Effects of Interfraction Dose Variations of Target and Organs at Risk on Clinical Outcomes in High Dose Rate Brachytherapy for Cervical Cancer

Meeting dose prescription is critical to control tumors in radiation therapy. Interfraction dose variations (IDVs) from the prescribed dose in high dose rate brachytherapy (HDR) would cause the target dose to deviate from the prescription but their clinical effect has not been widely discussed in the literature. Our previous study found that IDVs followed a left-skewed distribution. The clinical effect of the IDVs in 100 cervical cancer HDR patients will be addressed in this paper. An in-house Monte Carlo (MC) program was used to simulate clinical outcomes by convolving published tumor dose response curves with IDV distributions. The optimal dose and probability of risk-free local control (RFLC) were calculated using the utility model. The IDVs were well-fitted by the left-skewed Beta distribution, which caused a 3.99% decrease in local control probability and a 1.80% increase in treatment failure. Utility with respect to IDV uncertainty increased the RFLC probability by 6.70% and predicted an optimal dose range of 83 Gy-91 Gy EQD2. It was also found that a 10 Gy dose escalation would not affect toxicity. In conclusion, HRCTV IDV uncertainty reduced LC probabilities and increased treatment failure rates. A dose escalation may help mitigate such effects.

Patient-specific dose correction for prostate postimplant evaluation with flexible timing of postimplant imaging

PURPOSE

The dosimetric effect of edema on prostate implants have long been realized, but large uncertainties still exist in the estimation of dose actually received by the prostate. This study attempted to develop a new method to accurately estimate dose delivered to the prostate accounting for the variation of prostate volume and seed distribution, edema half-lives, and times for postimplant evaluation.

METHODS AND MATERIALS

A series of prostate seed implants for Cs-131, Pd-103, and I-125 with various prostate volumes were simulated in a water phantom using the TG-43 algorithm on the Varian Eclipse treatment planning system. Dose analysis was performed to derive a quantitative relationship between the prostate peripheral dose and the prostate radius with the variation of prostate volume and seed distribution. Using this relationship to calculate dynamically, the total dose accumulated in the prostate (D_T ) accounting for the variation of prostate volume and seed distribution and edema half-lives. Moreover, the total dose can be estimated statically based on the prostate volume that can be determined in a computerized tomography (CT) image taken at a time after implantation. The statically estimated total dose (D_CT ) was compared with D_T to determine optimal imaging times as well as dose correction factors for other imaging times.

RESULTS

An inverse power law was established between the prostate peripheral dose and prostate radius. The value of the power was 1.3 for Cs-131 and I-125, and 1.5 for Pd-103, respectively. D_T was derived dynamically using the inverse power law. Given the edema half-lives, T_E , of 4, 9.3, and 25 days and the volume expansion of 1.1 and 2.0 times of the prostate without edema, the optimal times for postimplant imaging were: 7, 9, and 16 days for T_E  = 4 days; 10, 14, and 28 days for T_E  = 9.3 days; and 12, 19, 45 days T_E  = 25 days, for Cs-131, Pd-103, and I-125, respectively. D_CT calculated using the prostate volume determined on the optimal days agreed with D_T to 0.0%-1.8% and within 0.3% for most cases. For various prostate volumes, edema half-lives, and nonoptimal times, D_CT was able to achieve a 1% accuracy.

CONCLUSION

The postimplant dose calculation based on the proposed inverse power law for prostate seed implants with edema has improved the accuracy of postimplant dosimetry with accurate and patient-specific dose corrections accounting for prostate size, edema half-life, and postimplant imaging times. Optimal times for postimplant imaging have been accurately determined, and the high accuracy of postimplant dose calculation can be achieved for both optimal imaging times and nonoptimal imaging times.

Statistical Analysis of Interfraction Dose Variations of High-Risk Clinical Target Volume and Organs at Risk for Cervical Cancer High-Dose-Rate Brachytherapy

Purpose

High-dose-rate (HDR) brachytherapy for cervical cancer treatment includes significant uncertainties. The aim of this study was to quantify the interfraction dosimetric variation (IDV) of the high-risk clinical target volume (HRCTV) from the prescribed dose and the corresponding effect on organ-at-risk (OAR) dose based on a comprehensive statistical analysis.

Methods and Materials

Fifty patients with cervical cancer treated with high-dose-rate intracavity brachytherapy from October 2019 to December 2020 were retrospectively analyzed. The OARs of interest were the rectum, bladder, sigmoid, and bowel. The dosimetric parameters evaluated for all patients was the dose absorbed by 90% of the HRCTV ( D 90 ) and the dose absorbed by 0.1 ( D 0.1 c c ) and 2 cm3 ( D 2 c c ) of each respective OAR. The HRCTV variations were from the prescribed dose and the OAR variations were from the corresponding tolerance dose. Distribution fitting of the HRCTV variations was determined to quantify the IDV. Comparative statistics of the HRCTV variations with the OAR variations were conducted to determine correlations.

Results

The mean HRCTV variation from the prescribed dose was -2.53% ± 8.74%. The HRCTV variations and OAR variations showed moderate to weak linear correlations despite the variations being relative to each other, with the bladder D 2 c c having the strongest correlation. There was a 30.0% (±2.62%, 95% confidence interval) probability of underdosing the HRCTV (-5% variation from prescription) and a 23.3% (±2.62%, 95% confidence interval) probability of overdosing the HRCTV (+5% variation from prescription). This tendency to underdose the HRCTV was a consequence of HRCTV IDV not being normally distributed.

Conclusions

HRCTV dosimetric variations and OAR variations were complexly correlated with the bladder D 2 c c having the strongest correlation. HRCTV IDV was best described as a left-skewed distribution that indicates a tendency of underdosing the HRCTV. The clinical significance of such dose variations is expected and will be further investigated.

Superposed epoch analysis of physiological fluctuations: possible space weather connections

There is a strong connection between space weather and fluctuations in technological systems. Some studies also suggest a statistical connection between space weather and subsequent fluctuations in the physiology of living creatures. This connection, however, has remained controversial and difficult to demonstrate. Here we present support for a response of human physiology to forcing from the explosive onset of the largest of space weather events-space storms. We consider a case study with over 16 years of high temporal resolution measurements of human blood pressure (systolic, diastolic) and heart rate variability to search for associations with space weather. We find no statistically significant change in human blood pressure but a statistically significant drop in heart rate during the main phase of space storms. Our empirical findings shed light on how human physiology may respond to exogenous space weather forcing.

Physico-Chemical Characteristics of Shungite Rock of Kazakhstan

Physico-chemical characteristics of shugite rocks of Kazakhstan (Bakyrchik deposit) were studied using the methods of elementary analysis, IR-spectroscopy, scanning electron microscopy, Raman spectroscopy and X-ray phase analysis. The content of carbon in shungite rock was determined to be from 3% to 19%. The flotation technology for shungite rocks of Kazakhstan was developed, the content of carbon in the concentrate reaching 40.0%. When studying the elemental composition, the mineral part of shungite rocks was stated to be presented, mainly, by silicon, aluminium, calcium, magnesium, potassium, sodium, iron and titanium oxides. IR-spectroscopic investigations showed that in the concentrate, apart from polycyclic hydrocarbons containing methylene groups, there appeared carboxyl groups. The results of scanning electron microscopy (SEM) showed that flotation and thermal activation of shungite rocks on carbon allow obtaining a more developed surface structure and porosity. The structure of shungite carbon was shown by the method of Raman scattering to be close to that of glassy carbon. The results of X-ray diffraction analysis (XRD) of natural shungite rocks showed that the samples under study contained a carbonaceous substance and a number of mineral components: quartz, illite, bassanite, burgerite, muscovite. It is shown that shungite carbon of “Bakyrchik” deposit is identical to shungite of Zazhogino deposit in Russia. The stated physicochemical characteristics allow to determine the directions of the use of carbon concentrate for solution of ecological and technological problems.

Cross-talking between calcium and histamine in the expression of MAPKs in hypertensive vascular smooth muscle cells

Histamine (HA) is one of many neurotransmitters that have been implicated in cardiovascular functioning. Alterations in vascular smooth muscle due to the effects of histamine have been suggested. We investigated the modulatory effect of HA on mitogen activated protein kinase (MAPK) expression, specifically extracellular regulating kinase (ERK) 1 & 2 in vascular smooth muscle cells (VSMCs) from both spontaneously hypertensive (SHR) and control Wistar Kyoto (WKY) rats. Cross-talking between calcium (Ca2+) and HA during HA-induced modulatory effect on MAPK expression in SHR VSMCs was also investigated. A stimulatory increase in expression of ERK 1 & 2 was observed to be dose and time dependent with maximum expression occurring within 5 min in both SHR and WKY VSMCs. The stimulatory increase in expression is persistent for 60 min in SHR VSMCs, whereas, in WKY cells the stimulatory effect persists for only 20 min. Mepyramine, the H1 receptor antagonist, reduced the HA-induced increase in ERK 1 & 2 significantly in SHR VSMCs. A reduction in the HA stimulated increase in ERK 1 & 2 expression was observed at 20 min of exposing cells to diltiazem, the calcium channel blocker, whereas, the calcium chelator, BAPTA effect on ERK 1 & 2 expression was observed within 5 min in SHR VSMCs. The data demonstrates that cross-talking occurs between HA stimulation and Ca2+ induction during HA-induced activation of ERK 1 & 2 in VSMCs of both cell types. Although both intracellular calcium ([Ca2+]i) and extracellular Ca2+ maybe involved in the activation of ERK 1 & 2 by HA, the dependence on [Ca2+]i is more dramatic than the dependence on extracellular Ca2+ in hypertensive cells, which may contribute to the role of HA as a risk factor of hypertension in VSMCs of the aorta.

Protein Kinase C- alpha/betaII, delta, and zeta/lambda involvement in ethanol-induced MAPK expression in vascular smooth muscle cells

Protein Kinase C (PKC) exists as one of twelve serine/threonine isoforms and has been found to mediate ethanol-induced activation of the Mitogen-Activated Protein Kinase (MAPK) pathway. The aim of this study was to determine the PKC isoform(s) that are mediators of ethanol-induced MAPK activity (ERK 1 and 2) and to verify the necessity of calcium in this activation process using cell culture in the presence and absence of ethanol, and other agents that modulate PKC expression. Western blotting analysis was used to assess the effect of ethanol on activating classical (alpha/ssII), novel (delta) and atypical (zeta/lambda) PKC isoforms in vascular smooth muscle cells (VSMCs). The results indicate that ethanol treated VSMCs express the classical PKC-alpha/ssII, novel PKC-delta, and atypical PKC-zeta/lambda isoforms. The expression of PKC-alpha/ssII was inhibited within the first two min of stimulation, followed by activation with maximum expression at 10 min. Similarly, PKC-delta and zeta expressions were suppressed during the first two min of ethanol stimulation with maximum increase in expressions at 10 min. The PKC inhibitor GF109203X and the calcium chelating agent BAPTA, enhanced ethanol-induced PKC expression, whereas, diltiazem reduced expression of PKC by 10% of control. On the other hand, BAPTA in the presence of GF10203X inhibited expression of ERK 1 & 2 downstream from the PKC pathway, whereas, BAPTA alone enhanced expression. These results demonstrate also that classical, novel, and atypical PKCs respond to ethanol during the initial phase of activation of ERK 1 & 2.

Heterogeneity of histamine H3 receptor genomic expression in the cerebral cortex of spontaneously hypertensive rat

Specific binding of [3H]-N-alpha-methylhistamine to homogenates from cerebral cortex tissue was analyzed in aged Wistar Kyoto (WKY) and Spontaneously Hypertensive rats (SHR). Scatchard plot analysis of [3H]-N-alpha-methylhistamine binding of the H3 receptor in the cerebral cortex from aged (6, 9, 12, and 16 week) SHR animals indicated that Bmax increased, respectively, 38.05 +/- 1.58, 59.63 +/- 2.48, 79.17 +/- 5.02, and 84.41 +/- 3.72 fmol/mg of protein. Binding studies using tissue from WKY rats indicated that maximal binding (Bmax) of the ligand to the receptor was not significantly altered. The analyses also yielded Kd values of 5, 7.2, 6.3 and 3.8 nM in SHR tissue respectively. Primers based on the sequence of the third intracellular loop of the H3 receptor were amplified at 35 cycles yielding several amplicons. These amplicons expressed sizes 875, 485, and 280 bp in 6 and 9 week cortical tissue from WKY animals where as in cortical tissue from 6 and 9 week SHR animals only two amplicons were expressed, 485 and 280 bp, respectively. Differences in gene expression for 12 and 16 week WKY and SHR rats were also compared using identical primers. Five amplicons were expressed in cortical tissue from 12 and 16 week WKY rats with 1000, 900, 821, 485, and 430 bp where as in 12 and 16 week SHR animals only one amplicon was expressed at 485 bp. The present results imply (1) that H3 receptor density in cortical tissue of SHR animals increases with age where as the number of the expressed amplicons of the detected H3 receptor decreases; and (2) even though a decrease in number of expressed amplicons of the H3 receptor were observed, an increase in expression of the larger amplicon (~500 bp) is evident.

Ethanol-induced mitogen activated protein kinase activity mediated through protein kinase C

The aim of this study was to determine the pathway(s) by which ethanol activates mitogen-activated protein kinase (MAPK) signaling and to determine the role of Ca2+ in the signaling process. MAPK signaling was determined by assessing MAPK activity, measuring phosphorylated extracellular signaling-regulated kinase (pp 44 ERK-1 and pp 42 ERK-2) expression and ERK activity by measuring ERK-2-dependent phosphorylation of a synthetic peptide as a MAPK substrate in rat vascular smooth muscle cells. Ethanol activated extracellular signal-regulated kinase expression (ERK 1 and 2) could be observed when vascular smooth muscle cells (VSMCs) were stimulated for 5 min or less, but was inhibited when cells are treated for 10 min or more with 1-16 mM of ethanol. Maximum ethanol-induced MAPK activity was observed within 5 min with 4 or 8 mM. Ethanol stimulated MAPK activity was blocked by the protein kinase C (PKC) inhibitor (GF109203X) and epidermal growth factor (EGF) receptor antagonist (PD153035) by 41 +/- 24 and 34 +/- 12.3%, respectively. The calcium channel blocker, diltiazem and the chelating agent, BAPTA, reduced the activation of MAPK activity by ethanol, significantly. The data demonstrate that ethanol-stimulated MAPK expression is mediated partially through both the EGF-receptor and PKC intermediates and that activation through the PKC intermediate is calcium-dependent.

Heart function challenged with beta-receptor agonism or antagonism in a heart failure model

We have shown that chronic treatment with carteolol, a non-selective beta-adrenergic receptor antagonist, improved left ventricular (LV) function and survival in an avian model of dilated cardiomyopathy (DCM). The aim of the present study was to compare ex vivo heart function with and without beta-agonist and antagonist challenge. We investigated whether intracoronary infusion of a beta-blocker, carteolol or beta-agonist, isoproterenol decreased contractility. In the DCM group, isoproterenol resulted in a significantly greater increase in heart rate (71% vs. 28% compared to control hearts). To investigate the mechanism for the increase in heart rate, we exposed spontaneously beating neonatal cardiomyocytes to serum immunoglobulin (IgG) isolated from DCM animals. Serum IgG resulted in a significant increase in spontaneous beating rate in neonatal rat cardiomyocytes that was blocked by pre-treatment with a beta-blocker. Carteolol challenge did not significantly change heart rate but did significantly increase LV peak pressure in DCM hearts (62%) while coronary artery flow remained unchanged (2.7+/-0.1 vs 2.7+/-0.5 ml/min/g). These results show that 1) beta-receptor stimulation results in a greater tachycardic response in DCM animals, and 2) carteolol challenge improves myocardial contractility in hearts from DCM animals independent of heart rate or changes in coronary artery flow.

In vivo histamine release from brain cortex: the effects of modulating cellular and extracellular sodium and calcium channels

The in vivo mechanisms underlying the actions of modulating Na(+)- and Ca(2+)-sensitive channels and its effect on basal histamine release in the cerebral cortex of freely-moving unanesthetized rats was investigated. Basal histamine release in the cerebral cortex was determined by in vivo microdialysis coupled with high-performance liquid chromatography (HPLC) fluorometry detection. Basal levels of histamine were 0.67+/-0.02 pmol/10 microl of dialysate. Diltiazem, a Ca(2+) channel antagonist, produced a dose-dependent decrease in dialysate basal histamine concentration. Elevated K(+) (100 mM) in the perfusion medium increased basal histamine to a maximum of 223% of the baseline value. Similarly, diltiazem (60 mM) reduced the K(+), veratridine (100 microg/ml) and ouabain (100 microM)-evoked increase in dialysate histamine. Basal histamine decreased by 48% when the perfusate contained 3 microM of voltage dependent Na(+) antagonist tetrodotoxin. The results of these studies indicate that the release of histamine in rat cerebral cortex can be induced by modulating Na(+) and Ca(2+) channels and that the L-type voltage-dependent sensitive Ca(2+) channels are involved in this release process.

The use of isolated functional heart to pharmacologically characterize active ingredients in the aqueous extracts of Mareya micrantha

Aqueous extracts of Mareya micrantha are used as folk medicine in West Africa. However, no systemic investigation directed to the identification of the active ingredients in M. micrantha has been done. Therefore, this study investigated the effects of M. micrantha on the cardiac contractility of the isolated frog heart. Also, two sequential fractions from M. micrantha were separated and their effects on cardiac contractility investigated. M. micrantha concentration-dependently suppressed cardiac contractility. Separation of the cardioactive components in series by column chromatography (Sephadex G-50, Column 2.5 x 30 cm and 1 x 20 cm) produced two fractions which facilitated a leftward shift of the dose-response curve of the cardiodepressant effects suggesting that column chromatograph is effective in the isolation of the cardioactive ingredients in M. micrantha. The data suggest that M. micrantha contains cardioactive components and that contractions of the isolated functional frog heart can be used as a pharmacological activity marker during the process of isolation of cardioactive ingredients in M. micrantha.

The effects of stress on lipoproteins and catecholamines in rats

In order to investigate the effects of transportation stress on metabolic activities, we measured the changes in plasma lipoprotein and catecholamine levels in those rats that had just arrived in our Animal Facility and age-matched rats which had acclimatized in the Facility for at least 21 days. The acclimatized rats were considered as control, and the values from the newly arrived rats was done within 4-6 days of their arrival in the Facility. The cholesterol levels in very low-density lipoprotein (VLDL) and low-density lipoprotein (LDL) were higher (71-84%) than the control levels. Also, the stressed animals had higher levels of norepinephrine (4.5-fold) and epinephrine (3-fold) than the control levels. However, dopamine levels was 34-fold lower than that of control. On the basis of the data, we concluded that the change in plasma levels of lipoprotein and catecholamines in response to the transportation stress is significant and may require at least three weeks after the transportation to establish a stable baseline for investigations in which the plasma levels of lipoproteins and catecholamines is a critical factor.

Serotonin-immunoreactive neurons and endogenous serotonin in the opisthosomal ventral nerve cord of the horseshoe crab, Limulus polyphemus

It has been suggested that serotonin serves as a neurotransmitter in the horseshoe crab, Limulus polyphemus. While some studies of identified groups of central neurons have been conducted, little is known concerning the neuronal organization in Limulus central ganglia. This study was undertaken to determine the localization of serotoninergic neurons in the opisthosomal ventral nerve cord of Limulus and to construct a basis for further comparative biochemical and pharmacological studies of the specific function of these neurons. Endogenous serotonin was detected in the ventral nerve cord (chain of abdominal ganglia) by high-performance liquid chromatography and electrochemical detection (HPLC-EC). Endogenous serotonin was quantified in the 9th through 13th ganglia, anterior (hemal) nerves, posterior (branchial) nerves, and connectives. The serotonin content in the abdominal ganglia was significantly reduced when the ganglia were incubated for 24 hours in Leibovitz's (L-15) medium containing reserpine or 5,7-dihydroxytryptamine (5,7-DHT), neurotoxins that block the uptake of serotonin into storage vesicles. The distribution of serotonin-immunoreactive neurons in the ventral nerve cord was determined by indirect immunocytochemistry. Treatment of the chain of ganglia with an anti-serotonin antiserum followed by treatment with a fluorescent-labeled antiserum raised against the primary antibody demonstrated specific staining in each ganglion, the ganglionic roots, and connectives. Clusters of serotonin-immunoreactive neurons were observed anteriolaterally and posteriorly in each ganglion. Processes from dense fiber bundles extended from these clusters of neurons to the central region of each ganglion. These results demonstrate that serotonin-immunoreactive neurons are present in the opisthosomal ventral nerve cord of the horseshoe crab and that serotonin may function as a neurotransmitter.

Emergency thoracotomy: a four-year review

The case records of 200 patients who had emergency thoracotomy for penetrating trauma were reviewed. The mortality was 47% (93/200) for the entire series, 27% (21/79) for stab wounds and 60% (72/121) for gunshot wounds. Of 55 patients who underwent thoracotomy in the emergency department, 8 (15%) survived. Twelve patients "dead" at the scene could not be resuscitated. Nineteen patients sustained cardiac arrest in the ambulance, 3 (16%) of whom survived. Of 19 who had cardiac arrest in the emergency department, 5 (26%) survived. Of 38 patients who had cardiac arrest in the ambulance or emergency department, 14 with stab wounds had a 43% survival and 24 with gunshot wounds had a survival of only 8%. Patients who underwent thoracotomy in the operating room (OR) had a higher survival, 68% (99/145). For those with thoracic, extremity, or neck injuries, survival was 81% (93/115). For those who had an OR thoracotomy for aortic cross-clamping because of abdominal injuries, survival was only 17% (5/30). Early thoracotomy has a place in the management of patients who have cardiac arrest in the ambulance or emergency department because of penetrating chest, neck, or extremity injuries, especially if caused by stab wounds. Cross-clamping of the thoracic aorta for massive abdominal bleeding should be applied selectively.