Total body irradiation for bone marrow transplantation: the Memorial Sloan-Kettering Cancer Center experience

In May 1979, Memorial Sloan-Kettering embarked on a programme of hyperfractionated TBI (HFTBI), 1320 cGy in 11 fractions over 4 days with partial lung shielding (1 HVL), followed by cyclophosphamide (60 mg/kg/d x 2d) for cytoreduction prior to allogeneic bone marrow transplantation (BMT). Anterior and posterior chest wall electron "boosts" were given to the areas blocked (600 cGy in 2 fractions) on the last two days of treatment. Since then, we have treated over 600 patients with HFTBI, the majority for allogeneic BMT. Several modifications have occurred over the years. We have added a "boost" electron dose of 400 cGy to the testes in all male leukemic patients; this reduced testicular relapses from a rate of 14% (4/28) to 0%. In an attempt to increase engraftment of T-depleted BMTs, we added one additional fraction; since our present dose/fraction was also increased to 125 cGy, we now deliver a total dose of 1500 cGy in 12 fractions over 4 days for allogeneic transplants. Tolerance to HFTBI has been excellent relative to the single dose (SD) regimen utilised prior to May, 1979. The incidence of fatal interstitial pneumonitis (IP) decreased from 50% in the SD regimen to 18% after the introduction of HFTBI. In children, the incidence of IP was only 4% with HFTBI. With the introduction of T-depleted marrows, fatal IP in adults has decreased also, e.g. to less than 10% in CML patients. With conventional BMT after HFTBI, relapse at 5 years has been exceedingly low (e.g. in children, 13% for ALL, 2nd remission and 0% for AML, 1st remission) and engraftment has been 100%. With matched T-depleted BMT, rejections have occurred in 15% overall; the incidence of graft failure has not been reduced by the higher dose of HFTBI. Relapses in this setting are equivalent to relapses with conventional BMT for AML, but appear to be increased for ALL. Radiobiological findings related to HFTBI will also be discussed.

Myocardial protection by simple systemic hypothermia without aortic occlusion

Systemic hypothermia at 25 degrees-28 degrees C without chemical cardioplegia was used in 908 patients undergoing coronary artery bypass grafting. Local coronary artery flow was interrupted only during grafting of a distal anastomosis. Systemic perfusion pressure was maintained at 80-100 mmHg, hematocrit at 20%-25%, and pCO2 and pH were monitored during hypothermia according to the alpha-stat principle, while the left ventricle was vented routinely. Proximal anastomoses were performed just before extracorporeal circulation was started by only partially occluding the ascending aorta. Preoperatively 61.9% of the patients had had a myocardial infarction, and 44% had unstable angina. In 14% a severe lesion of the main stem of the left coronary artery was present. Left ventricular function was moderately depressed in 25% and severely depressed in 8% of the patients. Forty-eight patients (5.3%) were aged 70 years or older. The mean number of grafts placed per patient was 3.3. Perioperative myocardial infarction occurred in 3%. Death due to left ventricular failure occurred in 0.4%. No left ventricular assist devices were needed; an intra-aortic balloon pump was used in 1%; positive inotropic support was required in 3.8% of the patients. These results indicate that systemic hypothermia alone provides safe myocardial protection and in certain cases may be the method of choice, particularly if aortic cross clamping or administration of cardioplegic solution is contraindicated. In addition, this method provides rapid revascularization of a severely ischemic zone, as present after unsuccessful PTCA procedures.

Dose computations for three-dimensional radiation treatment planning

The knowledge of radiation dose at all points of interest within a patient's body is essential for the evaluation of treatment plans and for the judicious selection of the best one from among a set of competing plans. This paper discusses the physical and geometric aspects of radiation dose distribution calculations necessary for three-dimensional treatment planning. A practical method of obtaining dose distributions for a given arrangement of beams and beam modifiers is with the aid of computer calculations based on mathematical formalisms derived from the principles of physics. The most accurate method of computing dose is by Monte Carlo stimulation of radiation transport. However, this method is extremely CPU time intensive and too complicated to implement for routine radiation treatment planning. Approximate semi-empirical methods have to be employed to compute dose distributions within reasonably short times. Conventional approximate methods do not yield results of adequate accuracy. Newer methods that are better able to take into account the three-dimensional nature of radiation transport have been introduced but require considerably greater computing capacity. Furthermore, computing power needs for dose calculations for three-dimensional treatment planning are one to two orders of magnitude greater than the corresponding needs of two-dimensional treatment planning. However, the concern for greater computing power requirements is being lessened somewhat with the advent of high speed computers and specialized hardware, and with the development of clever algorithms for speeding up dose calculations. For three-dimensional treatment planning some geometric issues, such as the calculation of dose at points in three-dimensional space, the incorporation of three-dimensional patient and beam geometry into a system for dose calculations, the choice of optimum grid spacing, radiological pathlength calculations, and algorithms for speeding up dose calculation, take on added importance compared to the corresponding issues for conventional two-dimensional planning. These issues are also discussed here briefly.

Autonomic function tests in cases of chronic severe anaemia

Autonomic functions were studied in 30 adult cases of chronic severe anaemia (CSA) and equal number of age and sex matched healthy controls. Blood pressure and heart rate responses to standing, to respiration (expiratory-inspiratory ratio), to Valsalva manoeuvre (Valsalva ratio) and to hand immersion in ice cold water and given 1.8 mg of atropine intravenously were studied. Patients with CSA had significantly high basal pulse rate and low blood pressure as compared to control subjects (p less than 0.001). The expiratory inspiratory ratio was abnormal in 30% of the cases of CSA (p greater than 0.10) valsalva ratio was abnormal in 50% of cases (p less than 0.01) and postural tachycardia was observed in 60% of cases (p less than 0.001). Normal response to hand immersion in ice cold water was observed in 56.6% of cases (p less than 0.001). Atropine resulted in tachycardia in 73.4% of cases of CSA as compared to 86.7% of controls (p less than 0.10). All the cases of CSA showed one or more abnormal response and in 16.6% of cases all responses were abnormal.

Comparative efficacy of atenolol and labetalol in essential hypertension--a double blind cross over trial

In a double blind cross-over drug trial, antihypertensive effects (resting and after dynamic exercise) of atenolol and of labetalol were studied in 20 patients of mild to moderate essential hypertension. Both drugs exhibited almost equal antihypertensive response, and were well tolerated. Haemodynamic variables (HR, SBP, DBP and RPP), both at rest and after maximal tread mill exercise, were significantly altered (P less than 0.001) by both drugs. Exercise capacity was observed to be marginally improved by atenolol. Although the antihypertensive effect, when compared between the two drugs, was not statistically significant, individual suitability or comparison revealed a preference for atenolol in 17 patients and for labetalol in 3 patients.

Three-dimensional radiation treatment planning

A major aim of radiation therapy is to deliver sufficient dose to the tumour volume to kill the cancer cells while sparing the nearby healthy organs to prevent complications. With the introduction of devices such as CT and MR scanners, radiation therapy treatment planners have access to full three-dimensional anatomical information to define, simulate, and evaluate treatments. There are a limited number of prototype software systems that allow 3D treatment planning currently in use. In addition, there are more advanced tools under development or still in the planning stages. They require sophisticated graphics and computation equipment, complex physical and mathematical algorithms, and new radiation treatment machines that deliver dose very precisely under computer control. Components of these systems include programs for the identification and delineation of the anatomy and tumour, the definition of radiation beams, the calculation of dose distribution patterns, the display of dose on 2D images and as three dimensional surfaces, and the generation of computer images to verify proper patient positioning in treatment. Some of these functions can be performed more quickly and accurately if artificial intelligence or expert systems techniques are employed.

Retinopathy in insulin dependent diabetes mellitus (IDDM) in south India

The prevalence of diabetic retinopathy was assessed by direct and indirect ophthalmoscopy in a group of patients with insulin dependent diabetes mellitus (IDDM). Fourteen percent of patients had retinopathy. Proliferative retinopathy and severe background retinopathy including maculopathy were both seen in four percent of patients. It is possible that the lower prevalence rates for these complications is due to the shorter duration of diabetes in our patients.

Molecular basis of the early events in plant–fungus interaction

Fungal spores that land on aerial surfaces of plants first come into contact with plant cuticle. The cuticle is composed of an insoluble polyester called cutin, which is composed of hydroxy and hydroxyepoxy fatty acids and associated soluble waxes. The wax components can trigger differentiation of germinating fungal spores into infection structures. The penetration of the fungus into the plant requires enzymatic degradation of the polyester and the underlying carbohydrate barriers. The polyesterase, called cutinase, is induced by the contact with the plant surface. The small amount of cutinase carried by the spore generates a small amount of cutin monomers upon contact with the host, and the unique monomers trigger expression of the cutinase gene. This transcriptional level control can be demonstrated with isolated nuclei. Upon incubation of nuclei with cutin monomer and a soluble protein factor from the fungus, cutinase transcription is selectively activated. Structure activity relationships showed that the cutinase transcription activation required all of the structural elements of the cutin monomer. The cutinase transcript generated by the isolated nuclei was identical in size to the cutinase mRNA induced in the fungal cultures, which indicated usual initiation and termination. Fungal infection triggers defense reaction in plants. Plant peroxidases were implicated in the defense response of plants to fungal attack and stress. A highly anionic peroxidase involved in suberization of cell walls in tomato plants in response to fungal attack was cloned and sequenced. It was observed that in resistant lines of tomato the expression of this anionic peroxidase was induced 1 day earlier than in susceptible lines.Key words: cutinase, cutin monomers, pectate lyase, Fusarium solani pisi, anionic peroxidase.

Steroid induced glaucoma and cataract

Long term use of topical & systemic steroids produce secondary open angle glaucoma similar to chronic simple glaucoma. The increased IOP caused by prolonged steroid therapy is reversible but the damage produced by it is irreversible. In this study, we analysed 25 patients (44 eyes) with steroid induced glaucoma, who reported to us with dimness of vision, haloes and elevated I.O.P. and were using steroids for long duration due to various causes. The behaviour of the I.O.P. due to different steroid preparations, the type of lenticular change, and the management of those cases are discussed in this paper. From our study we conclude that dexamethasone and betamethasone both topical as well as systemic are more potent in producing glaucoma and cataract than medrysone and prednisolone. The condition is reversible without permanent damage when the duration of steroid therapy is short and vice versa.

Evaluation of a non-mydriatic camera in Indian and European diabetic patients

The value of the Canon CR3-45NM non-mydriatic fundus camera in screening for diabetic retinopathy has been assessed in two ethnic groups, namely, 45 Indian and 40 European diabetic patients. There was 72% agreement between ophthalmoscopy by an ophthalmologist and the photographic assessment, and 100% agreement on clinically important lesions requiring treatment. However, peripheral retinal lesions, seen on ophthalmoscopy but lying outside the photographic field, occurred in 4% of eyes. 6% of photographs were totally unassessable and an additional 12% were only partially assessable. The prevalence and severity of retinopathy was similar in Indian and European patients. The advantages and disadvantages of the non-mydriatic camera in screening for diabetic retinopathy are discussed.

A comprehensive three-dimensional radiation treatment planning system

A comprehensive software system has been developed to allow 3-dimensional planning of radiation therapy treatments using the extensive anatomical information made available by imaging modalities such as CT and MR. Biological structures of interest and tumor volumes are defined by outlines drawn on a sequence of CT slices. Beam set-ups may then be determined in three dimensions by displaying the structure contours in a beam's eye view, or in two dimensions using a single CT cut. Each beam defined may be shaped by the specification of block aperture contours, and its intensity may be modified with the use of planar compensators. 3D dose calculation algorithms are discussed. To evaluate the calculation results, dose volume histograms are provided, as well as various types of displays in two and three dimensions, including dose on arbitrarily oriented planes, dose on the surface of anatomical objects, and isodose surfaces. Computer generated beam films are also available as an aid in patient set-up verification. These tools, and others, provide the basis for a comprehensive 3D system that can be used throughout the treatment planning process.

Pancreatic B-cell function in relation to diabetic retinopathy in Asian Indian NIDDM patients

Pancreatic B-cell function in relation to diabetic retinopathy was studied in 195 NIDDM patients with long-standing diabetes. Background diabetic retinopathy (BDR) was present in 95 (48.7%) and proliferative retinopathy (PDR) in 17 (8.7%) of the subjects. There was no significant difference between the BDR, PDR, and non-retinopathy groups with respect to age, age at diagnosis of diabetes and HbA1 values. Mean duration of diabetes was higher in the PDR group (p less than 0.05). Serum C-peptide values showed no correlation with the presence of retinopathy or with the duration of diabetes. The C-peptide values were widely scattered in patients with BDR and PDR showing no association between pancreatic B-cell reserve and occurrence or severity of retinopathy in NIDDM patients. Thus, decreased pancreatic B-cell reserve does not appear to be a risk factor for diabetic retinopathy in NIDDM patients.

Extraction of pencil beam kernels by the deconvolution method

A method has been developed to extract pencil beam kernels from measured broad beam profiles. In theory, the convolution of a symmetric kernel with a step function will yield a function that is symmetric about the inflection point. Conversely, by deconvolution, the kernel may be extracted from a measured distribution. In practice, however, due to the uncertainties and errors associated with the measurements and due to the singularities produced in the fast Fourier transforms employed in the deconvolution process, the kernels thus obtained and the dose distributions calculated therefrom, often exhibit erratic fluctuations. We propose a method that transforms measured profiles to new, modified distributions so that they satisfy the theoretical symmetry condition. The resultant kernel from the deconvolution is then free of fluctuations. We applied this method to compute photon and electron dose distributions at various depths in water and electron fluence distributions in air. The agreement between measured and computed profiles is within 1% in dose or 1 mm in distance in high dose gradient regions.

The effect of angular spread on the intensity distribution of arbitrarily shaped electron beams

Knowledge of the relative intensity distribution at the patient's surface is essential for pencil beam calculations of three-dimensional dose distributions for arbitrarily shaped electron beams. To calculate the relative intensity distribution, the spatial spread resulting from angular spread is convolved with a two-dimensional step function whose shape corresponds to the applicator aperture. Two different approaches to obtain angular spread or the equivalent spatial spread are investigated. In the first method, the pencil beam angular spread is assumed to be Gaussian in shape. The angular spread constants (sigma theta) are then obtained from the slopes of measured intensity profiles. In the second method, the angular spread, in the form of an array of numerical values, is obtained by the deconvolution of measured intensity profiles. After obtaining the angular spread, the calculation for convolution is done in a number of parallel planes normal to the central axis at various distances from the electron collimator. Intensity at any arbitrary point in space is computed by interpolating between intensity distributions in adjacent planes on either side of the point. The effects of variations in angular spread as a function of field size for two treatment machines, one with a scanned electron beam and the other with a scattering foil, have been studied. The consequences of assuming angular spread to be of Gaussian shape are also examined. The electron intensity calculation techniques described in this paper apply primarily to methods of dose calculations that employ pencil beams generated using Monte Carlo simulations.

Clinical features of diabetes in the young as seen at a diabetes centre in south India

This study reports on the clinical pattern of 545 consecutive young diabetic patients with age at onset below 30 years attending a diabetes centre in Southern India. Three hundred and fourteen patients (57.7%) were classified as having non-insulin-dependent diabetes of the young (NIDDY), 119 (22%) as insulin-dependent diabetes (IDDM) and 28 (5%) as malnutrition-related diabetes (MRDM); 4% fibrocalculous pancreatic diabetes and 1% protein-deficient pancreatic diabetes. The remaining 84 patients could not be classified into any of the above categories. A positive family history of diabetes was more common in NIDDY compared to the other groups (P less than 0.001). While 40.3% of patients with IDDM had age at onset below 15 years, the other types of diabetes were rarely seen in patients younger than this. Body mass index (BMI) did not reliably indicate the MRDM forms of diabetes as 70% of patients with IDDM also had a BMI of less than 18, one of the criteria recommended for the diagnosis of MRDM. C-peptide levels in MRDM were intermediate between the IDDM and NIDDY groups. Microvascular complications were present in all the groups of young diabetics. The frequency was higher in NIDDY patients who also had a longer duration of diabetes. There was an increasing prevalence of complications with increasing duration of diabetes.

Dose computations for asymmetric fields defined by independent jaws

Asymmetric fields defined by independent jaws can be used to split a beam or to match adjacent fields. We have extended a method originally developed for symmetric fields to calculate the dose for asymmetric fields. The dose to a point is computed as the product of the tissue maximum ratio (TMR), the off center ratio (OCR), and the inverse square factor. The TMR is computed from the measured central axis depth doses for symmetric fields. The OCR is obtained by multiplying the primary OCR (POCR) and the boundary factors (BF's) for the four jaws. The POCR's and BF's were derived from measured beam profiles, which include the effect of off-axis beam quality variations. Using this method, the beam profiles and isodose distributions for asymmetric fields of a 6-MV accelerator were calculated and compared with the measured data. The agreement is within experimental errors both in the penumbra region and along the central ray of the asymmetric field.

A technique for computing dose volume histograms for structure combinations

Graphical displays of three-dimensional dose distribution data are often too complex to be easily assimilated and interpreted for the evaluation of radiation treatment plans. Histograms showing dose versus volume are convenient and useful tools for summarizing dose distribution information throughout the entire volume of a given anatomic structure. They can quickly highlight characteristics such as dose uniformity and hot and cold spots, and can be used to produce statistics including tumor control and normal tissue complication probabilities. To obtain a dose volume histogram for a given structure, it may be necessary to examine its spatial relationships with neighboring structures. They may overlap, be completely disjoint, or one may be contained within another. To resolve potential ambiguities, a procedure has been developed that assigns hierarchies to anatomical structures for the purpose of histogram calculation. The hierarchy assigned to each structure is used to determine the structure within which a given dose matrix point is considered to lie. In this manner, regions of structure intersection are assigned to one object or another, and dose volume histograms can be calculated for each structure separately. From this framework, addition and subtraction of histograms can also be performed. Details of the algorithm are presented along with an example using patient data.

Arbitrary oblique image sections for 3-D radiation treatment planning

Methods for selecting and computing arbitrary image sections for displaying anatomic and isodose information for three-dimensional treatment planning are investigated. Selection of the desired plane may be made by defining a plane that is perpendicular to an existing image section (called the base image) and passing through a line on the base image. Alternatively, the anatomic structures displayed perspectively in three dimensions as a series of contours that can be rotated and translated may be used to define an arbitrary plane for image reconstruction. The viewing screen is considered to be the plane of interest. As a typical three-dimensional image of 30 to 60 sections requires considerable computer storage (on the order of 25 megabytes), a reconstruction algorithm may need extensive memory space or CPU and disk I/O time. Of the schemes examined, we believe the following is the most efficient. One pair of images is read from the disk at a time in sequence and intersections of the rows of the cutting plane with the box formed by the consecutive images are computed. Pixel values of all points between the given images are computed by interpolation. Special cases, such as the cutting plane being parallel to or coincident with an existing image, must be considered separately.

Monte Carlo simulation of a cobalt-60 beam

We have used the Stanford Electron Gamma Shower (EGS) Monte Carlo code to compute photon spectra from an AECL Theratron 780 cobalt-60 unit. Particular attention has been paid to the careful modeling of the geometry and material construction of the cobalt-60 source capsule, source housing, and collimator assembly. From our simulation, we conclude that the observed increase in output of the machine with increasing field size is caused by scattered photons from the primary definer and the adjustable collimator. We have also used the generated photon spectra as input to a pencil beam model to calculate the tissue-air ratios in water and compared it to a model which uses a monochromatic photon energy of 1.25 MeV.

Use of fast Fourier transforms in calculating dose distributions for irregularly shaped fields for three-dimensional treatment planning

In three-dimensional radiation treatment planning, essentially all fields are irregular and compensated. Consequently, it is important to predict accurately dose for such fields to ensure adequate coverage of the target region and sparing of healthy tissues. Traditional approaches, namely, those involving scatter integration and extended source and those utilizing negatively weighted fields, are inaccurate, especially near the boundaries defined by blocks and collimators. In the method presented in this paper, dose distributions for arbitrarily shaped beams are calculated by two-dimensional convolution of the relative primary photon fluence distributions and kernels representing the cross-sectional profiles of a pencil beam at a series of depths. The pencil beam dose distributions are computed, once and for all, with the Monte Carlo method for photon energy spectrum for each treatment machine. The finite size of the source, which is important for cobalt machines, is also taken into account using convolution of the source with the relative primary fluence distribution. Convolutions are performed using fast Fourier transforms on an array processor. Results of calculations are in excellent agreement with measured data. While no data are presented for fields modified by compensators, the method of calculation should apply at least as well for such fields since the variations in fluence distribution for compensated fields are not as sharp as for points near the block boundaries.

Choice of optimum megavoltage for accelerators for photon beam treatment

Over three decades ago, the development of megavoltage accelerators revolutionized radiation oncology and provided the therapist with photons and electrons of any desired energy. The initial advantages cited for high energy photon therapy, listed below, have proved valid and accelerators have almost totally replaced orthovoltage units. Initially, it appeared that most of these cited advantages should continue to improve with increasing energy, and there has been an impetus for the production of ever higher megavoltage accelerators. Some of these advantages are reviewed in this paper. Also, recent investigations have indicated increasing diffuseness of the photon beam boundary with increasing energy because of lateral transport of electrons. The impact on treatment planning as a function of energy of the increase in volume dose due to the diffuseness of beam boundaries, "build-down" and "rebuild-up" effects in tissues at cavity and inhomogeneity interfaces, bone absorption, and photoneutron production are discussed. Consideration of the behavior of these parameters indicates that optimum photon energies have been achieved and that the impetus for higher megavoltages is unwarranted for most treatment. For many therapeutic applications, there are major advantages of 4 MV to 8 MV photon beams relative to 60Co gamma rays. For large lesions in the abdomen or pelvis there is an advantage to energies above those provided by 15 MV units. The various considerations above are discussed and summarized as a function of lesion site and megavoltage.

Off-center ratios for three-dimensional dose calculations

A new method is proposed for computing the off-center ratios (OCR's) in three-dimensional dose calculations. For an open field, the OCR at a point is computed as the product of the primary OCR (POCR) and the boundary factors (BF's). The POCR describes the beam profile for an infinite field, that is, without the effect of the collimators. It is defined as the ratio of the dose at a point off the central ray to the dose at the point on the central ray at the same depth for an infinite field. The POCR is a function of radial distance from the beam central ray and depth. The BF describes the shape of the beam in the neighborhood of the field boundary defined by the collimators. It is defined as the ratio of the OCR at a point for a finite field to the OCR at the same point for an infinite field. The BF is a function of distance from the field boundary, depth, and field size. For a wedged field, we assume that the boundary factors remain the same as for open fields but the POCR's are altered. The changes in beam profiles are described by a factor called the wedge profile factor (WPF), defined as the ratio of the dose at a point for the largest wedged field to the dose at the same point for an open field of the same field size. The WPF is a function of lateral distance from the beam central plane and depth. Calculated OCR's using this new method are in agreement with the measured data along both the transverse and the diagonal directions of the field.

Retinal revascularisation in diabetic retinopathy

The case history of a 33-year-old diabetic patient who has had diabetes for 24 years is presented. When first seen in 1975 he had bilateral proliferative retinopathy with new vessels in the retinal periphery. He had large areas of capillary non-perfusion lateral to the macula in the right eye associated with the new vessels. Nine years later, after extensive repeated photocoagulation, revascularisation of large areas previously not perfused were seen. The vessels are in the plane of the retina and do not have the appearance of new vessels.

Differential pencil beam dose computation model for photons

Differential pencil beam (DPB) is defined as the dose distribution relative to the position of the first collision, per unit collision density, for a monoenergetic pencil beam of photons in an infinite homogeneous medium of unit density. We have generated DPB dose distribution tables for a number of photon energies in water using the Monte Carlo method. The three-dimensional (3D) nature of the transport of photons and electrons is automatically incorporated in DPB dose distributions. Dose is computed by evaluating 3D integrals of DPB dose. The DPB dose computation model has been applied to calculate dose distributions for 60Co and accelerator beams. Calculations for the latter are performed using energy spectra generated with the Monte Carlo program. To predict dose distributions near the beam boundaries defined by the collimation system as well as blocks, we utilize the angular distribution of incident photons. Inhomogeneities are taken into account by attenuating the primary photon fluence exponentially utilizing the average total linear attenuation coefficient of intervening tissue, by multiplying photon fluence by the linear attenuation coefficient to yield the number of collisions in the scattering volume, and by scaling the path between the scattering volume element and the computation point by an effective density.

Apocytochrome c induces pH-dependent vesicle fusion

The ability of apocytochrome c and the heme containing respiratory chain component, cytochrome c, to induce fusion of phosphatidylcholine (PC) small unilamellar vesicles containing 0-50 mol % negatively charged lipids was examined. Both molecules mediated fusion of phosphatidylserine (PS):PC 1:1 vesicles as measured by energy transfer changes between fluorescent lipid probes in a concentration- and pH-dependent manner, although cytochrome c was less potent and interacted over a more limited pH range than the apocytochrome c. Maximal fusion occurred at pH 3, far below the pKa of the 19 lysine groups contained in the protein (pI = 10.5). A similar pH dependence was observed for vesicles containing 50 mol % cardiolipin (CL), phosphatidylglycerol (PG), and phosphatidylinositol (PI) in PC but the apparent pKa values varied somewhat. In the absence of vesicles, the secondary structure of apocytochrome c was unchanged over this pH range, but in the presence of negatively charged vesicles, the polypeptide underwent a marked conformational change from random coil to alpha-helix. By comparing the pH dependencies of fusion induced by poly-L-lysine and apocytochrome c, we concluded that the pH dependence derived from changes in the net charge on both the vesicles and apocytochrome c. Aggregation could occur under conditions where fusion was imperceptible. Fusion increased with increasing mole ratio of PS. Apocytochrome c did induce some fusion of vesicles composed only of PC with a maximum effect at pH 4. Biosynthesis of cytochrome c involves translocation of apocytochrome c from the cytosol across the outer mitochondrial membrane to the outer mitochondrial space where the heme group is attached. The ability of apocytochrome c to induce fusion of both PS-containing and PC-only vesicles may reflect characteristics of protein/membrane interaction that pertain to its biological translocation.

Validity of the concept of separating primary and scatter dose

The technique of separating dose into primary and scatter components for calculating photon dose distributions is widely used. The primary and scatter dose models ignore ignore the fact that electrons have a finite range. This may be a good approximation for 60Co photons but not for higher energies. For the latter, the range of electrons may be several centimeters in soft tissue and even longer in lungs and will lead to errors in computed dose in regions where electronic equilibrium does not exist. Ignoring the finite range of electrons will affect dose at points such as those near the beam boundaries, near inhomogeneity boundaries, and at bone-soft-tissue interfaces. Other possible problems associated with the definition and use of "primary" and "scatter" dose in dose distribution calculations result from extrapolation of measured data to obtain data for zero and very large field sizes and from the use of these quantities, which are defined for central axis, for points at large distances from the central axis. This paper examines the limits of the validity of these assumptions.

Retinopathy in tropical pancreatic diabetes

In a study of the retinopathy profile of 40 patients with tropical pancreatic diabetes, a form of secondary diabetes seen in tropical countries, diabetic retinopathy was detected in 13 patients. Ten patients had background retinopathy and three patients had proliferative retinopathy requiring laser photocoagulation. In two patients, fibrous retinitis proliferans was present. Three patients had evidence of diabetic maculopathy. To our knowledge, this is the first report of severe and sight-threatening retinopathy occurring with secondary diabetes. Retinopathy in these forms of diabetes has hitherto been considered to be rare or, if present, only of a mild background type.

Energy and angular distributions of photons from medical linear accelerators

For accurate three-dimensional treatment planning, new models of dose calculations are being developed which require the knowledge of the energy spectra and angular distributions of the photons incident on the surface of the patient. Knowledge of the spectra is also useful in other applications, including the design of filters and beam modifying devices and determination of factors to convert ionization chamber measurements to dose. We have used Monte Carlo code (EGS) to compute photon spectra for a number of different linear accelerators. Both the target and the flattening filter have been accurately modeled. We find the mean photon energy to have a value lower than the generally perceived value of one-third the maximum energy. As expected, the spectra become softer as the distance from the central axis increases. Verification of the spectra is performed by computing dose distributions and half-value layers in water using the calculated spectra and comparing the results with measured data. We also examined the angular distributions of photons incident on the surface of the phantom. In currently used models of dose computations, it is assumed that the angular distribution of photons with respect to fan lines emanating from the source is negligible. Although the angular spread of photons with respect to the incident direction has been found to be small, its contribution to the diffuseness of the beam boundaries is significant.

Clinical experience with a computerized record and verify system

To improve the quality of patient care by detecting and preventing many types of treatment mistakes, we have implemented a computerized system for recording and verifying external beam radiation treatments on our therapy machines. It inhibits the radiation beam if treatment machine settings do not agree with prescribed values to within maximum permissible deviations (tolerances). The tolerances are determined from experience and adjusted when necessary to make the system more effective and less susceptible to "false alarms." The system uses a common data base for all treatment machines. As a result, it permits statistical analysis and generation of reports based on data encompassing the entire patient population as well as verification of treatments of patients transferred from one machine to another. Reports of verification failures reveal patterns of mistakes. Knowing these, attempts can be made to reduce the frequency of verification failures. "Significant" mistakes that were prevented are extracted by treatment planning personnel from these reports. Analysis of data indicates a rate of approximately 150 "significant" mistakes detected and prevented per machine per year, representing 1.0% of all fields treated. We present and discuss our experiences with the system and with the frequency, patterns, and significance of verification failures. We selected a few of the patients for whose treatments significant set-up mistakes were made, and were detected and prevented by the Record and Verify System. We include discussions of the overall effect these mistakes would have had on dose distribution had they not been prevented.

High prevalence of maturity-onset diabetes of the young (MODY) among Indians

This article describes the high prevalence of maturity-onset diabetes in the young (MODY) in an Indian clinic population of diabetic patients. MODY appears to be more common among Indians than among Caucasians. Only 27% of MODY patients had definite autosomal-dominant inheritance. In 73% the mode of inheritance was not definite. Microvascular complications were common and macrovascular complications rare. The high prevalence of MODY in this diabetes clinic might suggest an ethnic variation in diabetes.

Measurements of radiation dose distributions for shielded cervical applicators

Cervical applicators with shielded ovoids are employed to reduce dose to the rectum and bladder. Because of asymmetries introduced by the shields, dose distribution calculations for individual patients will require extensive computer reference data for the ovoid sources. Requisite 3-D dose distributions were measured for an unshielded and a shielded ovoid containing a Cs-137 source, using a computerized system employing a diode in a water phantom. The probe stops at each measurement point and accumulates dose for several seconds. The system automates horizontal positioning of the detector and angular motion of the ovoid to obtain dose in one plane. The detector is moved manually to other planes for a complete three dimensional set of measurements. In order to suppress the energy and directional dependence of the diode, final dose distributions are calculated from ratios of shielded to unshielded data in conjunction with independently measured TLD data for unshielded sources.

Computation of radiation dose distributions for shielded cervical applicators

While cervical applicators with shielded ovoids are used widely in brachytherapy, we know of no system for calculating dose distributions for them. For shielded sources, because of a lack of symmetry and because of a rapid variation of dose as a function of position relative to the source, extensive measured data in three dimensions are required. In the method we have developed, the dose at a given point from a source in a shielded ovoid is calculated by multiplying the dose from an unshielded source by the "effective attenuation factor" of the shields. The latter quantity is obtained by linear-interpolation in a three-dimensional table generated from measurements described in an earlier paper. The unshielded-source dose is calculated as the product of source strength, time of implant, distance-dependent geometry factor and a tabulated quantity called the "relative dose rate factor". Relative dose rate factor is obtained by dividing measured dose rate by the product of geometry factor and source strength. Division by the geometry factor reduces the amount of data required with respect to accuracy in linear-interpolation. Input localization data must include not only the position of the end points defining the source but also a third reference point to define the orientation of the shields.

Tropical pancreatic diabetes in South India: heterogeneity in clinical and biochemical profile

Clinical and biochemical studies were carried out in 33 patients with diabetes secondary to chronic calcific, non-alcoholic pancreatitis (tropical pancreatic diabetes) and in 35 Type 2 (non-insulin-dependent) diabetic patients and 35 non-diabetic subjects. Despite lower body mass indices, only 25% of patients with tropical pancreatic diabetes had clinical evidence of malnutrition. There was no history of cassava ingestion. Mean serum cholesterol concentration was significantly lower in the tropical pancreatic diabetic patients (p less than 0.01) in comparison with the Type 2 diabetic patients or non-diabetic subjects, due to a significantly decreased concentration of LDL cholesterol (p less than 0.01) and VLDL cholesterol (p less than 0.05). Basal and post-glucose stimulated concentrations of serum C-peptide were highest in those pancreatic diabetic patients (n = 11) who responded to oral hypoglycaemic drugs, intermediate in the majority (n = 17), who were insulin dependent and ketosis resistant and negligible in a small sub-group (n = 5) who were ketosis prone. The occurrence of microangiopathy in pancreatic diabetic patients was common and similar to that in Type 2 diabetic patients. Thus, tropical pancreatic diabetes in South India appears to be heterogeneous with respect to level of nutrition, severity of glucose intolerance, B-cell function, response to therapy and the occurrence of microvascular complications.

A computerized record and verify system for radiation treatments

We have developed a general purpose, comprehensive, and highly reliable computerized Record and Verify System to detect and prevent mistakes in the delivery of external beam radiation therapy. This system helps prevent accidental delivery of dangerous dose, improves quality control, and provides invaluable record keeping and report generating capabilities. Currently, treatment machine and couch parameter settings of four different machines are monitored by the system and compared with prescribed values. The system inhibits a machine from being turned on if the settings do not agree with the prescribed values to within specified maximum permissible deviations. The system is user-friendly and provides useful, complete, and easily accessible data. We describe many aspects of the system including hardware, software, data, and operation, and we conclude with a brief discussion of clinical experience and preliminary data.

Epidemiologic and laboratory observations of Chlamydia psittaci infection in pet birds

Psittacosis was diagnosed in 13 (24%) of 55 pet bird submissions in the first 3 months of 1983, compared with 18 (17%) of 103 in 1982, 4 (4.6%) of 87 in 1981, and 3 (8%) of 36 in 1980. The numbers and types of birds in which psittacosis was diagnosed were 2 of 47 budgerigars, 8 of 45 cockatiels , 3 of 11 small parrots ( lovebirds , conures ), 20 of 116 medium-sized parrots (African Grays, Amazons ), 2 of 21 macaws , and 3 of 21 cockatoos . Thirty-nine percent of psittacosis-positive birds were received from pet bird owners, compared with 21% from pet shops, 18% from pet bird breeders and fanciers, and 13% from pet bird jobbers and retailers . Most frequently observed clinical signs were anorexia, weight loss, and diarrhea or yellowish droppings. Major gross lesions were splenohepatomegaly (77%), followed by enteritis (53%), sinusitis (47%), airsacculitis (37%), pneumonitis (23%), and pericarditis (10%). Regarding the 38 cases of confirmed psittacosis in pet birds since 1980, transmission of the disease to human beings was confirmed in 2 cases and suspected in 4 cases.

Increased LDL cholesterol in non-insulin-dependent diabetics with maculopathy

Serum cholesterol and its various lipoprotein fractions and triglycerides were measured in 50 non-insulin-dependent diabetic patients, 25 without retinopathy (group A) and 25 with diabetic maculopathy (group B) initially before control of diabetes, and again, after achieving good metabolic control. The lipid parameters were also estimated in 25 healthy non-diabetic subjects. The groups were well matched for sex, age, duration of diabetes and body weight. Mean serum total cholesterol and LDL cholesterol levels were significantly higher in group B when compared to group A, before and after achieving good metabolic control of diabetes (p less than 0.001). Mean total/HDL cholesterol and mean LDL/HDL cholesterol ratios were also significantly increased in group B as compared to group A (p less than 0.01) both before and after good diabetic control in these patients. Mean serum HDL and VLDL cholesterol and triglyceride concentrations were similar in groups A and B. The mean serum lipid concentrations in the diabetic patients without retinopathy (group A) were comparable to those of non-diabetic subjects.

Sources of electron contamination for the Clinac-35 25-MV photon beam

A detailed Monte Carlo approach has been employed to investigate the sources of electron contamination for the 25-MV photon beam generated by Varian's Clinac-35. Three sources of contamination were examined: (a) the flattening filter and beam monitor chamber, (b) the fixed primary collimators downstream from the monitor chamber and the adjustable photon jaws, and (c) the air volume separating the treatment head from the observation point. Five source-to-surface distances (SSDs) were considered for a single field size, 28 cm in diameter at 80 cm SSD. It was found that for small SSDs (80-100 cm), the dominant sources of electron contamination were the flattening filter and the beam monitor chamber which accounted for 70% of the unwanted electrons. Thirteen percent of the remaining electrons originated in the downstream primary collimators and the photon jaws, and 17% were produced in air. At larger SSDs, the fraction of unwanted electrons originating in air increased. At 400 cm SSD, 61% of the contaminating electrons present in the beam were produced in air, 34% originated in the flattening filter and beam monitor chamber, and 5% were due to interactions in the fixed collimators downstream from the monitor chamber and the adjustable photon jaws. These calculated results are substantiated by recent experiments.

Response of citrus to vesicular–arbuscular mycorrhizal inoculation in unsterile soils

Response of citrus to inoculation with the endomycorrhizal fungus Glomus fasciculatum in four soil types of India was studied under greenhouse conditions. Inoculation increased the dry weight of shoot and root and nutrient content of plants. Plants grown in sandy soils responded to a greater extent compared with plants grown in clayey or lateritic soils. The results brought out that mycorrhizal inoculation could be beneficial in certain unsterile soils in spite of the presence of native endophytes.

Standardization of therapy machine interface for treatment monitoring

Computerized monitoring of radiation treatments is an effective tool in detecting and preventing errors in treatment delivery. Most manufacturers now supply optional treatment monitoring (Record and Verify) systems. These differ significantly in their features and are, in general, incompatible with each other. Based on our examination of four different commercial systems, we believe that these commercial and individualized systems are not adequate and are difficult to use. In a radiation therapy facility with more than one treatment machine, it is highly desirable, for a variety of reasons, that such a system be implemented on a central computer which monitors all machines. A centralized record and verify system which allows the storage of all data on a long term basis in an on-line common data base permits much easier access to individual patient data as well as useful data analysis and reports. Every patient's demographic, prescription and treatment data are then available on all treatment machines. This is particularly useful for cases in which a patient may be transferred from one machine to the other. Such a system is also easier to operate. The development of such a treatment monitoring system requires that the protocol of communication between the therapy machine and the computer, and the data describing therapy machine settings transmitted to the computer be standardized. We propose that every manufacturer supply an optional interface meeting this standard. A description of the proposed standard evolved in four years of our work in this field is given.

Investigation of buildup dose from electron contamination of clinical photon beams

The contribution made by contaminating electrons present in a clinical photon beam to the buildup dose in a polystyrene phantom has been calculated and compared to measurements. A Monte Carlo technique was employed. The calculation was divided into two parts. First, the accelerator treatment head was simulated in detail using the EGS-PEGS electromagnetic shower code. Then, information obtained from these calculations was used to compute dose curves in a polystyrene phantom. Two cases were considered, one in which both electrons and photons were incident upon the phantom, and another in which electrons were eliminated from the incident beam. Results of these calculations agree with recent experimental findings. A decrease in buildup dose as well as a shift in dmax was observed when electrons were eliminated from the beam.