Pituitary Apoplexy: Pitfalls in Diagnosis.

Headache is a common presenting complaint in the emergency department. A rare cause is pituitary apoplexy - a complication of pituitary adenoma consisting of hemorrhage or infarction of the primary tumor accounting for approximately 1 % of headaches. A 44-year-old female presented with intractable headache, nausea, photophobia and later - signs of meningeal irritation. Initial imaging demonstrated no mass or hemorrhage, labs showed only leukocytosis and elevated CRP. Patient was started on empiric acyclovir and methylprednisolone. CSF analysis was negative for meningitis, thus MRI of the brain was performed which demonstrated a 2.5 cm suprasellar mass. Initial Pituitary hormone evaluation demonstrated low prolactin, normal TSH and low ACTH thought to be due to steroid use. Repeat laboratory evaluation demonstrated hypopituitarism. Patient underwent resection of the adenoma with pathology consistent with pituitary apoplexy. We highlight the need for careful evaluation of patients presenting with headache and signs of meningeal irritation given 16 % prevalence of pituitary adenoma. CT of the head may not always demonstrate acute infarction, with MRI of the brain remaining the most sensitive imaging modality. Given the common use of methylprednisolone for headache, a pitfall in the diagnosis of pituitary apoplexy includes proper assessment of a pituitary panel prior to initiation of steroids.

Identifying Critical Evidence Gaps in Wound Closure and Incision Management After Total Knee Arthroplasty: Delphi Panel Insights.

INTRODUCTION: In orthopaedic surgery, particularly total knee arthroplasty (TKA), the management of surgical wounds is critical for optimal wound healing and successful patient outcomes. Despite advances in surgical techniques, challenges persist in effectively managing surgical wounds to prevent complications and infections. This study aimed to identify and address the critical evidence gaps in wound management in TKA, including preoperative optimization, intraoperative options, and for the avoidance of postoperative complications. These are important issues surrounding wound management, which is essential for improving patient recovery and the overall success of the surgery. METHODS: Utilizing the Delphi method, this study brought together 20 experienced orthopaedic surgeons from Europe and North America. Conducted from April to September 2023, the process involved three stages: an initial electronic survey, a virtual meeting, and a concluding electronic survey. The panel reviewed and reached a consensus on 26 specific statements about wound management in TKA based on a comprehensive literature review. During these three stages and after further panel review, an alternative goal of the Delphi panel was to also identify critical evidence gaps in the current understanding of wound management practices for TKA. RESULTS: While the panel reached consensus on various wound management practices, they highlighted several major evidence gaps. Also, there was general consensus on issues such as wound closure methods including the use of mesh-adhesive dressings, skin glue, staples, sutures (including barbed sutures),and negative-pressure wound therapy (NPWT). However, it was deemed necessary that further evidence needs to be generated to address the cost-effectiveness of each and develop best practices for promoting patient outcomes. The identification of these gaps points to areas requiring more in-depth research and improvements to enhance wound care in TKA. DISCUSSION: The identification of these major evidence gaps underscores the need for targeted research in wound management surrounding TKA. Addressing these evidence gaps is crucial for the future development of more effective, efficient, and patient-friendly wound care strategies. Future research should prioritize these areas, focusing on comparative effectiveness studies and further developing clear guidelines for the use of emerging technologies. Bridging these gaps has the potential to improve patient outcomes, reduce complications, and elevate the overall success rate of TKA surgeries.

Predictors of persistent moderate and severe food insecurity in a longitudinal survey in Mexico during the COVID-19 pandemic.

Background: Household food insecurity (HFI) increased in Latin America by 9% between 2019 and 2020. Scant evidence shows who was unable to recover from the COVID-19 pandemic. Our aim was to use a Machine Learning (ML) approach to identify consistent and influential predictors of persistent moderate or severe HFI over 2 years. Methods: We use a three-wave longitudinal telephone survey with a probabilistic sample representative of the Mexican population. With a response rate of 51.3 and 60.8% for the second and third waves, the final sample size consisted of 1,074 individuals. The primary outcome was persistent HFI, i.e., respondents who reported moderate or severe HFI in 2021 and 2022. Twelve income-related predictors were measured in 2020, including baseline HFI. We employed 6 supervised ML algorithms to cross-validate findings in models, examined its precision with 4 standard performance indicators to assess precision, and used SHAP values (Shapley Additive exPlanations) to identify influential predictors in each model. Results: Prevalence of persistent moderate/severe HFI in 2021 and 2022 was 8.8%. Models with only a HFI 2020 baseline measure were used as a reference for comparisons; they had an accuracy of 0.79, a Cohen's Kappa of 0.57, a sensitivity of 0.68, and a specificity of 0.88. When HFI was substituted by the suite of socioeconomic indicators, accuracy ranged from 0.70 to 0.84, Cohen's Kappa from 0.40 to 0.67, sensitivity from 0.86 to 0.90, and specificity from 0.75 to 0.82. The best performing models included baseline HFI and socioeconomic indicators; they had an accuracy between 0.81 and 0.92, a Cohen's Kappa between 0.61 and 0.85, a sensitivity from 0.74 to 0.95, and a specificity from 0.85 to 0.92. Influential and consistent predictors across the algorithms were baseline HFI, socioeconomic status (SES), adoption of financial coping strategies, and receiving government support. Discussion: Persistent HFI can be a relevant indicator to identify households that are less responsive to food security policies. These households should be prioritized for innovative government support and monitored to assess changes. Forecasting systems of HFI can be improved with longitudinal designs including baseline measures of HFI and socioeconomic predictors.

Multi-institutional investigation into the robustness of intra-cranial multi-target stereotactic radiosurgery plans to patient setup errors.

PURPOSE: This study aimed to analyse correlations between planning factors including plan geometry and plan complexity with robustness to patient setup errors. METHODS: Multiple-target brain stereotactic radiosurgery (SRS) plans were obtained through the Trans-Tasman Radiation Oncology Group (TROG) international treatment planning challenge (2018). The challenge dataset consisted of five intra-cranial targets with a 20 Gy prescription. Setup error was simulated using an in-house tool. Dose to targets was assessed via dose covering 99 % (D99 %) of gross tumour volume (GTV) and 98 % of planning target volume (PTV). Dose to organs at risk was assessed using volume of normal brain receiving 12 Gy and maximum dose covering 0.03 cc of brainstem. Plan complexity was assessed via edge metric, modulation complexity score, mean multi-leaf collimator (MLC) gap, mean MLC speed and plan modulation. RESULTS: Even for small (0.5 mm/°) errors, GTV D99 % was reduced by up to 20 %. The strongest correlation was found between lower complexity plans (larger mean MLC gap and lower edge metric) and higher robustness to setup error. Lower complexity plans had 1 %-20 % fewer targets/scenarios with GTV D99 % falling below the specified tolerance threshold. These complexity metrics correlated with 100 % isodose volume sphericity and dose conformity, though similar conformity was achievable with a range of complexities. CONCLUSIONS: A higher level of importance should be directed towards plan complexity when considering plan robustness. It is recommended when planning multi-target SRS, larger MLC gaps and lower MLC aperture irregularity be considered during plan optimisation due to higher robustness should patient positioning errors occur.

Bioinformatics Analysis Reveals E6 and E7 of HPV 16 Regulate Metabolic Reprogramming in Cervical Cancer, Head and Neck Cancer, and Colorectal Cancer through the PHD2-VHL-CUL2-ELOC-HIF-1α Axis.

Human papillomavirus 16 (HPV 16) infection is associated with several types of cancer, such as head and neck, cervical, anal, and penile cancer. Its oncogenic potential is due to the ability of the E6 and E7 oncoproteins to promote alterations associated with cell transformation. HPV 16 E6 and E7 oncoproteins increase metabolic reprogramming, one of the hallmarks of cancer, by increasing the stability of hypoxia-induced factor 1 α (HIF-1α) and consequently increasing the expression levels of their target genes. In this report, by bioinformatic analysis, we show the possible effect of HPV 16 oncoproteins E6 and E7 on metabolic reprogramming in cancer through the E6-E7-PHD2-VHL-CUL2-ELOC-HIF-1α axis. We proposed that E6 and E7 interact with VHL, CUL2, and ELOC in forming the E3 ubiquitin ligase complex that ubiquitinates HIF-1α for degradation via the proteasome. Based on the information found in the databases, it is proposed that E6 interacts with VHL by blocking its interaction with HIF-1α. On the other hand, E7 interacts with CUL2 and ELOC, preventing their binding to VHL and RBX1, respectively. Consequently, HIF-1α is stabilized and binds with HIF-1ß to form the active HIF1 complex that binds to hypoxia response elements (HREs), allowing the expression of genes related to energy metabolism. In addition, we suggest an effect of E6 and E7 at the level of PHD2, VHL, CUL2, and ELOC gene expression. Here, we propose some miRNAs targeting PHD2, VHL, CUL2, and ELOC mRNAs. The effect of E6 and E7 may be the non-hydroxylation and non-ubiquitination of HIF-1α, which may regulate metabolic processes involved in metabolic reprogramming in cancer upon stabilization, non-degradation, and translocation to the nucleus.

Green Foaming of Biologically Extracted Chitin Hydrogels Using Supercritical Carbon Dioxide for Scaffolding of Human Osteoblasts.

Chitin is a structural polysaccharide abundant in the biosphere. Chitin possesses a highly ordered crystalline structure that makes its processing a challenge. In this study, chitin hydrogels and methanogels, prepared by dissolution in calcium chloride/methanol, were subjected to supercritical carbon dioxide (scCO2) to produce porous materials for use as scaffolds for osteoblasts. The control of the morphology, porosity, and physicochemical properties of the produced materials was performed according to the operational conditions, as well as the co-solvent addition. The dissolution of CO2 in methanol co-solvent improved the sorption of the compressed fluid into the hydrogel, rendering highly porous chitin scaffolds. The chitin crystallinity index significantly decreased after processing the hydrogel in supercritical conditions, with a significant effect on its swelling capacity. The use of scCO2 with methanol co-solvent resulted in chitin scaffolds with characteristics adequate to the adhesion and proliferation of osteoblasts.

Normative Values for Daily Functional Recovery Patterns Following Total Knee Arthroplasty.

BACKGROUND: Wearable devices provide the ability for clinical teams to continuously monitor patients' rehabilitation progress with objective data. Understanding expected recovery patterns following total knee arthroplasty (TKA) enables prompt identification of patients failing to meet these milestones. The aim of this study was to establish normative values for daily functional recovery in the first 6 weeks after TKA using a wearable device. METHODS: This prospective study included patients who underwent TKA between 2020 and 2023, treated by 11 surgeons from 8 institutions. Eligible participants were aged 18 or older, had a primary unilateral TKA, and owned a smartphone. Knee range of motion, total daily steps, cadence, and device usage were measured continuously over 6 weeks. Statistical analysis included analysis of variance using post hoc Tukey honest significant difference tests. RESULTS: The cohort of 566 participants had a mean age of 65 and 69 for men and women, respectively (range, 50 to 80). Women comprised 61% (n = 345) of study participants. There were 82% of women and 90% of men who had a body mass index > 30. The average daily wear time of the device was 12 hours (±4) for a total of 45 days (±27). Recovery was nonlinear, with the greatest gains in the first 3 weeks postsurgery for all metrics. Men demonstrated greater total daily step counts and cadence when compared to women. Obese patients demonstrated poorer performance when compared to lower body mass index patients. CONCLUSIONS: To our knowledge, this study presents the first normative data for tracking daily functional recovery in TKA patients using wearable sensors. Standardizing the TKA recovery timeline allows surgeons to isolate factors affecting patients' healing processes, accurately counsel them preoperatively, and intervene more promptly postoperatively when rehabilitation is not within standard recovery parameters.

Combined deletion of Mct8 and Dio2 impairs SVZ neurogliogenesis and olfactory function in adult mice.

Within the adult mouse subventricular zone (SVZ), neural stem cells (NSCs) produce neuroblasts and oligodendrocyte precursor cells (OPCs). T3, the active thyroid hormone, influences renewal and commitment of SVZ progenitors. However, how regulators of T3 availability affect these processes is less understood. Using Mct8/Dio2 knockout mice, we investigated the role of MCT8, a TH transporter, and DIO2, the T3-generating enzyme, in regulating adult SVZ-neurogliogenesis. Single-cell RNA-Seq revealed Mct8 expression in various SVZ cell types in WT mice, while Dio2 was enriched in neurons, astrocytes, and quiescent NSCs. The absence of both regulators in the knockout model dysregulated gene expression, increased the neuroblast/OPC ratio and hindered OPC differentiation. Immunostainings demonstrated compromised neuroblast migration reducing their supply to the olfactory bulbs, impairing interneuron differentiation and odor discrimination. These findings underscore the pivotal roles of MCT8 and DIO2 in neuro- and oligodendrogenesis, offering targets for therapeutic avenues in neurodegenerative and demyelinating diseases.

Circumvention of Topoisomerase IIα Intron 19 Intronic Polyadenylation in Acquired Etoposide-Resistant Human Leukemia K562 Cells.

DNA topoisomerase IIα (TOP2α; 170 kDa, TOP2α/170) is an essential enzyme for proper chromosome dysjunction by producing transient DNA double-stranded breaks and is an important target for DNA damage-stabilizing anticancer agents, such as etoposide. Therapeutic effects of TOP2α poisons can be limited due to acquired drug resistance. We previously demonstrated decreased TOP2α/170 levels in an etoposide-resistant human leukemia K562 subline, designated K/VP.5, accompanied by increased expression of a C-terminal truncated TOP2α isoform (90 kDa; TOP2α/90), which heterodimerized with TOP2α/170 and was a determinant of resistance by exhibiting dominant-negative effects against etoposide activity. Based on 3'-rapid amplification of cDNA ends, we confirmed TOP2α/90 as the translation product of a TOP2α mRNA in which a cryptic polyadenylation site (PAS) harbored in intron 19 (I19) was used. In this report, we investigated whether the resultant intronic polyadenylation (IPA) would be attenuated by blocking or mutating the I19 PAS, thereby circumventing acquired drug resistance. An antisense morpholino oligonucleotide was used to hybridize/block the PAS in TOP2α pre-mRNA in K/VP.5 cells, resulting in decreased TOP2α/90 mRNA/protein levels in K/VP.5 cells and partially circumventing drug resistance. Subsequently, CRISPR/CRISPR-associated protein 9 with homology-directed repair was used to mutate the cryptic I19 PAS (AATAAA→ACCCAA) to prevent IPA. Gene-edited clones exhibited increased TOP2α/170 and decreased TOP2α/90 mRNA/protein and demonstrated restored sensitivity to etoposide and other TOP2α-targeted drugs. Together, results indicated that blocking/mutating a cryptic I19 PAS in K/VP.5 cells reduced IPA and restored sensitivity to TOP2α-targeting drugs. SIGNIFICANCE STATEMENT: The results presented in this study indicate that CRISPR/CRISPR-associated protein 9 gene editing of a cryptic polyadenylation site (PAS) within I19 of the TOP2α gene results in the reversal of acquired resistance to etoposide and other TOP2-targeted drugs. An antisense morpholino oligonucleotide targeting the PAS also partially circumvented resistance.

Targeting Neutrophil Extracellular Trap Formation: Exploring Promising Pharmacological Strategies for the Treatment of Preeclampsia.

Neutrophils, which constitute the most abundant leukocytes in human blood, emerge as crucial players in the induction of endothelial cell death and the modulation of endothelial cell responses under both physiological and pathological conditions. The hallmark of preeclampsia is endothelial dysfunction induced by systemic inflammation, in which neutrophils, particularly through the formation of neutrophil extracellular traps (NETs), play a pivotal role in the development and perpetuation of endothelial dysfunction and the hypertensive state. Considering the potential of numerous pharmaceutical agents to attenuate NET formation (NETosis) in preeclampsia, a comprehensive assessment of the extensively studied candidates becomes imperative. This review aims to identify mechanisms associated with the induction and negative regulation of NETs in the context of preeclampsia. We discuss potential drugs to modulate NETosis, such as NF-κß inhibitors, vitamin D, and aspirin, and their association with mutagenicity and genotoxicity. Strong evidence supports the notion that molecules involved in the activation of NETs could serve as promising targets for the treatment of preeclampsia.

A randomised clinical trial of awake prone positioning in COVID-19 suspects with acute hypoxemic respiratory failure.

Background: Awake prone position (APP) has been reported to improve oxygenation in patients with COVID-19 disease and to reduce the requirement for invasive mechanical ventilation for patients requiring support with high flow nasal cannula. There is conflicting data for patients requiring lower-level oxygen support. Research question: Does APP reduce escalation of oxygen support in COVID-19 patients requiring supplementary oxygen?The primary outcome was defined as an escalation of oxygen support from simple supplementary oxygen (NP, HM, NRB) to NIV (CPAP or BiPAP), HFNC or IMV; OR from NIV (CPAP or BiPAP) or HFNC to IMV by day30. Study design: Two center, prospective, non-blind, randomised controlled trial. Patients with confirmed or suspected COVID-19 pneumonia requiring ≥ 5 liters/min oxygen to maintain saturations ≥ 94 % were randomised to either APP or control group. The APP group received a 3-h APP session three times per day for three days. Results: Between 9 May and July 13, 2021, 89 adults were screened and 61 enrolled, 31 to awake prone position and 30 controls. There was no difference in the primary outcome, 7 (22.6 %) patients randomised to APP and 9 (30.0 %) controls required escalation of oxygen support (OR 0.68 (0.22-2.14), P = 0.51). There were no differences in any secondary outcomes, in APP did not improve oxygenation. Interpretation: In COVID-19 patients, the use of APP did not prevent escalation of oxygen support from supplementary to invasive or non-invasive ventilation or improve patient respiratory physiology. Trial registration: NCT04853979 (clinicaltrials.gov).

HPLC-Based Metabolomic Analysis and Characterization of Amaranthus cruentus Leaf and Inflorescence Extracts for Their Antidiabetic and Antihypertensive Potential.

The aim of this study was to investigate the potential of Amaranthus cruentus flavonoids (quercetin, kaempferol, catechin, hesperetin, naringenin, hesperidin, and naringin), cinnamic acid derivatives (p-coumaric acid, ferulic acid, and caffeic acid), and benzoic acids (vanillic acid and 4-hydroxybenzoic acid) as antioxidants, antidiabetic, and antihypertensive agents. An analytical method for simultaneous quantification of flavonoids, cinnamic acid derivatives, and benzoic acids for metabolomic analysis of leaves and inflorescences from A. cruentus was developed with HPLC-UV-DAD. Evaluation of linearity, limit of detection, limit of quantitation, precision, and recovery was used to validate the analytical method developed. Maximum total flavonoids contents (5.2 mg/g of lyophilized material) and cinnamic acid derivatives contents (0.6 mg/g of lyophilized material) were found in leaves. Using UV-Vis spectrophotometry, the maximum total betacyanin contents (74.4 mg/g of lyophilized material) and betaxanthin contents (31 mg/g of lyophilized material) were found in inflorescences. The leaf extract showed the highest activity in removing DPPH radicals. In vitro antidiabetic activity of extracts was performed with pancreatic α-glucosidase and intestinal α-amylase, and compared to acarbose. Both extracts exhibited a reduction in enzyme activity from 57 to 74%. Furthermore, the in vivo tests on normoglycemic murine models showed improved glucose homeostasis after sucrose load, which was significantly different from the control. In vitro antihypertensive activity of extracts was performed with angiotensin-converting enzyme and contrasted to captopril; both extracts exhibited a reduction of enzyme activity from 53 to 58%. The leaf extract induced a 45% relaxation in an ex vivo aorta model. In the molecular docking analysis, isoamaranthin and isogomphrenin-I showed predictive binding affinity for α-glucosidases (human maltase-glucoamylase and human sucrase-isomaltase), while catechin displayed binding affinity for human angiotensin-converting enzyme. The data from this study highlights the potential of A. cruentus as a functional food.

Mango Fruit Detachment of Trees after Applying a Blend Composed of HNO3 and Charcoal Activated.

As young workers prefer urban labors and migrate to USA and Canada, mango harvesting is becoming scarce on Mexican coasts. This seasonal labor is becoming expensive and when many orchards produce fruit simultaneously, grower losses increase. In this research, an innovative fruit detachment method was tested after applying a viscous paste to the pedicel of mango fruits hanging in the tree. Activated carbon or charcoal (AC), was mixed with different amounts of nitric acid to provide three AC composite blends named: light, medium, and dense. The nanomaterial was applied with a brush to the fruit pedicel/peduncle taking up to 4 h before the mango fruits felt to a net below the tree canopy. Mango detachment experiments indicated that the medium blend was the most efficient in releasing the fruit, taking an average of 2 h. The dense nano-material decreased latex exudation to 7% of the fruits. Fruit maturity emerged as a crucial factor for detachment time, followed by mango weight.

Prevalence of disability secondary to work-related musculoskeletal injuries among orthopaedic surgeons.

Background: Orthopaedic surgeons encounter many work-place hazards that can lead to musculoskeletal injuries (MSI) and their clinical sequelae. This study aims to evaluate musculoskeletal injuries among orthopaedic surgeons and compare their rates of disability claims and time off work. Additionally, this study provides a perspective on the financial impact of work-related injuries among orthopaedic surgeons. Methods: An electronic survey was developed to assess work-place hazards among orthopaedic surgeons. The survey included questions on demographics, musculoskeletal injuries, and disabilities. Electronic surveys were emailed to all current members of the American Academy of Orthopaedic Surgeons (AAOS) between March and April 2021 in the United States. Descriptive statistics were run for all variables and chi-squared and t-tests when applicable. Results: 1645 members of the AAOS completed the survey (7.03 % response rate), and 243 (14.9 %) reported a work-related injury to their place of employment at some point during their career. Of the respondents, 1129 (76.4 %) reported having active disability insurance, and 61 (3.7 %) orthopaedic surgeons filed a disability claim secondary to a work-related injury at some point during their career. Of the surgeons that claimed disability, 39 (66.1 %) returned to work, and 20 (33.9 %) had an early retirement. Foot/ankle injuries led to the highest rates of early retirement overall (62.5 %). Conclusion: This study captures the prevalence of disability claims made by orthopaedic surgeons due to work-place hazards. To our knowledge, this is the first study to broadly compare disability claims amongst orthopaedic surgeons. This data should be used to implement changes in the orthopaedic community to decrease injuries and disability claims.

Biomechanical and histological comparison of two suture configurations for soft tissue grafts: speedtrap™ versus krackow stitch.

To compare 2 different graft preparation techniques to determine biomechanical strength and resultant tissue trauma evaluated by histology. Twelve common flexors of the finger's tendons were prepared with either tubulization (SpeedTrap™) or transtendon stiches (Orthocord™). The stiffness, resistance and energy at maximum load were tested for biomechanical assessment in both groups. After load testing, Samples were stained with hematoxylin and eosin (HE) to evaluate histological damage. We observe that the time to prepare tendons with SpeedTrap™ was 8.3 times faster (1:25 min) than traditional ones (15:02 min). In all cases, the mean values for SpeedTrap™ were higher in terms of strength, stiffness and energy at maximum load than for traditional suture but without significant difference (p > 0.05). The Krackow stitch produces greater structural damage to the collagen fibers while SpeedTrap™ maintains better organized arrangement of the fibers after tubulization preparation. With the results obtained, we can conclude that the tubulization technique allows faster graft preparation with less structural damage to the manipulated tissue without altering the biomechanical resistance provided by the transtendon suture technique.

Characterization of the Relative Change in Objective and Subjective Metrics by Baselining Patients Who Have Wearable Technology Before Total Knee Arthroplasty.

BACKGROUND: Wearable sensors and associated supporting technologies (ie, patient applications) can provide both objective (joint position, step counts, etc.) and subjective data (ie, pain scores and patient-reported outcome measures) to track a patient's episode of care. Establishing a subjective and objective baseline of a patient's experience may arguably be beneficial for multiple reasons, including setting recovery expectations for the patient and demonstrating the effectiveness or success of the intervention. METHODS: In this pilot study, we characterized a subset of patients (n = 82 from 7 surgeons) using a wearable sensor system at least 6 days before total knee arthroplasty and provided postsurgical data up to 50 days postintervention. The 5-day average before surgery for total step counts (activity), achieved flexion and extension on a progress test (functional limit) and visual analog scale daily pain score were calculated. The difference from baseline was then calculated for each patient for each day postsurgery and reported as averages. RESULTS: On average, a patient will experience a relative deficit of 4,000 steps immediately following surgery that will return to near-baseline levels 50 days postintervention. A 30° deficit in flexion and a 10° deficit in extension will return at a similar rate as steps. Relative pain scores will worsen with an increase of approximately 3 points immediately following surgery. However, pain will decrease by 2 points relative to baseline between 40 and 50 days. CONCLUSIONS: The results of this pilot study demonstrate a method to baseline a patient's presurgical subjective and objective data and to provide a reference for postsurgical recovery expectations. Applications for these data include benchmarking for evaluating intervention success as well as setting patient expectations.

Vacuolar Degradation of Plant Organelles.

Plants continuously remodel and degrade their organelles due to damage from their metabolic activities and environmental stressors, as well as an integral part of their cell differentiation programs. Whereas certain organelles use local hydrolytic enzymes for limited remodeling, most of pathways that control the partial or complete dismantling of organelles rely on vacuolar degradation. Specifically, selective autophagic pathways play a crucial role in recognizing and sorting plant organelle cargo for vacuolar clearance, especially under cellular stress conditions induced by factors like heat, drought, and damaging light. In these short reviews, we discuss the mechanisms that control the vacuolar degradation of chloroplasts, mitochondria, endoplasmic reticulum, Golgi, and peroxisomes, with an emphasis on autophagy, recently discovered selective autophagy receptors for plant organelles, and crosstalk with other catabolic pathways.

Incorporating plan complexity into the statistical process control of volumetric modulated arc therapy pre-treatment verifications.

BACKGROUND: Statistical process control (SPC) is a powerful statistical tool for process monitoring that has been highly recommended in healthcare applications, including radiation therapy quality assurance (QA). The AAPM TG-218 report described the clinical implementation of SPC for Volumetric Modulated Arc Therapy (VMAT) pre-treatment verifications, pointing out the need to adjust tolerance limits based on plan complexity. However, the quantification of plan complexity and its integration into SPC remains an unresolved challenge. PURPOSE: The primary aim of this study is to investigate the incorporation of plan complexity into the SPC framework for VMAT pre-treatment verifications. The study explores and evaluates various strategies for this incorporation, discussing their merits and limitations, and provides recommendations for clinical application. METHODS: A retrospective analysis was conducted on 309 VMAT plans from diverse anatomical sites using the PTW OCTAVIUS 4D device for QA measurements. Gamma Passing Rates (GPR) were obtained, and lower control limits were computed using both the conventional Shewhart method and three heuristic methods (scaled weighted variance, weighted standard deviations, and skewness correction) to accommodate non-normal data distributions. The 'Identify-Eliminate-Recalculate' method was employed for robust analysis. Eight complexity metrics were analyzed and two distinct strategies for incorporating plan complexity into SPC were assessed. The first strategy focused on establishing control limits for different treatment sites, while the second was based on the determination of control limits as a function of individual plan complexity. The study extensively examines the correlation between control limits and plan complexity and assesses the impact of complexity metrics on the control process. RESULTS: The control limits established using SPC were strongly influenced by the complexity of treatment plans. In the first strategy, a clear correlation was found between control limits and average plan complexity for each site. The second approach derived control limits based on individual plan complexity metrics, enabling tailored tolerance limits. In both strategies, tolerance limits inversely correlated with plan complexity, resulting in all highly complex plans being classified as in control. In contrast, when plans were collectively analyzed without considering complexity, all the out-of-control plans were highly complex. CONCLUSIONS: Incorporating plan complexity into SPC for VMAT verifications requires meticulous and comprehensive analysis. To ensure overall process control, we advocate for stringent control and minimization of plan complexity during treatment planning, especially when control limits are adjusted based on plan complexity.

4-aminopyridine improves evoked potentials and ambulation in the taiep rat: A model of hypomyelination with atrophy of basal ganglia and cerebellum.

The taiep rat is a tubulin mutant with an early hypomyelination followed by progressive demyelination of the central nervous system due to a point mutation in the Tubb4a gene. It shows clinical, radiological, and pathological signs like those of the human leukodystrophy hypomyelination with atrophy of the basal ganglia and cerebellum (H-ABC). Taiep rats had tremor, ataxia, immobility episodes, epilepsy, and paralysis; the acronym of these signs given the name to this autosomal recessive trait. The aim of this study was to analyze the characteristics of somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) in adult taiep rats and in a patient suffering from H-ABC. Additionally, we evaluated the effects of 4-aminopyridine (4-AP) on sensory responses and locomotion and finally, we compared myelin loss in the spinal cord of adult taiep and wild type (WT) rats using immunostaining. Our results showed delayed SSEPs in the upper and the absence of them in the lower extremities in a human patient. In taiep rats SSEPs had a delayed second negative evoked responses and were more susceptible to delayed responses with iterative stimulation with respect to WT. MEPs were produced by bipolar stimulation of the primary motor cortex generating a direct wave in WT rats followed by several indirect waves, but taiep rats had fused MEPs. Importantly, taiep SSEPs improved after systemic administration of 4-AP, a potassium channel blocker, and this drug induced an increase in the horizontal displacement measured in a novelty-induced locomotor test. In taiep subjects have a significant decrease in the immunostaining of myelin in the anterior and ventral funiculi of the lumbar spinal cord with respect to WT rats. In conclusion, evoked potentials are useful to evaluate myelin alterations in a leukodystrophy, which improved after systemic administration of 4-AP. Our results have a translational value because our findings have implications in future medical trials for H-ABC patients or with other leukodystrophies.

A radiotherapy community data-driven approach to determine which complexity metrics best predict the impact of atypical TPS beam modeling on clinical dose calculation accuracy.

PURPOSE: To quantify the impact of treatment planning system beam model parameters, based on the actual spread in radiotherapy community data, on clinical treatment plans and determine which complexity metrics best describe the impact beam modeling errors have on dose accuracy. METHODS: Ten beam modeling parameters for a Varian accelerator were modified in RayStation to match radiotherapy community data at the 2.5, 25, 50, 75, and 97.5 percentile levels. These modifications were evaluated on 25 patient cases, including prostate, non-small cell lung, H&N, brain, and mesothelioma, generating 1,000 plan perturbations. Differences in the mean planned dose to clinical target volumes (CTV) and organs at risk (OAR) were evaluated with respect to the planned dose using the reference (50th-percentile) parameter values. Correlation between CTV dose differences, and 18 different complexity metrics were evaluated using linear regression; R-squared values were used to determine the best metric. RESULTS: Perturbations to MLC offset and transmission parameters demonstrated the greatest changes in dose: up to 5.7% in CTVs and 16.7% for OARs. More complex clinical plans showed greater dose perturbation with atypical beam model parameters. The mean MLC Gap and Tongue & Groove index (TGi) complexity metrics best described the impact of TPS beam modeling variations on clinical dose delivery across all anatomical sites; similar, though not identical, trends between complexity and dose perturbation were observed among all sites. CONCLUSION: Extreme values for MLC offset and MLC transmission beam modeling parameters were found to most substantially impact the dose distribution of clinical plans and careful attention should be given to these beam modeling parameters. The mean MLC Gap and TGi complexity metrics were best suited to identifying clinical plans most sensitive to beam modeling errors; this could help provide focus for clinical QA in identifying unacceptable plans.