Variation in the isocentre of a Philips Linear Accelerator (SL–20) used for stereotactic radiosurgery/stereotactic radiotherapy

Stereotactic irradiation, either in the form of stereotactic radiosurgery (SRS) or stereotactic radiotherapy (SRT) of brain lesions requires high precision and submillimetre accuracy in the isocentre, the main determinants being gantry and couch rotations. It is thus necessary to evaluate the isocentre variation due to gantry and couch rotations in the particular setup for SRS/SRT. This paper describes variation in the isocentre of a Philips (now Elekta) SL-20 linear accelerator modified for adapting a couch-mounted radiosurgery system. By considering the isocentre as defined by a mechanical index as the standard, the variations in the isocentre of the linear accelerator were independently measured for the gantry and for couch rotations. The variation in the isocentre for gantry rotation was found to be between 0.1 mm and 0.9 mm, conforming to the submillimetre accuracy required for SRS/SRT. However, the isocentre variation due to couch rotation varied considerably, possibly because the couch is of the RAM type. The isocentre variation due to couch rotation is rectified by microadjusting the couch mount at the time of treatment using a laser target localizing frame. It is our conclusion that a modified linear accelerator can be used for performing SRS/SRT after careful and separate evaluation of the isocentre stability due to gantry and couch rotations.     

A guide to the evaluation of fourth cranial nerve palsies

PURPOSE To devise a cost-effective guide for the evaluation of fourth nerve palsies (FNP). METHODS A review of the pertinent English language literature was performed to devise a guide for the evaluation (including neuroimaging) of FNP. The authors report a retrospective review of imaging studies performed on 206 patients with FNP. RESULTS The literature was used to develop the imaging guide. In the retrospective chart review of 206 patients from two tertiary care centers, 28 patients (13.6%) underwent a computed tomography scan and/or a magnetic resonance scan. Of these patients, five had associated neurological symptoms (non-isolated), one was traumatic, five were congenital, four were vasculopathic, eleven were non-vasculopathic, and two were progressive. Following the recommendations of the imaging guide, the five isolated congenital FNP and the four isolated vasculopathic FNP would not have undergone neuroimaging studies. The total costs of these neuroimaging studies in these nine patients were 19,000 dollars. Four patients in the retrospective review with associated neurological deficits (non-isolated) should have undergone neuroimaging according to the guide, but did not. CONCLUSIONS Although the evaluation of FNP can be difficult, the decision to order neuroimaging can be improved by using an imaging guide. An imaging guide for the evaluation of FNP may allow more appropriate and cost-effective imaging of these patients. Isolated congenital, old traumatic, or vasculopathic FNP do not require neuroimaging studies. Patients with non-isolated FNP should have directed neuroimaging studies based upon the results of clinical examination.     

Stimulation of interleukin-6 and prostaglandin E2 secretion from peritoneal macrophages by polymers of albumin

Interleukin-6 (IL-6) is a multifunctional cytokine that is elevated in vivo during acute infection, chronic inflammation, and some hematopoietic malignancies. To understand how IL-6 becomes elevated in vivo, it is important to identify factors that can stimulate its secretion from effector cells. We found that commercial preparations of bovine serum albumin (BSA) stimulated murine macrophages to secrete high levels of IL-6. In fact, BSA was at least as potent as bacterial lipopolysaccharide (LPS) in stimulating IL-6 production. Stimulation was clearly visible at concentrations as low as 20 micrograms/mL and reached saturation at 0.5 to 1 mg/mL albumin, at which concentration 1.1 x 10(6) oil-elicited macrophages produced 6,000 +/- 700 B9 units of IL-6 in an overnight incubation. Prostaglandin E2 production was induced by the same concentrations of BSA. Both resident and oil- elicited peritoneal cells were responsive to the albumin. The stimulatory activity did not derive from contamination of the protein with Escherichia coli LPS; when compared directly with LPS, the response to BSA was more rapid, had a higher amplitude, and was not inhibitable by polymyxin B. In addition, macrophages isolated from C3H/HeJ mice, which have an inherited defect in their ability to respond to LPS, secreted IL-6 in response to BSA but not to LPS. The stimulatory activity was stable to heat, mild acid, and reduction/alkylation and copurified with albumin on Cibachron Blue agarose (Sigma, St Louis, MO) and anti-albumin immunoaffinity chromatography. Comparison of different sources and preparations of albumin showed differences in the levels of IL-6-inducing activity; three different lots of commercial fatty acid-free BSA and one lot of polymer-enhanced BSA stimulated IL-6 secretion by more than 100-fold over basal levels whereas other preparations showed more limited activity. A sample of BSA that was active in vitro caused a marked elevation of IL-6 when injected into BALB/c mice, thus demonstrating inflammatory activity in vivo. When the albumin preparations were fractionated by ion exchange and gel filtration chromatography and then analyzed by sodium dodecyl sulfate-gel electrophoresis and Western blot immunoassay, it was found that the IL-6-inducing activity resided in high molecular weight polymers of albumin. The ability of albumin polymers to stimulate IL-6 production represents a novel mechanism for modulation of this cytokine.     

The midaortic syndrome: diagnosis and treatment

The midaortic syndrome is an unusual entity seen in children and adolescents. It is characterized by severe narrowing of the abdominal aorta with progressive involvement of the renal and visceral branches. Eleven patients (aged 5 months to 15 years) suspected of having midaortic syndrome were examined preoperatively and postoperatively. All patients had hypertension and were examined with midstream aortography. All aortograms showed a smooth, segmental stenosis of the abdominal aorta and severe bilateral proximal renal artery stenosis. In three patients, percutaneous transluminal angioplasty of the renal artery was attempted, two preoperatively and one for a postoperative stricture. None showed long-term success, presumably due to the progressive nature of the disease. Grafts were surgically placed in ten patients and produced successful results in nine.     

Anti-Inflammatory and Antioxidant Effects of an Ethanolic Extract of the Aerial Parts of Hilleria Latifolia (Lam.) H. Walt. (Phytolaccaceae)

Various parts of the perennial herb Hilleria latifolia (Lam.) H. Walt. (Family: Phytolaccaceae) are used in Ghanaian traditional medicine for the treatment of several inflammatory-related disorders. The present study examined the anti-inflammatory effect of an ethanolic extract of the aerial parts of Hilleria latifolia (HLE) in acute and chronic inflammation models. Since free radicals and reactive oxygen species are implicated in inflammatory diseases, the antioxidant potential of HLE was also investigated in in vitro experimental models. HLE (10–300 mg kg⁻¹, p.o.), either preemptively or curatively, significantly inhibited carrageenan-induced foot oedema in 7-day old chicks. Similarly, the NSAID diclofenac (10–100 mg kg⁻¹, i.p.) and the steroidal anti-inflammatory agent dexamethasone (0.3–3 mg kg⁻¹, i.p.) dose-dependently reduced the oedema in both pre-emptive and curative treatments. In the Freund''s adjuvant induced-arthritis model in rats, HLE as well as the positive controls, dexamethasone and methotrexate, showed significant anti-arthritic properties when applied to established adjuvant arthritis. HLE (10–300 mg kg⁻¹, p.o.) significantly reduced oedema in the ipsilateral paw of rats but failed to prevent systemic arthritic spread. The DMARD methotrexate (0.1–1 mg kg⁻¹, i.p.) and dexamethasone (0.3–3 mg kg⁻¹, i.p.) reduced significantly the total polyarthritic oedema as well as the spread of the arthritis from the ipsilateral to the contralateral paws of the treated animals. The extract (0.03–1.00 mg ml⁻¹) exhibited Fe³⁺ reducing activity, scavenged DPPH and prevented lipid peroxidation. These findings suggest that the extract exerts in vivo anti-inflammatory activity after oral administration and also has antioxidant properties which may contribute to its activity.     

Linkage analysis of candidate regions for coeliac disease genes

A strong HLA association is seen in coeliac disease [specifically to the DQ(alpha1*0501,beta1*0201 heterodimer], but this cannot entirely account for the increased risk seen in relatives of affected cases. One or more genes at HLA-unlinked loci also predispose to coeliac disease and are probably stronger determinants of disease susceptibility than HLA. A recent study has proposed a number of candidate regions on chromosomes 6p23 (distinct from HLA), 6p12, 3q27, 5q33.3, 7q31.3, 11p11, 15q26, 19p13.3, 19q13.1, 19q13.4 and 22cen for the location of a non-HLA linked susceptibility gene. We have examined these regions in 28 coeliac disease families by linkage analysis. There was excess sharing of chromosome 6p markers, but no support for a predisposition locus telomeric to HLA. No significant evidence in favour of linkage to coeliac disease was obtained for chromosomes 3q27, 5q33.3, 7q31.3, 11p11, 19p13.3, 19q13.1, 19q13.4 or 22cen. There was, however, excess sharing close to D15S642. The maximum non-parametric linkage score was 1.99 (P = 0.03). Although the evidence for linkage of coeliac disease to chromosome 15q26 is not strong, the well established association between coeliac disease and insulin dependent diabetes mellitus, together with the mapping of an IDDM susceptibility locus (IDDM3) to chromosome 15q26, provide indirect support for this as a candidate locus conferring susceptibility to coeliac disease in some families.      

Primary spinal epidural extraosseous Ewing’s sarcoma: Report of five cases and literature review

Ewing’s sarcoma is the most common malignant bone tumour occurring in children and adolescents and exists in two different clinicopathological entities: osseous Ewing’s sarcoma (OES) and extraosseous Ewing’s sarcoma (EES). Five cases of primary epidural EES are described, which presented with non‐specific symptoms leading to a long diagnostic delay. The median age at diagnosis was 22 years (range 13–36 years). The median diagnostic delay was 3 months. All patients had one or more neurological deficits. All underwent surgical exploration with a laminectomy and partial resection followed by adjuvant radiotherapy to a dose of 46–50 Gy and chemotherapy with VAC (vincristine, adriamycin and cyclophosphamide) alternating with ICE (ifosphamide, cisplatin and etoposide) for at least six cycles. The mean follow‐up period is 21.2 months (range 11–32 months). Four of the five patients achieved a complete remission and are disease free at the time of writing this report. Two patients have a residual neurological deficit – both having presented with long history of neurological deficit. Primary spinal epidural EES should be suspected whenever young patients present with back pain and/or radicular pain, have abnormal neurology and an extradural mass is demonstrated on MRI. Surgical excision followed by adjuvant radiotherapy (50 Gy) and combination chemotherapy (VAC alternating with ICE) achieved local and systemic control in these patients. A greater number of patients and longer follow up are required to evolve a generally accepted treatment policy for this aggressive but potentially curable malignancy.