How should pathogen transmission be modelled?

Host-pathogen models are essential for designing strategies for managing disease threats to humans, wild animals and domestic animals. The behaviour of these models is greatly affected by the way in which transmission between infected and susceptible hosts is modelled. Since host-pathogen models were first developed at the beginning of the 20th century, the 'mass action' assumption has almost always been used for transmission. Recently, however, it has been suggested that mass action has often been modelled wrongly. Alternative models of transmission are beginning to appear, as are empirical tests of transmission dynamics.

Effect of B vitamins and genetics on success of in-vitro fertilisation: prospective cohort study

BACKGROUND

There is a need to understand what affects the success of in-vitro fertilisation (IVF) and the rate of resulting twin births so that pregnancy rates can be improved and multiple gestations avoided. Our aim was to assess the role of B vitamins and genetics.

METHODS

We did a prospective cohort study of 602 women undergoing fertility treatment. We assessed intake of folate and vitamin B12 with a questionnaire and measured their plasma and red-blood-cell concentrations by radioimmunoassay. We measured five B-vitamin-related gene variants in women who received treatment and in 932 women who conceived naturally.

FINDINGS

The likelihood of a twin birth after IVF rose with increased concentrations of plasma folate (1.52, 1.01-2.28; p=0.032) and red-cell folate (1.28, 1.00-1.65; p=0.039). There was no association between folate and vitamin B12 levels and likelihood of a successful pregnancy. Women homozygous for the 1298 CC variant of methylenetetrahydro-folate reductase (MTHFR), rather than the AA variant, were less likely to produce a livebirth after IVF (0.24, 0.08-0.71; p=0.003) or to have had a previous pregnancy (0.42, 0.21-0.81; p=0.008).

INTERPRETATION

Our findings suggest that MTHFR genotype is linked to a woman's potential to produce healthy embryos (possibly through interaction with genes related to DNA methylation). In women likely to have a successful IVF pregnancy, high folate status increases the likelihood of twin birth after multiple embryo transfer. Proposals to fortify the UK diet with folic acid could lead to an increase in the number of twins born after IVF.

UK quantitative WB-DWI technical workgroup: consensus meeting recommendations on optimisation, quality control, processing and analysis of quantitative whole-body diffusion-weighted imaging for cancer

OBJECTIVE

Application of whole body diffusion-weighted MRI (WB-DWI) for oncology are rapidly increasing within both research and routine clinical domains. However, WB-DWI as a quantitative imaging biomarker (QIB) has significantly slower adoption. To date, challenges relating to accuracy and reproducibility, essential criteria for a good QIB, have limited widespread clinical translation. In recognition, a UK workgroup was established in 2016 to provide technical consensus guidelines (to maximise accuracy and reproducibility of WB-MRI QIBs) and accelerate the clinical translation of quantitative WB-DWI applications for oncology.

METHODS

A panel of experts convened from cancer centres around the UK with subspecialty expertise in quantitative imaging and/or the use of WB-MRI with DWI. A formal consensus method was used to obtain consensus agreement regarding best practice. Questions were asked about the appropriateness or otherwise on scanner hardware and software, sequence optimisation, acquisition protocols, reporting, and ongoing quality control programs to monitor precision and accuracy and agreement on quality control.

RESULTS

The consensus panel was able to reach consensus on 73% (255/351) items and based on consensus areas made recommendations to maximise accuracy and reproducibly of quantitative WB-DWI studies performed at 1.5T. The panel were unable to reach consensus on the majority of items related to quantitative WB-DWI performed at 3T.

CONCLUSION

This UK Quantitative WB-DWI Technical Workgroup consensus provides guidance on maximising accuracy and reproducibly of quantitative WB-DWI for oncology. The consensus guidance can be used by researchers and clinicians to harmonise WB-DWI protocols which will accelerate clinical translation of WB-DWI-derived QIBs.

The impact of cardiology on the collective effective dose in the North of England

Two cardiology X-ray rooms were monitored with dose-area product meters as part of a Regional Patient Dosimetry Programme. Dose-area product measurements on over 2000 patients undergoing examinations in the cardiology rooms are presented. The data have been corrected according to patient size where possible. In room A mean dose-area product values for coronary angiography, coronary angioplasty, radiofrequency ablation and mitral valvuloplasty were found to be 47.7, 72.2, 91.1 and 161.9 Gy cm2 respectively. In room B mean dose-area product values for coronary angiography and coronary angioplasty were found to be 23.4 and 51.6 Gy cm2 respectively. Observational studies were used to deduce the typical projections and technique factors. This typical examination was used to simulate an angiogram from which it was possible to derive factors to convert measured dose-area product values into estimates of effective dose. In room A, the effective doses were estimated to be 9.4, 14.2, 17.3 and 29.3 mSv for coronary angiography, coronary angioplasty, radiofrequency ablation and mitral valvuloplasty, respectively. The effective doses during coronary angiography and coronary angioplasty, performed in room B, were found to be 4.6 and 10.2 mSv, respectively. A regional survey of the frequency of these cardiac procedures was performed. It was deduced that the annual collective effective dose from these cardiac procedures in the North of England, the former Northern Region, was 45.7 manSv.

Multicentre, deep learning, synthetic-CT generation for ano-rectal MR-only radiotherapy treatment planning

BACKGROUND AND PURPOSE

Comprehensive dosimetric analysis is required prior to the clinical implementation of pelvic MR-only sites, other than prostate, due to the limited number of site specific synthetic-CT (sCT) dosimetric assessments in the literature. This study aims to provide a comprehensive assessment of a deep learning-based, conditional generative adversarial network (cGAN) model for a large ano-rectal cancer cohort. The following challenges were investigated; T2-SPACE MR sequences, patient data from multiple centres and the impact of sex and cancer site on sCT quality.

METHOD

RT treatment position CT and T2-SPACE MR scans, from two centres, were collected for 90 ano-rectal patients. A cGAN model trained using a focal loss function, was trained and tested on 46 and 44 CT-MR ano-rectal datasets, paired using deformable registration, respectively. VMAT plans were created on CT and recalculated on sCT. Dose differences and gamma indices assessed sCT dosimetric accuracy. A linear mixed effect (LME) model assessed the impact of centre, sex and cancer site.

RESULTS

A mean PTV D95% dose difference of 0.1% (range: -0.5% to 0.7%) was found between CT and sCT. All gamma index (1%/1 mm threshold) measurements were >99.0%. The LME model found the impact of modality, cancer site, sex and centre was clinically insignificant (effect ranges: -0.4% and 0.3%). The mean dose difference for all OAR constraints was 0.1%.

CONCLUSION

Focal loss cGAN models using T2-SPACE MR sequences from multiple centres can produce generalisable, dosimetrically accurate sCTs for ano-rectal cancers.

Variability in prostate and seminal vesicle delineations defined on magnetic resonance images, a multi-observer, -center and -sequence study

Background

The use of magnetic resonance (MR) imaging as a part of preparation for radiotherapy is increasing. For delineation of the prostate several publications have shown decreased delineation variability using MR compared to computed tomography (CT). The purpose of the present work was to investigate the intra- and inter-physician delineation variability for prostate and seminal vesicles, and to investigate the influence of different MR sequence settings used clinically at the five centers participating in the study.

Methods

MR series from five centers, each providing five patients, were used. Two physicians from each center delineated the prostate and the seminal vesicles on each of the 25 image sets. The variability between the delineations was analyzed with respect to overall, intra- and inter-physician variability, and dependence between variability and origin of the MR images, i.e. the MR sequence used to acquire the data.

Results

The intra-physician variability in different directions was between 1.3 - 1.9 mm and 3 – 4 mm for the prostate and seminal vesicles respectively (1 std). The inter-physician variability for different directions were between 0.7 – 1.7 mm and approximately equal for the prostate and seminal vesicles. Large differences in variability were observed for individual patients, and also for individual imaging sequences used at the different centers. There was however no indication of decreased variability with higher field strength.

Conclusion

The overall delineation variability is larger for the seminal vesicles compared to the prostate, due to a larger intra-physician variability. The imaging sequence appears to have a large influence on the variability, even for different variants of the T2-weighted spin-echo based sequences, which were used by all centers in the study.

Modelling the impact of predation on reintroductions of bridled nailtail wallabies

Predation by introduced foxes and cats is generally thought to be the main reason for the poor success rate of macropod reintroductions on the Australian mainland. Predator-prey theory suggests that predation may have particularly severe impacts on very small populations, especially if a more common primary prey species is present (such as the rabbit). Thus, a sufficiently large reintroduction may overcome predation and succeed where a smaller one would fail. The minimum viable population would, however, be much larger than that predicted by standard population-viability analysis. We use a simple stochastic model based upon the bridled nailtail wallaby to explore this possibility. Even very small amounts of predation (2-4 individuals per six months) can be sufficient to cause reintroductions of up to 50 animals to fail. No clear threshold population size beyond which reintroductions will succeed is evident and, for a given mean, the probability distribution of predation has a very limited impact on the success of reintroductions. In almost all circumstances, a single reintroduction of a given size is preferable to multiple reintroductions of the same total number of individuals.

Evaluating the repeatability and set-up sensitivity of a large field of view distortion phantom and software for magnetic resonance-only radiotherapy

BACKGROUND AND PURPOSE

Magnetic Resonance (MR)-only radiotherapy requires geometrically accurate MR images over the full scanner Field of View (FoV). This study aimed to investigate the repeatability of distortion measurements made using a commercial large FoV phantom and analysis software and the sensitivity of these measurements to small set-up errors.

MATERIALS AND METHODS

Geometric distortion was measured using a commercial phantom and software with 2D and 3D acquisition sequences on three different MR scanners. Two sets of repeatability measurements were made: three scans acquired without moving the phantom between scans (single set-up) and five scans acquired with the phantom re-set up in between each scan (repeated set-up). The set-up sensitivity was assessed by scanning the phantom with an intentional 1 mm lateral offset and independently an intentional 1° rotation.

RESULTS

The mean standard deviation of distortion for all phantom markers for the repeated set-up scans was < 0.4 mm for all scanners and sequences. For the 1 mm lateral offset scan 90 % of the markers agreed within two standard deviations of the mean of the repeated set-up scan (median of all scanners and sequences, range 78%-93%). For the 1° rotation scan, 80% of markers agreed within two standard deviations of the mean (range 69%-93%).

CONCLUSIONS

Geometric distortion measurements using a commercial phantom and associated software appear repeatable, although with some sensitivity to set-up errors. This suggests the phantom and software are appropriate for commissioning a MR-only radiotherapy workflow.

IPEM Topical Report: A 2018 IPEM survey of MRI use for external beam radiotherapy treatment planning in the UK

The benefits of integrating MRI into the radiotherapy pathway are well published, however there is little consensus in guidance on how to commission or implement its use. With a view to developing consensus guidelines for the use of MRI in external beam radiotherapy (EBRT) treatment planning in the UK, a survey was undertaken by an Institute of Physics and Engineering in Medicine (IPEM) working-party to assess the current landscape of MRI use in EBRT in the UK. A multi-disciplinary working-party developed a survey to understand current practice using MRI for EBRT treatment planning; investigate how MRI is currently used and managed; and identify knowledge gaps. The survey was distributed electronically to radiotherapy service managers and physics leads in 71 UK radiotherapy (RT) departments (all NHS and private groups). The survey response rate was 87% overall, with 89% of NHS and 75% of private centres responding. All responding centres include EBRT in some RT pathways: 94% using Picture Archiving and Communication System (PACS) images potentially acquired without any input from RT departments, and 69% had some form of MRI access for planning EBRT. Most centres reporting direct access use a radiology scanner within the same hospital in dedicated (26%) or non-dedicated (52%) RT scanning sessions. Only two centres reported having dedicated RT MRI scanners in the UK, lower than reported in other countries. Six percent of radiotherapy patients in England (data not publically available outside of England) have MRI as part of their treatment, which again is lower than reported elsewhere. Although a substantial number of centres acquire MRI scans for treatment planning purposes, most centres acquire less than five patient scans per month for each treatment site. Commissioning and quality assurance of both image registration and MRI scanners was found to be variable across the UK. In addition, staffing models and training given to different staff groups varied considerably across the UK, reflecting the current lack of national guidelines. The primary barriers reported to MRI implementation in EBRT planning included costs (e.g. lack of a national tariff for planning MRI), lack of MRI access and/or capacity within hospitals. Despite these challenges, significant interest remains in increasing MRI-assisted EBRT planning over the next five years.

Paediatric pelvic imaging: improvement in gonad shield placement by multidisciplinary audit

BACKGROUND

In 1996, there were local reports of poor gonad protection for paediatric pelvic radiographs.

OBJECTIVES

To investigate the nature of the problem and make necessary improvements.

MATERIALS AND METHODS

A retrospective audit of 218 paediatric pelvic radiographs was undertaken in 1997. Each radiograph was assessed for the presence of a gonad shield, appropriateness of the device and its position. A multidisciplinary team was formed with representation from radiology, radiography, orthopaedics and medical physics to investigate ways of improving technique and reducing patient dose. These included radiographer training and the introduction of digital fluoroscopy as an alternative imaging technique in follow-up patients. There were further rounds of data collection in 1998 and 1999.

RESULTS

In round 1, a gonad shield was present in 77.9 % of boys' films and 76 % of girls' films where one should have been, increasing to 85.2 % and 85.4 % respectively by round 3 of the audit (P < 0.05). Only 31.6 % of boys' devices and 21.9 % of girls' devices were correctly positioned in round 1, increasing to 78.3 % and 94.3 %, respectively, by round 3 of the audit (P < 0.05). After round 1, no inappropriate devices were used.

CONCLUSION

Audit was an effective tool in gaining the resources needed to improve technique and reduce radiation exposure in children. The multidisciplinary approach was vital in the success of this project.

Live-trapping of the northern hairy-nosed wombat (Lasiorhinus krefftii): population-size estimates and effects on individuals

The northern hairy-nosed wombat, one of the most endangered large mammals known, occurs only in Epping Forest National Park, central Queensland. The results of a 3-stage trapping programme, carried out between 1985 and 1993, were used to estimate population size by means of three separate modelling approaches: minimum number alive (MNA), mark-recapture, and trapping effort. Trapping procedure varied among sessions, and each estimator was applied to sessions only where its use was appropriate. The population-size estimate for 1985-86 was 67 (trap effort) with MNA of 58; for 1988-89 it was 62 (Jolly-Seber mark-recapture estimate), with MNA of 48 and upper 95% confidence limit of 77; and for 1993 it was 65 (Chao mark-recapture and trap effort), with MNA of 43 and upper 95% confidence limit of 186 (Chao mark-recapture). No population trends were observed, although variability in estimates and wide confidence intervals meant that power to do so was limited. Trapping affected the health and behaviour of wombats. Animals that were trapped twice within 10 nights lost an average of 0.62 kg (P = 0.006) between captures. Wombats that were trapped twice within the first four nights of traps being set on a burrow showed less weight loss than those trapped for the second time after 5-7 nights (0.23 kg v. 1.54 kg). The effects of trapping appeared to remain with animals for some time, since animals trapped twice more than 30 nights apart and within six months weighed an average of 0.5 kg less (P = 0.013) on second capture. When areas were trapped twice in succession with a 3-week gap, population-size estimates were lower for the second period of trapping. Thus, some wombats may have temporarily left areas disturbed by trapping. The deleterious impact of trapping may be reduced by restricting trapping to periods of four nights. Trapping effectiveness may be increased by minimising disturbance immediately before trapping and by moving traps between periods of trapping.

IPEM topical report: guidance on the use of MRI for external beam radiotherapy treatment planning. Phys Med Biol 2021;66:055025. [PMID: 33450742 DOI: 10.1088/1361-6560/abdc30]

This document gives guidance for multidisciplinary teams within institutions setting up and using an MRI-guided radiotherapy (RT) treatment planning service. It has been written by a multidisciplinary working group from the Institute of Physics and Engineering in Medicine (IPEM). Guidance has come from the experience of the institutions represented in the IPEM working group, in consultation with other institutions, and where appropriate references are given for any relevant legislation, other guidance documentation and information in the literature. Guidance is only given for MRI acquired for external beam RT treatment planning in a CT-based workflow, i.e. when MRI is acquired and registered to CT with the purpose of aiding delineation of target or organ at risk volumes. MRI use for treatment response assessment, MRI-only RT and other RT treatment types such as brachytherapy and gamma radiosurgery are not considered within the scope of this document. The aim was to produce guidance that will be useful for institutions who are setting up and using a dedicated MR scanner for RT (referred to as an MR-sim) and those who will have limited time on an MR scanner potentially managed outside of the RT department, often by radiology. Although not specifically covered in this document, there is an increase in the use of hybrid MRI-linac systems worldwide and brief comments are included to highlight any crossover with the early implementation of this technology. In this document, advice is given on introducing a RT workload onto a non-RT-dedicated MR scanner, as well as planning for installation of an MR scanner dedicated for RT. Next, practical guidance is given on the following, in the context of RT planning: training and education for all staff working in and around an MR scanner; RT patient set-up on an MR scanner; MRI sequence optimisation for RT purposes; commissioning and quality assurance (QA) to be performed on an MR scanner; and MRI to CT registration, including commissioning and QA.

Modelling Wildlife-Parasite Interactions to Help Plan and Interpret Field Studies

The positive role that modelling has played in the understanding of wildlife and parasite population dynamics is reviewed with particular emphasis on macroparasitic infection, and how modelling can lead to better understanding in the future is discussed.

IPEM Topical Report: an international IPEM survey of MRI use for external beam radiotherapy treatment planning

Introduction/Background. Despite growing interest in magnetic resonance imaging (MRI), integration in external beam radiotherapy (EBRT) treatment planning uptake varies globally. In order to understand the current international landscape of MRI in EBRT a survey has been performed in 11 countries. This work reports on differences and common themes identified.Methods. A multi-disciplinary Institute of Physics and Engineering in Medicine working party modified a survey previously used in the UK to understand current practice using MRI for EBRT treatment planning, investigate how MRI is currently used and managed as well as identify knowledge gaps. It was distributed electronically within 11 countries: Australia, Belgium, Denmark, Finland, France, Italy, the Netherlands, New Zealand, Sweden, the UK and the USA.Results. The survey response rate within the USA was <1% and hence these results omitted from the analysis. In the other 10 countries the survey had a median response rate of 77% per country. Direct MRI access, defined as either having a dedicated MRI scanner for radiotherapy (RT) or access to a radiology MRI scanner, varied between countries. France, Italy and the UK reported the lowest direct MRI access rates and all other countries reported direct access in ≥82% of centres. Whilst ≥83% of centres in Denmark and Sweden reported having dedicated MRI scanners for EBRT, all other countries reported ≤29%. Anatomical sites receiving MRI for EBRT varied between countries with brain, prostate, head and neck being most common. Commissioning and QA of image registration and MRI scanners varied greatly, as did MRI sequences performed, staffing models and training given to different staff groups. The lack of financial reimbursement for MR was a consistent barrier for MRI implementation for RT for all countries and MR access was a reported important barrier for all countries except Sweden and Denmark.Conclusion. No country has a comprehensive approach for MR in EBRT adoption and financial barriers are present worldwide. Variations between countries in practice, equipment, staffing models, training, QA and MRI sequences have been identified, and are likely to be due to differences in funding as well as a lack of consensus or guidelines in the literature. Access to dedicated MR for EBRT is limited in all but Sweden and Denmark, but in all countries there are financial challenges with ongoing per patient costs. Despite these challenges, significant interest exists in increasing MR guided EBRT planning over the next 5 years.

The benefit of MR-only radiotherapy treatment planning for anal and rectal cancers: A planning study

INTRODUCTION

Limited evidence exists showing the benefit of magnetic resonance (MR)-only radiotherapy treatment planning for anal and rectal cancers. This study aims to assess the impact of MR-only planning on target volumes (TVs) and treatment plan doses to organs at risks (OARs) for anal and rectal cancers versus a computed tomography (CT)-only pathway.

MATERIALS AND METHODS

Forty-six patients (29 rectum and 17 anus) undergoing preoperative or radical external beam radiotherapy received CT and T2 MR simulation. TV and OARs were delineated on CT and MR, and volumetric arc therapy treatment plans were optimized independently (53.2 Gy/28 fractions for anus, 45 Gy/25 fractions for rectum). Further treatment plans assessed gross tumor volume (GTV) dose escalation. Differences in TV volumes and OAR doses, in terms of Vx Gy (organ volume (%) receiving x dose (Gy)), were assessed.

RESULTS

MR GTV and primary planning TV (PTV) volumes systematically reduced by 13 cc and 98 cc (anus) and 44 cc and 109 cc (rectum) respectively compared to CT volumes. Statistically significant OAR dose reductions versus CT were found for bladder and uterus (rectum) and bladder, penile bulb, and genitalia (anus). With GTV boosting, statistically significant dose reductions were found for sigmoid, small bowel, vagina, and penile bulb (rectum) and vagina (anus).

CONCLUSION

Our findings provide evidence that the introduction of MR (whether through MR-only or CT-MR pathways) to radiotherapy treatment planning for anal and rectal cancers has the potential to improve treatments. MR-related OAR dose reductions may translate into less treatment-related toxicity for patients or greater ability to dose escalate.

Applying a commercial atlas-based synthetic Computed Tomography algorithm to patients with hip prostheses for prostate Magnetic Resonance-only radiotherapy

BACKGROUND AND PURPOSE

Magnetic Resonance (MR)-only prostate radiotherapy has recently been clinically implemented using commercial synthetic Computed Tomography (sCT) algorithms. However patients with hip prostheses have been excluded from all MR-only research to date and assumed to require dedicated sCT algorithms. This study aimed to investigate the dosimetric accuracy of applying a commercial sCT algorithm, based on an atlas of patients without hip prostheses, to patients with prostheses.

MATERIALS AND METHODS

18 patients with unilateral hip prostheses received MR and CT scans in the radiotherapy position. sCTs were generated from the MR using a commercial algorithm. The clinical Volumetric Modulated Arc Therapy (VMAT) plan, consisting of partial arcs which avoided the prosthesis, was recalculated using the sCT and the dose distribution compared.

RESULTS

The mean isocentre dose difference was ΔD = (-0.4 ± 0.2)% (mean ± standard error of the mean (sem), range - 1.9%, 1.1%) and the mean differences in Planning Target Volume, bladder and rectum mean doses were ≤0.3%. The 3D global gamma pass rate with dose difference 1% and distance to agreement 1 mm within the body was Γ_Body^1/1 = (95.0 ± 0.5)% (sem) and within the 50% isodose volume, which excluded the prosthesis, was Γ_50%^1/1 = (98.5 ± 0.4)% (sem). The pass rate within the PTV was Γ_PTV^2/2 ≥ 99.7% for all patients, although for PTVs close (≤3.5 cm) to the prosthesis Γ_PTV^1/1 < 85% for three patients. The sCT did not accurately represent the prosthesis with a mean difference in radiological isocentre depth near the prosthesis of Δd_Outside^Rad = (15.8 ± 2.6) mm (sem). However inside the treatment plan arc the difference was Δd_Inside^Rad = (-1.8 ± 0.5) mm (sem).

CONCLUSIONS

Using a commercial prostate sCT algorithm for patients with unilateral hip prostheses is dosimetrically accurate (<0.5%) as long as the routine prosthesis-avoidance treatment planning approach is used and the PTV is >3.5 cm from the prosthesis. This suggests MR-only prostate radiotherapy can be extended to patients with hip prostheses without requiring a specific sCT algorithm.

Horse populations are severely underestimated in a region at risk of Hendra virus spillover

OBJECTIVE

To identify the size and distribution of the horse population in the Northern Rivers Region of NSW, including changes from 2007 to 2021, to better understand populations at risk of Hendra virus transmission.

METHODS

Census data from the 2007 Equine Influenza (EI) outbreak were compared with data collected annually by New South Wales Local Land Services (LLS) (2011-2021), and with field observations via road line transects (2021).

RESULTS

The horse populations reported to LLS in 2011 (3000 horses; 0.77 horses/km2) was 145% larger than that reported during the EI outbreak in 2007 (1225 horses; 0.32 horses/km2). This was inconsistent with the 6% increase in horses recorded from 2011 to 2020 within the longitudinal LLS dataset. Linear modelling suggested the true horse population of this region in 2007 was at least double that reported at the time. Distance sampling in 2021 estimated the region's population at 10,185 horses (3.89 per km2; 95% CI = 4854-21,372). Field sampling and modelling identified higher horse densities in rural cropland, with the percentage of conservation land, modified grazing, and rural residential land identified as the best predictors of horse densities.

CONCLUSIONS

Data from the 2007 EI outbreak no longer correlates to the current horse population in size or distribution and was likely not a true representation at the time. Current LLS data also likely underestimates horse populations. Ongoing efforts to further quantify and map horse populations in Australia are important for estimating and managing the risk of equine zoonoses.