A randomized trial comparing percutaneous endoscopic gastrostomy (PEG) and radiologically inserted percutaneous gastrostomy (RIG)

BACKGROUND AND OBJECTIVE

At present, percutaneous endoscopic gastrostomy (PEG) is the procedure of choice in establishing a permanent feeding tube in patients with chronic severe dysphagia. This is the first prospective randomized study in adults comparing PEG with radiologically inserted gastrostomy (RIG).

METHODS

Randomization of 106 patients, eligible for both techniques, to PEG (pull method) or RIG. The groups were comparable in terms of age, body mass index, and underlying diseases. Adverse events were reported 10 and 30 days after the operative procedure, and mortality was up until 6 months. The validated European Quality of life 5 Dimensions 3 level version (EQ-5D) questionnaire was used for health status measurements.

RESULTS

The procedures were successfully completed in all patients. The median operative time was 10 min for PEG and 20 min for RIG (p < 0.001). The overall rate of adverse events was lower for PEG (22%) than for RIG (51%, p = 0.002), mostly due to less local self-limiting stoma reactions and tube problems. The 30-day mortality was lower after PEG (2% versus 14%, p = 0.020). Patient-scored health status remained low for the entire cohort, with an EQ-5D utility index of 0.164. Self-rated health was low but improved in the RIG group (52.5 from 41.1, out of 100).

CONCLUSION

PEG can be recommended as the primary procedure in patients in need of a feeding gastrostomy, mainly due to a lower frequency of tube complications. However, as the two techniques complement each other, RIG is also a valid alternative method.

CLINICAL TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number ISRCTN17642761. https://doi.org/10.1186/ISRCTN17642761.

Study protocol for locoregional precision treatment of hepatocellular carcinoma with transarterial chemoembolisation (TACTida), a clinical study: idarubicin dose selection, tissue response and survival

INTRODUCTION

Hepatocellular carcinoma (HCC) is a common cause of cancer-related death, often detected in the intermediate stage. The standard of care for intermediate-stage HCC is transarterial chemoembolisation (TACE), where idarubicin (IDA) is a promising drug. Despite the fact that TACE has been used for several decades, treatment success is unpredictable. This clinical trial has been designed believing that further improvement might be achieved by increasing the understanding of interactions between local pharmacology, tumour targeting, HCC pathophysiology, metabolomics and molecular mechanisms of drug resistance.

METHODS AND ANALYSIS

The study population of this single-centre clinical trial consists of adults with intermediate-stage HCC. Each tumour site will receive TACE with two different IDA doses, 10 and 15 mg, on separate occasions. Before and after each patient's first TACE blood samples, tissue and liquid biopsies, and positron emission tomography (PET)/MRI will be performed. Blood samples will be used for pharmacokinetics (PK) and liver function evaluation. Tissue biopsies will be used for histopathology analyses, and culturing of primary organoids of tumour and non-tumour tissue to measure cell viability, drug response, multiomics and gene expression. Multiomics analyses will also be performed on liquid biopsies. PET/MRI will be used to evaluate tumour viability and liver metabolism. The two doses of IDA will be compared regarding PK, antitumour effects and safety. Imaging, molecular biology and multiomics data will be used to identify HCC phenotypes and their relation to drug uptake and metabolism, treatment response and survival.

ETHICS AND DISSEMINATION

Participants give informed consent. Personal data are deidentified. A patient will be withdrawn from the study if considered medically necessary, or if it is the wish of the patient. The study has been approved by the Swedish Ethical Review Authority (Dnr. 2021-01928) and by the Medical Product Agency, Uppsala, Sweden.

TRIAL REGISTRATION NUMBER

EudraCT number: 2021-001257-31.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Toward adaptive radiotherapy for lung patients: feasibility study on deforming planning CT to CBCT to assess the impact of anatomical changes on dosimetry

Changes in lung architecture during a course of radiotherapy can alter the planned dose distribution to the extent that it becomes clinically unacceptable. This study aims to validate a quantitative method of determining whether a replan is required during the course of conformal radiotherapy. The proposed method uses deformable image registration (DIR) to flexibly map planning CT (pCT) data to the anatomy of online CBCT images. The resulting deformed CT (dCT) images are used as a basis for assessing the effect of anatomical change on dose distributions. The study used retrospective data from a sample of seven replanned lung patients. The settings of an in-house, open-source DIR algorithm were first optimised for CT-to-CBCT registrations of the anatomy of the thorax. Using these optimised parameters, each patient's pCT was deformed to the CBCT acquired immediately before the replan. Registration accuracy was rigorously validated both geometrically and dosimetrically to confirm that the dCTs could reliably be used to inform replan decisions. A retrospective evaluation of the changes in dose delivered over time was then carried out for a single patient to demonstrate the clinical application of the proposed method. The geometric analysis showed good agreement between deformed structures and those same structures manually outlined on the CBCT images. Results were consistently better than those achieved with rigid-only registration. In the dosimetric analysis, dose distributions derived from the dCTs were found to match closely to the 'gold standard' replan CT (rCT) distributions across dose volume histogram and absolute dose difference measures. The retrospective analysis of serial CBCTs of a single patient produced reliable quantitative assessment of the dose delivery. Had the proposed method been available at the time of treatment, it would have enabled a more objective replan decision. DIR is a valuable clinical tool for dose recalculation in adaptive radiotherapy protocols for lung cancer patients.

Early low cerebral blood flow and high cerebral lactate: prediction of delayed cerebral ischemia in subarachnoid hemorrhage

OBJECTIVE

Delayed cerebral ischemia (DCI) following subarachnoid hemorrhage (SAH) is one of the major contributors to poor outcome. It is crucial to be able to detect early signs of DCI to prevent its occurrence. The objective of this study was to determine if low cerebral blood flow (CBF) measurements and pathological microdialysis parameters measured at the bedside can be observed early in patients with SAH who later developed DCI.

METHODS

The authors included 30 patients with severe SAH. The CBF measurements were performed at Day 0–3 after disease onset, using bedside xenon-CT. Interstitial glucose, lactate, pyruvate, glycerol, and glutamate were measured using microdialysis.

RESULTS

Nine of 30 patients developed DCI. Patients with DCI showed significantly lower global and regional CBF, and lactate was significantly increased in these patients. A high lactate/pyruvate ratio was also detected in patients with DCI.

CONCLUSIONS

Early low CBF measurements and a high lactate and lactate/pyruvate ratio may be early warning signs of the risk of developing DCI. The clinical value of these findings needs to be confirmed in larger studies.

Investigating the influence of intraindividual changes in perceived stress symptoms on injury risk in soccer

Research has shown that high levels of stress and stress responsivity can increase the risk of injuries. However, most of the research that has supported this notion has focused on between-person relationships, ignoring the relationships at the within-person level. As a result, the objective of this study was to investigate if within-person changes in perceived stress symptoms over a 1-month time period could predict injury rates during the subsequent 3 months. A prospective design with two measurement points (Time 1-at the beginning of the season and Time 2-1 month into the season) was utilized. A total of 121 competitive soccer players (85 males and 36 females; M_age  = 18.39, SD = 3.08) from Sweden and the United States completed the Kessler Psychological Distress Scale (KPDS) and a demographic sheet at Time 1. The KPDS was also completed at Time 2, and all acute injuries that occurred during the subsequent 3-month period were recorded. A Bayesian latent change scores model was used to determine whether within-person changes in stress symptoms could predict the risk of injury. Results revealed that there was a credible positive effect of changes in stress symptoms on injury rates, indicating that an increase in reported stress symptoms was related to an increased risk for injury. This finding highlights the importance of creating caring and supportive sporting environments and relationships and teaching stress management techniques, especially during the earlier portion of competitive seasons, to possibly reduce the occurrence of injuries.

Bedside Xenon-CT Shows Lower CBF in SAH Patients with Impaired CBF Pressure Autoregulation as Defined by Pressure Reactivity Index (PRx)

BACKGROUND

Subarachnoid hemorrhage (SAH) is a disease with a high rate of unfavorable outcome, often related to delayed cerebral ischemia (DCI), i.e., ischemic injury that develops days-weeks after onset, with a multifactorial etiology. Disturbances in cerebral pressure autoregulation, the ability to maintain a steady cerebral blood flow (CBF), despite fluctuations in systemic blood pressure, have been suggested to play a role in the development of DCI. Pressure reactivity index (PRx) is a well-established measure of cerebral pressure autoregulation that has been used to study traumatic brain injury, but not extensively in SAH.

OBJECTIVE

To study the relation between PRx and CBF in SAH patients, and to examine if PRx can be used to predict DCI.

METHODS

Retrospective analysis of prospectively collected data. PRx was calculated as the correlation coefficient between mean arterial blood pressure (MABP) and intracranial pressure (ICP) in a 5 min moving window. CBF was measured using bedside Xenon-CT (Xe-CT). DCI was diagnosed clinically.

RESULTS

47 poor-grade mechanically ventilated patients were studied. Patients with disturbed pressure autoregulation (high PRx values) had lower CBF, as measured by bedside Xe-CT; both in the early (day 0-3) and late (day 4-14) acute phase of the disease. PRx did not differ significantly between patients who developed DCI or not.

CONCLUSION

In mechanically ventilated and sedated SAH patients, high PRx (more disturbed CBF pressure autoregulation) is associated with low CBF, both day 0-3 and day 4-14 after onset. The role of PRx as a monitoring tool in SAH patients needs further studying.

Increased risk of critical CBF levels in SAH patients with actual CPP below calculated optimal CPP

Background

Cerebral pressure autoregulation can be quantified with the pressure reactivity index (PRx), based on the correlation between blood pressure and intracranial pressure. Using PRx optimal cerebral perfusion pressure (CPPopt) can be calculated, i.e., the level of CPP where autoregulation functions best. The relation between cerebral blood flow (CBF) and CPPopt has not been examined. The objective was to assess to which extent CPPopt can be calculated in SAH patients and to investigate CPPopt in relation to CBF.

Methods

Retrospective study of prospectively collected data. CBF was measured bedside with Xenon-enhanced CT (Xe-CT). The difference between actual CPP and CPPopt was calculated (CPP∆). Correlations between CPP∆ and CBF parameters were calculated with Spearman’s rank order correlation coefficient (rho). Separate calculations were done using all patients (day 0–14 after onset) as well as in two subgroups (day 0–3 and day 4–14).

Results

Eighty-two patients with 145 Xe-CT scans were studied. Automated calculation of CPPopt was possible in adjunct to 60% of the Xe-CT scans. Actual CPP < CPPopt was associated with higher numbers of low-flow regions (CBF <10 ml/100 g/min) in both the early phase (day 0–3, n = 39, Spearman’s rho = −0.38, p = 0.02) and late acute phase of the disease (day 4–14, n = 35, Spearman’s rho = −0.39, p = 0.02). CPP level per se was not associated with CBF.

Conclusions

Calculation of CPPopt is possible in a majority of patients with severe SAH. Actual CPP below CPPopt is associated with low CBF.

Injuries in Swedish floorball: a cost analysis

The epidemiology of sport injuries is well documented. However, the costs are rarely discussed. Previous studies have presented such costs in specific sports or localization. No study has investigated the costs related to injuries in elite floorball. Thus, the aim of this study was to estimate cost of injuries in Swedish elite floorball players. During 1 year, 346 floorball players were prospectively followed. All time-loss injures were recorded. The injured players were asked to complete a questionnaire regarding their costs tied to the injury. Mean costs were calculated by multiplying the total resource use with the collected unit costs and dividing these total costs with the number of injuries as well as players. The results showed that the average cost per injury increased with the level of severity and ranged from 332 to 2358 Euros. The mild and moderate overuse injuries were costlier than the corresponding traumatic injuries. However, the severe traumatic injuries were associated with higher costs than overuse injuries. Knee injuries were the costliest. Our results indicate that there are costs to be saved, if floorball injuries can be avoided. They should be of interest to decision makers deciding whether to invest in preventive interventions.

Monitoring of Cerebral Blood Flow and Metabolism Bedside in Patients with Subarachnoid Hemorrhage - A Xenon-CT and Microdialysis Study

Cerebral ischemia is the leading cause of morbidity and mortality following aneurysmal subarachnoid hemorrhage (SAH). Although 70% of the patients show angiographic vasospasm only 30% develop symptomatic vasospasm defined as delayed cerebral ischemia (DCI). Early detection and management of reversible ischemia is of critical importance in patients with SAH. Using a bedside Xenon enhanced computerized tomography (Xenon-CT) scanner makes it possible to measure quantitative regional Cerebral blood flow (CBF) bedside in the neurointensive care setting and intracerebral microdialysis (MD) is a method that offers the possibility to monitor the metabolic state of the brain continuously. Here, we present results from nine SAH patients with both MD monitoring and bedside Xenon-CT measurements. CBF measurements were performed within the first 72 h following bleeding. Six out of nine patients developed DCI at a later stage. Five out of six patients who developed DCI had initial global CBF below 26 ml/100 g/min whereas one had 53 ml/100 g/min. The three patients who did not develop clinical vasospasm all had initial global CBF above 27 ml/100 g/min. High lactate/pyruvate (L/P) ratio was associated with lower CBF values in the area surrounding the catheter. Five out of nine patients had L/P ratio ≥25 and four of these patients had CBF ≤ 22 ml/100 g/min. These preliminary results suggest that patients with initially low global CBF on Xenon-CT may be more likely to develop DCI. Initially low global CBF was accompanied with metabolic disturbances determined by the MD. Most importantly, pathological findings on the Xenon-CT and MD could be observed before any clinical signs of DCI. Combining bedside Xenon-CT and MD was found to be useful and feasible. Further studies are needed to evaluate if DCI can be detected before any other signs of DCI to prevent progress to infarction.

An optimal frequency range for assessing the pressure reactivity index in patients with traumatic brain injury

The objective of this study was to identify the optimal frequency range for computing the pressure reactivity index (PRx). PRx is a clinical method for assessing cerebral pressure autoregulation based on the correlation of spontaneous variations of arterial blood pressure (ABP) and intracranial pressure (ICP). Our hypothesis was that optimizing the methodology for computing PRx in this way could produce a more stable, reliable and clinically useful index of autoregulation status. The patients studied were a series of 131 traumatic brain injury patients. Pressure reactivity indices were computed in various frequency bands during the first 4 days following injury using bandpass filtering of the input ABP and ICP signals. Patient outcome was assessed using the extended Glasgow Outcome Scale (GOSe). The optimization criterion was the strength of the correlation with GOSe of the mean index value over the first 4 days following injury. Stability of the indices was measured as the mean absolute deviation of the minute by minute index value from 30-min moving averages. The optimal index frequency range for prediction of outcome was identified as 0.018-0.067 Hz (oscillations with periods from 55 to 15 s). The index based on this frequency range correlated with GOSe with ρ=-0.46 compared to -0.41 for standard PRx, and reduced the 30-min variation by 23%.

Favorable Outcome in Traumatic Brain Injury Patients With Impaired Cerebral Pressure Autoregulation When Treated at Low Cerebral Perfusion Pressure Levels

BACKGROUND:

Cerebral pressure autoregulation (CPA) is defined as the ability of the brain vasculature to maintain a constant blood flow over a range of different systemic blood pressures by means of contraction and dilatation.

OBJECTIVE:

To study CPA in relation to physiological parameters, treatment, and outcome in a series of traumatic brain injury patients.

METHODS:

In this prospective observational study, 44 male and 14 female patients (age, 15–72 years; mean, 38.7 years; Glasgow Coma Scale score, 4-13; median, 7) were analyzed. Patients were divided into groups on the basis of status of CPA (more pressure active vs more pressure passive) and level of cerebral perfusion pressure (CPP; low vs high CPP). The proportions of favorable outcome in the groups were assessed. Differences in physiological variables in the different groups were analyzed.

RESULTS:

Patients with more impaired CPA treated at CPP levels below median had a significantly higher proportion of favorable outcome compared with patients with more impaired CPA treated at CPP levels above median. No significant difference in outcome was seen between patients with more intact CPA when divided by level of CPP. In patients with more impaired CPA, CPP &lt; 50 mm Hg and CPP &lt; 60 mm Hg were associated with favorable outcome, whereas CPP &gt; 70 mm Hg and CPP &gt; 80 mm Hg were associated with unfavorable outcome. In patients with more intact CPA, no difference in physiological variables was seen between patients with favorable and unfavorable outcomes.

CONCLUSION:

Our results support that in traumatic brain injury patients with impaired CPA, CPP should not be elevated.

Bartonella spp. seroprevalence in healthy Swedish blood donors

Serum samples were collected from healthy blood donors in 5 regions in Sweden in 1999, i.e. from the local Blood Centres (collecting facilities) in Boden, Jönköping, Lund, Skövde, and Uppsala. In total, 498 serum samples (63% males, 37% females) were received and tested by immunofluorescence assay for antibodies against B. elizabethae, B. grahamii, B. henselae (Houston-1), B. henselae (Marseille), B. quintana, and B. vinsonii subsp. vinsonii. An overall Bartonella spp. seroprevalence of 16.1% was found, with a predominance of immunoreactivity to B. elizabethae, at 14.1%; B. grahamii, 2.6%; B. henselae (Houston-1), 1.2%; B. henselae (Marseille), 1.8%; B. quintana, 0.2%; and B. vinsonii subsp. vinsonii, 0.0%. Univariate and multivariate analyses of epidemiological and demographical information revealed an increased rate of B. elizabethae seropositivity in blood donors working outdoors, being out in the wild a minimum of once a week, hunting moose, having cat contact, and travelling to Eastern Europe. Living in the southern region of Sweden (Lund area) was associated with decreased seropositivity to B. elizabethae.

Factors influencing factor VIII activity in frozen plasma

BACKGROUNDS AND OBJECTIVES

Fresh frozen human plasma is an important raw material in the production of coagulation factor concentrates used in patients with haemorrhagic disorders. The aim of the study was to determine how the handling of plasma influences the recovery of coagulation factor VIII activity (FVIII:C), i.e. the influence of time between donation and freezing, of the freezing time and of the ice front velocity. We also studied a tentative eutectic point in human plasma.

MATERIALS AND METHODS

Aliquots of plasma from 12 different donors were kept at room temperature for 2, 4 and 6 h before start of freezing. We achieved fast freezing with a freezer that blows cooled air at a high velocity on the plasma containers. Freezing times were 0.5, 1, 4 and 24 h. Temperature was registered continuously during freezing. Plasma and NaCl solutions were frozen slowly to investigate the eutectic point.

RESULTS

Storage at room temperature for 6 h caused a small but statistically significant decrease in FVIII:C. Slow freezing with programmed freezing times of 4 and 24 h caused a more pronounced drop in FVIII:C as compared to that of 30 and 60 min. We found no eutectic point in plasma or in plasma with addition of 2 % (w/v) NaCl.

CONCLUSION

For an optimal yield of FVIII, freezing should start within 4 h after plasma donation. We propose the use of the term 'ice front velocity' instead of 'freezing speed', taking into consideration that the volume and shape of plasma containers may differ. We found only a marginal loss of FVIII:C when the ice front velocity was 26 mm/h or faster, but a significant loss when it was 9 mm/h or slower. We recommend freezing times of 60 min or shorter. We were not able to demonstrate any eutectic point in human plasma. We therefore recommend that the term eutectic point should not be used as a reference temperature in guidelines on plasma handling.

Anorectal irradiation in pelvic radiotherapy: an assessment using in-vivo dosimetry

The objectives of this study were to measure by in-vivo techniques the radiation doses received by the anorectum during pelvic radiotherapy and compare these with doses predicted by a GE TARGET treatment planning system. Nine patients with cancers of the prostate, bladder, cervix or uterus were planned with computed tomography (CT) using the TARGET system. A Scanditronix rectal probe containing five n-type photon-detecting diodes was placed in the anorectum during the planning CT scans. The probe position was standardized with the five diodes at 2 cm intervals from the anal verge. The probe diodes were calibrated for 10 MV photons. Doses were measured for each diode for two consecutive fractions in the first four patients and for five consecutive fractions in the remaining five. Thermoluminescent dosimeters were used initially to verify diode doses. The TARGET and diode measured doses were compared. In all patients diodes situated in the target volume were within 7% of predicted doses. This improved to 2.5% after measurement on five fractions. At the edges of the target volume, wide variability existed between measured and predicted doses (measured dose range -68% to +68% of predicted dose). Outside the target volume, considerable doses (up to 0.3 Gy per fraction) were measured in the anal canal, which were not predicted by TARGET. We conclude that TARGET planned doses are accurate within the confines of the target volume. The greatest variability was seen at the edges of the target volume, where dose can vary by 50% across a 1 cm distance in the anterior-posterior plane. TARGET does not account for scattered dose beyond the field edges and therefore underestimates the dose received by the anal canal.

HLA-DR4 and salivary immunoglobulin A reactions to oral streptococci

The aim of this study was to describe and compare salivary immunoglobulin A (IgA) antibody reactions to extracts of strains of three oral streptococci in human leukocyte antigen (HLA)-DR4-positive and -DR4-negative subjects. Whole paraffin-stimulated saliva samples were collected from 27 apparently healthy subjects. Previous HLA typing showed that 20 subjects were DR4 positive and 7 were DR4 negative. HLA-DRB1*04 subtyping was performed among the DR4-positive subjects. Whole-cell antigen extracts from Streptococcus mutans (KPSK 2), Streptococcus sobrinus (OMZ 65) and Streptococcus parasanguis (Nt 62) were separated in SDS-PAGE. The antigens were immunoblotted with diluted saliva (Western blot), scanned and analyzed in a computer system. All immunoblot bands were recorded in DR4-positive and DR4-negative saliva pools, and bands with an optical density >or=0.1 were selected for analysis in individual salivas. The DR4-negative subjects in general had more immunoblot bands and more distinct bands than did the DR4-positive subjects. A higher concentration of total IgA in saliva was correlated with more bands, especially to antigens separated from S. mutans. When the number of bands was calculated per IgA unit, significant differences were observed between DR4-positive and DR4-negative salivas. This was particularly seen for S. mutans and S. parasanguis. As the number of bands was analyzed in relation to DR4 subgroups, DRB1*04, there was a lower salivary IgA activity to S. mutans in the DRB1*0401 and *0404. The variable level of correlation previously demonstrated for S. mutans colonisation and serologically defined DR4 positive subjects might be explained by the heterogeneity in this group, and the relation should be sought on a subgroup level.

Evaluation of compensation in breast radiotherapy: a planning study using multiple static fields

PURPOSE

A method that uses electronic portal imaging to design intensity-modulated beams for compensation in breast radiotherapy was implemented using multiple static fields in a planning study. We present the results of the study to verify the algorithm, and to assess improvements to the dosimetry.

METHODS AND MATERIALS

Fourteen patients were imaged with computed tomography (CT) and on a treatment unit using an electronic portal imager. The portal imaging data were used to design intensity-modulated beams to give an ideal dose distribution in the breast. These beams were implemented as multiple static fields added to standard wedged tangential fields. Planning of these treatments was performed on a commercial treatment planning system (Target 2, IGE Medical Systems, Slough, U.K.) using the CT data for each patient. Dose-volume histogram (DVH) analysis of the plans with and without multileaf collimator (MLC) compensation was carried out. This work has been used as the basis for a randomized clinical trial investigating whether improvements in dosimetry are correlated with the reduction of long-term side effects from breast radiotherapy.

RESULTS

The planning analysis showed a mean increase in target volume receiving 95-105% of prescribed dose of 7.5% (range -0.8% to 15.9%) when additional MLC compensation was applied. There was no change to the minimum dose for all 14 patient data sets. The change in the volume of breast tissue receiving over 105% of prescribed dose, when applying MLC compensation, was between -1.4% and 11.9%, with positive numbers indicating an improvement. These effects showed a correlation with breast size; the larger the breast the greater the amount of improvement.

CONCLUSIONS

The method for designing compensation for breast treatments using an electronic portal imager has been verified using planning on CT data for 14 patients. An improvement was seen in planning when applying MLC compensation and this effect was greater the larger the breast size.

Coping strategies among long-term injured competitive athletes. A study of 81 men and women in team and individual sports

Differences in personality, mood and coping ability between athletes of a high competitive level with long-term injuries (n = 81), with a mean age of 24.4 years, and a matched non-injured group (n = 64), with a mean age of 24.2 years, were investigated. Three self-rating scales were employed: mood adjective check-list, general coping questionnaire and Karolinska scales of personality. Although no differences in basic personality traits were found, being injured was found to result in a depressed mood state and in the activation of coping strategies directed at receiving help. Comparisons were made between injured male and female athletes as well as between team-sport and individual-sport athletes. Women were found to become more anxious and tense and to have a stronger inclination to use emotion-focused coping strategies. Team-sport athletes were found to cope more in terms of 'passive acceptance' of help from others, whereas individual athletes were found to activate 'problem-solving' strategies in face of a stressor. The results suggest that social aspects of rehabilitative work are important and support the concept that rehabilitative work with long-term injured athletes should be individualized to be maximally effective. They also support the usefulness of cognitive models of the injured athlete's experience of being long-term injured. Such models, however, do not account for differences between the sexes or between individual and team athletes.

HLA-DR4 and number of mutans streptococci in saliva among dental students and staff

Our aim was to corroborate previous findings that HLA-DR4 carriers are characterized by higher levels of mutans streptococci in saliva than are individuals expressing other HLA-DR types. Of 68 subjects (dental students, staff, and faculty) who were sampled for salivary counts of mutants streptococci, 13 subjects with the lowest counts of mutans streptococci and 15 subjects with the highest counts were selected for HLA-typing. Of the 13 who expressed HLA-DR4, 8 were heavily colonized by mutants streptococci. Although a trend towards a relationship was found between HLA-DR4 carriage and high levels of mutans streptococci, it was not statistically significant. In this selected population, knowledge of how to minimize the risk of caries and mutans streptococci level may have influenced the results.

HLA DRB1* typing and cartilage oligomeric matrix protein (COMP) as predictors of joint destruction in recent-onset rheumatoid arthritis

The carriage of a characteristic sequence of amino acids at position 67-72 in the third hypervariable region of the HLA DRB1 chain has been linked to susceptibility to rheumatoid arthritis (RA). Whether this epitope is also a predictor of more severe disease remains controversial. Cartilage oligomeric matrix protein (COMP) is a protein, the serum levels of which have been found to correlate with large joint destructive disease in previous work. In this paper, we compare DRB1* typing and serum COMP levels in a prospectively observed group of RA patients with or without early hip joint destruction. The COMP levels at study inclusion, median 11 months from onset of symptoms, were significantly higher in the patients with early hip joint destruction compared to the patients in the more benign group. There was no difference in the number of disease susceptibility-related epitopes between the groups. DRB1*04, in contrast, was found among 8/8 patients with hip destruction, but also in 5/8 more benign cases. We conclude that in this type of RA patient, COMP serum levels are more informative predictors of aggressive disease than HLA DRB1* typing.

Development of radiographic damage during the first 5-6 yr of rheumatoid arthritis. A prospective follow-up study of a Swedish cohort

The objective of this study was to describe the development of radiographic damage in patients with RA and to search for predictors of radiographic progression over 5 yr. One hundred and thirteen patients, 75 female and 38 male, mean age 53 yr, with definite RA and mean disease duration of 11.4 months, were followed prospectively for 5 yr at an out-patient clinic. Radiographs of the hands and feet were performed annually, and evaluated according to Larsen. The predictive value of demographic, clinical and laboratory variables at study start was evaluated. A stepwise logistic regression model was applied. We found that radiological joint damage occurred early and was significantly progressive during the 5 study years. The rate of progression was most prominent during the first 2 yr. At study start, 53% of the patients had no detectable erosions, but only 11% remained non-erosive. Twenty-six per cent of the patients with the initial presence of erosions did not progress substantially and needed no aggressive therapy. High joint damage progression during the first year, female gender and high baseline ESR could predict 57% of the patients with high total radiographic progression. Age, disease duration, rheumatoid factor, genetic factors, active joint count and the presence of erosions at study start had no predictive value.

Associations of HLA-DRB and -DQB genes with two and five year outcome in rheumatoid arthritis

OBJECTIVE

To evaluate the clinical usefulness of genomic HLA typing during the first five years of established rheumatoid arthritis (RA).

METHODS

The HLA-DRB and -DQB alleles were determined by restriction length polymorphisms and polymerase chain reaction amplification with sequence specific primers in 99 Swedish patients with RA. Clinical features after two and five years disease duration were related to the genetic pattern. Seventy four patients were seropositive, 25 had nodules, 90 developed erosions, and 15 required joint replacements. Twelve patients were in remission after five years. Disability was assessed by health assessment questionnaire, and radiographic damage in hands and feet by the Larsen method.

RESULTS

Eighty seven per cent of the patients carried the conserved third hypervariable region sequence (HVR3), 32% had DRB1*04 on one allele, and 26% had DRB1*04 on both alleles (all frequencies significantly greater than in controls). Frequencies of DRB1*04 associated DQB*0301 and *0302 were normal. Patients carrying DRB1*04 on both alleles tended to have more radiographic changes after two years, but this difference had diminished after five years. Disability did not vary with regard to the genotype. Homozygous HVR3 patients had about three times greater risk of undergoing joint replacement. Homozygosity for HVR3 and presence of DQB*0302 both tended to be associated with erosive disease.

CONCLUSIONS

We confirmed a strong association of disease with the presence of the shared epitope on one or two alleles. However, genotype was not strongly associated with disease severity after two and five years disease duration, and thus the value of genomic typing to select patients for early aggressive therapy is questionable.

HLA frequency in patients with chronic secretory otitis media

It is well established that relationships exist between the frequencies of certain HLA antigens and various disease entities. In an earlier study we found a significant correlation between the frequency of HLA-A2 and HLA-A3 and recurrent acute otitis media (rAOM). Of 34 HLA antigens analysed, HLA-A2 occurred in 80.0% and HLA-A3 in only 11.1% of children with rAOM as compared to 55.9% and 27.5%, respectively, in healthy controls. In the present study we investigated the frequencies of the same 34 HLA antigens in 40 children who had been regularly controlled at our clinic for chronic secretory otitis media (SOM) for at least 6 years. HLA-A2 was found in 52.0% (21/40) and HLA-A3 in 27.5% (11/40) of these children, figures on a par with those of healthy controls. The HLA-A2 frequency was significantly lower in chronic SOM patients than in rAOM children. Some other non-significant differences were also found between these two groups. The results indicate a difference in hereditary influence on the pathogenesis of rAOM and that of chronic SOM.

HLA-DR antigens, Gm allotypes and antiallotypes in early rheumatoid arthritis--their relation to disease progression

OBJECTIVE

Evaluation of the prognostic value of immunogenetic markers in early rheumatoid arthritis (RA).

METHODS

Ninety-nine patients with definite RA and disease duration 24 months or less were followed with standardized assessment. Disability was assessed by the HAQ index and radiographic changes in hands and feet by the Larsen method. The frequencies of HLA-DR genes were determined by serological typing, Gm allotype distribution by classical hemagglutination inhibition test, and occurrence of anti-Gm allotypes by use of anti-Rh coats. The immunogenetic findings were related to disease severity after 2 years' followup.

RESULTS

Functional capacity was well preserved, disease activity was less, but radiographic changes in hands and feet had increased considerably at study finish. A group of 13 patients had developed rapidly progressive changes of hip and/or shoulder joints, all requiring arthroplasty. There was a significantly increased frequency of HLA-DR4. Twenty-seven of the 68 HLA-DR4 positive patients were putatively homozygous. HLA-DR4 was not related to disability or to severe small joint destruction. However, progressive large joint damage was significantly more prevalent in homozygous patients (p < 0.01). Gm allotype distribution was normal and not related to clinical findings. Anti-Gm antibodies were common and frequently specific for nonhost Gm allotype. Fifty-six patients carried anti-G1m(a), and occurrence of this antibody was significantly associated with radiographic progression of small joints (p = 0.01), presence of nodules (p < 0.01) and number of active joints (p = 0.001).

CONCLUSION

Immunogenetic markers aided in identifying patients with early RA with more severe disease.

HLA antigens and recurrent acute otitis media

The frequencies of a number of HLA antigens were investigated in 45 individuals with clinical recurrent acute otitis media (rAOM), defined as six or more episodes of AOM during a 12-month period, and were compared to those in a control group from the same district. HLA-A2 was found to occur in 80% of the rAOM group, as compared to 55.9% of controls (p less than 0.01). HLA-A3 antigen occurred in only 11.1% of the rAOM group in contrast to 27.5% of controls (p less than 0.05). Among 22 prospectively followed children without any AOM during their first 3 years of life, the frequencies of HLA-A2 and HLA-A3 antigens were comparable with those among controls.

HLA frequency in patients with recurrent acute otitis media

Clinical data suggest the involvement of hereditary factors in children susceptible to recurrent acute otitis media. That relationships of varying degree exist between the frequencies of certain HLA antigens and various disease entities is well established. In the present study, we investigated the frequencies of a number of HLA antigens in 45 patients with clinical recurrent acute otitis media and compared these frequencies with those in a control group from the same district. The HLA-A2 antigen occurred in 80% (36/45) of the group with recurrent acute otitis media, as compared with 56% of controls. Of a subgroup of 11 children with recurrent acute otitis media who were prospectively followed up, 10 (91%) were HLA-A2 positive. The HLA-A3 antigen occurred in only 11% (5/45) of the group with recurrent acute otitis media as a whole (n = 45) in comparison with 28% of controls. Among 22 prospectively followed up children without any episode of acute otitis media during the first 3 years of life, the frequency of HLA-A2 was 45% (10/22) and that of HLA-A3, 32% (7/22). The results indicate the existence of a relationship between recurrent acute otitis media and the HLA-A locus, suggesting the involvement of genetic factors in the disease.

Human leukocyte antigens in relation to colonization by mutans streptococci in the oral cavity

Mutans streptococci are well established as caries-inducing microorganisms in man. Most humans carry the bacteria, but in highly different numbers. This cannot be explained by environmental factors only. The aim of this study was to investigate a possible association between levels of colonization by mutans streptococci and the presence of certain B and DR human leukocyte antigens (HLA). Altogether, 170 subjects who had their HLA antigens determined (76 renal transplant patients and 94 healthy blood donors) were selected for the investigation. Paraffin-stimulated saliva samples were taken using the wooden spatula method with subsequent cultivation of mutans streptococci on mitis salivarius bacitracin agar plates. An association between the absence of HLA-DR 4 antigens and low, or undetectable, levels of mutans streptococci was found. This was statistically significant for the immunosuppressed renal transplant subjects. The same trend was observed among the healthy blood donors.

HLA-antigens in renal transplanted patients with varicella-zoster infection

The frequency of the HLA B 40 antigen was significantly higher among renal transplanted patients with herpes zoster infection than in controls. The presence of HLA B 40 may be related to impaired immune response in transplanted and immunosuppressed carriers.

HLA-typing in a family with six intracranial aneurysms

The pedigree of a family where three of nine siblings had suffered from aneurysmal subarachnoid haemorrhage (SAH) was explored, by means of interviews and revisions of population and medical records. We thus found two nephews with previously ruptured intracranial aneurysms. Subsequently high resolution computerised tomography (CT) scans were performed in the remaining six siblings, one of which was shown to harbor an intracranial aneurysm. This individual was subjected to uncomplicated clipping of the aneurysm. Typing of human leukocyte antigen (HLA) was performed in 15 individuals of the pedigree. Three of the six HLA-antigens recently reported to occur in increased frequently in a series of (non-familial) patients with ruptured aneurysm were found, namely B7, DR2 and Cw2. Most noteable was the expression of the antigen B7 in five of the six individuals with aneurysm in the investigated family. At present HLA-typing is not a useful screening tool to identify individuals in the general population with an increased risk of developing intracranial aneurysms. The present study shows that HLA-typing could neither be used to predict the occurrence of intracranial aneurysms in the siblings in the investigated family. HLA-typing may provide further clues to our understanding of the etiology of intracranial aneurysms, especially concerning possible genetic factors. The authors thus would like to encourage HLA-typing in previously known and newly detected families with accumulation of intracranial aneurysms.

Complement components in normal pregnancy

Sixteen complement components were analysed at three different occasions during a normal pregnancy. Samples were also obtained at delivery and six weeks post partum. All factors but C1 IA and D increased during the pregnancy. Six weeks after the delivery, the levels of all components but C1s, C4 and C6 showed a beginning normalisation. In 15 per cent of the women, C1 IA was functionally inactive at delivery.

Age at onset, sex distribution and HLA antigen frequency in patients with primary glomerulonephritis progressing to terminal uraemia. An epidemiological survey

In a retrospective study of 138 HLA-typed patients with primary glomerulonephritis progressing to terminal uraemia, a bimodal curve of age at onset of disease was observed among males. An initial peak occurred between 16 and 25 years of age, and a second peak between the ages of 46 and 55. The prevalence of HLA B40 was found to be high among males in the first group, and a relationship was found to exist between the presence of HLA B40 and increased titres of ASO (antistreptolysin O). No such findings were made either in the second group of males or in the female group. Among females, a single peak for age of onset occurred between 6 and 15 years. The frequency of HLA B40 did not differ significantly from that of the controls. The results of this study suggest a relationship to exist, predominantly in younger males, between primary glomerulonephritis with fatal outcome and HLA B40-related alterations in the immunological response to beta-streptococcal infection.

C1 activation, with C1q in excess of functional C1 in synovial fluid from patients with rheumatoid arthritis

Free Clq, in functionally active form was present in increased amounts in the synovial fluid of patients with rheumatoid arthritis. The presence of free Clq was associated with low concentrations of hemolytic C1, low C4 and raised amounts of C3dg/d fragments in the synovial fluid. The findings suggested intra-articular C1 activation with dissociation of C1 into free C1q and complexes containing C1r, C1s, and C1 inactivator. However, the immunochemical properties of synovial fluid C1r-C1s-C1 inactivator complexes appeared to differ from those of the complexes formed in serum, which hampered quantification with the assay used. Control patients with osteoarthritis or spondylarthritic syndromes did not show evidence of intra-articular complement activation, even though 1 patient with Reiter's disease had unexplained low concentrations of synovial fluid C4 and C3. The concentrations of circulating complement components were largely normal in the patients. Slightly increased concentrations of free C1q and C1r-C1s-C1 inactivator complexes in serum and C3dg/d fragments in EDTA plasma were observed, particularly in the patients with rheumatoid arthritis.

Complement activation in primary biliary cirrhosis: an in vitro model

Increased concentrations of C3dg were demonstrated in plasma from patients with primary biliary cirrhosis (PBC), indicating in vivo activation of C3. Rapid spontaneous C3 cleavage by the classical pathway was observed in vitro in serum and in EDTA plasma reconstituted with Ca++ and Mg++, suggesting the presence of complement-activating substances. On incubation with fresh normal serum, purified polyclonal IgM from patients with PBC induced C1 activation, C4 cleavage, and C3dg formation. No C3 cleavage was observed when PBC-IgM was incubated with a C2-deficient serum. We suggest that the complement activation in vivo in PBC, which occurs predominantly by the classical pathway and is characterized by increased concentrations of C1 activation complexes, decreased C4 concentrations, and hypercatabolism of C3, is attributable to an abnormal IgM population.

Sequential studies of complement activation in systemic lupus erythematosus

C1 and C3 activation, measured as C1r-C1s-C1 inactivator C1s-C1r-C1IA complexes in serum and circulating C3d were studied in serial samples from 33 patients with SLE. All patients demonstrated exacerbations during observation periods of 10-30 months and were divided into groups according to principal clincal features (mild SLE, severe extra-renal SLE, and lupus glomerulonephritis). Increased C1 activation was consistently found during exacerbation. C3d in plasma was a feature associated with severe disease flares. Activation of C1, but not of C3, was documented before flare-ups of disease activity, but such predictive information was mostly restricted to patients with extra-renal disease. C2 cleavage in plasma, studied serially in a few patients, appeared to be closely associated with C1 activation. Circulating immune complexes, measured with solid-phase C1q assay, did not always increase before development of clinical manifestations. Remission of symptoms was paralleled by decreasing concentrations of C1r-C1s-C1IA and of, when present, C3d. Similar findings were made for immune complexes but only in severe disease. Persisting C3d was observed in 3 patients, who subsequently developed renal failure. C1q levels were transiently low during flare-ups of lupus glomerulonephritis, but otherwise the concentrations of C1q, C4 and C3 did not show consistent patterns of variation in relation to disease activity.