Multiscale design of cell-free biologically active architectural structures

Cell-free protein expression systems are here combined with 3D-printed structures to study the challenges and opportunities as biofabrication enters the spaces of architecture and design. Harnessing large-scale additive manufacturing of biological materials, we examined the addition of cell-free protein expression systems ("TXTL" i.e., biological transcription-translation machinery without the use of living cells) to printed structures. This allowed us to consider programmable, living-like, responsive systems for product design and indoor architectural applications. This emergent, pluripotent technology offers exciting potential in support of health, resource optimization, and reduction of energy use in the built environment, setting a new path to interactivity with mechanical, optical, and (bio) chemical properties throughout structures. We propose a roadmap towards creating healthier, functional and more durable systems by deploying a multiscale platform containing biologically-active components encapsulated within biopolymer lattices operating at three design scales: (i) supporting cell-free protein expression in a biopolymer matrix (microscale), (ii) varying material properties of porosity and strength within two-dimensional lattices to support biological and structural functions (mesoscale), and (iii) obtaining folded indoor surfaces that are structurally sound at the meter scale and biologically active (we label that regime macroscale). We embedded commercially available cell-free protein expression systems within silk fibroin and sodium alginate biopolymer matrices and used green fluorescent protein as the reporter to confirm their compatibility. We demonstrate mechanical attachment of freeze-dried bioactive pellets into printed foldable fibrous biopolymer lattices showing the first steps towards modular multiscale fabrication of large structures with biologically active zones. Our results discuss challenges to experimental setup affecting expression levels and show the potential of robust cell-free protein-expressing biosites within custom-printed structures at scales relevant to everyday consumer products and human habitats.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

COVID-19 DIAGNOSIS BY POINT OF CARE LUNG ULTRASOUND: A NOVEL DEEP LEARNING ARTIFICIAL INTELLIGENCE METHOD

BACKGROUND

METHODS AND RESULTS

CONCLUSION

Determining the Effectiveness of a New Device for Hand Therapy (The FEPSim Device): Feasibility Protocol for a Randomized Controlled Trial Study

Background

Impairments of the forearm, wrist, and hand affect a sizable proportion of individuals and impose a significant economic burden on health care systems. FEPSim is a medical device for hand and wrist rehabilitation. The FEPSim device could be part of the standard of care for upper extremity rehabilitation during therapeutic activities to increase range of motion, dexterity, and strength. FEPSim has not yet been tested in a health care setting; therefore, a trial of the effectiveness of FEPSim in upper extremity rehabilitation is warranted.

Objective

This study aims to assess the feasibility of conducting a definitive trial in terms of recruitment, eligibility criteria, the type and number of diagnoses included, the length and dosage of the intervention, and data collection methods. This study also aims to gather clinical and statistical information as well as information related to the cost and usability, which allows for an economic evaluation of the device.

Methods

The trial will use a randomized controlled design comprising 47 intervention participants and 47 control group participants. Participants will be adults (age≥18 years) attending outpatient rehabilitation with limitations in their forearm, wrist, or hand function due to distal radial or ulnar fractures, stroke, or osteoarthritis. This study’s primary outcome variables are related to patients’ range of motion and strength, specifically active and passive wrist flexion and extension range of motion; active and passive forearm pronation and supination range of motion; grip strength; and pinch strength. The secondary outcome variables are related to patients’ perceived wrist pain and disability in activities of daily living. The patients’ perceived wrist pain and disability in activities of daily living will be measured using the patient-rated wrist evaluation questionnaire. The control group will receive the standard of care at each of the 2 hospital facilities (Glenrose Rehabilitation and Royal Alexandra Hospitals). The intervention group will receive the same standard of care as the control group at each facility and will use the FEPSim device for therapeutic activities to increase strength, range of motion, resistance, and dexterity. All the participants will be assessed at baseline (week 0); weeks 2, 4, and 8; and postintervention (week 10).

Results

The FEPSim study was launched in April 2020. This study is currently on hold because of the global COVID-19 pandemic. The recruitment process is expected to resume by September 2020, and the primary impact analysis is expected to be conducted by December 2020.

Conclusions

This study will provide valuable information on the measurement of comparative intervention effects, technology acceptance by hand therapists, and how associated treatment and product costs will contribute to the evidence planning process, which will be crucial for the future adoption of FEPSim.

Trial Registration

International Standard Randomized Controlled Trial Number Registry ISRCTN13656014; https://www.isrctn.com/ISRCTN13656014

International Registered Report Identifier (IRRID)

PRR1-10.2196/22145

Clinical commissioning of intensity-modulated proton therapy systems: Report of AAPM Task Group 185

Proton therapy is an expanding radiotherapy modality in the United States and worldwide. With the number of proton therapy centers treating patients increasing, so does the need for consistent, high-quality clinical commissioning practices. Clinical commissioning encompasses the entire proton therapy system's multiple components, including the treatment delivery system, the patient positioning system, and the image-guided radiotherapy components. Also included in the commissioning process are the x-ray computed tomography scanner calibration for proton stopping power, the radiotherapy treatment planning system, and corresponding portions of the treatment management system. This commissioning report focuses exclusively on intensity-modulated scanning systems, presenting details of how to perform the commissioning of the proton therapy and ancillary systems, including the required proton beam measurements, treatment planning system dose modeling, and the equipment needed.

Can CT imaging improve targeting accuracy in clip-based proton therapy of ocular melanoma?

To evaluate the benefit of adding CT imaging to the simulation process of clip-based proton therapy of ocular melanomas. For thirty ocular melanoma cases, the clip position in the eye model was determined based on orthogonal radiographs as well as on a CT image set. The geometrical shift of the clips between the standard simulation process and standard simulation process with addition of CT imaging (CT-guided) was determined. The dosimetric impact was evaluated by developing treatment plans based on both the standard-process model and the CT-guided model. In 40% of the studied cases, the difference in clip position between eye models created with and without CT was less than 0.5 mm. This difference was more than 1 mm in 17% of cases. The dosimetric impact of shifts below 1 mm was low because these shifts did not exceed the planning margins. For the four cases with a shift of more than 1 mm a reduction in target coverage (ΔV99%) of  -3% to  -6% was observed. Changes in macula and optic-disc mean dose of up to 16% and 35% of the prescribed dose were seen when these structures abutted the target. Adding CT imaging to the simulation process is beneficial in select cases where discrepancies between the eye model and ophthalmology measurements occur or where a critical structure is located close to the target and improved localization accuracy is wanted. For the majority of patients, addition of CT imaging does not result in quantifiable changes in dosimetry. Nevertheless, CT imaging is a valuable tool in the quality control of the modeling and treatment-planning process of clip-based eye treatments.

Prognostic factors of radiation dermatitis following passive-scattering proton therapy for breast cancer

BACKGROUND

To identify prognostic factors for grade 3 radiation dermatitis following passive-scattering proton therapy for breast cancer.

METHODS

This retrospective study included data on 23 (11 post-mastectomy and 12 post-lumpectomy) breast cancer patients who underwent proton therapy with the passive scattering technique in our institute from 2012 to 2016. Each patient received 50-50.4 cobalt Gy equivalent (CGE) at 1.8 or 2 CGE per daily fraction. Logistic regression analysis was performed to identify prognostic factors for grade 3 skin toxicity. Receiver operating characteristic (ROC) curve analysis and the area under the curve (AUC) were used to evaluate the performance of the models.

RESULTS

43% of the studied patients developed grade 3 radiation dermatitis. The dose-volume histogram (DVH) parameters of V52.5CGE and D10cm³ to skin5mm were correlated with grade 3 radiation dermatitis in both univariate and multivariate logistic regression analyses. Univariate logistic regression analysis suggested that D10cm³ to skin5mm (AUC = 0.69) and V52.5CGE to skin5mm (AUC = 0.70) were prognostic for grade 3 skin toxicity. The models using the combination of D10cm³ to skin5mm or V52.5CGE to skin5mm with breast volume marginally increased the AUC to 0.72 and 0.73, respectively. Models using the combination of D10cm³ to skin5mm or V52.5CGE to skin5mm with history of smoking increased the AUC to 0.75 and 0.83, respectively.

CONCLUSION

In the current study, we identified prognostic factors for grade 3 radiation dermatitis in patients treated with passive-scattering proton therapy for breast cancer. This study provides promising tool for identifying high risk patients for whom treatment plan adjustment could be done to reduce the risk of radiation-induced grade 3 skin toxicity.

Facilitating integration of regulated pharmacy technicians into community pharmacy practice in Ontario: Results of an exploratory study

Background

The integration of regulated pharmacy technicians (RPTs) into community pharmacy practice was intended to relieve pharmacists of certain technical duties to facilitate greater provision of direct patient care services, commensurate with expanded scope of practice. There is scant data available regarding the success, value and impact of RPT integration, either in Canada or in other jurisdictions.

Methods

Pharmacists and RPTs working in community practices were interviewed. Qualitative data were categorized using an iterative coding process to identify themes related to barriers and facilitators to integrating and optimizing the role of the RPT in community practice in Ontario.

Results

A total of 16 RPTs and 12 pharmacists were interviewed from community sites in Ontario. Strategies for facilitating successful integration of RPTs into daily workflow were identified, based on 4 major themes: environmental factors, interpersonal factors, professional identity formation and innovative use of delegation.

Interpretation

Integration of RPTs into community practice is complex and requires careful management, planning, training and follow-up to ensure attainment of objectives. Simply hiring RPTs and placing them into existing workflow patterns is generally not a successful implementation strategy.

Conclusions

Implementation strategies identified through this study can provide employers, managers, pharmacists and RPTs with opportunities to enhance RPT integration and optimize the role of both pharmacists and RPTs in community practice.

Evaluation of the range shifter model for proton pencil-beam scanning for the Eclipse v.11 treatment planning system

Existing proton therapy pencil‐beam scanning (PBS) systems have limitations on the minimum range to which a patient can be treated. This limitation arises from practical considerations, such as beam current intensity, layer spacing, and delivery time. The range shifter (RS) — a slab of stopping material inserted between the nozzle and the patient — is used to reduce the residual range of the incident beam so that the treatment ranges can be extended to shallow depths. Accurate modeling of the RS allows one to calculate the beam spot size entering the patient, given the proton energy, for arbitrary positions and thicknesses of the RS in the beam path. The Eclipse version 11 (v11) treatment planning system (TPS) models RS‐induced beam widening by incorporating the scattering properties of the RS material into the V‐parameter. Monte Carlo simulations with Geant4 code and analytical calculations using the Fermi‐Eyges (FE) theory with Highland approximation of multiple Coulomb scattering (MCS) were employed to calculate proton beam widening due to scattering in the RS. We demonstrated that both methods achieved consistent results and could be used as a benchmark for evaluating the Eclipse V‐parameter model. In most cases, the V‐parameter model correctly predicted the beam spot size after traversing the RS. However, Eclipse did not enforce the constraint for a nonnegative covariance matrix when fitting the spot sizes to derive the phase space parameters, which resulted in incorrect calculations under specific conditions. In addition, Eclipse v11 incorrectly imposed limits on the individual values of the phase space parameters, which could lead to incorrect spot size values in the air calculated for beams with spot sigmas <3.8 mm. Notably, the TPS supplier (Varian) and hardware vendor (Ion Beam Applications) inconsistently refer to the RS position, which may result in improper spot size calculations.

PACS number(s): 87.53.Jw, 87.53.Kn, 87.55.kd, 87.56.‐v

Outcomes of Sinonasal Cancer Treated With Proton Therapy

PURPOSE

To report disease outcomes after proton therapy (PT) for sinonasal cancer.

METHODS AND MATERIALS

Eighty-four adult patients without metastases received primary (13%) or adjuvant (87%) PT for sinonasal cancers (excluding melanoma, sarcoma, and lymphoma). Common histologies were olfactory neuroblastoma (23%), squamous cell carcinoma (22%), and adenoid cystic carcinoma (17%). Advanced stage (T3 in 25% and T4 in 69%) and high-grade histology (51%) were common. Surgical procedures included endoscopic resection alone (45%), endoscopic resection with craniotomy (12%), or open resection (30%). Gross residual disease was present in 26% of patients. Most patients received hyperfractionated PT (1.2 Gy [relative biological effectiveness (RBE)] twice daily, 99%) and chemotherapy (75%). The median PT dose was 73.8 Gy (RBE), with 85% of patients receiving more than 70 Gy (RBE). Prognostic factors were analyzed using Kaplan-Meier analysis and proportional hazards regression for multiple regression. Dosimetric parameters were evaluated using logistic regression. Serious, late grade 3 or higher toxicity was reported using the National Cancer Institute Common Terminology Criteria for Adverse Events, version 4. The median follow-up was 2.4 years for all patients and 2.7 years among living patients.

RESULTS

The local control (LC), neck control, freedom from distant metastasis, disease-free survival, cause-specific survival, and overall survival rates were 83%, 94%, 73%, 63%, 70%, and 68%, respectively, at 3 years. Gross total resection and PT resulted in a 90% 3-year LC rate. The 3-year LC rate was 61% for primary radiation therapy and 59% for patients with gross disease. Gross disease was the only significant factor for LC on multivariate analysis, whereas grade and continuous LC were prognostic for overall survival. Six of 12 local recurrences were marginal. Dural dissemination represented 26% of distant recurrences. Late toxicity occurred in 24% of patients (with grade 3 or higher unilateral vision loss in 2%).

CONCLUSIONS

Dose-intensified, hyperfractionated PT with or without concurrent chemotherapy results in excellent LC after gross total resection, and results in patients with gross disease are encouraging. Patients with high-grade histology are at greater risk of death from distant dissemination. Continuous LC is a major determinant of survival justifying aggressive local therapy in nearly all cases.

Development of a golden beam data set for the commissioning of a proton double-scattering system in a pencil-beam dose calculation algorithm

PURPOSE

The purpose of this investigation is to determine if a single set of beam data, described by a minimal set of equations and fitting variables, can be used to commission different installations of a proton double-scattering system in a commercial pencil-beam dose calculation algorithm.

METHODS

The beam model parameters required to commission the pencil-beam dose calculation algorithm (virtual and effective SAD, effective source size, and pristine-peak energy spread) are determined for a commercial double-scattering system. These parameters are measured in a first room and parameterized as function of proton energy and nozzle settings by fitting four analytical equations to the measured data. The combination of these equations and fitting values constitutes the golden beam data (GBD). To determine the variation in dose delivery between installations, the same dosimetric properties are measured in two additional rooms at the same facility, as well as in a single room at another facility. The difference between the room-specific measurements and the GBD is evaluated against tolerances that guarantee the 3D dose distribution in each of the rooms matches the GBD-based dose distribution within clinically reasonable limits. The pencil-beam treatment-planning algorithm is commissioned with the GBD. The three-dimensional dose distribution in water is evaluated in the four treatment rooms and compared to the treatment-planning calculated dose distribution.

RESULTS

The virtual and effective SAD measurements fall between 226 and 257 cm. The effective source size varies between 2.4 and 6.2 cm for the large-field options, and 1.0 and 2.0 cm for the small-field options. The pristine-peak energy spread decreases from 1.05% at the lowest range to 0.6% at the highest. The virtual SAD as well as the effective source size can be accurately described by a linear relationship as function of the inverse of the residual energy. An additional linear correction term as function of RM-step thickness is required for accurate parameterization of the effective SAD. The GBD energy spread is given by a linear function of the exponential of the beam energy. Except for a few outliers, the measured parameters match the GBD within the specified tolerances in all of the four rooms investigated. For a SOBP field with a range of 15 g/cm2 and an air gap of 25 cm, the maximum difference in the 80%-20% lateral penumbra between the GBD-commissioned treatment-planning system and measurements in any of the four rooms is 0.5 mm.

CONCLUSIONS

The beam model parameters of the double-scattering system can be parameterized with a limited set of equations and parameters. This GBD closely matches the measured dosimetric properties in four different rooms.

A Web application for the management of clinical workflow in image-guided and adaptive proton therapy for prostate cancer treatments

Image‐guided radiotherapy (IGRT), based on radiopaque markers placed in the prostate gland, was used for proton therapy of prostate patients. Orthogonal X‐rays and the IBA Digital Image Positioning System (DIPS) were used for setup correction prior to treatment and were repeated after treatment delivery. Following a rationale for margin estimates similar to that of van Herk,⁽¹⁾ the daily post‐treatment DIPS data were analyzed to determine if an adaptive radiotherapy plan was necessary. A Web application using ASP.NET MVC5, Entity Framework, and an SQL database was designed to automate this process. The designed features included state‐of‐the‐art Web technologies, a domain model closely matching the workflow, a database‐supporting concurrency and data mining, access to the DIPS database, secured user access and roles management, and graphing and analysis tools. The Model‐View‐Controller (MVC) paradigm allowed clean domain logic, unit testing, and extensibility. Client‐side technologies, such as jQuery, jQuery Plug‐ins, and Ajax, were adopted to achieve a rich user environment and fast response. Data models included patients, staff, treatment fields and records, correction vectors, DIPS images, and association logics. Data entry, analysis, workflow logics, and notifications were implemented. The system effectively modeled the clinical workflow and IGRT process.

PACS number: 87

Hepatosplenic T-cell lymphoma, immunosuppressive agents and biologicals: what are the risks?

We present three cases of the rare hepatosplenic T-cell lymphoma (HSTCL); two patients suffering from Crohn disease who developed HSTCL on azathioprine without exposure to biologicals, and a third patient who had psoriasis treated using etanercept, cyclosporine and methotrexate. The evidence for an association between HSTCL and immunosuppressive drugs and biologicals is reviewed. We argue for improved pharmacovigilance processes to help determine the benefit to risk ratios for the use of these and other new agents.

A simplified methodology to produce Monte Carlo dose distributions in proton therapy

The purpose of this study was to develop a simplified methodology that will produce Monte Carlo (MC) dose distribution for proton therapy which can be used as a clinical aid in determining the adequacy of proton plans produced from the treatment planning system (TPS). The Geant4 Monte Carlo toolkit was used for all simulations. The geometry of the double scatter nozzle in the simulation was a simplification of the treatment nozzle. The proton source was modeled as discrete energy layers, each with a unique energy distribution and weighting factor. The simplified MC system was designed to give the same dose distribution as the measured data used to commission the TPS. After the simplified MC system was finalized, a series of verification comparisons were made between it, measurements, and the clinically used TPS. Comparisons included the lateral profile of a stair‐shaped compensator that simulated a sharp lateral heterogeneity and depth‐dose measurements through heterogeneous materials. The simplified MC system matched measurements to within 2% or 2 mm for all commissioning data under investigation; moreover, the distal edge and lateral penumbra was within 1 mm of the measurements. The simplified MC system was able to better reproduce the measured profiles for a stair‐shaped compensator than the TPS. Both MC and TPS matched the measured depth dose through heterogeneous materials to within 2% or 2 mm. The simplified MC system was straightforward to implement, and produced accurate results when compared to measurements. Therefore, it holds promise as a clinically useful methodology to validate the relative dose distribution of patient treatment plans produced by the treatment planning systems.

PACS number: 87.55.K‐, 87.55.ne

Stiff fingers as an unwanted side effect of intravascular tadalafil gel abuse

The internet provides the public with unregulated access to a wide range of medications. We present the case of a 43-year-old man who purchased oral tadalafil gel on the internet and injected it into his left radial artery. He presented 48 hours after injection with signs of ischaemia distal to the injection site requiring a combination of medical and surgical treatment. This unique case highlights the potential dangers of unregulated access to medication and the consequences of intravascular injection of oral gels.

A dosimetric comparison of intensity-modulated proton therapy optimization techniques for pediatric craniopharyngiomas: a clinical case study

BACKGROUND

To evaluate the dosimetric characteristics of intensity-modulated proton therapy (IMPT) optimization techniques and pencil-beam scanning (PBS) nozzle designs on pediatric craniopharyngiomas.

PROCEDURE

We compared a double-scatter (DS) plan with IMPT plans using single-field uniform dose (SFUD) optimization or multi-field optimization (MFO) and different PBS nozzles. The clinical impacts of SFUD versus MFO, range shifters, and two different PBS nozzles were compared. For target coverage assessment, the conformity index and inhomogeneity coefficient were evaluated.

RESULTS

Although both proton therapy techniques achieved adequate target coverage, IMPT achieved a better conformity index of 0.78 versus 0.60 for DS. For the inhomogeneity coefficient, IMPT with MFO performed better than using SFUD or DS. MFO with the dedicated nozzle (MFO-DN) achieved the best result of 0.023, as compared to values of 0.03 or higher for the other plans. IMPT achieved lower doses to the normal tissues, as compared to DS; MFO-DN had the best results. The DN provided the best beam-spot characteristics and the sharpest lateral penumbra. MFO reduced the need for range shifters.

CONCLUSIONS

As compared to DS proton therapy for pediatric craniopharyngiomas, IMPT achieved significantly better target coverage and dose sparing of normal tissue. Nozzle designs that provided small beam spots and sharp lateral penumbra allowed for better target coverage and reduced dose to normal tissue. In the case of shallow targets, MFO, in contrast to SFUD, required minimal use of range shifters, which preserved the penumbra and the dosimetric advantage. MFO-DN proved to be the optimal technique for IMPT.

Proton therapy for skull base chordomas: an outcome study from the university of Florida proton therapy institute

Objectives Skull base chordoma is a rare, locally aggressive tumor located adjacent to critical structures. Gross total resection is difficult to achieve, and proton therapy has the conformal advantage of delivering a high postoperative dose to the tumor bed. We present our experience using proton therapy to treat 33 patients with skull base chordomas. Design Retrospective outcomes study. Setting University of Florida Proton Therapy Institute; 2007 to 2011. Participants A total of 33 patients with skull base chordomas received postoperative three-dimensional conformal proton therapy. The patients were 79% male and 6% diabetic; 27% had received a gross total resection. Main Outcome Measures The gross tumor/tumor bed received a dose between 77.4 CGE and 79.4 CGE. Local control and overall survival were tracked, and radiation toxicity was assessed using a modified Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer Late Radiation Morbidity Scoring Scheme. Results Median follow-up for all patients was 21 months. Local control and overall survival rates at 2 years were 86% and 92%, respectively. Grade 2 toxicity was observed in 18% of our cohort in the form of unilateral hearing loss partially corrected with a hearing aid. No grade 2 or higher optic or brainstem toxicities were observed. Conclusions Proton therapy is an effective treatment modality for skull base chordomas.

Proton therapy for head and neck cancer: rationale, potential indications, practical considerations, and current clinical evidence

There is a strong rationale for potential benefits from proton therapy (PT) for selected cancers of the head and neck because of the opportunity to improve the therapeutic ratio by improving radiation dose distributions and because of the significant differences in radiation dose distribution achievable with x-ray-based radiation therapy (RT) and PT. Comparisons of dose distributions between x-ray-based and PT plans in selected cases show specific benefits in dose distribution likely to translate into improved clinical outcomes. However, the use of PT in head and neck cancers requires special considerations in the simulation and treatment planning process, and currently available PT technology may not permit realization of the maximum potential benefits of PT. To date, few clinical data are available, but early clinical experiences in sinonasal tumors in particular suggest significant improvements in both disease control and radiation-related toxicity.

Dosimetric characterization of whole brain radiotherapy of pediatric patients using modulated proton beams

This study was designed to investigate dosimetric variations between proton plans with (PPW) and without (PPWO), a compensator for whole brain radiotherapy (WBRT). The retrospective study on PPW and PPWO in Eclipse and XiO systems and photon plans (XP) using controlled segments in Pinnacle system was performed on nine pediatric patients for craniospinal irradiations. DVHs and derived metrics, such as the homogeneity index (HI), the doses to 2%(D2%) and 5%(D5%) volumes, and mean dose (Dmean) of the whole brain (i.e., PTV), and the organs at risk (OARs) such as lens and skull, were obtained. The PPW plans from both Eclipse and XiO systems uncovered the following advantages: (1) encompassing a cribriform plate area with the 100% isodose line was better than either PPWO or XP, according to calculated two‐dimensional distributions of one patient; (2) the mean value of D5% for lens was reduced to 23.6% of DP from 54.1% for PPWO or 41.6% for XP; and (3) the mean value of Dmean for skull was reduced to 94.8% of DP from either 98.4% for PPWO or 98.3% for XP. However, the PPW plans also exposed several disadvantages including: (1) the HI of PTV increased to 7.7 from 4.7 for PPWO or 3.7 for XP; (2) D2% to PTV increased to 108.8% of DP from 104.8% for PPWO or 105.1% for XP; and (3) D5% to the skull increased to 104.9% of DP from 101.6% for PPWO or 103.4% of for XP. One‐half of the observed variations were caused by different penumbra on lateral profiles and distal fall‐off depth doses of protons in Eclipse and XiO. Because the utilization on the sharp proton distal fall‐off was limited for WBRT, the difference between PPW and PPWO or XP indicated no distinguishable improvement by using a compensator in proton plans.

PACS number: 87.55.‐x

Development of gluconeogenesis in neonatal rat liver. Effect of premature delivery

1. An assay method for the determination of phosphopyruvate carboxylase activity is described in which improved sensitivity is obtained by separation of the enzyme from interfering pyruvate kinase by zone sedimentation. 2. The molecular weight of rat liver phosphopyruvate carboxylase determined by zone sedimentation is about 68000. 3. Premature delivery of rat foetuses by uterine section results in the rapid appearance of phosphopyruvate carboxylase, but hexose diphosphatase and pyruvate carboxylase, already present in the foetal rat liver, are not significantly affected, and glucose 6-phosphatase activity is only slightly affected. 4. The rate of incorporation of [(14)C]pyruvate into glucose by liver slices is also greatly increased by premature delivery and there is a highly significant linear correlation between this process and the phosphopyruvate carboxylase activity.

Development of gluconeogenesis in neonatal rat liver. Effect of triamcinolone

1. The normal development of the key enzymes of gluconeogenesis in rat liver, glucose 6-phosphatase, hexose diphosphatase, phosphopyruvate carboxylase and pyruvate carboxylase, was measured during the neonatal period. 2. Glucose 6-phosphatase, hexose diphosphatase and pyruvate carboxylase are all present in the late foetal liver, but all the enzymes show an increase in activity after birth. 3. Phosphopyruvate carboxylase is not present in liver extracts from foetal rats, but activity appears immediately after birth and increases rapidly over the first day and then more slowly to reach its maximum at the fourth postnatal day. 4. The fluorinated synthetic glucocorticoid, triamcinolone, was administered to foetal rats at various gestation times by intraperitoneal injection in utero and the animals were killed at intervals between 4 and 48hr. later. 5. The administration of triamcinolone results in slight depression of glucose 6-phosphatase, and a more significant depression of hexose diphosphatase to about one-half its normal activity in foetal rat liver. 6. Triamcinolone injection is without effect on pyruvate carboxylase activity and does not result in premature appearance of phosphopyruvate carboxylase in foetal rat liver. 7. Pyruvate kinase and aspartate amino-transferase activities in foetal rat liver are both depressed by triamcinolone treatment, whereas phosphofructokinase activity is elevated. 8. Tyrosine amino-transferase activity in foetal rat liver is markedly elevated in animals exposed to triamcinolone for 10hr. or more, but the effect is only observed in animals close to term. 9. The results are discussed in relation to mechanisms involved in the initial synthesis of tissue-specific enzymes in developing tissues, and it is concluded that glucocorticoids do not initiate the synthesis of the gluconeogenic enzymes.