Prospective Assessment of Fluorine-18-Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography (FDG-PET/CT) for Early Identification of Checkpoint-Inhibitor-Induced Pseudoprogression.

The activity of immune checkpoint inhibitors (ICIs) in patients with metastatic melanoma is often monitored using fluorine-18-fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) scans. However, distinguishing disease progression (PD) from pseudoprogression (PsPD), where increased FDG uptake might reflect immune cell activity rather than tumor growth, remains a challenge. This prospective study compared the efficacy of dual-time point (DTP) FDG-PET/CT with modified response criteria (PERCIMT) in differentiating PsPD from PD. From July 2017-January 2021, 41 patients suspected to have PsPD on an evaluation scan were prospectively included (29 evaluable). A subsequent DTP FDG-PET/CT scan was conducted within 14 days, followed by a confirmatory FDG-PET/CT scan. Additionally, PERCIMT were applied. DTP FDG-PET/CT identified 24% with PsPD and 76% with PD. Applying PERCIMT criteria, 69% showed PsPD, while 31% had PD. On follow-up, 10 patients (34%) demonstrated confirmed PsPD, while 19 (66%) exhibited PD. The sensitivity and specificity of DTP FDG-PET/CT were 20% and 74%, respectively, and for PERCIMT this was 80% and 37%, respectively. Our findings suggest limited efficacy of DTP FDG-PET/CT in distinguishing PsPD from PD in ICI-treated patients with metastatic melanoma. The use of PERCIMT could complement clinical assessment and be incorporated in multidisciplinary team conferences for enhanced decision-making.

Clinical Evaluation of Deep Learning for Tumor Delineation on 18F-FDG PET/CT of Head and Neck Cancer.

Artificial intelligence (AI) may decrease 18F-FDG PET/CT-based gross tumor volume (GTV) delineation variability and automate tumor-volume-derived image biomarker extraction. Hence, we aimed to identify and evaluate promising state-of-the-art deep learning methods for head and neck cancer (HNC) PET GTV delineation. Methods: We trained and evaluated deep learning methods using retrospectively included scans of HNC patients referred for radiotherapy between January 2014 and December 2019 (ISRCTN16907234). We used 3 test datasets: an internal set to compare methods, another internal set to compare AI-to-expert variability and expert interobserver variability (IOV), and an external set to compare internal and external AI-to-expert variability. Expert PET GTVs were used as the reference standard. Our benchmark IOV was measured using the PET GTV of 6 experts. The primary outcome was the Dice similarity coefficient (DSC). ANOVA was used to compare methods, a paired t test was used to compare AI-to-expert variability and expert IOV, an unpaired t test was used to compare internal and external AI-to-expert variability, and post hoc Bland-Altman analysis was used to evaluate biomarker agreement. Results: In total, 1,220 18F-FDG PET/CT scans of 1,190 patients (mean age ± SD, 63 ± 10 y; 858 men) were included, and 5 deep learning methods were trained using 5-fold cross-validation (n = 805). The nnU-Net method achieved the highest similarity (DSC, 0.80 [95% CI, 0.77-0.86]; n = 196). We found no evidence of a difference between expert IOV and AI-to-expert variability (DSC, 0.78 for AI vs. 0.82 for experts; mean difference of 0.04 [95% CI, -0.01 to 0.09]; P = 0.12; n = 64). We found no evidence of a difference between the internal and external AI-to-expert variability (DSC, 0.80 internally vs. 0.81 externally; mean difference of 0.004 [95% CI, -0.05 to 0.04]; P = 0.87; n = 125). PET GTV-derived biomarkers of AI were in good agreement with experts. Conclusion: Deep learning can be used to automate 18F-FDG PET/CT tumor-volume-derived imaging biomarkers, and the deep-learning-based volumes have the potential to assist clinical tumor volume delineation in radiation oncology.

Machine-learning guided Venom Induced Dermonecrosis Analysis tooL: VIDAL.

Snakebite envenoming is a global public health issue that causes significant morbidity and mortality, particularly in low-income regions of the world. The clinical manifestations of envenomings vary depending on the snake's venom, with paralysis, haemorrhage, and necrosis being the most common and medically relevant effects. To assess the efficacy of antivenoms against dermonecrosis, a preclinical testing approach involves in vivo mouse models that mimic local tissue effects of cytotoxic snakebites in humans. However, current methods for assessing necrosis severity are time-consuming and susceptible to human error. To address this, we present the Venom Induced Dermonecrosis Analysis tooL (VIDAL), a machine-learning-guided image-based solution that can automatically identify dermonecrotic lesions in mice, adjust for lighting biases, scale the image, extract lesion area and discolouration, and calculate the severity of dermonecrosis. We also introduce a new unit, the dermonecrotic unit (DnU), to better capture the complexity of dermonecrosis severity. Our tool is comparable to the performance of state-of-the-art histopathological analysis, making it an accessible, accurate, and reproducible method for assessing dermonecrosis in mice. Given the urgent need to address the neglected tropical disease that is snakebite, high-throughput technologies such as VIDAL are crucial in developing and validating new and existing therapeutics for this debilitating disease.

Postpartum cessation of urban space use by a female baboon living at the edge of the City of Cape Town.

Species with slow life history strategies that invest in few offspring with extended parental care need to adapt their behavior to cope with anthropogenic changes that occur within their lifetime. Here we show that a female chacma baboon (Papio ursinus) that commonly ranges within urban space in the City of Cape Town, South Africa, stops using urban space after giving birth. This change of space use occurs without any significant change in daily distance traveled or social interactions that would be expected with general risk-sensitive behavior after birth. Instead, we suggest this change occurs because of the specific and greater risks the baboons experience within the urban space compared to natural space, and because leaving the troop (to enter urban space) may increase infanticide risk. This case study can inform methods used to manage the baboons' urban space use in Cape Town and provides insight into how life history events alter individuals' use of anthropogenic environments.

Quantifying allo-grooming in wild chacma baboons (Papio ursinus) using tri-axial acceleration data and machine learning.

Quantification of activity budgets is pivotal for understanding how animals respond to changes in their environment. Social grooming is a key activity that underpins various social processes with consequences for health and fitness. Traditional methods use direct (focal) observations to calculate grooming rates, providing systematic but sparse data. Accelerometers, in contrast, can quantify activity budgets continuously but have not been used to quantify social grooming. We test whether grooming can be accurately identified using machine learning (random forest model) trained on labelled acceleration data from wild chacma baboons (Papio ursinus). We successfully identified giving and receiving grooming with high precision (81% and 91%) and recall (87% and 79%). Giving grooming was associated with a distinct rhythmical signal along the surge axis. Receiving grooming had similar acceleration signals to resting, and thus was more difficult to assign. We applied our machine learning model to n = 680 collar data days from n = 12 baboons and found that grooming rates obtained from accelerometers were significantly and positively correlated with direct observation rates for giving but not receiving grooming. The ability to collect continuous grooming data in wild populations will allow researchers to re-examine and expand upon long-standing questions regarding the formation and function of grooming bonds.

Effects of accelerometry-derived physical activity energy expenditure on urinary C-peptide levels in a wild primate (Papio ursinus).

Animals have finite energy reserves for growth, survival, and reproduction and must maintain a stable energy balance. Measuring energy balance in the wild, however, is beset with methodological challenges. Quantification of urinary C-peptide (uCP), a proxy for insulin secretion, has enabled researchers to non-invasively estimate energy balance, and positive relationships between uCP levels and energy intake have been documented in numerous non-human primates. Comparatively few studies show that, consistent with insulin physiology, energy expenditure also alters levels of uCP. The timescale and extent of this relationship, however, remains unclear given the reliance on crude measures of activity and inferred energy expenditure. Here, for the first time, we test for effects of accelerometer-derived Vectorial Dynamic Body Acceleration (VeDBA) - a continuous measure of physical activity energy expenditure - on urinary C-peptide (uCP) levels in n = 12 wild chacma baboons (Papio ursinus). Applying a model selection approach, we show that VeDBA summed over short timescales (30 min to 1 h) prior to urine collection was negatively associated with uCP levels. Using the acceleration-based time individuals spent 'non-stationary' (i.e. locomoting) prior to urine collection as a predictor - instead of summed VeDBA - revealed similar but less clear results. Overall, the negative relationship between VeDBA and uCP levels highlights the importance of quantifying physical activity energy expenditure when using uCP measures to estimate energy balance and has potential implications for the field of energetics accelerometry.

Sex differences in clinical characteristics of migraine and its burden: a population-based study.

BACKGROUND AND PURPOSE: Understanding migraine in a sex-specific manner is crucial for improving clinical care, diagnosis and therapy for both females and males. Here, data on sex differences are provided in the presentation of migraine in a large European-based population cohort, which is representative of the general population. METHODS: A population-based study of 62,672 Danish blood donors (both present and previous donors), of whom 12,658 had migraine, was performed. All participants completed a 105-item diagnostic migraine questionnaire sent via an electronic mailing system (e-Boks) between May 2020 and August 2020. The questionnaire allowed for correct diagnosis of migraine according to the International Classification of Headache Disorders, third edition. RESULTS: The migraine questionnaire was in-cohort validated and had a positive predictive value of 97% for any migraine, a specificity of 93% and a sensitivity of 93%. There were 9184 females (mean age 45.1 years) and 3434 males (mean age 48.0 years). The 3-month prevalence of migraine without aura was 11% in females and 3.59% in males. The 3-month prevalence of migraine with aura was 1.72% in females and 1.58% in males. In females, the age-related 3-month prevalence of migraine without aura increased markedly during childbearing age. In males, migraine both with and without aura showed less age variation. Females had a higher frequency of migraine attacks (odds ratio [OR] 1.22) but a lower frequency of non-migraine headaches (OR = 0.35). Females also had a greater intensity of pain, more unilateral and pulsatile pain, and exacerbation by physical activity (OR = 1.40-1.49) as well as more associated symptoms (OR = 1.26-1.98). Females carried 79% of the total migraine disease burden, which was almost exclusively driven by migraine without aura (77%), whilst there was no sex difference in the disease burden of migraine with aura. CONCLUSION: Females have more severe disease, resulting in a much higher migraine disease burden than indicated by prevalence alone.

Dynamics of collective motion across time and species.

Most studies of collective animal behaviour rely on short-term observations, and comparisons of collective behaviour across different species and contexts are rare. We therefore have a limited understanding of intra- and interspecific variation in collective behaviour over time, which is crucial if we are to understand the ecological and evolutionary processes that shape collective behaviour. Here, we study the collective motion of four species: shoals of stickleback fish (Gasterosteus aculeatus), flocks of homing pigeons (Columba livia), a herd of goats (Capra aegagrus hircus) and a troop of chacma baboons (Papio ursinus). First, we describe how local patterns (inter-neighbour distances and positions), and group patterns (group shape, speed and polarization) during collective motion differ across each system. Based on these, we place data from each species within a 'swarm space', affording comparisons and generating predictions about the collective motion across species and contexts. We encourage researchers to add their own data to update the 'swarm space' for future comparative work. Second, we investigate intraspecific variation in collective motion over time and provide guidance for researchers on when observations made over different time scales can result in confident inferences regarding species collective motion. This article is part of a discussion meeting issue 'Collective behaviour through time'.

Disseminated Primary Uterine Hepatoid Adenocarcinoma with α-Fetoprotein Production Demonstrated on 18F-FDG PET/CT.

We present the 18F-Fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) findings in a 57-year-old woman with post-menopausal bleeding diagnosed with hepatoid adenocarcinoma (HAC) with a primary tumour in the uterine corpus and a highly elevated level of serum-α-fetoprotein (S-AFP) at presentation. HAC is a variant of adenocarcinoma with hepatic differentiation representing a heterogeneous group of neoplasms that morphologically and immunphenotypically resemble hepatocellular carcinoma (HCC) but are of extrahepatic origin. Microscopically, they are usually poorly differentiated adenocarcinomas proliferating in solid sheets or in a trabecular or cord-like arrangement. Primary uterine HAC is exceedingly rare with a general poor prognosis, and data is sparse and limited to case reports, making the clinical management challenging. Various primary anatomical sites have been reported in the literature, with the stomach being the most common primary site. 18F-FDG PET/CT plays an important role in staging and follow-up in many gynecological malignancies including uterine corpus cancer. To the best of our knowledge, this is the first report describing a primary uterine hepatoid adenocarcinoma with metastases to bone, vagina and lymph nodes on 18F-FDG PET/CT. By utilizing the ability of PET to detect early metabolic changes prior to visible structural changes on conventional imaging, this case illustrates a potential role of 18FDG-PET/CT in the staging of primary endometrial HAC by depicting distant metastasis that is not readily identifiable on CT alone.

Population-based prevalence of cranial autonomic symptoms in migraine and proposed diagnostic appendix criteria.

BACKGROUND: Migraine with cranial autonomic symptoms is well described in the literature, but its prevalence in previous studies varies enormously. A precise estimate of the prevalence in a population-based material is important because migraine with cranial autonomic symptoms might represent an endophenotype, in which genetic and pathophysiological features differ from those without cranial autonomic features. The aim of the present study, therefore, was to estimate the prevalence in a big population-based sample using both questionnaire-based diagnosis (N = 12,620) and interview-based diagnosis (N = 302). We validate questionnaire-based diagnosis of migraine with cranial autonomic symptoms and develop the first diagnostic criteria for future research of this possible endophenotype. METHODS: The Danish Blood Donor Study included 127,802 persons who all received a migraine diagnostic questionnaire. Participants who had answered the diagnostic questionnaire constituted the Danish Migraine Population Cohort (N = 62,677) of whom 12,620 had migraine. The diagnostic migraine questionnaire included questions about the following cranial autonomic symptoms: Facial/forehead sweating, lacrimation, ptosis, conjunctival injection, rhinorrhea, nasal congestion, and miosis. Validation was performed by a follow-up semi-structured, purpose-built interview of 302 participants with migraine, where detailed questions were asked to ascertain the validity of the symptoms. RESULTS: The questionnaire-based prevalences of one, respectively two cranial autonomic symptoms were 57% and 31%. The semi-structured interview-based prevalences of one, respectively two symptoms were 44% and 22%. The most common symptoms were facial/forehead sweating (39%) and lacrimation (24%). The specificity of the questionnaire was 80% and the sensitivity was 68%. Correlation analysis showed a weak correlation between symptoms ranging from 0.07 - 0.41, and no clear clustering of symptoms was detected. We suggest the first diagnostic appendix criteria for genetic and epidemiological studies and tighter criteria for clinical and pathophysiological studies. We encourage further studies of severity and consistency of symptoms. CONCLUSION: Migraine with cranial autonomic symptoms is prevalent in the general population. Suggested diagnostic appendix criteria are important for future studies of this possible migraine endophenotype.

Simultaneous investigation of urinary and faecal glucocorticoid metabolite concentrations reveals short- versus long-term drivers of HPA-axis activity in a wild primate (Papio ursinus).

Glucocorticoids (GCs), a class of steroid hormones released through activation of the hypothalamic-pituitary-adrenal (HPA) axis, perform many vital functions essential for survival, including orchestrating an organism's response to stressors by modulating physiological and behavioural responses. Assessing changes and variation in GC metabolites from faecal or urine samples allows for the non-invasive monitoring of HPA-axis activity across vertebrates. The time lag of hormone excretion differs between these sample matrices, which has implications for their suitability for studying effects of different temporal nature on HPA-axis activity. However, simultaneous comparisons of predictors of faecal and urinary GC metabolites (fGCs and uGCs, respectively) are lacking. To address this gap, we employ frequent non-invasive sampling to investigate correlates of fGCs and uGCs in wild chacma baboons (Papio ursinus) (n = 17), including long-term (dominance rank, season, female reproductive state) and short-term (time of day, daily weather conditions) factors. Correlated with increasing day length, fGCs gradually decreased from winter to summer. No seasonal effect on uGCs was found but 'rain days' were associated with increased uGCs. Pregnant females had significantly higher fGCs compared to cycling and lactating females, whereas uGCs were not statistically different across reproductive states. A circadian effect was observed in uGCs but not in fGCs. Dominance rank did not affect either fGCs or uGCs. Our study highlights the difference in inherent fluctuation between uGCs and fGCs and its potential consequences for HPA-axis activity monitoring. While uGCs offer the opportunity to study short-term effects, they undergo more pronounced fluctuations, reducing their ability to capture long-term effects. Given the increasing use of urine for biological monitoring, knowledge of this potential limitation is crucial. Where possible, uGCs and fGCs should be monitored in tandem to obtain a comprehensive understanding of short- and long-term drivers of HPA-axis activity.

Flexible group cohesion and coordination, but robust leader-follower roles, in a wild social primate using urban space.

Collective behaviour has a critical influence on group social structure and organization, individual fitness and social evolution, but we know little about whether and how it changes in anthropogenic environments. Here, we show multiple and varying effects of urban space-use upon group-level processes in a primate generalist-the chacma baboon (Papio ursinus)-within a managed wild population living at the urban edge in the City of Cape Town, South Africa. In natural space, we observe baboon-typical patterns of collective behaviour. By contrast, in urban space (where there are increased risks, but increased potential for high-quality food rewards), baboons show extreme flexibility in collective behaviour, with changes in spatial cohesion and association networks, travel speeds and group coordination. However, leader-follower roles remain robust across natural and urban space, with adult males having a disproportionate influence on the movement of group members. Their important role in the group's collective behaviour complements existing research and supports the management tactic employed by field rangers of curbing the movements of adult males, which indirectly deters the majority of the group from urban space. Our findings highlight both flexibility and robustness in collective behaviour when groups are presented with novel resources and heightened risks.

Energetics at the urban edge: Environmental and individual predictors of urinary C-peptide levels in wild chacma baboons (Papio ursinus).

As human-modified landscapes encroach into natural habitats, wildlife face a reduction in natural food sources but also gain access to calorie-rich, human-derived foods. However, research into the energetics of wildlife living within and adjacent to urban and rural landscapes is lacking. C-peptide - a proxy for insulin production and a diagnostic tool for assessing pancreatic function in humans and domestic animals - can be quantified non-invasively from urine (uCP) and may provide a way to investigate the energetic correlates of living in human-altered landscapes. UCP is increasingly used in studies of primate energetics, and here we examine predictors of variation in uCP levels in n = 17 wild chacma baboons (Papio ursinus) living at the urban edge on the Cape Peninsula, South Africa. We find that uCP was positively associated with food provisioning and negatively with night fasting. UCP levels were comparable between winter and summer but significantly lower during spring, possibly driven by consumption of energy-rich seeds during summer and more human-derived foods during winter. UCP was elevated in pregnant females and similar for lactating and cycling females. We find no effect of dominance rank on uCP. Samples collected with synthetic Salivettes had significantly lower uCP levels than directly pipetted samples. Overall, our results indicate that uCP is a reliable, non-invasive measure of energy balance and intake in baboons, and suggest potential energetic benefits of living at the urban edge. More broadly, studies of uCP may offer unique insight into the environmental control of hormone-behaviour relationships in species crossing natural and urban environments.

The multilevel society of a small-brained bird.

Animal societies can be organised in multiple hierarchical tiers [1]. Such multilevel societies, where stable groups move together through the landscape, overlapping and associating preferentially with specific other groups, are thought to represent one of the most complex forms of social structure in vertebrates. For example, hamadryas baboons (Papio hamadryas) live in units consisting of one male and one or several females, or of several solitary males, that group into clans. These clans then come together with solitary bachelor males to form larger bands [2]. This social structure means that individuals have to track many different types of relationships at the same time [1,3]. Here, we provide detailed quantitative evidence for the presence of a multilevel society in a small-brained bird, the vulturine guineafowl (Acryllium vulturinum). We demonstrate that this species lives in large, multi-male, multi-female groups that associate preferentially with specific other groups, both during the day and at night-time communal roosts.

Experimental field evidence that out-group threats influence within-group behavior.

In social species, conspecific outsiders present various threats to groups and their members. These out-group threats are predicted to affect subsequent within-group interactions (e.g., affiliation and aggression) and individual behavior (e.g., foraging and vigilance decisions). However, experimental investigations of such consequences are rare, especially in natural conditions. We used field-based call playbacks and fecal presentations on habituated wild dwarf mongooses (Helogale parvula)-a cooperatively breeding, territorial species-to examine postinteraction responses to the simulated threat of a rival group. Dwarf mongooses invested more in grooming of groupmates, foraged closer together, and more regularly acted as sentinels (a raised guard) after encountering indicators of rival-group presence compared to control conditions. These behavioral changes likely arise from greater anxiety and, in the case of increased vigilance, the need to seek additional information about the threat. The influence of an out-group threat lasted at least 1 h but individuals of different dominance status and sex responded similarly, potentially because all group members suffer costs if a contest with rivals is lost. Our results provide field-based experimental evidence from wild animals that out-group threats can influence within-group behavior and decision making, and suggest the need for greater consideration of the lasting impacts of social conflict.

Repeatability of FDG PET/CT metrics assessed in free breathing and deep inspiration breath hold in lung cancer patients.

We measured the repeatability of FDG PET/CT uptake metrics when acquiring scans in free breathing (FB) conditions compared with deep inspiration breath hold (DIBH) for locally advanced lung cancer. Twenty patients were enrolled in this prospective study. Two FDG PET/CT scans per patient were conducted few days apart and in two breathing conditions (FB and DIBH). This resulted in four scans per patient. Up to four FDG PET avid lesions per patient were contoured. The following FDG metrics were measured in all lesions and in all four scans: Standardized uptake value (SUV)peak, SUVmax, SUVmean, metabolic tumor volume (MTV) and total lesion glycolysis (TLG), based on an isocontur of 50% of SUVmax. FDG PET avid volumes were delineated by a nuclear medicine physician. The gross tumor volumes (GTV) were contoured on the corresponding CT scans. Nineteen patients were available for analysis. Test-retest standard deviations of FDG uptake metrics in FB and DIBH were: SUVpeak FB/DIBH: 16.2%/16.5%; SUVmax: 18.2%/22.1%; SUVmean: 18.3%/22.1%; TLG: 32.4%/40.5%. DIBH compared to FB resulted in higher values with mean differences in SUVmax of 12.6%, SUVpeak 4.4% and SUVmean 11.9%. MTV, TLG and GTV were all significantly smaller on day 1 in DIBH compared to FB. However, the differences between metrics under FB and DIBH were in all cases smaller than 1 SD of the day to day repeatability. FDG acquisition in DIBH does not have a clinically relevant impact on the uptake metrics and does not improve the test-retest repeatability of FDG uptake metrics in lung cancer patients.

18 F-FDG PET/CT for planning external beam radiotherapy alters therapy in 11% of 581 patients.

BACKGROUND: 18 F-FDG PET/CT (FDG PET/CT) used in radiotherapy planning for extra-cerebral malignancy may reveal metastases to distant sites that may affect the choice of therapy. AIM: To investigate the role of FDG PET/CT on treatment strategy changes induced by the use of PET/CT as part of the radiotherapy planning. 'A major change of treatment strategy' was defined as either including more lesions in the gross tumour volume (GTV) distant from the primary tumour or a change in treatment modalities. METHODS: The study includes 581 consecutive patients who underwent an FDG PET/CT scan for radiotherapy planning in our institution in the year 2008. All PET/CT scans were performed with the patient in treatment position with the use of immobilization devices according to the intended radiotherapy treatment. All scans were evaluated by a nuclear medicine physician together with a radiologist to delineate PET-positive GTV (GTV-PET). RESULTS: For 63 of the patients (11%), the PET/CT simulation scans resulted in a major change in treatment strategy because of the additional diagnostic information. Changes were most frequently observed in patients with lung cancer (20%) or upper gastrointestinal cancer (12%). In 65% of the patients for whom the PET/CT simulation scan revealed unexpected dissemination, radiotherapy was given - changed (n = 38) or unchanged (n = 13) according to the findings on the FDG PET/CT. CONCLUSION: Unexpected dissemination on the FDG PET/CT scanning performed for radiotherapy planning caused a change in treatment strategy in 11% of 581 patients.

Functional and genetic epidemiological characterisation of the FFAR4 (GPR120) p.R270H variant in the Danish population.

BACKGROUND: p.R270H (rs116454156) in the long chain fatty acid 7TM receptor FFAR4 (GPR120) which results in impaired Gαq (Gq) coupled signalling, has been associated with obesity. We aimed to extend the functional in vitro analyses of p.R270H and to investigate the association with obesity and glucose-related traits in the Danish population. METHODS: Surface expression, Gq and Gi coupled signalling as well as ß-arrestin recruitment were examined in vitro. p.R270H was genotyped using the exome chip array in 11 479 Danish adult individuals. Of these 4391 were obese and 4415 were normal weight. Association with quantitative metabolic traits comprised 8720 non-diabetic individuals. RESULTS: p.R270H showed reduced surface expression of FFAR4. Ligand-independent activity was eliminated and strongly impaired through the Gq and Gi signalling pathways, respectively. The ligand-induced maximal signalling efficacy of p.R270H was reduced only through the Gq pathway. The p.R270H variant did not affect ß-arrestin recruitment. p.R270H was not associated with increased risk of obesity nor increased fasting plasma glucose levels in the Danish study populations. Nor was it associated with these two traits in the European Network for Genetic and Genomic Epidemiology consortium data (N=34 901-71 175; p>0.70). It was also not associated with waist-hip ratio, glucose metabolism during an oral glucose tolerance test, lipid levels or with markers of adiposity (leptin, adiponectin), inflammation (high-sensitive C reactive protein; hs-CRP) and liver function (alanine aminotransferase) in the Danish population (p>0.05). CONCLUSIONS: We demonstrate that p.R270H of FFAR4 impairs Gq and Gi signalling of FFAR4 in vitro; however, this impaired signalling for p.R270H does not translate into associations with human metabolic phenotypes in the investigated populations.

Normativity under change: Older persons with implantable cardioverter defibrillator.

BACKGROUND: In modern society, death has become 'forbidden' fed by the medical technology to conquer death. The technological paradigm is challenged by a social-liberal political ideology in postmodern Western societies. The question raised in this study was as follows: Which arguments, attitudes, values and paradoxes between modern and postmodern tendencies concerning treatment and care of older persons with an implantable cardioverter defibrillator appear in the literature? AIMS: The aim of this study was to describe and interpret how the field of tension concerning older persons with an implantable cardioverter defibrillator - especially end-of-life issues - has been expressed in the literature throughout the last decade. METHODS: Paul Ricoeur's reflexive interpretive approach was used to extract the meaningful content of the literature involving qualitative, quantitative and normative literature. Analysis and interpretation involved naive reading, structural analysis and critical interpretation. ETHICAL CONSIDERATIONS: The investigation complied with the principles outlined in the Declaration of Helsinki. FINDINGS AND DISCUSSIONS: The unifying theme was 'Normativity under change'. The sub-themes were 'Death has become legitimate', 'The technological imperative is challenged' and 'Patients and healthcare professionals need to talk about end-of-life issues'. There seems to be a considerable distance between the normative approach of how practice ought to be and findings in empirical studies. CONCLUSION: Modern as well as postmodern attitudes and perceptions illustrate contradictory tendencies regarding deactivation of the implantable cardioverter defibrillator and replacement of the implantable cardioverter defibrillator in older persons nearing the end of life. The tendencies challenge each other in a struggle to gain position. On the other hand, they can also complement each other because professionalism and health professional expertise cannot stand alone when the patient's life is at stake but must be unfolded in an alliance with the patient who needs to be understood and accepted in his vulnerability.

Spatio-temporal stability of pre-treatment 18F-Fludeoxyglucose uptake in head and neck squamous cell carcinomas sufficient for dose painting.

BACKGROUND: The pre-treatment 18F-Fludeoxyglucose (FDG) avid subvolume of the tumor has shown promise as a potential target for dose painting in patients with in head and neck squamous cell carcinomas (HNSCC). PURPOSE: The purposes of this study are: 1) to assess the pre-treatment spatio-temporal variability of FDG PET/CT target volumes and 2) to assess the impact of this variability on dose distribution in dose painting plans in patients with HNSCC. MATERIAL AND METHODS: Thirty patients were enrolled and scanned twice, three days apart, days prior to treatment. Delineation of the FDG avid subvolume of the tumor and lymph nodes on both scans was performed by a specialist in nuclear medicine yielding GTVPET1 and GTVPET2 and segmentation based on SUV iso-contours were constructed yielding two metabolic target volumes, MTV1 and MTV2. Images were co-registered rigidly and dose painting plans with dose escalation up to 82 Gy to GTVPET1 were planned and GTVPET2 was copied from the co-registered images to the dose planning scan. Variation in dose to the target and modeled tumor control probability were assessed as measures of the impact of imaging variations in a dose painting scenario. RESULTS: Twenty-four patients were available for full analysis. The median mismatch between GTVPET1 and GTVPET2 was 14.2% (1.7 cm(3)). The median difference in dose to the FDG planning target volume was 0.3 Gy (PTVPET) and 0.4 Gy (PTVMTV). Median difference in the modeled tumor control probability (TCP) was < 0.2% and 23 of 24 patients had a difference in expected TCP < 1%. CONCLUSIONS: Pre-treatment FDG PET/CT target volumes were stable and day-to-day variability had no relevant impact on dose distribution and expected tumor control in dose painting plans.