The pediatric glucocorticoid toxicity index

OBJECTIVES

To develop a Pediatric glucocorticoid toxicity index (pGTI), a standardized, weighted clinical outcome assessment that measures change in glucocorticoid (GC) toxicity over time.

METHODS

Fourteen physician experts from 7 subspecialties participated. The physician experts represented multiple subspecialties in which GCs play a major role in the treatment of inflammatory disease: nephrology, rheumatology, oncology, endocrinology, genetics, psychiatry, and maternal-fetal medicine. Nine investigators were from Canada, Europe, or New Zealand, and 5 were from the United States. Group consensus methods and multi-criteria decision analysis were used. The pGTI is an aggregate assessment of GC toxicities that are common, important, and dynamic. These toxicities are organized into health domains graded as minor, moderate, or major and are weighted according to severity. The relative weights were derived by group consensus and multi-criteria decision analysis using the 1000Minds^TM software platform. Two quantitative scores comprise the overall toxicity profile derived from pGTI data: (1) the Cumulative Worsening Score; and (2) the Aggregate Improvement Score. The pGTI also includes a qualitative, unweighted record of GC side-effects known as the Damage Checklist, which documents less common toxicities that, although potentially severe, are unlikely to change with varying GC dosing.

RESULTS

One hundred and seven (107) toxicity items were included in the pGTI and thirty-two (32) in the Damage Checklist. To assess the degree to which the pGTI corresponds to expert clinical judgement, the investigators ranked 15 cases by clinical judgement from highest to lowest GC toxicity. Expert rankings were then compared to case ranking by the pGTI, yielding excellent agreement (weighted kappa 0.86). The pGTI was migrated to a digital environment following its development and initial validation. The digital platform is designed to ensure ease-of-use in the clinic, rigor in application, and accuracy of scoring. Clinic staff enter vital signs, laboratory results, and medication changes relevant to pGTI scoring. Clinicians record findings for GC myopathy, skin toxicity, mood dysfunction, and infection. The pGTI algorithms then apply the weights to these raw data and calculate scores. Embedded logic accounts for the impact of age- and sex-related reference ranges on several health domains: blood pressure, lipid metabolism, and bone mineral density. Other algorithms account for anticipated changes in the height Z-scores used in the growth domain, thereby addressing a concern unique to GC toxicity in children. The Damage Checklist ensures comprehensive measurement of GC toxicity but does not contribute to pGTI scoring, because the scored domains emphasize manifestations of GC toxicity that are likely to change over the course of a trial.

CONCLUSIONS

We describe the development and initial evaluation of a weighted, composite toxicity index for the assessment of morbidity related to GC use in children and adolescents. Developing the pGTI digital platform was essential for performing the nuanced calculations necessary to ensure rigor, accuracy, and ease-of-use in both clinic and research settings.

POS0859 C-REACTIVE PROTEIN AND INTERLEUKIN-6: POTENTIAL BIOMARKERS OF DISEASE ACTIVITY AND TREATMENT RESPONSE IN SYSTEMIC SCLEROSIS-INTERSTITIAL LUNG DISEASE

Background

Clinically feasible and valid biomarkers of systemic sclerosis-interstitial lung disease (SSc-ILD) are needed. While promising candidate biomarkers are under investigation (e.g., KL-6, CCL-8), clinical assays for these proteins are not currently available. C-reactive protein (CRP) measurements are feasible, cost-effective, and have been shown to predict mortality in SSc.1 Measuring interleukin (IL)-6, a proinflammatory cytokine implicated in SSc-ILD pathogenesis, is also feasible in most clinical settings.

Objectives

(1) To investigate whether CRP and IL-6 levels change in response to treatment with immunosuppression in SSc-ILD; (2) To explore whether the change in CRP and IL-6 predict the future course of forced vital capacity (FVC).

Methods

CRP and IL-6 levels were measured in serum at baseline and after 12 months in participants of Scleroderma Lung Study (SLS) II (patients with active SSc-ILD receiving 24 months of mycophenolate or 12 months cyclophosphamide followed by 12 months of placebo2). Measured values were log-transformed to remove skewness. The FVC%-predicted was measured every 3 months over the course of 24 months. Spearman’s correlations evaluated the relationship between baseline CRP or IL-6 measurements and other patient parameters. Paired t-tests were used to compare the change in individual CRP and IL-6 measurements from baseline to 12 months. Linear mixed effects models were used to examine the relationship between the change in CRP and IL-6 (baseline to 12 months) and the subsequent course of the FVC (12 to 24 months). All analysis were performed for the entire cohort and separately by treatment arm.

Results

Of the 142 participants of SLS II, 101 had CRP and IL-6 measurements at baseline and 12 months. Baseline CRP and IL-6 levels correlated significantly with higher modified Rodnan skin score (CRP: r=0.3, P=0.005; IL-6: r=0.2, P=0.01) and shorter disease duration (CRP: r=-0.3, P=0.005; IL-6: r=-0.2, P=0.01) and were higher in patients with diffuse SSc (CRP: P=0.007; IL-6: P=0.01). Relationships to baseline FVC and DLCO were not observed. CRP decreased significantly from baseline to 12 months in the whole group (P=0.01), but the decrease was slightly greater in patients randomized to mycophenolate versus cyclophosphamide (-0.47 vs. -0.33 ug/mL). IL-6 also decreased from baseline to 12 months in the whole group with a trend towards significance (P=0.10) (Figure 1). The mean decrease in IL-6 was again slightly greater in patients randomized to mycophenolate versus cyclophosphamide (-0.31 vs. -0.10 pg/mL). After controlling for baseline FVC and treatment arm in the mixed effects model, there was a relationship between the decrease in CRP from baseline to 12 months and an improved course of FVC 12 to 24 months (Estimate -0.64), but this did not reach significance (P=0.14). However, after controlling for baseline FVC and treatment arm, a greater decrease in IL-6 from baseline to 12 months was significantly associated with a greater improvement in FVC from 12 to 24 months (Estimate -1.28; P=0.01).

Figure 1.

Change in CRP (A) and IL-6 (B) from baseline to 12 months by treatment arm in SLS II. CYC=cyclophosphamide (Blue), MMF=mycophenolate (red)

Conclusion

Patients with active SSc-ILD receiving one year of immunosuppressive therapy in the SLS II study experienced reductions in their CRP and IL-6 levels over this interval. The magnitude of the decrease in CRP and IL-6 over the first year also correlated with the course of FVC over the ensuing 12 months. These findings suggest a dynamic relationship between CRP and IL-6 measurements and the course of SSc-ILD in patients on immunosuppressive therapy. Further investigation of these findings is warranted.

References

[1]Liu et al. Arthritis Care Res 2013.

[2]Tashkin et al. Lancet Resp Med 2016.

Disclosure of Interests

Elizabeth Volkmann Speakers bureau: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Grant/research support from: Forbius, Kadmon, Horizon, Boehringer Ingelheim, Donald Tashkin: None declared, Holly Wilhalme: None declared, Marka Lyons: None declared, Grace Kim: None declared, Jonathan Goldin: None declared, Michael Roth Grant/research support from: Genentech, Shervin Assassi Consultant of: Boehringer Ingelheim

POS0852 SYMPTOMS OF GASTROESOPHAGEAL REFLUX ARE A BETTER PREDICTOR OF SYSTEMIC SCLEROSIS-RELATED INTERSTITIAL LUNG DISEASE PROGRESSION THAN QUANTITATIVE RADIOGRAPHIC ASSESSMENT OF ESOPHAGEAL PARAMETERS

Background

Esophageal dysfunction affects the majority of patients with systemic sclerosis (SSc). Gastroesophageal reflux (GERD)-associated microaspiration may serve as an inciting and/or exacerbating factor in the pathogenesis of interstitial lung disease (ILD) in SSc. Few studies have investigated the relationship between objective measures of esophageal involvement in SSc and the progression of SSc-ILD.

Objectives

(1) To investigate whether patient-reported symptoms of GERD predict SSc-ILD severity and progression; (2) To explore whether quantitative radiographic measurements of esophageal parameters predict SSc-ILD severity and progression.

Methods

Participants of Scleroderma Lung Study (SLS) II (24 months of mycophenolate versus 12 months cyclophosphamide followed by 12 months of placebo in patients with active SSc-ILD) were included.1 The UCLA SCTC GIT 2.0 was used to assess the severity of reflux at baseline. Quantitative image analysis was used to calculate the diameter and area of the esophagus in the area of maximum dilation. Univariate and multivariable linear regression analyses were used to evaluate the relationship between baseline reflux scores/esophageal parameters and the severity and progression of SSc-ILD based on the quantitative radiographic extent of ILD (QILD) and fibrosis (QLF) in the lobe of maximum involvement (LM). All multivariable models controlled for treatment arm and baseline ILD severity, as well as proton pump inhibitor (PPI) use.

Results

Among the 141 of 142 SLS II participants with patient-reported reflux scores at baseline, the mean score was 0.57, indicating moderate reflux. The mean maximal esophageal diameter and area at baseline were 22 mm and 242 mm2, respectively. There were no significant correlations between reflux scores, esophageal diameter, esophageal area and QILD-LM and QLF-LM at baseline. However, in the 96 participants with HRCT scans available at 24 months, increased reflux scores were significantly associated with worsening of QLF-LM and QILD-LM (Figure 1). Even after controlling for disease severity at baseline, treatment arm and PPI use, reflux scores remained significantly associated with change in QLF-LM (P-value 0.05) and QILD-LM (P-value 0.003). Neither the maximum esophageal area, nor the maximum esophageal diameter was associated with the change in QILD-LM or QLF-LM in univariate or multivariate analyses.

Figure 1.

Increased reflux scores at baseline are associated with increased progression (worsening) of QILD (A) and QLF (B) in the lobe of maximum involvement in patients with SSc-ILD.

Conclusion

Increased self-reported reflux was independently associated with worsening radiographic fibrosis and ILD in patients receiving treatment for SSc-ILD. The maximum esophageal diameter and esophageal area did not correlate with reflux scores and did not predict severity or progression of SSc-ILD. These findings illustrate the importance of eliciting a careful patient history of reflux symptoms in patients with ILD and further highlight the need for improved objective measures of esophageal dysfunction in SSc.

References

[1]Tashkin et al. Lancet Resp Med 2016.

Disclosure of Interests

Elizabeth Volkmann Speakers bureau: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Grant/research support from: Forbius, Horizon, Kadmon, Boehringer Ingelheim, Donald Tashkin: None declared, Mei Leng: None declared, Grace Kim: None declared, Jonathan Goldin: None declared, Michael Roth Grant/research support from: Genentech

POS0068 CHANGES IN QUANTITATIVE INTERSTITIAL LUNG DISEASE SCORES ON HIGH-RESOLUTION CT IN IDIOPATHIC INFLAMMATORY MYOSITIS

Background

The idiopathic inflammatory myopathies (IIM) are autoimmune connective tissue diseases affecting skeletal muscle, skin and other organ systems. IIM-related interstitial lung disease (IIM-ILD) is the most common extra-muscular manifestation, being the leading cause of morbidity and mortality. Several studies have suggested that ILD pattern based on chest high-resolution computed tomography (HRCT) can be related to disease course and treatment response, but the results vary considerably. Moreover, the clinical impact of the quantitative ILD (QILD) score, a validated computer-aided scoring system in assessing ILD severity from HRCT, and its longitudinal changes have not yet been evaluated in IIM-ILD.

Objectives

This study aims to investigate ILD patterns and QILD scores in patients with IIM-ILD, to identify their clinical impact, and to delineate longitudinal changes of QILD measurement.

Methods

A total of 80 patients with IIM (polymyositis 22, and dermatomyositis 58) who underwent at least 2 times of serial HRCT scans were included. Visual ILD patterns were assessed by multiple thoracic radiologists. Quantitative analysis of HRCT was presented as total extent of QILD scores (%) in whole lung and most severe zone. Individual time-estimated ΔQILD score between first 2 visits was derived using a linear approximation of yearly change, where the duration of median (IQR) was 1.0 (0.4-1.6) years in the first 2 HRCT scans.

Results

The median (IQR) age of the patients was 52.0 (43.5-58.5) years and 60 (75.0%) were women. Baseline median score of whole lung-QILD and most severe zone-QILD were 28.1% (19.1-43.8) and 68.0% (45.5-81.8), respectively, and QILD score showed significant correlations with pulmonary function tests (r=-0.349, p=0.002 for % predicted forced vital capacity; and r=-0.381, p=0.001 for % predicted diffusing capacity for carbon monoxide). The individual time-estimated yearly ΔQILD score between first 2 visits presented that approximately half of the patients showed improvement or stability in QILD scores; however, when patients were sorted by visual assessment in ILD subtype on HRCT, approximately two-thirds of the patients with usual interstitial pneumonia (UIP) pattern were aggravated in QILD scores and less than half of subjects with nonspecific interstitial pneumonia and organizing pneumonia were aggravated (Figure 1, 80% for UIP vs. 44.4% for non-UIP, p=0.013). There was no immunosuppressive drugs related to meaningful improvement in QILD scores during first 2 visits. Notably, we observed significant aggravation of QILD scores in tacrolimus users (n=7, median time-estimated whole lung-yarly ΔQILD 20.3 (2.7-38.4)) compared with tacrolimus non-users (n=73, median time estimated whole lung-yearly ΔQILD -1.2 (-8.3-6.5)). Among 80 patients, 6 (7.5%) were died due to various lung complications. Higher baseline QILD scores were noted in deaths (median whole lung-QILD 45.4 (32.9-56.5)) than in survivors (median whole lung-QILD 26.9 (19.0-42.4)), albeit not significant (p=0.084). Poor survival rate was observed in patients with high grade of ground glass opacity by visual assessment in right upper lobe (log-rank test, p=0.042). Among subgroup of patients with 3 serial HRCT scans (n=41), dynamic changes of four distinct patterns (improving, worsening, convex, and concave) were observed.

Figure 1.

Cleveland dot plot of individual time-estimated yearly ΔQILD during fist 2 visits.

Conclusion

The changes in QILD score in IIM-ILD are dynamic and present different by visual assessment. QILD score has the potential for evaluation of the severity changes, prognosis and medication response in patients with IIM-ILD.

References

[1]Tashkin DP, et al. Ann Rheum Dis 2016;75(2):374-81.

7 truncated values in the graph A. NSIP: nonspecific interstitial pneumonia; OP: organizing pneumonia; UIP: usual interstitial pneumonia.

Disclosure of Interests

None declared

Working together better for mental health in children and young people during a pandemic: experiences from North Central London during the first wave of COVID-19

Direct risk from infection from COVID-19 for children and young people (CYP) is low, but impact on services, education and mental health (so-called collateral damage) appears to have been more significant. In North Central London (NCL) during the first wave of the pandemic, in response to the needs and demands for adults with COVID-19, general paediatric wards in acute hospitals and some paediatric emergency departments were closed. Paediatric mental health services in NCL mental health services were reconfigured. Here we describe process and lessons learnt from a collaboration between physical and mental health services to provide care for CYP presenting in mental health crisis. Two new 'hubs' were created to coordinate crisis presentations in the region and to link community mental health teams with emergency departments. All CYP requiring a paediatric admission in the first wave were diverted to Great Ormond Street Hospital, a specialist children's hospital in NCL, and a new ward for CYP mental health crisis admissions was created. This brought together a multidisciplinary team of mental health and physical health professionals. The most common reason for admission to the ward was following a suicide attempt (n=17, 43%). Patients were of higher acute mental health complexity than usually admitted to the hospital, with some CYP needing an extended period of assessment. In this review, we describe the challenges and key lessons learnt for the development of this new ward setting that involved such factors as leadership, training and also new governance processes. We also report some personal perspectives from the professionals involved. Our review provides perspective and experience that can inform how CYP with mental health admissions can be managed in paediatric medical settings.

OP0268 TREATMENT STATUS AFFECTS HOW PULMONARY BIOMARKERS PREDICT PROGRESSION OF SYSTEMIC SCLEROSIS-RELATED INTERSTITIAL LUNG DISEASE

Background:

The course of interstitial lung disease (ILD) varies considerably in patients with systemic sclerosis (SSc), and no biomarkers have been found to consistently predict ILD progression in this population. Treatment may affect how a candidate biomarker correlates with improvement/worsening of SSc-ILD. We hypothesized that specific proteins recovered from bronchoalveolar lavage (BAL) would differentially predict progression of SSc-ILD based on whether a patient was receiving ILD therapy.

Objectives:

(1) To assess the relationship between 68 unique BAL proteins measured in participants of Scleroderma Lung Study (SLS) I1 and changes in radiographic extent of SSc-ILD; (2) To determine if treatment affects whether a specific protein predicts improvement or worsening of SSc-ILD.

Methods:

Bronchoscopy was performed on 144 of the 158 participants in SLS I (Cyclophosphamide [CYC] vs. placebo) with 103 BAL samples available for analysis. BAL was lyophilized, concentrated 10X and used in a multiplex protein analysis of 68 distinct cytokines, chemokines and growth factors. Quantitative imaging analysis (QIA) was used to calculate the extent of radiographic fibrosis (QLF) in the whole lung using HRCT of the chest at baseline and 12 months. Multivariable linear regression models were created to determine the key BAL proteins associated with change in QLF scores using a backward selection process adjusting for treatment arm and ILD severity. The bootstrap procedure was employed for internal validation.

Results:

A number of BAL proteins were significantly associated with change in QLF scores at 12 months; however, the directionality of these associations was often based on the presence/absence of treatment. For example, increased levels of granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin (IL)-1, monocyte chemoattractant protein (MCP)-3, chemokine ligand (CCL)-5, transforming growth factor (TGF)-β, hepatocyte growth factor (HGF), stem cell factor (SCF), IL-4, TGF-α, were associated with worse QLF scores in patients who received placebo; whereas, increased levels of these same proteins were associated with improved QLF scores in patients who received CYC (Figure). Increased levels of Fractalkine were associated with worse in QLF scores, and increased levels of IL-7 were associated with improved QLF scores, regardless of treatment arm. In the multivariable model adjusting for treatment arm and baseline severity of ILD, IL-1, MCP-3, surfactant protein C, IL-7, and CCL-5 were independently associated with change in QLF scores.

Figure 1.

Example of a specific BAL protein (GM-CSF) that predicts worse QLF scores in patients receiving placebo (Group B, Red dotted line) and improved QLF scores in patients receiving CYC (Group A, Blue solid line). Shaded areas represent 95% confidence intervals.

Conclusion:

Proteins that mediate both inflammation and fibrosis differentially affected progression of SSc-ILD based on treatment status. Higher levels of certain proteins predicted worsening of ILD in patients receiving placebo, but improvement in patients receiving CYC. Measuring these proteins could help to identify patients who: (1) are at risk for ILD progression, and (2) may preferentially benefit from treatment with immunosuppression.

References:

[1]Tashkin DP, et al. NEJM 2006.

Disclosure of Interests:

Elizabeth Volkmann Consultant of: Boehringer Ingelheim, Grant/research support from: Corbus, Forbius, Donald Tashkin: None declared, Mei Leng: None declared, Ning Li: None declared, Grace Kim: None declared, Jonathan Goldin: None declared, Airi Harui: None declared, Michael Roth Grant/research support from: Genentech/Roche

OP0267 SHORT-TERM CHANGES IN THE RADIOGRAPHIC EXTENT OF INTERSTITIAL LUNG DISEASE PREDICT LONG-TERM MORTALITY IN SYSTEMIC SCLEROSIS

Background:

The forced vital capacity (FVC) is often used as the primary endpoint in treatment trials for systemic sclerosis-interstitial lung disease (SSc-ILD), and while trends in FVC have been found to predict mortality in SSc-ILD,1,2 FVC measurements are also influenced by extra-pulmonary factors, such as cutaneous sclerosis, myopathy, and patient/technician effort. Change in the quantitative extent of ILD (QILD) on HRCT is an emerging endpoint in clinical trials; however, no studies have evaluated whether changes in radiographic extent ILD predict mortality in SSc-ILD.

Objectives:

To evaluate the relationship between changes QILD in the whole lung (WL) and long-term survival in patients who participated in the Scleroderma Lung Study (SLS) I3 and II.4

Methods:

SLS I randomized 158 SSc-ILD patients to 12 months of cyclophosphamide (CYC) vs. placebo. SLS II randomized 142 SSc-ILD patients to 12 months of CYC, followed by 12 months of placebo vs. 24 months of mycophenolate (MMF). QILD-WL scores were calculated at baseline and 12 months (SLS I) and 24 months (SLS II). Participants were followed for up to 12 (SLS I) and 8 years (SLS II). Using landmark survival analysis, Kaplan Meier curves were generated to compare survival between participants who had worse QILD-WL scores (≥2% increase) and those who had stable/improved QILD-WL scores (<2% increase). Cox proportional hazards models were created to determine whether the change in QILD-WL scores predicted survival after controlling other variables found to affect survival in these cohorts.

Results:

Among all the SLS I and II participants, 82 and 90 had follow up HRCT scans, respectively, and were included in these analyses. SLS I participants with an increase in QILD-WL scores of ≥2% at 12 months had significantly worse long-term survival (P= 0.01; Figure). Similarly, SLS II participants with an increase in QILD-WL scores of ≥2% at 24 months had significantly worse long-term survival (P= 0.019; Figure). After adjusting for baseline FVC, age, and modified Rodnan skin score (mRSS), an increase in QILD-WL scores of ≥2% remained associated with worse long-term survival in SLS I (trend: P=0.089) and SLS II (P=0.014).

Conclusion:

Progression of the radiographic extent of ILD of ≥2% was associated with worse long-term survival in two independent SSc cohorts with extensive long-term follow up. The findings provide compelling evidence that short-term changes in the radiographic extent of ILD may serve as a surrogate endpoint for mortality in patients with SSc.

References:

[1]Goh NS, et al. Arthritis Rheum 2017.

[2]Volkmann ER, et al. Ann Rheum Dis 2019.

[3]Tashkin DP, et al. NEJM 2006.

[4]Tashkin DP, et al. Lancet Resp Med 2016.

Disclosure of Interests:

Elizabeth Volkmann Consultant of: Boehringer Ingelheim, Grant/research support from: Forbius, Corbus, Donald Tashkin: None declared, Michael Roth Grant/research support from: Genentech/Roche, Jonathan Goldin: None declared, Grace Kim: None declared

SAT0286 BIOLOGICAL CORRELATES OF RADIOGRAPHIC FEATURES OF INTERSTITIAL LUNG DISEASE IN SYSTEMIC SCLEROSIS: AN IN DEPTH ANALYSIS OF BRONCHOALVEOLAR PROTEINS OF SCLERODERMA LUNG STUDY I PARTICIPANTS

Background:

Systemic sclerosis-related interstitial lung disease (SSc-ILD) involves a combination of inflammation, fibrosis and vascular pathology that is typically assessed on CT imaging as a mixture of ground-glass opacification (GGO) and fibrotic changes. We hypothesized that proteins recovered from bronchoalveolar lavage (BAL) could be used to probe the underlying pathobiology associated with GGO and fibrotic changes.

Objectives:

(1) To assess the relationship between 68 unique BAL proteins measured in participants of Scleroderma Lung Study (SLS) I1and radiographic and physiologic measures of ILD; (2) To identify inter-correlations among specific proteins to enlighten our understanding of how specific biological pathways contribute to SSc-ILD.

Methods:

Bronchoscopy was performed on 144 of the 158 participants in SLS I with 103 BAL samples available for analysis. BAL was lyophilized, concentrated 10X and used in a multiplex protein analysis for 68 different cytokines, chemokines and other factors. Kendall tau correlations were performed to assess the relationship between individual proteins and baseline measures of pulmonary function and quantitative CT scores for fibrosis, GGO and total ILD. Those proteins found to correlate significantly with at least 2 clinical measures of ILD were entered into a cluster analysis with inter-correlations expressed as a heatmap.

Results:

Significant correlations were observed between fibrosis scores and several biologic pathways including pro-fibrotic factors (transforming growth factor beta [TGF-β], platelet-derived growth factor [PDGF]), proteins involved in tissue remodeling (Matrix metallopeptidase [MMP]-1,7,8,9; Hepatocyte growth factor [HGF]), and those involved in monocyte/macrophage migration and activation (Monocyte chemoattractant protein [MCP]-1,3; macrophage colony-stimulating factor [MCSF]). These same pathways correlated with the diffusing capacity for carbon monoxide (DLCO). In contrast, GGO scores correlated primarily with immune and inflammatory mediators (interleukin [IL]-5,8,13,15, IL-1 receptor antagonist and interferon gamma) with only limited overlap to proteins that related to fibrosis. Vascular endothelial growth factor (VEGF) levels were lower in patients with more extensive GGO, fibrosis and diffusion impairment, suggesting that vascular changes are a central feature of SSc-ILD. Specific proteins were highly correlated with one another in a pattern suggesting biologically-related networks (Figure) that might provide additional insight regarding disease pathogenesis.

Conclusion:

Combining a diverse analysis of BAL proteins with the rich dataset available from SSc-ILD patients participating in SLS I, the study findings suggest the involvement of distinct biologic pathways, inter-related networks, and specific biologic signatures associated with unique radiographic features of ILD. The relationship of these factors to other SSc disease features, patient outcomes and as predictors of treatment responses will be studied in future analyses.

References:

[1]Tashkin DP, et al. NEJM 2006.

Figure.

Correlation heatmap of BAL proteins associated with at least 2 clinical measures of ILD in SSc patients. Absolute correlations are depicted, and darker colors signify stronger correlations.

Disclosure of Interests:

Elizabeth Volkmann Grant/research support from: Forbius, Corbus Pharmaceuticals, Consultant of: Boehringer Ingelheim, Forbius, Speakers bureau: Boehringer Ingelheim, Donald Tashkin: None declared, Ning Li: None declared, Grace Kim: None declared, Jonathan Goldin: None declared, Airi Harui: None declared, Michael Roth Grant/research support from: Genentech/Roche

A prospective cohort study of thoracic ultrasound in acute respiratory failure: the C3PO protocol

OBJECTIVES

This study was performed to assess the clinical utility of a standardised thoracic ultrasound examination when added to standard care in patients with acute respiratory failure admitted to an intermediate care unit. This study aimed to assess the impact on clinical diagnosis, clinician confidence and management. Ultrasound has been shown to have utility in patients admitted to intensive care and emergency; however, utility in a ward setting is unknown.

DESIGN

Prospective cohort study.

SETTING

Tertiary hospital in Melbourne, Australia.

PARTICIPANTS

50 patients with acute respiratory failure requiring admission to an intermediate care unit.

MAIN OUTCOME MEASURES

(1) Change in clinical diagnosis or additional clinical diagnosis following thoracic ultrasound. (2) Change in diagnostic confidence following thoracic ultrasound. (3) Change to management following thoracic ultrasound.

RESULTS

In 34% of patients, ultrasound detected unexpected findings that changed or added to the clinical diagnosis. Diagnostic confidence was increased in 44%, and the treating clinician altered the management plan in 30% as a result of the ultrasound. Ultrasound was particularly useful in clarifying the diagnosis in patients with multiple initial diagnoses, reducing to a single diagnosis in 69%.

CONCLUSIONS

Thoracic ultrasound has clinical utility in non-intubated adults with acute respiratory failure managed outside intensive care settings. It changed aetiological diagnosis, increases diagnostic confidence and altered clinical management in one out of three patients scanned. Our results suggest extended utility of thoracic ultrasound in acute respiratory failure to a broader context outside the intensive care unit population.

Assessment of previous tuberculosis status using questionnaires, chest X-rays and computed tomography scans

SETTING

Accurate diagnosis of previous pulmonary tuberculosis disease (PPTB) status is important clinically and in research. Reliable records of bacteriologically confirmed tuberculosis (TB) are frequently unavailable.

OBJECTIVES

To evaluate the use of questionnaires and chest imaging to determine PPTB status in a high TB prevalence population.

DESIGN

PPTB status was assessed using two questionnaires, chest X-ray (CXR) and high-resolution chest computed tomography (CT) scans reported by experienced readers. The study population comprised adults aged >40 years diagnosed with obstructive lung disease in a community-based prevalence survey.

RESULTS

The Burden of Obstructive Lung Disease (BOLD) questionnaire and a second comprehensive questionnaire (PTbQ) provided a history of PPTB in respectively 38% (n = 41) and 36.4% (n = 39) of 107 participants. On CXR, 43.3% (45/104) had evidence of PPTB, with good inter-reader agreement (κ = 0.73). Changes compatible with PPTB were identified on chest CT in 68.3% (71/104) of the subjects. Questionnaire and CXR had negative predictive values for PPTB of 48% and 47%, respectively, compared to a composite definition.

CONCLUSION

Both questionnaire and CXR markedly underestimate the prevalence of previous TB in patients with chronic obstructive pulmonary disease. The combination of a structured questionnaire and CT scan is more useful when a diagnosis of PPTB needs to be ruled out.

Between-Scanner and Between-Visit Variation in Normal White Matter Apparent Diffusion Coefficient Values in the Setting of a Multi-Center Clinical Trial

PURPOSE

To study the between-scanner variation and the between-visit reproducibility of brain apparent diffusion coefficient (ADC) measurements in the setting of a multi-center chemotherapy clinical trial for glioblastoma multiforme.

METHODS AND MATERIALS

ADC maps of 52 patients at six sites were calculated in-house from diffusion-weighted images obtained by seven individual scanner models of two vendors. The median and coefficient of variation (CV) of normal brain white matter ADC values from a defined region of interest were used to evaluate the differences among scanner models, vendors, magnetic fields, as well as successive visits. All patients participating in this study signed institutional review board approved informed consent. Data acquisition was performed in compliance with all applicable Health Insurance Portability and Accountability Act regulations. The study spanned from August 1, 2006, to January 29, 2008.

RESULTS

For baseline median ADC, no difference was observed between the different scanner models, different vendors, and different magnetic field strength. For baseline ADC CV, a significant difference was found between different scanner models (p = 0.0002). No between-scanner difference was observed in ADC changes between two visits. For between-visit reproducibility, significant difference was seen between the ADC values measured at two successive visits for the whole patient group.

CONCLUSION

The CVs varied significantly between scanners, presumably due to image noise. Consistent scanner parameter setup can improve reproducibility of the ADC measurements between visits.

Sleep disturbance in menopause

Sleep disturbance during menopause is a common and important complaint faced by many women. There are many factors that may play a role in this problem, including vasomotor symptoms and changing hormone levels, circadian rhythm abnormalities, exacerbation of primary insomnia, mood disorders, coexistent medical conditions as well as lifestyle factors. Sleep can be measured both objectively and subjectively; however, correlation between the two measures is not high. Most of the menopause-related sleep disturbances have been reported as qualitative in nature; however, there have also been studies showing changes in objective measures. This discrepancy has implications with regard to evaluation of research in sleep and menopause, as well as application in the clinical setting. Investigations of inadequate sleep and sleep problems during the menopausal period and obtaining a thorough understanding of the factors contributing to these problems are essential in formulating treatment strategies. Such strategies can vary from hormonal treatment and medications to lifestyle and behavioural modification.

Bronchoscopic lung-volume reduction with Exhale airway stents for emphysema (EASE trial): randomised, sham-controlled, multicentre trial

BACKGROUND

Airway bypass is a bronchoscopic lung-volume reduction procedure for emphysema whereby transbronchial passages into the lung are created to release trapped air, supported with paclitaxel-coated stents to ease the mechanics of breathing. The aim of the EASE (Exhale airway stents for emphysema) trial was to evaluate safety and efficacy of airway bypass in people with severe homogeneous emphysema.

METHODS

We undertook a randomised, double-blind, sham-controlled study in 38 specialist respiratory centres worldwide. We recruited 315 patients who had severe hyperinflation (ratio of residual volume [RV] to total lung capacity of ≥0·65). By computer using a random number generator, we randomly allocated participants (in a 2:1 ratio) to either airway bypass (n=208) or sham control (107). We divided investigators into team A (masked), who completed pre-procedure and post-procedure assessments, and team B (unmasked), who only did bronchoscopies without further interaction with patients. Participants were followed up for 12 months. The 6-month co-primary efficacy endpoint required 12% or greater improvement in forced vital capacity (FVC) and 1 point or greater decrease in the modified Medical Research Council dyspnoea score from baseline. The composite primary safety endpoint incorporated five severe adverse events. We did Bayesian analysis to show the posterior probability that airway bypass was superior to sham control (success threshold, 0·965). Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00391612.

FINDINGS

All recruited patients were included in the analysis. At 6 months, no difference between treatment arms was noted with respect to the co-primary efficacy endpoint (30 of 208 for airway bypass vs 12 of 107 for sham control; posterior probability 0·749, below the Bayesian success threshold of 0·965). The 6-month composite primary safety endpoint was 14·4% (30 of 208) for airway bypass versus 11·2% (12 of 107) for sham control (judged non-inferior, with a posterior probability of 1·00 [Bayesian success threshold >0·95]).

INTERPRETATION

Although our findings showed safety and transient improvements, no sustainable benefit was recorded with airway bypass in patients with severe homogeneous emphysema.

FUNDING

Broncus Technologies.

Patterns of progression in patients with recurrent glioblastoma treated with bevacizumab

OBJECTIVE

We evaluated patterns of tumor progression in patients with recurrent glioblastoma who were treated with bevacizumab (BEV) alone or in combination with irinotecan (CPT-11) while participating in the BRAIN study.

METHODS

An independent neuroradiologist reviewed MRI scans at baseline and progression in patients who received BEV (n = 85) or BEV+CPT-11 (n = 82) while on BRAIN. Tumor patterns were scored as local, distant, diffuse, or multifocal. Median progression-free survival (PFS) and overall survival (OS) were estimated using Kaplan-Meier methods. Hazard ratios for PFS and OS were estimated using a Cox regression model.

RESULTS

Twenty-eight percent of patients who participated in BRAIN had nonlocal disease at baseline (72% local disease). Sixty-seven (79%) patients treated with single-agent BEV and 57 (70%) patients treated with BEV+CPT-11 experienced disease progression while on BRAIN. Most patients in each treatment group did not have a change in the radiographic pattern of their tumor (i.e., "no shift") at the time of progression. The proportion of BEV patients with no shift (82%) was greater than that of BEV+CPT-11 patients (53%, χ(2) p = 0.0004), and a greater proportion of BEV+CPT-11 patients (39%) compared with BEV patients (16%) experienced local-to-diffuse tumor pattern at progression (χ(2) p = 0.002). Patients treated with BEV or BEV+CPT-11 who had local-to-local or local-to-diffuse progression patterns had similar efficacy outcomes, including objective response, PFS, and OS.

CONCLUSIONS

Most patients treated with BEV or BEV+CPT-11 on BRAIN did not experience a change from baseline in radiographic characteristics of disease at the time of progression.

Apparent diffusion coefficient histogram analysis stratifies progression-free survival in newly diagnosed bevacizumab-treated glioblastoma

BACKGROUND AND PURPOSE

Currently it is difficult to predict tumor response to anti-angiogenic therapy in individual patients. Our aim was to determine if ADC histogram analysis can stratify progression-free and overall survival in patients with newly diagnosed GBM treated "up-front" (ie, before tumor recurrence) with bevacizumab.

MATERIALS AND METHODS

Up-front bevacizumab-treated and control patients (n = 59 and 62, respectively) with newly diagnosed GBM were analyzed by using an ADC histogram approach based on enhancing tumor. Progression-free and overall survival was determined by using Cox proportional HRs and the Kaplan-Meier method with logrank and Wilcoxon tests.

RESULTS

For up-front bevacizumab-treated patients, lower ADC(L) was associated with significantly longer progression-free survival (median, 459 days for ADC(L) < 1200 versus 315 days for ADC(L) ≥ 1200 10(-6)mm(2)/s; P = .008, logrank test) and trended with longer overall survival (581 versus 429 days, P = .055). ADC values did not stratify progression-free or overall survival for patients in the control group (P = .92 and P = .22, respectively). Tumors with MGMT promoter methylation had lower ADC(L) values than unmethylated tumors (mean, 1071 versus 1183 10(-6)mm(2)/s; P = .01, 2-group t test).

CONCLUSIONS

Pretreatment ADC histogram analysis can stratify progression-free survival in bevacizumab-treated patients with newly diagnosed GBM. Lower ADC is associated with tumor MGMT promoter methylation, which may, in part, account for the favorable outcome associated with low ADC(L) tumors.

Detection of myocardial perfusion abnormalities: standard dual-source coronary computed tomography angiography versus rest/stress technetium-99m single-photo emission CT

We compared coronary dual-source computed tomography angiography (corDSCTA) with technetium-99m single-photon emission computed tomography (SPECT) for the detection of myocardial perfusion abnormalities. Fifty-five consecutive patients underwent both gated myocardial perfusion SPECT and corDSCTA, the latter during a single arterial-phase injection of contrast agent. The perfusion defects visualised by corDSCTA correlated with the findings of rest/stress SPECT. Abnormal findings on stress SPECT, which were due to either ischaemia or infarct, were found in 24 patients. In comparison to SPECT at rest, corDSCTA detected perfusion defects with a sensitivity and specificity of 100% and 78%, respectively. Compared to SPECT at stress, the sensitivity and specificity values of corDSCTA were 83.3% and 90.3%, respectively. On corDSCTA , the average attenuation values of perfusion defects that corresponded to chronic infarcts (-8.5+/-22.2 HU) were significantly lower (p = 0.002) than those of non-infarct-related perfusion defects (43.1+/-17.5 HU). Using rest/stress SPECT is the gold standard for the diagnosis of myocardial ischaemia, corDSCTA was able to diagnose ischaemic disease (defined as the presence of high-grade stenotic CAD (>or=50% luminal narrowing)) with a sensitivity and specificity of 59% and 89%, respectively, in patients with no known history of myocardial infarction (n = 4). Thus, corDSCTA may serve as a diagnostic tool for the detection of perfusion abnormalities (first) visualised by SPECT. There appears to be a limited correlation between coronary stenotic disease and SPECT findings.

Dynamics and dilemmas in working with families in Inpatient CAMH services

Working with the families of children and adolescents who are being treated in an Inpatient Child and Adolescent Mental Health facility can be both a vital part of the composite treatment package, and also a potential locus of tension, ambivalence and family-team rivalries. This article looks in detail at how collaborative principles put into practice in Inpatient CAMHS settings can benefit the children, adolescents, parents and siblings so that the family-plus-team system can be accessed as a working model for change in mutually desired directions. These principles include working in partnership with parents, being willing to learn from families and avoiding a culture of blame. The value of adopting a developmental perspective is also highlighted. Some thoughts on addressing stuck situations are shared and the importance of self-reflexivity in staff groups is emphasized. Case examples and clinical vignettes are included to illustrate both the difficulties and some experiences of their resolution on a particular children's inpatient unit.

Genetic loci determining bone density in mice with diet-induced atherosclerosis

This study investigates the phenotypic and genetic relationships among bone-density-related traits and those of adipose tissue and plasma lipids in mice with diet-induced atherosclerosis. Sixteen-month-old female F2 progeny of a C57BL/6J and DBA/2J intercross, which had received an atherogenic diet for 4 mo, were examined for multiple measures of femoral bone mass, density, and biomechanical properties using both computerized tomographic and radiographic methods. In addition, body weight and length, adipose tissue mass, plasma lipids and insulin, and aortic fatty lesions were assessed. Bone mass was inversely correlated with extent of atherosclerosis and with a prooxidant lipid profile and directly correlated with body weight, length, and, most strongly, adipose tissue mass. Quantitative trait locus (QTL) analysis, using composite interval mapping (CIM) and multi-trait analysis, identified six loci with multi-trait CIM LOD scores > 5. Three of these coincided with loci linked with adipose tissue and plasma high-density lipoprotein. Application of statistical tests for distinguishing close linkage vs. pleiotropy supported the presence of a potential pleiotropic effect of two of the loci on these traits. This study shows that bone mass in older female mice with atherosclerosis has multiple genetic determinants and provides phenotypic and genetic evidence linking the regulation of bone density with adipose tissue and plasma lipids.

Coronary-artery calcification in young adults with end-stage renal disease who are undergoing dialysis

BACKGROUND

Cardiovascular disease is common in older adults with end-stage renal disease who are undergoing regular dialysis, but little is known about the prevalence and extent of cardiovascular disease in children and young adults with end-stage renal disease.

METHODS

We used electron-beam computed tomography (CT) to screen for coronary-artery calcification in 39 young patients with end-stage renal disease who were undergoing dialysis (mean [+/-SD] age, 19+/-7 years; range, 7 to 30) and 60 normal subjects 20 to 30 years of age. In those with evidence of calcification on CT scanning, we determined its extent. The results were correlated with the patients' clinical characteristics, serum calcium and phosphorus concentrations, and other biochemical variables.

RESULTS

None of the 23 patients who were younger than 20 years of age had evidence of coronary-artery calcification, but it was present in 14 of the 16 patients who were 20 to 30 years old. Among those with calcification, the mean calcification score was 1157+/-1996, and the median score was 297. By contrast, only 3 of the 60 normal subjects had calcification. As compared with the patients without coronary-artery calcification, those with calcification were older (26+/-3 vs. 15+/-5 years, P<0.001) and had been undergoing dialysis for a longer period (14+/-5 vs. 4+/-4 years, P< 0.001). The mean serum phosphorus concentration, the mean calcium-phosphorus ion product in serum, and the daily intake of calcium were higher among the patients with coronary-artery calcification. Among 10 patients with calcification who underwent follow-up CT scanning, the calcification score nearly doubled (from 125+/-104 to 249+/-216, P=0.02) over a mean period of 20+/-3 months.

CONCLUSIONS

Coronary-artery calcification is common and progressive in young adults with end-stage renal disease who are undergoing dialysis.

Pitfalls in the diagnosis of thoracic aortic dissection at CT angiography

Two hundred seventy-five computed tomographic (CT) angiograms of the thoracic aorta were obtained over a period of approximately 4 years in patients with suspected or known aortic dissection. In all cases, unenhanced images were initially obtained, followed by contrast material-enhanced images. A variety of pitfalls were encountered that mimicked aortic dissection. These pitfalls were attributable to technical factors (eg, improper timing of contrast material administration relative to image acquisition); streak artifacts generated by high-attenuation material, high-contrast interfaces, or cardiac motion; periaortic structures (eg, aortic arch branches, mediastinal veins, pericardial recess, thymus, atelectasis, pleural thickening or effusion adjacent to the aorta); aortic wall motion and normal aortic sinuses; aortic variations such as congenital ductus diverticulum and acquired aortic aneurysm with thrombus; and penetrating atherosclerotic ulcer. Although several of these pitfalls are easy to recognize and therefore unlikely to present a diagnostic problem, others are potentially confusing. Familiarity with these common pitfalls, coupled with a knowledge of normal intrathoracic anatomy, will facilitate recognition of true aortic dissection and help avoid misdiagnosis at thoracic aortic CT angiography.

Spinal nephroblastoma in an Irish wolfhound

A 1-year-old Irish wolfhound was presented with a history of slowly progressive left pelvic limb paresis. A neurological examination demonstrated bilateral deficits referable to the thoracolumbar spinal cord. Lumbar cerebrospinal fluid contained neoplastic cells. An intradural, extramedullary mass was demonstrated by myelography at the caudal aspect of T13. Surgical excision was abandoned owing to severe macroscopic damage to, and apparent infiltration of, the cord, and the dog was euthanased. The tumour was diagnosed histologically as an extrarenal nephroblastoma. Nephroblastoma should be suspected in young, large-breed dogs with intradural extramedullary masses over spinal segments T10-L2. The prognosis for complete recovery after surgical excision is guarded to poor.

Computed radiography dual energy subtraction: performance evaluation when detecting low-contrast lung nodules in an anthropomorphic phantom

A dedicated chest computed radiography (CR) system has an option of energy subtraction (ES) acquisition. Two imaging plates, rather than one, are separated by a copper filter to give a high-energy and low-energy image. This study compares the diagnostic accuracy of conventional computed radiography to that of ES obtained with two radiographic techniques. One soft tissue only image was obtained at the conventional CR technique (s = 254) and the second was obtained at twice the radiation exposure (s = 131) to reduce noise. An anthropomorphic phantom with superimposed low-contrast lung nodules was imaged 53 times for each radiographic technique. Fifteen images had no nodules; 38 images had a total of 90 nodules placed on the phantom. Three chest radiologists read the three sets of images in a receiver operating characteristic (ROC) study. Significant differences in Az were only found between (1) the higher exposure energy subtracted images and the conventional dose energy subtracted images (P = .095, 90% confidence), and (2) the conventional CR and the energy subtracted image obtained at the same technique (P = .024, 98% confidence). As a result of this study, energy subtracted images cannot be substituted for conventional CR images when detecting low-contrast nodules, even when twice the exposure is used to obtain them.

The evolution of an integrated timeline for oncology patient healthcare

The introduction of computers in the medical environment has contributed to the proliferation of medical data, often making it difficult to consolidate information on a single patient. In patients with complex medical problems, such as oncology patients, the lack of data integration can negatively impact on patient care. This paper presents an infrastructure for the creation of an integrated multimedia timeline that automatically combines patient information from distributed hospital information sources, and creates a visual summary of pertinent events in a patient's medical history. In this prototype, we focus on oncology patients under treatment for advanced cancers.

Estimation of the left ventricular ejection fraction using a novel multiphase, dark-blood, breath-hold MR imaging technique

OBJECTIVE

In this paper, we evaluate a recently proposed dual-phase dark-blood MR sequence for estimating the left ventricular ejection fraction, compare Simpson's method of estimation of ejection fraction with a model based on the biplane method, assess the reproducibility of both methods, and finally, test a semiautomated method for contouring the endocardial border.

SUBJECTS AND METHODS

An MR pulse sequence was implemented to acquire cardiac images in both diastolic and systolic phases within a single breath-hold. A special magnetization preparation scheme rendered blood dark while a segmented acquisition allowed breath-hold scan times. Five healthy volunteers and five patients with cardiac disease were imaged. Ejection fractions were estimated using (1) long-axis and four-chamber biplane views with an ellipsoid model and (2) a series of short-axis views in combination with Simpson's model. These values of ejection fractions were then compared with values obtained from echocardiography.

RESULTS

Estimates of ejection fractions obtained using biplane ellipsoid volume and Simpson's rule methods varied by 14% in healthy volunteers. However, for patients with severe cardiomyopathy, differences between the values of ejection fraction obtained with the two methods varied by as much as 150%. Ejection fraction estimates obtained from MR images with the biplane ellipsoid method and from echocardiography varied by approximately 14% for all subjects. Ejection fraction estimates obtained with the semiautomated algorithm agreed well with estimates obtained with manual contours made by experienced radiologists. Intraobserver variability was low for both the short-axis (3%) and biplane (4%) methods. However, interobserver variability of the biplane method (12%) exceeded that of the short-axis method (4%). Interexamination variability (9%) was the largest factor in determining the reproducibility of the ejection fraction estimates.

CONCLUSION

Breath-hold dark-blood MR imaging technique with simultaneous acquisition of a series of short-axis views during systolic and diastolic phases permits rapid and accurate estimates of ejection fractions in healthy subjects and in patients. Model based biplane MR imaging methods are less reliable in patients with global cardiomyopathy. The estimation of ejection fractions can be automated using the proposed contouring algorithm and the dark-blood short-axis views.

Chest teleradiology in a teaching hospital emergency practice

OBJECTIVE

New standards for hospital accreditation and health care reimbursement may require that faculty subspecialists be more available after regular working hours to supervise residents in academic radiology departments. We designed a receiver operating characteristic study to determine whether a thoracic radiologist who evaluated computed radiography (CR) images of the chest at a home-based teleradiology workstation could add significant value to a junior resident's interpretations of films within the hospital for acutely ill patients.

SUBJECTS AND METHODS

Using a hybrid cassette, we obtained analog chest films and CR images simultaneously for each of 252 acutely ill patients in the emergency department and in an intensive care unit. Interpretations of the analog films by three first-year residents were analyzed for 11 parameters deemed critical for patient management. Likewise, CR images of the same chest studies were viewed on a home teleradiology workstation by a faculty thoracic radiologist who analyzed the images for these 11 interpretive parameters. All interpretations by radiology residents and by the home-based thoracic radiologist were then compared with the interpretations of a consensus panel consisting of another thoracic radiologist and a full-time emergency department radiologist.

RESULTS

Analysis of the pooled results from the three junior residents as a group failed to show significant differences between their interpretations of chest films and the interpretations of CR images by a thoracic radiologist at a home workstation. However, we observed significant differences for several image interpretation parameters between individual residents and the home-based radiology subspecialist.

CONCLUSION

The data confirm that significant value can be added to the interpretations of chest films by individual junior residents when a home-based thoracic radiologist uses teleradiology to provide expert interpretations. Accordingly, it is reasonable to infer that on-line supervision by faculty subspecialists via teleradiology could be used to complement the scheduled visits that are being made now by individual faculty members of our institution to interpret films periodically with a radiology resident during overnight and weekend periods.

A unified timeline model and user interface for multimedia medical databases

A multimedia medical database model and prototype is described for supporting a timeline-based presentation of information. The database links image and text data in a way that permits users to look at medical information in a single unified view. Various visualization programs permit the user to view data in various ways, including full image views, graphs, and tables. Our technology is applied for proof-of-concept to two areas: thoracic oncology and thermal tumor ablation therapy of the brain. This effort is part of the multidisciplinary KMeD project in collaboration with medical research and clinical treatment projects at UCLA.