Hydrogen Gas Inhalation Attenuates Acute Impulse Noise Trauma: A Preclinical In Vivo Study

OBJECTIVE

Molecular hydrogen (H₂) has shown therapeutic potential in several oxidative stress-related conditions in humans, is well-tolerated, and is easily administered via inhalation.The aim of this preclinical in vivo study was to investigate whether impulse noise trauma can be prevented by H₂ when inhaled immediately after impulse noise exposure.

METHODS

Guinea pigs (n = 26) were subjected to impulse noise (n = 400; 156 dB SPL; 0.33/s; n = 11; the Noise group), to impulse noise immediately followed by H₂ inhalation (2 mol%; 500 ml/min; 1 hour; n = 10; the Noise + H₂ group), or to H₂ inhalation (n = 5; the H₂ group). The acoustically evoked ABR threshold at 3.15, 6.30, 12.5, 20.0, and 30.0 kHz was assessed before and 4 days after impulse noise and/or H₂ exposure. The cochleae were harvested after the final ABR assessment for quantification of hair cells.

RESULTS

Noise exposure caused ABR threshold elevations at all frequencies (median 35, 35, 30, 35, and 35 dB SPL, the Noise group; 20, 25, 10, 13, and 20 dB SPL, the Noise + H₂ group; P < .05) but significantly less so in the Noise + H₂ group (P < .05). Outer hair cell (OHC) loss was in the apical, mid, and basal regions 8.8%, 53%, and 14% in the Noise group and 3.5%, 22%, and 1.2% in the Noise + H₂ group. The corresponding inner hair cell (IHC) loss was 0.1%, 14%, and 3.5% in the Noise group and 0%, 2.8%, and 0% in the Noise + H₂ group. The difference between the groups was significant in the basal region for OHCs (P = .003) and apical (P = .033) and basal (P = .048) regions for IHCs.

CONCLUSIONS

Acute acoustic trauma can be reduced by H₂ when inhaled immediately after impulse noise exposure.

Evaluation of an extracorporeal ozone-based bactericide system for the treatment of Escherichia coli sepsis

BACKGROUND

Sepsis is associated with substantial mortality rates. Antibiotic treatment is crucial, but global antibiotic resistance is now classified as one of the top ten global public health risks facing humanity. Ozone (O₃) is an inorganic molecule with no evident function in the body. We investigated the bactericide properties of ozone, using a novel system of extracorporeal ozone blood treatment. We hypothesized that ozone would decrease the concentration of viable Escherichia coli (E. coli) in human whole blood and that the system would be technically feasible and physiologically tolerable in a clinically relevant model of E. coli sepsis in swine.

METHODS

The E. coli strain B09-11822, a clinical isolate from a patient with septic shock was used. The in vitro study treated E. coli infected human whole blood (n = 6) with ozone. The in vivo 3.5-h sepsis model randomized swine to E. coli infusion and ozone treatment (n = 5) or E. coli infusion and no ozone treatment (n = 5). Live E. coli, 5 × 10⁷ colony-forming units (CFU/mL) was infused in a peripheral vein. Ozone treatment was initiated with a duration of 30 min after 1.5 h.

RESULTS

The single pass in vitro treatment decreased E. coli by 27%, mean 1941 to 1422 CFU/mL, mean of differences - 519.0 (95% CI - 955.0 to - 82.98, P = 0.0281). pO₂ increased (95% CI 31.35 to 48.80, P = 0.0007), pCO₂ decreased (95% CI - 3.203 to - 1.134, P = 0.0069), oxyhemoglobin increased (95% CI 1.010 to 3.669, P = 0.0113). Methemoglobin was not affected. In the sepsis model, 9/10 swine survived. One swine randomized to ozone treatment died from septic shock before initiation of the treatment. Circulatory, respiratory, and metabolic parameters were not affected by the ozone treatment. E. coli in arterial blood, in organs and in aerobic and anaerobic blood cultures did not differ. Hemoglobin, leucocytes, and methemoglobin were not affected by the treatment.

CONCLUSIONS

Ozone decreased the concentration of viable E. coli in human whole blood. The system was technically feasible and physiologically tolerable in porcine sepsis/septic shock and should be considered for further studies towards clinical applications.

Respiratory outcomes after a 1-year treatment of obstructive sleep apnoea with bibloc versus monobloc oral appliances: a multicentre, randomized equivalence trial

Objective: The benefit of bibloc over monobloc appliances in treating obstructive sleep apnoea (OSA) has not been evaluated in randomized trials. We hypothesized that these types of appliances would be equally effective.Material and methods: In this multicentre, randomized equivalence trial, patients with OSA received one type of bibloc or one type of monobloc treatment. At baseline, a 1-night polygraphy study was done, and this was repeated after 1 year. The outcome was any change in the apnoea-hypopnoea index (AHI) and the limits of equivalence between the two devices were set at ±5 AHI units.Results: Of 302 patients, 146 were randomly assigned to bibloc and 156 to monobloc appliances. In 88 and 104 patients, respectively, there were significant reductions in the AHI (p < .001) with a mean change of -16.7 (95% CI -19.4 to -14.1) in the bibloc and -11.8 (-14.9 to -8.7) in the monobloc groups. The proportions of responders defined as having an AHI <10 were 68% and 65% for the bibloc and monobloc groups, respectively. Treatment-related adverse events were mild, transient and the dropouts were more frequent in the bibloc group.Conclusions: Both types of treatments positively and significantly reduced respiratory disturbances, but at the 1-year follow-up, they were not significantly different in treating OSA, with a numerically greater reduction of the AHI value with the bibloc appliance. However, the higher proportion of treatment-related adverse events and higher proportion of dropouts among bibloc users should be balanced against the advantage of a greater reduction in the AHI.

Middle Ear Administration of a Particulate Chitosan Gel in an in vivo Model of Cisplatin Ototoxicity

Background

Middle ear (intratympanic, IT) administration is a promising therapeutic method as it offers the possibility of achieving high inner ear drug concentrations with low systemic levels, thus minimizing the risk of systemic side effects and drug-drug interactions. Premature elimination through the Eustachian tube may be reduced by stabilizing drug solutions with a hydrogel, but this raises the secondary issue of conductive hearing loss.

Aim

This study aimed to investigate the properties of a chitosan-based particulate hydrogel formulation when used as a drug carrier for IT administration in an in vivo model of ototoxicity.

Materials and Methods

Two particulate chitosan-based IT delivery systems, Thio-25 and Thio-40, were investigated in albino guinea pigs (n = 94). Both contained the hearing protecting drug candidate sodium thiosulfate with different concentrations of chitosan gel particles (25% vs. 40%). The safety of the two systems was explored in vivo. The most promising system was then tested in guinea pigs subjected to a single intravenous injection with the anticancer drug cisplatin (8 mg/kg b.w.), which has ototoxic side effects. Hearing status was evaluated with acoustically evoked frequency-specific auditory brainstem response (ABR) and hair cell counting. Finally, in vivo magnetic resonance imaging was used to study the distribution and elimination of the chitosan-based system from the middle ear cavity in comparison to a hyaluronan-based system.

Results

Both chitosan-based IT delivery systems caused ABR threshold elevations (p < 0.05) that remained after 10 days (p < 0.05) without evidence of hair cell loss, although the elevation induced by Thio-25 was significantly lower than for Thio-40 (p < 0.05). Thio-25 significantly reduced cisplatin-induced ABR threshold elevations (p < 0.05) and outer hair cell loss (p < 0.05). IT injection of the chitosan- and hyaluronan-based systems filled up most of the middle ear space. There were no significant differences between the systems in terms of distribution and elimination.

Conclusion

Particulate chitosan is a promising drug carrier for IT administration. Future studies should assess whether the physical properties of this technique allow for a smaller injection volume that would reduce conductive hearing loss.

The feasibility of an encapsulated cell approach in an animal deafness model

For patients with profound hearing loss a cochlear implant (CI) is the only treatment today. The function of a CI depends in part of the function and survival of the remaining spiral ganglion neurons (SGN). It is well known from animal models that inner ear infusion of neurotrophic factors prevents SGN degeneration and maintains electrical responsiveness in deafened animals. The purpose with this study was to investigate the effects of a novel encapsulated cell (EC) device releasing neurotrophic factors in the deafened guinea pig.

The results showed that an EC device releasing glial cell line-derived neurotrophic factor (GDNF) or brain-derived neurotrophic factor (BDNF) implanted for four weeks in deafened guinea pigs significantly preserved the SGNs and maintained their electrical responsiveness. There was a significant difference between BDNF and GDNF in favour of GDNF. This study, demonstrating positive structural and functional effects in the deafened inner ear, suggests that an implanted EC device releasing biologically protective substances offers a feasible approach for treating progressive hearing impairment.

Cisplatin-induced metabolome changes in serum: an experimental approach to identify markers for ototoxicity

BACKGROUND

Ototoxicity from treatment with the anticancer drug cisplatin remains a clinical problem. A wide range of intracellular targets of cisplatin has been found in vivo.

AIM

To investigate cisplatin-induced change of the serum metabolite profile and its association with ototoxicity.

MATERIAL AND METHODS

Guinea pigs (n = 14) were treated with cisplatin (8 mg/kg b.w., i.v.) 30 min after administration of the otoprotector candidate sodium thiosulfate (group STS; n = 7) or sodium chloride (group NaCl; n = 7). Ototoxicity was evaluated by ABR (3-30 kHz) before and 4 d after drug treatment, and by assessment of hair cell loss. A blood sample was drawn before and 4 d after drug treatment and the polar metabolome in serum was analyzed using LC-MS.

RESULTS

Cisplatin-treatment caused significant threshold elevations and outer hair cell (OHC) loss in both groups. The ototoxicity was generally lower in group STS, but a significant difference was reached only at 30 kHz (p = .007). Cisplatin treatment altered the metabolite profile significantly and similarly in both groups. A significant inverse correlation was found between L-acetylcarnitine, N-acetylneuraminic acid, ceramide, and cysteinylserine and high frequency hearing loss in group NaCl. The implication of these correlations should be explored in targeted studies.

Identification of endothelin-converting enzyme-2 as an autoantigen in autoimmune polyendocrine syndrome type 1

Autoimmune polyendocrine syndrome type 1 (APS1) is a rare monogenic autoimmune disorder caused by mutations in the autoimmune regulator (AIRE) gene. High titer autoantibodies are a characteristic feature of APS1 and are often associated with particular disease manifestations. Pituitary deficits are reported in up to 7% of all APS1 patients, with immunoreactivity to pituitary tissue frequently reported. We aimed to isolate and identify specific pituitary autoantigens in patients with APS1. Immunoscreening of a pituitary cDNA expression library identified endothelin-converting enzyme (ECE)-2 as a potential candidate autoantigen. Immunoreactivity against ECE-2 was detected in 46% APS1 patient sera, with no immunoreactivity detectable in patients with other autoimmune disorders or healthy controls. Quantitative-PCR showed ECE-2 mRNA to be most abundantly expressed in the pancreas with high levels also in the pituitary and brain. In the pancreas ECE-2 was co-expressed with insulin or somatostatin, but not glucagon and was widely expressed in GH producing cells in the guinea pig pituitary. The correlation between immunoreactivity against ECE-2 and the major recognized clinical phenotypes of APS1 including hypopituitarism was not apparent. Our results identify ECE-2 as a specific autoantigen in APS1 with a restricted neuroendocrine distribution.

Structural changes in the inner ear over time studied in the experimentally deafened guinea pig

Today a cochlear implant (CI) may significantly restore auditory function, even for people with a profound hearing loss. Because the efficacy of a CI is believed to depend mainly on the remaining population of spiral ganglion neurons (SGNs), it is important to understand the timeline of the degenerative process of the auditory neurons following deafness. Guinea pigs were transtympanically deafened with neomycin, verified by recording auditory brainstem responses (ABRs), and then sacrificed at different time points. Loss of SGNs as well as changes in cell body and nuclear volume were estimated. To study the effect of delayed treatment, a group of animals that had been deaf for 12 weeks was implanted with a stimulus electrode mimicking a CI, after which they received a 4‐week treatment with glial cell‐derived neurotrophic factor (GDNF). The electrical responsiveness of the SGNs was measured by recording electrically evoked ABRs. There was a rapid degeneration during the first 7 weeks, shown as a significant reduction of the SGN population. The degenerative process then slowed, and there was no difference in the amount of remaining neurons between weeks 7 and 18. © 2016 The Authors Journal of Neuroscience Research Published by Wiley Periodicals, Inc.

SKIN DOSE, EFFECTIVE DOSE AND RELATED RISK IN TRANSCATHETER AORTIC VALVE IMPLANTATION (TAVI) PROCEDURES: IS THE CANCER RISK ACCEPTABLE FOR YOUNGER PATIENTS?

The aim of this study was to estimate conversion coefficients for maximum entrance skin dose (MESD) and effective dose (E) for patients undergoing transcatheter aortic valve implantation (TAVI) and to evaluate the risk of exposure-induced cancer death (REID) for prospectively younger patients. Effective doses and risks were estimated for 22 patients using PCXMC whereas MESDs were estimated for a sub-group of 15 patients using Gafchromic film. The estimated conversion coefficients for skin dose [CCS = MESD/dose-area product (DAP)] and E (CCE = E/DAP) were 9.7±1.5 and 0.24±0.02 mSv/Gy cm(2), respectively. The REID ranged from 1:9900 to 1:1400 and by decreasing the age of examination to 40-50 y of age, the REID increased with a factor of 2 for females and 1.5 for males. The organ at risk was the lung. Currently, the patient population is elderly with radiation-induced skin injuries as the main risk. The risk of cancer induction should additionally be considered if younger patient populations are to be treated.

Dendrogenin A and B two new steroidal alkaloids increasing neural responsiveness in the deafened guinea pig

Aim: To investigate the therapeutic potential for treating inner ear damage of two new steroidal alkaloid compounds, Dendrogenin A and Dendrogenin B, previously shown to be potent inductors of cell differentiation.

Methods: Guinea pigs, unilaterally deafened by neomycin infusion, received a cochlear implant followed by immediate or a 2-week delayed treatment with Dendrogenin A, Dendrogenin B, and, as comparison artificial perilymph and glial cell-line derived neurotrophic factor. After a 4-week treatment period the animals were sacrificed and the cochleae processed for morphological analysis. Electrically-evoked auditory brainstem responses (eABRs) were measured weekly throughout the experiment.

Results: Following immediate or delayed Dendrogenin treatment the electrical responsiveness was significantly maintained, in a similar extent as has been shown using neurotrophic factors. Histological analysis showed that the spiral ganglion neurons density was only slightly higher than the untreated group.

Conclusions: Our results suggest that Dendrogenins constitute a new class of drugs with strong potential to improve cochlear implant efficacy and to treat neuropathy/synaptopathy related hearing loss. That electrical responsiveness was maintained despite a significantly reduced neural population suggests that the efficacy of cochlear implants is more related to the functional state of the spiral ganglion neurons than merely their number.

A prospective 10-year follow-up polygraphic study of patients treated with a mandibular protruding device

PURPOSE

This 10-year follow-up prospective study aimed to evaluate the effects of treatment with a mandibular protruding device (MPD) on respiratory parameters and subjective symptoms in patients with obstructive sleep apnea (OSA) or snoring.

METHODS

Seventy-seven consecutive patients diagnosed with OSA or snoring were treated with an MPD. At baseline and the 10-year follow-up, a polygraphic examination and questionnaires on sleep quality were administrated and weight, and neck size was measured.

RESULTS

At the 10-year follow-up, we examined 64 of the 77 patients and recorded their current treatment (45 MPD, 9 continuous positive airway pressure (CPAP), and 10 no treatment). For MPD patients, 89 % reported MPD use every night and 9 % several nights a week. Compared to baseline, MPD users with OSA had a significantly decreased oxygen desaturation index (ODI) (p = 0.006) and increased lowest arterial oxygen saturation, SaO2 nadir (p = 0.007) after 10 years. MPD treatment was successful for 70 % of OSA patients, yet 89 % subjectively considered themselves cured, indicating overestimation of the treatment effect. OSA patients who responded to treatment maintained baseline weight and neck size, while these increased for non-responders. Of the baseline snorers still using an MPD, 93 % maintained an ODI value of <5. All CPAP users had an ODI value of <5. Both OSA and snorers using an MPD had significantly fewer self- and relative reports of snoring, apnea, daytime tiredness, and poor night sleep quality (p < 0.001).

CONCLUSIONS

MPD treatment is well tolerated and effective in a long-term, 10-year perspective. Weight gain may jeopardize MPD effects. Both patients and relatives reported significantly less snoring and fewer periods of apnea.

Cometin is a novel neurotrophic factor that promotes neurite outgrowth and neuroblast migration in vitro and supports survival of spiral ganglion neurons in vivo

Neurotrophic factors are secreted proteins responsible for migration, growth and survival of neurons during development, and for maintenance and plasticity of adult neurons. Here we present a novel secreted protein named Cometin which together with Meteorin defines a new evolutionary conserved protein family. During early mouse development, Cometin is found exclusively in the floor plate and from E13.5 also in dorsal root ganglions and inner ear but apparently not in the adult nervous system. In vitro, Cometin promotes neurite outgrowth from dorsal root ganglion cells which can be blocked by inhibition of the Janus or MEK kinases. In this assay, additive effects of Cometin and Meteorin are observed indicating separate receptors. Furthermore, Cometin supports migration of neuroblasts from subventricular zone explants to the same extend as stromal cell derived factor 1a. Given the neurotrophic properties in vitro, combined with the restricted inner ear expression during development, we further investigated Cometin in relation to deafness. In neomycin deafened guinea pigs, two weeks intracochlear infusion of recombinant Cometin supports spiral ganglion neuron survival and function. In contrast to the control group receiving artificial perilymph, Cometin treated animals retain normal electrically-evoked brainstem response which is maintained several weeks after treatment cessation. Neuroprotection is also evident from stereological analysis of the spiral ganglion. Altogether, these studies show that Cometin is a potent new neurotrophic factor with therapeutic potential.

Post-treatment effects of local GDNF administration to the inner ears of deafened guinea pigs

For patients with profound hearing loss, a cochlear implant is the only treatment available today. The function of a cochlear implant depends in part on the function and survival of spiral ganglion neurons. Following deafferentation, glial cell-derived neurotrophic factor (GDNF) is known to affect spiral ganglion neuron survival. The purpose of this study was to assess delayed GDNF treatment after deafening, the effects of cessation of GDNF treatment, and the effects of subsequent antioxidants on responsiveness and survival of the spiral ganglion neurons. Three-week deafened (by local neomycin administration) guinea pigs were implanted in the scala tympani with a combined cochlear implant electrode and cannula. GDNF (1 μg/mL) or artificial perilymph was then delivered for 4 weeks, following which the animals received systemic ascorbic acid  +  Trolox or saline for an additional 4 weeks. Thresholds for electrically-evoked auditory brain stem responses (eABRs) were significantly elevated at 3 weeks with deafness, stabilized with GDNF, and showed no change with GDNF cessation and treatment with antioxidants or saline. The populations of spiral ganglion neurons were reduced with deafness (by 40% at 3 weeks and 70% at 11 weeks), and rescued from cell death by GDNF with no further reduction at 8 weeks following 4 weeks of cessation of GDNF treatment equally in both the antioxidant- and saline-treated groups. Local growth factor treatment of the deaf ear may prevent deterioration in electrical responsiveness and rescue auditory nerve cells from death; these effects outlast the period of treatment, and may enhance the benefits of cochlear implant therapy for the deaf.

In vivo infusion of UTP and uridine to the deafened guinea pig inner ear: effects on response thresholds and neural survival

Nucleotides and nucleosides are known to function as neurotransmitters and neuromodulators but have recently been shown to have a trophic effect on neurons. It has previously been shown, in an animal model for cochlear implants, that local infusion of neurotrophic factors intervenes with the degenerative processes occurring after deafening and protects the auditory spiral ganglion neurons so that electrical responsiveness is maintained. Here we test the hypothesis that nucleosides and nucleotides have a similar effect on the acutely damaged inner ear. Pigmented guinea pigs received a cochlear implant electrode for measuring electrically evoked auditory brainstem responses and a miniosmotic pump for delivering drugs directly to the cochlea. The animals were deafened by a 48-hr infusion with 10% neomycin, followed by 23 days of treatment with primarily UTP, uridine nucleotides, or as control artificial perilymph. Electrically evoked responses were measured weekly, and at the end of the experiment the cochleae were collected and processed for morphological analysis and spiral ganglion neuron counting. Both UTP- and uridine-treated groups showed significantly better response after 23 days of treatment compared with the control group. The densities of spiral ganglion neuron were significantly higher for both treated groups compared with the control group treated with artificial perilymph. The results demonstrate that UTP and uridine rescue auditory neurons and suggest that drugs acting on purinoceptors could be of clinical importance.

Skin dose alarm levels in cardiac angiography procedures: is a single DAP value sufficient?

Maximum estimated skin doses to patients undergoing coronary angiography procedures were obtained using radiographic slow film and diode dosemeters. Conversion factors of maximum entrance skin dose versus dose-area product (MESD/DAP) for diagnostic (coronary angiography (CA); 20 patients; 2 operators) and interventional procedures (percutaneous transluminal coronary angiography (PTCA); 10 patients; 1 operator) were 4.3 (mean value of 10 CA; operator A), 3.5 (mean value of 10 CA; operator B) and 9.7 (mean value of 10 PTCA; operator B) mGy(Gycm2)(-1), respectively. The results emphasise a need for both operator- and procedure-specific conversion factors. Compared with a single, global factor for all cardiac procedures and/or operators that is commonly applied today, such a refinement is expected to improve the accuracy in skin dose estimations from these procedures. Consequently, reference DAP values used in the clinic to define patients who could suffer from a radiation induced skin injury following a cardiac procedure, should be defined for each operator/procedure. The film technique was found to be superior to the diode in defining conversion factors in this study, and allowed for a rapid and accurate estimation of MESD for each patient. With appropriate positioning of the diode, a combined film/diode technique has a potential use in the training of new angiography operators. The patient body mass index (BMI) value was a good indicator of the variation in average lung dose (critical organ) between patients. The highest lung dose/DAP value was obtained for normal sized patients (BMI: 19-26), and was close to 1.5 mGy(Gycm2)(-1) with both CA and PTCA procedures.

A mandibular protruding device in obstructive sleep apnea and snoring

The overall purpose behind treatment in sleep-breathing disorders is to ease breathing and thereby reduce the risk of morbidity. The mandibular protruding device (MPD) is one method of treating both obstructive sleep apnea (OSA) and snoring. The aims of the studies were to study MPD users after 2 years and evaluate the following aspects of the MPD: subjective and objective effects on sleep, influences on airway passages and hard tissues, and the incidence and types of adverse events of the masticatory system including temporomandibular disorders. Further aims were to evaluate the impact of body posture and the effects of the MPD on pharyngeal width and to validate two methods for measuring mandibular protrusion and MPD advancement.

MATERIALS AND METHODS

Seventy-seven subjects with OSA or snorers without OSA. were admitted to the study after a medical examination, which included a somnographic registration. The patients completed questionnaires regarding sleep quality and symptoms from the masticatory system, and underwent a clinical jaw function examination, were given an MPD, and were subjected to lateral cephalometric examination. Two follow-ups, 6 months and 2 years after MPD treatment were conducted. The study population comprised 65 patients at the 2-year follow-up.

RESULTS

At the 2-year follow-up, a significant reduction of the subjective complaints was noted by 90% of the MPD users. In the objective evaluation, the oxygen desaturation index (ODI) of the OSA group (n = 39) decreased significantly from a mean of 14.7 to 3.1 and the mean arterial oxygen saturation (SaO2) increased significantly from 78% to 89%. The snorers maintained their initial values. In the total group, MPD treatment significantly increased most pharyngeal measures and lifted the hyoid bone. The pharyngeal area decreased significantly--by more than 50%--when the patient was supine, and the velum area increased significantly. At the 2-year follow-up, on upright cephalogram without MPD, the pharyngeal area had significantly increased and the velum area had significantly decreased. The mandible was posteriorly rotated (P < 0.01) as well as the lower incisors were proclined (P < 0.05). Mandibular advancement and vertical opening with an MPD, as measured with a ruler, compared well with measurements taken from a cephalogram. At the 2-year follow-up significant changes in the mean mandibular range of protrusion (+0.6 mm), overjet (-0.5 mm), and overbite (-0.8 mm) were registered. Nine of the 65 patients had developed a lateral open bite, and 2 were aware of the change. The reported frequency of headache was significantly reduced. At the 2-year follow-up there was a significant reduction in pain during mandibular movements.

CONCLUSIONS

MPD treatment significantly reduced subjective complaints of sleep disturbances and significantly reduced ODI values among OSA patients. A high MPD compliance rate after 2 years (84%) indicated a well-tolerated treatment and a low rate of side effects were noted. The key factor in OSA and snoring is the obstruction of pharynx. The MPD treatment significantly increased the pharyngeal passages and significantly reduced the size of velum and thereby facilitated the breathing.

Aspects of MR image distortions in radiotherapy treatment planning

BACKGROUND

Registration of computed tomography (CT) and magnetic resonance (MR) images are commonly performed to define the different target regions used in radiotherapy treatment planning (RTTP). The accuracy of target definition will then depend on the spatial accuracy of the CT and MR data, and on the technique used to register the images. CT images are usually regarded as geometrically correct, while MR images are known to suffer from geometric distortion. The aim of this paper is to discuss the possible impact of MR image distortions in the radiotherapy treatment planning process.

METHODS

The origin, magnitude, and relative impact of the different sources of geometric distortions that affect the MR image data at different magnetic fields and for different acquisition settings are described. Techniques for distortion correction are reviewed, and their limitations are outlined. The sensitivity of image registration techniques to the presence of geometric distortions in the MR data is discussed. Finally, an overview of image registration techniques used and results obtained in clinical radiotherapy treatment planning applications is given.

RESULTS

Spatial distortions in MR images vary with field strength and with the image acquisition protocol. The spatial accuracy generally decreases with distance from the magnet isocenter. Distortion correction techniques based on phantom evaluations cannot adequately model patient-induced distortions.

CONCLUSION

Image protocols with high gradient bandwidths should be used to reduce the spatial distortions in MR images. Correction techniques based only on phantom measurements could be sufficient at low magnetic fields, while at higher fields additional corrections of patient-related distortions might be needed. Registration techniques based on matching of Landmark points located far from the magnet isocenter are especially prone to MR distortions.

Noise-induced aspartate and glutamate efflux in the guinea pig cochlea and hearing loss

Aspartate and glutamate were monitored in the scala tympani of the guinea pig cochlea using in vivo microdialysis before and during noise exposure. Moderate level broad band noise [105 dB sound pressure level (SPL), 30 min] neither altered the levels of aspartate or glutamate, nor auditory brainstem response (ABR) thresholds. High level noise exposure (135 dB SPL, 30 min) caused a large increase in aspartate (330%), a smaller increase in glutamate (150%), and a permanent ABR threshold shift of 60-75 dB between 2.0 and 12.5 kHz. Morphological analysis of the cochlea revealed a collapse of supporting structures, swelling of the afferent dendrites under the inner hair cells, and outer hair cell loss. Pretreatment with the NMDA antagonist, MK 801 (1 mg/kg body weight, i.p.) 1 h before noise exposure protected the afferent dendrites from swelling but did not protect the collapse of supporting structures, outer hair cell loss, or auditory thresholds. In conclusion, the noise-induced increase in aspartate and glutamate release in the cochlea and the protective effect of NMDA antagonism suggest that these two neurotransmitters are involved in noise-induced hearing loss.

Characterization of hearing in an X,0 'Turner mouse'

Turner's syndrome is due to total (45,X) or partial (mosaicism) loss of one X-chromosome. The main features are short stature, ovarian dysgenesis with no estrogen production and infertility. In addition to ear and hearing disorders, middle ear problems including acute/serous otitis media and chronic middle ear disease are frequent. Sensorineural hearing loss is often seen with a dip in the mid-frequencies and also an early high frequency loss. In this study, middle-and inner-ear pathology was characterized using physiological and morphological techniques in a 'Turner mouse' that has been generated with the chromosomal aberration X,0. Otitis media was found in some of these X,0 animals, a symptom that is seldom found in control animals. The auditory brainstem responses (ABR) of the Turner mouse showed a progressive hearing loss in the high frequency region that exceeded the normal age-related hearing loss of control mice and increased latencies of the first ABR wave. Outer hair cell loss was apparent in the cochlear basal turn of Turner mice. Decreases in the amplitude of distortion product otoacoustic emissions were correlated with the loss of ABR threshold sensitivity. These results indicate that hearing problems in the Turner mouse seems to be of cochlear origin with an eighth nerve component. This Turner mouse model appears to have ear and hearing problems quite similar to humans and can therefore be used as a model to determine the auditory pathology underlying this syndrome.

Medial olivocochlear efferent terminals are protected by sound conditioning

Synaptophysin immunoreactivity was used as a marker for the olivocochlear efferent system that innervates the outer hair cells of the cochlea. An intense noise exposure at either 6.3 kHz or 1.0 kHz caused a significant reduction in anti-synaptophysin immunoreactivity within the 8-6 mm or 14-11 mm distance from the round window, respectively. In the region of the main lesion, the reduction in synaptophysin immunoreactivity for both the 6.3 and 1.0 kHz exposures correlated well with outer hair cell loss. In regions peripheral to the main lesion, some remnants of efferent nerve endings could remain even when their associated outer hair cells were missing. Pre-treatment with a low level sound conditioner (either at 6.3 tone or 1.0 kHz) effectively reduced the efferent and outer hair cell pathology induced by the 6.3 and 1.0 kHz intense noise exposures, respectively. The results demonstrate the feasibility of using anti-synaptophysin immunoreactivity as an effective means of quantifying pathological alterations to the medial cochlear efferent terminals throughout the cochlea. Furthermore, the results show that sound conditioning significantly reduces damage to the efferent terminals.

Effects of trabecular bone on marrow relaxation in the tibia

The effects of bone on marrow relaxation in the trabecular volume of the most proximal 3 cm in the left tibia were studied with a RF-spoiled gradient echo MRI protocol on a 1.0 T MR unit. The MR measurements were performed on six healthy volunteers, and repeated within one month in order to assess the precision of the method. In the same subjects, the area bone mineral density (BMD, g/cm2) was measured at the left proximal femur using dual-energy X-ray absorptiometry. The calcaneus of the same side was examined with quantitative ultrasound. The marrow T2* relaxation deviated from a mono-exponential decay, and resembled the decay of subcutaneous fat. The shape of the relaxation curve reflected the presence of several spectral components in bone marrow, and was further influenced by the amount and structure of the surrounding trabecular bone. The bone marrow decays showed substantially reduced inter-subject variability after normalisation of the marrow data fit parameters to corresponding values for s.c. fat. This suggests the use of an internal adipose tissue reference in order to correct for diet-related variations of marrow T2* estimates. The mean relative precision of the MR measurements was between 5% and 10% depending on the data fit model. Moderate-to-strong correlations between DXA BMD indices in the proximal femur and MR parameters were found (r(max)=-0.96; p < 0.01), while ultrasound-derived measures of bone strength measured on the calcaneus demonstrated significantly weaker correlations to the MR parameters (r(max)=-0.78; p > 0.05). The method employed in this study showed reasonable precision and a moderate to good correlation compared to other bone parameters derived at the same extremity, and is a promising tool for the use on patients.

Verification of single beam treatment planning using a ferrous dosimeter gel and MRI (FeMRI)

A method for analysing and comparing treatment planning system (TPS) data and ferrous dosimeter gel measurements evaluated with MRI (FeMRI) was developed, including image processing to final absorbed dose images. Measurements were analysed according to this method and FeMRI data were thereby compared with the TPS-calculated dose distribution. For photons, differences between FeMRI- and TPS dose data were mainly within +/- 2%. Minor shortcomings found in both the FeMRI system and the TPS are explained and discussed. For electron beams, there was an overall good agreement. It was found that the TPS underestimates the lateral scattering dose outside the primary beam, but the reported dose difference corresponds to a small spatial deviation (less than 2 mm). It is important to consider this single beam data comparison when the method is extended to more complicated situations, for example when using several beams.

[Alcohol-induced cognitive impairment is reversible. Neuropsychological tests but not MRT show improvement after abstinence]

Of alcoholic patients who underwent MRI (magnetic resonance imaging) of the brain and neuropsychological tests shortly after discontinuation of heavy drinking, a subgroup underwent repeat MRI scans and neuropsychological assessment one year later. The reduction in drinking habits was associated with cognitive improvement but no significant difference in MRI variables including T1-relaxation time.

Improvements in absorbed dose measurements for external radiation therapy using ferrous dosimeter gel and MR imaging (FeMRI)

A ferrous gel, based on ferrous (Fe) sulphate and agarose, was used with a clinical magnetic resonance imaging (MRI) scanner to obtain relative dose distribution data from therapeutic photon and electron beams. The FeMRI gel was scanned using a new MRI acquisition protocol optimized for T1 measurements. Thorough comparisons with silicon semiconductor detector and ionization chamber measurements, as well as with Monte Carlo calculations, were performed in order to quantify the improvements obtained using FeMRI for dose estimations. Most of the relative doses measured with FeMRI were within 2% of the doses measured with other methods. The larger discrepancies (2-4%) found at shallow depths are discussed. The uncertainty in relative dose measurements using FeMRI was significantly improved compared with previously reported results (5-10%, one standard deviation, 1 SD), and is today between 1.6% and 3.3% (depending on dose level, 2 SD). This corresponds to an improvement in the minimum detectable dose (3 SD above background) from approximately 2 Gy to better than 0.6 Gy. The results obtained in this study emphasize the importance of obtaining basic FeMRI dose data before the method is extended to complicated treatment regimes.

Reducing noise damage by using a mid-frequency sound conditioning stimulus

Sound conditioning guinea pigs to a 6.3 kHz tone at 78 dB SPL for either 13 or 24 days provides significant physiological (auditory brain stem responses, ABR; and distortion product otoacoustic emissions, DPOAE) and morphological (cochleograms) protection against a subsequent traumatic exposure (6.3 kHz, 100 dB SPL for 24 h) delivered 2 h after sound conditioning. Threshold shifts (ABR, DPOAE) were significantly reduced and the degree of hair cell loss was minimal. When a 1 week pause was given between the end of the sound conditioning and the traumatic exposure, protection was still observed, but to a lesser degree. These findings demonstrate that mid-frequency sound conditioning protects against noise trauma and that the protective effect is maintained for at least 1 week.

Dosimeter gel and MR imaging for verification of calculated dose distributions in clinical radiation therapy

A dosimeter gel, based on an agarose gel infused with a ferrous sulphate solution and evaluated in a magnetic resonance scanner, was used for complete verification of calculated dose distributions. Two standard treatment procedures, treatment of cancer in the urinary bladder and treatment of breast cancer after modified radical mastectomy, were examined using pixel-by-pixel and dose volume histogram comparison. The dose distributions calculated with the dose planning system was in very good agreement with the measured ones. However, in the case of the more complicated breast cancer treatment, some discrepancies were found, mainly at the beam abutment region. This may be explained by field displacements errors and by a small limitation of the dose planning utilising small electron beams in this region. The dosimeter gel system have proven to be a useful tool for dosimetry in clinical radiation therapy applications.

Magnetic resonance imaging of lower extremity muscles and isokinetic strength in foot dorsiflexors in patients with prior polio

The thigh and lower leg of six patients with prior polio were examined using magnetic resonance imaging (MRI), and the strength of their weak foot dorsiflexors was measured isokinetically. Spinecho images of the lower extremities were visually evaluated on a semi-quantitative four-point scale, and T1 and T2 relaxation times of the lower leg anterior compartment were analysed. There were prominent MRI signs of randomly distributed muscle degeneration. The high signal intensity changes in the affected muscles on T1-weighted images and T1 and T2 values indicated replacement of muscle fibres with fat and the accumulation of tissue water, respectively. MRI findings were compared with isokinetic strength in foot dorsiflexor muscles. Foot dorsiflexor peak torque values at 30 deg/s ranged from 6 to 29 Nm. There was no significant correlation between MRI visual scoring, T1 and T2 relaxation times and peak torque values at 30 deg/s. However, the most severe MRI changes with visual scoring and T2 relaxation times were observed in the patients with the most pronounced muscle weakness.

Morphological and functional preservation of the outer hair cells from noise trauma by sound conditioning

Guinea pigs were sound conditioned to a low-level, long-term pure tone stimulus (1 kHz, 81 dB SPL, 24 days) before exposure to a traumatic noise (1 kHz, 105 dB SPL, 72 h). Auditory brainstem response thresholds and distortion product otoacoustic emissions were obtained at selected frequencies before sound conditioning and at day 1, 5, 10, and 15 during sound conditioning as well as on the final 24th day. Auditory brainstem responses at 1 and 2 kHz were not affected at any time during sound conditioning. The amplitude of the distortion product otoacoustic emission showed minor alterations (below 10 dB) at selected frequencies only during the initial stages (day 1, 5, and 10) of sound conditioning in some, but not all the animals. Distortion product amplitudes were similar to control values on the 15th and 24th day of conditioning. Surface preparations of the organ of Corti did not reveal any significant hair cell loss induced by sound conditioning. The effect of a traumatic exposure (1 kHz, 105 dB SPL, 72 h) on a control group and a sound conditioned group was determined. The distortion product otoacoustic emission amplitude measured 4 weeks after the cessation of the traumatic exposure revealed significant differences. The amplitude of the distortion product otoacoustic emission for the control group was depressed at all tested frequencies and at lower frequencies (2.8, 2.1, and 1.75 kHz) the emissions did not show an increase in response to increases in intensity, of the primaries. The sound conditioned group showed increases in distortion product amplitude with increases in the intensity of the primaries for all tested frequencies and statistically significant reductions from the pre-exposure values were not found. Surface preparations from the control group indicated that the traumatic noise exposure affected nearly 100% of the outer hair cells around the 14 mm distance from the round window. The sound conditioned group showed a significantly less (50%) outer hair cell loss than the control group. The sound conditioned group illustrated an altered pattern of damage after subsequent noise trauma. There were two distinct regions of outer hair cell loss, one being around the 16 mm distance and the other around the 12 mm distance from the round window. These results imply that the intrinsic properties of the outer hair cells and/or the organ of Corti have been altered by sound conditioning.

Distribution of muscle degeneration in Welander distal myopathy--a magnetic resonance imaging and muscle biopsy study

Seven patients with Welander distal myopathy were subjected to magnetic resonance imaging (MRI) of the lower extremity, and muscle biopsies of the tibialis anterior, soleus and vastus lateralis muscles. MRI revealed abnormalities in both the anterior and posterior compartments of the lower leg in three of the patients, and in only the posterior compartment in the rest of the patients. No MRI abnormalities were found in either the proximal muscles of the leg or in the peroneal or posterior tibial muscle groups. Affected muscles had T1- and T2-values indicating a replacement of muscle fibres with fat tissue. Muscle biopsies showed pathological changes varying from slight to severe in tibialis anterior and soleus muscles in all patients. No muscle fibre abnormalities were seen in the vastus lateralis muscle in any of the patients. In accordance with earlier reports from patients with Welander distal myopathy, there was muscle degeneration of tibialis anterior muscles corresponding to the weakness of dorsal extension of the feet, but also degeneration in the muscles of the posterior compartment. The patients did not, however, show any clinical signs of weakness related to posterior muscle groups. There is no evidence of involvement of proximal muscles of the leg clinically, with MRI or in muscle biopsies.

Phase equilibria and formation of vesicles of dioleoylphosphatidylcholine in glycerol/water mixtures

The lipid 1,2-dioleoyl-sn-glycero-3-phosphocholine (DOPC) forms a lamellar liquid crystalline phase (L alpha) in arbitrary mixtures of glycerol and water. The phase has been characterized by means of X-ray diffraction, 31P-NMR spectroscopy and differential scanning calorimetry (DSC). In the L alpha state, and for DOPC concentrations greater than 50% (w/w), the thickness of the lipid bilayer decreases, while the area of the polar head group increases with increasing glycerol concentration. The phase transition from gel to L alpha state occurs in the range of 240 to 260 K. Contrary to a previous (McDaniel, R.V., McIntosh, T.J. and Simon, S.A. (1983) Biochim. Biophys. Acta 731, 97) study of 1,2-dipalmitoyl-sn-glycero-3-phosphocholine (DPPC) we find that in the gel state, the thickness of the DOPC lipid bilayer is greater than that in the L alpha state. This suggests that in the gel state, the lipid acyl chains of DOPC are in extended configuration. The lamellar phase reaches its maximum swelling at about 50% (w/w) of DOPC. At lower DOPC concentrations a two-phase system is formed where the lamellar phase exists in equilibrium with excess of solvent. Unilamellar vesicles can be prepared from a diluted suspension of the lamellar phase either by using the sonicator or extruder technique. We show this by means of 31P-NMR, EPR and fluorescence spectroscopy. The mean radius of the vesicles, prepared by a sonicator, has been determined at different glycerol/water mixtures. It is found to decrease continuously from 100 A at 100% water to a minimum of 75 A at about 50% water in the solvent mixture. By further decreasing the water content in the solution, the radius rapidly increases, and a mean radius of 450 A is estimated at a water content of 10%. The rotational relaxation times of a fluorescent probe and two EPR spin probes, solubilized in DOPC vesicles, have been measured at different glycerol/water mixtures. It is found that the rotational rates are always much slower in the systems containing glycerol.

Properties of the phase-alternating phase-shift (PHAPS) multiple spin-echo protocol in MRI: a study of the effects of imperfect RF pulses

The effects of imperfect radiofrequency (RF) pulses on the echo amplitudes from the Carr-Purcell (CP), Carr-Purcell-Meiboom-Gill (CPMG), and the PHase-Alternating Phase-Shift (PHAPS; combination of CP and CPMG) multiple spin-echo schemes were studied. Properties of the PHAPS scheme for transverse relaxation time measurements was emphasized. Numerical simulations on non-relaxing spin systems were performed to assess the properties of selective (damped sinc shaped) and nonselective refocusing pulses in terms of effective spatial selectivity and generation of secondary echo signal. Analytical solutions of the Bloch equations were applied to study the generation and propagation of stimulated echo signal caused by nonideal 180 degrees phase reversals, and the results were used to analyse the numerical simulations in terms of primary and stimulated echo components. Finally, the simulated echo train patterns from the different MSE schemes were compared with MR imaging measurements. It was found that the underestimation of T2 values by the PHAPS protocol with selective refocusing pulses is mainly an effect of an "artificial" echo amplitude decay in the CP scheme, while the CPMG scheme produces a typical even-odd echo pattern (different from corresponding echo patterns in conventional high resolution NMR). Both effects are related to the flip angle error and phase dispersion along the slice selection direction from selective RF pulses, and are not significantly influenced by stimulated echo interference for nonrelaxing spin systems. However, the presence of stimulated echoes at the time of the primary echoes implies a dependence on T1 of the PHAPS echo amplitudes. In the CPMG protocol, different gradient schemes have been implemented to defocus stimulated echoes. However, the results indicate that there exists stimulated components that will not be affected by such gradients, and that the optimization of the RF refocusing pulses then remain the main objective.

Dependence on T1 of the echo amplitudes from multiple spin-echo sequences with equidistant echoes: simulation studies

Transverse relaxation times were estimated from numerical simulations on spin systems using multi-echo spin-echo MRI protocols. The influence of T1 on the echo amplitudes via stimulated echo components was studied. The resulting effects on T2 estimates from the Carr-Purcell (CP), Carr-Purcell-Meiboom-Gill (CPMG), and Phase-Alternating-Phase-Shift (PHAPS; combination of CP and CPMG), multiple echo schemes were examined. Protocols with either spatially selective or nonselective refocusing pulses were studied. An intravoxel static field inhomogeneity of 0.1, 1, and 10 ppm was stimulated. The dependence on T1 of the T2 estimates was notable for T1 values below approximately 800 msec for all protocols. The PHAPS scheme provided rather accurate, but underestimated, T2 values when selective refocusing was used. With nonselective refocusing, PHAPS T2 values were overestimated and demonstrated a pronounced dependence on magnetic field inhomogeneity. In general, long T2 values were erroneous with the PHAPS protocol. The results indicate that a CPMG protocol structure provides a more robust method for T2 estimations than the PHAPS protocol.

Three-dimensional dose mapping from gamma knife treatment using a dosimeter gel and MR-imaging

A new method has been investigated for the mapping of dose distributions in three dimensions delivered by the Leksell gamma knife. The irradiation unit is used to selectively treat small volumes in the brain with single high doses of ionising radiation--a treatment procedure known as radiosurgery. The dosimetry method investigated utilises a dosimeter gel consisting of ferrous sulphate solution and agarose which is, prior to irradiation, loaded into a cavity in a spherical phantom. Chemical changes induced in the gel by the radiation are measured by means of an MR-scanner. This imaging method permits rapid evaluation of the dose distribution in an irradiated volume. It thus offers a potential verification of individual radiation intracranial target treatment regimes as well as quality assurance measurements, assuming that the precision and accuracy of the dose mapping are adequate. The dose and its distribution registered by the gel dosimeter, in this initial experiment, are in good agreement with corresponding computed data obtained with the KULA treatment planning system of the gamma knife. The gel has thus the potential of being an attractive alternative dose mapping method to those used at present in radiosurgery, i.e. radiographic film and small ionisation chambers. The precision of the dosimeter gel is, however, not yet sufficient high to be used as a basic dosimetry system for the gamma knife.

MR imaging of absorbed dose distributions for radiotherapy using ferrous sulphate gels

The measurement of absorbed dose distributions using dosemeter gel and magnetic resonance imaging (MRI) in a standard geometry has been investigated. Absorbed depth-dose curves and profiles measured with this new technique show good agreement with corresponding measurements using diodes. This was proven in a 60Co beam as well as an electron beam. The dosemeter gel is made of agarose and ferrous sulphate solution. The dose response is linear (r = 0.9996) in the investigated dose interval, 0-40 Gy. The sensitivity is a factor of about six higher compared to ordinary ferrous sulphate solution, known as 'Fricke'. This is a true 3D dose measurement technique which will have a number of applications in radiation therapy, since it is possible to mould the gel to arbitrary geometries, mix different radiation qualities and integrate the absorbed dose from different kinds of fields.

Resolution of biexponential transverse relaxation in magnetic resonance imaging

The accuracy in measurements of mono- and biexponential transverse relaxation processes with an MRI unit (0.5 T) was studied with a binary phantom. Comparison with spectrometer measurements (0.5 T) demonstrated that the imager underestimated the T2 values for monoexponential processes. Numerical resolution of biexponential processes also yielded underestimated relaxation times, but the resolution of a slow, constant component from faster components was relatively precise and consistent, provided the T2 ratio was above 2.5 in the T2 range 200-800 ms for a spin-echo sequence with 32 echoes. The effects of signal-averaging, strength of slice-selective gradient, single- versus multi-slice mode and repetition time were of little importance. In coronal slices a spurious biexponentiality occurred occasionally from monoexponential sources. The influence of stochastic noise was of minor importance compared to the effect of systematic noise.

Ultrasonic appearance of adenomatous and hyperplastic parathyroid glands

An investigation was made of the sonographic and histopathologic characteristics of 27 parathyroid adenomas and 11 primary and secondary hyperplastic parathyroid glands demonstrated by ultrasound before surgical confirmation. All the hyperplastic glands and 21 of the adenomas had a homogeneously sonolucent interior structure and a smooth periphery. The adenomas and hyperplastic glands were sonographically indistinguishable except for 5 large adenomas which had areas of varying echodensity and an irregularly nodulated periphery. The ultrasonically inhomogeneous adenomas were histopathologically more heterogeneous with asymmetric, nodular enlargement. One patient had a cystic adenoma. The results are discussed in relation to the ultrasonic appearance of thyroid noduli and lymph nodes being the main source of errors in parathyroid ultrasonography.