Sarcopenia and myosteatosis in patients undergoing curative radiotherapy for head and neck cancer: Impact on survival, treatment completion, hospital admission and cost

BACKGROUND

Computed tomography (CT) is the gold standard of body composition analysis at the tissue-organ level. The present study aimed to determine the impact of CT-defined sarcopenia and myosteatosis on outcomes, including overall survival, unplanned hospital admissions and related costs, in patients who had completed treatment of curative intent for head and neck cancer (HNC).

METHODS

Retrospective observational study of patients undergoing radiotherapy of curative intent ± other treatment modalities for HNC. Tissue density data derived at the third lumbar vertebra (L3) were evaluated with sarcopenia defined per sex-specific published threshold values for skeletal muscle index, stratified by body mass index and mean skeletal muscle attenuation in HU (Hounsfield units).

RESULTS

Pre- or post-treatment images were available for 79/98 patients (80.6%) and 61/98 patients (62.2%), respectively. Sarcopenia was present in 42/79 patients pre-treatment and 36/61 patients post-treatment, whereas myosteatosis was present in 63/79 patients pre-treatment and 48/61 patients post-treatment. In patients with pre- and post-treatment images (n = 60), the median (range) percentage weight change was -8.5% (-29.9 to +11.7). On multivariable analysis, a post-treatment sarcopenia hazard ratio of 3.87 (95% confidence interval = 1.22-12.24, P = 0.021) and a pre-treatment myosteatosis hazard ratio of 8.86 (95% confidence interval = 1.12-69.88, P = 0.038) were independent predictors of reduced overall survival. There was no difference in radiotherapy or chemotherapy treatment completion based on pre-treatment sarcopenia status. The mean (SD) difference unplanned hospital admission cost was $15 846 ($17 707) for patients without sarcopenia versus $47 945 ($82 688) for patients with sarcopenia at any time point (P = 0.077).

CONCLUSIONS

As CT-defined sarcopenia and myosteatosis hold clinically meaningful prognostic value, muscle status evaluation is recommended in routine clinical practice.

A filtering approach for PET and PG predictions in a proton treatment planning system

Positron emission tomography (PET) and prompt gamma (PG) detection are promising proton therapy monitoring modalities. Fast calculation of the expected distributions is desirable for comparison to measurements and to develop/train algorithms for automatic treatment error detection. A filtering formalism was used for positron-emitter predictions and adapted to allow for its use for the beamline of any proton therapy centre. A novel approach based on a filtering formalism was developed for the prediction of energy-resolved PG distributions for arbitrary tissues. The method estimates PG yields and their energy spectra in the entire treatment field. Both approaches were implemented in a research version of the RayStation treatment planning system. The method was validated against PET monitoring data and Monte Carlo simulations for four patients treated with scanned proton beams. Longitudinal shifts between profiles from analytical and Monte Carlo calculations were within -1.7 and 0.9 mm, with maximum standard deviation of 0.9 mm and 1.1 mm, for positron-emitters and PG shifts, respectively. Normalized mean absolute errors were within 1.2 and 5.3%. When comparing measured and predicted PET data, the same more complex case yielded an average shift of 3 mm, while all other cases were below absolute average shifts of 1.1 mm. Normalized mean absolute errors were below 7.2% for all cases. A novel solution to predict positron-emitter and PG distributions in a treatment planning system is proposed, enabling calculation times of only a few seconds to minutes for entire patient cases, which is suitable for integration in daily clinical routine.

Offline imaging of positron emitters induced by therapeutic helium, carbon and oxygen ion beams with a full-ring PET/CT scanner: experiments in reference targets

In vivo verification of light ion therapy based on positron-emission tomography (PET) imaging of irradiation induced patient activation relies on activity predictions from Monte-Carlo (MC) or analytical computational engines for comparison to the measurements. In order to achieve the necessary accuracy, experimental data are indispensable for the validation of the calculation models. For this we irradiated thick reference targets with mono-energetic helium, carbon and oxygen ion beams and measured the resulting material activation offline with a commercial full-ring PET/CT scanner located nearby the treatment room. Acquired PET data were analysed over time to separate the activity contribution of different radionuclides. Determined production yields were compared to published findings obtained from in-beam activation measurements with a limited-angle double-head PET camera. In addition, we investigated the time-dependence of the measured radionuclide-specific contributions and of the distal activity range, as well as the lateral spread of the activity signal as a function of beam penetration depth. We present radionuclide-specific depth-resolved activity distributions and production yields for the radionuclides [Formula: see text], [Formula: see text] and [Formula: see text], dominating irradiation-induced patient activation. We observe systematically lower production yields with a ratio between the dual-head and our full-ring PET measurements of, on average, 1.7 and 1.3 for the oxygen and carbon beam irradiations, and 1.7 (2.1) for the high (low) energy helium beam irradiations. Findings on the temporal development of the activity range confirm the expectation, with the oxygen beam induced signal being the most sensitive scenario. The experimental data reported in this work, acquired with a state-of-the-art full ring PET scanner, provide a comprehensive and consistent basis for the benchmarking of PET signal calculation engines. In particular, they can support a fine-tuning of the underlying physics models used by the respective implementation and therefore improve the accuracy of PET-based therapy verifications at current and future treatment facilities.

Development of selected bacterial groups of the rectal microbiota of healthy calves during the first week postpartum

Aims

The intestinal microbiota of newborn calves is largely unexplored even if it is of great significance for their future health. Therefore, the aim of the study was to gain a better insight into the development dynamics of certain bacterial groups during the first week of life.

Methods and Results

Faecal samples of healthy Simmental calves (dual‐purpose breed; n = 80), bottle fed and raised in a dairy farm were taken immediately after birth and at 6/12/24/48/72/168 h (h) after birth. Samples were analysed using cultural, biochemical and molecular–biological methods. The aerobe, anaerobe, Enterobacteriaceae and Enterococcus counts of healthy calves increased significantly between 6 and 24 h postpartum (P <0·05). Apart from the anaerobes, bacterial counts decreased after reaching a plateau at 24–48 h. Enterococcus faecalis was detected in significantly higher counts compared to E. faecium (P <0·05). Lactobacilli developed more slowly and increased until day 7 after birth to a mean value of 6·8 × 10⁷ CFU per g. MALDI‐TOF analysis of 2338 lactobacilli isolates resulted in 36 different species.

Conclusions

Lactobacillus reuteri became the most common Lactobacillus sp. during the first week of life.

Significance and Impact of the Study

This fact seems to be very important for the calf’s intestinal health because L. reuteri is known to show in vitro bactericidal effects against bacterial pathogens and anti‐infective activities against rotaviruses and Cryptosporidium parvum.

Risk of institutionalization following fragility fractures in older people

Previously independent living older people suffering fractures of the hip have a high risk of new admission to a nursing home during the subsequent months. This study shows that older people admitted to hospital for fractures of the pelvis and spine have a similar risk of admission to a nursing home.

INTRODUCTION

Fall-related fractures are a serious threat to the health and well-being of older persons. Long-term consequences of hip fractures such as institutionalization and mortality are well-known. The impact of other fragility fractures is less well-understood. The aim of this study was to estimate risks of institutionalization and death for different fragility fractures and compare them with the corresponding risks after hip fracture.

METHODS

Data was retrieved from a German health insurance company. Between 2005 and 2008 more than 56,000 community-dwelling people with a hospital admission or discharge diagnosis of a fracture of the femur, spine, pelvis, proximal humerus, distal radius, tibia, or fibula were included. Crude and age-adjusted 6-month incidence rates for institutionalization and death were calculated. To compare the risks of institutionalization or mortality of non-hip fractures with the risk after hip fracture, multivariate regression models were applied.

RESULTS

Crude institutionalization rates and mortality were highest in patients with hip fracture. However, after adjustment for age, functional status, and comorbidity, risks of institutionalization after fractures of pelvis (relative risk (RR), 0.94; 95% confidence interval (CI) 0.86; 1.02 in women and 0.89; 95% CI 0.70; 1.12 in men), and spine (RR, 0.95; 95% CI 0.87; 1.03 in women and 0.91; 95% CI 0.76; 1.08 in men) were not statistically different compared to the risk after hip fracture.

CONCLUSIONS

The risk of institutionalization after fractures of the spine and pelvis was similar to the risk after hip fracture. These fracture sites seem to be associated with a significant decline in physical function.

[Bony knee injuries in childhood and adolescence]

While fractures around the knee are known to be rare, physicians have encountered a rise in the frequency due to the increased participation of children and adolescents in high-impact sports at a younger age. Even if the treatment of fractures in some cases resembles that in adults, the diagnostics and treatment in childhood and adolescence require a hígh level of experience in order avoid possible sequelae and to enable early recognition. Thorough diagnostics using clinical and imaging investigations as well as a precise weighing up of the treatment are essential to minimize differences in leg length and axial malpositioning of the leg. A decision between conservative and operative treatment is made for both the femur and tibia depending on the type of fracture. Decisive is the degree of dislocation of the fracture. In operative treatment, the axis conform reduction and subsequent stress stable treatment are particularly decisive. Avulsion trauma, bony avulsions of the intercondylar eminence and patellar injuries are also treated conservatively with immobilization or surgically with the aid of various fixation techniques, depending on the degree of dislocation.

An overview of recent developments in FLUKA PET tools

The new developments of the FLUKA Positron-Emission-Tomography (PET) tools are detailed. FLUKA is a fully integrated Monte Carlo (MC) particle transport code, used for an extended range of applications, including Medical Physics. Recently, it provided the medical community with dedicated simulation tools for clinical applications, including the PET simulation package. PET is a well-established imaging technique in nuclear medicine, and a promising method for clinical in vivo treatment verification in hadrontherapy. The application of clinically established PET scanners to new irradiation environments such as hadrontherapy requires further experimental and theoretical research to which MC simulations could be applied. The FLUKA PET tools, besides featuring PET scanner models in its library, allow the configuration of new PET prototypes via the FLUKA Graphical User Interface (GUI) Flair. Both the beam time structure and scan time can be specified by the user, reproducing PET acquisitions in time, in a particle therapy scenario. Furthermore, different scoring routines allow the analysis of single and coincident events, and identification of parent isotopes generating annihilation events. Two reconstruction codes are currently supported: the Filtered Back-Projection (FBP) and Maximum-Likelihood Expectation Maximization (MLEM), the latter embedded in the tools. Compatibility with other reconstruction frameworks is also possible. The FLUKA PET tools package has been successfully tested for different detectors and scenarios, including conventional functional PET applications and in beam PET, either using radioactive sources, or simulating hadron beam irradiations. The results obtained so far confirm the FLUKA PET tools suitability to perform PET simulations in R&D environment.

[Intravesical salpingiosis: case report and review of the literature]

Endosalpingiosis of the urinary bladder is a rare benign condition characterised by the presence of ectopic endosalpingeal tissue in the bladder. If histology shows two or more Müllerian-derived components, this condition is referred to as Müllerianosis.To our knowledge less than 20 cases of Müllerianosis and 5 cases of endosalpingiosis have been documented in the literature.Although the pathogenesis remains unclear, two theories exist. The implantation theory assumes that Müllerian-derived tissue gets implanted in the wall of the urinary bladder during pelvic surgery. The second theory proposes a metaplastic origin of the disease.Patients suffering from endosalpingiosis or Müllerianosis may present with symptoms such as suprapubic pain, frequent urination, dysuria or gross haematuria, possibly with a cyclical appearance.We present the case of a 40-year-old female patient, who primarily presented with painful haematuria and was diagnosed with endosalpingiosis and treated by transurethral resection. Also we review the current literature.

International Bullous Diseases Group: consensus on diagnostic criteria for epidermolysis bullosa acquisita

BACKGROUND

Epidermolysis bullosa acquisita (EBA) is a complex autoimmune bullous disease disease with variable clinical presentations and multiple possible diagnostic tests, making an international consensus on the diagnosis of EBA essential.

OBJECTIVES

To obtain an international consensus on the clinical and diagnostic criteria for EBA.

METHODS

The International Bullous Diseases Group (IBDG) met three times to discuss the clinical and diagnostic criteria for EBA. For the final voting exercise, 22 experts from 14 different countries voted on 50 different items. When > 30% disagreed with a proposal, a discussion was held and re-voting carried out.

RESULTS

In total, 48 of 50 proposals achieved consensus after discussion. This included nine diagnostic criteria, which are summarized in a flow chart. The IBDG was unable to determine one procedure that would be applicable worldwide. A limitation of the study is that differential diagnosis of bullous systemic lupus erythematosus has not been addressed.

CONCLUSIONS

This first international consensus conference established generally agreed-upon clinical and laboratory criteria defining the clinical classification of and diagnostic testing for EBA. Holding these voting exercises in person with the possibility of discussion prior to voting has advantages in reaching consensus over Delphi exercises with remote voting.

Methods for identification and differentiation of different Shewanella spp. isolates for diagnostic use

Shewanella spp. are Gram-negative, rod-shaped, motile bacteria that are widely distributed in marine and freshwater environments. The bacteria are present in the physiological microflora of fish from temperate waters and are known as fish spoilage species. From clinically healthy fish and from fish with skin ulcerations, Shewanella spp. is regularly isolated, indicating a possible role as fish pathogen. In this study, 74 isolates of Shewanella spp. were analysed. For species identification, biochemical techniques, 16S rRNA sequencing, MALDI-TOF MS and the Sherlock Microbial Identification System (MIS) based on the composition of fatty acid ethyl esters were compared. The phylogenetic relationship, cytotoxicity in vitro and resistance against antibiotics were tested. The most reliable method for species identification was 16S rRNA sequencing. From diseased fish, clinically healthy fish and the aquatic environment, different Shewanella species were isolated. This indicates that Shewanella spp. is widespread in the aquatic milieu and acts as a secondary pathogen. The virulence of Shewanella spp. is probably not depending on the species but on the isolate itself. Many isolates of Shewanella spp. were showing multiresistances against antibiotic substances, especially in samples derived from retailers and in routine diagnostics, all Shewanella spp. should therefore be tested for resistances against antibiotic agents.

A New Approach to Phenotyping Disseminated Tumor Cells: Methodological advances and Clinical Implications

At the time of primary therapy (surgery, systemic chemotherapy and/or radiation), disseminated tumor cells in the bone marrow can be found in almost one-third of patients with cancer of the breast, ovary, esophagus, stomach, colon, and other solid tumors. Whereas the prognostic impact of the mere presence of these cells is still a matter of debate, it has been shown that expression of tumor-associated antigens in disseminated tumor cells is linked to more aggressive disease. Therefore, further characterization of disseminated tumor cells at the protein and gene level has become increasingly important. To date, the most common detection method for disseminated tumor cells in the bone marrow is an immunocytochemical approach using cytokeratin-directed antibodies for detection of epithelial cells and the APAAP system for their visualization. We have established a new double immunofluorescence technique enabling simultaneous detection, phenotyping, and antigen quantification of disseminated tumor cells. Mononuclear cells from bone marrow are enriched by Ficoll gradient centrifugation and cytospins are prepared. Double immunofluorescence is performed using antibodies against cytokeratins 8/18/19 (mAb A45B/B3) and the uPA receptor CD87 (pAb HU277). CD87 expression is recorded by confocal laser scanning microscopy (CLSM) using fluorescence labeled latex beads as the reference; staining intensities of all the scans are then summed and quantified (extended focus). This protocol, originally designed for disseminated tumor cells in bone marrow, can also be applied to disseminated tumor cells in blood, to leukapheresis cells or to cells present in malignant ascites or other malignant effusions. The tumor cells detected may be used for gene and mRNA analyses. Furthermore, disseminated tumor cells also represent interesting targets for clinical studies on patient prognosis or prediction of therapy response as well as for specific tumor-biological therapies.

Efeito de Soluções de Reumedecimento na Resistência de União de Materiais Endodônticos Biocerâmicos

Avaliar a influência de soluções de reumedecimento sobre a resistência de união à dentina radicular de uma guta-percha convencional (GP) e um composto experimental à base de vidro niobofosfato bioativo e guta-percha (GNB) associado a um cimento biocerâmico. Condutos de 80 pré-molares inferiores foram preparados utilizando instrumentos de NiTi e irrigação com hipoclorito de sódio e EDTA foram divididos aleatoriamente em quatro grupos segundo guta-percha utilizada: GNB ou GP associada com Endosequence BC Sealer- BC e solução de reumedecimento antes da obturação (água destilada - AD solução salina de tampão fosfato - PBS fluido corporal simulado - SBF ou sem solução - controle). Os espécimes foram obturados com cone único e condensação vertical. Após 30 dias, foram seccionados em fatias e realizado o teste de push-out para avaliar a resistência de união e o tipo de fratura analisado com lupa estereoscópica. Os dados foram analisados por two-way ANOVA e teste de Holm-Sidak (p<0,05). Houve diferença significativa para os tipos de guta-percha (P<0,001) e para as soluções de reumedecimento (p0,003). Interação guta-percha vs. soluções de reumedecimento não foi significativa (p 0,53). Solução de SBF proporcionou um aumento na resistência de união para a guta-percha. Associação de GNB+BC aumentou os valores de resistência de união quando comparados com a GP+BC. Uso de SBF aumentou os valores de resistência de união dos grupos estudados. Associação de GNB+BC foi benéfica, aumentando os valores de resistência de união de dentina quando comparado com a associação com GP.Palavras-chave: Endodontia. Guta-Percha. Materiais Biomiméticos.

The 67P/Churyumov-Gerasimenko observation campaign in support of the Rosetta mission

We present a summary of the campaign of remote observations that supported the European Space Agency's Rosetta mission. Telescopes across the globe (and in space) followed comet 67P/Churyumov-Gerasimenko from before Rosetta's arrival until nearly the end of the mission in September 2016. These provided essential data for mission planning, large-scale context information for the coma and tails beyond the spacecraft and a way to directly compare 67P with other comets. The observations revealed 67P to be a relatively 'well-behaved' comet, typical of Jupiter family comets and with activity patterns that repeat from orbit to orbit. Comparison between this large collection of telescopic observations and the in situ results from Rosetta will allow us to better understand comet coma chemistry and structure. This work is just beginning as the mission ends-in this paper, we present a summary of the ground-based observations and early results, and point to many questions that will be addressed in future studies.This article is part of the themed issue 'Cometary science after Rosetta'.