Practical needle selection for Vienna-style applicators: improving therapeutic ratio in hybrid intracavitary-interstitial brachytherapy

Purpose

Hybrid intracavitary and interstitial (IC/IS) applicators improve dose distribution compared to traditional IC applicators in cervical high-dose-rate (HDR) brachytherapy. There is a learning curve to these applicators, and initial standard needle insertion patterns have not been well-established. In this study, we quantified dosimetric benefits of IC/IS applicators, and offer practical initial interstitial needle-selection, insertion depths, and dwell position recommendations.

Material and methods

Fifteen patients previously treated with a tandem and ring IC applicator and magnetic resonance (MR)-guidance were re-planned at first fraction using a digital template of Vienna-style interstitial needles. IC/IS plans maintained identical high-risk clinical target volume (HR-CTV) D_90% while reducing dose to organs at risk (OARs). To assess the validity of planning using virtual needles, virtual needle templates were overlaid on twelve clinical IC/IS plans, and the displacements between 40 physical and virtual needles were measured at 3 cm depth.

Results

The median HR-CTV volume in the present study was 19.6 cc (range, 6.6-60.5 cc). HR-CTV D_90% was maintained in all re-plans. Median bladder D_2cc decreased from 5.4 Gy per fraction to 4.8 Gy (p = 0.003); median rectum D_2cc decreased from 2.4 Gy per fraction to 2.0 Gy (p = 0.007). We suggest that a standard loading pattern should include needles in lateral channels 4, 5, and 9, 10 inserted 3 cm deep, with dwell times < 20% of the combined tandem and ring dwells. The mean displacement between planned and physical needles was 1.8 mm. All needles but three deviated less than 3.3 mm, demonstrating the validity of re-planning with virtual needles.

Conclusions

Hybrid IC/IS applicators maintain excellent D_90% coverage while improving dose to OARs compared to IC-only applicators, even in non-bulky HR-CTVs. We offer practical recommendations for needle selection, insertion depth, and relative weighting for Vienna-style applicators in small HR-CTVs. These results support previous publications, offering practical recommendations for users of Vienna-style hybrid applicators.

Direct Interstitial Decongestion in an Animal Model of Acute-on-Chronic Ischemic Heart Failure

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In ADHF, elevated CVP opposes thoracic duct lymph flow and impairs decongestion of the interstitial space.

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The use of a novel device for reducing CVP at the outflow of the thoracic duct was shown to be safe, well-tolerated, and effectively reduced EVLW, in an animal model of acute-on-chronic ischemic HF.

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Similar results were observed when translating this therapy to a human case study.

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Additional human studies to confirm these findings may establish device-based direct interstitial decongestion as a new treatment for ADHF.

Removal of excess fluid in acute decompensated heart failure (ADHF) targets the intravascular space, whereas most fluid resides in the interstitial space. The authors evaluated an approach to interstitial decongestion using a device to enhance lymph flow. The device was deployed in sheep with induced heart failure (HF) and acute volume overload to create a low-pressure zone at the thoracic duct outlet. Treatment decreased extravascular lung water (EVLW) volume (mL/kg) (-32% ± 9%, P = 0.029) compared to controls (+46% ± 9%, P = 0.003). Device-mediated thoracic duct decompression effectively reduced EVLW. Human studies may establish device-based interstitial decongestion as a new ADHF treatment.

Two decades of chronic kidney disease of unknown aetiology (CKDu) research: Existing evidence and persistent gaps from epidemiological studies in Sri Lanka

BACKGROUND

Chronic Kidney Disease of unknown origin (CKDu) excludes known primary renal conditions or systemic disease (such as diabetes mellitus or hypertension). Prominence of CKDu has been noted for some decades in Sri Lanka, especially among men in particular rural areas, prompting many studies directed towards environmental causation. This article critically reviews relevant primary studies.

METHODS

Articles for this literature review (n = 86) were found by searching Medline, Embase, Global Health and ProQuest databases over 2000-2020 utilizing a standard algorithm. Articles were critiqued according to criteria for diagnosis of CKDu, aetiological agents investigated, analytic methods employed and findings.

RESULTS

Criteria for diagnosis of CKDu varied significantly, including pre-selection by proteinuria, eGFR and biopsy proven interstitial nephritis. Prevalence studies have been largely conducted in the North Central Province, with recent studies demonstrating the presence of CKDu in other regions. Aetiological factors investigated in primary studies included water source, use of agrochemicals, agricultural work, heavy metals, snake bites, ayurvedic medication, heat stress, infectious diseases and usage of tobacco and betel leaf. There is no conclusive evidence for any one aetiological agent despite consistent evidence of distal factors such as male sex, rural residence and farming.

CONCLUSIONS

The current body of evidence for any aetiological agent as the cause of CKDu in Sri Lanka is limited. Further research with stronger study designs is necessary to increase knowledge of aetiology of CKDu in Sri Lanka to identify and eliminate exposure to possible causative agent(s) prior to concluding that the disease is multifactorial.

Acute Interstitial Pancreatitis With a Normal Lipase Level in the Background of Inflammatory Bowel Disease: A Case Report

Acute interstitial pancreatitis is usually diagnosed on the basis of clinical findings, elevated lipase level, and imaging. However, herein we present a case of a 44-year-old Caucasian male who presented with pancreatitis diagnosed on the clinical grounds in the background of inflammatory bowel disease.

Palliative Care for the Interstitial Lung Disease Patient a Must and Not Just a Need

Patients with interstitial lung disease (ILD) have many unmet palliative care needs. The majority of patients with chronic ILD have poor access to a specialist in palliative medicine and that is due to several barriers. The mortality for the ILD patient is high and reaches up to 80% if admitted to the ICU with respiratory failure. Palliative care addresses symptoms in diseases where cure is unlikely or impossible. Palliative care consultation also ensures communication among patients, caregivers and providers regarding treatments, prognosis, and end of life planning. Methods: We performed a literature review on palliative care and ILD, accessing articles published since 2002. We found 71 articles related to the topic. We chose 37 that were most relevant and with no redundancy of information to include in this review. Objectives: Summarize the palliative care needs of patients with ILD, discuss the barriers to receiving palliative care, and summarize clinical practice for providing palliative care to this patient population.

The Pulmonary Fibrosis Foundation Patient Registry. Rationale, Design, and Methods

Detailed understanding of longitudinal behavior, response to therapy, and applicable biomarkers for interstitial lung diseases (ILDs) is lacking. There is a need for a large multicenter registry that provides researchers and clinicians access to well-characterized data not limited to patients with idiopathic pulmonary fibrosis. The Pulmonary Fibrosis Foundation Patient Registry (PFF-PR) is a database that collects baseline and longitudinal demographic and clinical information about patients with ILDs in the United States. The objective of this study is to describe the patient population, data collection process, and opportunities for retrospective and prospective research with the PFF-PR. Individuals 18 years or older who had ILD diagnosed and who were seen at PFF-PR centers who provided informed consent were eligible to participate. Baseline and longitudinal demographic, spirometric, radiographic, morbidity, and mortality data are recorded into a secure electronic data capture system. Starting in 2016, the PFF-PR has collected data on 2,003 patients at 42 clinical sites in the United States. At the time of enrollment, the mean age of participants was 68 years old. Most (62%) of participants were male, and 58% had a positive smoking history. The mean forced vital capacity was 69% predicted, and the mean diffusing capacity of the lung for carbon monoxide was 43% predicted. Forty-one percent of patients were using supplemental oxygen, and 39% were on antifibrotic therapy. Reasons for attrition were mostly death or transplant, with low rates of loss to follow-up or withdrawal. The PFF-PR is a large multicenter United States-based registry that provides researchers and clinicians access to well-characterized ILD patient data.

Spectrum of Renal Lesions on Autopsy: Experience of a Tertiary Level Institute Based on Retrospective Histopathological Analysis

INTRODUCTION

Last few decades have seen a remarkable increase in the elderly population. Aging is an established risk factor for chronic kidney diseases associated with increased mortality and morbidity. The frequency and spectrum of renal pathology on autopsy specimen is not well documented and is often overlooked by physicians as well as forensic pathologists.

AIM

The present study aims to find out the prevalence and pattern of various types of renal pathologies, based on the histopathological analysis of renal tissue where autopsies were performed whether related or unrelated to renal diseases.

MATERIAL AND METHODS

This retrospective study of six years consisted of 557 autopsies. The bits of 417 samples of kidney tissue/whole kidney, retrieved at the time of autopsy were received, processed, and examined.

RESULTS

The male to female ratio approximately was 2:1, and 83.69% of cases were in 11-50 years age groups. Among the 159 cases having definitive renal findings, the commonest pathologies were seen in tubules and interstitial tissues (58.49% cases), followed by 38.36% cases with involvement of all components of renal tissues. There were four cases of isolated vascular changes and one case having Hodgkin's lymphoma. The series had 12 cases of renal tuberculosis.

CONCLUSIONS

The study highlights the various lesions of kidney found in renal tissue obtained on autopsy. The physician as well as forensic pathologists must be aware of the high prevalence and wide spectrum of possible pathologies in the kidney. The focus should be to develop more efficacious diagnostic methods for timely intervention.

Deep Learning of Computed Tomography Virtual Wedge Resection for Prediction of Histologic Usual Interstitial Pneumonitis

Rationale: The computed tomography (CT) pattern of definite or probable usual interstitial pneumonia (UIP) can be diagnostic of idiopathic pulmonary fibrosis and may obviate the need for invasive surgical biopsy. Few machine-learning studies have investigated the classification of interstitial lung disease (ILD) on CT imaging, but none have used histopathology as a reference standard.Objectives: To predict histopathologic UIP using deep learning of high-resolution computed tomography (HRCT).Methods: Institutional databases were retrospectively searched for consecutive patients with ILD, HRCT, and diagnostic histopathology from 2011 to 2014 (training cohort) and from 2016 to 2017 (testing cohort). A blinded expert radiologist and pulmonologist reviewed all training HRCT scans in consensus and classified HRCT scans based on the 2018 American Thoracic Society/European Respriatory Society/Japanese Respiratory Society/Latin American Thoracic Association diagnostic criteria for idiopathic pulmonary fibrosis. A convolutional neural network (CNN) was built accepting 4 × 4 × 2 cm virtual wedges of peripheral lung on HRCT as input and outputting the UIP histopathologic pattern. The CNN was trained and evaluated on the training cohort using fivefold cross validation and was then tested on the hold-out testing cohort. CNN and human performance were compared in the training cohort. Logistic regression and survival analyses were performed.Results: The CNN was trained on 221 patients (median age 60 yr; interquartile range [IQR], 53-66), including 71 patients (32%) with UIP or probable UIP histopathologic patterns. The CNN was tested on a separate hold-out cohort of 80 patients (median age 66 yr; IQR, 58-69), including 22 patients (27%) with UIP or probable UIP histopathologic patterns. An average of 516 wedges were generated per patient. The percentage of wedges with CNN-predicted UIP yielded a cross validation area under the curve of 74% for histopathological UIP pattern per patient. The optimal cutoff point for classifying patients on the training cohort was 16.5% of virtual lung wedges with CNN-predicted UIP and resulted in sensitivity and specificity of 74% and 58%, respectively, in the testing cohort. CNN-predicted UIP was associated with an increased risk of death or lung transplantation during cross validation (hazard ratio, 1.5; 95% confidence interval, 1.1-2.2; P = 0.03).Conclusions: Virtual lung wedge resection in patients with ILD can be used as an input to a CNN for predicting the histopathologic UIP pattern and transplant-free survival.

Recognition of Connective Tissue Disease-Related Interstitial Pneumonia Based on Histological Score-A Validation Study of an Online Diagnostic Decision Support Tool

Objectives: to evaluate the number of cases of idiopathic pulmonary fibrosis (IPF) that included histological features of connective tissue disease (CTD) and to check whether they demonstrated the clinical features of CTD, using a previously reported CTD-interstitial pneumonia (IP) index that histologically differentiates CTD-associated and idiopathic IP. Methods: patients diagnosed with IPF following video-assisted thoracoscopic biopsy through multidisciplinary team diagnosis between 2014 and 2017 were selected. Pathological observation was made by four pathologists who scored eight observational items needed for the CTD-IP index. Cases determined as CTD, by the CTD-IP index, were extracted, and their clinical features were compared. Results: a total of 94 cases of IPF were identified, of which 20 were classified into the CTD group using the CTD-IP index with reasonable interobserver agreement (k = 0.76). Cases pathologically classified into the CTD group were significantly associated with female sex, non-smoking history, autoantibody positivity, and CTD symptoms (p = 0.01, 0.03, 0.01, and 0.04, respectively). Conclusions: patients with IPF with pathological findings of CTD showed clinical characteristics similar to those of patients with CTD.

Dilemma of diagnosing thoracic sarcoidosis in tuberculosis endemic regions: An imaging-based approach. Part 1

Sarcoidosis is a multi-systemic disorder of unknown etiology, although commonly believed to be immune-mediated. Histologically, it is characterized by noncaseating granuloma which contrasts against the caseating granuloma seen in tuberculosis (TB), an infectious disease that closely mimics sarcoidosis, both clinically as well as radiologically. In TB-endemic regions, the overlapping clinico-radiological manifestations create significant diagnostic dilemma, especially since the management options are markedly different in the two entities. Part 1 of this review aims to summarize the clinical, laboratory, and imaging features of sarcoidosis, encompassing both typical and atypical manifestations, in an attempt to distinguish between the two disease entities.

Reliability and validity of the Glittre-ADL test to assess the functional status of patients with interstitial lung disease

The study objective was to investigated the reliability and validity of the ADL-Glittre test (TGlittre) to assess the functional status of patients with interstitial lung disease (ILD). Twenty-one individuals with ILD participated (age: 63 ± 11 years; DLCO: 51.0 ± 12.6%predicted), evaluated with body plethysmography, Saint George Respiratory Questionnaire, modified Medical Research Council dyspnea scale, six-minute walk test (6MWT) and monitoring of physical activity of daily living. Two TGlittre were performed, with an interval of 30 minutes between them. The TGlittre demonstrated high test-retest reliability, with an intraclass correlation coefficient of 0.90 (95%CI: 0.75–0.96; p < 0.001). Nineteen patients (90.5%) performed better on the second test (mean difference between TGlittre 1 and 2: −0.57 ± 0.96 minute; p = 0.001), with a learning effect of 11.6%. The time in TGlittre correlated with 6MWT (r = −0.70; p = 0.002) and with the total energy expenditure in physical activity of daily living (r = −0.52; p = 0.02). In %predicted, TGlittre and 6MWT also correlated (r = −0.50; p = 0.04). Correlations were observed between TGlittre and pulmonary function variables (r = −0.47 to −0.57; p = 0.01 to p = 0.04). There was no difference in the physiological response between TGlittre 1 and 2, and between TGlittre and 6MWT (p > 0.05). In conclusion, the TGlittre is reliable and valid for assessing functional status of patients with ILD.

The Risk Factors for Radiation Pneumonitis After Single-Fraction Carbon-Ion Radiotherapy for Lung Cancer or Metastasis

Simple Summary

There was no reports about the risk factors of high dose single-fraction carbon-ion radiotherapy. Although there were only small number of patients with symptomatic radiation pneumonitis after this treatment, we showed that the risk factors of radiation pneumonitis include the dose–volume parameter.

Abstract

There are no studies on the risk factors of radiation pneumonitis (RP) after carbon-ion radiotherapy at a dose of 50 Gy (relative biological effectiveness (RBE)) in a single fraction. The objective of this study was to identify factors associated with RP after radiotherapy, including dose–volume parameters. Ninety-eight patients without a history of thoracic radiotherapy who underwent treatment for solitary lung tumors between July 2013 and April 2016 were retrospectively analyzed. Treatment was planned using Xio-N. The median follow-up duration was 53 months, and the median clinical target volume was 32.3 mL. Three patients developed grade 2 RP, and one patient developed grade 3 interstitial pneumonitis. None of the patients developed grade 4 or 5 RP. The dose-volume parameters of the normal lung irradiated at least with 5–30 Gy (RBE), and the mean lung dose was significantly lower in patients with grade 0–1 RP than in those with grade 2–3 RP. Pretreatment with higher SP-D and interstitial pneumonitis were significant factors for the occurrence of symptomatic RP. The present study showed a certain standard for single-fraction carbon-ion radiotherapy that does not increase the risk of RP; however, further validation studies are needed.

Relationship of Urethral Dose and Genitourinary Toxicity Among Patients Receiving Vaginal High Dose Rate Interstitial Brachytherapy

AIMS

Interstitial brachytherapy (ISBT) plays an important role in the management of locally advanced gynaecological malignancies. However, the relationship between urinary toxicity and dose to the urethra is not well understood. We sought to evaluate the correlation between urethral dose and the incidence of genitourinary complications among patients undergoing vaginal high dose rate ISBT.

MATERIALS AND METHODS

Eighty-three patients treated with ISBT between August 2014 and April 2018 were retrospectively reviewed. CTCAE version 5.0 was used to grade toxicity. Individual treatment plans were evaluated to collect dose parameters. Urethral contours were added to the structure sets using a uniform 1 cm diameter brush and minimum doses to the hottest 0.1, 0.2 and 0.5 cm³ (D0.1cm³, D0.2cm³ and D0.5cm³) of the urethra were obtained. Total (ISBT ± external beam radiotherapy) equivalent doses in 2 Gy fractions (EQD2) received by the targets and organs at risk were calculated. Numerical counts (%) and medians (interquartile range) were used to characterise the data. Fisher's exact and the Mann-Whitney-Wilcox tests were used as appropriate. Receiver operator curve analysis was used to define the urethral threshold dose that correlated to genitourinary toxicity.

RESULTS

The median age and follow-up times were 67 years (59-75) and 25 months (16-37), respectively. Patients had predominantly primary endometrial (49%) and vaginal (37%) cancer, with four (5%) patients with metastatic rectal cancer to the vagina. Twenty-four of 79 (30%) patients experienced acute genitourinary toxicity and 34 of 71 (48%) experienced late genitourinary toxicity. In both analyses, the median urethral dose was significantly higher among those with toxicity. Receiver operator curve analysis indicated that D0.1cm³, D0.2cm³ and D0.5cm³ of the urethra were associated with the development of toxicity at doses >78, >71 and >62 Gy, respectively.

CONCLUSION

Urethral dose seems to predict genitourinary toxicity in ISBT of vaginal tumours. Further study with an expanded cohort and longer follow-up is warranted.

Tubulointerstitial nephritis without glomerular crescent formation as an underestimated subgroup of renal involvement among microscopic polyangiitis patients: A case report

Although extra-glomerular involvement of microscopic polyangiitis is not regarded as a characteristic finding of the disease, tubulointerstitial nephritis should be considered as a new subclass of renal involvement.

Interstitial Cystitis/Bladder Pain Syndrome's Correlations with Pregnancy and Neonatal Outcomes: A Study of a Population Database

PURPOSE

Our objective was to evaluate the associations with interstitial cystitis during pregnancy using a United States inpatient database.

MATERIALS AND METHODS

We conducted a retrospective cohort study utilizing the Nationwide Inpatient Sample database from the Healthcare Cost and Utilization Project. ICD-9 code number 595.1 was used to extract cases of chronic interstitial cystitis and these pregnancies were compared to pregnancies without chronic interstitial cystitis, using the Chi-squared test to evaluate nominal variables. A multivariate logistic regression model was subsequently used to adjust for statistically significant confounders (p value <0.05).

RESULTS

There were 9,095,995 deliveries during the study period; 793 pregnant women were found to have chronic interstitial cystitis. When controlling for confounding effects in terms of pregnancy outcomes, the diagnosed group had a greater risk of developing pregnancy-induced hypertension (adjusted OR 1.57, 95% CI 1.21-2.05), preeclampsia (adjusted OR 2.06, 95% CI 1.47-2.87), preterm delivery (adjusted OR 1.63, 95% CI 1.23-2.17), preterm premature rupture of membranes (adjusted OR 2.18, 95% CI 1.25-3.79), chorioamnionitis (adjusted OR 2.05, 95% CI 1.24-3.37), delivery via cesarean section (adjusted OR 1.57, 95% CI 1.32-1.88), maternal infection (adjusted OR 2.19, 95% CI 1.40-3.43), and deep venous thromboembolism (adjusted OR 10.56, 95% CI 3.37-33.09).

CONCLUSIONS

Interstitial cystitis diagnosis is associated with an increased risk of preeclampsia, preterm birth, and other adverse pregnancy outcomes in this database study. Prospective studies are required to confirm the findings of the correlation between interstitial cystitis and adverse pregnancy outcomes.

Environmental exposure to asbestos and the risk of lung cancer: a systematic review and meta-analysis

Asbestos is a carcinogen associated with lung cancer, but few studies have examined the increased risk of lung cancer due to environmental asbestos exposure. We performed a systematic review and meta-analysis to evaluate the association between environmental asbestos exposure and lung cancer. We searched for articles on non-occupational or environmental asbestos exposure and lung cancer in PubMed, EMBASE, CINAHL and Web of Science databases. Our review included 15 studies, and except studies on ingestion exposure we performed a meta-analysis for 13 studies with respect to the type of exposure (neighbourhood and domestic/household exposure). Subgroup analyses and meta-regression were also performed. A significant increase in the risk of lung cancer was found for neighbourhood exposure (1.48, 95% CI 1.18 to 1.86), while the risk was not significantly increased for domestic/household exposure (1.04, 95% CI 0.85 to 1.27). With regard to neighbourhood exposure, naturally occurring asbestos and women were both associated with a higher risk of lung cancer; however, such an increase was not significantly greater compared with that associated with other sources of asbestos exposure and men. Although cautious interpretation is needed due to the large degree of heterogeneity and the small number of included studies, our findings imply that living near the source of asbestos increases the risk of lung cancer.

Risk of interstitial lung disease in patients treated for atrial fibrillation with dronedarone versus other antiarrhythmics

Purpose

To compare risks of interstitial lung disease (ILD) between patients treated with dronedarone versus other antiarrhythmics.

Methods

Parallel retrospective cohort studies were conducted in the United States Department of Defense Military Health System database (DoD) and the HealthCore Integrated Research Database (HIRD). Study patients were treated for atrial fibrillation (AF) with dronedarone, amiodarone, sotalol, or flecainide. Propensity score matching was employed to create analysis cohorts balanced on baseline variables considered potential confounders of treatment decisions. The study period of July 20, 2008 through September 30, 2014 included a 1‐year baseline and minimum 6 months of follow‐up, for patients with drugs dispensed between July 20, 2009 and March 31, 2014. Suspect ILD outcomes were reviewed by independent adjudicators. Cox proportional hazards regression compared risk of confirmed ILD between dronedarone and each comparator cohort. A sensitivity analysis examined the effect of broadening the outcome definition.

Results

A total 72 ILD cases (52 DoD; 20 HIRD) were confirmed among 27 892 patients. ILD risk was significantly higher among amiodarone than dronedarone initiators in DoD (HR = 2.5; 95% CI = 1.1–5.3, p = 0.02). No difference was detected in HIRD (HR = 1.0; 95% CI = 0.4–2.4). Corresponding risks in sotalol and flecainide exposure groups did not differ significantly from dronedarone in either database.

Conclusions

ILD risk among AF patients initiated on dronedarone therapy was comparable to or lower than that of amiodarone initiators, and similar to that of new sotalol or flecainide users. This finding suggests that elevated ILD risk associated with amiodarone does not necessarily extend to dronedarone or other antiarrhythmic drugs.

Venezia applicator with oblique needles improves clinical target volume coverage in distal parametrial tumor residue compared to parallel needles only

Purpose

Residual distal parametrial involvement after radiochemotherapy is a true challenge for brachytherapists since the width and asymmetry of high-risk clinical target volume (HR-CTV) are difficult to cover properly with a standard implant.

Material and methods

Dosimetric plans of five patients treated with Venezia advanced gynecological applicator at our institution were reviewed. For each patient, we compared the original plan with a new plan where oblique needles were removed and re-optimized manually. Optimization process was halted when EQD2₁₀ D₉₀ HR-CTV reached 90 Gy, when one hard constraint to organs at risk (OARs) was reached according to the EMBRACE II protocol, or when dose-rate of one of OARs exceeded 0.6 Gy/h.

Results

Tumors were large; median HR-CTV volume was 64 cc and median distance between tandem and outer contour of HR-CTV was 40 mm. For the five patients, HR-CTV EQD2₁₀ D₉₀ was superior in the plan using oblique needles, with a median difference of 6.5 Gy (range, 1.7-8.5 Gy). Median D₉₀ HR-CTV and intermediate-risk CTV (IR-CTV) were significantly increased with oblique needles: 85.9 Gy (range, 83.2-90.3 Gy) vs. 81.5 Gy (range, 77.4-84 Gy), and 68.7 Gy (range, 66.3-72.3 Gy) vs. 67 Gy (range, 64.3-69.1 Gy), p = 0.006 for both. There were no significant differences in the dose to OARs. Plans with only parallel needles had less favorable dose distribution, with cold spots on the outer parametria and higher vaginal activation to compensate parametrial coverage in its inferior part.

Conclusions

Venezia^TM applicator permits reproducible application to increase CTV coverage in patients with distal parametrial tumor residue during brachytherapy, while maintaining acceptable dose to OARs.

The value of imaging and clinical outcomes in a phase II clinical trial of a lysophosphatidic acid receptor antagonist in idiopathic pulmonary fibrosis

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive fibrotic lung disease characterized by worsening dyspnea and lung function and has a median survival of 2-3 years. Forced vital capacity (FVC) is the primary endpoint used most commonly in IPF clinical trials as it is the best surrogate for mortality. This study assessed quantitative scores from high-resolution computed tomography (HRCT) developed by machine learning as a secondary efficacy endpoint in a 26-week phase II study of BMS-986020 - an LPA1 receptor antagonist - in patients with IPF.

METHODS

HRCT scans from 96% (137/142) of randomized subjects were utilized. Quantitative lung fibrosis (QLF) scores were calculated from the HRCT images. QLF improvement was defined as ⩾2% reduction in QLF score from baseline to week 26.

RESULTS

In the placebo arm, 5% of patients demonstrated an improvement in QLF score at week 26 compared with 15% and 27% of patients in the BMS-986020 600 mg once daily (QD) and twice daily (BID) arms, respectively [versus placebo: p = 0.08 (600 mg QD); p = 0.0098 (600 mg BID)]. Significant correlations were found between changes in QLF and changes in percent predicted FVC, diffusing capacity for carbon monoxide (DLCO), and shortness of breath at week 26 (ρ = -0.41, ρ = -0.22, and ρ = 0.27, respectively; all p < 0.01).

CONCLUSIONS

This study demonstrated the utility of quantitative HRCT as an efficacy endpoint for IPF in a double-blind, placebo-controlled clinical trial setting.The reviews of this paper are available via the supplemental material section.

Urine interleukin-9 and tumor necrosis factor-α for prognosis of human acute interstitial nephritis

BACKGROUND

We previously demonstrated that urine interleukin (IL)-9 and tumor necrosis factor (TNF)-α can distinguish acute interstitial nephritis (AIN) from other causes of acute kidney injury. Here we evaluated the role of these biomarkers to prognosticate kidney function in patients with AIN.

METHODS

In a cohort of participants with biopsy-proven, adjudicated AIN, we tested the association of histological features and urine biomarkers (IL-9 and TNF-α) with estimated glomerular filtration rate measured 6 months after diagnosis (6 m-eGFR) controlling for eGFR before AIN and albuminuria. We also evaluated subgroups in whom corticosteroid use was associated with 6 m-eGFR.

RESULTS

In the 51 (93%) of the 55 participants with complete data, median (interquartile range) eGFR before and 6 m after AIN were 41 (27-69) and 28 (13-47) mL/min/1.73 m2, respectively. Patients with higher severity of interstitial fibrosis had lower 6 m-eGFR, whereas those with higher tubulointerstitial infiltrate had higher 6 m-eGFR. IL-9 levels were associated with lower 6 m-eGFR only in the subset of patients who did not receive corticosteroids [6m-eGFR per doubling of IL-9, -6.0 (-9.4 to -2.6) mL/min/1.73 m2]. Corticosteroid use was associated with higher 6 m-eGFR [20.9 (0.2, 41.6) mL/min/1.73 m2] only in those with urine IL-9 above the median (>0.66 ng/g) but not in others.

CONCLUSIONS

Urine IL-9 was associated with lower 6 m-eGFR only in participants not treated with corticosteroids. Corticosteroid use was associated with higher 6 m-eGFR in those with high urine IL-9. These findings provide a framework for IL-9-guided clinical trials to test efficacy of immunosuppressive therapy in patients with AIN.

A new species of Kerkia Radoman, 1978 (Caenogastropoda, Hydrobiidae) from Bosnia and Herzegovina

A new species of Kerkia, K.briani Rysiewska & Osikowski, sp. nov. is described from the spring Polički Studenac Vrelo (Crkvina), adjacent to the Trebišnjica River (Bosnia and Herzegovina) collected with Bou-Rouch technique, pumped from an interstitial habitat 50 cm below the bottom of the spring. The shell, female reproductive organs, and the penis are described and illustrated. Mitochondrial cytochrome oxidase subunit I (COI) and nuclear histone H3 partial sequences confirm the distinctness of the new species, and molecularly based phylogenetic relationships of Kerkia are briefly presented.

Correlates of 1-Year Change in Quality of Life in Patients with Urologic Chronic Pelvic Pain Syndrome: Findings from the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network

PURPOSE

We evaluated and identified baseline factors associated with change in health related quality of life among patients with interstitial cystitis/bladder pain syndrome and chronic prostatitis/chronic pelvic pain syndrome.

MATERIALS AND METHODS

A total of 191 men and 233 women with interstitial cystitis/bladder pain syndrome or chronic prostatitis/chronic pelvic pain syndrome (collectively referred to as urologic chronic pelvic pain syndrome) were followed for 12 months with bimonthly completion of the Short Form 12 to assess general mental and physical health related quality of life, and with biweekly assessment of condition specific health related quality of life using the Genitourinary Pain Index. A functional clustering algorithm was used to classify participants as improved, stable or worsened for each health related quality of life measure. Ordinal logistic regression was used to determine baseline factors associated with change.

RESULTS

Physical health related quality of life improved in 22% of the participants, mental health related quality of life improved in 25% and condition specific health related quality of life improved in 47%. Better baseline physical health related quality of life, older age and the presence of nonurological symptoms were associated with lower likelihood of improvement in physical health related quality of life. Better baseline mental health related quality of life, female sex, and greater baseline depression and stress were associated with a lower likelihood of improvement in mental health related quality of life. Better baseline condition specific health related quality of life and more severe baseline urologic chronic pelvic pain syndrome pain symptoms were associated with a lower likelihood of improvement in condition specific health related quality of life.

CONCLUSIONS

While several nonurologic chronic pelvic pain syndrome factors influenced the trajectory of general health related quality of life over time, only condition specific baseline health related quality of life and urologic chronic pelvic pain syndrome symptoms were associated with urologic chronic pelvic pain syndrome specific health related quality of life change. Significant differences in how urologic chronic pelvic pain syndrome impacts various aspects of health related quality of life suggest a multidisciplinary approach to assessment and treatment of these patients.