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Abstract Background The mitogen-activated protein kinase (MAPK) cascade is an evolutionarily ancient mechanism of signal transduction found in eukaryotic cells. In plants, MAPK cascades are associated with responses to various abiotic and biotic stresses such as plant pathogens. MAPK cascades function through sequential phosphorylation: MAPK kinase kinases (MAPKKKs) phosphorylate MAPK kinases (MAPKKs), and phosphorylated MAPKKs phosphorylate MAPKs. Of these three types of kinase, the MAPKKKs exhibit the most divergence in the plant genome. Their great diversity is assumed to allow MAPKKKs to regulate many specific signaling pathways in plants despite the relatively limited number of MAPKKs and MAPKs. Although some plant MAPKKKs, including the MAPKKKα of Nicotiana benthamiana (NbMAPKKKα), are known to play crucial roles in plant defense responses, the functional relationship among MAPKKK genes is poorly understood. Here, we performed a comparative functional analysis of MAPKKKs to investigate the signaling pathway leading to the defense response. Results We cloned three novel MAPKKK genes from N. benthamiana: NbMAPKKKβ, NbMAPKKKγ, and NbMAPKKKε2. Transient overexpression of full-length NbMAPKKKβ or NbMAPKKKγ or their kinase domains in N. benthamiana leaves induced hypersensitive response (HR)-like cell death associated with hydrogen peroxide production. This activity was dependent on the kinase activity of the overexpressed MAPKKK. In addition, virus-induced silencing of NbMAPKKKβ or NbMAPKKKγ expression significantly suppressed the induction of programmed cell death (PCD) by viral infection. Furthermore, in epistasis analysis of the functional relationships among NbMAPKKKβ, NbMAPKKKγ, and NbMAPKKKα (previously shown to be involved in plant defense responses) conducted by combining transient overexpression analysis and virus-induced gene silencing, silencing of NbMAPKKKα suppressed cell death induced by the overexpression of the NbMAPKKKβ kinase domain or of NbMAPKKKγ, but silencing of NbMAPKKKβ failed to suppress cell death induced by the overexpression of NbMAPKKKα or NbMAPKKKγ. Silencing of NbMAPKKKγ suppressed cell death induced by the NbMAPKKKβ kinase domain but not that induced by NbMAPKKKα. Conclusions These results demonstrate that in addition to NbMAPKKKα, NbMAPKKKβ and NbMAPKKKγ also function as positive regulators of PCD. Furthermore, these three MAPKKKs form a linear signaling pathway leading to PCD; this pathway proceeds from NbMAPKKKβ to NbMAPKKKγ to NbMAPKKKα.

Purpose: Volumetric modulated arc therapy (VMAT) is capable of acquiring projection images using electronic portal imaging device (EPID). Commercial EPID-based dosimetry software, dosimetry check (DC), allows in vivo dosimetry using projection images. The purpose of this study was to evaluate in vivo dosimetry for prostate cancer using VMAT., Method: VMAT plans were generated for eight patients with prostate cancer using treatment planning system (TPS), and patient quality assurances (QAs) were carried out with phantom. We analyzed five plans as phantom study and five plans as patient study. Projection images were acquired during VMAT delivery. DC converted acquired images into fluence images and used a pencil beam algorithm to calculate dose distributions delivered on the CT images of the phantom and the patients. We evaluated isocenter point doses and gamma analysis in both studies and dose indexes of planning target volume (PTV), bladder and rectum in patient study., Results and Discussion: Dose differences at the isocenter were less than a criterion in both studies. Pass rates of the gamma analysis were less than a criterion by two plans in the phantom study. Dose indexes of reconstructed distribution were lower than original plans and standard deviations of PTV in reconstructed distribution were larger than original plans. The errors were caused by some issues, such as the commissioning of DC, variations in patient anatomy, and patient positioning., Conclusion: The method was feasible to non-invasively perform in vivo dose evaluation for prostate cancer using VMAT.

Purpose: IGRT (image guided radiation therapy) is a useful technique for implementing precisely targeted radiation therapy. Quality assurance and quality control (QA/QC) medical linear accelerators with a portal imaging system (electronic portal imaging device: EPID) are the key to ensuring safe IGRT. The Winston-Lutz test (WLT) provides an evaluation of the MV isocenter, which is the intersection of radiation, collimator, and couch isocenters. A flexmap can indicate a displacement of EPID from the beam center axis as a function of gantry angles which can be removed from the images. The purpose of this study was to establish a novel method for simultaneously carrying out WLT and acquiring a flexmap using rotational irradiation. We also observed long-term changes in flexmaps over a period of five months., Method: We employed rotational irradiation with a rectangular field (30×30 mm). First, the displacement of EPID from the beam center axis, indicated by the ball bearing (BB) center, was evaluated using an in-house program. The location of the BB center was then modified according to WLT. Second, a second irradiation was used to acquire a flexmap. We performed this examination regularly and evaluated long-term changes in the flexmap., Results and Discussion: It proved feasible to perform WLT and flexmap measurements using our proposed methods. The precision of WLT using rotational irradiation was 0.1 mm. In flexmap analysis, the maximum displacement from the mean value for each angle was 0.4 mm over five months., Conclusion: We have successfully established a novel method of simultaneously carrying out WLT and flexmap acquisition using rotational irradiation. Maximum displacement from the mean in each angle was 0.4 mm over five months.

Perioperative fluid management for cases with severely compromised cardiac function undergoing major non-cardiac surgery remains a challenge. Dynamic parameters such as stroke volume variation (SVV) and cardiac index obtained by arterial pulse contour analysis may not be sufficient for fluid optimization because individualized optimal parameter values are difficult to determine in cardiac patients. We report two cases of abdominal surgery with severe pre-existing impairment of cardiac function (ejection fraction < 30%) complicated by severe pulmonary and renal dysfunction. In Case 1, because of unreliably high SVV values due to a sudden onset of cardiac arrhythmia, we performed colloid bolus infusion targeting central venous oxygen saturation (ScvO2) above 80%. In Case 2, cardiac index and stroke volume index remained unchanged despite the decrease of SVV after colloid bolus infusion. Infusion of dobutamine was useful for maintaining the ScvO2 above 75% in a rather hypovolemic state (SVV of 10-15%). Our cases suggest that the use of central venous oxygen saturation together with arterial pulse contour analysis may aid decision-making for individualized fluid optimization and use of inotropics in severely compromised cardiac patients undergoing major abdominal surgery.

Bronchial fistula due to bronchial compression is a rare complication following both open surgical and endovascular repair of thoracic aortic aneurysms. We report on the airway management for a case of emergent thoracic endovascular aortic repair (TEVAR) in a patient with left bronchial obstruction due to hemoptysis. A 68-year-old man had undergone total arch replacement 8 years before, and was preoperatively diagnosed with aortobronchial fistula in the left lung. To prevent obstruction of the right lung by rebleeding in the left bronchus, we planned to exchange the single lumen endotracheal tube placed following hemoptysis to a double lumen tube prior to the operation. With assisted spontaneous breathing, bronchoscopy performed before replacing of the endotracheal tube showed obstruction of the left bronchus with many clots. With bronchoscopic assistance, clots were removed from the left bronchus and oxygenation improved significantly. We found a blue nylon suture penetrating the bronchial wall, most likely from a previous operation. However, bronchoscopy did not disclose aortobronchial fistula. Following TEVAR, the patient was diagnosed with bronchopleural fistula induced by bronchial compression due to blood vessel prosthesis and surrounding felt strips. Cooperation from surgeons and careful airway management were required to prevent life-threatening oxygenation insufficiency.

Volumetric modulated arc therapy (VMAT) is a rotational intensity-modulated radiotherapy (IMRT) technique capable of acquiring projection images for cone-beam computed tomography (CBCT). Respiratory-correlated cone-beam computed tomography, namely 4D-CBCT, serves to assess the displacement of a tumor position between planning and treatment due to organ motion and respiration, and is important for more accurate radiation therapy. On the other hand, recently, a 320-detector row CT scanner, namely 4D-CT, has become available that allows axial volumetric scanning of a 16-cm-long range in a patient without table movement. The goal of our research is to establish a new method of verification during treatment in stereotactic body radiotherapy. In this study, we compare the movement of the tumor between "before treatment" using 4D-CT and "in treatment" using 4D-CBCT. Three patients (55-68 years of age) with lung tumors underwent CT scans for radiotherapy planning using 4D-CT scans to analyze the movement of the tumor before treatment. The patients were treated by VMAT while acquiring projection images. 4D-CBCT datasets were reconstructed from the projection images using in-house programs. The tumor positions in 4D-CT and 4D-CBCT were detected and the movement of the tumor between "before treatment" and "in treatment" was similar. The movement of the tumors during treatment was predictable from 4D-CT before treatment. Furthermore, 4D-CBCT clarified the tumor position during treatment and could reevaluate the actual tumor position and dose distribution. We have successfully shown the movement of the tumor between "before treatment" using 4D-CT and "in treatment" using 4D-CBCT.