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Background Projection radiography and, more recently, computed tomography (CT) play an important role in forensic age estimation. Both in terms of general criminal responsibility and government regulations concerning refugee care, it is important to differentiate correctly between youths and adults. A disadvantage of age estimation in CT is the ionizing radiation exposure. Purpose To investigate how far the CT dose can be reduced without losing diagnostic confidence in assessing the different stages of ossification of the medial clavicle. Material and Methods We prospectively scanned 25 postmortem cases with a fixed parameters protocol (FPP) and a care dose modulation protocol (CDMP) for different scan parameters. Two radiologists assessed the diagnostic image quality using a 5-point Likert scale. Inter-reader agreement was evaluated with Cohen's kappa. Differences in doses between FPP and CDMP were assessed with the one-tailed t-test. Results The best combination of diagnostic image quality and lowest radiation dose was obtained using a CDMP with 100 kV and 40 mAs and an FPP with 100 kV and 30 mAs. Doses for 120 kV were significantly higher (one-tailed P Discussion Our results confirm that CT imaging at 100 kV allows a sufficient image quality that is diagnostic for age estimation in the ossification of the medial clavicle.

Multiple treatments for metastatic, hormone-sensitive prostate cancer (mHSPC) are available, but their effects on health-related quality of life (HRQoL) and benefit-harm balance remain unclear.To assess clinical effectiveness regarding survival and HRQoL, safety, and benefit-harm balance of mHSPC treatments.We searched MEDLINE, EMBASE, CENTRAL, and ClinicalTrials.gov until March 1, 2022. Randomized controlled trials (RCTs) comparing docetaxel, abiraterone, enzalutamide, apalutamide, darolutamide, and radiotherapy combined with androgen deprivation therapy (ADT) mutually or with ADT alone were eligible. Three reviewers independently performed screening, data extraction, and risk of bias assessment in duplicate.Across ten RCTs, we found relevant survival benefits for ADT + docetaxel (high certainty according to the Grading of Recommendations, Assessment, Development and Evaluation [GRADE]), ADT + abiraterone (moderate certainty), ADT + enzalutamide (low certainty), ADT + apalutamide (high certainty), and ADT + docetaxel + darolutamide (high certainty) compared with ADT alone. ADT + radiotherapy appeared effective only in low-volume de novo mHSPC. We found a short-term HRQoL decrease lasting 3-6 mo for ADT + docetaxel (moderate certainty) and a potential HRQoL benefit for ADT + abiraterone up to 24 mo of follow-up (moderate certainty) compared with ADT alone. There was no difference in HRQoL for ADT + enzalutamide, ADT + apalutamide, or ADT + radiotherapy over ADT alone (low-high certainty). Grade 3-5 adverse effect rates were increased with all systemic combination treatments. A benefit-harm assessment showed high probabilities (60%) for a net clinical benefit with ADT + abiraterone, ADT + enzalutamide, and ADT + apalutamide, while ADT + docetaxel and ADT + docetaxel + darolutamide appeared unlikely (40%) to be beneficial.Despite substantial survival benefits, no systemic combination treatment showed a clear HRQoL improvement compared with ADT alone. We found evidence for a short-term HRQoL decline with ADT + docetaxel and a higher net clinical benefit with ADT + abiraterone, ADT + apalutamide and ADT + enzalutamide. While individualized decision-making remains important and economic factors need to be considered, the evidence may support a general preference for the combination of ADT with androgen receptor axis-targeted therapies over docetaxel-containing strategies.We assessed different combination treatments for metastatic hormone-sensitive prostate cancer. While survival was better with all systemic combination treatments, there was no clear improvement in health-related quality of life compared with androgen deprivation therapy alone. Novel hormonal combination treatments had a more favorable benefit-harm balance than combination treatments that include chemotherapy.

Radiotherapy (RT) professionals are not officially recognised or have formal education in many countries, with RT being often a very short component of a broader programme. This study aims to investigate Belgian stakeholders’ perpectives regarding existing barriers and solutions for the education and professional development of Radiation therapists (RTT) which regroups medical imaging technol- ogists (MIT) and nurses working in RT. Methods: Nine experts with vast experience in RT were invited to be interviewed; eight participated (4 heads of the RT departments, 2 school representatives, 2 national society's representatives). A semi- structured questionnaire was used. The first two authors open-coded all interviews using thematic analysis. Results: Five themes and eleven sub-themes were drawn from the analysis. Belgian MIT and nurses in RT perform the same roles, but have different educational backgrounds. The barriers in education and professional development are related to law, education landscape, economics, social-cultural context, politics and professional identity. The main difference between the French and Dutch-speaking parts of the country were at the education level. The proposed solutions included modifying the legislative framework surrounding the RTT profession, setting up financial support, formalizing the educational requirements and increasing professional awareness. Future strategies might include the development of advanced roles and responsibilities. Conclusions: Current law, educational landscape and lack of economic support were the main barriers identified. Except for the educational background, no fundamental differences were found between nurses and MIT in the French and Dutch-speaking parts. Perspectives for both professional groups are linked to future legislative and financial actions, the stakeholders involved and a clear strategic vision. In the upcoming years, increased responsibilities and the creation of a master's degree should be foreseen. Implications for practice: Regulation of RTT profession and education and an increase in RT-specific training must be implemented in Belgium to ensure professional development and optimized treat- ment delivery

Background and purpose: The geometrical accuracy of auto-segmentation using convolutional neural networks (CNNs) has been demonstrated. This study aimed to investigate the dose-volume impact of differences between automatic and manual OARs for locally advanced (LA) and peripherally located early-stage (ES) non-small cell lung cancer (NSCLC).Material and methods: A single CNN was created for automatic delineation of the heart, lungs, main left and right bronchus, esophagus, spinal cord and trachea using 55/10/40 patients for training/validation/testing. Dice score coefficient (DSC) and 95th percentile Hausdorff distance (HD95) were used for geometrical analysis. A new treatment plan based on the auto-segmented OARs was created for each test patient using 3D for ES-NSCLC (SBRT, 3-8 fractions) and IMRT for LA-NSCLC (24-35 fractions). The correlation between geometrical metrics and dose-volume differences was investigated.Results: The average (+/- 1 SD) DSC and HD95 were 0.82 +/- 0.07 and 16.2 +/- 22.4 mm, while the average dosevolume differences were 0.5 +/- 1.5 Gy (ES) and 1.5 +/- 2.8 Gy (LA). The geometrical metrics did not correlate with the observed dose-volume differences (average Pearson for DSC: -0.27 +/- 0.18 (ES) and -0.09 +/- 0.12 (LA); HD95: 0.1 +/- 0.3 mm (ES) and 0.2 +/- 0.2 mm (LA)).Conclusions: After post-processing, manual adjustments of automatic contours are only needed for clinically relevant OARs situated close to the tumor or within an entry or exit beam e.g., the heart and the esophagus for LA-NSCLC and the bronchi for ES-NSCLC. The lungs do not need to be checked further in detail.

Absent or reversed end diastolic flow (AREDF) in umbilical artery (UA) Doppler are known phenomena during fetal interventions such as fetal spina bifida (fSB) repair. The clinical importance of these Doppler findings and the impact on children's outcome is not yet clarified.Between 2010 and 2019, 132 patients underwent SB repair at our center. The group with AREDF-UA was compared to the group with normal UA Doppler during the intervention. Primary endpoint was the FIGO-Score of the cardiotocography (CTG) 1, 2, and 6 hours postoperatively and their correlation to the ARED-UA flow. Secondary endpoints were the neonatal parameters and two-year neurodevelopmental outcome assessed using the Bayley Scale of Infant and Toddler Development Third Edition (Bayley-III).None of the fetuses showed AREDF before SB repair. In 107 patients (82%) normal UA-Doppler and in 23 (18%) AREDF-UA was observed during or immediately after SB surgery. AREDF-UA was more often observed after version of the fetus (p = 0.045). 17 (13 %) cases showed AEDF-UA and 6 (5%) cases REDF-UA. On the first day after SB surgery the AREDF-UA disappeared in all 23 cases. No significant difference in the CTGs at 1, 2, and 6 hours postoperatively and on the first postoperative day between the two groups was found (p 0.05). GA at delivery, UA-pH, 5-minute Apgar and birth weight were comparable between both groups and there was no difference regarding the two-year neurodevelopmental outcome (p0.05). Also the neurodevelopmental outcome did not differ between children with an absent or a reversed EDF-UA.The postoperative CTGs after a short-term phase of AREDF-UA during fSB repair normalize similarly as in normal UA-Doppler cases. AREDF-UA during fSB repair did not negatively influence postnatal or 2-year neurodevelopmental outcome compared with a normal UA-flow. This article is protected by copyright. All rights reserved.

Microscopy has been essential to elucidate micro- and nano-scale processes in space and time and has provided insights into cell and organismic functions. It is widely employed in cell biology, microbiology, physiology, clinical sciences and virology. While label-dependent microscopy, such as fluorescence microscopy, provides molecular specificity, it has remained difficult to multiplex in live samples. In contrast, label-free microscopy reports on overall features of the specimen at minimal perturbation. Here, we discuss modalities of label-free imaging at the molecular, cellular and tissue levels, including transmitted light microscopy, quantitative phase imaging, cryogenic electron microscopy or tomography and atomic force microscopy. We highlight how label-free microscopy is used to probe the structural organization and mechanical properties of viruses, including virus particles and infected cells across a wide range of spatial scales. We discuss the working principles of imaging procedures and analyses and showcase how they open new avenues in virology. Finally, we discuss orthogonal approaches that enhance and complement label-free microscopy techniques. Graphical Abstract The refractive index of Huh-7 cell infected with CoV-229E-GFP at 31 h after infection, shown in false color. The full movie and technical details are available as Supplementary Movie 1. The color bar ranges from refractive index values of 1.339 to 1.363, scale bar 10 µm.

Orbital metastases secondary to neuroendocrine tumors are exceedingly rare. We present a unique case of a 30-year-old female initially presenting with fever, chills, periorbital swelling, and painful proptosis. CT orbits revealed two ovoid-shaped ring-enhancing lesions in the right lateral and superior rectus muscles and clear sinuses, atypical for infectious post-septal cellulitis. Further work-up included serologic analysis, auto-immune panel, and MRI. Further imaging showed pseudocystic orbital lesions mimicking orbital cysticercosis. Additionally, given the bilateral nature of the lesions and patient’s country of origin, this parasitic process was highly suspected. A course of albendazole and steroids led to resolution of symptoms. With a presentation at age 30, this is by far the youngest case reported in literature to date.

Objectives To compare the value of zero echo time (ZTE) and gradient echo “black bone” (BB) MRI sequences for bone assessment of the sacroiliac joint (SI) using computed tomography (CT) as the reference standard. Materials and methods Between May 2019 and January 2021, 79 patients prospectively underwent clinically indicated 3-T MRI including ZTE and BB imaging. Additionally, all patients underwent a CT scan covering the SI joints within 12 months of the MRI examination. Two blinded readers performed bone assessment by grading each side of each SI joint qualitatively in terms of seven features (osteophytes, subchondral sclerosis, erosions, ankylosis, joint irregularity, joint widening, and gas in the SI joint) using a 4-point Likert scale (0 = no changes–3 = marked changes). Scores were compared between all three imaging modalities. Results Interreader agreement was largely good (k values: 0.5–0.83). Except for the feature “gas in SI joint” where ZTE exhibited significantly lower scores than CT (p p > 0.52) with inter-modality agreement being substantial to almost perfect (Krippendorff’s alpha coefficients: 0.724–0.983). When combining the data from all features except for gas in the SI joint and when binarizing grading scores, combined sensitivity/specificity was 76.7%/98.6% for ZTE and 80.8%/99.1% for BB, respectively, compared to CT. Conclusions The performance of ZTE and BB sequences was comparable to CT for bone assessment of the SI joint. These sequences may potentially serve as an alternative to CT yet without involving exposure to ionizing radiation.

Purpose: Biopsy-based assessment of H3 K27 M status helps in predicting survival, but biopsy is usually limited to unusual presentations and clinical trials. We aimed to evaluate whether radiomics can serve as prognostic marker to stratify diffuse intrinsic pontine glioma (DIPG) subsets. Methods: In this retrospective study, diagnostic brain MRIs of children with DIPG were analyzed. Radiomic features were extracted from tumor segmentations and data were split into training/testing sets (80:20). A conditional survival forest model was applied to predict progression-free survival (PFS) using training data. The trained model was validated on the test data, and concordances were calculated for PFS. Experiments were repeated 100 times using randomized versions of the respective percentage of the training/test data. Results: A total of 89 patients were identified (48 females, 53.9%). Median age at time of diagnosis was 6.64 years (range: 1–16.9 years) and median PFS was 8 months (range: 1–84 months). Molecular data were available for 26 patients (29.2%) (1 wild type, 3 K27M-H3.1, 22 K27M-H3.3). Radiomic features of FLAIR and nonenhanced T1-weighted sequences were predictive of PFS. The best FLAIR radiomics model yielded a concordance of .87 [95% CI: .86–.88] at 4 months PFS. The best T1-weighted radiomics model yielded a concordance of .82 [95% CI: .8–.84] at 4 months PFS. The best combined FLAIR + T1-weighted radiomics model yielded a concordance of .74 [95% CI: .71–.77] at 3 months PFS. The predominant predictive radiomic feature matrix was gray-level size-zone. Conclusion: MRI-based radiomics may predict progression-free survival in pediatric diffuse midline glioma/diffuse intrinsic pontine glioma.

Ataxia is one of the most common pediatric movement disorders and can be caused by a large number of congenital and acquired diseases affecting the cerebellum or the vestibular or sensory system. It is mainly characterized by gait abnormalities, dysmetria, intention tremor, dysdiadochokinesia, dysarthria, and nystagmus. In young children, ataxia may manifest as the inability or refusal to walk. The diagnostic approach begins with a careful clinical history including the temporal evolution of ataxia and the inquiry of additional symptoms, is followed by a meticulous physical examination, and, depending on the results, is complemented by laboratory assays, electroencephalography, nerve conduction velocity, lumbar puncture, toxicology screening, genetic testing, and neuroimaging. Neuroimaging plays a pivotal role in either providing the final diagnosis, narrowing the differential diagnosis, or planning targeted further workup. In this review, we will focus on the most common form of ataxia in childhood, cerebellar ataxia (CA). We will discuss and summarize the neuroimaging findings of either the most common or the most important causes of CA in childhood or present causes of pediatric CA with pathognomonic findings on MRI. The various pediatric CAs will be categorized and presented according to (a) the cause of ataxia (acquired/disruptive vs. inherited/genetic) and (b) the temporal evolution of symptoms (acute/subacute, chronic, progressive, nonprogressive, and recurrent). In addition, several illustrative cases with their key imaging findings will be presented.

To assess the ability of four-dimensional (4D) flow MRI to measure hepatic arterial hemodynamics by determining the effects of spatial resolution and respiratory motion suppression in vitro and its applicability in vivo with comparison to two-dimensional (2D) phase-contrast MRI.A dynamic hepatic artery phantom and 20 consecutive volunteers were scanned. The accuracies of Cartesian 4D flow sequences with k-space reordering and navigator gating at four spatial resolutions (0.5- to 1-mm isotropic) and navigator acceptance windows (± 8 to ± 2 mm) and one 2D phase-contrast sequence (0.5-mm in -plane) were assessed in vitro at 3 T. Two sequences centered on gastroduodenal and hepatic artery branches were assessed in vivo for intra - and interobserver agreement and compared to 2D phase-contrast.In vitro, higher spatial resolution led to a greater decrease in error than narrower navigator window (30.5 to -4.67% vs -6.64 to -4.67% for flow). In vivo, hepatic and gastroduodenal arteries were more often visualized with the higher resolution sequence (90 vs 71%). Despite similar interobserver agreement (κ = 0.660 and 0.704), the higher resolution sequence had lower variability for area (CV = 20.04 vs 30.67%), flow (CV = 34.92 vs 51.99%), and average velocity (CV = 26.47 vs 44.76%). 4D flow had lower differences between inflow and outflow at the hepatic artery bifurcation (11.03 ± 5.05% and 15.69 ± 6.14%) than 2D phase-contrast (28.77 ± 21.01%).High-resolution 4D flow can assess hepatic artery anatomy and hemodynamics with improved accuracy, greater vessel visibility, better interobserver reliability, and internal consistency.• Motion-suppressed Cartesian four-dimensional (4D) flow MRI with higher spatial resolution provides more accurate measurements even when accepted respiratory motion exceeds voxel size. • 4D flow MRI with higher spatial resolution provides substantial interobserver agreement for visualization of hepatic artery branches. • Lower peak and average velocities and a trend toward better internal consistency were observed with 4D flow MRI as compared to 2D phase-contrast.

Repetitive transcranial magnetic stimulation (rTMS) is a tool that can be used to administer treatment for neuropsychiatric disorders such as major depressive disorder, although the clinical efficacy is still rather modest. Overly general stimulation protocols that consider neither patient-specific depression symptomology nor individualized brain characteristics, such as anatomy or structural and functional connections, may be the cause of the high inter- and intraindividual variability in rTMS clinical responses. Multimodal neuroimaging can provide the necessary insights into individual brain characteristics and can therefore be used to personalize rTMS parameters. Optimal coil positioning should include a three-step process: 1) identify the optimal (indirect) target area based on the exact symptom pattern of the patient; 2) derive the cortical (direct) target location based on functional and/or structural connectomes derived from functional and diffusion magnetic resonance imaging data; and 3) determine the ideal coil position by computational modeling, such that the electric field distribution overlaps with the cortical target. These TMS-induced electric field simulations, derived from anatomical and diffusion magnetic resonance imaging data, can be further applied to compute optimal stimulation intensities. In addition to magnetic resonance imaging, electroencephalography can provide complementary information regarding the ongoing brain oscillations. This information can be used to determine the optimal timing and frequency of the stimuli. The heightened benefits of these personalized stimulation approaches are logically reasoned, but speculative. Randomized clinical trials will be required to compare clinical responses from standard rTMS protocols to personalized protocols. Ultimately, an optimized clinical response may result from precision protocols derived from combinations of personalized stimulation parameters.

There has been growing evidence of the benefits of high-intensity aerobic interval training (HIIT) and resistance training (RES) for populations with cancer. However, these two modalities have not yet been performed alone in rectal cancer patients undergoing neoadjuvant chemoradiotherapy (NACR T). Therefore, this study aimed to determine the feasibility of HIIT and RES in rectal cancer patients undergoing NACR T.Rectal cancer patients set to undergo NACRT were randomly assigned to HIIT intervention, RES intervention, or the usual care. Feasibility of HIIT and RES was assessed by measuring recruitment rate, adherence (retention rate, attendance rate, and exercise sessions duration and intensity), and adverse events. Endpoints (changes in fatigue, health-related quality of life, depression, daytime sleepiness, insomnia, sleep quality, functional exercise capacity, and executive function) were assessed at baseline and at week 5.Among the 20 eligible patients, 18 subjects were enrolled and completed the study, yielding a 90% recruitment rate and 100% retention rate. Attendance at exercise sessions was excellent, with 92% in HIIT and 88% in RES. No exercise-related adverse events occurred.This study demonstrated that HIIT and RES are feasible in rectal cancer patients undergoing NACR T.www.clinicaltrials.gov, NCT03252821 (date of registration: March 30, 2017).

Purpose Recently, a significant association was shown between novel growth patterns on histopathology of prostate cancer (PCa) and prostate-specific membrane antigen (PSMA) uptake on [68Ga]PSMA-PET. It is the aim of this study to evaluate the association between these growth patterns and ADC (mm2/1000 s) values in comparison to [68Ga]PSMA uptake on PET/MRI. Methods We retrospectively evaluated patients who underwent [68Ga]PSMA PET/MRI for staging or biopsy guidance, followed by radical prostatectomy at our institution between 07/2016 and 01/2020. The dominant lesion per patient was selected based on histopathology and correlated to PET/MRI in a multidisciplinary meeting, and quantified using SUVmax for PSMA uptake and ADCmean for diffusion restriction. PCa growth pattern was classified as expansive (EXP) or infiltrative (INF) according to its properties of forming a tumoral mass or infiltrating diffusely between benign glands by two independent pathologists. Furthermore, the corresponding WHO2016 ISUP tumor grade was evaluated. The t test was used to compare means, Pearson’s test for categorical correlation, Cohen’s kappa test for interrater agreement, and ROC curve to determine the best cutoff. Results Sixty-two patients were included (mean PSA 11.7 ± 12.5). The interrater agreement between both pathologists was almost perfect with κ = 0.81. While 25 lesions had an EXP-growth with an ADCmean of 0.777 ± 0.109, 37 showed an INF-growth with a significantly higher ADCmean of 1.079 ± 0.262 (p max for the EXP-growth (19.2 ± 10.9) versus the INF-growth (9.4 ± 6.2, p mean could be observed (p = 0.982 and p = 0.861, respectively). Conclusion PCa with INF-growth showed significantly lower SUVmax and higher ADCmean values compared to PCa with EXP-growth. Within the growth groups, ADCmean values were independent from ISUP grading.

Purpose 2-[18F]FDG PET/CT is of utmost importance for radiation treatment (RT) planning and response monitoring in lung cancer patients, in both non-small and small cell lung cancer (NSCLC and SCLC). This topic has been addressed in guidelines composed by experts within the field of radiation oncology. However, up to present, there is no procedural guideline on this subject, with involvement of the nuclear medicine societies. Methods A literature review was performed, followed by a discussion between a multidisciplinary team of experts in the different fields involved in the RT planning of lung cancer, in order to guide clinical management. The project was led by experts of the two nuclear medicine societies (EANM and SNMMI) and radiation oncology (ESTRO). Results and conclusion This guideline results from a joint and dynamic collaboration between the relevant disciplines for this topic. It provides a worldwide, state of the art, and multidisciplinary guide to 2-[18F]FDG PET/CT RT planning in NSCLC and SCLC. These practical recommendations describe applicable updates for existing clinical practices, highlight potential flaws, and provide solutions to overcome these as well. Finally, the recent developments considered for future application are also reviewed.

This observational cohort study investigates neurocognitive functioning (NCF) and its associations with overall survival (OS), disease-free survival (DFS) and patient-reported psychological toxicities in locally-advanced and metastatic non-small cell lung (NSCLC) cancer patients receiving loco-regional radiotherapy and/or systemic therapy. Objective NCF data was collected with six psychometrically validated neurocognitive tests. Subjective NCF was assessed with the cognitive domain of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 items. Psychological toxicity data was collected with the patient-reported outcomes version of the common terminology criteria for adverse events. Meaningful clinical important differences were determined for changes in NCF. Univariate Cox proportional hazards models and generalized linear models were used to determine statistical significance (p 0.01). In total, 50 patients were recruited. At baseline, 13 (26%) patients had an impaired objective NCF. Over time, deterioration was seen in 11% (n = 3), 5% (n = 1) and 6% (n = 1) of patients at 2-3, 6 and 12 months post-treatment. The OS of patients with a normal NCF at baseline was longer than those with an impaired baseline NCF (29.5 vs 17.1 months). No statistical significance has been reached between NCF and OS (p = .353) nor NCF and DFS (p = .251). Objective NCF was not correlated with subjective NCF (p = .193), nor anxiety (p = .504), depression (p = .513), memory problems (p = .813) and concentration problems (p = .813). Systemic treatment and loco-regional radiotherapy may have a temporarily negative impact on NCF in a small proportion of locally-advanced and metastatic NSCLC. Baseline NCF could be a predictor for OS.

Objective: Competency-based surgical education requires detailed and actionable feedback to ensure adequate and efficient skill development. Comprehensive operative capture systems such as the Operating Room Black Box (ORBB; Surgical Safety Technologies, Inc), which continuously records and synchronizes multiple sources of intraoperative data, have recently been integrated into hybrid rooms to provide targeted feedback to endovascular teams. The objective of this study is to develop step, error, and event frameworks to evaluate technical performance in elective endovascular aortic repair (EVAR) comprehensively captured by the ORBB (Surgical Safety Technologies, Inc; Toronto, Canada). Methods: This study is based upon a modified Delphi consensus process to create evaluation frameworks for steps, errors, and events in EVAR. International experts from Vascular Surgery and Interventional Radiology were identified, based on their records of publications and invited presentations, or serving on relevant journal editorial boards. In an initial open-ended survey round, experts were asked to volunteer a comprehensive list of steps, errors, and events for a standard EVAR of an infrarenal aorto-iliac aneurysm (AAA). In subsequent survey rounds, the identified items were presented to the expert panel to rate on a 5-point Likert scale. Delphi survey rounds were repeated until the process reached consensus with a predefined agreement threshold (Cronbach α>0.7). The final frameworks were constructed with items achieving an agreement (responses of 4 or 5) from greater than 70% of experts. Results: Of 98 invited proceduralists, 38 formed the expert consensus panel (39%), consisting of 29 vascular surgeons and 9 interventional radiologists, with 34% from North America and 66% from Europe. Consensus criteria were met following the third round of the Delphi consensus process (Cronbach α=0.82–0.93). There were 15, 32, and 25 items in the error, step, and event frameworks, respectively (within-item agreement=74%–100%). Conclusion: A detailed evaluation tool for the procedural steps, errors, and events in infrarenal EVAR was developed. This tool will be validated on recorded procedures in future work: It may focus skill development on common errors and hazardous steps. This tool might be used to provide high-quality feedback on technical performance of trainees and experienced surgeons alike, thus promoting surgical mastery.

Introduction: In select cases, in utero surgery for myelomeningocele (MMC) leads to better outcomes than postnatal repair. However, maternal HIV infection constitutes a formal exclusion criterion due to the potential of vertical HIV transmission. Encouraged by a previous case of a successful fetal spina bifida repair in a Hepatitis Bs antigen-positive woman, a plan was devised allowing for fetal surgery. Case Report: In utero MMC repair was performed although the mother was HIV-infected. To minimize the risk of in utero HIV transmission, the mother was treated by highly active antiretroviral therapy throughout gestation as well as intravenous zi­dovudine administration during maternal-fetal surgery. The mother tolerated all procedures very well without any sequelae. The currently 20 month-old toddler is HIV negative and has significantly benefitted from fetal surgery. Discussion/Conclusion: This case shows that maternal HIV is not a priori a diagnosis that excludes fetal surgery. Rather, it might be a surrogate for moving towards personalized medicine and away from applying too rigorous exclusion criteria in the selection of candidates for maternal-fetal surgery.

Increased pulse wave reflection in the fetal arterial system, illustrated by a second systolic peak (M-sign) in middle cerebral artery (MCA) Doppler waveforms, allows interpretation of fetal systemic vasoconstriction. Little is known about fetal vascular regulation during fetal spina bifida (fSB) repair. Therefore, the aim of this study was to analyze MCA-Doppler waveform changes before, during, and after fSB repair.31 pregnant women who underwent fSB repair were included. Fetal MCA-Doppler waveforms were prospectively analyzed before, during and after fSB repair, and categorized as follows: normal systolic downslope, systolic shoulder, second systolic peak (M-sign), and concave systolic downslope. These MCA waveforms were related to maternal and fetal characteristics, to anesthetic medication, and to umbilical artery (UA) waveforms.Before fSB repair, all fetuses repeatedly presented M-signs. After initiation of desflurane for general anesthesia, systolic shoulder and the M-sign vanished in 24/31 (78%) fetuses and 19/31 (61%) showed transient UA ARED flow. A significant association between these two Doppler findings was found (p=0.007). After fSB repair, signs of increased pulse wave reflection reappeared but resolved over time (23 days ± 20, SD) in all fetuses.Both fSB and intrauterine repair influence fetal vascular regulation. This phenomenon can be illustrated by MCA-Doppler waveforms. While anesthetic agents transiently eliminated M-signs and often provoked a UA ARED flow, fSB repair finally led to normalization of MCA-Doppler waveforms indicating return to normal fetal vascular regulation.Eine erhöhte Pulswellenreflektion im fetalen Kreislauf, im Sinne erhöhter Vasoaktivität, spiegelt sich in einem zweiten systolischen Ausschlag (M-Zeichen) der A. cerebri media (ACM) wider. Bisher ist kaum etwas über die fetale Kreislaufregulation während der fötalen Spina Bifida (fSB) Operation bekannt. Daher war das Ziel dieser Studie, die Änderungen im ACM-Dopplerwellenmuster vor, während und nach fSB-Operationen zu analysieren.31 konsekutiv für fSB operierte Feten wurden eingeschlossen. ACM-Doppler wurden prospektiv vor, während und nach der fSB-Operation analysiert und wie folgt kategorisiert: normal, systolische Schulter, M-Zeichen, konkaves Muster. Die Wellenmuster wurden mit maternalen und fetalen Charakteristika sowie mit Narkosemitteln und dem A. umbilicalis-(UA)-Muster korreliert.Alle Feten zeigten M-Zeichen vor der fSB-Operation. Nach Beginn der Vollnarkose mit Desfluran verschwanden die Zeichen der Vasokonstriktion in 24/31 (78%) – und 19/31 (61%) der Feten zeigten einen Block oder Rückfluss in der UA. Der Zusammenhang zwischen beiden Dopplerbefunden war signifikant (p=0,007). Zeichen erhöhter Pulswellenreflektion sind nach der fSB-Operation initial wieder erschienen, über die Zeit (23 Tage ± 20, SD) jedoch bei allen Feten verschwunden.Die fSB-Läsion und eine fetale Operation beeinflussen den fetalen Kreislauf. Dieses Phänomen lässt sich gut mittels ACM-Doppler illustrieren. Während die Narkosemittel das M-Zeichen passager verschwinden lassen und oft ein pathologisches UA-Muster provozieren, resultiert die fSB-Operation letztlich in einer Normalisierung des ACM-Dopplermusters bzw. des fetalen Kreislaufes.

Introduction: Endovascular aortic repair (EVAR) is widely used as an alternative to open repair in elective and even in emergent cases of ruptured abdominal aortic aneurysm (rAAA). One of the most frequent complications after EVAR is type II endoleak (T2EL). In elective therapy, evidence-based therapeutic recommendations for T2EL are limited. Completely unclear is the role of T2EL after EVAR for rAAA (rEVAR). This study aims to investigate the significance of T2ELs after rEVAR. Patients and methods: This is a retrospective single-center data analysis of all patients who underwent rEVAR between January 2010 and December 2020 with primary T2EL. The outcome criteria were overall and T2EL-related mortality and reintervention rate as well as development of aneurysm diameter over follow-up (FU). Results: During the study period between January 2010 and December 2020, 35 (25%) out of 138 patients with rEVAR presented a primary postoperative T2EL (age 74±11 years, 34 males). At rupture, mean aneurysm diameter was 73±12 mm. Follow-up was 26 (0–172) months. The reintervention-free survival was 69% (95% confidence interval [CI]: 55%–86%) at 30 days, 58% (95% CI: 43%–78%) at 1 year, and 52% (95% CI: 36%–75%) at 3 years. In 40% (n=14), T2ELs resolved spontaneously within a median time of 3.4 (0.03–85.6) months. The overall and T2EL reintervention rates were 43% (n=15) and 9% (n=3), respectively. Within 30 days, 11 patients (31%) required reintervention, of which 2 were T2EL related. Aneurysm sac growth by ≥5 mm was seen in 3 patients (9%), and aneurysm shrinkage rate was significantly higher in sealed T2EL group (86% vs 5%, pConclusion: T2ELs after rEVAR showed a benign course in most cases. In the short term, the possibility of persistent bleeding should be considered. In the mid term, a consequent FU protocol is required to detect known late complications after EVAR at an early stage and to prevent secondary rupture and death.

6-(fluoro-18F)-3-(1H-pyrrolo[2,3-c]pyridin-1-yl)isoquinolin-5-amine ([18F]MK6240) has high affinity and selectivity for hyperphosphorylated tau and readily crosses the blood-brain barrier. This study investigated whether the early phase of [18F]MK6240 can be used to provide a surrogate index of cerebral perfusion. Methods: Forty-nine subjects who were cognitively normal (CN), had mild cognitive impairment (MCI), or had Alzheimer's disease (AD) underwent paired dynamic [18F]MK6240 and [11C]Pittsburgh compound B (PiB) PET, as well as structural MRI to obtain anatomic information. Arterial blood samples were collected in a subset of 24 subjects for [18F]MK6240 scans to derive metabolite-corrected arterial input functions. Regional time-activity curves were extracted using atlases available in the Montreal Neurologic Institute template space and using FreeSurfer. The early phase of brain time-activity curves was analyzed using a 1-tissue-compartment model to obtain a robust estimate of the rate of transfer from plasma to brain tissue, K 1 (mL⋅cm-3⋅min-1), and the simplified reference tissue model 2 was investigated for noninvasive estimation of the relative delivery rate, R 1 (unitless). A head-to-head comparison with R 1 derived from [11C]PiB scans was performed. Grouped differences in R 1 were evaluated among CN, MCI, and AD subjects. Results: Regional K 1 values suggested a relatively high extraction fraction. R 1 estimated noninvasively from simplified reference tissue model 2 agreed well with R 1 calculated indirectly from the blood-based compartment modeling (r = 0.99; mean difference, 0.024 ± 0.027), suggesting that robust estimates were obtained. R 1 measurements obtained with [18F]MK6240 correlated strongly and overall agreed well with those obtained from [11C]PiB (r = 0.93; mean difference, -0.001 ± 0.068). Statistically significant differences were observed in regional R 1 measurements among CN, MCI, and AD subjects, notably in the temporal and parietal cortices. Conclusion: Our results provide evidence that the early phase of [18F]MK6240 images may be used to derive a useful index of cerebral perfusion. The early and late phases of a [18F]MK6240 dynamic acquisition may thus offer complementary information about the pathophysiologic mechanisms of the disease.

PURPOSE This in vitro study aimed to investigate the changes in mechanical properties in dentin of third molars after radiation therapy using variable doses and frequencies. METHODS AND MATERIALS Rectangular cross sectioned dentin hemisections (N = 60, n = 15 per group; >7 × 4 × 1.2 mm) were prepared using extracted third molars. After cleansing and storage in artificial saliva, random distribution was performed to 2 irradiation settings, namely AB or CD (A, 30 single doses of irradiation [2 Gy each] for 6 weeks; B, control group of A; C, 3 single doses of irradiation [9 Gy each]; and D, control group of C). Various parameters (fracture strength/maximal force, flexural strength, and elasticity modulus) were assessed using a universal Testing Machine (ZwickRoell). The effect of irradiation on dentin morphology was evaluated by histology, scanning electron microscopy, and immunohistochemistry. Statistical analysis was performed using 2-way analysis of variance and paired and unpaired t tests at a significance level of 5%. RESULTS Significance could be found considering the maximal force applied to failure when the irradiated groups were compared with their control groups (A/B, P < .0001; C/D, P = .008). Flexural strength was significantly higher in the irradiated group A compared with control group B (P < .001) and for the irradiated groups A and C (P = .022) compared with each other. Cumulative radiation with low irradiation doses (30 single doses; 2 Gy) and single irradiation with high doses (3 single doses; 9 Gy) make the tooth substance more prone to fracture, lowering the maximal force. The flexural strength decreases when cumulative irradiation is applied, but not after single irradiation. The elasticity modulus showed no alteration after irradiation treatment. CONCLUSIONS Irradiation therapy affects the prospective adhesion of dentin and the bond strength of future restorations, potentially leading to an increased risk of tooth fracture and retention loss in dental reconstructions.

Purpose To introduce a mathematical framework and in-silico validation of turbulent flow spectrum imaging (TFSI) of stenotic flow using phase-contrast MRI, evaluate systematic errors in quantitative turbulence parameter estimation, and propose a novel method for probing the Lagrangian velocity spectra of turbulent flows. Theory and Methods The spectral response of velocity-encoding gradients is derived theoretically and linked to turbulence parameter estimation including the velocity autocorrelation function spectrum. Using a phase-contrast MRI simulation framework, the encoding properties of bipolar gradient waveforms with identical first gradient moments but different duration are investigated on turbulent flow data of defined characteristics as derived from computational fluid dynamics. Based on theoretical insights, an approach using velocity-compensated gradient waveforms is proposed to specifically probe desired ranges of the velocity autocorrelation function spectrum with increased accuracy. Results Practical velocity-encoding gradients exhibit limited encoding power of typical turbulent flow spectra, resulting in up to 50% systematic underestimation of intravoxel SD values. Depending on the turbulence level in fluids, the error due to a single encoding gradient spectral response can vary by 20%. When using tailored velocity-compensated gradients, improved quantification of the Lagrangian velocity spectrum on a voxel-by-voxel basis is achieved and used for quantitative correction of intravoxel SD values estimated with velocity-encoding gradients. Conclusion To address systematic underestimation of turbulence parameters using bipolar velocity-encoding gradients in phase-contrast MRI of stenotic flows with short correlation times, tailored velocity-compensated gradients are proposed to improve quantitative mapping of turbulent blood flow characteristics., Magnetic Resonance in Medicine, 87 (3), ISSN:0740-3194, ISSN:1522-2594

Background The irradiation of breast cancer patients with included internal mammary lymph nodes challenges radiation planning with regard to robustness and protection of OARs. In this publication, a feasible hybrid radiation technique is presented with a retrospective dosimetric and radiobiological analysis of patient data of our institute from 2016 to 2020 and robustness analysis. Methods The proposed hybrid irradiation technique consists of two IMRT tangents and two partial VMAT fields. The retrospective dosimetric and radiobiological evaluation are made for 217 patient treatments (right- and left-sided). The robustness is evaluated regarding an artificial swelling from 0.4 to 1.5 cm for a random example patient and compared to a pure VMAT planning technique with use of a virtual bolus. The out of field stray dose is calculated for a selected patient plan and compared to alternative radiation techniques. Results The coverage D95% of the PTVEval (with breast swelling of 1.5 cm) changes for the hybrid plan from 96.1 to 92.1% of prescribed dose and for the pure VMAT plan from 94.3 to 87%. The retrospective dosimetric evaluation of patient irradiations reveals a Dmean for total lung 6.5 ± 0.9 Gy (NTCP[Semenenko 2008] 2.8 ± 0.5%), ipsilateral lung 10.9 ± 1.5 Gy, contralateral lung 2.2 ± 0.6 Gy, heart 2.1 ± 1.1 Gy (ERR[Schneider 2017] 0.02 ± 0.17%) and contralateral breast 1.7 ± 0.6 Gy. The scatter dose of the hybrid irradiation technique is higher than for pure VMAT and lower than for pure IMRT irradiation. Conclusions The feasibility of the proposed planning technique is shown by treating many patients with this technique at our radiotherapy department. The hybrid radiation technique shows a good sparing of the OARs in the retrospective analysis and is robust with regards to a breast swelling of up to 1.5 cm. The slightly higher stray dose of the hybrid technique compared to a pure VMAT technique originates from higher number of MUs and lower conformity.

Objective.De-centralized data analysis becomes an increasingly preferred option in the healthcare domain, as it alleviates the need for sharing primary patient data across collaborating institutions. This highlights the need for consistent harmonized data curation, pre-processing, and identification of regions of interest based on uniform criteria.Approach.Towards this end, this manuscript describes theFederatedTumorSegmentation (FeTS) tool, in terms of software architecture and functionality.Main results.The primary aim of the FeTS tool is to facilitate this harmonized processing and the generation of gold standard reference labels for tumor sub-compartments on brain magnetic resonance imaging, and further enable federated training of a tumor sub-compartment delineation model across numerous sites distributed across the globe, without the need to share patient data.Significance.Building upon existing open-source tools such as the Insight Toolkit and Qt, the FeTS tool is designed to enable training deep learning models targeting tumor delineation in either centralized or federated settings. The target audience of the FeTS tool is primarily the computational researcher interested in developing federated learning models, and interested in joining a global federation towards this effort. The tool is open sourced athttps://github.com/FETS-AI/Front-End.

PURPOSE: To characterize and report on dosimetric outcomes of image guided adaptive brachytherapy (IGABT) using intracavitary and interstitial (IC/IS) applicators including oblique needles (O-needles) in locally advanced cervical cancer (LACC). METHODS AND MATERIALS: Twenty LACC patients treated with radio-chemotherapy and offered IC/IS-IGABT including O-needles were analyzed. An in-house 3D-printed vaginal template was used to steer the needles parallel and obliquely in relation to the tandem, supplemented with free-hand needles if needed. Implant characteristics and loading patterns were analyzed. Using the equivalent dose in 2Gy-fractions (EQD2) concept, cumulative (EBRT+BT) V85, V75, V60Gy, targets/OARs doses and high dose volumes (150%, 200% and 300% (100% = 85 Gy EQD210)) were evaluated. RESULTS: Median(range) tumor width at diagnosis was 5.5(3.6; 7.5)cm; CTVHR volume was 45(23; 136)cm3 with maximum distance from tandem to CTVHR border of 3.4(2.5; 4.8)cm. T-stage distribution was IIB/III/IVA in 6(30%)/9(45%)/5(25%) of patients. At BT, 13(65%) patients had distal parametrial/pelvic wall infiltration. Median(range) number of needles per patient was 11(8–18). Average distribution of intrauterine, vaginal and interstitial dwell times were 31%, 25% and 44%, respectively. Median(range) dwell-time per dwell position was 11(2–127)% of average point-A based standard loading. Median V85Gy/V150%/V200%/V300% were 85(38; 171)/41(21; 93)/22(12; 41)/7(4; 19) cm3; CTVHR D90% was 93(83; 97)Gy EQD210; bladder/rectum/sigmoid/bowel D2cm3 were 78(64; 104)/65(52; 76)/59(53; 69)/61(47; 76)Gy EQD23. CONCLUSIONS: The use of O-needles in patients with large and/or unfavorable tumors resulted in excellent target coverage and OARs sparing. Intrauterine and vaginal loadings were reduced compared to standard loading and almost half of the loading was shifted into IS needles. This was achieved with gentle loading in the majority of dwell positions.

In "Joint EANM/SNMMI/ESTRO Practice Recommendations for the Use of 2-[18F]FDG-PET/CT External Beam Radiation Treatment Planning in Lung Cancer V1.0" clinical indications for PET-CT in (non-)small cell lung cancer are highlighted and selective nodal irradiation is discussed. Additionally, concepts about target definition, target delineation and treatment evaluation are reviewed. (C) 2022 Published by Elsevier B.V.

Background and purpose: The requirement of computed tomography (CT) for radiotherapy planning may be bypassed by synthetic CT (sCT) generated from magnetic resonance (MR), which has recently led to the clinical introduction of MR-only radiotherapy for specific sites. Further developments are required for abdominal sCT, mostly due to the presence of mobile air pockets affecting the dose calculation. In this study we aimed to overcome this limitation for abdominal sCT at a low field (0.35 T) hybrid MR-Linac. Materials and methods: A retrospective analysis was conducted enrolling 168 patients corresponding to 215 MR-CT pairs. After the exclusion criteria, 152 volumetric images were used to train the cycle-consistent generative adversarial network (CycleGAN) and 34 to test the sCT. Image similarity metrics and dose recalculation analysis were performed. Results: The generated sCT faithfully reproduced the original CT and the location of the air pockets agreed with the MR scan. The dose calculation did not require manual bulk density overrides and the mean deviations of the dose-volume histogram dosimetric points were within 1 % of the CT, without any outlier above 2 %. The mean gamma passing rates were above 99 % for the 2 %/ 2 mm analysis and no cases below 95 % were observed. Conclusions: This study presented the implementation of CycleGAN to perform sCT generation in the abdominal region for a low field hybrid MR-Linac. The sCT was shown to correctly allocate the electron density for the mobile air pockets and the dosimetric analysis demonstrated the potential for future implementation of MR-only radiotherapy in the abdomen., Physics and Imaging in Radiation Oncology, 24, ISSN:2405-6316

PURPOSE: Development of a model characterizing risk variation with RBE to investigate how the incidence risk for all solid cancers combined varies with higher neutron RBEs and different organ dose types. MATERIAL AND METHODS: The model is based on RERF data with separate neutron and gamma dose information. RESULTS: For both additive and multiplicative linear excess risks per unit organ averaged dose, a reduction of 50% in the risk coefficient per weighted dose arises when a neutron RBE of 110 is used instead of 10. Considering risk per unit liver dose, this reduction occurs for an RBE of 130 and for risks per unit colon dose for an RBE of 190. The change in the shape of the dose response curve when using higher neutron RBEs is evaluated. The curvature changed and became significantly negative for males at an RBE of 140 for colon dose, 100 for liver dose and 80 for organ averaged dose. For females this is the case at an RBE of 110, 80 and 60, respectively. CONCLUSIONS: Uncertainties in neutron RBE values should be considered when radiation risks and the shape of dose responses are deduced from cancer risk data from the atomic bomb survivors.

Teaching Point: A posterior tibial lip fracture is a rare avulsion fracture at the tibial insertion of the posterior tibiofibular ligament that causes significant ankle instability and often requires surgical intervention. ispartof: JOURNAL OF THE BELGIAN SOCIETY OF RADIOLOGY vol:106 issue:1 ispartof: location:England status: published

Purpose Intrauterine claustrum and subplate neuron development have been suggested to overlap. As premature birth typically impairs subplate neuron development, neonatal claustrum might indicate a specific prematurity impact; however, claustrum identification usually relies on expert knowledge due to its intricate structure. We established automated claustrum segmentation in newborns. Methods We applied a deep learning-based algorithm for segmenting the claustrum in 558 T2-weighted neonatal brain MRI of the developing Human Connectome Project (dHCP) with transfer learning from claustrum segmentation in T1-weighted scans of adults. The model was trained and evaluated on 30 manual bilateral claustrum annotations in neonates. Results With only 20 annotated scans, the model yielded median volumetric similarity, robust Hausdorff distance and Dice score of 95.9%, 1.12 mm and 80.0%, respectively, representing an excellent agreement between the automatic and manual segmentations. In comparison with interrater reliability, the model achieved significantly superior volumetric similarity (p = 0.047) and Dice score (p Conclusion The developed fast and accurate automated segmentation has great potential in large-scale study cohorts and to facilitate MRI-based connectome research of the neonatal claustrum. The easy to use models and codes are made publicly available.