Feasibility of abdominal fat quantification on MRI and impact on effectiveness of abdominal compression for radiotherapy motion management.

The impact of fat on abdominal compression effectiveness in abdominal cancers was determined using magnetic resonance imaging (MRI). Visceral and subcutaneous fat were delineated on T2W 3D MRI, and motion change with compression was measured on 2D cine MRI. Results from 16 participants showed no correlation between fat percentage, body mass index (BMI), and motion change. Median BMI was 28.7 (SD, 4.9). Mean motion reduction was 7.8 mm (IQR, 5.0; p = 0.001) with compression. While no direct link was found between fat, BMI, and compression effectiveness, abdominal compression remains crucial for motion management in radiotherapy planning, providing dosimetric benefits.

An evaluation of radiographers' extended practice in the detection of brain metastases on magnetic resonance images.

INTRODUCTION: Patients who undergo magnetic resonance (MR) imaging to confirm or rule out metastatic brain disease are required to wait for image review by a radiologist before leaving the department at the institute where this study was carried out. The aim was to evaluate whether radiographers can review images and reduce waiting times in those patients without metastases. METHODS: Prospective observational study of MR radiographers (n = 11) was undertaken. Radiographers commented on images to confirm whether the images showed evidence of metastatic disease, pathology but no metastases, or no pathology. Responses were compared to the radiological report (reference standard). Online questionnaires determined the views and opinions of radiographers (n = 8) and consultant radiologists (n = 6) towards radiographers expanding their scope of practice to include the confirmation or exclusion of brain metastases. RESULTS: Despite a lack of formal training for image reviewing, overall level of agreement between the radiographer reviews and reference standard was 77.9 % (κ = 0.45). Pooled sensitivity and specificity were 88.6 % & 71.3 % respectively. Kendall's τ = -0.03 (bootstrap 95 % CI -0.73 to 0.61, p = 0.925). Positive predictive value (PPV) was 65.5 % (CI 59.2%-71.4 %) and negative predictive value (NPV) 91.1 % (CI 84.9%-94.9 %). Radiographers and radiologists surveyed demonstrated a willingness to engage with role expansion. CONCLUSION: Based on our small study and interdisciplinary survey, local radiographers and radiologists agree, following a program of radiographer training, screening for brain metastases by radiographers could be implemented. IMPLICATIONS FOR PRACTICE: With appropriate governance and training support, the introduction of formal radiographer screening for patients referred to exclude brain metastases could provide more efficient working practice.

Barriers and facilitators to conducting radiotherapy clinical trials: Findings from a UK survey.

INTRODUCTION: As an essential component of service delivery, radiotherapy clinical trials were championed within the NHS England service specifications. A call for a 15% increase in research and clinical trial activity, alongside a demand for equity of access for patients with cancer subsequently ensued. National understanding of current radiotherapy clinical trials operational practices is absent, but essential to help establish the current provision required to support the development of a strategic plan for implementation of NHS England's specifications. METHODS: A cross-sectional survey was developed by a multi-disciplinary team and distributed to therapeutic radiography clinical trial leads across the UK to ascertain the current provision of radiotherapy clinical trials only, including workforce resources and the trials management processes to establish a benchmark and identify potential barriers, enablers, and opportunities to increase access to clinical trials. RESULTS: Thirty-two complete responses were obtained equating to 49% of the total UK NHS departments and 74% of those departments invited. Four key findings were identified: 1) research strategy and systems, 2) participation and activity in radiotherapy clinical trials, 3) access to clinical trials at alternative departments and 4) facilitators & barriers. Overarchingly a lack of radiotherapy clinical trials strategy or supported processes were apparent across the UK, aggravating existing barriers to trial activity. CONCLUSION: It is essential for radiotherapy clinical trials to be embedded in to departmental and Trust strategy, this will help to ensure the processes and resources required for trial delivery are not only in place, but also recognised as imperative and important for patients with cancer as radiotherapy treatment delivery. IMPLICATIONS FOR PRACTICE: Failure to address the barriers or build upon the facilitators may result in UK radiotherapy departments facing challenges in achieving the 15% increase in radiotherapy clinical trial activity.

A novel use for routine CBCT imaging during radiotherapy to detect COVID-19.

INTRODUCTION: Thoracic CT is a useful tool in the early diagnosis of patients with COVID-19. Typical appearances include patchy ground glass shadowing. Thoracic radiotherapy uses daily cone beam CT imaging (CBCT) to check for changes in patient positioning and anatomy prior to treatment through a qualitative assessment of lung appearance by radiographers. Observation of changes related to COVID-19 infection during this process may facilitate earlier testing improving patient management and staff protection. METHODS: A tool was developed to create overview reports for all CBCTs for each patient throughout their treatment. Reports contain coronal maximum intensity projection (MIP's) of all CBCTs and plots of lung density over time. A single therapeutic radiographer undertook a blinded off-line audit that reviewed 150 patient datasets for tool optimisation in which medical notes were compared to image findings. This cohort included 75 patients treated during the pandemic and 75 patients treated between 2014 and 2017. The process was repeated retrospectively on a subset of the 285 thoracic radiotherapy patients treated between January-June 2020 to assess the efficiency of the tool and process. RESULTS: Three patients in the n = 150 optimisation cohort had confirmed COVID-19 infections during their radiotherapy. Two of these were detected by the reported image assessment process. The third case was not detected on CBCT due to minimal density changes in the visible part of the lungs. Within the retrospective cohort four patients had confirmed COVID-19 based on RT-PCR tests, three of which were retrospectively detected by the reported process. CONCLUSION: The preliminary results indicate that the presence of COVID-19 can be detected on CBCT by therapeutic radiographers. IMPLICATIONS FOR PRACTICE: This process has now been extended to clinical service with daily assessments of all thoracic CBCTs. Changes noted are referred for oncologist review.

Blurring the lines for better visualisation.

On-treatment imaging in radiotherapy has evolved over the last 60 years, bringing with it changes in the roles of radiographers, radiologists and oncologists. The ability to acquire and interpret high quality images (2D kilovoltage and megavoltage imaging and 3D CT and cone-beam CT) for radiotherapy planning and delivery requires therapy radiographers to have skills and knowledge that overlap with those of diagnostic radiographers. With the implementation of MRI-guided radiotherapy, treatment radiographers and clinical oncologists are exploring new territory, requiring truly collaborative working practices with their radiology partners. This short communication introduces the first images acquired using the hybrid MR Linac at our institution.

Magnetic resonance imaging sequence evaluation of an MR Linac system; early clinical experience.

OBJECTIVES: To systematically identify the preferred magnetic resonance imaging (MRI) sequences following volunteer imaging on a 1.5 Tesla (T) MR-Linear Accelerator (MR Linac) for future protocol development. METHODS: Non-patient volunteers were recruited to a Research and Ethics committee approved prospective MR-only imaging study on a 1.5T MR Linac system. Volunteers attended 1-3 imaging sessions that included a combination of mDixon, T1w, T2w sequences using 2-dimensional (2D) and 3-dimensional (3D) acquisitions. Each sequence was acquired over 2-7 minutes and reviewed by a panel of 3 observers to evaluate image quality using a visual grading analysis based on a 4-point Likert scale. Sequences were acquired and modified iteratively until deemed fit for purpose (online image matching or re-planning) and all observers agreed they were suitable in 3 volunteers. RESULTS: 26 volunteers underwent 31 imaging sessions of six general anatomical regions. Images were acquired in one or two of six general anatomical regions: male pelvis (n = 9), female pelvis (n = 4), chestwall/breast (n = 5), lung/oesophagus (n = 5), abdomen (n = 3) and head and neck (n = 5). Images were acquired using a pre-defined exam-card that on average, included six sequences (range 2-10), with a maximum scan time of approximately one hour. The majority of observers preferred T2-weighted sequences. The thorax teams were the only groups to prefer T1-weighted imaging. CONCLUSIONS: An iterative process identified sequence agreement in all anatomical regions. These sequences will now be evaluated in patient volunteers. ADVANCES IN KNOWLEDGE: This manuscript is the first publication sharing the results of the first systematic selection of MRI sequences for use in on-board MRI-guided radiotherapy by end-users (therapeutic radiographers and clinical oncologists) in healthy volunteers.

A compact Class D RF power amplifier for mobile nuclear magnetic resonance systems.

A 20 MHz Class D amplifier with an output of 100 W of RF power has been developed. The compact size printed circuit board area of 50 cm2 and efficiency of 73% make it suitable for mobile nuclear magnetic resonance (NMR) systems. Test results show that the rise and ring down times of the amplifier are less than 0.2 µs, and it is capable of producing constant amplitude pulses as short as 2 µs. Experiments using a Carr Purcell Meiboom Gill pulse sequence with a NMR MOUSE sensor confirm that the Class D amplifier is suitable for mobile NMR applications.

Comparison of four target volume definitions for pancreatic cancer. Guidelines for treatment of the lymphatics and the primary tumor.

BACKGROUND AND PURPOSE: Target volume definitions for radiotherapy in pancreatic ductal adenocarcinoma (PDAC) vary substantially. Some groups aim to treat the primary tumor only, whereas others include elective lymph nodes (eLNs). eLNs close to the primary tumor are often included unintentionally within the treatment volume, depending on the respective treatment philosophies. We aimed to measure the percentages of anatomical coverage of eLNs by comparing four different contouring guidelines. PATIENTS AND METHODS: Planning target volumes (PTVs) were contoured using planning computed tomography (CT) scans of 11 patients with PDAC based on the Oxford, RTOG (Radiation Therapy Oncology Group), Michigan, and SCALOP (Selective Chemoradiation in Advanced Localised Pancreatic Cancer trial) guidelines. Clinical target volumes (CTVs) included the peripancreatic, para-aortic, paracaval, celiac trunk, superior mesenteric, and portal vein lymph node areas. Volumetric comparisons of the coverage of all eLN regions were conducted to illustrate the differences between the four contouring strategies. RESULTS: The PTV sizes of the RTOG and Oxford guidelines were comparable. The SCALOP and Michigan PTV sizes were similar to each other and significantly smaller than the RTOG and Oxford PTVs. A large variability of eLN coverage was found for the various subregions according to the respective contouring strategies. CONCLUSION: This is the first study to directly compare the percentage of anatomical coverage of eLNs according to four PTVs in the same patient cohort. Potential practical consequences are discussed in detail.

The dependence on magnetic field strength of correlated internal gradient relaxation time distributions in heterogeneous materials.

Magnetic susceptibility differences in porous media produce local gradients within the pore space. At high magnetic fields, these inhomogeneities have the potential to greatly affect nuclear magnetic resonance measurements. We undertake a study using a new NMR technique to measure the internal gradients present in highly heterogeneous samples over a wide range of magnetic field strengths. Our results show that even at ultra-high fields there can exist signal at internal gradient strengths sufficiently small that techniques for suppressing unwanted side effects have the possibility to be used. Our findings encourage the use of these high and ultra-high field strengths for a broader range of samples. Our results also give experimental evidence to support the theory of internal gradient scaling as a function of field strength within pores.

A mobile one-sided NMR sensor with a homogeneous magnetic field: the NMR-MOLE.

A new portable NMR sensor with a novel one-sided access magnet design, termed NMR-MOLE (MObile Lateral Explorer), has been characterised in terms of sensitivity and depth penetration. The magnet has been designed to be portable and create a volume with a relatively homogeneous magnetic field, 15,000 ppm over a region from 4 to 16 mm away from the probe, with maximum sensitivity at a depth of 10 mm. The proton NMR frequency is 3.3 MHz. We have demonstrated that with this approach a highly sensitive, portable, unilateral NMR sensor can be built. Such a design is especially suited for the characterisation of liquids in situations where unilateral or portable access is required.

Short-term effects of severe dietary carbohydrate-restriction advice in Type 2 diabetes--a randomized controlled trial.

OBJECTIVE: This study sought to examine the effects of a 3-month programme of dietary advice to restrict carbohydrate intake compared with reduced-portion, low-fat advice in obese subjects with poorly controlled Type 2 diabetes. RESEARCH DESIGN AND METHODS: One hundred and two patients with Type 2 diabetes were recruited across three centres and randomly allocated to receive group education and individual dietary advice. Weight, glycaemic control, lipids and blood pressure were assessed at baseline and 3 months. Dietary quality was assessed at the end of study. RESULTS: Weight loss was greater in the low-carbohydrate (LC) group (-3.55 +/- 0.63, mean +/- sem) vs. -0.92 +/- 0.40 kg, P = 0.001) and cholesterol : high-density lipoprotein (HDL) ratio improved (-0.48 +/- 0.11 vs. -0.10 +/- 0.10, P = 0.01). However, relative saturated fat intake was greater (13.9 +/- 0.71 vs. 11.0 +/- 0.47% of dietary intake, P < 0.001), although absolute intakes were moderate. CONCLUSIONS: Carbohydrate restriction was an effective method of achieving short-term weight loss compared with standard advice, but this was at the expense of an increase in relative saturated fat intake.

Geographical distribution of breast cancers on the mammogram: an interval cancer database.

Auditing interval cancers is an important part of a breast screening radiologist's continuing education. We set out to determine whether the position of interval cancers on the mammogram differs from those detected at screening. The 773 interval cancers so far identified, and the first 200 screen detected cancers, have been entered onto a Microsoft Access 97 database developed to record pathological and radiological features, including the position of the cancer on a stylized diagram using a "point and click" system. Reports were generated showing positions of all interval cancers by classification and reader. The distribution of true interval cancers is statistically different from screen detected cancers on both views. The distribution of the false negative and screen detected cancers only differs on the oblique view. False negative and true interval cancers are of the same distribution on both craniocaudal and oblique views. However, these differences do not appear to be practically useful when applied to individual readers. We have developed a database that allows systematic recording of pathological and radiological information regarding breast cancers. Additionally, it can record the geographic position of the cancer with minimal memory requirements. Statistical differences in the distribution of false negative and screen detected cancers have been demonstrated and the stylized diagrams reinforce the importance of the conventional review areas. Although this has not identified any "blind spots" in our own readers, it nevertheless provides film readers with a tool to audit their own work.

Involvement of nitric oxide in the deregulation of cytosolic calcium in cerebellar neurons during combined glucose-oxygen deprivation.

Nitric oxide (NO) has been proposed as a neuronal messenger molecule in hypoxic/ischemic cell injury (Nowicki et al., 1991; Trifiletti, 1992). We conducted studies in a model of combined glucose-oxygen deprivation using cultured rat cerebellar granule cells. Experiments were designed to test the hypothesis that sustained elevation of cytosolic calcium ([Ca2+]i) and NO generation act in concert to trigger neuronal injury after anoxic insult. A hypoxic state was achieved by perfusing the cells with medium pre-equilibrated with argon gas. [Ca2+]i was monitored using digital-imaging fluorescence microscopy in cells loaded with fura-2 AM. Under short-term hypoxic conditions, cells displayed a progressive and sustained, moderate increase of [Ca2+]i, which returned to near basal levels on restoration of O2-containing medium. Prolonged hypoxic conditions (> 60 min) caused irreversible elevation of [Ca2+]i followed by disruption of cell membrane integrity, as indicated by severe swelling, loss of regular cell shape and processes, leakage of dye fura-2, and propidium iodide uptake ("point of no return"). Pretreatment with NG-nitro-L-arginine methyl ester (L-NAME, 100 microM), a specific NO synthase inhibitor, markedly delayed the onset of intensity of the rise of [Ca2+]i. The hypoxia-induced elevation of [Ca2+]i was also greatly attenuated if L-NAME (100 microM) was added to the argon-perfused medium before the cells demonstrated signs of irreversible injury. Prolonged or repeated hypoxic conditions, however, caused a rapid and intense increase of [Ca2+]i, which could not be blocked by inhibition of NO synthase (NOS). In addition, reoxygenation after the "point of no return," as characterized above, greatly potentiated [Ca2+]i overload and facilitated the process of cell injury. The potentiation and facilitation of cell damage, as demonstrated by rapid massive increase of [Ca2+]i and subsequent cell death, was not blocked by NOS inhibitor, L-NAME.

A method to distinguish between chemical shift and susceptibility effects in NMR microscopy and its application to insect larvae.

We propose a simple method of distinguishing Zeeman broadening arising from susceptibility inhomogeneity and chemical shift variation, applicable to NMR microscopy. The method is based on the use of a specially built probe-head in which orthogonal sample alignment is possible using the same radiofrequency (RF) coil. This allows the investigation of alignment effects in image distortion and relies on the fact that the isotropic chemical shift is invariant under reorientation, whereas the susceptibility-related local field will depend strongly on relative orientation of bounding surfaces with the external polarizing field. We apply this approach to the study of a simple phantom, and an insect larva (Spodoptera litura Fabricius), demonstrating in the latter case that susceptibility variations are sufficiently small to allow chemical shift imaging on a scale greater than 1 ppm.

Tityustoxin-K alpha, from scorpion venom, blocks voltage-gated, non-inactivating potassium current in cultured central neurons.

Whole-cell voltage-clamp was used to examine the effects of tityustoxin-K alpha (TsTX-K alpha), from the venom of the scorpion Tityus serrulatis, on voltage-gated K+ currents in cultured hippocampal neurons and cerebellar granule cells. Slowly activating, noninactivating outward currents (IK) were generated by depolarizing steps from a holding potential of -60 mV to potentials positive to -40 mV. TsTX-K alpha produced a dose-dependent block of the sustained outward current. The fraction of total current blocked ranged from 10 to 60% over a concentration range of 2.5-120 nM in both cerebellar and hippocampal neurons. A hyperpolarizing prepulse to -100 mV was used to generate a rapidly inactivating current with properties like those of IA. When IA was isolated pharmacologically (with 5-10 mM TEA to block IK) or by subtracting IK from total outward current, TsTX-K alpha had no effect on the IA in either cell type. TsTX-K alpha also had no apparent effect on the leak conductance or on the inward rectifier current in these cells. The data indicate that TsTX-K alpha in cultured mammalian neurons is a potent and selective blocker of a voltage-gated, non-inactivating K+ current with properties like those of a delayed rectifier.

Practical aspects of shielded gradient-coil design for localised in vivo NMR spectroscopy and small-scale imaging.

For a number of NMR applications the availability of screened gradients is crucial to minimize the effect of eddy currents on the NMR signal. In this paper we review two types of shielded gradient design: the target field and minimum inductance methods. The two designs are compared and construction details are presented. A novel coil design constructed with a double-sided primary and a single layered screen is outlined. Experimental results for both target field and minimum inductance coils are presented and compared.

Ciguatoxin-2 is a diastereomer of ciguatoxin-3.

Ciguatoxin-2, a major ciguatoxin present in the flesh and viscera of ciguateric fishes, has been shown by 1H nuclear magnetic resonance studies (2-dimensional homonuclear Hartman Hahn, nuclear Overhauser effect and decoupling difference experiments) to be a diastereomer of ciguatoxin-3, differing only in stereochemistry at carbon 52 (a quaternary carbon). This difference accounts for the significant changes in the chemical shift of resonances for protons in this region of ciguatoxin-2. Differences between ciguatoxin-1, -2 and -3 involve modifications at only one end of the ciguatoxins (ring M) and modest differences in potency, indicating that this ring contributes to, but is not critical for, high affinity binding of the ciguatoxins to voltage-dependent sodium channels. It is proposed that ciguatoxin-2 originates from a different precursor to the precursor (presumably gambiertoxin-4b) for ciguatoxin-1 and -3, and that both precursors are produced by a common biosynthetic pathway in Gambierdiscus toxicus.

Potentiation of quinolinate-induced hippocampal lesions by inhibition of NO synthesis.

Low doses of quinolinic acid (QUIN) administered intracerebroventricularly (ICV) to rats produced either no damage or mild to moderate damage in the pyramidal cell layer of the hippocampus and resulted in mild, limbic seizures in the majority of animals treated. The same dose of QUIN following ICV pretreatment with the nitric oxide synthase inhibitor N-nitro-L-arginine (NARG), produced extensive hippocampal lesions with complete loss of the pyramidal layer in 50% of the animals, and moderate damage with total neuronal loss in areas CA1 and CA3 in the remainder of the group. Animals treated with both NARG and QUIN also exhibited a greater incidence of severe convulsive behavior (9/11) and 3 deaths. Pretreatment with the nitric oxide-generating drug molsidomine attenuated the enhanced toxicity observed with combined NARG-QUIN treatment, resulting primarily in no detectable hippocampal damages and mild seizures resembling those produced by QUIN alone. Administration of NARG alone produced neither seizure activity nor histological evidence of neurotoxicity. We conclude that inhibition of nitric oxide production with NARG potentiates the neurotoxicity of quinolinic acid in the rat hippocampus.

Efficient analysis of protein 2D NMR spectra using the software package EASY.

The program EASY supports the spectral analysis of biomacromolecular two-dimensional (2D) nuclear magnetic resonance (NMR) data. It provides a user-friendly, window-based environment in which to view spectra for interactive interpretation. In addition, it includes a number of automated routines for peak-picking, spin-system identification, sequential resonance assignment in polypeptide chains, and cross peak integration. In this uniform environment, all resulting parameter lists can be recorded on disk, so that the paper plots and handwritten notes which normally accompany manual assignment of spectra can be largely eliminated. For example, in a protein structure determination by 2D 1H NMR, EASY accepts the frequency domain datasets as input, and after combined use of the automated and interactive routines it can yield a listing of conformational constraints in the format required as input for the calculation of the 3D structure. The program was extensively tested with current protein structure determinations in our laboratory. In this paper, its main features are illustrated with data on the protein basic pancreatic trypsin inhibitor.