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Executive SummaryThe EC Directive 2013/59/Euratom states in article 56 that exposures of target volumes in nuclear medicine treatments shall be individually planned and their delivery appropriately verified. The Directive also mentions that medical physics experts should always be appropriately involved in those treatments. Although it is obvious that, in nuclear medicine practice, every nuclear medicine physician and physicist should follow national rules and legislation, the EANM considered it necessary to provide guidance on how to interpret the Directive statements for nuclear medicine treatments.For this purpose, the EANM proposes to distinguish three levels in compliance to the optimization principle in the directive, inspired by the indication of levels in prescribing, recording and reporting of absorbed doses after radiotherapy defined by the International Commission on Radiation Units and Measurements (ICRU): Most nuclear medicine treatments currently applied in Europe are standardized. The minimum requirement for those treatments is ICRU level 1 (“activity-based prescription and patient-averaged dosimetry”), which is defined by administering the activity within 10% of the intended activity, typically according to the package insert or to the respective EANM guidelines, followed by verification of the therapy delivery, if applicable. Non-standardized treatments are essentially those in developmental phase or approved radiopharmaceuticals being used off-label with significantly (> 25% more than in the label) higher activities. These treatments should comply with ICRU level 2 (“activity-based prescription and patient-specific dosimetry”), which implies recording and reporting of the absorbed dose to organs at risk and optionally the absorbed dose to treatment regions. The EANM strongly encourages to foster research that eventually leads to treatment planning according to ICRU level 3 (“dosimetry-guided patient-specific prescription and verification”), whenever possible and relevant. Evidence for superiority of therapy prescription on basis of patient-specific dosimetry has not been obtained. However, the authors believe that a better understanding of therapy dosimetry, i.e. how much and where the energy is delivered, and radiobiology, i.e. radiation-related processes in tissues, are keys to the long-term improvement of our treatments.

As part of an International Agency for Research on Cancer (IARC) international epidemiological study of workers in the pulp and paper industry, previously unpublished exposure measurements were assembled in a database. This article summarizes the results of 3,873 measurements carried out in the production departments of paper and paperboard mills and recycling plants in 12 countries. In the paper and paperboard mills, most of the agents were measured in the pulping and refining departments and in on-machine coating and winding of paper/paperboard. Exposures to asbestos, carbon monoxide, formaldehyde, fungal spores, bacteria, nitrogen dioxide, minerals dusts, paper dust, sulphuric acid and different solvents sometimes exceeded exposure limit values. In the re-pulping and de-inking departments of recycling plants high exposures to formaldehyde, fungal spores, bacteria and paper dust were observed. High exposures to asbestos, bioaerosols, carbon monoxide and paper dust were found in many departments; ammonia, formaldehyde, mineral and paper dust and solvents were found in coating machines; and diphenyl and polychlorobiphenyls (PCBs) were found in some special circumstances. Measurements in the newsprint and uncoated paper machine departments revealed only a few elevated exposures. In nearly all departments, measurements of epichlorohydrin, PCBs, sulphur dioxide, hydrogen sulphide and mercaptans tended to be low, often even below their detection limits. In spite of some uncertainties in the measurement data, the study provides new insights into the level and variation of occupational exposures of production workers in the paper and paperboard industry. © Springer-Verlag 2004.

The Papers Presented at the Annual Meetings of the Knee Society Symposium includes selected papers read at the 2007 Annual Interim Meeting of the Knee Society held in Sienna, Italy in September 2007, and the 2008 Open Scientific Meeting of the Knee Society, held in San Francisco in March 2008. The wide range and high quality of the scientific material presented here is a credit to the excellent work of the Knee Society education committee and particularly to its Program Chair, Gil Scuderi, MD. Each of these papers is focused, concise and highly readable, which is a credit to the outstanding work of the staff at CORR in providing clear and consistent guidelines for each of the authors whose work was accepted for publication. The 2008 Ranawat Award was authored by Dr. Patricia Franklin and colleagues for their work on patient-specific attributes that affect the functional outcome after total knee replacement. While considerable interest in patient outcomes research has been present for some time now, we are still uncovering the hidden power, and the hidden pitfalls, of such evaluation tools in orthopaedics. Dr. Franklin and colleagues effectively demonstrate the substantial influence of specific patient characteristics in determining the ultimate functional outcome after knee replacement. These data are useful for surgeons and patients alike as part of the preoperative discussion so that expectations can be managed more appropriately. Further, this paper provides some insight into additional strategies that might be employed prior to knee replacement to affect some patient attributes that adversely impact outcome. The 2008 Coventry Award paper was authored by D’Lima, Colwell, and colleagues from the Scripps Clinic for their innovative report that directly measured the in vivo forces that the knee experiences after total knee arthroplasty. In an outstanding collaboration between basic science researchers, engineers, and clinicians, Dr. Colwell’s group designed and implanted in three patients an instrumented tibial component that allowed the direct measurement of both knee forces and moments in vivo. These results begin to give us a true glimpse of the forces that are seen by total knee bearing surfaces and fixation interfaces thus providing us with a more scientific approach to what have otherwise been empiric recommendations regarding physical activities after total knee arthroplasty. The 2008 John Insall Award paper was authored by Dr. Steven MacDonald and colleagues from London, Ontario and addressed the specific impact of gender on the clinical outcome after total knee arthroplasty. The introduction into the marketplace of so-called gender-specific total knee components has been met with a competing mix of interest and skepticism among surgeons, while among patients curiosity might be the most appropriate descriptor. This scientific work again highlights the powerful relationship between preoperative variables and postoperative outcomes. These authors rightly highlight the importance of focusing on the change or improvement in preoperative to postoperative outcomes measures and balance that against the absolute scores. Female gender was associated with lower preoperative scores with these outcomes tools so perhaps it is not surprising some of the postoperative scores remain lower than those observed in males. The change or improvement from preoperative to postoperative, however, appears to be similar between males and females after total knee arthroplasty. The remaining papers in this symposium are grouped to include new information regarding total knee surgical technique, gender-related issues in technique and outcome, computer navigation, patellar resurfacing, total knee materials and design issues and revision total knee concerns. As surgeons we have specific interest in improving our intraoperative skills. In this symposium there is information on a method to determine rotational position of total knee components, data on the impact of a ligament balancing technique on the rate of lateral retinacular release, and the introduction of an extramedullary femoral referencing system to facilitate less invasive surgery. Gender-related issues are addressed in a series of papers that look at both documenting physical measurement differences in knee anatomy and then measuring outcomes differences. While little doubt exists that gender-associated differences can be measured, what remains to be determined is the clinical importance of such findings, and in that area we collectively still have work to do. While it appears that the initial wave of enthusiasm for computer navigation in total knee arthroplasty has crested, we are now at a point where more definitive scientific data are emerging regarding the benefits and drawbacks to this particular technology. Two of the implicit promises of computer navigation have been that it may make the occasional knee surgeon more like the expert surgeon, and that a navigation system can be the eye that facilitates accurate minimally invasive surgery. In this symposium there are scientific data that cast some doubt on promise number two, and all of us in the scientific community continue to look for evidence that navigation is reproducibly accurate when used by the occasional knee surgeon. The added costs of this technology is an issue yet to be addressed. Revision TKA is an area of ascending importance as the demographics of our population point to a growing need in this area. In this Symposium there are useful data on the outcomes differences between primary and revision TKA, comparative data on in-hospital complications between primary and revision TKA, isolated patellar revision, patellar bone loss problems and the use of stems in conjunction with constrained condylar knee designs. The Knee Society remains committed to advancing scientific knowledge and educating clinicians worldwide regarding surgery of the knee. We hope that our readers find this Symposium to be intellectually rigorous and clinically useful.

Infantile haemangioma (IH) is the most frequent childhood tumour. Although it is benign and self-limiting, severe complications can arise due to localisation and fast tumour growth. Management and therapy of IH has changed greatly after 2008 with propranolol. However, the pathogenesis remains elusive. This update provides an overview of all possible mechanisms currently considered. We discuss the possibility that several mechanisms act together, although local hypoxia seems to be important. Clinically, in about half of the cases, an IH is preceded by an anaemic macula (local ischaemia) or a so-called precursor lesion. Laboratory findings indicate stabilisation and an increased transcription activity of hypoxia-inducible factor 1 alpha (HIF1α), leading to up-regulation of its downstream target genes (such as vascular endothelial growth factor (VEGF)), which normally occurs in cases of hypoxia. Conclusion: Three main hypotheses have been proposed, namely (1) the theory of tissue hypoxia, (2) the theory of embolization of placental endothelial cells and (3) the theory of increased angiogenic and vasculogenic activity.

The purpose and focus of the Musculoskeletal Tumor Society is stated on the organization’s website. “The mission of the Musculoskeletal Tumor Society is to advance the science of orthopaedic oncology and to promote high standards of patient care. It does this through excellence in education and research” [1]. The 2008 MSTS meeting in Phoenix, AZ, November 6–8, 2008, and hence this symposium, follows part of the prescription, providing an excellent forum for education. The second portion of the mission statement encourages advancing orthopaedic oncology through research. The organization has enjoyed limited success in conducting or promoting research despite valiant efforts by the leaders of the Research Committee. Why? Answers come from the membership, the discipline, and the organization. The membership of the MSTS has changed dramatically over the years. The original “Piranha Club” had 18 domestic orthopaedic surgeons, of whom only one remains actively practicing surgical oncology. The roster has ballooned to over 220 members, including Candidate, Affiliate, and Emeritus Members. While this reflects successful maturation of orthopaedic oncology, it has a dilutive effect on research and possibly even clinical progress. Case volume is correlated with outcome in all other cancer systems studied to date, for disease of organs ranging from prostate to pancreas. Why shouldn’t it also be true for bone and soft tissue sarcomas? As knowledge and training disseminate, experience per surgeon inevitably declines. Smaller case loads prevent concentrated expertise. Paradoxically, the numerical expansion of our membership may have improved our ability to deliver more convenient, good quality care to more people, but it may prevent us from making substantive advances in the field. Single centers usually lack the volume to ask or answer important questions. Collaboration is essential to maintain patient numbers required to study rare diseases. Standardization of treatment protocols is essential if the cases from different centers may be combined. This requires strong-willed commitment on the part of musculoskeletal oncologists to suppress some of their individuality and cooperate. This is necessary to advance the discipline and improve patient care. Large cooperative groups (eg, Children’s Oncology Group or COG, the Southwest Oncology Group or SWOG) have failed due to their cumbersome structure and an inability to channel resources to orthopaedic problems. The greatest success has been in ad hoc collaborations such as that coordinated by the MSTS to review the outcome of patients treated by limb salvage or amputation for distal femoral osteosarcoma [2], or the Toronto Group’s prospective evaluation of prognostic genetic markers (p53 and RB) in osteosarcoma patients from six centers [3]. This symposium includes a variety of novel and informative clinical papers dealing with resection and reconstruction techniques. However, most are single center studies that should be viewed as hypothesis generating ideas. They require confirmation in larger trials involving other centers to show the results can be generalized. The levels of evidence are typically IV. There is also a deficiency in basic and translational research needed to advance the field. Clearly, more effort needs to be expended to improve the quality and generalizability of our research. Investigators and reviewers need to support cluster- and association-based comparative research efforts, clinical trials, and basic investigations. There are national initiatives in this direction. Responding to the challenge proposed by the American Academy of Orthopaedic Surgeons, the Musculoskeletal Tumor Society is trying to develop evidence-based assessments of practice. This symposium includes the Society’s first effort along those lines, summarizing the best available opinion regarding the biopsy of musculoskeletal tumors. More recently, the AAOS/ORS/NIH sponsored a workshop in Albuquerque to define the research agenda for prospective outcome studies in each orthopaedic subspecialty. Two tumor projects made the final cut of recommendations. The first was a prospective study of proximal femoral metastases, comparing internal fixation (rodding) with joint arthroplasty. The second was a long-term followup of reconstructions performed for patients randomized to receive, or not receive, muramyl tripeptide phosphoethanolamine (MTP-PE) in the national Intergroup-133 study. These projects should receive the support of the oncology community, and would be good topics on which the MSTS could focus and include in future CORR Symposia.

The paper has presented a practical application result of large scale linear programming to real-time optimal production scheduling in actual pulp and paper mill. Real-time application brings in several restrictions and requirements. The system based on a 32-bit minicomputer has been in operation since March 1986, providing optimal production schedules every 8 hours. The reduction in production cost is estimated to be more than 1% on the average. We believe that this is one of a few practical and successful real-time application cases of large scale linear programming realized on a mini-computer which also runs several hundreds real-time tasks.

The pulp and paper manufacturing industry generates large quantities of wastewater and has been described as a significant pollutant of the aquatic environment for many decades. The majority of pulp mills are located in the U.S. and Canada, and these countries are therefore subject to the greatest environmental impact. Some form of toxicity following exposure to mill effluent has been documented in numerous species, both aquatic and terrestrial, and the compounds present in effluents can affect multiple physiological processes, including hepatic mechanisms, reproduction and development, and endocrine function. Although the effects of PME on wildlife have been known for some time, the detection of chlorinated organic compounds generated substantial concern to humans because of the potential risk of exposure to these highly toxic compounds through environmental persistence and bioaccumulation. Government regulations were imposed on the pulping industry in an effort to prevent further contamination and reduce the toxic potential of pulp mill effluent to both humans and wildlife.

AAPS-FDA workshop white paper : Microdialysis principles, application, and regulatory perspectives report from the joint AAPS-FDA workshop, November 4-5, 2005, Nashville, TN

Five years ago our department migrated from a film-based imaging environment to a PACS-based environment. We discovered that our reliance on paper tracking forms for clinical history and dictation information was hindering our practice. Integrating dictation with PACS was one of three key components we needed to free ourselves from the tyranny of paper, the other two being an online worklist and an online patient history. We discuss our evolution to a (mostly) paperless reading room environment, our implementation, general performance, and future development plans, focusing on integrated dictation.