Considerations for MR-linac bunker shielding design.

Purpose.To show the considerations followed for MR-linac in shielding design for the first MR-linac in Mexico following the national clinical necessities.Method.The National Council on Radiation Protection and Measurements (NCRP) 151 recommendations were followed for the shielding design for primary and secondary barriers and the door design. The calculations were made considering the clinical demands in the country, that is, intensity modulated (IMRT) and 3D conformal radiotherapy (3DC-RT) in 80%-20% proportion.Results.The values obtained in the level survey fully comply with the limits established by the national regulatory authority and with those recommended by the International Commission on Radiological Protection (ICRP) for public and occupational exposures.Conclusion.It is remarkable that the workload may increase or that the doses per patient may increase considering occupancy factors, which would allow the introduction of hypofractionated techniques with the same number of patients considered in this work without the need to make modifications in the bunker design.

Assessment of PTV margin adequacy for single isocenter multiple brain metastases using genetic algorithms.

Purpose. To study the impact on dose coverage and the dose to the healthy tissue applying optimized margins in single isocenter multiple brain metastases radiosurgery (SIMM-SRS) in linac machine based on setup rotations/translations induced errors calculated by a genetic algorithm (GA).Method.The following quality indices of SIMM-SRS were analyzed for 32 plans (256 lesions): Paddick conformity index (PCI), gradient index (GI), maximum (Dmax) and mean (Dmean) doses, local and global V12for the healthy brain. A GA based on Python packages were used to determine the maximum shift produced by induced errors of 0.2°/0.2 mm, and 0.5°/0.5 mm in 6 degrees of freedom.Results.In terms of Dmax, and Dmean, the quality of the optimized-margin plans remains unchanged (p > 0.072) concerning the original plan. However, considering the 0.5°/0.5 mm plans, PCI and GI decreased for ≥10 metastases, and local, and global V12increased considerably in all cases. To consider 0.2°/0.2 mm plans, PCI and GI get worse but local, and global V12improved in all cases.Conclusion.GA facilities to find the individualized margins automatically among the number of possible permutations of the setup order. The user-dependent margins are avoided. This computational approach takes into account more SRS sources of uncertainty, enabling the protection of the healthy brain by 'smartly' reducing the margins, and maintaining clinically acceptable target volumes' coverage in most cases.

Factores asociados a la contaminación microbiológica de la carne de pollo comercializada en El Salvador / Factors associated with microbiological contamination of chicken meat marketed in El Salvador

Objetivo. Determinar los factores higiénico-sanitarios asociados a la contaminación microbiológica de la carne de pollo comercializada en los mercados municipales de El Salvador. Materiales y métodos. Se realizó un estudio transversal analítico en los 33 mercados municipales de las cabeceras departamentales de El Salvador. La muestra se calculó a partir de 456 puestos de venta, obteniendo un total de 256 puestos. Por cada puesto se obtuvo una muestra de carne de pollo. El análisis microbiológico se realizó en el Laboratorio Nacional de Salud Pública. Se calcularon frecuencias, porcentajes, medidas de tendencia central y de asociación utilizando SPSS versión 21. Resultados. En el 74% de las muestras se encontró Escherichia coli, en el 24%, Staphylococcus aureus y en el 16%, Salmonela spp. La presencia de Salmonella spp, estuvo asociada con el no uso de desinfectante para las manos y no utilizar toalla para secarse las manos. La presencia de E. coli estuvo asociada al uso de accesorios personales y la inadecuada temperatura de almacenamiento. Mientras que la presencia de S. aureus, estuvo asociada a la falta de lavado de manos, no utilizar toalla para secarse las manos y no utilizar delantal. Conclusión. Las condiciones higiénico-sanitarias de los manipuladores y de los puestos de venta están asociadas a la contaminación microbiológica en la carne de pollo comercializada en El Salvador.

Objective. To determine the hygienic-sanitary factors associated with the microbiological contamination of chicken meat sold at the municipal markets of El Salvador. Materials and methods. An analytical cross-sectional study was conducted in 33 municipal markets of the 14 departmental capitals of El Salvador. The sample consisted of 256 out of 456 possible market stalls. A sample of chicken meat was obtained from each market stall. The microbiological analysis was conducted at the National Public Health Laboratory. Frequencies, percentages, measures of central tendency and association were calculated with SPSS version 21. Results. Escherichia coli was found in 74% of the samples, Staphylococcus aureus in 24% and Salmonella spp. in 1%. The presence of Salmonella spp. was associated with not using hand sanitizer and not using towels for drying the hands. S. aureus was associated with the use of personal accessories and improper storage. The presence of S. aureus was associated with the lack of hand washing, not using a towel to dry the hands and not wearing an apron. Conclusion. The hygienic-sanitary conditions of the handlers and the market stalls were associated with microbiological contamination of chicken meat marketed in El Salvador.

Perception and Recognition of Clinical Medical Physicist Roles and Responsibilities by Specialist Physician Staff: The First Mexican Survey.

Introduction: Although medical physics as a profession is recognized as part of the health-care professional workforce by the International Labor Organization, in the Mexican context, the figure of the medical physicist (MP) is often inappropriately associated solely with technical work, leading to perception, recognition, and salary implications. The aim of this study was to explore the perception of medical specialists regarding the role and responsibilities of MPs in clinical practice in Mexico. Methods: A national survey was answered by medical personnel, ranging from residents to qualified specialists in November 2019. The questionnaire consisted of ten questions related to perception of MPs. The survey was open to all medical specialists regardless of their involvement in the use of ionizing radiations or otherwise. Results: It was shown that approximately two-thirds of specialists know and recognize the medical physics profession in hospitals and the roles and responsibilities of MPs. However, 19% of medical specialists considered the standard of service as inadequate. Conclusion: MPs must exert greater efforts to promote their status and enhance the recognition of their contribution to health care. The low level of recognition in diagnostic and interventional radiology and in nuclear medicine in Mexico might be related to nonexistent or unclear documentation and inadequate regulations, policies, or directives promoted by the health-care authorities.

Importance of Beam-Matching between TrueBeam STx and Novalis Tx in Pre-Treatment Quality Assurance Using Portal Dosimetry.

Flexibility and efficiency in a radiotherapy department with different linear accelerators (linacs) can be improved if they are dosimetrically equivalent, and there is no need of plan or patient-specific quality assurance (PSQA) modification. From 2012 to 2017, our institution purchased three Novalis Tx and one TrueBeam STx beam-matched accelerators with the same high-resolution multileaf collimator (MLC). They are matched taking as reference dosimetric data from Novalis Tx SN-5479. We showed the importance of beam-matched dosimetric units by the use of electronic portal image device (EPID) and Delta4 PSQA. It was able to treat patients on a different machine than the machine used for PSQA. Depth dose, beam profiles, output factors, dosimetric leaf gap, and MLC transmission were compared for all energies and linacs. PSQA in all linacs for 30 volumetric-modulated arc therapy plans was also compared. Prostate, breast, and head-and-neck cases were selected to consider low, middle, and high plan complexity, respectively. The comparisons were evaluated using EPID and Delta4 phantom. Dosimetric differences between the three Novalis Tx and TrueBeam STx in all energies were lower than 1%. The only significant difference was observed in Novalis EPID in middle complexity when the criterion was tighter in distance. This result could be related with the nonsymmetric dose delivery of semi arcs. In all other cases, there were no differences in two different EPID evaluations. However, TrueBeam EPID values were slightly higher than Novalis EPID values. This could be associated with the high-resolution novel diode detector TrueBeam EPID. The dosimetric data indicated that the Novalis Tx and TrueBeam STx are equivalent. PSQA using EPID and Delta4 phantom showed that there are no dosimetric differences in any of the linacs. These results revealed the flexibility performance in PSQA by beam-matching.

Use of genetic algorithm for PTV optimization in single isocenter multiple metastases radiosurgery treatments with Brainlab Elements™.

PURPOSE: To optimize PTV margins for single isocenter multiple metastases stereotactic radiosurgery through a genetic algorithm (GA) that determines the maximum effective displacement of each target (GTV) due to rotations. METHOD: 10 plans were optimized. The plans were created with Elements Multiple Mets™ (Brainlab AG, Munchen, Germany) from a predefined template. The mean number of metastases per plan was 5 ± 2 [3,9] and the mean volume of GTV was 1.1 ± 1.3 cc [0.02, 5.1]. PTV margin criterion was based on GTV-isocenter distance and target dimensions. The effective displacement to perform specific rotational combination (roll, pitch, yaw) was optimized by GA. The original plans were re-calculated using the PTV optimized margin and new dosimetric variations were obtained. The Dmean, D99, Paddick conformity index (PCI), gradient index (GI) and dose variations in healthy brain were studied. RESULTS: Regarding targets located shorter than 50 mm from the isocenter, the maximum calculated displacement was 2.5 mm. The differences between both PTV margin criteria were statistically significant for Dmean (p = 0.0163), D99 (p = 0.0439), PCI (p = 0.0242), GI (p = 0.0160) and for healthy brain V12 (p = 0.0218) and V10 (p = 0.0264). CONCLUSION: The GA allows to determine an optimized PTV margin based on the maximum displacement. Optimized PTV margins reduce the detriment of dosimetric parameters. Greater PTV margins are associated with an increase in healthy brain volume.

Microfluidic chip enables single-cell measurement for multidrug resistance in triple-negative breast cancer cells.

Aims: Triple-negative breast cancer patients are commonly treated with combination chemotherapy. Nonetheless, outcomes remain substandard with relapses being of a frequent occurrence. Among the several mechanisms that result in treatment failure, multidrug resistance, which is mediated by ATP-binding cassette proteins, is the most common. Regardless of the substantial studies conducted on the heterogeneity of cancer types, only a few assays can distinguish the variability in multidrug resistance activity between individual cells. We aim to develop a single-cell assay to study this. Methods: This experiment utilized a microfluidic chip to measure the drug accumulation in single breast cancer cells in order to understand the inhibition of drug efflux properties. Results: Selection of single cells, loading of drugs, and fluorescence measurement for intracellular drug accumulation were all conducted on a microfluidic chip. As a result, measurements of the accumulation of chemotherapeutic drugs (e.g., daunorubicin and paclitaxel) in single cells in the presence and absence of cyclosporine A were conducted. Parameters such as initial drug accumulation, signal saturation time, and fold-increase of drug with and without the presence cyclosporine A were also tested. Conclusion: The results display that drug accumulation in a single-cell greatly enhanced over its same-cell control because of inhibition by cyclosporine A. Furthermore, this experiment may provide a platform for future liquid biopsy studies to characterize the multidrug resistance activity at a single-cell level.

Dendritic cell immunotherapy for stage IV melanoma.

Active boosting of the antitumour immune response of patients with solid malignancies has been tested in a large number of trials. Isolated complete clinical responses have been reported, however, they have not been replicated in subsequent studies. We recently reported objective clinical responses to a dendritic cell/irradiated autologous tumour cell 'vaccine' in patients with distant metastatic (stage IV) melanoma. Here we describe our experience in a second cohort of patients with stage IV melanoma, using this dendritic cell-based immunotherapy in a cryopreserved format. Of 46 patients enrolled into the study, three had complete remission of all detectable disease, and a further three had partial clinical responses. These data confirm that dendritic cell-based immunotherapy has potential as a therapy in a limited number of patients with stage IV melanoma. To our knowledge, this is the first demonstration that cryopreserved dendritic cells can elicit complete clinical responses in patients with advanced cancer. Our observations support randomized controlled trials to validate the findings.

Dendritic cell immunotherapy for breast cancer.

Novel adjuvant therapies are urgently needed to complement the existing treatment options for breast cancer. The advent of the use of dendritic cells (DCs) for cancer immunotherapy provides a unique opportunity to overcome the relative non-immunogenic property of breast tumours and address the underlying immunodeficiency. To date, the success of this approach has been limited, possibly due to the targeting of specific tumour antigens that rapidly mutate and, thus, become undetectable to the immune system. A more efficient approach would include preparations encompassing multiple antigens, such as those provided by loading of whole tumour cells or tumour RNA. It is proposed that targeting mammary stem cells responsible for resistance to chemo/immunotherapy, through the expression of a broad array of wild-type and mutated tumour antigens in the context of DCs, will become a mainstay for immunotherapy of breast cancer.

The key role of CD40 ligand in overcoming tumor-induced dendritic cell dysfunction.

Overcoming dendritic cell (DC) dysfunction is a prerequisite for successful active immunotherapy against breast cancer. CD40 ligand (CD40L), a key molecule in the interface between T-lymphocytes and DCs, seems to be instrumental in achieving that goal. Commenting on our data that CD40L protects circulating DCs from apoptosis induced by breast tumor products, Lenahan and Avigan highlighted the potential of CD40L for immunotherapy. We expand on that argument by pointing to additional findings that CD40L not only rescues genuine DCs but also functionally improves populations of immature antigen-presenting cells that fill the DC compartment in patients with breast cancer.

A population of HLA-DR+ immature cells accumulates in the blood dendritic cell compartment of patients with different types of cancer.

Dendritic cell (DC) defects are an important component of immunosuppression in cancer. Here, we assessed whether cancer could affect circulating DC populations and its correlation with tumor progression. The blood DC compartment was evaluated in 136 patients with breast cancer, prostate cancer, and malignant glioma. Phenotypic, quantitative, and functional analyses were performed at various stages of disease. Patients had significantly fewer circulating myeloid (CD11c+) and plasmacytoid (CD123+) DC, and a concurrent accumulation of CD11c(-)CD123(-) immature cells that expressed high levels of HLA-DR+ immature cells (DR(+)IC). Although DR(+)IC exhibited a limited expression of markers ascribed to mature hematopoietic lineages, expression of HLA-DR, CD40, and CD86 suggested a role as antigen-presenting cells. Nevertheless, DR(+)IC had reduced capacity to capture antigens and elicited poor proliferation and interferon-gamma secretion by T-lymphocytes. Importantly, increased numbers of DR(+)IC correlated with disease status. Patients with metastatic breast cancer showed a larger number of DR(+)IC in the circulation than patients with local/nodal disease. Similarly, in patients with fully resected glioma, the proportion of DR(+)IC in the blood increased when evaluation indicated tumor recurrence. Reduction of blood DC correlating with accumulation of a population of immature cells with poor immunologic function may be associated with increased immunodeficiency observed in cancer.

HLA-DR+ immature cells exhibit reduced antigen-presenting cell function but respond to CD40 stimulation.

Dendritic cells (DC) have been implicated in the defective function of the immune system during cancer progression. We have demonstrated that patients with cancer have fewer myeloid (CD11c+) and plasmacytoid (CD123(hi)) DC and a concurrent accumulation of CD11c(-)CD123- immature cells expressing HLA-DR (DR(+)IC). Notably, DR(+)IC from cancer patients have a reduced capacity to stimulate allogeneic T-cells. DR(+)IC are also present in healthy donors, albeit in smaller numbers. In this study, we assessed whether DR(+)IC could have an impact on the immune response by comparing their function with DC counterparts. For this purpose, DR(+)IC and DC were purified and tested in the presentation of antigens through major histocompatibility complex (MHC) II and MHC-I molecules. DR(+)IC were less efficient than DC at presenting antigens to T-cells. DR(+)IC induced a limited activation of T-cells, eliciting poor T-helper (Th) 1 and preferentially inducing Th2-biased responses. Importantly, despite DR(+)IC's poor responsiveness to inflammatory factors, in samples from healthy volunteers and breast cancer patients, CD40 ligation induced phenotypic maturation and interleukin 12 secretion, in turn generating more efficient T-cell responses. These data underscore the importance of inefficient antigen presentation as a mechanism for tumor evasion and suggest an approach to improve the efficacy of DC-based immunotherapy for cancer.

MHC class I-restricted exogenous presentation of a synthetic 102-mer malaria vaccine polypeptide.

The circumsporozoite (CS) is the most abundant surface protein of the Plasmodium sporozoite, and is also present early in the liver stage of the infection. Following successful protective experiments in mice and monkeys, the synthetic 102-mer malaria vaccine polypeptide representing the C-terminal region of the CS of Plasmodium falciparum was tested in a clinical trial with healthy human volunteers. This vaccine induced strong CD8(+), CD4(+) T lymphocyte and antibody responses specific for the immunizing peptide. CD8(+) T lymphocyte responses elicited in HLA-A*0201 volunteers recognized two well-defined cytotoxic T lymphocyte epitopes within the CS. Here, we show that both monocyte-derived dendritic cells (Mo-DC) and Epstein-Barr virus-transformed B-lymphoblastoid cells (LCL) can present a cytotoxic T lymphocyte epitope contained within the 102-mer synthetic peptide. Paraformaldehyde and low temperature inhibited presentation, indicating that cellular processing was required. Using specific inhibitors, we show that, in both cell types, processing requires the proteasome and the MHC class I pathway, while the endosomal compartment appears to be critical only for the presentation by Mo-DC. Antigen uptake is associated with actin polymerization in both cell types. These in vitro results demonstrate the likely pathway of antigen presentation achieved via vaccination with this synthetic peptide.

Use of long synthetic peptides to study the antigenicity and immunogenicity of the Plasmodium vivax circumsporozoite protein.

Three long synthetic peptides corresponding to amino (N), repeat (R) and carboxyl (C) regions of the Plasmodium vivax circumsporozoite (CS) protein were synthesised and used to assess their potential as vaccine candidates. Antigenicity studies were carried out using human blood samples from residents of a malaria-endemic area of Colombia, and immunogenicity was tested in Aotus monkeys. The N and C peptides spanned the total native amino and carboxyl flanking regions, whereas the R peptide corresponded to a construct based on the first central nona-peptide repeated in tandem three times and colinearly linked to a universal T-cell epitope (ptt-30) derived from tetanus toxin. All three peptides had been shown previously to contain several B-, T-helper (Th) and Cytotoxic T Lymphocytes (CTL) epitopes. Sixty-one percent of the human sera reacted with the R region, whereas 35 and 39% of the samples had antibodies against the N and C peptides, respectively. Human Peripheral Blood Mononuclear Cells (PBMC) showed higher levels of IFN-gamma than IL-4 when stimulated with peptides containing Th epitopes. Aotus monkeys immunised with the peptides formulated in either Montanide ISA720 or Freund's adjuvants produced strong antibody responses that recognised the peptide immunogens and the native circumsporozoite protein on sporozoites. Additionally, high IFN-gamma production was induced when Aotus lymphocytes were stimulated in vitro with each of the three peptides. We observed boosting of antibody responses and IFN-gamma production by exposure to live sporozoites. These results confirm the high antigenicity and immunogenicity of such synthetic polypeptides and underline their vaccine potential.

OM-174, a new adjuvant with a potential for human use, induces a protective response when administered with the synthetic C-terminal fragment 242-310 from the circumsporozoite protein of Plasmodium berghei.

The goal of this project was the evaluation of a novel immunomodulatory adjuvant for human use, OM-174, which is a soluble adjuvant derived from Escherichia coli lipid A. For this study, we used a synthetic peptide, known for its safety and reproducibility and the murine model of BALB/c mice. The long peptide (PbCS 242-310) used corresponds to the C-terminal region of the circumsporozoite protein (CSP) that is the major protein on the surface of Plasmodium sporozoites. Subcutaneous injections of PbCS 242-310 in combination with soluble adjuvant OM-174 induced long lasting peptide-specific antibody titres comparable to those obtained by immunization with incomplete Freund's adjuvant (IFA). The ex vivo evaluation of the CD8(+) T cell response by IFN-gamma ELISPOT assay revealed that the injection of polypeptide with OM-174 adjuvant induced, compared to IFA, a similar and an eight-fold increased frequency of peptide-specific lymphocytes in the draining lymph-nodes and in the spleen, respectively. The CD8(+) T-cells are specific for the sequence PbCS 245-253, a well-known H-2K(d)-restricted CTL epitope, and are cytotoxic as shown in a chromium release assay. Immunization of BALB/c mice with this polypeptide in combination with adjuvant OM-174 conferred a protection after challenge with live Plasmodium berghei sporozoites.The strong antibody and CTL responses observed to a synthetic peptide in mice, the safety profile of the adjuvant and its extensive physico-chemical characterization suggest that OM-174 has a potential use in vaccine formulations for humans.

Identification of HLA-A2 restricted CD8(+) T-lymphocyte responses to Plasmodium vivax circumsporozoite protein in individuals naturally exposed to malaria.

Specific CD8(-) T-lymphocyte (CTL) activity against Plasmodium pre-erythrocytic stages (P-ES) derived antigens is considered one of the most important mechanisms for malaria protection. Plasmodium vivax is the second most prevalent human malaria parasite species distributed worldwide. Although several CTL epitopes have been identified in Plasmodium falciparum P-ES derived antigens, none has been described for P. vivax to date. In this study, we analysed HLA-A*0201 specific CD8(-) T-lymphocyte responses to the P. vivax circumsporozoite (CS) protein in both malaria exposed and non-exposed populations from the Colombian Pacific Coast. First, we analysed the prevalence of HLA-A2 allele in the study populations and found that approximately 38 of the individuals expressed this molecule and that 50 of them were HLA-A*0201. We then selected, on the P. vivax CS, five peptide sequences containing the HLA-A*0201 binding motifs and used the corresponding synthetic peptides to evaluate the CD8(-) T-lymphocyte interferon (IFN)-gamma response. Peripheral blood mononuclear cells from the HLA-A*0201 donors were in vitro stimulated with these peptides and IFN-gamma production was determined by an ELISPOT assay. Specific CD8(-) T-lymphocyte responses were detected for three peptides located in the C-terminal region of the protein. Specific responses to these peptides were also detected in several individuals expressing different HLA-A*02 subtypes. The potential of these peptides to induce specific cytolysis and that of long synthetic peptides comprising these epitopes as P. vivax malaria vaccine subunits are being studied.

Current issues in dendritic cell cancer immunotherapy.

Dendritic cells (DCs) initiate and direct the immune response. Their inability to detect danger signals from transformed cells and to generate an effective immunological response may allow cells with a malignant phenotype to evolve into cancers. This defect can be corrected for many cancer types and the immune response boosted to eliminate malignant cells by means of DC-based vaccines/therapies. Rapid advances in our understanding of basic DC physiology and improved methods for DC isolation have made clinical application of DC therapy practical, and encouraging phase I/II results are emerging.