Indian Traditional Treatments for Psoriasis: A Critical Appraisal of Available Evidence Supporting Efficacy / 中国结合医学杂志

OBJECTIVE@#To examine data from studies supporting the clinical efficacy of medical approaches from India traditional systems of medicines like Ayurveda, Unani, Siddha, and Homeopathy for psoriasis using outcome indicators employed in clinical practice and research.@*METHODS@#Searches were conducted between December 2019 and September 2020 in databases PubMed, Scopus, Web of Science and Ovid Medline using search terms including traditional, complementary, psoriasis, Kushtha, Ayurveda, Siddha, Unani, Homeopathy and clinical. Controlled trials, case series and case reports published from India were included.@*RESULTS@#Data of 17 selected studies were extracted. Treatment efficacy in terms of improvement in Psoriasis Area and Severity Index (PASI) score or/and percentage reduction in score (PASI 50, PASI 75 and PASI 90) or/and patient-reported outcomes using instruments like Dermatology Life Quality Index and Psoriasis Disability Index were noted. All studies reported good improvement as per the study specific outcome. However, study characteristics, including study design, sample size, follow-up period, inclusion and exclusion criteria were heterogeneous, and the choice of outcome measures was not adequate to conclude the effectiveness of intervention. The use of some herbs as common ingredients in several formulations across different systems of medicines were noted in analyzing individual formulation.@*CONCLUSIONS@#Future studies must incorporate a comprehensive study design with specific outcome measures like PASI, PASI 75, PASI 90, quality of life parameters, compliance to medications, adverse reactions, remission period, relapse rate and cost-effectiveness with long term follow-up. The currently available evidence on the roles of these herbs at molecular level in psoriasis is preliminary.

MBL PRODUCING P.PENNERI - A MAJOR THREAT TO THE HOSPITAL

Introduction: Proteus spp. has been the signi?cant cause of wound infections as they commonly colonize the wound. Simultaneously multiple drug resistance mechanisms also pose a therapeutic challenge. P.penneri is commonly misidenti?ed as P.mirabilis which is multidrug resistant. The current study was Aim and objectives: conducted to determine the prevalence of MBLs in P.penneri among wound infections at a tertiary care hospital from Western Maharashtra. Specimens collected from wounds of OPD and IPD patients were examined by standard Material and Methods: bacteriological methods. All Proteus isolates were subjected to Antimicrobial susceptibility and MBL production test as per CLSI guidelines. Total 1826 wound samples were screened over the period of May 2017 to July 2018. Overall Results: prevalence of Proteus spp. was 7.12%, P.mirabilis being the commonest. Among all isolates 53.68% and 37.04% of P.mirabilis and P.vulgaris were ESBL producers, respectively. The rate for MBL production was 11.58% and 0% for P.mirabilis and P.vulgaris, respectively. On the contrary 75% of P.penneri isolates were ESBL producers and 12.5% were MBL producers. Discussion and conclusion: Emergence of ESBL and MBL producers is of special concern as Proteus spp. is intrinsically resistant to tigecycline and colistin. Identi?cation of P.penneri from clinical specimens is necessary, due to its multidrug resistance which makes clinical treatment extremely dif?cult. This will limit its control and eradication especially from wound infections as they are common colonizers. Therefore isolation of such beta lactamases producing P.penneri shall be considered as an alarming sign to control the spread of this superbug.

Study of maternal and fetal outcome in pregnancy beyond 40 weeks: a prospective observational study at a tertiary institute

Background: Prolonged pregnancy is one that exceeds 42 0/7weeks. Management of prolonged pregnancy is very challenging in modern obstetrics.Methods: It is prospective observational study in department of Obstetrics and Gynecology, Shri B.M Patil medical college and Research center, deemed to be University, Vijayapur, North karnataka. Study period was from January 2018 to January 2019.Results: Total of 186 pregnant women were included in the study. Results in terms of age, gravidity, gestational age, time of induction, mode of delivery, neonatal outcome and maternal complications.Conclusion: Pregnancies beyond 40 weeks require early detection, effective fetal monitoring and proper planning of labour. In pregnancies beyond 40 weeks, decision of induction should be taken cautiously as early induction leads to failure of induction and increased rates of lower (uterine) segment Caesarean section (LSCS), while delayed induction leads to increased fetal complications.

Serum lactate as a prognostic marker in patients with sepsis: a prospective study

Background: A prospective study to estimate the serum lactate levels and as a prognostic marker in patients with sepsis.Methods: 170 patients admitted with sepsis in B.L.D.E. (Deemed to be University) Shri. B. M. Patil Medical College, Hospital and Research Centre, Vijayapur from October 2014 to June 2016.Results: In this study the mean serum lactate value of first sample in survivors (146 patients) is 3.8±1.2 and non-survivors (24 patients) is 6.2±1.9 with p value<0.001 which is significant. The serum lactate value of the second sample in survivors (146) is 2.7±1.0 and in non survivors (24) is 6.3±1.8 with p value<0.001 which is significant. The mean value of serum lactate 1st sample collected at the time of admission is 4.1±1.6 and the mean value of serum lactate second sample collected at 24 - 48 hours after admission is 3.1±1.6.Conclusions: Lactate level more than 4 mmol/l, patients are at highest risk of mortality and an aggressive resuscitation strategy shall be warranted. Hence serum lactate is considered as an independent and significant prognostic marker in patients with sepsis and evaluates the treatment outcome.

Evaluation of vitamin D levels in term pregnancy and its obstetric outcome in Indian women

Background: Vitamin D deficiency is currently a global pandemic affecting all age groups. Vitamin D is considered a fundamental hormone in calcium homeostasis and bone health. Risk of vitamin D deficiency increases during pregnancy due to increased maternal and fetal demands and altered vitamin D metabolism. Recently, maternal vitamin D deficiency has been linked to adverse pregnancy outcomes, including preeclampsia, gestational diabetes, fetal growth restriction and preterm birth. Adequate vitamin D status appears to be relevant to health at all ages, and even in prenatal life.Methods: This is a cross sectional, observational study conducted in the department of obstetrics and gynaecology at R. L. Jalappa Hospital. A total number of 160 subjects were included. 5 ml of venous blood was collected and was centrifuged at 3000 rpm and stored at - 80°C till analysis. Analysis of 25-hydroxy Vitamin D was done using ELISA.Results: Majority of the subjects were vitamin D deficient (81.87%) and 12.5% were vitamin D insufficient and only 5.63% were vitamin D sufficient. The prevalence of vitamin D deficiency was more among primigravidas (85.6%) and was associated with higher rates of caesarean section (92.4%). High prevalence of vitamin D deficiency was seen in lower middle socioeconomic class (62.5%). Maternal vitamin D deficiency was associated low birth weight of neonates (100%).Conclusions: In this study it was concluded that majority of subjects were vitamin D deficient and belonged to lower middle socioeconomic class. Majority of this subjects who underwent caesarean section were vitamin D deficient. Vitamin D deficiency was associated only with low birth weight of neonates and no other adverse obstetric outcome.

Peritoneal metastasis in Stage IB1 adenocarcinoma cervix: A rare entity

The presence of ovarian or peritoneal metastasis in early-stage cervical malignancy is a rare entity. It often poses a diagnostic challenge whether it is a synchronous primary tumor or a metastatic lesion. A 63-year-old postmenopausal woman presented with Stage 1B1 carcinoma cervix with ascites, and a 5.8 cm × 4.2 cm × 3.5 cm left solid adnexal mass. She underwent Type III radical hysterectomy, excision of peritoneal mass, with bilateral pelvic and paraaortic lymphadenectomy and infracolic omentectomy. On histopathology, cervix showed features of adenocarcinoma, and the peritoneal mass revealed similar histomorphology as cervical growth with metastatic tumor deposits in omentum. Immunohistochemistry (IHC) was utilized to determine the origin of mass. The early stage disease and histology may not always predict the distant metastasis. Therefore, a thorough pretreatment evaluation, meticulous intraoperative assessment, and IHC are mandatory for optimum management and prognostication

Neutrophil and Platelet to Lymphocyte Ratio in Prevailing the Oxidative Stress and its Relation with the Endothelial Dysfunction in Preeclampsia

Background: Preeclampsia (PE) is a pregnancy specific,hypertensive disorder. It affects 2-8% pregnancies.Oxidative stress and systemic inflammation areproposed to contribute significantly to the preeclampsiapathophysiology. The present study, aim is to determineand compare the markers of oxidative stress, endothelialdysfunction, systemic inflammatory markersNeutrophil/Lymphocyte Ratio (NLR) and Platelet/Lymphocyte Ratio (PLR) in preeclampsia andgestational age matched healthy controls. Material andMethods: This study was conducted in the Departmentof Biochemistry and Department of Obstetrics andGynecology, Sri Devaraj Urs Medical College, Kolar,Karnataka. The study included 98 preeclamptic womenand 98 normotensive pregnant women. Five ml venousblood was collected from all the study subjects. Bloodsample in EDTA vials was used for the complete bloodcount. NLR and PLR were calculated. Plasma was usedfor Ferric Reducing Ability of Plasma (FRAP) assay.Serum was used for the estimation of Malondialdehyde(MDA), nitric oxide, blood sugar, renal parameters andliver enzymes i.e., Aspartate Transaminase (AST),Alanine Transaminase (ALT), Lactate Dehydrogenase(LDH) and magnesium. Corresponding urine sampleswere collected for urinary protein analysis by dipstickmethod. Fetal outcome was recorded. Results:Gestational age was significantly low in preeclampticwomen as compared to those of controls. Bloodpressure (Systolic and diastolic), mean arterial pressure,body mass index, pulse rate, serum creatinine, uric acid,AST, ALT, LDH, MDA and NLR were increasedsignificantly in preeclamptic women as compared tothose of controls. In subgroup analysis, NLR wasincreased significantly in severe preeclamptics ascompared to mild preeclamptics. Serum Nitric Oxide(NO) and FRAP levels were decreased significantly inpreeclamptic women as compared to those of controls.Significantly decreased birth weight was observed inbabies born to preeclamptic mothers compared withcontrols. Conclusion: The present study resultsconclude that increased oxidative stress in termsincreased MDA, decreased NO and reduced antioxidantstatus (FRAP) in preeclamptic women, results inadverse perinatal outcome. In addition, maternal NLRcould be considered as a marker for severity ofpreeclampsia

Prevalence and determinants of nocturnal enuresis in school going children in Southern Maharashtra, India

Background: Nocturnal enuresis or bedwetting is a common health problem in children in the age group of 5 to 15 years. In India the prevalence of nocturnal enuresis ranges from approximately 7% to 12.6%. The prevalence from other parts of the world ranges from 6% to 42%. This study was planned to find the prevalence and determinants of nocturnal enuresis in school going children.Methods: This cross-sectional study was conducted in four primary and secondary schools in Solapur. A predefined questionnaire, prepared in English and translated to local languages, Marathi and Kannada, was handed over to all the children attending the selected schools. Children were asked to hand over the questionnaire to their parents and return with the filled questionnaire. The questionnaire was prepared to obtain the information related to the socio-demographic factors of the family and child, frequency of enuresis and information related the risk factors. Nocturnal enuresis was defined if the frequency of enuresis was more than twice per week.Results: The overall prevalence of nocturnal enuresis was 11.4 %. The maximum prevalence was found in the age group of 8 -9 years (22.96 %). The prevalence of nocturnal enuresis in boys (14.34 %) was significantly more than the prevalence in girls (8.31 %). The study showed that nocturnal enuresis was significantly associated with stress, poor school performance, sleep pattern (hard to awaken), family history, burning micturition etc. But it was not associated with maternal or paternal education, birth order, type of family.Conclusions: The prevalence of nocturnal enuresis is 11.40 % in school going children and it is associated with age, sex, stress, family history, burning micturition, hyperactive child, poor school performance, sleep pattern (hard to awake) avoidance of going to micturate before sleep etc.

Nutritional anaemia: clinical and haematological presentation in children

Background: There are three main causes of anemia, decreased production of RBCs, and excessive destruction of RBCs or Excessive blood loss. In India, the main reason of anaemia is the decreased production due to nutritional deficiency. The main nutrients required in the process of haemoglobin production are iron, folic acid and cyanocobalamine. The objective of the present study was to find the clinical presentations and hematological changes in children with nutritional anaemia.Methods: This Cross-sectional study was conducted from January 2018 to October 2018 in the department of Paediatrics of Ashwini Rural Medical College Hospital and Research Centre, Solapur. Children visiting the paediatric OPD due to any illness and having clinical suspicion of anemia were initially screened for inclusion in the study. Detailed laboratory investigation such as CBC, peripheral blood for Leishman's stain and reticulocyte count were performed. Serum Ferritin, vitamin B12, folic acid levels were also done to ascertain the cause of anemia. World Health Organization recommended criteria were used to diagnose and grade the anemia.Results: A total of 405 anemic children were included in the study. Out of that 213 were boys and 192 were girls. A total of 226 children presented with mild anemia. The most common clinical presentation was respiratory tract infection, found in 62.22 % of children followed by fever in 53.09 % of children. Maximum numbers of patients were suffering from iron deficiency anemia, followed by folic acid deficiency. Deficiency of both of these nutrients was also common. Vit B12 deficiency was found in only 5 children.Conclusions: The study concluded that iron deficiency anemia was the commonest nutritional anemia in children in the age group of 5 to 15 years. Second most common deficiency was of folic acid. Majority of the anemic patients presented with respiratory tract infection and fever.

Drug utilization study of antihypertensive drugs in hypertensive diabetic patients in a tertiary care hospital.

Background: Diabetes along with hypertension is a very common ailment afflicting millions of people worldwide. The socio-economic stress caused by the morbidity and mortality associated with it is mind boggling. Hence, this study was undertaken to study the utilization of antihypertensive drugs in hypertensive diabetic patients. Methods: A prospective study was conducted on 100 hypertensive diabetic patients aged between 18 and 90 years of either gender attending Basaveshwar Teaching and General Hospital, Kalaburagi. The data collected were statistically analyzed and presented as counts and percentages. Results: In our study, we found that majority (63%) were male patients and majority belonged to 51-70 years age group. The majority of the patients were prescribed angiotensin converting enzyme inhibitors (ACEIs) alone (19%), followed by a combination of ACEIs and calcium channel blockers (9%). The generic prescribing was only 23%, and patient’s knowledge of correct dosage was 64%. Conclusion: In this study, it has been observed that the antihypertensives drugs were prescribed rationally, but the generic prescribing was only 23% which is inappropriate prescribing behavior. Hence, physicians should be educated to prescribe drugs in the generic name so that the cost of drugs is reduced.

Evaluation of Maternal Thyroid Hormone Status and Atherogenic Potency in Pre Eclampsia in Kolar District- A South West of India.

Aim: To determine maternal thyroid hormone status and lipid profile in preeclampsia. Study Design: A prospective case control study consist of two groups such as group 1 normotensive non-preeclamptic group and group 2 as cases with clinically diagnosed preeclampsia Place and Duration of Study: Department of Obstetrics and Gynaecology, RL Jalappa Hospital and Research Centre kolar, between January 2012 and June 2013. Methodology: A total number of 100 pregnant patients were enrolled in the present study. Amongst, normotensive and preeclamptic pregnant women Group 1 (n=50) as controls (n=50). Group-2 (n=50) were preeclampsia cases. Five ml of blood samples were collected from each normal pregnant and preeclampsia patients. Thyroid hormone levels and lipid parameters were estimated using spectrophotometric method. Statistical analysis carried out by using Mean ± SD, and ‘t’ test. Results: The Mean ± SD values of T3 ng/ml (1.56±0.38), T4 (1.37±0.36) mcg/dl, TSH (2.45±1.23) mcIU/ml in normal pregnants and T3 ng/ml (1.37±0.36), T4 (9.87±2.83) mcg/dl, TSH (6.15±5.51) mcIU/ml in preeclampsia cases were presented. Similarly Mean ± SD values of total cholesterol (181.62±44.33) mg/dl, HDL cholesterol (49.44±11.54) mg/dl, Triglycerides (198.10±49.84) mg/dl, LDL cholesterol (104.90±29.58) mg/dl, and Total cholesterol/HDL cholesterol ratio (3.67) were from control group and total cholesterol (222.60±70.07) mg/dl, HDL cholesterol (45.92±11.81), Triglycerides (278.66±93.46) mg/dl, LDL cholesterol (116.52±49.26) mg/dl, and cholesterol and HDL cholesterol ratio (4.84) in preeclampsia were presented respectively. Conclusion: Pre eclampsia patients have higher levels of TSH and lower levels of T3 and T4 in comparison to normotensive pregnant women. This changes in the thyroid hormones did not correlate with the severity of preeclampsia between mild and severe pre eclampsia groups. Dyslipidemia was observed in pre eclampsia group than in the normotensive group indicates the possible atherogenic potential. This association may be useful in understanding the pathologic processes of preeclampsia.

Development of bioconjugate from Streptomyces tyrosinase and gold nanoparticles for rapid detection of phenol constituents.

Most of the phenol compounds are toxic and have been considered as hazardous pollutants. Several physicochemical and biological methods are available to detect and monitor the phenol pollutants in water and soil. In the present study, phenol constituents of winery, paper and plastic industrial effluents were successfully detected employing tyrosinase-gold nanoparticles bioconjugate. The synthesis of extracellular tyrosinase and gold nanoparticles was achieved by a single isolate of Streptomyces sp. DBZ-39. Enhanced production (369.41 IU) of tyrosinase was produced in submerged bioprocess employing response surface method with central composite design. Extracellular gold nanoparticles synthesized (12-18 nm) by Streptomyces sp. DBZ-39 were characterized with TEM, EDAX and FTIR analysis. A rapid detection (within 10 min) of phenol constituents from winery effluents was achieved by bioconjugate, when compared to tyrosinases and gold nanoparticles independently. Streptomyces tyrosinase could exhibit relatively a better performance than commercially available mushroom tyrosinase in the detection of phenol constituents. Winery effluent has shown much higher content (0.98 O.D) of phenol constituents than paper and plastic effluents based on the intensity of color and U.V absorption spectra.

Trends on oxidative stress and antioxidant status in fluoride affected areas in Kolar district, India.

Fluoride in cellular respiratory processes and its association in free radical generation are extensively studied. Cell permeability generates the oxidative stress through free radical species entry that sequentially affects the cellular biomolecules and cause toxic effects. Present study intended to determine the trend of oxidative stress and antioxidant status in the fluoride affected area that may raise the need for supplementation of antioxidants. Oxidative stress denoted in terms of ischemia modified albumin and antioxidants by vitamin C & total antioxidant capacity. Methods: Sixty subjects were divided into two groups. Group I (control) from fluoride unaffected areas (n=30) and group II subjects from fluoride affected area (n=30). Serum was assayed for Ischemia Modified Albumin (IMA), plasma for Total Antioxidant Capacity (TAC) and vitamin C. Results: The mean ± SD of IMA, TAC, and vitamin C of individuals subjected in fluoride affected areas are 2.403 ± 0.543, 210 mmol/l ± 82.2 and 0.62 mg/dl ± 0.23 respectively. The values were compared to individuals from fluoride unaffected areas have IMA (1.054 ABSU ± 0.851), TAC (312 mmol/l ± 62.1) and vitamin C (0.93 mg/dl ± 0.14) with P <0.001. Conclusion: The present study revealed that, individuals subjected to fluoride affected areas have more oxidative stress and decreased levels of antioxidant status indicates the risk of generation of free radicals intensity as a chief component of oxidative stress. This research outcome necessitates dietary supplementation of nutrient antioxidants to minimize the consequences of oxidative damage to vital biomolecules in fluoridated affected areas.

Optimization of the Cultural Parameters for Improved Production of Antimicrobial Metabolites by Streptomyces gulbargensis DAS 131.

Aims: To investigate the influence of appropriate culture medium by optimizing the cultural conditions affecting the growth and bioactive metabolite production by Streptomyces gulbargensis DAS 131 under submerged culture conditions in order to reduce the cost of fermentation process to improve the formation of antimicrobial compounds. Place and Duration of Study: Department of Botany and Microbiology, January 2012 to May 2012. Methodology: The impact of environmental parameters such as incubation period, pH, temperature and salt concentration and effect of various nutrients such as carbon and nitrogen sources and minerals on the antimicrobial metabolite production by Streptomyces gulbargensis DAS 131 was evaluated by employing agar well diffusion assay. Growth was measured in the form of dry mycelial weight. Results: The optimum pH and temperature for bioactive metabolite production were 7 and 35°C respectively. Highest antimicrobial metabolite production was found when the strain was inoculated into the medium amended with glucose at the concentration of 2%, soya peptone at the rate of 1% and NaCl at the concentration of 5% and incubated for six days under shaking conditions. The metabolites showed good antimicrobial activity against Gram positive and Gram negative bacteria, as well as unicellular and multicellular fungi. Conclusion: S. gulbargensis DAS 131 isolated from the semi-arid soils of Gulbarga, Northern Karnataka province, India exhibited broad spectrum antimicrobial activity. It was found that the antimicrobial metabolite production by the strain was positively influenced by carbohydrates, nitrogen sources and minerals.

Optimization of Process Parameters for Improved Production of Bioactive Metabolites by Streptomyces tritolerans DAS 165T.

Aims: To optimize the process parameters for enhanced production of bioactive metabolites by Streptomyces tritolerans DAS 165T. Place and Duration of Study: Department of Botany and Microbiology, April 2012 to August 2012. Methodology: Agar well diffusion assay was employed to study the effect of environmental parameters such as incubation period, pH, temperature and salt concentration and influence of various nutrients such as carbon and nitrogen sources and minerals on the bioactive metabolite production by Streptomyces tritolerans DAS 165T.  Results: The production of antimicrobial metabolite was high when the strain was cultured for six days at 35ºC in medium (pH 7.5) with sucrose at the concentration of 2% (carbon source), soya peptone at the concentration of 1% (nitrogen source) and sodium chloride at the concentration of 5%.  Conclusion: This is the first report on the optimization of bioactive metabolite production by Streptomyces tritolerans DAS 165T. As the strain exhibited potent antimicrobial activity, it may be explored for biotechnological purposes.

child with xeroderma pigmentosum for excision of basal cell carcinoma

Xeroderma pigmentosum [XP] is characterized by hypersensitivity to sunlight, ocular involvement, and progressive neurological complications. These manifestations are due to a cellular hypersensitivity to ultraviolet radiation leading to a defect in repair of DNA by the process of nucleotide excision repair. Basal cell carcinoma which is rare in children can occur with XP. Though the XP induced changes are predominately dermatologic, pose several challenges in anaesthetic management. Hence, we are reporting a 9-year-old child with XP scheduled for excision of basal cell carcinoma under general anaesthesia

Production, purification and characterization of L-asparaginase from Streptomyces gulbargensis

L-asparaginase is an anti-neoplastic agent used in the lymphoblastic leukaemia chemotherapy. In the present study a novel strain, Streptomyces gulbargensis was explored for the production of extra-cellular L-asparaginase using groundnut cake extract. The optimum pH, temperature, inoculum size and agitation speed for enzyme production were pH 8.5, 40ºC, 1x10(8)spores/ml and 200 rev/min respectively. Maltose (0.5 percent) and L-asparagine (0.5 percent) proved to be the best carbon and nitrogen sources respectively. The enzyme was purified 82.12 fold and the apparent molecular weight of the enzyme was found to be 85 kDa. The optima pH and temperature for the enzyme were 9.0 and 40ºC respectively. The enzyme was more stable at the alkaline pH than at the acidic one and it retained 55 percent of the activity at 80ºC for 60 min.

Use of transrectal ultrasound for high dose rate interstitial brachytherapy for patients of carcinoma of uterine cervix / 부인종양

OBJECTIVE: Transrectal ultrasound (TRUS) has been widely used for guiding prostate implants, but not much for interstitial brachytherapy (IBT) of cervix cancer. The aim of our study is to report our experience with TRUS guided high dose rate (HDR) IBT in patients with carcinoma of uterine cervix. METHODS: During the year 2005-2006, 25 patients of cervical cancer not suitable for intracavitary radiotherapy (ICRT), were enrolled in this prospective study. We used B-K Medical USG machine (Falcon 2101) equipped with a TRUS probe (8658) having a transducer of 7.5 MHz for IBT. Post procedure, a CT scan was done for verification of needle position and treatment planning. Two weekly sessions of HDR IBT of 8-10 Gy each were given after pelvic external beam radiation therapy. RESULTS: A total of 40 IBT procedures were performed in 25 patients. Average duration of implant procedure was 50 minutes. There was no uterine perforation in any of 11 patients in whom central tandem was used. CT scan did not show needle perforation of bladder/rectum in any of the patients. During perioperative period, only 1 procedure (2.5%) was associated with hematuria which stopped within 6 hours. Severe late toxicity was observed in 3 (12%) patients. Overall pelvic control rate was 64%. CONCLUSION: Our experience suggests that TRUS is a practical and effective imaging device for guiding the IBT procedure of cervical cancer patients. It helps in accurate placements of needles thus avoiding the injury to normal pelvic structures.

Comparison of geometric uncertainties using electronic portal imaging device in focal three-dimensional conformal radiation therapy using different head supports.

AIMS AND OBJECTIVES: To study the geometric uncertainties in the treatment and evaluate the adequacy of the margins employed for planning target volume (PTV) generation in the treatment of focal conformal radiotherapy (CRT) for patients with brain tumors treated with different head support systems. MATERIALS AND METHODS: The study population included 11 patients with brain tumors who were to be treated with CRT. Contrast-enhanced planning CT scan (5-mm spacing and reconstructed to 2 mm) of brain were performed. Five patients were immobilized using neck support only (NR-only) and six patients had neck support with flexion (NRF), the form of immobilization being decided by the likely beam arrangements to be employed for that particular patient. The data was transferred to the planning system (CadPlan) where three-dimensional conformal radiation therapy was planned. Digitally reconstructed radiographs (DRRs) were created for the orthogonal portals with the fixed field sizes of 10 x 10 taken at the isocenter. Treatment verification was done using an amorphous silicon detector portal imaging device for using orthogonal portals and the DRR was used as a reference image. An image matching software was used to match the anatomical landmarks in the DRR and the portal imaging and the displacement of the portals in x, y axis and rotation were noted in the anteroposterior (AP) and lateral images. Electronic portal imaging was repeated twice weekly and an average of 8-14 images per patient was recorded. The mean deviation in all the directions was calculated for the each patient. Comparison of setup errors between the two head support systems was done. RESULTS: A total 224 images were studied in anterior and lateral portals. The patient group with NR-only had 100 images, while the NRF group had 124 images. The mean total error in all patients, NR-only group, and NRF group was 0.33 mm, 0.24 mm, and 0.79 mm in the mediolateral (ML) direction; 1.16 mm, 0.14 mm, and 2.22 mm in the AP direction; and 0.67 mm, 0.31 mm, and 0.96 mm in the superoinferior (SI) direction, respectively. The systematic error (S) in all patients, NR-only group, and NRF group in the ML direction was 0.31 mm, 0.28 mm, and 0.78 mm; 1.29 mm, 0.1 mm, and 2.24 mm in the AP direction; and 0.75 mm, 0.52 mm, and 0.94 mm in the SI direction, respectively. Random error (s) in all patients, NR-only group, and NRF group in the ML direction was 1.25 mm, 1.04 mm, and 1.41 mm; 1.31 mm, 1.36 mm, and 1.28 mm in the AP direction; 1.38 mm, 1.37 mm, and 1.39 mm in the SI direction, respectively. In all patients, the PTV margin with Stroom's formula in the NR-only and NRF group was 1.29 mm and 2.55 mm in the ML, 1.15 mm and 5.38 mm in the AP, and 2.0 mm and 2.85 mm in the SI directions, respectively. CONCLUSION: A PTV margin of 5 mm appears to be adequate; further reduction to 3 mm may be considered based on our results. Errors were significantly higher in the AP direction with NRF when compared to NR-only. Differential PTV margin may therefore be considered, with more margin in the AP and less in other directions, especially with the use of flexion devices.