Optimising craniospinal irradiation for medulloblastoma: a dosimetric comparison of two VMAT planning methods.

Background: Craniospinal irradiation (CSI) poses a challenging planning process because of the complex target volume. Traditional 3D conformal CSI does not spare any critical organs, resulting in toxicity in patients. Here the dosimetric advantages of volumetric-modulated arc therapy (VMAT) using partial arc and avoidance sectors are compared with each other in planning in adult patients undergoing CSI to develop a clinically feasible technique that is both effective and efficient. Patient and methods: Eight adult patients treated with CSI were retrospectively identified. In total 16 plans were made. We generated two plans for each patient: 1. VMAT plan using partial arc, namely VMAT_pa. 2. VMAT plan using avoidance sectors, namely VMAT_as. The dose prescribed was 36 Gy in 20 fractions. The dose-volume histogram for planning target volume (PTV) and organs at risk (OAR) (lens, eye, heart, thyroid, lungs, liver, gonads and kidneys) were analysed and compared. Dose parameters of mean dose, V95%, and V107% for the PTV were evaluated. Results: The median length of PTV is 65.58 cm (45.8-79.5). The volume of PTV receiving 95% of the dose (V95%) in both the plans are 97.51% (VMAT_as) and 97.99% (VMAT_pa) (p = 0.121) while V107% are 0.733 and 0.742 for VMAT_as and VMAT_pa, respectively (p = 0.969). The doses of OARs such as lens, eye, liver and gonads were comparable. The mean heart dose was 10.4 and 9.0 Gy in VMAT_as and VMAT_pa plans, respectively (p = 0.005). Significant lower doses to the thyroid, kidneys and lungs were seen in VMAT plans using avoidance sectors. Conclusion: This study provides a practically useful VMAT planning method for the treatment of CSI and illustrates the ability of VMAT using avoidance sectors to generate highly conformal and homogeneous treatment plans for CSI, while limiting the dose to the relevant OARs.

Immunoglobulins: Mechanistic Approaches in Moderation of Various Inflammatory and Anti-Inflammatory Pathways.

Immunoglobulins (Ig) are proteins that help fight infections. IgG (IgG1, IgG2, IgG3, IgG4), IgM, IgA, IgD, and IgE are the five immunoglobulin subtypes that make up the majority of our immune system. Beneficial effects have been observed on the administration of Ig in diseases like Kawasaki, multiple myositis, chronic inflammatory demyelinating polyneuropathy (CIDP), and immune thrombocytopenia purpura (ITP). The Fc region, FcγRs, and FcRn of the IgG interact to provide both pro- and anti-inflammatory effects. IgM blocks immune-mediated inflammation using N-like glycans. It has been demonstrated that IgM demonstrates its antiinflammatory activity through IgM anti-leukocyte auto-antibodies (IgM-ALA). Since IgA is the second most prevalent and important Ig that operates on the primary objective in the immune system, which exhibits inhibitory signals in the body and generates inflammation in host cells, it plays a critical role in controlling mucosal homeostasis in the gastrointestinal (GI) tract. Additionally, it has been discovered that activating FcαRI boosts cytokine responses at different levels. IgD, a mysterious class of Ig once discovered, has a role in many disorders, including myeloma and Hodgkin's disease. The stability of IgD with development shows a different role, which has an advantage for the host's survival. IgE is mainly associated with many allergic diseases (food allergies), mediates type 1 responses, and has defenses against parasitic infections, which makes it an important parameter for monoclonal antibodies. Studies showed the possible roles of immunoglobulins, from which it came to light that immunoglobulins have their functions as agonists and antagonists in inflammation.

A comprehensive overview of juvenile idiopathic arthritis: From pathophysiology to management.

Rheumatoid Arthritis (RA) is a progressive autoimmune disease. It is among the most widespread chronic illnesses in children, with an annual incidence of 1.6 to 23 new instances per 100,000 adolescents. About 1 child in every 1000 develops Juvenile Idiopathic Arthritis (JIA) type of chronic arthritis. The cause of JIA is not well known but what known is that it involves inflammation of the synovium and destruction of tissues in joints which can cause early-onset of oligo articular JIA. It is challenging to diagnose the condition in some children who initially complain of pain and joint swelling as there is no blood test discovered that can confirm the diagnoses of JIA. As JIA patients are immunosuppressed due to the use of drugs, making them vulnerable to catch infections like COVID-19 which can lead to cardiovascular diseases having high rate of morbidity and mortality. The comorbidity like Diabetes has higher incidence in these patients resulting in synergistic effect on inflammation. Currently, the connection of genetics in JIA provides evidence that HLA Class I and II alleles have a role in the pathophysiology of various subtypes of JIA which includes inflammation in the axial skeletal. The primary objective of therapy in juvenile idiopathic arthritis is the suppression of clinical symptoms. The pharmacological approach includes use of medications like DMARDs, NSAIDs etc. and non-pharmacological approach includes physiotherapy, which helps in restoring normal joint function and herbs as adjuvants which has the benefit of no side effects.

A study of endothelial cell count pre- and post-neodymium-doped yttrium aluminum garnet laser iridotomy in subacute angle closure using specular microscope.

AIM: The aim of this study was to study the effect of neodymium-doped yttrium aluminum garnet (Nd:YAG) laser iridotomy on corneal endothelial cell count in patients with subacute angle closure using specular microscope. MATERIALS AND METHODS: In this prospective study, 50 cases of narrow-angle Grade 1 and Grade 2 (Shaffer gonioscopic grading) visiting the Regional Institute of Ophthalmology, Government Medical College, Amritsar underwent Nd:YAG laser peripheral iridotomy. After obtaining informed written consent, specular microscopy was performed before and after iridotomy at 1 week, 1 month, 3rd month, and at 6th-month follow-up visits. Central, nasal, and temporal endothelial cell counts were evaluated through noncontact specular microscopy. RESULTS: The mean participant age was 51.52 ± 7.9 years, and majority of the participants were females (76%). The mean IOP before the laser was 19.25 ± 1.914 mmHg and it varied from 18.50 ± 1.647 to 18.25 ± 1.699 mmHg (day 1, p = 0.06 and at 6 months, p = 0.04) following laser procedure. The mean corneal endothelial cell count at superotemporal site before laser peripheral iridotomy was 2844 ± 260, and this value decreased to 2807 ± 263, 2699 ± 267, 2656 ± 270, and 2591 ± 275 cells/mm2 at postiridotomy, 1, 3, and 6 months' follow-up visits, respectively; these differences were statistically significant (p < 0.05). The mean total energy required to produce iridotomy was 14.88 ± 6.71 mJ, ranging from 5 to 37 mJ. The linear regression analysis indicated no statistical correlation between change in endothelial cell count at the treated site and total mean energy used. No significant difference was found between preiridotomy and postiridotomy corneal thickness at any site. CONCLUSION: This study demonstrated a significant endothelial cell loss at the treated site in 6 months' follow-up and suggested that Nd:YAG laser iridotomy may pose hazard to the corneal endothelium, although corneal decompensation at the treated site or as a whole was not seen.