Deep inspirational breast hold (DIBH) for right breast irradiation: Improved sparing of liver and lung tissue.

Objective: To reduce liver and lung dose during right breast irradiation while maintaining optimal dose to the target volume. This dose reduction has the potential to decrease acute side effects and long-term toxicity. Materials and Methods: 16 patients treated with radiation therapy for localized carcinoma of the right breast were included retrospectively. For the planning CT, each patient was immobilised on an indexed board with the arms placed above the head. CT scans were acquired in free-breathing (FB) as well as with deep inspiration breath hold (DIBH). Both scans were acquired with the same length. Planning target volumes (PTV's) were created with a 5 mm margin from the respective clinical target volumes (CTV's) on both CT datasets. The liver was outlined as scanned. Dose metrics evaluated were as follows: differences in PTV coverage, dose to the liver (max, mean, V90%, V50%, V30%), dose to lung (mean, V20Gy, relative electron density) and dose to heart (Dmax). The p-values were calculated using Wilcoxon signed-rank tests. A p-value was significant when <0.05. Results: Differences in PTV coverage between plans using FB and DIBH were less than 2 %. Maximum liver dose was significantly less using DIBH: 17.5 Gy versus FB: 40.3 Gy (p < 0.001). The volume of the liver receiving 10 % of the dose was significantly less using DIBH with 1.88 cm3 versus 72.2 cm3 under FB (p < 0.001). The absolute volume receiving 20 Gy in the right lung was larger using DIBH: 291 cm3 versus 230 cm3 under FB (p < 0.001) and the relative volume of lung receiving dose greater than 20 Gy was smaller with DIBH: 11.5 % versus 14 % in FB (p = 0.007). The relative electron density of lung was significantly less with DIBH: 0.59 versus 0.62 with FB, (p < 0.001). This suggests that the lung receives less dose due to its lower density when using DIBH. Conclusion: Radiation of the right breast using DIBH spares liver and lung tissue significantly and thus carries the potential of best practice for right sided breast cancer.

Risk of death at home or on hospital readmission after discharge with pediatric tracheostomy.

OBJECTIVE: To evaluate outcomes of patients discharged home following tracheostomy, including the timing and place of death for non-survivors. STUDY DESIGN: We retrospectively reviewed medical records of infants undergoing tracheostomy between 2006 and 2017, within the first year of life for congenital or acquired neonatal conditions. RESULTS: Of the 224 patients discharged after tracheostomy, 127 (57%) required home mechanical ventilation (MV). Overall, 40 (18%) patients died (65% were on MV); 38% of the deaths occurred at home and 63% at a subsequent hospitalization. Having tube feeding was identified as significantly associated with increased mortality on multivariate analysis. Having a tracheostomy for upper airway obstruction was the only variable significantly associated with increased risk of death at home on multivariate analysis. CONCLUSIONS: Having tube feeding was associated with increased risk of death overall and having the tracheostomy for obstructive airway conditions was associated with death occurring at home.

A Current View of SARS-CoV-2 Vaccine Policies Amongst Pediatric Renal Transplant Centers and Relationships to State Policy.

Given its mortality benefit, renal transplantation remains the ideal treatment modality for end stage renal disease in children. Despite the recent expansion of use in young children, the novel SARS-CoV-2 vaccine has not been universally accepted. Similarly, vaccine related state regulations are heterogenous. We present a cross-sectional analysis of institutional specific vaccination policies at US pediatric renal transplant centers and relationships to state legislation. We found that 36.1% of institutions require COVID-19 vaccination prior to transplant, while 17 states have current legislation prohibiting proof of vaccination as a means of access to public services. Of the 63.9% of transplant centers without immunization requirement, almost two-thirds are located in states without prohibitory regulations. Despite an unclear primary influence of institutional policy, our study demonstrates a lack of standardization and potential to create unnecessary inequities.

Age-dependent effects of social isolation on mesolimbic dopamine release.

In humans, social isolation is a known risk factor for disorders such as substance use disorder and depression. In rodents, social isolation is a commonly used environmental manipulation that increases the occurrence of behaviors related to these disorders. Age is thought to influence the effects of social isolation, but this predictive relationship is not well-understood. The present study aimed to determine the effects of social isolation on mesolimbic dopamine release at different developmental age points in mice. The experimental ages and their corresponding comparison to human age stages are as follows: 1 month = adolescence, 4 months = mature adulthood, 12 months = middle adulthood, and 18 months = older adult. Mice were socially isolated for 6 weeks during these developmental stages, then in vivo fixed potential amperometry with recording electrodes in the nucleus accumbens was used to measure stimulation-evoked dopamine release, the synaptic half-life of dopamine, dopamine autoreceptor functioning, and the dopaminergic response to cocaine. Isolation altered dopamine functioning in an age-dependent manner. Specifically, isolation increased dopamine release in the adult ages, but not adolescence, potentially due to increased inhibitory effects of dopamine autoreceptors following adolescent social isolation. Regarding the cocaine challenge, isolation increased dopaminergic responses to cocaine in adolescent mice, but not the adult mice. These findings have implications for clinical and experimental settings. Elucidating the relationship between age, social isolation, and neurochemical changes associated with substance use disorder and depression may lead to improvements in preventing and treating these disorders.

Structural basis for the glucan phosphatase activity of Starch Excess4.

Living organisms utilize carbohydrates as essential energy storage molecules. Starch is the predominant carbohydrate storage molecule in plants while glycogen is utilized in animals. Starch is a water-insoluble polymer that requires the concerted activity of kinases and phosphatases to solubilize the outer surface of the glucan and mediate starch catabolism. All known plant genomes encode the glucan phosphatase Starch Excess4 (SEX4). SEX4 can dephosphorylate both the starch granule surface and soluble phosphoglucans and is necessary for processive starch metabolism. The physical basis for the function of SEX4 as a glucan phosphatase is currently unclear. Herein, we report the crystal structure of SEX4, containing phosphatase, carbohydrate-binding, and C-terminal domains. The three domains of SEX4 fold into a compact structure with extensive interdomain interactions. The C-terminal domain of SEX4 integrally folds into the core of the phosphatase domain and is essential for its stability. The phosphatase and carbohydrate-binding domains directly interact and position the phosphatase active site toward the carbohydrate-binding site in a single continuous pocket. Mutagenesis of the phosphatase domain residue F167, which forms the base of this pocket and bridges the two domains, selectively affects the ability of SEX4 to function as a glucan phosphatase. Together, these results reveal the unique tertiary architecture of SEX4 that provides the physical basis for its function as a glucan phosphatase.

Structural insights into glucan phosphatase dynamics using amide hydrogen-deuterium exchange mass spectrometry.

Laforin and starch excess 4 (SEX4) are founding members of a class of phosphatases that dephosphorylate phosphoglucans. Each protein contains a carbohydrate binding module (CBM) and a dual-specificity phosphatase (DSP) domain. The gene encoding laforin is mutated in a fatal neurodegenerative disease called Lafora disease (LD). In the absence of laforin function, insoluble glucans that are hyperphosphorylated and exhibit sparse branching accumulate. It is hypothesized that these accumulations trigger the neurodegeneration and premature death of LD patients. We recently demonstrated that laforin removes phosphate from phosphoglucans and hypothesized that this function inhibits insoluble glucan accumulation. Loss of SEX4 function in plants yields a similar cellular phenotype; an excess amount of insoluble, hyperphosphorylated glucans accumulates in cells. While multiple groups have shown that these phosphatases dephosphorylate phosphoglucans, there is no structure of a glucan phosphatase and little is known about the mechanism whereby they perform this action. We utilized hydrogen-deuterium exchange mass spectrometry (DXMS) and structural modeling to probe the conformational and structural dynamics of the glucan phosphatase SEX4. We found that the enzyme does not undergo a global conformational change upon glucan binding but instead undergoes minimal rearrangement upon binding. The CBM has improved protection from deuteration when bound to glucans, confirming its role in glucan binding. More interestingly, we identified structural components of the DSP that also have improved protection from deuteration upon glucan addition. To determine the position of these regions, we generated a homology model of the SEX4 DSP. The homology model shows that all of these regions are adjacent to the DSP active site. Therefore, our results suggest that these regions of the DSP participate in the presentation of the phosphoglucan to the active site and provide the first structural analysis and mode of action of this unique class of phosphatases.

Conservation of the glucan phosphatase laforin is linked to rates of molecular evolution and the glucan metabolism of the organism.

BACKGROUND: Lafora disease (LD) is a fatal autosomal recessive neurodegenerative disease. A hallmark of LD is cytoplasmic accumulation of insoluble glucans, called Lafora bodies (LBs). Mutations in the gene encoding the phosphatase laforin account for approximately 50% of LD cases, and this gene is conserved in all vertebrates. We recently demonstrated that laforin is the founding member of a unique class of phosphatases that dephosphorylate glucans. RESULTS: Herein, we identify laforin orthologs in a protist and two invertebrate genomes, and report that laforin is absent in the vast majority of protozoan genomes and it is lacking in all other invertebrate genomes sequenced to date. We biochemically characterized recombinant proteins from the sea anemone Nematostella vectensis and the amphioxus Branchiostoma floridae to demonstrate that they are laforin orthologs. We demonstrate that the laforin gene has a unique evolutionary lineage; it is conserved in all vertebrates, a subclass of protists that metabolize insoluble glucans resembling LBs, and two invertebrates. We analyzed the intron-exon boundaries of the laforin genes in each organism and determine, based on recently published reports describing rates of molecular evolution in Branchiostoma and Nematostella, that the conservation of laforin is linked to the molecular rate of evolution and the glucan metabolism of an organism. CONCLUSION: Our results alter the existing view of glucan phosphorylation/dephosphorylation and strongly suggest that glucan phosphorylation is a multi-Kingdom regulatory mechanism, encompassing at least some invertebrates. These results establish boundaries concerning which organisms contain laforin. Laforin is conserved in all vertebrates, it has been lost in the vast majority of lower organisms, and yet it is an ancient gene that is conserved in a subset of protists and invertebrates that have undergone slower rates of molecular evolution and/or metabolize a carbohydrate similar to LBs. Thus, the laforin gene holds a unique place in evolutionary biology and has yielded insights into glucan metabolism and the molecular etiology of Lafora disease.