External validation of a lung cancer-based prediction model for two-year mortality in esophageal cancer patient cohorts.

PURPOSE/OBJECTIVE: Chemo-radiotherapy can improve the oncological outcome of esophageal cancer (EC) patients, but may cause long term radiation-induced toxicity, including an increased risk of non-cancer related death. For lung cancer patients, a model to predict 2-year total mortality using mean heart dose (MHD) and gross tumor volume (GTV) has previously been developed and validated. This project aimed to externally validate this model in EC patients. METHODS: Five EC patient cohorts from 3 different Dutch centres were used for model validation. External validity of the model was assessed separately in definitive (n = 170) and neo-adjuvant (n = 568) chemoradiotherapy (dCRT and nCRT) patients. External validity was assessed in terms of calibration by calibration plots, calibration-in-the-large (CITL) and calibration slope (CS), and discrimination by assessment of the c-statistic. If suboptimal model performance was observed, the model was further updated accordingly. RESULTS: For the dCRT patients, good calibration was found after adjustment of the intercept (CITL 0.00; CS 1.08). The c-statistic of the adjusted model was 0.67 (95%CI: 0.58 to 0.75). For nCRT patients the model needed adjustment of both the slope and the intercept because of initial miscalibration in the validation population (CITL 0.00; CS 1.72). After recalibration, the model showed perfect calibration (i.e., CITL 0, CS 1), as is common after recalibration. The c-statistic of the recalibrated model equaled 0.62 (95%CI: 0.57 to 0.67). CONCLUSION: The existing model for 2-year mortality prediction in lung cancer patients, based on the predictive factors MHD and GTV, showed good performance in EC patients after updating the intercept and/or slope of the original model.

Model-Based Selection for Proton Therapy in Breast Cancer: Development of the National Indication Protocol for Proton Therapy and First Clinical Experiences.

AIMS: Proton therapy is a radiation technique that yields less dose in normal tissues than photon therapy. In the Netherlands, proton therapy is reimbursed if the reduced dose to normal tissues is predicted to translate into a prespecified reduction in toxicity, based on nationally approved validated models. The aim of this paper is to present the development of a national indication protocol for proton therapy (NIPP) for model-based selection of breast cancer patients and to report on first clinical experiences. MATERIALS AND METHODS: A national proton therapy working group for breast cancer (PWG-BC) screened the literature for prognostic models able to estimate the individual risk of specific radiation-induced side-effects. After critical appraisal and selection of suitable models, a NIPP for breast cancer was written and subjected to comments by all stakeholders. The approved NIPP was subsequently introduced to select breast cancer patients who would benefit most from proton therapy. RESULTS: The model of Darby et al. (N Engl J Med 2013; 368:987-82) was the only model fulfilling the criteria prespecified by the PWG-BC. The model estimates the relative risk of an acute coronary event (ACE) based on the mean heart dose. The absolute lifetime risk of ACE <80 years was calculated by applying this model to the Dutch absolute incidence of ACE for female and male patients, between 40 and 70 years at breast cancer radiotherapy, with/without cardiovascular risk factors. The NIPP was approved for reimbursement in January 2019. Based on a threshold value of a 2% absolute lower risk on ACE for proton therapy compared with photons, 268 breast cancer patients have been treated in the Netherlands with proton therapy between February 2019 and January 2021. CONCLUSION: The NIPP includes a model that allows the estimation of the absolute risk on ACE <80 years based on mean heart dose. In the first 2 years, 268 breast cancer patients have been treated with proton therapy in The Netherlands.

An automated, quantitative, and case-specific evaluation of deformable image registration in computed tomography images.

A prerequisite for adaptive dose-tracking in radiotherapy is the assessment of the deformable image registration (DIR) quality. In this work, various metrics that quantify DIR uncertainties are investigated using realistic deformation fields of 26 head and neck and 12 lung cancer patients. Metrics related to the physiologically feasibility (the Jacobian determinant, harmonic energy (HE), and octahedral shear strain (OSS)) and numerically robustness of the deformation (the inverse consistency error (ICE), transitivity error (TE), and distance discordance metric (DDM)) were investigated. The deformable registrations were performed using a B-spline transformation model. The DIR error metrics were log-transformed and correlated (Pearson) against the log-transformed ground-truth error on a voxel level. Correlations of r ⩾ 0.5 were found for the DDM and HE. Given a DIR tolerance threshold of 2.0 mm and a negative predictive value of 0.90, the DDM and HE thresholds were 0.49 mm and 0.014, respectively. In conclusion, the log-transformed DDM and HE can be used to identify voxels at risk for large DIR errors with a large negative predictive value. The HE and/or DDM can therefore be used to perform automated quality assurance of each CT-based DIR for head and neck and lung cancer patients.

Radiation-induced fibrosis in the boost area after three-dimensional conformal radiotherapy with a simultaneous integrated boost technique for early-stage breast cancer: A multivariable prediction model.

BACKGROUND AND PURPOSE: To develop a multivariable prediction model for the risk of grade⩾2 fibrosis in the boost area after breast conserving surgery (BCS) followed by three-dimensional conformal radiotherapy (RT) with a simultaneous integrated photon boost (3D-CRT-SIB), five years after RT. MATERIAL AND METHODS: This prospective cohort study included 1,030 patients treated with RT for breast cancer (stage 0-III), after BCS. Data regarding physician-rated fibrosis and dose-volume parameters were available in 546 patients. A multivariable logistic regression model for grade⩾2 fibrosis was generated. RESULTS: At 5years, grade⩾2 fibrosis was observed in 13.4% of the patients. The multivariable analysis resulted in a prediction model for grade⩾2 fibrosis in the boost area including three independent variables: patient age, breast volume receiving⩾55Gy (V55 CTV breast) and the maximum radiation dose in the breast (Dmax). CONCLUSIONS: A multivariable prediction model was developed including age, V55 CTV breast and Dmax for grade⩾2 fibrosis in the boost area after breast cancer RT using a 3D-CRT-SIB technique. This model can be used to estimate the risk of fibrosis and to optimize dose distributions aiming at reducing this risk.

New precise measurement of the pion weak form factors in pi+-->e+ nugamma decay.

We have measured the pi+-->e+ nugamma branching ratio over a wide region of phase space, based on a total of 65 460 events acquired using the PIBETA detector. Minimum-chi2 fits to the measured (E(e+), E(gamma) energy distributions result in the weak form factor value of F(A)=0.0119(1) with a fixed value of F(V)=0.0259. An unconstrained fit yields F(V)=0.0258(17) and F(A)=0.0117(17). In addition, we have measured a=0.10(6) for the dependence of F(V) on q2, the e+ nu pair invariant mass squared, parametrized as F(V)(q2)=F(V)(0)(1+aq(2)). The branching ratio for the kinematic region E(gamma)>10 MeV and theta(e(+)gamma)>40 degrees is measured to be B(expt)=73.86(54)x10(-8). Earlier deviations we reported in the high-E(gamma)-low-E(e+) kinematic region are resolved without a tensor term. We also derive new values for the pion polarizability alpha(E)=2.78(10)x10(-4) fm3 and neutral pion lifetime tau(pi0)=(8.5+/-1.1)x10(-17) s.

[Mastitis caused by Yersinia pseudotuberculosis in a cow]. / Mastitis bij het rund door Yersinia pseudotuberculosis.

Subclinical mastitis with a raised somatic cell count was diagnosed in a cow in her fifth lactation. It was caused by Yersinia pseudotuberculosis, which can also infect humans. This is the first time that Yersinia pseudotuberculosis has been isolated from a mastitis sample in The Netherlands. Despite treatment with antibiotics in the dry period, Yersinia pseudotuberculosis was still present in the same quarter in the subsequent lactation. The somatic cell count was still high and milk production was much lower than in previous lactation. The pathogen did not spread to other quarters of the same cow or to herd mates on the farm over a 1-year period.

Diagnosis of pulmonary embolism: ventilation perfusion scintigraphy versus helical computed tomography pulmonary angiography.

The present study compared the accuracy of ventilation perfusion scintigraphy (VQS) and CT pulmonary angiography (CTPA) for the diagnosis of pulmonary embolism. This was a prospective observational study of 112 patients with suspected pulmonary embolism (PE) who could be studied with both investigations within 24 h. Results were compared to final diagnosis at completion of 6-month follow up, using receiver operating characteristic (ROC) analysis. Pulmonary embolism was diagnosed in 27 referred patients (24%). The sensitivity and specificity of VQS and CTPA were similar to that reported from the literature. A normal VQ scan had the highest negative predictive value (100%), while a high-probability VQ scan had the highest positive predictive value (92%). There was no overall difference (area under the ROC curve (AUC)) between VQS (AUC (95% CI) = 0.82 (0.75,0.89)) and CTPA (AUC = 0.88 (0.81,0.94)) for the diagnosis of PE. Among patients with abnormal chest X-rays, CTPA (AUC 0.90 (0.83,0.97)) appeared somewhat better than VQS (AUC 0.78 (0.68,0.88)) but this difference did not reach statistical significance. In this instance, CTPA is at least as accurate as VQS and may provide an opportunity to make alternative diagnoses.

[A New Ex-Vivo 3D Bladder Matrix Model for Standardised Evaluation of Urothelial Transfection Methods]. / Entwicklung und Evaluation eines neuartigen 3D-Blasenmatrixmodelles zur standardisierten Untersuchung verschiedener Transfektionsmethoden.

PURPOSE: Gene therapy strategies are a promising new alternative option in the treatment of cancer diseases and great effort is dedicated to the development of new gene transfer methods. At present, in vitro cell culture experiments or in vivo animal trials are the only available alternatives in the search for new gene transfer methods. We attempted to develop and evaluate a new 3D matrix model as a step between in vitro experiments and animal trials. MATERIALS AND METHODS: We generated a convenient model with an agarose gel as a basis for small intestinal submucosa or a polyethylene membrane. The produced model consisting of human smooth muscle cells and human bladder carcinoma cells was transfected with a modified standard Lipofectamine trade mark 2000 transfection procedure and visualised by fluorescence microscopy after cryo-sectioning. RESULTS: With the help of this new technique it is possible to generate three dimensional tissues consisting of different types of cells in which the cells are adherent on the polyethylene and the SIS-membrane during the entire treatment. The resulting model was successfully transfected with the pEGFP-N1 plasmid. CONCLUSIONS: This new three dimensional model allows the standardised evaluation of new transfection methods on multilayered ex-vivo generated tissues consisting of different cells.

Gene delivery into prostate cancer cells by holmium laser application.

New approaches to treat prostate cancer (PCA) are utilizing gene therapy and aim to correct the disease at the genetic level. Getting a gene efficiently into the target cell is the subject of much interest. We used a holmium laser for transfecting rat PCA cells with the reporter gene pEGFP. By FACS analysis and fluorescence microscopy, we could demonstrate that cellular delivery of plasmid DNA was possible with high efficiencies up to 41.3%. Therefore, transfection of PCA cells by holmium laser might offer a promising new gene transfer strategy to PCA with minimal invasiveness.

In vitro transfection of human bladder cancer cells by acoustic energy.

BACKGROUND: The objective of this study was to examine and quantify the shock-wave-induced transfection of human bladder carcinoma cells. MATERIALS AND METHODS: Cell suspensions were transfected with different concentrations of the pEGFP-N1 plasmid. Shock-waves were applied in a degassed water bath with different numbers of impulses at different energy levels. Additionally, the effects of different DNA concentrations, frequencies and the absence/presence of a liquid air border were examined. RESULTS: After shock-wave application, the transfection rate increased up to a maximum of 27.10% after 1000 impulses at an energy level of 0.5 mJ/mm2. In comparison negative control groups were transfected significantly below 1%. An increase in acoustic power and frequency and of DNA concentration and the presence of a liquid-air border resulted in an increasing transfection rate. CONCLUSION: The results demonstrate that naked plasmid DNA can easily and effectively be delivered to malignant urothelial cells in vitro upon exposure to lithotripter-generated shock-waves.

Elective awake intubation in a patient with massive multinodular goitre presenting for radioiodine treatment.

We present the management of the potential airway complications in a case of massive multinodular goitre treated with radioactive iodine. The patient's trachea was prophylactically intubated, using a fibreoptic technique, to prevent further airway compromise due to thyroid oedema following radioactive iodine treatment. He remained awake and intubated for five days and was extubated when there was no clinical evidence of thyroid oedema as a consequence of his treatment. This approach avoided the considerable risk of thyroidectomy in a morbidly obese patient with airway obstruction. To the authors' knowledge this approach has not been previously described.

Brain glioma and human leukocyte antigens (HLA)--is there an association.

Expression of human leukocyte antigens (HLA) is important for the immune response against infectious agents and malignant cells. Association of single HLA antigens or HLA haplotypes with disease has been investigated previously, and positive correlations between HLA and some cancers, such as cervical or nasopharyngeal carcinomas have been reported. In the present study, HLA antigen frequencies of 65 adult Caucasian patients with low-grade, anaplastic, or malignant astrocytic glioma (WHO grades II-IV) were compared with 157 racially similar, asymptomatic control individuals. Both standard serologic and PCR techniques for HLA typing were employed for all patients and controls. Our results suggest a positive association between single HLA antigens and presence of symptomatic cerebral glioma. Compared with the control population, patients positive for HLA-A*25 had a 3.0-fold increased risk of glioma (p = 0.04), patients positive for HLA-B*27, a 2.7-fold risk (p = 0.03), and patients positive for HLA-DRB1*15, a 2.2-fold risk (p = 0.03), whereas HLA-DRB1*07 was associated with a 0.4-fold decreased risk of glioma (p = 0.02). Occurrence rate of some HLA antigen combinations and estimated haplotypes was also different in glioma patients. Thus, HLA-DRB1*15:DRB5*(51) occurrence in combination with HLA-DRB1*11 was associated with a 13.4-fold increased risk of glioma (p = 0.001), and the incidence of HLA-Cw*6:DRB1*07 with a 0.2-fold decreased risk of glioma (p = 0.03). In conclusion, single HLA antigens and their combinations and estimated haplotypes are possibly significantly more or less frequent in persons developing symptomatic cerebral glioma during their adult life, compared with asymptomatic individuals.

Association of chronic lymphocytic leukemia with specific alleles of the HLA-DR4:DR53:DQ8 haplotype in German patients.

The etiology of chronic lymphocytic leukemia (CLL) remains unknown, though a genetic susceptibility has been suggested. Results of complete DNA typing of HLA alleles in CLL patients are lacking. We compared HLA class I and class II frequencies in 101 German CLL patients and 157 healthy German controls as determined by PCR-SSP/SSO DNA analysis and serologic typing. The most striking difference was the increased frequency of HLA-DRB4*0103 [relative risk (RR) = 2.74, p < 0.0025] among patients. The presence of alleles HLA-DRB1*0401, HLA-DQB1*0302 and HLA-DPB1*0301 as well as of homozygosity for HLA-DQB1 was also associated with a higher risk for CLL, though none of these differences remained significant after correction for multiple comparisons. No association was found for any HLA class I allele. Haplotype analysis revealed a CLL-specific linkage disequilibrium for HLA-DRB1*0401:DRB4*0103 and HLA-DRB4*0103:DQB1*0302. Our results suggest that CLL could be associated with distinct class II alleles of the Caucasian haplotype HLA-DR4:DR53:DQ8, which has also been related to a susceptibility for several auto-immune diseases. The positive, though weak, association of CLL with HLA-DPB1*0301 might represent an independent susceptibility factor since no linkage disequilibrium existed with any of the other CLL-associated alleles. None of the previously reported associations with HLA class I antigens was confirmed. Our results suggest that factors within or close to the human MHC class II region confer susceptibility to CLL.

HLA-A, B, Cw and DRB1, DRB3/4/5, DQB1, DPB1 frequencies in German immunoglobulin A-deficient individuals.

HLA class I and II frequencies and haplotype frequencies were determined in 80 German immunoglobulin (Ig)A-deficient individuals and 157 healthy controls with normal IgA levels using serological and DNA typing methods. For several alleles, significant associations were found, which could be explained mainly in the context of a positive association with three different extended haplotypes (HLA-B*08:DRB1*0301: DQB1*0201, HLA-B*14:DRB1*0102:DQB1*0501 and HLA-B*44:DRB1*0701:DQB1*0202) and a negative association with a fourth haplotype (HLA-B*07:DRB1*1501:DQB1*0602). Furthermore, for the first time this study reports a positive association of IgA deficiency with DPB1 alleles. Homozygosity rate for the gene loci DRB1 and DQB1 was increased in IgA deficiency. Further analysis suggested a different pattern of HLA associations depending on the degree of IgA deficiency and the gender of the IgA-deficient individuals.

Shape of the orbital opening: individual characterization and analysis of variability in modern humans, Gorilla gorilla, and Pan troglodytes.

The description of the human orbital shape is principally qualitative in the classical literature, and characterised by adjectives such as circular, rectangular or quadrangular. In order to provide a precise quantification and interpretation of this shape, a study based on automatic image analysis and Fourier analysis was carried out on 45 human skulls (30 males, 15 females), and for comparison on 61 skulls of Gorilla gorilla (40 males, 21 females), and 34 skulls of Pan troglodytes (20 males, 14 females). Sexual dimorphism in the shape of the orbital opening was not demonstrated. Its dominant morphological features could be characterized by Fourier analysis; elliptical elongation and quadrangularity were dominant morphological features of the shape of the orbital opening in the three species. Elliptical elongation was more marked in humans and Pan, whereas quadrangularity was particularly emphasized in Gorilla. An intraspecific variability of the shape of the orbital opening existed in humans, Gorilla and Pan, and seemed close in the three species. Interspecific partition between humans, Gorilla and Pan was demonstrated despite the variability observed in the three species studied. Interspecific differences between Gorilla and the Pan-humans group were principally explained by the differences in quadrangularity, and by differences in orientation of triangularity and pentagonality. Differences in the shape of the orbital opening between humans and Pan were principally explained by differences in hexagonality, and by differences in orientation of quadrangularity. A closeness of shape between some humans and some individuals in Pan and, to a lesser degree, with some individuals in Gorilla was observed, demonstrating the existence of a morphological continuum of the shape of the orbital opening in hominoids.

Shape of the piriform aperture in Gorilla gorilla, Pan troglodytes, and modern Homo sapiens: characterization and polymorphism analysis.

By using new methodologies based on automatic image analysis, the shape of the piriform aperture was analyzed in Gorilla gorilla (33 males, 13 females), Pan troglodytes (35 males, 22 females), and modern Homo sapiens (30 males, 12 females). The determination of the piriform aperture index (breadth/height) allowed the authors to demonstrate a marked elongation of the aperture in Homo compared with Gorilla and Pan. Individual characterization of the shape was possible with great precision and without ambiguity by using Fourier analysis. An absolute, interspecific partition between Gorilla, Pan, and Homo resulted from the canonical discriminant analysis of the Fourier descriptors. However, a closeness of shape between some individuals in Pan and some in Gorilla and Homo was observed, demonstrating a morphological continuum of the shape of the piriform aperture in hominoids: Pan was in intermediate position between Gorilla and Homo. Interspecific differences between Homo and the group Pan-Gorilla were explained principally by the differences in elongation (amplitude of the second harmonic) and pentagonality (amplitude of the fifth harmonic) and by differences in orientation of quadrangularity (phase of the fourth harmonic). Differences in the shape of the piriform aperture between Pan and Gorilla were explained by differences in orientation of elongation (phase of the second harmonic) and by differences in the component of triangularity (amplitude of the third harmonic). In Gorilla and Pan, the little, elongated, and relatively trapezoidal piriform aperture seems to be a shared primitive feature (plesiomorphic), whereas an elongated piriform aperture seems to be a characteristic and derived feature (apomorphic) of modern Homo sapiens.

Independent component filters of natural images compared with simple cells in primary visual cortex.

Properties of the receptive fields of simple cells in macaque cortex were compared with properties of independent component filters generated by independent component analysis (ICA) on a large set of natural images. Histograms of spatial frequency bandwidth, orientation tuning bandwidth, aspect ratio and length of the receptive fields match well. This indicates that simple cells are well tuned to the expected statistics of natural stimuli. There is no match, however, in calculated and measured distributions for the peak of the spatial frequency response: the filters produced by ICA do not vary their spatial scale as much as simple cells do, but are fixed to scales close to the finest ones allowed by the sampling lattice. Possible ways to resolve this discrepancy are discussed.

Dipyridamole thallium-201 scintigraphy for early risk stratification of patients after uncomplicated myocardial infarction.

OBJECTIVE: To determine the safety and prognostic value of dipyridamole thallium-201 scintigraphy performed in patients within three to five days of acute myocardial infarction, including those receiving thrombolytic treatment. DESIGN: A prospective study of dipyridamole thallium-201 scintigraphy in patients early after acute myocardial infarction. SETTING: University hospital. PATIENTS: 200 patients who were clinically uncomplicated at day 3 after infarction, 92 (46%) of whom had received thrombolysis. MAIN OUTCOME MEASURES: Incidence of cardiac death, non-fatal reinfarction, readmission to hospital for unstable angina, or non-elective revascularisation procedure within six months' follow up. RESULTS: No patient had a serious complication from the dipyridamole study. At six month follow up, 55 patients (28%) had suffered a defined cardiac event. Patients who received thrombolysis had the same extent of thallium-201 redistribution and the same occurrence of subsequent cardiac events as those not receiving thrombolysis. Patients who subsequently had an event had more myocardial segments showing thallium-201 redistribution than event free patients: 2.7 (SD 1.9) v 1.2 (1.4), respectively (p < 0.001). Among all clinical and scintigraphic variables, multivariate analysis identified the extent of thallium-201 redistribution as the only independent predictor of outcome (p < 0.001). Among 63 patients (32%) of the study cohort who showed more than two myocardial segments with thallium-201 redistribution, the adjusted risk ratio for a cardiac event was 7.5 (95% confidence interval 2.9 to 19.1) compared with patients without any redistribution. CONCLUSIONS: Dipyridamole thallium-201 scintigraphy can be performed safely within a few days of the event in patients with uncomplicated myocardial infarction, including those who received thrombolysis, and can identify a subgroup of patients at high risk of future ischaemic events.

Modelling the power spectra of natural images: statistics and information.

Power spectra of an extensive set of natural images were analysed. Both the total power in a spectrum (corresponding to image contrast) and its dependence on spatial frequency vary considerably between images, and also within images when considered as functions of orientation. A series of probabilistic models for power spectra enabled calculating the information obtained from prior knowledge of parameters describing spectra. Most information is gained from contrast, 1/f2 spatial frequency behaviour, and contrast as a function of orientation. Variations in spatial frequency behaviour are relatively unimportant. For oriented contrast, a bandwidth of 10-30 deg is sufficient to obtain most information.

Indocyanine-green angiography in patients with occult choroidal neovascularization.

Several studies have stressed the role of indocyanine-green (ICG) angiography in patients with occult choroidal neovascularization (O-CNV) secondary to age-related maculopathy (ARM). The present study was undertaken to evaluate the percentage of eyes that could be converted from O-CNV without suffering pigment epithelial detachment (PED) in well-defined CNV using ICG angiography with a scanning laser system. A total of 112 patients with ARM and O-CNV without PED were included in this prospective study. All patients underwent ICG angiography with a scanning laser system. The early phase (first 3 min) of the ICG angiogram was analyzed for the presence of a neovascular network, whereas focal or irregular hyperfluorescence was noted in the late phase. The early phase of the ICG angiograms revealed in 62 (55%) eyes a well-defined CNV. In 55 of these eyes, late irregular hyperfluorescent and hypofluorescent zones were observed. Another 27 eyes presented with focal hyperfluorescent areas in the latephase studies without having shown a well-demarcated area of neovascularization in the early phase of the ICG angiogram. This study confirms that ICG angiography is an important adjunctive method to fluorescein angiography. In more than 50% of eyes with O-CNV the ICG angiograms obtained with a scanning laser ophthalmoscope enable the visualization of a neovascular network in the early phase.