Automated multiclass segmentation, quantification, and visualization of the diseased aorta on hybrid PET/CT–SEQUOIA

Background Cardiovascular disease is the most common cause of death worldwide, including infection and inflammation related conditions. Multiple studies have demonstrated potential advantages of hybrid positron emission tomography combined with computed tomography (PET/CT) as an adjunct to current clinical inflammatory and infectious biochemical markers. To quantitatively analyze vascular diseases at PET/CT, robust segmentation of the aorta is necessary. However, manual segmentation is extremely time-consuming and labor-intensive. Purpose To investigate the feasibility and accuracy of an automated tool to segment and quantify multiple parts of the diseased aorta on unenhanced low-dose computed tomography (LDCT) as an anatomical reference for PET-assessed vascular disease. Methods A software pipeline was developed including automated segmentation using a 3D U-Net, calcium scoring, PET uptake quantification, background measurement, radiomics feature extraction, and 2D surface visualization of vessel wall calcium and tracer uptake distribution. To train the 3D U-Net, 352 non-contrast LDCTs from (2-[18F]FDG and Na[18F]F) PET/CTs performed in patients with various vascular pathologies with manual segmentation of the ascending aorta, aortic arch, descending aorta, and abdominal aorta were used. The last 22 consecutive scans were used as a hold-out internal test set. The remaining dataset was randomly split into training (n = 264; 80%) and validation (n = 66; 20%) sets. Further evaluation was performed on an external test set of 49 PET/CTs. The dice similarity coefficient (DSC) and Hausdorff distance (HD) were used to assess segmentation performance. Automatically obtained calcium scores and uptake values were compared with manual scoring obtained using clinical softwares (syngo.via and Affinity Viewer) in six patient images. intraclass correlation coefficients (ICC) were calculated to validate calcium and uptake values. Results Fully automated segmentation of the aorta using a 3D U-Net was feasible in LDCT obtained from PET/CT scans. The external test set yielded a DSC of 0.867 ± 0.030 and HD of 1.0 [0.6–1.4] mm, similar to an open-source model with a DSC of 0.864 ± 0.023 and HD of 1.4 [1.0–1.8] mm. Quantification of calcium and uptake values were in excellent agreement with clinical software (ICC: 1.00 [1.00–1.00] and 0.99 [0.93–1.00] for calcium and uptake values, respectively). Conclusions We present an automated pipeline to segment the ascending aorta, aortic arch, descending aorta, and abdominal aorta on LDCT from PET/CT and to accurately provide uptake values, calcium scores, background measurement, radiomics features, and a 2D visualization. We call this algorithm SEQUOIA (SEgmentation, QUantification, and visualizatiOn of the dIseased Aorta) and is available at https://github.com/UMCG-CVI/SEQUOIA. This model could augment the utility of aortic evaluation at PET/CT studies tremendously, irrespective of the tracer, and potentially provide fast and reliable quantification of cardiovascular diseases in clinical practice, both for primary diagnosis and disease monitoring

The necessity of drawing up the annual production plan and the importance of establishment crop structure for next agricultural year

Planning represents establishment and substantiate the objectives, accomplish tasks and necessary resources for appropriate period plan ( of perspective, annual, quarterly, monthly). Drawing up annual production plan into a ferm is required primarily for evolution or involution recorded by economical phenomenes, which directly determines the operation of the farm. After determining the annual production plan can establish structures and cultures for the next agricultural year using modeling and simulation methods. Following the application of modeling and simulation methods in a farm resulting optimal dimensions of business operations with profit maximization in terms of economic efficiency increased

Cardiac MRI of the athlete's heart

The increase in pre-participation cardiovascular screening using the Lausanne protocol will ultimately lead to an increased use of cardiac MRI and MDCT in the cardiovascular work-up of athletes. The role of cardiac MRI is well established in the evaluation of cardiomyopathies, myocarditis, aortic stenosis and diseases of the aorta. 3D-MRCA can detect coronary artery anomalies of wrong sinus origin, but is limited in identifying coronary artery disease. As coronary artery disease is the most common cause of sudden cardiac death in athletes over 35 years of age, MDCT (including coronary artery calcium score and coronary angiography) is a useful tool for cardiovascular risk stratification and assessment of the extent of coronary artery disease. At the expense of higher radiation exposure, MDCT can also be used for assessment of cardiac function. Chapter 2. Brief coaching using an adapted short axis cardiac MRI protocol with specific instructions, provides reproducible volume, function and mass quantification of the RV and LV to facilitate standardized cardiac MRI analysis for both clinical practice and research purposes. Chapter 3. The endurance athlete’s heart shows increased ventricular volumes, diameters, wall-mass and wall-thickness. In young athletes of 18 to 40 years of age, high training-hours/week, high BSA and male gender result in an increased overlap with standard thresholds for cardiomyopathy. Chapter 4. Only athletes show a significant decrease in BSA corrected values for ventricular volumes and LV wall-mass with increasing age. As non-athletes show no significant differences with increasing age, this effect in athletes probably reflects the change in training intensity per training-hour more than a direct effect of age. As the mature athletes still have significantly higher ventricular volumes and wall-mass than their matched non-athletes and significantly lower values as compared to young athletes, they form a distinct group of athletes requiring separate reference values. Chapter 5. BSA-corrected and training intensity and gender-stratified values are required for the correct assessment of normal adaptation of the atria to prolonged endurance training. Atrial and ventricular enlargement remains balanced (balanced adaptation) with higher training intensity, for both comparison of left to right side of the heart as well as for atrium to ventricle size for each side. Chapter 6. In healthy individuals and endurance athletes, cardiac MRI systematically shows larger values of ventricular and atrial dimensions and volumes compared to echocardiography, while wall-thickness and wall-mass are smaller. Chapter 7. A 10 minute 3D-MRCA protocol can be used to screen for CAA in asymptomatic athletes under 35 years old. Chapter 8 and 9. With this thesis we provide reproducible age, gender, training hours/week and body surface area specific cardiac MRI reference values of normal cardiac adaptation to physical training. This will help distinguish an athlete’s heart from cardiomyopathy and reduce inconclusive cardiac MRI reports due to the grey area between physiological adaptation and cardiomyopathy. The value of 3D-MRCA in detecting proximal coronary artery anomalies can be used as part of the standard cardiac MRI protocol to screen young competitive athletes and non-athletes. Screening for stenosis is currently less feasible with 3D-MRCA

Therapeutic drug monitoring-guided treatment versus standard dosing of voriconazole for invasive aspergillosis in haematological patients: a multicentre, prospective, cluster randomised, crossover clinical trial.

OBJECTIVES: Voriconazole therapeutic drug monitoring (TDM) is recommended based on retrospective data and limited prospective studies. This study aimed to investigate whether TDM-guided voriconazole treatment is superior to standard treatment for invasive aspergillosis. METHODS: A multicentre (n = 10), prospective, cluster randomised, crossover clinical trial was performed in haematological patients aged ≥18 years treated with voriconazole. All patients received standard voriconazole dose at the start of treatment. Blood/serum/plasma was periodically collected after treatment initiation of voriconazole and repeated during treatment in both groups. The TDM group had measured voriconazole concentrations reported back, with dose adjustments made as appropriate, while the non-TDM group had voriconazole concentrations measured only after study completion. The composite primary endpoint included response to treatment and voriconazole treatment discontinuation due to an adverse drug reaction related to voriconazole within 28 days after treatment initiation. RESULTS: In total, 189 patients were enrolled in the study. For the composite primary endpoint, 74 patients were included in the non-TDM group and 68 patients in the TDM group. Here, no significant difference was found between both groups (P = 0.678). However, more trough concentrations were found within the generally accepted range of 1-6 mg/L for the TDM group (74.0%) compared with the non-TDM group (64.0%) (P < 0.001). CONCLUSIONS: In this trial, TDM-guided dosing of voriconazole did not show improved treatment outcome compared with standard dosing. We believe that these findings should open up the discussion for an approach to voriconazole TDM that includes drug exposure, pathogen susceptibility and host defence. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov registration no. NCT00893555