Definition of prostatic contours using tomodensitometric slices: study of differences among radiotherapists and between examinations]

Accuracy of conformal treatment planning for prostatic radiotherapy is based on the contours of target volumes (prostate +/- seminal vesicles) and normal tissues (rectum and bladder), drawn on CT (computed tomography) images by radiation oncologists. The interpretation of a given CT image can be different from one radiation oncologist to another, and may change in time with the state of filling of the bladder and of the rectum during the treatment. In order to quantify these variations, 12 patients treated with conformal radiotherapy for prostate carcinoma (pelvis 40 Gy/20 sessions + prostate 30 Gy/15 sessions) had two series of CT at one month intervals. Contouring of prostate, rectum and bladder were performed independently on each CT by two radiation oncologists. The first CT scan (planning CT) and the first series of contours (planning contours) were used for treatment planning. The contours of the second scan were compared to the planning contours after image fusion based on manual superimposition of bony anatomy of the two sets of CT images. Coherence ratio were defined to measure discrepancies in prostate volumes between radiation oncologists (RCE) and between scans (RCT). The mean RCE was 38 +/- 7% (1 standard deviation). Those discrepancies were primarily located at the prostate apex and at the interface between bladder and prostate and between rectum and prostate. The mean RCT was 42 +/- 8% (1 sigma). Those discrepancies were due to the prostate motion related to the state of filling of the rectum and bladder. For bladder and rectal walls, less important differences were observed between the two radiation oncologists for the same CT (4.5% for rectal volume receiving 65 Gy or more, 3% for bladder volume receiving 65 Gy or more). However, important differences in bladder and rectal volumes receiving 65 Gy or more (16% and 7% respectively) were noted for the same patient from a CT to another due to the variation in bladder or rectal filling. New techniques for planning CT acquisition are needed to decrease the discrepancies due to contouring. The treatment must, as far as possible, be delivered with an empty bladder and rectum in order to ensure a good reproduction of the initially planned treatment.     

The decision to operate: role of integrated computed tomography positron emission tomography in staging oesophageal and oesophagogastric junction cancer by the multidisciplinary team

OBJECTIVE: Our objective was to assess the role of fusion positron emission tomography-computed tomography (PET-CT) in staging patients for minimally invasive oesophagectomy (MIO) with potentially resectable disease from the perspective of a multidisciplinary team (MDT) deciding on operability with conventional staging investigations. METHODS: Fifty consecutive patients presenting with potentially operable oesophageal or oesophagogastric junctional tumours were staged with computed tomography (CT) and endoluminal ultrasound (EUS). The MDT categorised patients as group A (n=33; CT N0M0) or group B (n=17; CT N1/possible M1). All patients underwent FDG PET-CT. Patients with localised disease (at T3), including single level N1 disease on PET-CT, were deemed suitable for induction chemotherapy followed by surgery. RESULTS: PET-CT re-categorised 12% of patients as inoperable on grounds of distant metastases (four in group A, two in group B). Five patients did not proceed to resection for other reasons. Two had metastatic disease at thoracoscopy. Resection specimens (n=37) contained 24 nodes (median). Compared with pN status, positive predictive value of PET-CT was 40% and negative predictive value was 43%. The expected PET-CT N1 group had the highest mean number of involved nodes. Median survival for all patients (n=50) was 31.9 months for group A compared with 17.3 months for group B (not statistically significant). There was no significant difference between patients who were PET-CT N0 or N1 in survival or disease-free survival in patients undergoing surgery (n=37). CONCLUSIONS: PET-CT informs the MDT decision to operate in avoiding futile surgery in stage IV disease or widespread nodal disease. In this study, overall PET-CT N1 status has low positive and negative predictive value for overall pN status.     

Agglutination of Red Blood Cells from Patients with Diabetes mellitus by a Polyclonal Human Antibody Specific for D-Glucose

We have previously described an antibody which will agglutinate red blood cells which had been incubated in vitro in D-glucose. This antibody is specific for the ring form of glucose, beta-D-glucopyranose. The current report demonstrates that without prior in vitro incubation with glucose, red blood cells from 36 of 38 patients with diabetes mellitus, and 7 of 70 patients not diagnosed as diabetic were agglutinated by this antibody. Strength of agglutination of red blood cells from diabetic patients correlated with both glucose (r = 0.61; p less than 0.001) and hemoglobin A1c levels (r = 0.50; p less than 0.01) in simultaneously obtained samples. This reactivity could be reversed by incubating red blood cells from diabetics for several hours in saline. This report suggests that red blood cells from diabetic patients have membrane-bound glucose that can be detected immunologically. Reversibility of the reaction and rapidity of in vitro glycosylation suggests short-term binding of glucose. To our knowledge, this is the first report documenting immunological detection of in vivo short-term reversible binding of glucose to cellular membranes.     

Underutilization of autologous blood donation among eligible elective surgical patients

In January 1983, blood banks encouraged the use of autologous blood for transfusion in elective surgical patients due to the advent of transfusion-associated AIDS. Since autologous blood does not transmit hepatitis and other viruses and does not cause alloimmunization, it should be utilized whenever possible. To determine whether patients eligible to predeposit autologous blood before elective operation were actually doing so, we studied patients at three hospitals between January 1 and June 30, 1985. Patients considered eligible for autologous predeposit blood donation were adults with preoperative hemoglobin levels of 11 g/dl or more who underwent elective surgical procedures for which blood transfusion was anticipated. Excluded were patients undergoing cardiovascular, intracranial, or renal transplant procedures. Of eligible patients, only 11 percent (32 of 278) predeposited blood; of these, 81 percent (26 of 32) were transfused with only autologous blood. Among eligible patients who did not predeposit blood, all could have benefited from predepositing because transfusion was likely for the procedure. Of those who did not predeposit, 33 percent (83 of 246) received homologous blood and therefore would have benefited from autologous donation. We conclude that autologous donations are underutilized for medically eligible patients undergoing elective operation.     

Cardiovascular risk factors in young snuff-users and cigarette smokers

We studied cardiovascular risk factors in 21 young men who were habitual snuff-users, and compared them with the same risk factors in 18 non-tobacco-users and 19 cigarette smokers of the same age and body mass index. Both snuff-users and smokers showed increased levels of alcohol and coffee consumption and a decreased level of physical exercise compared to non-users. Both groups of tobacco-users showed increased serum insulin levels compared to the control group at similar blood glucose concentrations. In contrast to the smokers, snuff-users showed no significant elevation of diastolic blood pressure, haemoglobin concentrations, white cell count, serum cholesterol or triglyceride levels. Snuff users had higher plasma fibrinogen levels than non-users (P = 0.07). The use of snuff by young men appears to have less impact than smoking on cardiovascular risk factors, with the possible exception of elevated serum insulin and plasma fibrinogen levels.     

Digital imaging of the chest

During the past several years, image acquisition in nuclear medicine, computed tomography, ultrasonography, subtraction angiography, and magnetic resonance has been by digitization. Despite these advances, research in the development of digital imaging in conventional radiography has lagged behind. Although studies with a variety of digital techniques have been carried out on several fronts, we still do not possess a method that has captured the imagination of the majority of radiologists and other physicians to a point where it could replace conventional screen-film imaging. This article reviews the current status and general principles of the technology, focusing on the four digital radiographic techniques that have shown the greatest promise - film digitization, an image intensifier - based system, photostimulable phosphor plates, and a scanned projection system. The physical aspects of each of the four systems and the clinical results that have been reported to date, as well as the advantages and disadvantages of each system, are presented.     

The effect of maintenance cimetidine therapy on the medical, social and economic aspects of patients with chronic gastric ulcers. A placebo-controlled prospective study

We studied the effect of cimetidine maintenance therapy on the socioeconomic life of patients with gastric ulcers in the year after healing and the extent to which treatment was cost-effective. One hundred and seventy patients with a healed ulcer were studied for periods of up to one year after healing; 116 patients completed one year of observation. A double-blind randomized prospective study was performed that compared cimetidine (400 mg at night) with placebo. Analysis was performed on the intention-to-treat principle. The treated group showed benefit over the placebo group; major or minor symptoms were experienced on fewer days, and more months were symptom-free. Male patients were wakened with ulcer pain on fewer nights, led a more normal social life, and had less ulcer-related sick-leave; female patients had less total sick leave. The proven ulcer recurrence rate was lower in the treated group. Fewer endoscopies were performed in this group and the resultant cost saving was equivalent to the cost expenditure on cimetidine treatment. A modest saving in wages was afforded treated patients in the workforce, due to the reduction in sick leave. The principal benefit of cimetidine treatment appeared to be the lessening of the pain and discomfort and, hence, the distress and anxiety that was associated with ulcer disease. The cost-saving due to the reduced number of endoscopies compensated for the cost-expenditure of the cimetidine treatment.     

CD25+ CD4+ T cells, expanded with dendritic cells presenting a single autoantigenic peptide, suppress autoimmune diabetes

In the nonobese diabetic (NOD) mouse model of type 1 diabetes, the immune system recognizes many autoantigens expressed in pancreatic islet beta cells. To silence autoimmunity, we used dendritic cells (DCs) from NOD mice to expand CD25+ CD4+ suppressor T cells from BDC2.5 mice, which are specific for a single islet autoantigen. The expanded T cells were more suppressive in vitro than their freshly isolated counterparts, indicating that DCs from autoimmune mice can increase the number and function of antigen-specific, CD25+ CD4+ regulatory T cells. Importantly, only 5,000 expanded CD25+ CD4+ BDC2.5 T cells could block autoimmunity caused by diabetogenic T cells in NOD mice, whereas 10(5) polyclonal, CD25+ CD4+ T cells from NOD mice were inactive. When islets were examined in treated mice, insulitis development was blocked at early (3 wk) but not later (11 wk) time points. The expanded CD25+ CD4+ BDC2.5 T cells were effective even if administered 14 d after the diabetogenic T cells. Our data indicate that DCs can generate CD25+ CD4+ T cells that suppress autoimmune disease in vivo. This might be harnessed as a new avenue for immunotherapy, especially because CD25+ CD4+ regulatory cells responsive to a single autoantigen can inhibit diabetes mediated by reactivity to multiple antigens.     

Fatigue during acute isovolemic anemiain healthy, resting humans

BACKGROUND: Transfusion guidelines recommend that clinicians assess patients for signs and symptoms of anemia before the transfusion of RBCs. However, studies of signs and symptoms associated with acute isovolemic anemia are limited. The objective of this study was to determine whether acute reduction of Hb concentration to 5 g per dL would result in fatigue, tachycardia, or hypotension in resting, young, healthy, isovolemic humans, and whether changes were reversible with RBC transfusion. STUDY DESIGN AND METHODS: Conscious, resting, healthy adults less than 35 years old (n = 8) underwent acute isovolemic hemodilution to Hb of 5 g per dL and self-scored their energy level at various Hb concentrations. Heart rate and blood pressure were also measured. For controls, measurements of each subject were made during a comparable period of rest without hemodilution. RESULTS: During acute isovolemic hemodilution, energy levels decreased progressively and were lower at Hb of 7, 6, and 5 g per dL than at baseline (p<0.01) or in control sessions (p<0.05). The energy level was lower at Hb 7 g per dL than at 14 ( p = 0.005), lower at Hb 6 g per dL than at 7 (p = 0.01), and lower at Hb 5 g per dL than at 6 (p =0.01). Energy levels rose and were not different from baseline or control levels after transfusion of all autologous RBCs. Similarly, median heart rate increased with hemodilution to Hb of 7, 6, and 5 g per dL and decreased with transfusion of autologous RBCs. Supine blood pressure did not decrease with isovolemic hemodilution. CONCLUSION: In resting, young, healthy humans, acute isovolemic anemia to Hb levels of 7, 6, and 5 g per dL results in decreased self-scored energy levels and in an increase in heart rate but not in hypotension. Changes in energy and heart rate are reversible with the transfusion of autologous RBCs.     

Return of autologous blood donors as homologous blood donors

Autologous blood donors (ABDs) have been reported to have favorable attitudes toward returning as homologous blood donors (HBDs), but the frequency of return has not been well documented. ABDs eligible by history to be HBDs were followed at one blood center: 255 donating for elective surgery and 234 donating during pregnancy were followed for an average of 18 months and 20 months, respectively, from time of eligibility after surgery or postpartum. Male ABDs had a higher rate of return as HBDs, as 34 percent (21/62) returned to donate an average of 3 units, whereas 13 percent (56/427) of female ABDs returned as HBDs to donate an average of 2 units. Although a history of donation was associated with a higher rate of return (30%, 34/113), 11 percent (43/376) of ABDs with no history as HBDs returned to donate homologous units, despite having been recruited less frequently than prior HBDs. Overall, all male ABDs and female ABDs with an HBD history returned most frequently. The extra effort required for an autologous donor program may result in the recruitment of new donors into the HBD pool.