Estimation of parameters of dose-volume models and their confidence limits

Predictions of the normal-tissue complication probability (NTCP) for the ranking of treatment plans are based on fits of dose-volume models to clinical and/or experimental data. In the literature several different fit methods are used. In this work frequently used methods and techniques to fit NTCP models to dose response data for establishing dose-volume effects, are discussed. The techniques are tested for their usability with dose-volume data and NTCP models. Different methods to estimate the confidence intervals of the model parameters are part of this study. From a critical-volume (CV) model with biologically realistic parameters a primary dataset was generated, serving as the reference for this study and describable by the NTCP model. The CV model was fitted to this dataset. From the resulting parameters and the CV model, 1000 secondary datasets were generated by Monte Carlo simulation. All secondary datasets were fitted to obtain 1000 parameter sets of the CV model. Thus the 'real' spread in fit results due to statistical spreading in the data is obtained and has been compared with estimates of the confidence intervals obtained by different methods applied to the primary dataset. The confidence limits of the parameters of one dataset were estimated using the methods, employing the covariance matrix, the jackknife method and directly from the likelihood landscape. These results were compared with the spread of the parameters, obtained from the secondary parameter sets. For the estimation of confidence intervals on NTCP predictions, three methods were tested. Firstly, propagation of errors using the covariance matrix was used. Secondly, the meaning of the width of a bundle of curves that resulted from parameters that were within the one standard deviation region in the likelihood space was investigated. Thirdly, many parameter sets and their likelihood were used to create a likelihood-weighted probability distribution of the NTCP. It is concluded that for the type of dose response data used here, only a full likelihood analysis will produce reliable results. The often-used approximations, such as the usage of the covariance matrix, produce inconsistent confidence limits on both the parameter sets and the resulting NTCP values.     

Subtelomeric deletions detected in patients with idiopathic mental retardation using multiplex ligation-dependent probe amplification (MLPA)

Subtelomeric rearrangements are responsible for 5% to 10% of cases of unexplained mental retardation. Despite their clinical relevance, methods to screen for these cytogenetically invisible abnormalities on a routine base are scarce. We screened patients with idiopathic mental retardation for subtelomeric aberrations using multiplex ligation-dependent probe amplification (MLPA). This recently developed technique is based on PCR amplification of ligated probes hybridized to chromosome ends. Currently, 41 telomeres can be screened in just two multiplex reactions. Four subtelomeric rearrangements (5.3%) were detected in a group of 75 patients with mild to severe mental retardation in combination with dysmorphic features and/or a familial history of mental retardation: two terminal 1p deletions, a terminal 1q deletion, and a terminal 3p deletion. Deletions could be verified by FISH and marker analysis. In one case the MLPA indicated a terminal 21q deletion due to a 3-bp deletion at the site of the probe, giving a false-positive rate of 1.3%. This study demonstrates that MLPA is a fast and reliable screening method, potentially suitable for use in routine diagnostics.     

Detector line spread functions determined analytically by transport of Compton recoil electrons

To achieve the maximum benefit of conformal radiation therapy it is necessary to obtain accurate knowledge of radiation beam penumbras based on high-resolution relative dosimetry of beam profiles. For this purpose there is a need to perform high-resolution dosimetry with well-established routine dosimeters, such as ionization chambers or diodes. Profiles measured with these detectors must be corrected for the dosimeter's nonideal response, caused by finite dimensions and, in the case of an ionization chamber, the alteration of electron transport and a contribution of electrons recoiled in the chamber wall and the central electrode. For this purpose the line spread function (LSF) of the detector is needed. The experimental determination of LSFs is cumbersome and restricted to the specific detector and beam energy spectrum used. Therefore, a previously reported analytical model [Med. Phys. 27, 923-934 (2000)] has been extended to determine response profiles of routine dosimeters: shielded diodes and, in particular, ionization chambers, in primary dose slit beams. The model combines Compton scattering of incident photons, the transport of recoiled electrons by Fermi-Eyges small-angle multiple scattering theory, and functions to limit electron transport. It yields the traveling direction and the energy of electrons upon incidence on the detector surface. In the case of ionization chambers, geometrical considerations are then sufficient to calculate the relative amount of ionization in chamber air, i.e., the detector response, as a function of the detector location in the slit beam. In combination with the previously reported slit beam dose profiles, the LSF can then readily be derived by reconstruction techniques. Since the spectral contributions are preserved, the LSF of a dosimeter is defined for any beam for which the effective spectrum is known. The detector response profiles calculated in this study have been verified in a telescopic slit beam geometry, and were found to correspond to experimental profiles within 0.2 and 0.3 mm (full width at half-maximum) for a Wellhoefer IC15 chamber in a 6 and 25 MV-X x-ray beam, respectively. For a shielded diode these figures were found to be 0.2 and 0.1 mm, respectively. It is shown that a shielded diode in a primary beam needs only a small size-based correction of measured profiles. The effect of the LSF of an IC15 chamber on penumbra width has been determined for a set of model penumbras. The LSFs calculated by the application of the analytical model yield a broadening by 2 mm of a 3 mm wide penumbra (20%-80%). This is 0.5 mm (6 MV-X) to 1 mm (25 MV-X) smaller than found with the experimental LSFs. With a spatial correction based on the LSFs that were determined in this study, this broadening of up to 2 mm is eliminated, so that ionization chambers like the IC15 can be used for high-resolution relative dosimetry on a routine basis.     

Impact of donor lung quality on post-transplant recipient outcome in the Lung Allocation Score era in Eurotransplant – a historical prospective study

The aim of this study was to investigate whether there is an impact of donation rates on the quality of lungs used for transplantation and whether donor lung quality affects post-transplant outcome in the current Lung Allocation Score era. All consecutive adult LTx performed in Eurotransplant (ET) between January 2012 and December 2016 were included (N = 3053). Donors used for LTx in countries with high donation rate were younger (42% vs. 33% ≤45 years, P < 0.0001), were less often smokers (35% vs. 46%, P < 0.0001), had more often clear chest X-rays (82% vs. 72%, P < 0.0001), had better donor oxygenation ratios (20% vs. 26% with PaO₂/FiO₂ ≤ 300 mmHg, P < 0.0001), and had better lung donor score values (LDS; 28% vs. 17% with LDS = 6, P < 0.0001) compared with donors used for LTx in countries with low donation rate. Survival rates for the groups LDS = 6 and ≥7 at 5 years were 69.7% and 60.9% (P = 0.007). Lung donor quality significantly impacts on long-term patient survival. Countries with a low donation rate are more oriented to using donor lungs with a lesser quality compared to countries with a high donation rate. Instead of further stretching donor eligibility criteria, the full potential of the donor pool should be realized.     

The Acute and Early Effects of Whole-Brain Irradiation on Glial Activation,Brain Metabolism,and Behavior: a Positron Emission Tomography Study

Molecular Imaging and Biology - Radiotherapy is a frequently applied treatment modality for brain tumors. Concomitant irradiation of normal brain tissue can induce various physiological responses....     

Professionalism beyond medical school: An educational continuum?

Given the changes in society we are experiencing, the increasing focus on patient centred care and acknowledgment that medical education needs to continue not only in the residency programmes but throughout the doctors career, is not surprising. This article describes the attention currently paid to professionalism in the residency programmes, differences in perception of professionalism between patients, faculty, students and residents, differences in professionalism issues in the different educational phases, as well as their consequences for training and assessment regarding professionalism. Continuous medical education in professionalism is thereafter briefly discussed.