[Physical characterizations for an integrated 160-leaf multi-leaf collimator with a new concept design]

In this article, we present a physical characterization of the agility(™) (Elekta). agility(™) is composed of 160 interdigitating multileaf collimators (MLCs) with a width of 5 mm at the isocenter. The physical characterizations that include leaf position accuracy, leakage, field penumbra and the tongue-and-groove (T&G) effect were evaluated using well-commissioned 4, 6 and 10-MV photon beams. The leaf position accuracy was within 0.5 mm for all gantry angles and each MLC. The leakage was 0.44% on average and reached 0.47% at 10 MV: remarkably low due to a new design with tilted leaves. However, the T&G effect occurred due to tilt. It was approximately 20.8% on average and reached 22.3% at 6 MV. The penumbra width increased up to 8.5 mm at a field size of 20×20 cm at 4 MV. High position designed MLCs create a wider penumbra but show lower leakage and large head clearance. Head clearance is an important factor in stereotactic radiotherapy with multiple non-coplanar beams.

Lineage-specific purification of neural stem/progenitor cells from differentiated mouse induced pluripotent stem cells

Since induced pluripotent stem (iPS) cells have differentiation potential into all three germ layer-derived tissues, efficient purification of target cells is required in many fields of iPS research. One useful strategy is isolation of desired cells from differentiated iPS cells by lineage-specific expression of a drug-resistance gene, followed by drug selection. With this strategy, we purified neural stem/progenitor cells (NSCs), a good candidate source for regenerative therapy, from differentiated mouse iPS cells. We constructed a bicistronic expression vector simultaneously expressing blasticidin S resistance gene and DsRed under the control of tandem enhancer of a 257-base pair region of nestin second intron, an NSC-specific enhancer. This construct was efficiently inserted into the iPS genome by piggyBac transposon-mediated gene transfer, and the established subclone was differentiated into NSCs in the presence or absence of blasticidin S. Consequently, incubation with blasticidin S led to purification of NSCs from differentiated iPS cells. Our results suggest that a lineage-specific drug selection strategy is useful for purification of NSCs from differentiated iPS cells and that this strategy can be applied for the purification of other cell types.

Clinical features of a new disease concept, IgG4-related thyroiditis

OBJECTIVES

Immunoglobulin (Ig)G4-related disease is a recently proposed systemic disorder that includes autoimmune pancreatitis (AIP), Mikulicz's disease, and various other organ lesions. In the present retrospective study, we examined whether thyroid lesions should also be included in IgG4-related disease (Ig4-RD) under the new term IgG4-related thyroiditis.

METHOD

We enrolled 114 patients with Ig4-RD, including 92 patients with AIP, 15 patients with Mikulicz's disease, and seven patients with IgG4-related cholangitis, and analysed clinical findings, function, serum values of activity markers, computed tomography (CT) images, and histology of the thyroid gland.

RESULTS

Among the 22 patients (19%) in our cohort who were found to have hypothyroidism [thyroid stimulating hormone (TSH) > 4 mIU/L], 11 patients had clinical hypothyroidism [free thyroxine (FT4) < 1 ng/dL] and 11 patients had subclinical hypothyroidism (FT4 ≥ 1 ng/dL). Serum concentrations of IgG, IgG4, circulating immune complex (CIC), and β2-microglobulin (β2-MG) were significantly higher in the hypothyroidism group compared with the remaining 92 euthyroid patients, and serum C3 concentration was significantly lower. After prednisolone treatment, TSH values had decreased significantly (p = 0.005) in this group and FT4 values had increased significantly (p = 0.047). CT images showed that the thyroid glands of patients with clinical hypothyroidism had a significantly greater volume than those of the euthyroid and other groups. Pathological analysis of one resected thyroid gland disclosed a focused lesion with infiltration of lymphocytes and IgG4-bearing plasma cells and loss of thyroid follicles.

CONCLUSIONS

Thyroid lesions associated with hypothyroidism can be considered as a new disease termed IgG4-related thyroiditis. Awareness of this condition should lead to appropriate corticosteroid treatment that may prevent progression to a fibrous state.

[Practical method for six-dimensional online correction system with image guided radiation therapy]

In this study, we developed a correction method for coordinate transformation errors that are produced in combination with the ExacTrac X-ray system (BrainLAB) and HexaPOD (Elekta) in image guided radiation therapy (IGRT). The positional accuracy of the correction method was compared between the ExacTrac Robotics (BrainLAB) and no correction. We tried to correct iBeam evo couch top (Elekta) by operating two steps drive like ExacTrac Robotics. No correction for HexaPOD showed a maximal error of 4.52 mm, and the couch did not move to the correct position. However, our correction method for HexaPOD showed the positional accuracy within 1 mm. Our method has no significant difference with ExacTrac Robotics (paired t-test, P>0.1). But, when the correction values for the rotatory directions were large, the positional accuracy tended to be poor. The smallest setup errors for the rotatory directions are important for IGRT.

[Comparison of various image guided radiation therapy systems; image-guided localization accuracy and patient throughput]

In this study, we evaluated various image guided radiation therapy (IGRT) systems regarding accuracy and patient throughput for conventional radiation therapy. We compared between 2D-2D match (the collation by 2 X-rays directions), cone beam computed tomography (CBCT), and ExacTrac X-Ray system using phantom for CLINAC iX and Synergy. All systems were able to correct within almost 1 mm. ExacTrac X-Ray system showed in particular a high accuracy. As for patient throughput, ExacTrac X-Ray system was the fastest system and 2D-2D match for Synergy was the slowest. All systems have enough ability with regard to accuracy and patient throughput on clinical use. ExacTrac X-Ray system showed superiority with accuracy and throughput, but it is important to note that we have to choose the IGRT technique depending on the treatment site, the purpose, and the patient's state.

[Comparison of dose accuracy between 2D array detectors for pre-treatment IMRT QA]

The dosimetric properties between various 2D array detectors were compared and were evaluated with regard to the accuracy in absolute dose and dose distributions for clinical treatment fields. We used to check the dose accuracy: 2D array detectors; MapCHECK (Sun Nuclear), EPID (Varian Medical Systems), EPID-based dosimetry (EPIDose, Sun Nuclear), COMPASS (IBA) and conventional system; EDR2 film (Eastman Kodak), Exradin A-14SL ion chamber (0.016 cc, Standard Imaging). First, we compared the dose linearity, dose rate dependence, and output factor between the 2D array detectors. Next, the accuracy of the absolute dose and dose distributions were evaluated for clinical fields. All detector responses for the dose linear were in agreement within 1%, and the dose rate dependence and output factor agreed within a standard deviation of ±1.2%, except for EPID. This is because EPID is fluence distributions. In all the 2D array detectors, the point dose agreed within 5% with treatment planning system (TPS). Pass rates of each detector for TPS were more than 97% in the gamma analysis (3 mm/3%). EPIDose was in a good agreement with TPS. All 2D array detectors used in this study showed almost the same accuracy for clinical fields. EPIDose has better resolution than other 2D array detectors and thus this is expected for dose distributions with a small field.

A case of Ramsay Hunt syndrome in living-kidney transplant recipient

A 36-year-old woman underwent ABO-incompatible living-donor kidney transplantation. Immunosuppression was achieved by quadruple therapy with tacrolimus, basiliximab, mycophenolate mofetil (MMF), and prednisone. Desensitization and removal of anti-ABO antibody was achieved by administration of MMF for 4 weeks before transplantation followed by intravenous administration of rituximab, double-filtered plasmapheresis, and plasma exchange. At 1 month after transplantation, she complained of left ear pain without vesicle rash, tinnitus, and vertigo. Physical examination revealed left facial paralysis and nystagmus. T2 fluid-attenuated inversion recovery magnetic resonance imaging (MRI) visualized swelling of the left facial nerve. Real-time polymerase chain reaction showed the existence of varicella zoster virus DNA in the patient's tears and saliva. The final diagnosis was Ramsay Hunt syndrome without vesicle rash, which is called zoster sine herpete. The patient was treated by intravenous administration of acyclovir (3 mg/kg, 3 times per day) in addition to the reduction of the MMF dose. For facial nerve palsy, prednisolone was prescribed for 3 days and then gradually tapered. These treatments improved the symptoms of tinnitus and vertigo after a month; the facial nerve palsy completely disappeared after 10 months. This case demonstrated MRI to be a useful modality for the early diagnosis of Ramsay Hunt syndrome without vesicle eruption.

Changes in quality of life in deceased versus living-donor kidney transplantations

OBJECTIVE

In Japan, >80% of kidney transplantations (KTs) are performed from living donors because of a severe shortage of deceased donors. Moreover, >90% of deceased donors are non-heart-beating donors. In this study, we compared the quality of life (QOL) of the recipients between living- and deceased-donor KT performed in our hospital.

METHODS

QOLs of 91 recipients (11 deceased donors and 80 living donors) were analyzed using the Short Form 36 before and 1, 2, and 3 years after KT. Changes in QOLs were compared between deceased-donor KT (group DD) and living-donor KT (group LD).

RESULTS

In group DD, physical (PCS) and mental (MCS) component summary scores before transplantation were 43.7 and 48.7, respectively. PCS decreased to 35.3 at 1 year and 34.2 at 2 years, but increased to 52.6 at 3 years. MCS as 43.2 at 1 year, 52.2 at 2 years, and 44.5 at 3 years. In group LD, PCS and MCS before transplantation were 36.9 and 42.6, respectively. PCS increased to 43.3 at 1 year, 47.6 at 2 years, and 51.0 at 3 years, and MCS increased to 47.8 at 1 year, 50.1 at 2 years, and 49.6 at 3 years.

CONCLUSIONS

The recipients of living-donor KT showed an improvement of QOL immediately after transplantation. However, in the recipients of deceased-donor KT, physical QOL (PCS) decreased for 2 years after transplantation. The reasons seem to be long waiting period and the use of non-heart-beating donors in deceased-donor KT in Japan.

Lateral regions of the rodent striatum reveal elevated glutamate decarboxylase 1 mRNA expression in medium-sized projection neurons

The GABA-synthesizing enzymes glutamate decarboxylase (GAD)1 and GAD2 are universally contained in GABAergic neurons in the central nervous system of the mouse and rat. The two isoforms are almost identically expressed throughout the brain and spinal cord. By using in situ hybridization, we found that the mouse lateral striatum concentrates medium-sized projection neurons with high-level expression of GAD1, but not of GAD2, mRNA. This was confirmed with several types of riboprobe, including those directed to the 5'-noncoding, 3'-noncoding and coding regions. Immunohistochemical localization of GAD1 also revealed predominant localization of the enzyme in the same striatal region. The lateral region of the mouse striatum, harboring such neurons, is ovoid in shape and extends between interaural +4.8 and +2.8, and at lateral 2.8 and dorsoventral 2.0. This intriguing region corresponds to the area that receives afferent inputs from the primary motor and sensory cortex that are presumably related to mouth and forelimb representations. The lateral striatum is included in the basal ganglia-thalamocortical loop, and is most vulnerable to various noxious stimuli in the neurodegeneration processes involving the basal ganglia. We have confirmed elevated expression of GAD1 mRNA, but not of GAD2 mRNA, also in the rat lateral striatum. Image analysis favored the view that the regional increase is caused by elevated cellular expression, and that the greatest number of medium-sized spiny neurons were positive for GAD1 mRNA. The GAD1 mRNA distribution in the mouse lateral striatum partially resembled those of GPR155 and cannabinoid receptor type 1 mRNAs, suggesting functional cooperation in some neurons.

[Quality assurance of respiratory-gated stereotactic body radiation therapy in lung using real-time position management system]

In this study, we investigated comprehensive quality assurance (QA) for respiratory-gated stereotactic body radiation therapy (SBRT) in the lungs using a real-time position management system (RPM). By using the phantom study, we evaluated dose liberality and reproducibility, and dose distributions for low monitor unite (MU), and also checked the absorbed dose at isocenter and dose profiles for the respiratory-gated exposure using RPM. Furthermore, we evaluated isocenter dose and dose distributions for respiratory-gated SBRT plans in the lungs using RPM. The maximum errors for the dose liberality were 4% for 2 MU, 1% for 4-10 MU, and 0.5% for 15 MU and 20 MU. The dose reproducibility was 2% for 1 MU and within 0.1% for 5 MU or greater. The accuracy for dose distributions was within 2% for 2 MU or greater. The dose error along a central axis for respiratory cycles of 2, 4, and 6 sec was within 1%. As for geometric accuracy, 90% and 50% isodose areas for the respiratory-gated exposure became almost 1 mm and 2 mm larger than without gating, respectively. For clinical lung-SBRT plans, the point dose at isocenter agreed within 2.1% with treatment planning system (TPS). And the pass rates of all plans for TPS were more than 96% in the gamma analysis (3 mm/3%). The geometrical accuracy and the dose accuracy of TPS calculation algorithm are more important for the dose evaluation at penumbra region for respiratory-gated SBRT in lung using RPM.

[Cone-beam computed tomography-derived adaptive radiotherapy]

The purpose of this study was to evaluate the reliability of cone-beam computed tomography (CBCT)-derived adaptive radiotherapy. We evaluate planning computed tomography (pCT) and CBCT in 50 patients who had undergone image guided radiotherapy (IGRT) with CBCT. Irradiated sites included head, neck, chest, abdomen, and pelvis; there were 10 patients in each group. Treatment plans including 153 beam data were recalculated based on CBCT. To compare between pCT and CBCT, we estimated CT values of normal tissues, body contour, effective depth, and monitor units (MU) calculation. The maximum difference in CT values was observed in lung estimation. The 5 mm or more differences in depth were observed in 2 beams of 2 pelvic cases, but CBCT also demonstrated a shift of abdominal wall due to intestinal motility. There were downward trends for the effective depth and MU based on CBCT, especially in lung cases. However, the differences in prescribed dose due to MU calculation were less than 5% because all patients were treated with a multifield irradiation plan. CBCT provides not only precise daily setup but also accurate anatomical information on body contour. In addition, CBCT may be considered as a useful tool for dose calculation.

[Impact of setup error and anatomical change on dose distribution during conventional radiation therapy]

The purpose of this study was to evaluate the impact of setup error and anatomical change on dose distribution during conventional radiation therapy. We performed regional irradiation (Plan1) using opposing pair fields, and then we planned local irradiation (Plan2) with a computed tomography (CT) acquired at that time in 10 patients with advanced oral cancer. To consider the setup error, a minimum dose of gross tumor volume (GTV) and a maximum dose for the spinal cord were re-calculated with isocenter shifts of ±5 mm. We also evaluated an alteration of reference dose due to anatomical changes during radiation therapy. A minimum dose of GTV was decreased with isocenter shifts; the trend was stronger in Plan2 than Plan1 (-5.7% vs. -1.2%, p=0.02). Similarly, a maximum dose of spinal cord was increased with isocenter shifts, especially in Plan2 (12.2% vs. 0.5%, p<0.01). Anatomical changes during radiation therapy were observed in all patients, and the mean difference for depth was -4 mm in Plan1; the reference dose was increased in Plan1 and Plan2. Precise setup is necessary, especially for local irradiation in spite of anatomical changes during radiation therapy. Reimaging and replanning are recommended for patients with marked anatomical changes.

MicroRNA signature in diabetic wound healing: promotive role of miR-21 in fibroblast migration

A major complication of diabetes mellitus is the disruption of normal wound repair process, characterised by insufficient production of growth factors. A molecular genetic approach wherein resident cells synthesise and deliver the growth factors to the wound site would be a powerful therapeutic strategy to treat diabetic wounds. One such molecular approach could be the application of microRNAs (miRNAs). This study reports differential expression of miRNAs related to cell development and differentiation, during wound healing in diabetic mice. Comparison of skin tissue from normal and diabetic mice showed that 14 miRNAs were differentially expressed in diabetic skin; miR-146b and miR-21 were the most noteworthy. Expression pattern of these miRNAs was also altered during healing of diabetic wounds. A subset of miRNAs (miR-20b, miR-10a, miR-10b, miR-96, miR-128, miR-452 and miR-541) exhibited similar basal levels in normal and diabetic skins, but displayed dysregulation during healing of diabetic wounds. Amongst the miRNAs studied, miR-21 showed a distinct signature with increased expression in diabetic skin but decreased expression during diabetic wound healing. We analysed the role of miR-21 in fibroblast migration, because migration of fibroblasts into the wound area is an important landmark facilitating secretion of growth factors and migration of other cell types into the wound, thus enhancing the healing process. Using gain-of and loss-of function approaches, we show that miR-21 is involved in fibroblast migration. Our preliminary studies implicate an important role for miRNAs in the pathogenesis of diabetic wounds.

Manometric evaluation of oral function with a hand-held balloon probe

Tongue pressure measured with a disposable hand-held balloon probe has been used for assessing tongue function; however, no diagnostic standard for assessing other oral functions exists currently. In this study, to develop a method for multifactorial manometric evaluation of oral functions, 20 men and 20 women (21-32 years of age) were instructed to apply 7-s maximal voluntary muscular effort on a hand-held balloon probe placed against the anterior and lateral parts of the palate, buccal surface of the molars on the habitual chewing side and labial surface of the anterior teeth for measuring anterior and posterior tongue, cheek and lip pressures (LPs), respectively. Intra-session reproducibility was determined by three repeated measurements, and associations between the obtained and the conventional data on oral diadochokinesis were tested. The men exhibited higher values of all the pressure types. Further, both genders showed a positive correlation between anterior and posterior tongue pressures (PTPs) (P < 0·05), but only the women exhibited positive correlations between anterior tongue and cheek pressures, cheek and PTPs, anterior tongue and LPs, and cheek and LPs (P < 0·05). No statistically significant correlation was found between the pressures and the number of syllabic articulations, except between LP and the number of /pa/ articulations in the women (r = 0·524, P < 0·05). In conclusion, the balloon probe method enables objective manometric evaluation of oral functions and could be an effective tool for clinical epidemiological studies and evidence-based decision-making in nursing care.

[Dosimetric correction for a six degrees carbon fiber couch]

We investigated experimentally and clinically the influence of a six degree (6D) carbon fiber couch on conventional radiation therapy. We used 4, 6 and 10 MV X-rays and compared dose distributions based on correction methods, i.e. monitor unit (MU) addition, including computed tomography (CT) couch, and the couch modeling. Additionally, we evaluated the clinical value of dosimetric correction for the 6D couch in 30 patients treated with multi-field irradiation. In the phantom study, the maximum difference of isocenter doses attributable to the 6D couch was 5.1%; the difference was reduced with increasing X-ray energy. Although the isocenter dose based on each correction method was precise within ±1%, MU addition underestimated the surface dose. In the clinical study, the maximum difference of isocenter doses attributable to the 6D couch was 2.7%. The correction methods for the 6D couch provide for highly precise treatment planning. However, the clinical indication of complicated correction methods should be considered for each institution or each patient, because the influence of the 6D couch was reduced with multi-field irradiation.

Curcumin facilitates fibrinolysis and cellular migration during wound healing by modulating urokinase plasminogen activator expression

Urokinase plasminogen activator (uPA) plays a vital role in the early phases of wound healing by aiding fibrin dissolution and promoting the migration, proliferation, and adhesion of various cells to the wound bed. The efficacy of botanicals in healing wounds is an area of active research. Among these, curcumin, a yellow pigment abundant in turmeric rhizome, has been the center of extensive studies. This study focused on the effect of curcumin on uPA expression and its consequence on fibrin dissolution and cellular migration. Treatment of human fibroblast cells with curcumin caused an upregulation of uPA mRNA and protein. Activation of JNK and p38 MAPK signal pathways was necessary for the upregulation of uPA. Curcumin treatment resulted in an increase in fibrinolytic activity and cell migration towards the wound area. The involvement of uPA in fibrinolysis and cell migration was confirmed by zymography and siRNA studies, respectively.