A Randomised Phase II Trial to Evaluate the Feasibility of Radiotherapy Dose Escalation, Facilitated by Intensity-Modulated Arc Radiotherapy Techniques, in High-Risk Neuroblastoma

BACKGROUND AND PURPOSE

For high-risk neuroblastoma, planning target volume coverage is often compromised to respect adjacent kidney tolerance. This trial investigated whether intensity-modulated arc radiotherapy techniques (IMAT) could facilitate dose escalation better than conventional techniques.

MATERIALS AND METHODS

Children with high-risk abdominal neuroblastoma referred for radiotherapy to the primary tumour site and involved regional lymph nodes were randomised to receive either standard dose (21 Gy in 14 fractions) or escalated dose (36 Gy in 24 fractions) radiotherapy. Dual planning with both a conventional anterior-posterior parallel opposed pair radiotherapy technique and an IMAT technique was performed. The quality of target volume and organ-at-risk delineation, and dosimetric plans, were externally reviewed. Dosimetric parameters were used to judge the superior technique for treatment. This feasibility trial was not powered to detect improvement in outcome with dose escalation.

RESULTS

Between 2017 and 2020, 50 patients were randomised and dual-planned. The IMAT technique was judged more favourable in 48 patients. In all patients randomised to receive 36 Gy, IMAT would have permitted delivery of the full dose (median D50% 36.0 Gy, inter-quartile range 36.0-36.1 Gy) to the target volume, whereas dose compromise would have been required with conventional planning (median D50% 35.6 Gy, inter-quartile range 28.7-35.9 Gy).

CONCLUSION

IMAT facilitates safe dose escalation to 36 Gy in patients receiving radiotherapy for neuroblastoma. The value of dose escalation is now being evaluated in a current prospective phase III randomised trial.

Immunological effects of dimethyl fumarate treatment in blood and CSF of patients with primary progressive MS

Dimethyl fumarate is an efficient therapy used widely in patients with relapsing-remitting multiple sclerosis (RRMS). However, lacking effect of treatment has recently been reported in patients with primary progressive MS (PPMS) (Højsgaard Chow et al., 2021). In order to further analyze the immunological treatment response we investigated the systemic and intrathecal immunological effects of dimethyl fumarate (DMF) treatment in 50 patients with PPMS who participated in a 48-week randomized controlled trial with dimethyl fumarate vs placebo. We found substantial systemic immunomodulatory effects of DMF treatment comparable with those observed in patients with RRMS. However, intrathecal effects were limited and restricted to CD4⁺ T cells presumably resulting in higher concentrations of intrathecal IL-7.

Improvements in pain, medication use and quality of life in onabotulinumtoxinA-resistant chronic migraine patients following erenumab treatment - real world outcomes

Background

The CGRP antagonists offer a novel therapeutic approach in migraine. Their utility in patients with severe forms of chronic migraine is a subject of particular interest. We present outcomes of 9 months of erenumab treatment in a cohort of patients with difficult-to-control chronic migraine, all of whom had prior unsatisfactory response to onabotulinumtoxinA.

Methods

We offered erenumab to 98 patients with a prior unsatisfactory response to onabotulinumtoxinA. Eighty of 98 had trialled greater occipital nerve injections (82%), 32/98 peripheral neurostimulation (33%) and 18/98 intravenous dihydroergotamine (18%). Thirty eight of 98 (39%) met the definition of triptan overuse and 43/98 (44%) analgesic overuse. All patients met the EHF criteria for ‘resistant migraine’. Outcome measures (recorded monthly) included days with headache limiting activities of daily living (“red”), not limiting (“amber”), headache free (“green”), and requiring triptans or other analgesics. Quality of life scores - headache impact test 6 (HIT-6), patient health questionnaire 9 (PHQ-9) and pain disability index (PDI) - were also measured.

Results

Mean number of red days improved by − 6.4 days (SE 0.67, 95%CI − 7.7 to − 5.1, p=0.001) at 3 months; − 6.8 days (SE 0.96, 95%CI − 8.80 to − 4.9, p=0.001) at 6 months and − 6.5 days (SE 0.86, 95%CI − 8.3 to − 4.8, p=0.001) at 9 months. Repeated measures ANOVA confirmed improvements in the number of red (p=0.001), green (p=0.001), triptan (p=0.001) and painkiller days (p=0.001) as well as scores of the HIT-6 (p=0.001), PHQ-9 (p=0.001), and PDI (p=0.001) across the duration of study.

Conclusion

We observed improvements in pain, medication use and quality of life in onabotulinumtoxinA-resistant chronic migraine patients following erenumab treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10194-020-01214-2.

Higher levels of social and material deprivation are associated with higher rates of influenza-like illness-related emergency department visits: Edmonton, Alberta, 2004-2014

OBJECTIVES

Neighbourhood-level deprivation is associated with hospitalization related to respiratory infections; however, hospitalizations exclude many who seek care with less severe respiratory illnesses. Another major seasonal contributor to respiratory illness-associated healthcare burdens are influenza-like illness (ILI)-related emergency department (ED) visits. We investigated associations between area-level social and material deprivation and ILI-related ED use.

STUDY DESIGN

This is a retrospective ecological study.

METHODS

We linked ILI-related ED visit data (2004-2014) for Edmonton, Alberta to a Canadian area-level material and social deprivation index, categorizing deprivation into quintiles. Using a multivariable Poisson model with log population as the offset, we modelled the relationship between visit rates and material and social deprivation adjusting for week and season, age, sex and the interaction between age and sex.

RESULTS

We included 67,585 ILI-related ED visits, representing 1075.5 (95% confidence interval (CI) = 1067.4-1083.6) visits per 100,000 person-years. ILI-related visit rates increased as each of material and social deprivation increased; increases were slightly greater for material deprivation. Comparing the most deprived quintile to the least deprived quintile: for material deprivation, ILI-related ED visit rates were two times higher (rate ratio (RR) = 2.00, 95% CI = 1.96-2.05); and, for social deprivation, one-and-a-half times higher (RR = 1.47, 95% CI = 1.44-1.51).

CONCLUSIONS

Higher area-level material and social deprivation were associated with higher ILI-related ED visit rates. These findings can be used to identify areas that may need additional public health and healthcare resources and to improve targeting of prevention strategies. Understanding differentials in healthcare use such as this may be especially relevant to ensuring equity of outcomes for pandemic preparedness planning.

Comment on: "A novel approach to peatlands as archives of total cumulative spatial pollution loads from atmospheric deposition of airborne elements complementary to EMEP data: Priority pollutants (Pb, Cd, Hg)" by Ewa Miszczak, Sebastian Stefaniak, Adam Michczyński, Eiliv Steinnes and Irena Twardowska

A recent paper by Miszczak et al. (2020) examines metal contamination of mires in Poland and Norway. The authors conclude that lead (Pb) records in ombrotrophic peatlands cannot be used to reconstruct the chronological history of anthropogenic activities due to post-depositional mobility of the metal. We contest this general conclusion which stands in contrast with a significant body of literature demonstrating that Pb is largely immobile in the vast majority of ombrotrophic peatlands. Our aim is to reaffirm the crucial contribution that peat records have made to our knowledge of atmospheric Pb contamination. In addition, we reiterate the necessity of following established protocols to produce reliable records of anthropogenic Pb contamination in environmental archives.

Identifying the barriers and facilitators for homeless people to achieve good oral health

OBJECTIVE

A qualitative exploration of the barriers and facilitators for people experiencing homelessness achieving good oral health.

PARTICIPANTS

Adults using two homeless centres in Leeds.

METHODS

Focus group discussions were convened with homeless people using support services. Both an inductive and deductive approach to data analysis was taken. Themes were identified and then a framework applied to analysis using Nvivo software.

RESULTS

Three focus group discussions with 16 participants were conducted with people experiencing homelessness. The barriers identified were insufficient information on local dental services, negative attitudes of oral health professionals, low priority of dental care, anxiety and cost of dental treatments. Facilitators included single dental appointments, accessible dental locations and being treated with respect.

CONCLUSIONS

Despite the barriers that prevent people experiencing homelessness from maintaining and improving their oral health, the participants were aware that they needed oral healthcare and requested that dental services were made available to them and were accessible in line with their socioeconomic status and needs.

Effect of crowding and confinement on first-passage times: A model study

We study the "color dynamics" of a hard-disk fluid confined in an annulus, as well as the corresponding hard-sphere system in three dimensions, using event-driven simulation in order to explore the effect of confinement and self-crowding on the search for targets. We compute the mean first-passage times (MFPTs) of red particles transiting from the outer to the inner boundary as well as those of blue particles passing from the inner to the outer boundary for different packing fractions and geometries. In the steady state the reaction rate, defined as the rate of collision of red particles with the inner boundary, is inversely proportional to the sum of the MFPTs. The reaction rate is wall mediated (ballistic) at low densities and diffusion controlled at higher densities and displays a maximum at intermediate densities. At moderate to high densities, the presence of layering has a strong influence on the search process. The numerical results for the reaction rate and MFPTs are compared with a ballistic model at low densities and a Smoluchowski approach with uniform diffusivities at higher densities. We discuss the reasons for the limited validity of the theoretical approaches. The maximum in the reaction rate is qualitatively well rendered by a Bosanquet-like approach that interpolates between the two regimes. Finally, we compute the position-dependent diffusivity from the MFPTs and observe that it is out of phase with the radial density.

First-Passage Times in d-Dimensional Heterogeneous Media

Although there are many theoretical studies of the mean first-passage time (MFPT), most neglect the diffusive heterogeneity of real systems. We present exact analytical expressions for the MFPT and residence times of a pointlike particle diffusing in a spherically symmetric d-dimensional heterogeneous system composed of two concentric media with different diffusion coefficients with an absorbing inner boundary (target) and a reflecting outer boundary. By varying the convention, e.g., Itō, Stratonovich, or isothermal, chosen to interpret the overdamped Langevin equation with multiplicative noise describing the diffusion process, we find different predictions and counterintuitive results for the residence time in the outer region and hence for the MFPT, while the residence time in the inner region is independent of the convention. This convention dependence of residence times and the MFPT could provide insights about the heterogeneous diffusion in a cell or in a tumor, or for animal and insect searches inside their home range.

Cascading blockages in channel bundles

Flow in channel networks may involve a redistribution of flux following the blockage or failure of an individual link. Here we consider a simplified model consisting of N(c) parallel channels conveying a particulate flux. Particles enter these channels according to a homogeneous Poisson process and an individual channel blocks if more than N particles are simultaneously present. The behavior of the composite system depends strongly on how the flux of entering particles is redistributed following a blockage. We consider two cases. In the first, the intensity on each open channel remains constant while in the second the total intensity is evenly redistributed over the open channels. We obtain exact results for arbitrary N(c) and N for a system of independent channels and for arbitrary N(c) and N=1 for coupled channels. For N>1 we present approximate analytical as well as numerical results. Independent channels block at a decreasing rate due to a simple combinatorial effect, while for coupled channels the interval between successive blockages remains constant for N=1 but decreases for N>1. This accelerating cascade is due to the nonlinear dependence of the mean blocking time of a single channel on the entering particle flux that more than compensates for the decrease in the number of active channels.

Generalized model of blockage in particulate flow limited by channel carrying capacity

We investigate stochastic models of particles entering a channel with a random time distribution. When the number of particles present in the channel exceeds a critical value N, a blockage occurs and the particle flux is definitively interrupted. By introducing an integral representation of the n-particle survival probabilities, we obtain exact expressions for the survival probability, the distribution of the number of particles that pass before failure, the instantaneous flux of exiting particles, and their time correlation. We generalize previous results for N=2 to an arbitrary distribution of entry times and obtain exact solutions for N=3 for a Poisson distribution and partial results for N≥4.

Persistent and emerging micro-organic contaminants in Chalk groundwater of England and France

The Chalk aquifer of Northern Europe is an internationally important source of drinking water and sustains baseflow for surface water ecosystems. The areal distribution of microorganic (MO) contaminants, particularly non-regulated emerging MOs, in this aquifer is poorly understood. This study presents results from a reconnaissance survey of MOs in Chalk groundwater, including pharmaceuticals, personal care products and pesticides and their transformation products, conducted across the major Chalk aquifers of England and France. Data from a total of 345 sites collected during 2011 were included in this study to provide a representative baseline assessment of MO occurrence in groundwater. A suite of 42 MOs were analysed for at each site including industrial compounds (n=16), pesticides (n=14) and pharmaceuticals, personal care and lifestyle products (n=12). Occurrence data is evaluated in relation to land use, aquifer exposure, well depth and depth to groundwater to provide an understanding of vulnerable groundwater settings.

Long-term decline of the Amazon carbon sink

Atmospheric carbon dioxide records indicate that the land surface has acted as a strong global carbon sink over recent decades, with a substantial fraction of this sink probably located in the tropics, particularly in the Amazon. Nevertheless, it is unclear how the terrestrial carbon sink will evolve as climate and atmospheric composition continue to change. Here we analyse the historical evolution of the biomass dynamics of the Amazon rainforest over three decades using a distributed network of 321 plots. While this analysis confirms that Amazon forests have acted as a long-term net biomass sink, we find a long-term decreasing trend of carbon accumulation. Rates of net increase in above-ground biomass declined by one-third during the past decade compared to the 1990s. This is a consequence of growth rate increases levelling off recently, while biomass mortality persistently increased throughout, leading to a shortening of carbon residence times. Potential drivers for the mortality increase include greater climate variability, and feedbacks of faster growth on mortality, resulting in shortened tree longevity. The observed decline of the Amazon sink diverges markedly from the recent increase in terrestrial carbon uptake at the global scale, and is contrary to expectations based on models.

Detection of Aspergillus-specific antibodies by agar gel double immunodiffusion and IgG ELISA in feline upper respiratory tract aspergillosis

Feline upper respiratory tract aspergillosis (URTA) is an emerging infectious disease. The aims of this study were: (1) to assess the diagnostic value of detection of Aspergillus-specific antibodies using an agar gel double immunodiffusion (AGID) assay and an indirect immunoglobulin G (IgG) ELISA; and (2) to determine if an aspergillin derived from mycelia of Aspergillus fumigatus, Aspergillus niger and Aspergillus flavus can be used to detect serum antibodies against cryptic Aspergillus spp. in Aspergillus section Fumigati. Sera from cats with URTA (group 1: n = 21) and two control groups (group 2: cats with other upper respiratory tract diseases, n = 25; group 3: healthy cats and cats with non-respiratory, non-fungal illness, n = 84) were tested. Isolates from cats with URTA comprised A. fumigatus (n = 5), A. flavus (n = 1) and four cryptic species: Aspergillus felis (n = 12), Aspergillus thermomutatus (Neosartorya pseudofischeri, n = 1), Aspergillus lentulus (n = 1) and Aspergillus udagawae (n = 1). Brachycephalic purebred cats were significantly more likely to develop URTA than other breeds (P = 0.013). The sensitivity (Se) of the AGID was 43% and the specificity (Sp) was 100%. At a cut-off value of 6 ELISA units/mL, the Se of the IgG ELISA was 95.2% and the Sp was 92% and 92.9% for groups 2 and 3 cats, respectively. Aspergillus-specific antibodies against all four cryptic species were detected in one or both assays. Assay Se was not associated with species identity. Detection of Aspergillus-specific antibodies by IgG ELISA has high Se and Sp for diagnosis of feline URTA.

Temperature and peat type control CO2 and CH4 production in Alaskan permafrost peats

Controls on the fate of ~277 Pg of soil organic carbon (C) stored in permafrost peatland soils remain poorly understood despite the potential for a significant positive feedback to climate change. Our objective was to quantify the temperature, moisture, organic matter, and microbial controls on soil organic carbon (SOC) losses following permafrost thaw in peat soils across Alaska. We compared the carbon dioxide (CO2 ) and methane (CH4 ) emissions from peat samples collected at active layer and permafrost depths when incubated aerobically and anaerobically at -5, -0.5, +4, and +20 °C. Temperature had a strong, positive effect on C emissions; global warming potential (GWP) was >3× larger at 20 °C than at 4 °C. Anaerobic conditions significantly reduced CO2 emissions and GWP by 47% at 20 °C but did not have a significant effect at -0.5 °C. Net anaerobic CH4 production over 30 days was 7.1 ± 2.8 μg CH4 -C gC(-1) at 20 °C. Cumulative CO2 emissions were related to organic matter chemistry and best predicted by the relative abundance of polysaccharides and proteins (R(2) = 0.81) in SOC. Carbon emissions (CO2 -C + CH4 -C) from the active layer depth peat ranged from 77% larger to not significantly different than permafrost depths and varied depending on the peat type and peat decomposition stage rather than thermal state. Potential SOC losses with warming depend not only on the magnitude of temperature increase and hydrology but also organic matter quality, permafrost history, and vegetation dynamics, which will ultimately determine net radiative forcing due to permafrost thaw.

Non-markovian models of blocking in concurrent and countercurrent flows

We investigate models in which blocking can interrupt a particulate flow process at any time. Filtration, and flow in micro or nanochannels and traffic flow are examples of such processes. We first consider concurrent flow models where particles enter a channel randomly. If at any time two particles are simultaneously present in the channel, failure occurs. The key quantities are the survival probability and the distribution of the number of particles that pass before failure. We then consider a counterflow model with two opposing Poisson streams. There is no restriction on the number of particles passing in the same direction, but blockage occurs if, at any time, two opposing particles are simultaneously present in the passage.

An Empirical Model of Slope Ratio Comparisons

Comparing slopes is a fundamental graph reading task and the aspect ratio chosen for a plot influences how easy these comparisons are to make. According to Banking to 45°, a classic design guideline first proposed and studied by Cleveland et al., aspect ratios that center slopes around 45° minimize errors in visual judgments of slope ratios. This paper revisits this earlier work. Through exploratory pilot studies that expand Cleveland et al.'s experimental design, we develop an empirical model of slope ratio estimation that fits more extreme slope ratio judgments and two common slope ratio estimation strategies. We then run two experiments to validate our model. In the first, we show that our model fits more generally than the one proposed by Cleveland et al. and we find that, in general, slope ratio errors are not minimized around 45°. In the second experiment, we explore a novel hypothesis raised by our model: that visible baselines can substantially mitigate errors made in slope judgments. We conclude with an application of our model to aspect ratio selection.

The resilience and functional role of moss in boreal and arctic ecosystems

Mosses in northern ecosystems are ubiquitous components of plant communities, and strongly influence nutrient, carbon and water cycling. We use literature review, synthesis and model simulations to explore the role of mosses in ecological stability and resilience. Moss community responses to disturbance showed all possible responses (increases, decreases, no change) within most disturbance categories. Simulations from two process-based models suggest that northern ecosystems would need to experience extreme perturbation before mosses were eliminated. But simulations with two other models suggest that loss of moss will reduce soil carbon accumulation primarily by influencing decomposition rates and soil nitrogen availability. It seems clear that mosses need to be incorporated into models as one or more plant functional types, but more empirical work is needed to determine how to best aggregate species. We highlight several issues that have not been adequately explored in moss communities, such as functional redundancy and singularity, relationships between response and effect traits, and parameter vs conceptual uncertainty in models. Mosses play an important role in several ecosystem processes that play out over centuries - permafrost formation and thaw, peat accumulation, development of microtopography - and there is a need for studies that increase our understanding of slow, long-term dynamical processes.

Kinetics of a frictional granular motor

Within the framework of a Boltzmann-Lorentz equation, we analyze the dynamics of a granular rotor immersed in a bath of thermalized particles in the presence of a frictional torque on the axis. In numerical simulations of the equation, we observe two scaling regimes at low and high bath temperatures. In the large friction limit, we obtain the exact solution of a model corresponding to asymptotic behavior of the Boltzmann-Lorentz equation. In the limit of large rotor mass and small friction, we derive a Fokker-Planck equation for which the exact solution is also obtained.

Orientational ordering in sheared inelastic dumbbells

Using even driven simulations, we show that homogeneously sheared inelastic dumbbells in two dimensions are randomly orientated in the limit of low density. As the packing fraction is increased, particles first tend to orient along the extensional axis, and then as the packing fraction is further increased, the alignment shifts closer to the flow axis. The orientational order parameter displays a continuous increase with packing fraction and does not appear to exhibit a universal scaling with elongation. Except at the highest packing fractions, the orientational distribution function can be reconstructed with only the first coefficient of the Fourier expansion.

Equilibrium adsorption on a random site surface

We examine the reversible adsorption of spherical solutes on a random site surface in which the adsorption sites are uniformly and randomly distributed on a substrate. Each site can be occupied by one solute provided that the nearest occupied site is at least one diameter away. The model is characterized by the site density and the bulk phase activity of the adsorbate. We develop a general statistical mechanical description of the model, and we obtain exact expressions for the adsorption isotherms in limiting cases of large and small activity and site density, particularly for the one-dimensional version of the model. We also propose approximate isotherms that interpolate between the exact results. These theories are in good agreement with numerical simulations of the model in two dimensions.

Exactly solvable model of reversible adsorption on a disordered substrate

We consider the reversible adsorption of particles (monomers with exclusion nearest-neighbor sites) on a one-dimensional lattice, where adsorption occurs on a finite fraction of sites selected randomly. By comparing this one-dimensional system to the pure system where all sites are available for adsorption, we show that when the activity goes to infinity, there exists a mapping between this model and the pure system at the same density. By examining the susceptibilities, we demonstrate that there is no mapping at finite activity. However, when the site density is small or moderate, the mapping exists up to second order in site density. We also propose and evaluate approximate approaches that may be applied to systems where no analytic result is known.

Angular velocity distribution of a granular planar rotator in a thermalized bath

The kinetics of a granular planar rotator with a fixed center undergoing inelastic collisions with bath particles is analyzed both numerically and analytically by means of the Boltzmann equation. The angular velocity distribution evolves from quasi-Gaussian in the Brownian limit to an algebraic decay in the limit of an infinitely light particle. In addition, we compare this model to that of a planar rotator with a free center and discuss the prospects for experimental confirmation of these results.

Oral fluorescein angiography with the scanning laser ophthalmoscope in diabetic retinopathy: a case controlled comparison with intravenous fluorescein angiography

AIM

To compare the performance of oral fundus fluorescein angiography with a confocal scanning laser ophthalmoscope (SLO) with intravenous fundus fluorescein angiography (IVFFA) with a fundus camera in the assessment of sight-threatening diabetic retinopathy.

PATIENTS AND METHODS

A total of 25 patients undergoing IVFFA to investigate their diabetic retinopathy were recruited. Participants returned 1 week later and an oral angiogram with the SLO was performed. Six facets of the oral and intravenous angiograms were scored and compared: visualization of the foveal avascular zone (FAZ); branch retinal identification; macular leakage; identification of microaneurysms in areas of macular leakage; peripheral nonperfusion, and leakage from neovascular complexes.

RESULTS

Compared to IVFFA, the FAZ was unreliably visualized with oral angiography (Kappa 0.1, 95% CI 0-0.3). In contrast, macular leakage (Kappa 0.78, 95%, CI 0.72-0.83), identification of microaneurysms in areas of macular leakage (Kappa 0.78, 95%, CI 0.72-0.83), and neovascular complexes (Kappa 1.0) were reliably seen. Analysis of the visualization of peripheral nonperfusion was complicated by the finding that profuse dye leakage from neovascular complexes obscured the view of the peripheral retina. If the five angiograms in which this occurred were excluded, oral angiography identified 23 of the 24 eyes in which significant nonperfusion was found on IVFFA.

CONCLUSION

Oral angiography with the SLO can provide high-quality angiograms that allow judgments to be made about the presence of treatable diabetic maculopathy, proliferative diabetic retinopathy, and peripheral nonperfusion. In the presence of coexisting macular oedema, it proved to be an unreliable technique with which to investigate foveal ischaemia.

Convection in vibrated annular granular beds

The response to vibration of a granular bed, consisting of a standard cylindrical geometry but with the addition of a dissipative cylindrical inner wall, has been investigated both experimentally (using positron emission particle tracking) and numerically (using hard sphere molecular dynamics simulation). The packing fraction profiles and granular temperature distributions (in both vertical and horizontal directions) were determined as a function of height and distance from the axis. The two sets of results were in reasonable agreement. The molecular dynamics simulations were used to explore the behavior of the granular bed in the inner wall-outer wall coefficient of restitution phase space. It was observed that one could control the direction of the toroidal convection rolls by manipulating the relative dissipation at the inner and outer walls via the coefficients of restitution, and with several layers of grains it was seen that double convection rolls could also be formed, a result that was subsequently confirmed experimentally.