Intensity modulated proton therapy: a clinical example.

In this paper, we report on the clinical application of fully automated three-dimensional intensity modulated proton therapy, as applied to a 34-year-old patient presenting with a thoracic chordoma. Due to the anatomically challenging position of the lesion, a three-field technique was adopted in which fields incident through the lungs and heart, as well as beams directed directly at the spinal cord, could be avoided. A homogeneous target dose and sparing of the spinal cord was achieved through field patching and computer optimization of the 3D fluence of each field. Sensitivity of the resultant plan to delivery and calculational errors was determined through both the assessment of the potential effects of range and patient setup errors, and by the application of Monte Carlo dose calculation methods. Ionization chamber profile measurements and 2D dosimetry using a scintillator/CCD camera arrangement were performed to verify the calculated fields in water. Modeling of a 10% overshoot of proton range showed that the maximum dose to the spinal cord remained unchanged, but setup error analysis showed that dose homogeneity in the target volume could be sensitive to offsets in the AP direction. No significant difference between the MC and analytic dose calculations was found and the measured dosimetry for all fields was accurate to 3% for all measured points. Over the course of the treatment, a setup accuracy of +/-4 mm (2 s.d.) could be achieved, with a mean offset in the AP direction of 0.1 mm. Inhalation/exhalation CT scans indicated that organ motion in the region of the target volume was negligible. We conclude that 3D IMPT plans can be applied clinically and safely without modification to our existing delivery system. However, analysis of the calculated intensity matrices should be performed to assess the practicality, or otherwise, of the plan.

Positron emission tomography and fluorodeoxyglucose studies of metabolic hyperfrontality and psychopathology in the psilocybin model of psychosis.

The effects of the indolehallucinogen psilocybin, a mixed 5-HT2 and 5-HT1 agonist, on regional cerebral glucose metabolism were investigated in 10 healthy volunteers with PET and [F-18]-fluorodeoxyglucose (FDG) prior to and following a 15- or 20-mg dose of psilocybin. Psychotomimetic doses of psilocybin were found to produce a global increase in cerebral metabolic rate of glucose (CMRglu) with significant and most marked increases in the frontomedial and frontolateral cortex (24.3%), anterior cingulate (24.9%), and temporomedial cortex (25.3%). Somewhat smaller increases of CMRglu were found in the basal ganglia (18.5%), and the smallest increases were found in the sensorimotor (14.7%) and occipital cortex (14.4%). The increases of CMRglu in the prefrontal cortex, anterior cingulate, temporomedial cortex, and putamen correlated positively with psychotic symptom formation, in particular with hallucinatory ego disintegration. The present data suggest that excessive 5-HT2 receptor activation results in a hyperfrontal metablic pattern that parallels comparable metabolic findings associated with acute psychotic episodes in chronic schizophrenics and contrasts with the hypofrontality in chronic schizophrenic patients.

Relationships between the degree of Helicobacter pylori colonisation and the degree and activity of gastritis, surface epithelial degeneration and mucus secretion.

This study investigates the question as to whether, in Helicobacter pylori (H.p.) gastritis, any statistically significant relationships are to be found between the following histological parameters: degree of H.p. colonisation, the degree and activity of gastritis, degree of replacement of the foveolar epithelium by regenerating epithelium, and degree of mucus depletion. Forceps biopsy material obtained from 240 patients with NUD and H.p. gastritis (3 specimens from the antrum, 2 from the corpus) were investigated. The 5 histological parameters employed were graduated semiquantitatively as follows: 0 = normal findings, 1 = minimal, 2 = low-grade, 3 = medium-grade, 4 = high-grade. The evaluation showed that the degree and activity of gastritis, the degree of replacement of foveolar epithelium by regenerating epithelial cells, and the degree of mucus depletion are dependent upon the degree of H.p. colonisation (p < 0.0001). The gastritis parameters were more marked in the antrum than in the corpus. The intercorrelations were highly significant for all five parameters investigated, both in the antrum and corpus (p < 0.0001). On the basis of these results it is concluded that for the histological assessment of H.p. gastritis, in addition to H.p. colonisation, and the degree and activity of gastritis, but also the state of the foveolar epithelium and the mucus production of these epithelial cells should be considered.

[Evaluation and documentation of tomographic images and further data using the Apple-Macintosh PC]. / Auswertung und Dokumentation von tomographischen Bildern und weiteren Daten mit Apple-Macintosh-PC.

Use of the personal microcomputer for the analysis of clinical cardial PET studies acquired at the Paul Scherrer Institute in Villigen, Switzerland. At present this is the only PET facility in Switzerland. As the local computers were not usually available for image analysis, it was necessary to find a convenient way to visualize and analyze the PET images in our department in the Cantonal Hospital, Aarau (distance to Villigen some 30 km). The personal microcomputer is, as other authors have already shown, in fact capable of handling the acquired images (128 by 128 pixels) easily. We use a Macintosh IIcx (16 MHz Motorola 68030 CPU) as image analysis workstation. In spring 1990 we implemented a software which could read the original Siemens matrix file directly into the Macintosh PC. As the handling of this software was somewhat clumsy, we now use a very powerful software ("Explorer", UCLA), which is specially designed for PET analysis. Analysis of PET data on the personal computer saves both time and money as we are able to use a standard PC periphery, which is less expensive than specially designed medical units.

[A rare combination of two autoimmune diseases (scleroderma, primary biliary cirrhosis) in relation to parietal cell antibodies]. / Seltene Kombination von zwei Autoimmunerkrankungen (Sklerodermie, primär-biliäre Zirrhose) in Verbindung mit Belegzellantikörpern.

Case report of combined progressive sclerosis and primary biliary cirrhosis added to a chronical atrophic gastritis in the beginning. Diagnosis of one autoimmune disease should prompt a search for further associated autoimmune affections to care before there is a grave disease--if this is possible.

Study on the stability of the calibration and normalization in PET and the influence of drifts on the accuracy of quantification.

With regard to the quality control of quantification in positron emission tomography some characteristics were examined, to develop a simple method for frequent monitoring. The stability and uniformity of the detector count rate was checked by plotting the RMS deviation of the non normalized count rate and the standard deviation of the normalized count rate, each normalized to its value after the calibration or normalization respectively. Switching off a single detector did not impair the image quality, but the normalized image pixel counts were reduced by 2%-3% when a detector block was switched off. Thus in case of need, a weak detector can still be used to perform a scan. A reduced count rate capability at specific activities above 5 x 10(4) Bq/ml (approximately 1.5 x 10(5) corrected true system counts/s or approximately 1.5 x 10(4)/s for a plane) was found compared to the maximum usable activity of 8 x 10(4) Bq/ml obtained 1 year earlier, indicating a drift in the count loss corrections. A variation of the room temperature changes the temperature distribution inside the gantry by 5% per degree C and the drift of the sensitivity (normalized image pixel counts) is 2% per degree C.

[Esophageal reflux disease]. / Die gastroösophageale Refluxkrankheit.

Esophagitis caused by reflux is one of the most frequent diseases diagnosed by endoscopy of the upper gastrointestinal tract. Reflux may be physiological. The main pathological conditions causing reflux are the hiatus hernias and sequelae of surgical procedures. Esophagitis occurs exclusively in the layer of stratified epithelium. In early stages it presents as white stripes of erosion with a typical red frame or as a peptic lesion. The colors red or white are dependent upon depth of the process, coating and stage of healing. Pathogenesis, various forms of manifestation, and complications of the reflux disease can be understood if one knows about mucosal metaplasias which may occur. This metaplastic process involves replacement of areas of stratified epithelium by cylindrical epithelium. Peptic stenosis located highly in the esophagus usually indicates a distal segment of cylindrical epithelium. The so called endobrachyesophagus (Barrett esophagus) occurs in rare cases congenitally - it can be also found after complete healing of the esophagitis without any signs of inflammation or stenosis. Therefore it seems appropriate to introduce an additional classification for the Barrett esophagus (E0, EI-IV). The reflux disease is clinically important because of its tenacious clinical symptomatology and its complications. Endobrachyesophagus has been recognized as a precancerous condition and should be controlled regularly.

Phlegmonous gastritis after Indian ink marking.

A report is presented on a case of phlegmonous gastritis following gastroscopic Indian ink injection into the mucosa of the stomach in a 60-year-old woman patient wih early gastric carcinoma. The patient was discharged from hospital on the 11th day after Billroth II resection, in good condition. The necessity for disinfection and sterilization of the instruments employed is emphasized; the continued use of Indian ink marking is recommended.

[Treatment of duodenal ulcer with synthetic depot secretin - a double-blind study]. / Die Behandlung des Ulcus duodeni mit synthetischem Depot-Sekretin - eine Doppelblindstudie.

63 inpatients with duodenal ulcer disease were treated with either depot-secretin or placebo. Two different secretin-regimens were used. In group I 18 patients were given secretin twice daily. 11 ulcers from a total of 19 ulcers healed within 3 weeks. In group II 23 patients were given secretin once daily. 21 out of 28 ulcers healed within 3 weeks. In the placebo-treated group 24 ulcers were observed in 22 patients. Of these 15 healed within 3 weeks. There was no statistical difference in the healing rate between the 3 groups. However, depot-secretin significantly improved typical symptoms. Analgetics were used less frequently. Serious side effects did not occur.

[Hemorrhages from the pancreatic duct system: a severe complication in pancreatic diseases]. / blutungen aus dem Pankreasgangsystem -- eine schwere Komplikation von Erkrankungen der Bauchspeicheldrüse Diagnostisches und therapeutisches Vorgehen.

The incidence of hemorrhage into the gastrointestinal tract associated with formation of pancreatic pseudocysts or cystadenoma are very rare. When it does occur, it is almost always fatal. Two of our patients had intermittent episodes of upper gastrointestinal hemorrhage with severe anemia. After ERCP we performed subtotal resection of the pancreas in one case and total pancreatectomy in the other. The postoperative course was uncomplicated. Within the last 2 years no episodes of hemorrhage were seen.

Columnar-lined oesophagus (Barrett's syndrome) - congenital or acquired?

A segment of the distal oesophagus lined with columnar epithelium (endobrachy oesophagus, Barrett's oesophagus), is very frequently seen in association with chronic reflux conditions. Usually, this entity is an asymmetrical columnar-cell metaplasia of varying extent, with an unsharp epithelial junction line cranial, and showing various large residual islands of squamous epithelium. In addition, usually well-developed peptic lesions are also found. More rarely seen are cases with a longer, symmetrical, cranially sharply delimited columnar-epithelial-lined segment, in which peptic lesions and strictures are usually either restricted to the proximal section, or are lacking altogether. Among more than 100 patients presenting with endobrachy-oesophagus, 14 cases had the latter form of the condition. Seven had a solitary, high peptic stricture, and only 50% unequivocal hiatus hernia. In four patients there were no inflammatory changes at all. In 8 patients, fundic glands were observed. Of particular interest was the segment-like arrangement of cardiac and fundic glands in 2 of the patients. In only a single case were scar formations seen in the columnar-lined segment. Considered from the point of view of our embryological knowledge, certain forms of endobrachy-oesophagus would appear to represent a congenital anomaly.

Effects of Octylguanidine on Cell Permeability and Other Protoplasmic Properties of Allium cepa Epidermal Cells.

Effects of octylguanidine (OG) were studied on the permeability of cells of the adaxial epidermis of Allium cepa bulb scales to water and methyl urea and on the protoplast surface. Interference of OG with the Ca(2+) and Al(3+) action on the cell surface was also investigated.Permeability of the cell membrane for water and methyl urea increased nearly three times in presence of OG. The effect of OG on cell permeability depended on its direct contact with the protoplast surface.The effect of OG on the interaction between the protoplast surface and the cell wall (wall attachment) was marked and rapid; OG (225 micromolar) decreased the time for protoplast detachment in hypertonic solutions from 420 to 120 seconds. The plasmolyzed protoplasts were immediately rounded off while the controls without OG remained heavily concave.A considerable increase in protoplast detachment time and a decrease in rounding percentage were found when cells were plasmolyzed after pretreatment with AlCl(3) (0.05 molar for 2 minutes). This effect was partially reversed by KCl which was further enhanced by addition of OG.Penetration of OG into the mesoplasm was manifested only after 10 to 15 minutes. Vacuolization and swelling of the protoplasm, fragmentation of the protoplast, and aggregation of the spherosomes, however, were observed only 30 minutes after transfer. No evidence for penetration of OG into the vacuole was found.The results support earlier suggestions that OG acts primarily on the protoplast surface by interacting with membrane proteins as well as with phospholipids. In several aspects, OG acts on the cell surface similarly to a surfactant.

[Endoscopy of the resected stomach (author's transl)]. / Die Endoskopie des operierten Magens.

Endoscopy of the resected stomach is indicated in the presence of all types of symptoms affecting the stomach, in gastrointestinal bleeding, and within the framework of prophylactic screening and follow-up examinations for cancer detection. Frequent findings are peptic ulcers, suture granulomas, and reflux esophagitis. Carcinomas in the stump develop increasingly from the 10th to 15th postoperative years. In the resected stomach, the pylorocardial expansion type of gastritis predominates. Atrophy is not an obligatory finding. Foveolar hyperplasia is typical, predominantly in the region of the anastomosis.

[Surgical treatment of chronic pancreatitis. Indications and early results]. / Operative Behandlung der chronischen Pankreatitis. Indikationen und Frühergebnisse

A report is given on 28 resections on patients with chronic pancreatitis with a high frequency of severe destructive lesions in the head of the pancreas. Pseudocysts, single, multiple or extrapancreatic were present in almost 50%. Strictures of the Ductus Wirsungianus were found in 24 cases and 50% had multiple pancreatic stones. In these cases 12 partial and 9 total duodenopancreatectomies and 7 distal resections were performed. All patients with distal resections survived. Only one patient died in the group with partial and total duodenopancreatectomy, which accounts for a postoperative letality of 4.8%. Postoperative there were 4 reoccurrences of pancreatitis, due to further alcohol abusus, 1 patient died from alcohol intoxication. Patients with total seemed to do better than with partial pancreatectomy at a survey 18 months after operation.

[Determination of chymotrypsin in the stool by succinyl-L-phenylalanin-P-nitraniliden (Suphepa) in the diagnosis of pancreatic diseases (author's transl)]. / Bestimmung von Chymotrypsin im Stuhl mit Succinyl-L-Phenylalanin-P-Nitraliniden (Suphepa) in der Diagnostik von Pankreaserkrankungen

A specific substrate (Suphepa), which is well known in duodenal chymotrypsin determination (pancreozymin-secretin-test), is also suitable for the enzyme determination in stools from patients suspected of having a pancreas insufficiency of exocrine nature. The median value of 353 fecal chymotrypsin determination of 180 normal persons was 137 mug/g of native stool. There is a good correlation in comparing the fecal with the duodenal chymotrypsin: Out of 30 comparable patients, 10 patients had pathological values for the duodenal and fecal chymotrypsin determinations, whereas 18 patients had normal values. According to the results of the pancreozymin-secretin-test, false normal stool results were recorded for two patients. No false positive stool values were recorded for the comparative collective. The great accuracy, the modest instrumental expense and the negligible inconvenience for the patient are good in line with the requirements for a screening test.

[The valve of selective retrograde cholangiography in the radiological diagnosis of diseases of the biliary passages(author's transl)]. / Der Stellenwert der gezielten retrograden Cholangiographie in der radiologischen Diagnostik der Gallenwegserkrankungen

The value of selective endoscopic retrograde cholangiography in the radiological diagnosis of diseases of the biliary passages and neighbouring organs is discussed on the basis of 400 retrograde pancreatocholangiograms. The results of this endoscopic examination were compared with the findings of all the other preoperative examinations carried out. The diagnostic usefulness and limitations of various methods are discussed in relation to stenosis of the papilla, pancreatitis, carcinoma of the pancreas, tumours of the extrahepatic bile ducts and postoperative bile duct abnormalities. The diagnostic accuracy of 97% emphasises the value of co-operation between radiologists and endoscopists.

[Antral morphology and serum-gastrin levels in achlorhydria]. / Antrummorphologie und Serumgastrinspiegel bei Achlorhydrie

38 patients were found to have achlorhydria after maximal stimulation with pentagastrin and on multiple biopsies (atrophy of gastric mucosa). It was demonstrated that the sequence pH-antroreceptors-G cells-parietal cells-pH antroreceptors was interrupted already in mild or moderately severe superficial gastritis of the antral mucosa involving more than half of the antral surface. Reduction of specific functional epithelium is unlikely in this form of inflammation so that it is probably an effect of the pH receptors.