Comparison of Air-Gaps Effect in a Small Cavity on Dose Calculation for 6 MV Linac.

BACKGROUND: Many authors stated that cavities or air-gaps were the main challenge of dose calculation for head and neck with flattening filter medical linear accelerator (Linac) irradiation. OBJECTIVE: The study aimed to evaluate the effect of air-gap dose calculation on flattening-filter-free (FFF) small field irradiation. MATERIAL AND METHODS: In this comparative study, we did the experimental and Monte Carlo (MC) simulation to evaluate the presence of heterogeneities in radiotherapy. We simulated the dose distribution on virtual phantom and the patient's CT image to determine the air-gap effect of open small field and modulated photon beam, respectively. The dose ratio of air-gaps to tissue-equivalent was calculated both in Analytical Anisotropic Algorithm (AAA) and MC. RESULTS: We found that the dose ratio of air to tissue-equivalent tends to decrease with a larger field size. This correlation was linear with a slope of -0.198±0.001 and -0.161±0.014 for both AAA and MC, respectively. On the other hand, the dose ratio below the air-gap was field size-dependent. The AAA to MC dose calculation as the impact of air-gap thickness and field size varied from 1.57% to 5.35% after the gap. Besides, patient's skin and oral cavity on head and neck case received a large dose discrepancy according to this study. CONCLUSION: The dose air to tissue-equivalent ratio decreased with smaller air gaps and larger field sizes. Dose correction for AAA calculation of open small field size should be considered after small air-gaps. However, delivered beam from others gantry angle reduced this effect on clinical case.

[Adrenal disease diagnosis: management of adrenal incidentaloma]. / Diagnostic des pathologies surrénaliennes : mise au point d'un incidentalome surrénalien.

Adrenal glands are specialized in biosynthesis of several hormones correlated to different clinical phenotypes in case of excess or lack of production. In addition to secretion disorders, tumors, secreting or not, can take place in adrenal glands. Incidentalomas are the most common adrenal diseases in clinical practice. The challenge of the management is to determine whether the lesion is benign or malignant and secreting or not in order to direct therapeutic management towards surgical option, pharmacotherapy or clinical follow-up. Several radiographic characteristics allow to predict the benign or malignant nature of a lesion (size and density of the tumor, fat content,...). Adrenal carcinoma is a very rare cancer but should be excluded because its extremely poor prognosis. If most incidentalomas are non-secreting, it is important to ensure that there is no Cushing syndrome, even subclinical (± 10 % of incidentalomas) or pheochromocytoma (± 10 % of incidentalomas), pathologies associated with a higher incidence of cardiovascular complications. Careful clinical evaluation for symptoms and signs related to excessive adrenal hormones production is recommended to prescribe appropriate hormone assays. Finally, the surgical indication will be guided by the probability of malignancy, the presence and the degree of hypersecretion but also the age, the general health and the choice of the patient.

Les glandes surrénales assurent la synthèse d'une série d'hormones qui en cas d'hypo - ou d'hyper-sécrétion pathologique peuvent entraîner différentes manifestations cliniques. Outre ces dérèglements sécrétoires, les glandes surrénales peuvent être le siège du développement de tumeurs. Les incidentalomes sont de loin les pathologies surrénaliennes les plus fréquentes en clinique. Le défi de la mise au point consiste à définir si la lésion est bénigne ou maligne et sécrétante ou non-sécrétante afin d'orienter la prise en charge thérapeutique vers une option chirurgicale, un traitement médica-menteux ou un simple suivi clinique et/ou radio-logique. Plusieurs caractéristiques radiographi-ques permettent de prédire la nature bénigne ou maligne d'une lésion (taille et densité de la masse, contenu graisseux,…). Le carcinome surrénalien est un cancer rarissime, mais de pronostic tellement sombre qu'il est impératif d'exclure ce diagnostic. De même, si la plupart des incidentalomes sont non-sécrétants, il est important de s'assurer de l'absence d'un syndrome de Cushing, même infra-clinique (± 10 % des incidentalomes) ou d'un phéochromocytome (± 10 % des incidentalomes), hypersécrétions associées toutes deux à une incidence élevée de complications cardiovasculaires. On recommande donc une évaluation clinique minutieuse à la recherche de symptômes et signes en rapport avec une production excessive d'hormones surrénaliennes pour prescrire les dosages hormonaux appropriés. Enfin, l'indication opératoire sera guidée par la probabilité de malignité, la présence et le degré d'hypersécrétion mais aussi l'âge, l'état général et le choix du patient.

Volition and low back pain: When patients talk.

OBJECTIVE: Our objective was to explore, describe and understand volition of chronic low back pain (LBP) patients, highlighting barriers and facilitators to practicing regular physical activity in order to develop a questionnaire assessing those volitional competencies. METHODS: A content analysis of semi-structured interviews with 30 chronic LBP patients was performed. Participants were asked about their pain, motivation, physical abilities, barriers and facilitators to regular exercises and finally strategies implemented to achieve the exercise program. RESULTS: Patients often reported that they were motivated and that exercises had no negative effects on LBP. Many patients recognized having difficulties performing all their exercises regularly. The main barriers were: lack of time, fatigue, lack of visible results, pain and other daily priorities. The main facilitators were: group exercise, help from the therapist, strategic planning, favorable environment, pleasure associated with exercises, fear of pain recurrence and pain itself. CONCLUSION: Content analysis showed that sharing stories allowed patients to express their experience of LBP in their own words. It provides a solid ground to develop a questionnaire assessing volitional competencies in chronic LBP patients in order to identify patients who will not realize their exercises and help them be (more) active and avoid chronicity.

HA222 polymorphism in Influenza A(H1N1) 2009 isolates from Intensive Care Units and ambulatory patients during three influenza seasons.

Amino acid substitutions which can affect the receptor binding specificity of the influenza virus, like the substitution of aspartic acid with glycine in position 222 of the haemagglutinin (HA) of influenza virus A(H1N1) 2009, have been associated with increased viral pathogenicity and increased tropism for the lower respiratory tract. In this paper, the polymorphic site 222 and the site 223 of the HA1 polypeptide of H1N1 2009 viruses were analyzed in order to better clarify the role of these substitutions in H1N1 2009 virus virulence. Viral strains included in this study were collected in Tuscany during 3 different influenza seasons from patients with severe as well as with mild forms of influenza caused by A(H1N1) 2009 virus. In addition, the oseltamivir resistance of the H1N1 2009 strains circulating during the same seasons was monitored with the aim to evaluate whether these changes in the HA and in neuraminidase (NA) tend to be linked and to influence each other. Altogether, the results indicate that in severe forms of influenza viral population is more variable than in mild influenza, as regards the site 222. The frequency of such substitutions varied among the three seasons, it was highest in the season 2010-2011 and very low in the season 2012-2013. However these differences were not significant.

Hepatitis C virus infection and type 2 diabetes.

Hepatitis C virus (HCV) infection and Type 2 diabetes mellitus (T2DM) are two worldwide, major public health problems with increasing complication and mortality rates. Many epidemiological studies have demonstrated the significant association between T2DM and chronic HCV infection. In this paper we have reviewed the increasing evidence linking HCV infection and DM in more than one field (epidemiology, pathogenesis, clinical aspects, prevention and treatment). We have considered T2DM, acute and chronic HCV infection, and cirrhotic patients. Moreover, we have considered some particular populations, solid organ transplant recipients or HCV/human immunodeficiency virus (HIV) coinfected patients. In the final part we have analyzed the potential effect of the association between HCV infection and the development of DM in term of outcome and possibilities for prevention and treatment.

Investigation of an imported case of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection in Florence, Italy, May to June 2013.

On 31 May 2013, the first case of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection in Italy was laboratory confirmed in a previously healthy adult man, who developed pneumonia with moderate respiratory distress after returning from a holiday in Jordan. Two secondary cases were identified through contact tracing, among family members and colleagues who had not previously travelled abroad. Both secondary cases developed mild illness. All three patients recovered fully.

Molecular surveillance of pandemic influenza A(H1N1) viruses circulating in Italy from May 2009 to February 2010: association between haemagglutinin mutations and clinical outcome.

Haemagglutinin sequences of pandemic influenza A(H1N1) viruses circulating in Italy were examined, focusing on amino acid changes at position 222 because of its suggested pathogenic relevance. Among 169 patients, the D222G substitution was detected in three of 52 (5.8%) severe cases and in one of 117 (0.9%) mild cases, whereas the D222E mutation was more frequent and evenly distributed in mild (31.6%) and severe cases (38.4%). A cluster of D222E viruses among school children confirms reported human-to-human transmission of viruses mutated at amino acid position 222.

A FRET based melting curve analysis to detect nucleotide variations in HA receptor-binding site of H5N1 virus.

Outbreaks of highly pathogenic H5N1 influenza A virus represent a major public health problem because of the possibility of direct transmission of these viruses from avian species to humans. For influenza H5N1 hemagglutinin, a switch from SA-a-2, 3-Gal to SA-a-2, 6-Gal receptor specificity is a critical step that could lead to inter-human transmission. The monitoring of the receptor-binding preference of H5N1 viruses represents an instrument to detect a potential pandemic virus. The aim of this study was to develop a method based on the fluorescence resonance energy transfer (FRET) technology and melting peaks analysis for rapid screening of pandemic H5N1 influenza A virus. Three selected probes corresponding to a 23bp nucleotide sequence of the avian receptor-binding site were used in a real-time RT-PCR to detect nucleotide variations. Five strains of avian influenza A viruses isolated from avian species and two synthesized HA gene were tested. The results showed that the melting peaks analysis is a reliable screening method for detecting the variability of the H5N1 receptor-binding site.

Effectiveness of nanofiltration in removing small non-enveloped viruses from three different plasma-derived products.

The objective of this study was to assess the ability of nanofiltration of albumin solution, prothrombin complex (PTC) and factor IX (FIX) to remove two small, non-enveloped DNA viruses, parvovirus B19 (B19V) and torque teno virus (TTV). Virus removal was investigated with down-scale experiments performed with sequential steps of 35-nm and 15-nm nanofiltrations of products spiked with virus DNA-positive sera. Viral loads were determined by real-time PCRs. The 15-nm nanofiltration removed more than 4.0 B19V log from all the products, TTV was reduced of more than 3.0 log from albumin solution and FIX by 35-nm and 15-nm nanofiltrations, respectively, being viral DNA undetectable after these treatments. Traces of TTV were still found in PTC after the 15-nm nanofiltration. In conclusion, nanofiltration can be efficacious in removing small naked viruses but, since viruses with similar features can differently respond to the treatment, a careful monitoring of large-scale nanofiltration should be performed.

Schistosoma mansoni: developmental arrest of miracidia treated with histone deacetylase inhibitors.

In the present study, we examined the effect of the histone deacetylase (HDAC) inhibitors trichostatin A (TSA), valproic acid (VA) and sodium-butyrate on the metamorphosis of larvae of the human blood-fluke Schistosoma mansoni from the free-swimming miracidia into the intramolluskal sporocyst. We show that HDAC inhibitors block transformation in concentration dependant manner. TSA reversibly blocks this developmental process: only 13+/-11% of TSA treated miracidia transform into sporocysts in-vitro, compared to 92+/-3% in the mock-treated control. Other enzyme inhibitors such as cycloheximide or hydroxyurea had no effect on metamorphosis. For treatment of up to 4 h, the effect of TSA was completely reversible. Our data indicates that HDAC activity is necessary for the transformation of S. mansoni miracidia during infection of the snail host.

Cinnamomin: separation, crystallization and preliminary X-ray diffraction study.

Cinnamomin from Cinnamonum camphora seeds, a type II ribosome-inactivating protein that interferes with protein biosynthesis in mammalian cells, can induce the apoptosis of carcinoma cells and be used as an insecticide. A rapid and improved method has been developed for the extraction and purification of cinnamomin from camphora seed. Purification of cinnamomin is achieved with two successive steps of hydrophobic interaction chromatography carried out on a fast protein liquid chromatography (FPLC) system. Crystals suitable for X-ray diffraction analysis were obtained by vapor diffusion method. A complete data set at 2.8 A resolution has been collected. Data indexation and refinement indicate that the crystal is orthorhombic with space group P2(1)2(1)2(1) and unit cell dimensions a = 52.39 A, b = 126.33 A, c = 161.45 A. There are two molecules per asymmetric unit. Initial phasing by molecular replacement method yielded a solution, which will contribute to the structure determination. A molecular model will further the understanding of the mechanism of cinnamomin function. The latter will be combined with bio-informatics to facilitate the medical and other applications of cinnamomin.

Prospective monitoring of polyomavirus BK replication and impact of pre-emptive intervention in pediatric kidney recipients.

Polyoma BK virus (BKV)-associated nephropathy (PVAN) is a relevant cause of poor renal allograft survival. In a prospective analysis, we monitored BKV DNA in blood and urine samples from 62 consecutive pediatric kidney recipients. In patients with BKV replication, we analyzed the impact of reduction of maintenance immunosuppression on viral load kinetics and PVAN in patients with BKV replication. BKV-specific immunity was concomitantly evaluated on blood samples of viremic patients, by measuring the frequency of BKV-specific interferon-gamma-producing and cytotoxic T cells, and BKV IgG antibody levels. At a median follow-up of 24 months, BK viruria was observed in 39 of 62 patients, while BK viremia developed in 13 patients (21%). In all viremic patients, immunosuppression reduction resulted in the clearance of viremia, and prevented development of PVAN, without increasing the rate of acute rejection or causing graft dysfunction. As a consequence of immunosuppression adjustment, an expansion of BKV-specific cellular immunity was observed that coincided with viral clearance. We conclude that treating pediatric kidney transplant patients pre-emptively with immunosuppression reduction guided by BKV DNA in blood is safe and effective to prevent onset of PVAN. BKV-specific cellular immunity may be useful to guide this intervention.

Crystallization and preliminary X-ray diffraction analysis of E. coli arginyl-tRNA synthetase in complex form with a tRNAArg.

Amino acids are building blocks of proteins, while aminoacyl-tRNA synthetases (aaRSs) catalyze the first reaction in such building: the biosynthesis of proteins. The E. coli arginyl-tRNA synthetase (ArgRS) has been crystallized in complex form with tRNA(Arg) (B. stearothermophilus), at pH 5.6 using ammonium sulfate as a precipitating agent. Two crystal forms have been identified based on unit cell dimension. The complete data sets from both crystal forms have been collected with a primitive hexagonal space group. A data set of Form II crystals at 3.2 A and 94% completeness has been obtained, with unit cell parameters a = b = 98.0 A, c = 463.2 A, and alpha = beta = 90 degrees , gamma = 120 degrees , being different from a = b = 110.8 A, c = 377.8 A for form I. The structure determination will demonstrate the interaction of these two macromolecules to understand the special mechanism of ArgRS that requires the presence of tRNA for amino acid activation. Such complex structure also provides a wide opening for inhibitor search using bioinformatics.

[Polyomavirus BK-associated nephropathy after kidney transplantation]. / La nefropatia associata all'infezione da polyoma virus BK dopo trapianto renale.

Polyomavirus BK (BKV) infection has been lately recognized as a major cause of renal allograft dysfunction. BKV-related interstitial nephropathy (PVAN) may affect 1-10% of renal allograft recipients, occurring more frequently in the first 6 months after transplantation. Progression to irreversible allograft failure has been observed in up to 45% of all cases; thanks to increased PVAN awareness and improved diagnostic techniques, the rate of graft loss has lowered, more consistently in centres with active screening and intervention programs. PVAN pathogenesis is characterized by multiple synergizing factors, among which immunodepression plays a key role. PVAN diagnosis requires the evaluation of a renal biopsy showing polyomavirus cytopathic changes and confirming BKV through an ancillary technique such as immunohistochemistry. Given the focal nature of the disease, early diagnosis may be difficult to obtain. Thus, quantification of BKV-DNA in plasma has been suggested as surrogate marker for PVAN. To date, given the lack of controlled trials, there is no consensus on a 'standard' management of PVAN. However, evidence based on reported observations suggests that a step-wise reduction of immunosuppression, preceded by pulsed steroids in case of coexistent acute rejection, may improve outcomes. Additional options may be represented by drugs with antiviral activity, such as cidofovir, leflunomide or quinolones. Application of a preventive treatment based on viremia monitoring has been recently proposed.

Structural basis of the multispecificity demonstrated by 17beta-hydroxysteroid dehydrogenase types 1 and 5.

17Beta-hydroxysteroid dehydrogenases/ketosteroid reductases (17beta-HSDs/KSRs) catalyze the last step of sex steroid synthesis or the first step of their degradation, and are thus critical for many physiological processes. The multispecificity demonstrated by 17beta-HSDs is important for steroid metabolism in gonadal and peripheral tissues, and is a consequence of the architecture of their binding and catalytic sites. Structurally, most of the family members are short chain dehydrogenase-reductases (SDRs) except the type 5 enzyme, which is an aldo-keto reductase (AKR). 17Beta-HSD type 1, a representative of the SDR family, has been studied extensively since the 1950s. However, its structure was not determined until the 1990s. It has always been considered as estrogen specific, in accord with the narrow binding tunnel that has been structurally determined and has been found to be complementary to estrogens. A recent study revealed that, in spite of the enzyme's narrow binding tunnel, the pseudo-symmetry of C19 steroids leads to its alternative binding, resulting in the multispecificity of the enzyme. Expressed in ovary, breast and placenta, the enzyme catalyzes the formation of another estrogen A-diol from DHEA in addition to the biosynthesis of estradiol; it also inactivates the most active androgen DHT by both 17beta-hydroxysteroid oxidation and 3-ketosteroid reduction. Type 5 17beta-HSD (AKR1C3) differs significantly from the type 1 enzyme by possessing a spacious and flexible steroid-binding site. This is estimated to be about 960 or 470 A3 in ternary complex with testosterone or 4-dione, respectively, whereas the binding site volume of 17beta-HSD1 is only about 340 A3. This characteristic of the 17beta-HSD5 binding site permits the docking of various steroids in different orientations, which encompasses a wider range of activities from 20alpha-, 17beta- and 3alpha-HSD/KSR to prostaglandin 11-ketoreductase. The in vitro activities of the enzyme are significantly lower than the type 1 enzyme. In the ternary complex with testosterone, the steroid C3-C17 position is quasi-reversed as compared to the complex with 4-dione. The multi-specificity contributes significantly to steroid metabolism in peripheral tissues, due to the high levels of 17beta-HSD5 mRNA in both breast and prostate tissues.

Effects of aldehydes on CD36 expression.

INTRODUCTION: During the oil frying process lipid peroxidation compounds are formed. These products can modulate gene expression and alter cellular behaviour. The cellular uptake of oxidized LDL, a key step in the development of atherosclerosis, is mediated by the CD36 scavenger receptor, whose expression is down-regulated by alpha-tocopherol. OBJECTIVE: To determine the effects of water-soluble aldehydes, obtained from thermally oxidized sunflower oil on the expression of CD36 scavenger receptor in human monocytes (THP-1 cells). We also wanted to study the effects of alpha-tocopherol on CD36 expression in the presence of water-soluble aldehydes. MATERIALS AND METHODS: Sunflower oil was heated in a frying pan, at 180--200 degrees C for 40 min, water-soluble aldehydes were isolated, and the content of thiobarbituric acid reacting substances (TBARS) was determined. THP-1 monocytes were cultured in RPMI medium during 24 h and incubated with increasing concentrations of the water-soluble aldehydes (ranging from 0.05 to 1 microM) and with or without 50 microM of alpha-tocopherol. In parallel, THP-1 cells were cultured with the same volume of an extract obtained from non-oxidized oil or distilled water. The CD36 expression at the cell surface was studied with fluorescence-activated cell sorting (FACS). RESULTS: Monocytes incubated in a medium containing water-soluble aldehydes, showed a dose dependent increase in the expression of the CD36 protein on the cell surface, compared to with the control groups. When the cells were treated simultaneously with 50 microM of alpha-tocopherol a significant reduction in the expression of the CD36 protein was observed. CONCLUSION: Water-soluble aldehydes, extracted from thermally oxidized culinary oil, increase the expression of CD36. This effect is partially decreased by the presence of alpha-tocopherol.

Human parvovirus B19 experimental infection in human fibroblasts and endothelial cells cultures.

With the aim to detect what kind of cells, in addition to erythroid progenitors, could be involved in the pathogenesis of B19 infection in some connective tissue diseases, primary cultures of human fibroblasts (HF) and endothelial cells (HUVEC) were exposed to a B19 positive serum (350 genome copies/cell). The presence of NS1 and VP1 mRNA, in both HF and HUVEC cultures 1, 2 and 6 days after the exposure, indicated infection by B19 virus. However, no significant increase of B19 DNA level in the infected HF and HUVEC cultures was detectable through the entire incubation period of 6 days. It is possible that HF and HUVEC are not permissive for B19 virus replication or, alternatively, that few cells only get infected by B19 virus. HF and HUVEC stimulation with different growth factors or cytokines could be required for a B19 productive infection to occur.

Presence of TT virus DNA in bone marrow cells from hematologic patients.

Recent observations suggest that TT virus (TTV), in addition to liver, may also infect bone marrow. In this study, bone marrow samples and sera from 33 patients with haematological disorders and sera from 16 healthy controls were investigated for TTV DNA presence. Altogether TTV DNA sequences were demonstrated in bone marrow cells of 84.84% of patients. Moreover TTV DNA was detected in sera from 72.72% of patients and from 93.75% of controls. N22 sequences amplified from bone marrow cells and serum of 3 patients were analysed, after cloning: all these isolates were of type 2c and 2 or 3 variants were present in each isolate. After single strand DNA degradation, replicative forms were detectable in BM cells. This finding, in addition to the detection of variants similar in the BM and in the serum of the same patient could suggest that BM is a site of TTV replication (or one of the sites) from which the virus is spread in blood.