. To evaluate contribution of the imaging modalities to the classifier's performance, impurity-based importance measures were collected. Classifier performance was compared with radiology reports and interdisciplinary tumor board assessments. RESULTS: In 57/74 cases (77%), tumor progression was confirmed histopathologically (39 cases) or via follow-up imaging (18 cases), while remaining 17 cases were diagnosed as treatment-related changes. The classification accuracy of the Random Forest classifier was 0.86, 95% CI 0.77-0.93 (sensitivity 0.91, 95% CI 0.81-0.97; specificity 0.71, 95% CI 0.44-0.9), significantly above the no-information rate of 0.77 (p = 0.03), and higher compared to an accuracy of 0.82 for MRI (95% CI 0.72-0.9), 0.81 for [18F]-FET-PET (95% CI 0.7-0.89), and 0.81 for expert consensus (95% CI 0.7-0.89), although these differences were not statistically significant (p > 0.1 for all comparisons, McNemar test). [18F]-FET-PET hot-spot volume was single-most important variable, with relevant contribution from all imaging modalities. CONCLUSION: Automated, joint image analysis of [18F]-FET-PET and advanced MR imaging techniques APTw and DSC perfusion is a promising tool for objective response assessment in gliomas.

Intensity-modulated proton therapy, volumetric-modulated arc therapy, and 3D conformal radiotherapy in anaplastic astrocytoma and glioblastoma : A dosimetric comparison.

PURPOSE: The prognosis for high-grade glioma (HGG) patients is poor; thus, treatment-related side effects need to be minimized to conserve quality of life and functionality. Advanced techniques such as proton radiation therapy (PRT) and volumetric-modulated arc therapy (VMAT) may potentially further reduce the frequency and severity of radiogenic impairment. MATERIALS AND METHODS: We retrospectively assessed 12 HGG patients who had undergone postoperative intensity-modulated proton therapy (IMPT). VMAT and 3D conformal radiotherapy (3D-CRT) plans were generated and optimized for comparison after contouring crucial neuronal structures important for neurogenesis and neurocognitive function. Integral dose (ID), homogeneity index (HI), and inhomogeneity coefficient (IC) were calculated from dose statistics. Toxicity data were evaluated. RESULTS: Target volume coverage was comparable for all three modalities. Compared to 3D-CRT and VMAT, PRT showed statistically significant reductions (p < 0.05) in mean dose to whole brain (-20.2 %, -22.7 %); supratentorial (-14.2 %, -20,8 %) and infratentorial (-91.0 %, -77.0 %) regions; brainstem (-67.6 %, -28.1 %); pituitary gland (-52.9 %, -52.5 %); contralateral hippocampus (-98.9 %, -98.7 %); and contralateral subventricular zone (-62.7 %, -66.7 %, respectively). Fatigue (91.7 %), radiation dermatitis (75.0 %), focal alopecia (100.0 %), nausea (41.7 %), cephalgia (58.3 %), and transient cerebral edema (16.7 %) were the most common acute toxicities. CONCLUSION: Essential dose reduction while maintaining equal target volume coverage was observed using PRT, particularly in contralaterally located critical neuronal structures, areas of neurogenesis, and structures of neurocognitive functions. These findings were supported by preliminary clinical results confirming the safety and feasibility of PRT in HGG.

Computer-based automated left atrium segmentation and volumetry from ECG-gated coronary CT angiography data: comparison with manual slice segmentation and ultrasound planimetric methods.

PURPOSE: Enlargement of the left atrium is a risk factor for cardiovascular or cerebrovascular events. We evaluated the performance of prototype software for fully automated segmentation and volumetry of the left atrium. MATERIALS AND METHODS: In 34 retrospectively ECG-gated coronary CT angiography scans, the end-systolic (LAVsys) and end-diastolic (LAVdia) volume of the left atrium was calculated fully automatically by prototype software. Manual slice segmentation by two independent experienced radiologists served as the reference standard. Furthermore, two independent observers calculated the LAV utilizing two ultrasound planimetric methods ("area length" and "prolate ellipse") on CTA images. Measurement periods were compared for all methods. RESULTS: The left atrial volumes calculated with the prototype software were in excellent agreement with the results from manual slice segmentation (r = 0.97 - 0.99; p < 0.001; Bland-Altman) with excellent interobserver agreement between both radiologists (r = 0.99; p < 0.001). Ultrasound planimetric methods clearly showed a higher variation (r = 0.72 - 0.86) with moderate interobserver agreement (r = 0.51 - 0.79). The measurement period was significantly lower with the software (267 ± 28 sec; p < 0.001) than with ultrasound methods (431 ± 68 sec) or manual slice segmentation (567 ± 91 sec). CONCLUSION: The prototype software showed excellent agreement with manual slice segmentation with the least time consumption. This will facilitate the routine assessment of the LA volume from coronary CTA data and therefore risk stratification.

Isotope shift in the dielectronic recombination of three-electron ANd57+.

Isotope shifts in dielectronic recombination spectra were studied for Li-like (A)Nd(57+) ions with A=142 and A=150. From the displacement of resonance positions energy shifts deltaE(142 150)(2s-2p(1/2))=40.2(3)(6) meV [(stat)(sys)] and deltaE(142 150)(2s-2p(3/2))=42.3(12)(20) meV of 2s-2p(j) transitions were deduced. An evaluation of these values within a full QED treatment yields a change in the mean-square charge radius of (142 150)deltar(2)=-1.36(1)(3) fm(2). The approach is conceptually new and combines the advantage of a simple atomic structure with high sensitivity to nuclear size.

Storage-ring measurement of the hyperfine induced 47Ti18+(2s2p 3P0 --> 2s2 1S0) transition rate.

The hyperfine induced 2s2p (3)P(0) --> 2s(2) (1)S(0) transition rate A(HFI) in berylliumlike (47)Ti(18+) is measured. Resonant electron-ion recombination in a heavy-ion storage ring is employed to monitor the time dependent population of the (3)P(0) state. The experimental value A(HFI)=0.56(3) s(-1) is almost 60% larger than theoretically predicted.

Creatine supplementation in high school football players.

OBJECTIVE: To describe creatine supplementation patterns and behaviors associated with creatine supplementation in high school football players. DESIGN: A cross-sectional, multisite, anonymous, descriptive survey was conducted between October 1999 and February 2000. SETTING: 37 public high schools in Wisconsin. SUBJECTS: A total of 1,349 high school football players, grades 9-12. MAIN OUTCOME MEASURES: Self-reported prevalence of creatine use, as well as perceived benefits and risks. In addition, sources of information and influence regarding creatine supplementation were assessed. RESULTS: 30% of the respondents reported using creatine. Creatine use was lowest in the 9th grade (10.4%) and highest in the 12th grade (50.5%). 41% of the players at small schools stated they used creatine compared with 29% of the players in large schools. Enhanced recovery following a workout was the most likely perceived benefit of creatine supplementation, while dehydration was cited most often as a risk of creatine use. Users were encouraged to take creatine most often by their friends while their parents discouraged creatine use. CONCLUSIONS: Creatine use is widespread in high school football players. High school football players who use creatine may not be aware of the risks and benefits associated with creatine supplementation. Sports medicine professionals who work with this population need to educate athletes, coaches, and parents about the use of creatine as a performance-enhancing supplement.

Organized sports for children and preadolescents.

Participation in organized sports provides an opportunity for young people to increase their physical activity and develop physical and social skills. However, when the demands and expectations of organized sports exceed the maturation and readiness of the participant, the positive aspects of participation can be negated. The nature of parental or adult involvement can also influence the degree to which participation in organized sports is a positive experience for preadolescents. This updates a previous policy statement on athletics for preadolescents and incorporates guidelines for sports participation for preschool children. Recommendations are offered on how pediatricians can help determine a child's readiness to participate, how risks can be minimized, and how child-oriented goals can be maximized.

Strength training by children and adolescents.

Pediatricians are often asked to give advice on the safety and efficacy of strength training programs for children and adolescents. This review, a revision of a previous American Academy of Pediatrics policy statement, defines relevant terminology and provides current information on risks and benefits of strength training for children and adolescents.

[Snakebite---intoxication by cobra venom]. / Kobrabiss: ein ungewöhnlicher Notfall.

A private reptile breeder who handled exotic snakes was bitten by a Cobra near his ear. An ambulance was immediately called and the patient was transferred under unstable hemodynamic conditions to the nearest major hospital. During transport the patient had to undergo cardiopulmonary resuscitation. In the hospital, his status again deteriorated and he was intubated at a Glasgow coma scale of 5 and vasoactive medications were given. The patient was transferred by helicopter to a university hospital, where several doses of antivenom were given. After 4 days of deep coma the patient regained consciousness and spontaneous respiration and was extubated. Around the location of the bite wound angioedema and local necrosis developed. Surgical treatment of the wound was not necessary and 8 days after the incident the patient was fully recovered and was discharged from the hospital.

[Preoperatively asymptomatic left adrenal incidentaloma]. / Präoperativ asymptomatisches Inzidentalom der linken Nebenniere.

Since the introduction of new, very sensitive imaging procedures (ultrasonography, CT, MRI) the incidence of incidentally discovered, asymptomatic adrenal masses has clearly increased. These tumours are a new challenge to develop therapy and preoperative evaluation strategies, as the following case report shows. In a 29-year-old asymptomatic female patient a large adrenal tumour on the left side was discovered on abdominal ultrasonography during pregnancy. The further endocrinological examinations were normal. The patient was operated on post partum. During intraoperative manipulation of the tumour we observed an excessive increase in blood-pressure and heart rate. Shortly after removal of the tumour and immediate sympatholytic treatment the situation was under control. The intraoperative clinical situation and histological work-up of the tumour led to the diagnosis of phaeochromocytoma. The problem of adrenal incidentalomas is discussed on the basis of the current literature and an algorithm for preoperative evaluation is presented.

Medical coverage analysis for Wisconsin's Olympics: the Badger State Games.

The objective of this analysis is to determine the prevalence and severity of injuries encountered during the 1994-96 Badger State Summer Games Finals. Allocation of available medical personnel can be determined with this information. Medical contact with an athlete required an evaluation form to be completed by the health care professional covering the event. Information was compiled and analyzed to determine injury frequency and severity. Of the 31,580 athletes competing over the three year period in the 11 sports provided with medical personnel, 285 suffered a reportable injury. Soccer and basketball had the highest number of reported injuries with 68 and 65 injuries respectively. Basketball (2.00%), cycling (1.59%), wrestling (1.50%) and roller hockey (1.24%) had the highest injury rates. Severity of injury determined by the number of injuries transported to a medical facility found wrestling (23), soccer (22), basketball (11), and cycling (6) with the highest numbers of severe injuries. Wrestling (1.27%), basketball (.34%), soccer (.32%), and cycling (.21%) had the highest rate of severe injury. The most common sustained injuries were found to be sprains, strains, skin wounds, and contusions. These four types of injuries made up 70.18% of the injuries sustained. In conclusion, non-physician medical presence may be adequate coverage in most venues at multi-sport athletic competitions like the Badger State Games because of the relatively low frequency of severe injuries.

General principles in treating soft-tissue injuries.

Most primary care physicians will encounter soft tissue injuries in their office. The acute treatment of these injuries using the acronym RICEM is the most important part of treatment so that the athlete may progress to a more functional phase of rehabilitation in older to allow for a rapid recovery and safe return to sport.

[Nanofiltration in production of Beriplex P/N: increasing the capacity of virus elimination while maintaining product quality]. / Nanofiltration bei der Herstellung von Beriplex P/N: Erhöhung der Kapazität zur Viruseliminierung unter Beibehaltung der Produktqualität.

For the manufacture of the PCC Beriplex P/N, nanofiltration was introduced into the production process of Beriplex HS providing an additional means to heat treatment for the clearance/inactivation of viruses. By nanofiltration, large enveloped viruses (HSV-1, HIV-1) were completely eliminated by a factor of more than 7 log10. While medium-sized enveloped viruses (HBV, BVDV) were cleared by a factor of approximately 4 log10, small non-enveloped viruses (poliovirus) were not removed. The product profile remained, no thrombogenic activities were detected.

Syncope in athletes.

Syncope is a brief sudden loss of consciousness and muscle tone secondary to cerebral ischaemia, inadequate oxygen or glucose delivery to the brain. The causes of syncope may be benign and require very little in the way of evaluation or treatment. However, syncope may be the harbinger of sudden death, and extensive evaluation, monitoring and detailed recommendations regarding advisability of participating in sports should be reviewed with the patient. The history is the most important clue when attempting to identify which patient with syncope is at risk for sudden death. A careful cardiac and neurological examination should be performed in any patient presenting with syncope. Selective use of laboratory testing and cardiac monitoring may assist the practitioner in making the diagnosis. Most often patients with syncope will have a benign cause such as vaso-vagal events, hyperventilation or orthostatic hypotension. Patients with a cardiac condition causing their syncope are at increased risk for sudden death. The ominous, cardiac-related causes of syncope in the younger population include hypertrophic cardiomyopathy, aberrant coronary arteries and aortic dissection secondary to Marfan's syndrome. In the older athletic population, coronary atherosclerosis may present with syncope. Dysrhythmias may be the cause of syncope in both populations.

Sports injuries in young athletes.

Injuries to a skeletally immature athlete are common, but most of the injuries do not have long-term implications. There is no risk-free sport, and children tend to select the sports they wish to participate in based on their own desire, peer pressure, and their own talent regardless of the injury rate. Both acute and overuse injuries may occur. Open physes and apophyses represent unique structures that may be injured in this population. Prompt and proper identification of many of these injuries may allow the young athlete a relatively timely return to sports competition or recreation. Pediatricians and other primary care providers can make an active commitment to youth sports by learning more about these common sports-related injuries and becoming team physicians or joining local sports medicine advisory councils.

Athletes Test Positive for Morphine.

Three collegiate athletes tested positive for morphine after a championship competition; however, all three denied narcotic use. The medical team was stumped until the coach suggested a food source. Reviewing the literature and recreating the scenario helped identify the cause.

Critical evaluation of the 2-minute orthopedic screening examination.

OBJECTIVE: To determine the sensitivity and specificity of the 2-minute, 12-step, orthopedic screening examination. DESIGN: Prospective, single-blind study. SETTING: National Collegiate Athletic Association Division 1 athletics program. PARTICIPANTS: Two hundred fifty-nine male and female varsity athletes. INTERVENTIONS: The athletes were screened by five primary care physicians who were "blind" to each patient's history. The athletes were then evaluated by a team of orthopedic surgeons who had knowledge of each patient's history. Significant injuries were injuries that would limit participation, predispose to injury, or need further evaluation or rehabilitation. MAIN RESULTS: A total of 120 significant injuries were identified by compiling the results of the history and both physical examinations. Of the significant injuries, 91.6% were detected by history alone. Fourteen of the significant injuries were missed by the detailed orthopedic examination, but they were detected by the screening examination. The overall sensitivity of the screening examination compared with the results of all three methods was 50.8%, with a specificity of 97.5%, positive predictive value of 40.9%, and negative predictive value of 98.3%. Almost half of the false-positive screening findings were shoulder asymmetries. CONCLUSIONS: Even in mass screenings, the screening orthopedic examination should be used only in conjunction with an orthopedic history. Some modifications may improve the sensitivity of the screening examination.

Inactivation of HIV, HBV, HCV related viruses and other viruses in human plasma derivatives by pasteurisation.

Laboratory studies were made to verify the capacity and efficacy of the pasteurisation step (heat treatment at 60 degrees C for 10 hours in stabilized aqueous solution) in inactivating various pathogenic viruses (e.g. HIV, HBV, HCV related viruses, HAV, HSV, poliovirus). These experiments proved that pasteurisation effectively inactivates a broad spectrum of viruses with a range of different physicochemical properties. The results, summarized in inactivation kinetics, demonstrate that complete inactivation of high quantities of both enveloped (e.g. HIV, HCV related viruses) and non-enveloped (e.g. poliovirus) viruses takes place during pasteurisation. In clinical trials on the virus safety of plasma derivatives no case of AIDS, hepatitis B or C occurred. From these data we conclude that heat treatment at 60 degrees C in a stabilized aqueous solution confers a high margin of safety on human plasma protein preparations regarding the transmission of diseases such as AIDS or hepatitis.

Measurement of isometric force in children with and without Duchenne's muscular dystrophy.

The purpose of this study was to examine the consistency of measurements of maximal isometric force production in children using an electronic strain gauge. A standardized protocol of force testing from the Tufts Quantitative Neuromuscular Examination was adapted to obtain isometric force measurements in seven muscle groups bilaterally. Ten children with Duchenne's muscular dystrophy (DMD) and 10 age-matched children without DMD were recruited for the study. A generalizability framework was used to examine variations in measurements attributable to group differences, test occasions within the same day, and extremity side. Intertester reliability estimates were also completed on a subsample of children with and without DMD. A three-way analysis of variance between groups, sides, and test occasions demonstrated a significant group main effect for all muscle groups. In general, significant main effects were not present for side or test occasion. Test-retest intraclass correlation coefficients (ICCs) for all muscle groups ranged from .88 to .99 for the children with DMD and from .85 to .98 for the children without DMD. Intertester ICCs were slightly lower, ranging from .74 to .97 for the children with DMD and from .71 to .98 for the children without DMD. The results indicate that the electronic strain-gauge protocol produces reproducible force measurements in seven selected muscle groups in children with and without DMD. Brussock CM, Haley SM, Munsat TL, Bernhardt DB. Measurement of isometric force in children with and without Duchenne's muscular dystrophy.