Practice variation in the diagnosis of acute rejection among pediatric heart transplant centers: An analysis of the pediatric heart transplant society (PHTS) registry

BACKGROUND

Freedom from rejection in pediatric heart transplant recipients is highly variable across centers. This study aimed to assess the center variation in methods used to diagnose rejection in the first-year post-transplant and determine the impact of this variation on patient outcomes.

METHODS

The PHTS registry was queried for all rejection episodes in the first-year post-transplant (2010-2019). The primary method for rejection diagnosis was determined for each event as surveillance biopsy, echo diagnosis, or clinical. The percentage of first-year rejection events diagnosed by surveillance biopsy was used to approximate the surveillance strategy across centers. Methods of rejection diagnosis were described and patient outcomes were assessed based on surveillance biopsy utilization among centers.

RESULTS

A total of 3985 patients from 56 centers were included. Of this group, 873 (22%) developed rejection within the first-year post-transplant. Surveillance biopsy was the most common method of rejection diagnosis (71.7%), but practices were highly variable across centers. The majority (73.6%) of first rejection events occurred within 3-months of transplantation. Diagnosis modality in the first-year was not independently associated with freedom from rejection, freedom from rejection with hemodynamic compromise, or overall graft survival.

CONCLUSIONS

Rejection in the first-year after pediatric heart transplant occurs in 22% of patients and most commonly in the first 3 months post-transplant. Significant variation exists across centers in the methods used to diagnose rejection in pediatric heart transplant recipients, however, these variable strategies are not independently associated with freedom from rejection, rejection with hemodynamic compromise, or overall graft survival.

VADER: a variable dose-rate external 137Cs irradiator for internal emitter and low dose rate studies

In the long term, 137Cs is probably the most biologically important agent released in many accidental (or malicious) radiation disasters. It can enter the food chain, and be consumed, or, if present in the environment (e.g. from fallout), can provide external irradiation over prolonged times. In either case, due to the high penetration of the energetic γ rays emitted by 137Cs, the individual will be exposed to a low dose rate, uniform, whole body, irradiation. The VADER (VAriable Dose-rate External 137Cs irradiatoR) allows modeling these exposures, bypassing many of the problems inherent in internal emitter studies. Making use of discarded 137Cs brachytherapy seeds, the VADER can provide varying low dose rate irradiations at dose rates of 0.1 to 1.2 Gy/day. The VADER includes a mouse "hotel", designed to allow long term simultaneous residency of up to 15 mice. Two source platters containing ~ 250 mCi each of 137Cs brachytherapy seeds are mounted above and below the "hotel" and can be moved under computer control to provide constant low dose rate or a varying dose rate mimicking 137Cs biokinetics in mouse or man. We present the VADER design and characterization of its performance over 18 months of use.

Variation assessment of deformable registration in stereotactic radiosurgery

INTRODUCTION

The regular functions of CT-MRI registration include delineation of targets and organs-at-risk (OARs) in radiosurgery planning. The question of whether deformable image registration (DIR) could be applied to stereotactic radiosurgery (SRS) in its place remains a subject of debate.

METHODS

This study collected data regarding 16 patients who had undergone single-fraction SRS treatment. All lesions were located close to the brainstem. CT and MRI two image sets were registered by both rigid image registration (RIR) and DIR algorithms. The contours of the OARs were drawn individually on the rigid and deformable CT-MRI image sets by qualified radiation oncologists and dosimetrists. The evaluation metrics included volume overlapping (VO), Dice similarity coefficient (DSC), and dose. The modified demons deformable algorithm (VARIAN SmartAdapt) was used for evaluation in this study.

RESULTS

The mean range of VO for OARs was 0.84 ± 0.08, and DSC was 0.82 ± 0.07. The maximum average volume difference was at normal brain (17.18 ± 14.48 cm³) and the second highest was at brainstem (2.26 cm³ ± 1.18). Pearson correlation testing showed that all DIRs' OAR volumes were linearly and significantly correlated with RIRs' volume (0.679-0.992, two tailed, P << 0.001). The 100% dose was prescribed at gross tumor volume (GTV). The average maximum percent dose difference was observed in brainstem (26.54% ± 27.027), and the average mean dose difference has found at same organ (1.6% ± 1.66).

CONCLUSION

The change in image-registration method definitely produces dose variance, and is significantly more what depending on the target location. The volume size of OARs, however, was not statistical significantly correlated with dose variance.

Optimal technique of linear accelerator-based stereotactic radiosurgery for tumors adjacent to brainstem

Stereotactic radiosurgery (SRS) is a well-established technique that is replacing whole-brain irradiation in the treatment of intracranial lesions, which leads to better preservation of brain functions, and therefore a better quality of life for the patient. There are several available forms of linear accelerator (LINAC)-based SRS, and the goal of the present study is to identify which of these techniques is best (as evaluated by dosimetric outcomes statistically) when the target is located adjacent to brainstem. We collected the records of 17 patients with lesions close to the brainstem who had previously been treated with single-fraction radiosurgery. In all, 5 different lesion catalogs were collected, and the patients were divided into 2 distance groups-1 consisting of 7 patients with a target-to-brainstem distance of less than 0.5cm, and the other of 10 patients with a target-to-brainstem distance of ≥ 0.5 and < 1cm. Comparison was then made among the following 3 types of LINAC-based radiosurgery: dynamic conformal arcs (DCA), intensity-modulated radiosurgery (IMRS), and volumetric modulated arc radiotherapy (VMAT). All techniques included multiple noncoplanar beams or arcs with or without intensity-modulated delivery. The volume of gross tumor volume (GTV) ranged from 0.2cm(3) to 21.9cm(3). Regarding the dose homogeneity index (HIICRU) and conformity index (CIICRU) were without significant difference between techniques statistically. However, the average CIICRU = 1.09 ± 0.56 achieved by VMAT was the best of the 3 techniques. Moreover, notable improvement in gradient index (GI) was observed when VMAT was used (0.74 ± 0.13), and this result was significantly better than those achieved by the 2 other techniques (p < 0.05). For V4Gy of brainstem, both VMAT (2.5%) and IMRS (2.7%) were significantly lower than DCA (4.9%), both at the p < 0.05 level. Regarding V2Gy of normal brain, VMAT plans had attained 6.4 ± 5%; this was significantly better (p < 0.05) than either DCA or IMRS plans, at 9.2 ± 7% and 8.2 ± 6%, respectively. Owing to the multiple arc or beam planning designs of IMRS and VMAT, both of these techniques required higher MU delivery than DCA, with the averages being twice as high (p < 0.05). If linear accelerator is only 1 modality can to establish for SRS treatment. Based on statistical evidence retrospectively, we recommend VMAT as the optimal technique for delivering treatment to tumors adjacent to brainstem.

Contact Resistance of InGaN/GaN Light Emitting Diodes Grown on the Production Model Multi-Wafer MOVPE Reactor

We report both the device fabrication and characterization of InGaN/GaN single quantum well LEDs grown on sapphire substrates using multi-wafer MOVPE reactor. To improve current spreading of the LEDs, a self-aligned process is developed to define LED mesa that is coated with a thin, semi-transparent Ni/Au (40 Å/40 Å) layer. A detailed study on the ohmic contact resistance of Ni/Cr/Au on p-GaN versus annealing temperatures is carried out on transmission line test structures. It was found that the annealing temperatures between 300 to 500 °C yield the lowest specific contact resistance rc ( 0.016 Ω-cm2 at a current density of 66.7 mA/cm). Based on the extracted rc from the transmission line measurement, we estimate that the contact resistance of the p-type GaN accounts for ∼ 88% of the total series resistance of the LED.

Preferential depletion of gut CD4-expressing iNKT cells contributes to systemic immune activation in HIV-1 infection

Chronic inappropriate immune activation is the central defect-driving loss of CD4(+) T helper cells and progression to AIDS in persons with HIV-1 infection, but the mechanisms remain controversial. We examined key regulatory invariant receptor natural killer T (iNKT) cells in the gut, the largest reservoir of lymphocytes and a key arena of HIV-1 pathogenesis. In healthy control persons, the anti-inflammatory CD4(+) iNKT-cell subset predominated over the pro-inflammatory CD4(-) iNKT-cell subset in the gut, but not in the blood, compartment. HIV-1 infection resulted in a preferential loss of this anti-inflammatory CD4(+) iNKT-cell subset within the gut. The degree of loss of the CD4(+) iNKT-cell subset in the gut, but not in the blood, correlated to the systemic immune activation and exhaustion that have been linked to disease progression. These results suggest a potentially important contribution of gut iNKT-cell imbalance in determining the systemic immune activation that is the hallmark of HIV-1 pathogenesis.

MO-A-BRB-01: Non-Coplanar Rotational Therapy by Using High Efficient Unflattened Beams

The rapid dose fall-off from treatment target to the adjacent critical organs has been the Holy Grail for radiotherapy treatment planning. The modern treatment delivery technologies to address such goal include volumetric modulated rotational therapy, non-coplanar EVIRT beams and the use of unflattened beams to reduce the penumbra area. In this lecture, the integration of above techniques will be presented to achieve the goal of a sharp gradient dose around the target and also the discussion of middle to low dose volumes. Use of volumetric modulated rotational therapy by multiple non-coplanar arcs is an idea treatment modality to focus the high dose in the target area while spreading the low dose to even larger volume to reduce the middle range dose to surrounding critical organs. This is especially important for SBRT treatment plans since the fraction dose is much higher than the traditional fraction schema. The challenges we face today are 1. the gantry-couch (patient) collision issue for non-coplanar beam angles, 2. the treatment delivery efficiency due to multiple arc rotations and 3. the massive inverse optimization computation for multiple rotational arcs can be resource intensive and time consuming for treatment plan systems. It might not be easy to resolve all the challenges at one time. However, the high efficient unflattened beam can certainly improve the delivery speed by reducing the beam- on time and this, again, is essential to SBRT patients with high fractional dose. In this lecture, the non-coplanar rotational therapy treatment planning techniques will be presented and be evaluated by using comformality index, gradient index as well as dose volume histogram comparison. The differences in treatment delivery time will be tabulated and compared. At the end, the high-medium-low dose volumes will be illustrated with radiobiological models for the philosophy of sun tanned versus sun burned.

LEARNING OBJECTIVES

1. Understand treatment plan and dose gradient advantages of using non- coplanar rotational therapy 2. Understand potential delivery efficiency by using unflattened beams for multiple non-coplanar rotational beams 3. Understand sun tanned versus sun burned: the low dose volume and integrated dose.

Parotid gland-sparing 3-dimensional conformal radiotherapy results in less severe dry mouth in nasopharyngeal cancer patients: a dosimetric and clinical comparison with conventional radiotherapy

BACKGROUND AND PURPOSE

This study examined the efficacy of parotid gland sparing of three-dimensional conformal radiotherapy (3DCRT) compared with conventional radiotherapy for NPC patients. Both the dose given to the parotids and clinical assessment of dry mouth were conducted.

MATERIALS AND METHODS

Dry mouth was assessed for 108 patients treated with conventional technique and 72 treated with 3DCRT. Dose analysis was performed in 48 patients of the 3DCRT group. A dose of 70 Gy was given to the midplane in conventional radiotherapy and to 90% isodose volume in 3DCRT. Prognostic factors affecting the severity of dry mouth were analyzed using Generalized Estimating Equation (GEE).

RESULTS

In the 3DCRT group about 50% of the patients' parotid glands received less than 25 Gy. Parallel analysis of dry mouth shows a significant decrease in the incidence of severe xerostomia after 3DCRT. The proportion of patients without dry mouth was also significantly higher in the 3DCRT group than the conventional group at 1-3 years after completion of radiotherapy. Although 3DCRT delivered a higher dose to the tumor, it spared the parotid gland significantly better than the conventional treatment. Late toxicities were mostly similar between the 2 groups while local control in T4 patients and survival were improved for 3DCRT.

CONCLUSION

Dosimetrically and clinically 3DCRT is better than conventional technique regarding parotid gland protection.

Using a photon phase-space source for convolution/superposition dose calculations in radiation therapy

For a given linac design, the dosimetric characteristics of a photon beam are determined uniquely by the energy and radial distributions of the electron beam striking the x-ray target. However, in the usual commissioning of a beam from measured data, a large number of variables can be independently tuned, making it difficult to derive a unique and self-consistent beam model. For example, the measured dosimetric penumbra in water may be attributed in various proportions to the lateral secondary electron range, the focal spot size and the transmission through the tips of a non-divergent collimator; the head-scatter component in the tails of the transverse profiles may not be easy to resolve from phantom scatter and head leakage; and the head-scatter tails corresponding to a certain extra-focal source model may not agree self-consistently with in-air output factors measured on the central axis. To reduce the number of adjustable variables in beam modelling, we replace the focal and extra-focal sources with a single phase-space plane scored just above the highest adjustable collimator in a EGS/BEAM simulation of the linac. The phase-space plane is then used as photon source in a stochastic convolution/superposition dose engine. A photon sampled from the uncollimated phase-space plane is first propagated through an arbitrary collimator arrangement and then interacted in the simulation phantom. Energy deposition kernel rays are then randomly issued from the interaction points and dose is deposited along these rays. The electrons in the phase-space file are used to account for electron contamination. 6 MV and 18 MV photon beams from an Elekta SL linac are used as representative examples. Except for small corrections for monitor backscatter and collimator forward scatter for large field sizes (<0.5% with <20 x 20 cm2 field size), we found that the use of a single phase-space photon source provides accurate and self-consistent results for both relative and absolute dose calculations.

Dose effect of guidewire position in intravascular brachytherapy

It has been reported that the dose effects of metallic guidewires are significant in intravascular brachytherapy (IVBT) using a beta source. The purpose of this work is to investigate the dependence of these dose effects on guidewire position. The EGS4 Monte Carlo codes were used to perform the dose calculations for the 90Sr (NOVOSTE), 32P (Guidant) and 192Ir (BEST Ind.) sources with and without a guidewire in place. Guidewires were placed at various distances from the central axes of the sources. Due to the attenuation by the guidewires, a dose reduction of up to 70% behind a guidewire was observed for the beta sources, while the dose perturbation was found to be negligible for the gamma source. The dose reduction for the beta sources was found to be dependent on the guidewire location. For example, the dose reduction was 10% higher for a stainless steel guidewire located at 0.5 mm than that for the guidewire at 2 mm from the central axis of the source, The portion of the target volume affected (shadowed) dosimetrically by the guidewire was reduced when the guidewire was positioned farther away from the source. The shadow volume (in which the dose reduction occurs) can be reduced by up to 45% as the guidewire is moved away from the source axis from 0.5 mm to 2 mm. The dosimetric perturbations due to the presence of a metallic guidewire as well as their dependence on guidewire location should be considered in designing a new IVBT delivery device, in analysing the treatment efficacy, and/or in dose prescription for a beta source.

Dosimetric characteristics of dynamic wedged fields: a Monte Carlo study

We have developed a Monte Carlo (MC) technique using the EGS4/BEAM system to calculate dosimetric characteristics of dynamic wedges (DW) for photon beam radiotherapy. The simulation of DW was accomplished by weighting the history numbers of the electrons, which are incident on the target in accordance with the segmented treatment table. Calculations were performed for DW with wedge angles ranging from 15 degrees to 60 degrees as well as for open fields with different field sizes for both degrees 6 and 18 MV beams. The MC-calculated percentage depth dose (PDD) and beam profiles agreed with the measurements within +/- 2% (of the dose maximum along the beam axis) or +/- 2 mm in high dose gradient region. The DW slightly affects energy spectra of photons and contaminating electrons. These slight changes have no significant effects on PDD as compared to the open field. The MC-calculated dynamic wedge factors agree with the measurements within +/- 2%. The MC method enables us to provide more detailed beam characteristics for DW fields than a measurement method. This beam characteristic includes photon energy spectra, mean energy, spectra of contaminating electrons and effects of moving jaw on off-axis beam quality. These data are potentially important for treatment planning involving dynamic wedges.

Dose effects of guide wires for catheter-based intravascular brachytherapy

PURPOSE

Guide wires with high torquability and steerability are commonly used to navigate through a tortuous and/or branching arterial tree in a catheter-based intravascular brachytherapy procedure. The dosimetric effects due to the presence of metallic guide wires have not been addressed. This work investigates these dose effects for the three most commonly used beta and gamma sources (90Sr, 32P, and 192Ir).

METHODS AND MATERIALS

The EGS4 Monte Carlo codes were used to calculate the dose distributions for the 90Sr(NOVOSTE), 32P (Guidant), and 192Ir (BEST Ind.) with and without a guide wire in place. Energy spectra for particles exiting the sources were calculated from the full phase-space data obtained from the Monte Carlo simulations of the source constructions. Guide wires of various thicknesses and compositions were studied.

RESULTS

The dose perturbations due to the presence of guide wires were found to be far more significant for the 90Sr/90Y and 32P beta sources than those for the 192Ir gamma source. Because of the attenuation by the guide wires, a dose reduction of up to 60% behind a guide wire was observed for the beta sources, whereas the dose perturbation was found to be negligible for the gamma source. For a beta source, the dose perturbations depend on the thickness and the material of the guide wire. When the region behind a guide wire is part of an intravascular brachytherapy target, the presence of the guide wire results in a significant underdosing for beta sources. The underdosed region can extend a few mm behind the guide wire and up to 1 mm in other directions.

CONCLUSION

Significant dose perturbations by the presence of a metallic guide wire have been found in catheter-based intravascular brachytherapy using beta sources. The dose effects should be considered in the dose prescription and/or in analyzing the treatment outcome for beta sources. Such precautions are not necessary if using a gamma source.

Monte Carlo dose verification for intensity-modulated arc therapy

Intensity-modulated arc therapy (IMAT), a technique which combines beam rotation and dynamic multileaf collimation, has been implemented in our clinic. Dosimetric errors can be created by the inability of the planning system to accurately account for the effects of tissue inhomogeneities and physical characteristics of the multileaf collimator (MLC). The objective of this study is to explore the use of Monte Carlo (MC) simulation for IMAT dose verification. The BEAM/DOSXYZ Monte Carlo system was implemented to perform dose verification for the IMAT treatment. The implementation includes the simulation of the linac head/MLC (Elekta SL20), the conversion of patient CT images and beam arrangement for 3D dose calculation, the calculation of gantry rotation and leaf motion by a series of static beams and the development of software to automate the entire MC process. The MC calculations were verified by measurements for conventional beam settings. The agreement was within 2%. The IMAT dose distributions generated by a commercial forward planning system (RenderPlan. Elekta) were compared with those calculated by the MC package. For the cases studied, discrepancies of over 10% were found between the MC and the RenderPlan dose calculations. These discrepancies were due in part to the inaccurate dose calculation of the RenderPlan system. The computation time for the IMAT MC calculation was in the range of 20-80 min on 15 Pentium-Ill computers. The MC method was also useful in verifying the beam apertures used in the IMAT treatments.

Dynamic wedge versus physical wedge: a Monte Carlo study

The purpose of this study is to analyze the characteristics of dynamic wedges (DW) and to compare DW to physical wedges (PW) in terms of their differences in affecting beam spectra, energy fluence, angular distribution, contaminated electrons, and dose distributions. The EGS4/BEAM Monte Carlo codes were used to simulate the exact geometry of a 6 MV beam and to calculate 3-D dose distributions in phantom. The DW was simulated in accordance with the segmented treatment tables (STT). The percentage depth dose curves and beam profiles for PW, DW, and open fields were measured and used to verify the Monte Carlo simulations. The Monte Carlo results were found to agree within 2% with the measurements performed using film and ionizing chambers in a water phantom. The present EGS4 calculation reveals that the effects of a DW on beam spectral and angular distributions, as well as electron contamination, are much less significant than those for a PW. For the 6 MV photon beam, a 45 degrees PW can result in a 30% increase in mean photon energy due to the effect of beam hardening. It can also introduce a 5% dose reduction in the build-up region due to the reduction of contaminated electrons by the PW. Neither this mean-energy increase nor such dose reduction is found for a DW. Compared to a DW, a PW alters the photon-beam spectrum significantly. The dosimetric differences between a DW and a PW are significant and clearly affect the clinical use of these beams. The data presented may be useful for DW commissioning.

Lower limb skeletal muscle mass: development of dual-energy X-ray absorptiometry prediction model

Although magnetic resonance imaging (MRI) can accurately measure lower limb skeletal muscle (SM) mass, this method is complex and costly. A potential practical alternative is to estimate lower limb SM with dual-energy X-ray absorptiometry (DXA). The aim of the present study was to develop and validate DXA-SM prediction equations. Identical landmarks (i.e., inferior border of the ischial tuberosity) were selected for separating lower limb from trunk. Lower limb SM was measured by MRI, and lower limb fat-free soft tissue was measured by DXA. A total of 207 adults (104 men and 103 women) were evaluated [age 43 +/- 16 (SD) yr, body mass index (BMI) 24.6 +/- 3.7 kg/m(2)]. Strong correlations were observed between lower limb SM and lower limb fat-free soft tissue (R(2) = 0.89, P < 0.001); age and BMI were small but significant SM predictor variables. In the cross-validation sample, the differences between MRI-measured and DXA-predicted SM mass were small (-0.006 +/- 1.07 and -0.016 +/- 1.05 kg) for two different proposed prediction equations, one with fat-free soft tissue and the other with added age and BMI as predictor variables. DXA-measured lower limb fat-free soft tissue, along with other easily acquired measures, can be used to reliably predict lower limb skeletal muscle mass.

Telemedicine in the emergency department: a randomized controlled trial

Emergency physicians and nurses were trained in telemedicine techniques in two emergency departments, one rural (low volume) and one suburban (high volume). Fifteen patient complaints were selected as appropriate for the study. Of 122 patients who met the inclusion criteria, 104 (85%) consented to participate. They were randomized to control and experimental groups. The suburban emergency physician diagnosed and treated the control patients. Experimental patients presenting to the high-volume emergency department were evaluated and treated by the telemedicine nurse in person and the rural emergency physician via the telemedicine link. Immediately before discharge all telemedicine patients were re-evaluated by the suburban emergency physician. Data collected on each patient included: diagnosis; treatment; 72 h return visits; need for additional care; and satisfaction of patient, physicians and nurses. There were no significant differences (P > 0.05) for occurrence of 72 h return visits, need for additional care or overall patient satisfaction. The average patient throughput time (from admission to discharge) was 106 min for the telemedicine group and 117 min for the control group. Telemedicine was a satisfactory technique for the chosen group of patients in the emergency department and was acceptable to the participants.

Regional skeletal muscle measurement: evaluation of new dual-energy X-ray absorptiometry model

Although there is growing interest in studying muscle distribution, regional skeletal muscle (SM) mass measurement methods remain limited. The aim of the present study was to develop a new dual-energy X-ray absorptiometry (DEXA) model for estimating regional adipose tissue-free skeletal muscle mass (AT-free SM). Relationships were derived from Reference Man data between tissue-system- level components (i.e., AT-free SM, AT, skeleton, and skin) and molecular-level components including fat-free soft tissue, fat, and bone mineral. The proposed DEXA-SM model was evaluated by multiscan computerized axial tomography (CT). Twenty-seven male subjects [age, 36 +/- 12 (SD) yr; body mass, 73.2 +/- 12.4 kg; 20 were healthy, and 7 had acquired immunodeficiency syndrome] completed DEXA and CT studies. Identical landmarks for DEXA and CT measurements were selected in three regions, including calves, thighs, and forearms. There was a strong correlation for AT-free SM estimates between the new DEXA and CT methods (e.g., sum of three regions, r = 0.86, P < 0.001). Regional AT-free SM measured in the 27 subjects by DEXA and CT, respectively, were 3.44 +/- 0.60 and 3. 47 +/- 0.55 kg (difference 0.9%, P > 0.05) for calves, 10.49 +/- 1. 77 and 10.05 +/- 1.79 kg (difference 4.4%, P < 0.05) for thighs, 1. 36 +/- 0.49 and 1.20 +/- 0.41 kg (difference 13.3%, P < 0.01) for forearms, and 15.29 +/- 2.33 and 14.72 +/- 2.33 kg (difference 3.9%, P < 0.05) for the sum all three regions. Although the suggested DEXA-SM model needs minor refinements, this is a promising in vivo approach for measurement of regional SM, because DEXA is widely available, relatively inexpensive, and radiation exposure is low.

Stages at presentation, prognostic factors, and outcome of breast cancer in males

BACKGROUND

In order to support or refute conventional notions of breast cancer in males as a late-presenting disease associated with a worse prognosis than the same disease in females, we reviewed a recent, multi-institutional experience.

METHODS

A case series from three area hospital system cancer data bases was reviewed. Demographics, pathology, stages at presentation, and treatment were determined from the data set and correlated with outcomes (recurrence/survival).

RESULTS

Fifty-four patients (mean age 64.5, SD = 12.8) were identified; half of the tumors were stage T0 or T1, 62% were node negative (N0), and 57% had an American Joint Committee on Cancer (AJCC) stage grouping of IIA or less. Eighty-five percent of tumors examined expressed hormone receptors. There were no local-only recurrences in the 50 cases resected for cure, including 5 cases of minimal breast cancer treated by lumpectomy only. Five- and 10-year overall disease-free survival was AJCC stage related: 100% and 71%, respectively, for early stage (0-IIA) disease, and 71% and 20%, respectively, for advanced (IIB-IV) stage (P = 0.0051 by log-rank). Only AJCC stage and its components (tumor size, nodal status, presence of metastases) correlated with survival by multivariate analysis; other factors such as age, family history, and presenting symptoms/signs did not.

CONCLUSIONS

The majority of breast cancers in males present at early stages and are hormone receptor positive. In contrast to older notions of this disease as uniformly aggressive, we conclude that prognostic factors and stage-for-stage outcomes for breast cancer in males are similar to those published for the disease in females.

Age-related defects in spatial memory are correlated with defects in the late phase of hippocampal long-term potentiation in vitro and are attenuated by drugs that enhance the cAMP signaling pathway

To study the physiological and molecular mechanisms of age-related memory loss, we assessed spatial memory in C57BL/B6 mice from different age cohorts and then measured in vitro the late phase of hippocampal long-term potentiation (L-LTP). Most young mice acquired the spatial task, whereas only a minority of aged mice did. Aged mice not only made significantly more errors but also exhibited greater individual differences. Slices from the hippocampus of aged mice exhibited significantly reduced L-LTP, and this was significantly and negatively correlated with errors in memory. Because L-LTP depends on cAMP activation, we examined whether drugs that enhanced cAMP would attenuate the L-LTP and memory defects. Both dopamine D1/D5 receptor agonists, which are positively coupled to adenylyl cyclase, and a cAMP phosphodiesterase inhibitor ameliorated the physiological as well as the memory defects, consistent with the idea that a cAMP-protein kinase A-dependent signaling pathway is defective in age-related spatial memory loss.

Shorter survival in advanced human immunodeficiency virus type 1 infection is more closely associated with T lymphocyte activation than with plasma virus burden or virus chemokine coreceptor usage

To define predictors of survival time in late human immunodeficiency virus type 1 (HIV-1) disease, long- and short-duration survivors were studied after their CD4+ T cells fell to </=50/mm3. Immune activation of CD4+ and CD8+ T cells, as measured by elevated cell surface expression of CD38 antigen, was strongly associated with shorter subsequent survival (P</=.002). The naive CD45RA+CD62L+ T cell reserve was low in all subjects and did not predict survival (P=.34 for CD4+ and.08 for CD8+ cells). Higher virus burden correlated with CD8+ but not CD4+ cell activation and, after correcting for multiple comparisons, was not associated with shorter survival (P=.02). All of the patients' viruses used CCR5, CXCR4, or both, and coreceptor usage did not predict survival (P=. 27). Through mechanisms apparently unrelated to higher virus burden, immune activation is a major determinant of survival in advanced HIV-1 disease.

Calculation of head scatter factors at isocenter or at center of field for any arbitrary jaw setting

The purpose of this work is to calculate the head scatter factors for any arbitrary jaw setting by using two different semi-empirical methods. The head scatter factor at the center of field (COF) for any arbitrary jaw setting can be defined as H(COF)(X1,X2,Y1,Y2,r)=DairCOF(XI1,X2,Y1,Y2,r)/ [Dair(5,5,5,5,0)*OAR(r)], where X1, X2, Y1, and Y2 are the jaw positions; r is the distance between COF and isocenter (IC); OAR(r) is the Off-Axis-Ratio; DairCOF(X1,X2,Y1,Y2,r) is the dose in air measured at COF; Dair(5,5,5,5,0) is the dose in air measured at IC for the 10 x 10 cm2 field. In certain clinical situations, doses are prescribed at IC instead of COF for asymmetric fields. In these cases, head scatter factors should be determined at IC. It is found that the head scatter factors at IC for asymmetric fields [H(IC)(X1,X2,Y1,Y2)] are lower than H(COF)(X1,X2,Y1,Y2,r) for the same jaw setting by up to 4%. The values of H(IC)(X1,X2,Y1,Y2) and H(COF)(X1,X2,Y1,Y2,r) for a variety of jaw settings were measured using a miniphantom of 3-cm diameter for a 6- and a 18-MV photon beams. An equivalent square formula, derived presently at the source plane for any jaw setting, was used to calculate H(COF)(X1,X2,Y1,Y2,r). The calculation and the measurement agree within +/-1% (+/-0.5% for most clinical situations). To calculate H(IC)(X1,X2,Y1,Y2), we have generalized the Day's "quarter-field" method, i.e., H(IC)(X1,X2,Y1,Y2) = [H(X1,X1,Y1,Y1) + H(X1,X1,Y2,Y2) + H(X2,X2,Y1,Y1) + H(X2,X2,Y2,Y2)]/4. We found that the calculation and the measurement agree within +/-0.8% for the beams studied.

A randomized controlled trial of telemedicine in an emergency department

A prospective study of emergency department telemedicine was carried out at two hospitals in northern New Jersey. One hundred and twenty-two patients met the inclusion criteria. One hundred and four (85%) consented to participate, with 54 being randomized to the telemedicine group and 50 to the control group. Four patients did not complete the protocol. No significant differences were seen between the groups for: occurrence of 72 h emergency department return visits (0% vs 0%); need for additional care (2.3% vs 2.4%); positive patient-physician interaction (98% vs 100%); positive patient-nurse interaction (98% vs 98%); positive overall patient satisfaction (98% vs 95%). The average patient throughput time (time from admission to discharge) for the telemedicine group was 106 min; the average for the control group was 117 min. Telemedicine was found to be a satisfactory technique for pre-selected emergency department patients and was viewed by the physicians as an acceptable method of complementary care.

Tylenol Extended Relief overdose

In this report we describe the toxicokinetics of the Tylenol Extended Relief (TER) preparation of acetaminophen in human overdose. We collected 41 cases of TER overdose from five regional poison centers. Patients who met the following criteria were studied: a single ingestion of TER alone; confirmed time of ingestion; at least four acetaminophen determinations; and normal concentrations of liver function enzymes. With the exception of standard decontamination measures, treatment with N-acetylcysteine (NAC) if any acetaminophen level was above the treatment line of the Rumack-Matthew nomogram, and additional acetaminophen determinations, no interventions were recommended. Our study group comprised 13 patients, 12 female and 1 male, with single overdoses of 10.4 to 65 g TER. The acetaminophen elimination half-life was 3.1 +/- .8 hours (mean +/- SD; range, 1.3 to 4.0 hours; n = 12). The elimination phase for patients 2, 3, 4, 6, 8, 9, 11, 13 was delayed until 8.0 +/- 2.8 hours (range, 5 to 14 hours) after ingestion. Patients 3, 8, and 11--who had initial acetaminophen levels below the "possible toxicity" line of the Rumack-Matthew nomogram--later had acetaminophen levels above this line. No patient demonstrated a late or second acetaminophen peak. We conclude that the elimination half-life of TER acetaminophen is similar to that reported in overdose of immediate-release acetaminophen overdose. In a subgroup of patients, drug absorption continued beyond the 2 to 4 hours previously reported in immediate-release acetaminophen overdose. On the basis of our data, the use of a single 4-hour acetaminophen determination may lead to failure to recognize patients with potentially toxic TER ingestion. Until more toxicokinetic data are available, a reasonable approach would be to obtain at least one additional acetaminophen determination at least 4 to 6 hours after the first, if the first is obtained 4 to 8 hours after ingestion. NAC treatment should be initiated if either level is above the nomogram line but not if both levels fall below the nomogram line.

Aplastic anemia induced by an adulterated herbal medication

Herbal medication use is common in many cultural groups. Because these products are unregulated, the potential for significant toxicity exists. We report a case of aplastic anemia associated with the use of an herbal medication by a 12-year-old boy. On analysis, the herbal medication was found to contain phenylbutazone, which has been strongly associated with the production of similar hematologic abnormalities. The medication was not listed as an ingredient and no warning was present on the box.

The treatment of lead poisoning from gunshot wounds with succimer (DMSA)

Lead poisoning is an unusual complication of gunshot wounds that occurs when retained lead bullet fragments are in contact with body fluids capable of solubilizing lead. The epidemic of violence by gunfire may result in increasing numbers of lead poisoning cases from this exposure. The use of oral chelation for toxicity resulting from this mode of exposure has not been previously discussed. Cases of lead poisoning arising from bullet lead in the synovial cavity of the hip, synovial cavity of the chest, and pleural space are reported. A combination of surgical debridement and chelation therapy with oral succimer produced a satisfactory outcome in all three cases. Oral succimer may be a safe and effective chelation agent for treating lead toxicity in adults with high lead levels secondary to gun shot wounds.

Delaware Emergency Medical Services System: cardiac resuscitation

The Delaware EMS system has been in existence for 20 years. Initially begun as one paramedic unit serving New Castle County, it now comprises 15 units in a statewide system. The goal of this report is to detail the EMS system's impact on prehospital cardiac resuscitation and airway management. Emergency Medical Services (EMS) encompass all aspects of managing a sick or injured patient prior to arrival to the hospital. From the time a patient dials 911 until they arrive in the care of a doctor in an emergency room, the EMS system provides initial medical evaluation and care as well as transportation to the hospital. The components of Delaware's EMS system include: 1. Bystanders--the public is often called upon to perform CPR until trained rescuers arrive. 2. Medical Dispatchers--they receive incoming 911 calls and determine the personnel needed. 3. First responders--ambulance crews trained in basic life support (BLS). 4. Second responders--ambulance crews trained in advanced life support (ALS), paramedics. 5. Medical Control--doctors who are in radio contact with paramedics to provide medical advice.