A strategy to determine off-axis dosimetric leaf gap using OSLD and EPID

Background: The aim of the study was to investigate the dosimetric feasibility of using optically stimulated luminescence dosimeters (OSLD) and an electronic portal imaging device (EPID) for central axis (CAX) and off-axis (OAX) dosimetric leaf gap (DLG) measurement. Materials and methods: The Clinac 2100C/D linear accelerator equipped with Millennium-120 multileaf collimator (MLC) and EPID was utilized for this study. The DLG values at CAX and ± 1 cm OAX (1 cm superior and inferior to the CAX position, respectively along the plane perpendicular to MLC motion) were measured using OSLD (DLGOSLD) and validated using ionization chamber dosimetry (DLGICD). The two-dimensional DLG map (2D DLGEPID) was derived from the portal images of the DLG plan using a custom-developed software application that incorporated sliding aperture-specific correction factors. Results: DLGOSLD and DLGICD, though measured with diverse setup in different media, showed similar variation both at CAX and ± 1 cm OAX positions. The corresponding DLGEPID values derived using aperture specific corrections were found to be in agreement with DLGOSLD and DLGICD. The 2D DLGEPID map provides insight into the varying patterns of the DLG with respect to each leaf pair at any position across the exposed field. Conclusions: Commensurate results of DLGOSLD with DLGICD values have proven the efficacy of OSLD as an appropriate dosimeter for DLG measurement. The 2D DLGEPID map opens a potential pathway to accurately model the rounded-leaf end transmission with discrete leaf-specific DLG values for commissioning of a modern treatment planning system

The Spectrum of Autonomic Dysfunction in Myasthenic Crisis

Background: Autoimmune autonomic dysfunction is described in Myasthenia Gravis. In myasthenic crisis, the spectrum of autonomic dysfunction is hitherto uncharacterized. Objective: The objective of this study is to describe the spectrum of autonomic dysfunction in myasthenic crises using the composite autonomic symptom scale 31 (COMPASS 31) autonomic symptom questionnaire and power spectral analysis of heart rate variability (HRV), which is a simple way of estimating general autonomic dysfunction. Methods: Adult patients with myasthenic crisis from January 1, 2014 to March 15, 2015, were prospectively included in this study. The COMPASS 31 questionnaire for symptoms of autonomic dysfunction and power spectral analysis of HRV were assessed. These were compared with the patient's demographic and clinical parameters and with previous literature. IRB approval was obtained. Results: Sixteen patients were included (M:F 3:1). 15/16 patents (93%) had autonomic dysfunction on COMPASS 31 questionnaire. The domains of involvement were gastrointestinal (80%), orthostatic (67.7%), pupillomotor (67.7%); sudomotor (33.3%), and vasomotor (13.3%). Parasympathetic dysfunction predominance was suggested by the symptom profile. HRV analysis showed a low frequency (LF) spectral shift suggesting slowed parasympathetic responsiveness (LF normalized unit (nu): high frequency [HF] nu mean 8.35, standard deviation ± 5.4, 95% confidence interval 2.2–12.5), which significantly exceeded the mean LF nu: HF nu ratios of the majority of previously reported noncrises myasthenic populations. Conclusions: Myasthenic crisis has autonomic dysfunction involving multiple organ systems. Increased latency of parasympathetic reflexes is suggested. A comprehensive management protocol addressing different autonomic domains is required for holistic patient care