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The successful development of the economy of the Russian Federation implies the stability of civil turnover, proper fulfillment by counterparties of their obligations. The rupture of economic chains leads to an avalanchelike bankruptcy of economic entities, deterioration of the investment climate in the country. The article analyzes the issue of the possibility of a legal entity (debtor), in respect of which a bankruptcy case has been initiated, fulfilling property (non-monetary) obligations in favor of counterparties under contracts concluded before the initiation of bankruptcy proceedings against the debtor. Such execution may create preferential satisfaction of the claims of individual creditors over others with whom there are also contracts not executed by the debtor. Justified that property grants from the debtor can meet the goals of restoring the debtor’s solvency, replenishing the bankruptcy estate in the interests of all creditors, and therefore creditors’ claims for the performance of property obligations in kind should be subject to judicial protection and enforcement throughout the period of the insolvent debtor’s economic activity.

Behavioral responding is most beneficial when it reflects event timing. Compared to reward, there are fewer studies on timing of defensive responding. We gave female and male rats Pavlovian fear conditioning over a baseline of reward seeking. Two 100-s cues predicted foot shock at different time points. Rats acquired timing of behavioral responding to both cues. Suppression of reward seeking was minimal at cue onset and maximal before shock delivery. Rats also came to minimize suppression of reward seeking following cue offset. The results reveal timing as a mechanism to focus defensive responding to shock-imminent, cue periods.

International audience; Background: The rate of premature births in France is 6% and is increasing, as is the rate of extremely premature births. Morbidity and mortality rates in this population remain high despite significant medical progress. We aimed to evaluate the morbidity and mortality rate in preterm neonates weighing < 750 g and to evaluate their outcome at 2 years' corrected age (CA).Methods: This was a retrospective monocentric study including babies born between May 2011 and April 2013 who were preterm and weighed < 750 g. We evaluated mortality and morbidity in the neonatal period. At 2 years' CA, we focused on developmental quotient (DQ) with the Brunet-Lezine test, on neurosensory assessment (sleeping/behavior), and growth evaluation.Results: Among the 107 infants included, 29 (27%) died in the neonatal period. Mean gestational age was 25.6 weeks' gestation. Female sex and higher birth weight were independent predictors of survival. A total of 61 (78.2%) infants showed extra-uterine growth retardation at 36 weeks' postmenstrual age. At 2 years' CA, 57 children were followed up; 38 were evaluated using the Brunet-Lezine test, 20 (52.6%) had a DQc < 85, and none had a severe developmental delay (DQc < 50). Six (10%) children had cerebral palsy and 22 of 56 (39.2%) showed language delay. Growth retardation persisted in 15 of 52 (28.8%) children.Conclusion: Our results confirm the acute fragility of extremely low-birth-weight babies with a high rate of morbidity and mortality. At 2 years' CA, this population still shows a considerable rate of mild difficulties, whose long-term evolution needs to be followed. (C) 2020 French Society of Pediatrics.

Background and purpose: Anatomical changes induce differences between planned and delivered dose. Adaptive radiotherapy (ART) may reduce these differences but the optimal implementation is insufficiently clear. The aims of this study were to quantify the difference between planned and delivered dose in HNC patients, assess the consequential difference in normal tissue complication probability (Delta NTCP) and to explore the value of Delta NTCP as an objective selection strategy for ART.Materials and methods: For 52 patients, daily doses were accumulated to estimate the delivered dose. The difference from planned dose was analyzed for CTVs and 9 organs-at-risk (OAR). Delta NTCP was calculated for xerostomia, dysphagia, parotid gland dysfunction and tube feeding dependency at 6 months. ART was deemed necessary if Delta NTCP was >5%. The positive predicted value (PPV) was calculated for identification of ART-patients by clinical judgement, and Delta NTCP at fraction 10 and 15.Results: Delta NTCP >5% was seen five times for dysphagia and twice for the other toxicities. Only 5/9 patients with any Delta NTCP >5% clinically received ART, although ART had been done for 13/52 patients (PPV: 0.38). PPV was 0.86 and 0.75 for accumulated dose at fraction 10 and 15, respectively, using a Delta NTCP cut-off for the allocation of ART of 5%. Using other Delta NTCP cut-offs did not substantially improve PPV. With this cutoff the negative predictive value was 0.93 for Delta NTCP method of fraction 10 and fraction 15, and 0.90 for clinical judgement.Conclusion: To identify patients accurately for ART, NTCP calculations based on the dose differences between planned and delivered dose at fraction 10 are superior to clinical judgement. (C) 2019 Published by Elsevier B.V.

Cross sectional imaging is essential for the patient-specific planning and delivery of radiotherapy, a primary determinant of head and neck cancer outcomes. Due to challenges ensuring data quality and patient de-identification, publicly available datasets including diagnostic and radiation treatment planning imaging are scarce. In this data descriptor, we detail the collection and processing of computed tomography based imaging in 215 patients with head and neck squamous cell carcinoma that were treated with radiotherapy. Using cross sectional imaging, we calculated total body skeletal muscle and adipose content before and after treatment. We detail techniques for validating the high quality of these data and describe the processes of data de-identification and transfer. All imaging data are subject- and date-matched to clinical data from each patient, including demographics, risk factors, grade, stage, recurrence, and survival. These data are a valuable resource for studying the association between patient-specific anatomic and metabolic features, treatment planning, and oncologic outcomes, and the first that allows for the integration of body composition as a risk factor or study outcome.

Cross sectional imaging is essential for the patient-specific planning and delivery of radiotherapy, a primary determinant of head and neck cancer outcomes. Due to challenges ensuring data quality and patient de-identification, publicly available datasets including diagnostic and radiation treatment planning imaging are scarce. In this data descriptor, we detail the collection and processing of computed tomography based imaging in 215 patients with head and neck squamous cell carcinoma that were treated with radiotherapy. Using cross sectional imaging, we calculated total body skeletal muscle and adipose content before and after treatment. We detail techniques for validating the high quality of these data and describe the processes of data de-identification and transfer. All imaging data are subject- and date-matched to clinical data from each patient, including demographics, risk factors, grade, stage, recurrence, and survival. These data are a valuable resource for studying the association between patient-specific anatomic and metabolic features, treatment planning, and oncologic outcomes, and the first that allows for the integration of body composition as a risk factor or study outcome.

To develop a quality assurance (QA) workflow by using a robust, curated, manually segmented anatomic region-of-interest (ROI) library as a benchmark for quantitative assessment of different image registration techniques used for head and neck radiation therapy-simulation computed tomography (CT) with diagnostic CT coregistration.Radiation therapy-simulation CT images and diagnostic CT images in 20 patients with head and neck squamous cell carcinoma treated with curative-intent intensity-modulated radiation therapy between August 2011 and May 2012 were retrospectively retrieved with institutional review board approval. Sixty-eight reference anatomic ROIs with gross tumor and nodal targets were then manually contoured on images from each examination. Diagnostic CT images were registered with simulation CT images rigidly and by using four deformable image registration (DIR) algorithms: atlas based, B-spline, demons, and optical flow. The resultant deformed ROIs were compared with manually contoured reference ROIs by using similarity coefficient metrics (ie, Dice similarity coefficient) and surface distance metrics (ie, 95% maximum Hausdorff distance). The nonparametric Steel test with control was used to compare different DIR algorithms with rigid image registration (RIR) by using the post hoc Wilcoxon signed-rank test for stratified metric comparison.A total of 2720 anatomic and 50 tumor and nodal ROIs were delineated. All DIR algorithms showed improved performance over RIR for anatomic and target ROI conformance, as shown for most comparison metrics (Steel test, P.008 after Bonferroni correction). The performance of different algorithms varied substantially with stratification by specific anatomic structures or category and simulation CT section thickness.Development of a formal ROI-based QA workflow for registration assessment demonstrated improved performance with DIR techniques over RIR. After QA, DIR implementation should be the standard for head and neck diagnostic CT and simulation CT allineation, especially for target delineation.

When pancreatic cancer is not resectable or metastatic, it is classified as locally advanced pancreatic cancer. The majority of patients diagnosed with localized pancreatic cancer present with locally advanced disease. Currently, there is no consensus for optimal treatment of locally advanced pancreatic cancer. There has been much debate and controversy with regard to the best upfront treatment modality (chemotherapy and radiotherapy), sequencing of chemotherapy and radiation, and specific nuances of chemotherapy agents and radiation treatment techniques. The aims of treatment are to extend survival and improve quality of life by preventing development of distant metastatic disease and progression of local disease. Without surgery, the prognosis of these patients remains poor. This chapter provides a guide for management of locally advanced pancreatic cancer, with a predominant focus on radiation therapy planning.

Objectives To report the incidence and predictors of moderate/severe radial artery spasm (RAS) in patients undergoing cardiovascular percutaneous procedures through a transradial approach (TRA) in centers with TRA expertise. Background Data regarding the actual rate of clinically meaningful RAS are limited due to difference in study designs and operator expertise. Methods The RAS registry, an international (14 centers from Argentina, Chile, India, Indonesia, Macedonia, The Netherlands and United States of America) registry that included 1,868 patients undergoing TRA cardiovascular procedures (63.5% diagnostic and 56.5% therapeutic).All selected centers used TRA as default strategy in the cardiac catheterization laboratory. Throughout 2012, each center included all consecutive TRA cases (during a 2-month period) into a dedicated database covering clinical characteristics as well as procedural topics related to TRA patterns and RAS occurrence. Results The incidence of moderate/severe RAS was 2.7%. Only 0.7% of patients required crossover (8 to transfemoral and 5 to contralateral TRA). Patients with moderately/severe spasm were more frequently females, had a history of dyslipidemia, received more often a 7F sheath and more puncture attempts than patients without spasm. By multivariate analysis, the need for more than one attempt and the use of a 7 F sheath were independent predictors of the development of moderate/severe RAS. Conclusions The incidence of moderate/severe RAS is low in centers with a default TRA. Its development appears to be strongly related to the numbers of puncture attempts and the use of large sheaths. © 2013 Wiley Periodicals, Inc.

Purpose To determine the effect of interfractional changes in anatomy on the target and normal tissue dose distributions during course of radiotherapy in non–small-cell lung cancer patients. Methods and Materials Weekly respiration-correlated four-dimensional computed tomography scans were acquired for 10 patients. Original beam arrangements from conventional and inverse treatment plans were transferred into each of the weekly four-dimensional computed tomography data sets, and the dose distributions were recalculated. Dosimetric changes to the target volumes and relevant normal structures relative to the baseline treatment plans were analyzed by dose–volume histograms. Results The overall difference in the mean ± standard deviation of the doses to 95% of the planning target volume and internal target volume between the initial and weekly treatment plans was −11.9% ± 12.1% and −2.5% ± 3.9%, respectively. The mean ± standard deviation change in the internal target volume receiving 95% of the prescribed dose was −2.3% ± 4.1%. The overall differences in the mean ± standard deviation between the initial and weekly treatment plans was 3.1% ± 6.8% for the total lung volume exceeding 20 Gy, 2.2% ± 4.8% for mean total lung dose, and 34.3% ± 43.0% for the spinal cord maximal dose. Conclusion Serial four-dimensional computed tomography scans provided useful anatomic information and dosimetric changes during radiotherapy. Although the observed dosimetric variations were small, on average, the interfractional changes in tumor volume, mobility, and patient setup was sometimes associated with dramatic dosimetric consequences. Therefore, for locally advanced lung cancer patients, efforts to include image-guided treatment and to perform repeated imaging during the treatment course are recommended.

Major weight loss is common in patients with head and neck squamous cell carcinoma (HNSCC) who undergo radiotherapy (RT). How baseline and posttreatment body composition affects outcome is unknown.To determine whether lean body mass before and after RT for HNSCC predicts survival and locoregional control.Retrospective study of 2840 patients with pathologically proven HNSCC undergoing curative RT at a single academic cancer referral center from October 1, 2003, to August 31, 2013. One hundred ninety patients had computed tomographic (CT) scans available for analysis of skeletal muscle (SM). The effect of pre-RT and post-RT SM depletion (defined as a CT-measured L3 SM index of less than 52.4 cm2/m2 for men and less than 38.5 cm2/m2 for women) on survival and disease control was evaluated. Final follow-up was completed on September 27, 2014, and data were analyzed from October 1, 2014, to November 29, 2015.Primary outcomes were overall and disease-specific survival and locoregional control. Secondary analyses included the influence of pre-RT body mass index (BMI) and interscan weight loss on survival and recurrence.Among the 2840 consecutive patients who underwent screening, 190 had whole-body positron emission tomography-CT or abdominal CT scans before and after RT and were included for analysis. Of these, 160 (84.2%) were men and 30 (15.8%) were women; their mean (SD) age was 57.7 (9.4) years. Median follow up was 68.6 months. Skeletal muscle depletion was detected in 67 patients (35.3%) before RT and an additional 58 patients (30.5%) after RT. Decreased overall survival was predicted by SM depletion before RT (hazard ratio [HR], 1.92; 95% CI, 1.19-3.11; P = .007) and after RT (HR, 2.03; 95% CI, 1.02-4.24; P = .04). Increased BMI was associated with significantly improved survival (HR per 1-U increase in BMI, 0.91; 95% CI, 0.87-0.96; P .001). Weight loss without SM depletion did not affect outcomes. Post-RT SM depletion was more substantive in competing multivariate models of mortality risk than weight loss-based metrics (Bayesian information criteria difference, 7.9), but pre-RT BMI demonstrated the greatest prognostic value.Diminished SM mass assessed by CT imaging or BMI can predict oncologic outcomes for patients with HNSCC, whereas weight loss after RT initiation does not predict SM loss or survival.

For operative laryngoscopy, a laryngoscope is introduced into the anesthetized patient's mouth for exploration of the larynx and vocal cords. To improve the vision, a binocular microscope is positioned between the operator and the laryngoscope. This interferes, to some degree, with the introduction of instruments, particularly if the surgeon is using bimanual manipulation. In the case of lengthy operations, a fatigue or stress factor can be troublesome to the operator. The authors developed a video laryngoscope using standard blades. An angulated telescope attached to a TV camera was introduced in the top portion of the blade. An enlarged image from the anatomy was produced and viewed from a convenient distance. The manipulations are unobstructed, and simultaneous records can be obtained. It is the method of choice for teaching. The operative laryngoscope is less cumbersome and supersedes the microscope for viewing the endolarynx. This new technique was used successfully in 532 cases.

The purpose of this study was to investigate the potential of a head and neck magnetic resonance simulation and immobilization protocol on reducing motion-induced artifacts and improving positional variance for radiation therapy applications.Two groups (group 1, 17 patients; group 2, 14 patients) of patients with head and neck cancer were included under a prospective, institutional review board-approved protocol and signed informed consent. A 3.0-T magnetic resonance imaging (MRI) scanner was used for anatomic and dynamic contrast-enhanced acquisitions with standard diagnostic MRI setup for group 1 and radiation therapy immobilization devices for group 2 patients. The impact of magnetic resonance simulation/immobilization was evaluated qualitatively by 2 observers in terms of motion artifacts and positional reproducibility and quantitatively using 3-dimensional deformable registration to track intrascan maximum motion displacement of voxels inside 7 manually segmented regions of interest.The image quality of group 2 (29 examinations) was significantly better than that of group 1 (50 examinations) as rated by both observers in terms of motion minimization and imaging reproducibility (P.0001). The greatest average maximum displacement was at the region of the larynx in the posterior direction for patients in group 1 (17 mm; standard deviation, 8.6 mm), whereas the smallest average maximum displacement was at the region of the posterior fossa in the superior direction for patients in group 2 (0.4 mm; standard deviation, 0.18 mm). Compared with group 1, maximum regional motion was reduced in group 2 patients in the oral cavity, floor of mouth, oropharynx, and larynx regions; however, the motion reduction reached statistical significance only in the regions of the oral cavity and floor of mouth (P.0001).The image quality of head and neck MRI in terms of motion-related artifacts and positional reproducibility was greatly improved by use of radiation therapy immobilization devices. Consequently, immobilization with external and intraoral fixation in MRI examinations is required for radiation therapy application.

It is estimated that 48% of women with breast cancer are age 65 and older; yet, scant research focuses on this cohort. Recent advances in breast cancer management have raised many questions regarding appropriate treatment of older patients with cancer. Despite recent emphasis on medical interventions for older women, there is little focus on the unique clinical presentation and psychological sequelae of breast cancer in this population. While elderly women who survive breast cancer seem to cope better than their younger counterparts, their distress must not be overlooked. Interventions such as use of social support, spirituality, and exercise demonstrate therapeutic benefits for older women with cancer and should be explored. Nurses play a key role in educating and supporting older women with breast cancer and can help dispel many age-related myths and misconceptions.

The Supreme Court's refusal to recognize the existence of a basic affirmative right to health care may entail that women must retain a legal right to expel legal fetuses, even if Roe v. Wade is reversed and states are permitted to give fetuses legal standing as persons. Further, recognition of a basic affirmative right to health care would not entail that a woman in obliged to carry her fetus, even if a failure to do so would result in fetus' death. Duties correlative to basic affirmative rights are distributed among the members of society, not solely vested in single individuals.

To determine the proportion of patients in a private dermatology practice in whom melanoma was detected but was not the presenting complaint.Retrospective analytical case series.Private dermatology practice in Florida, from July 2005 through October 2008. Patients Patients with 126 melanomas, of which 51 were invasive and 75 were melanomas in situ.Proportion of melanomas detected as a result of patient complaint vs proportion determined by dermatologist-conducted full-body skin examination (FBSE). As a secondary analysis, we used logistic regression odds ratios (ORs) of association to examine whether dermatologist detection rather than patient complaint was associated with detecting thinner melanomas. A post hoc analysis was performed using a thickness cutoff of 1.0 mm to define a deep melanoma.Overall, 56.3% (95% confidence interval [CI], 47.6%-65.1%) of melanomas were found by the dermatologist and were not part of the presenting complaint. Of melanomas in situ, 60.0% (95% CI, 48.7%-71.3%) were dermatologist detected. Dermatologist detection was significantly associated with thinner melanomas, with an OR of 0.42 (P = .04). We found a significant association between thinner melanomas as a group (thickness1 mm) and dermatologist detection, with a logistic regression OR of 5.0 (95% CI, 1.0-25.3).Most melanomas detected in a general-practice dermatology setting were found as a result of dermatologist-initiated FBSE, not patient complaint. We found that dermatologist detection was associated with thinner melanomas and an increasing likelihood of the melanoma being in situ.

During the 1930s the federal government embarked upon an ambitious series of grant programs designed to counteract the Great Depression. The amounts distributed varied widely across the country and potentially contributed to population shifts. We estimate an aggregate discrete choice model, in which household heads choose among 466 economic subregions. The structural model allows us to decompose the effects of program spending on migration into three categories: the effect of spending on keeping households in their origin (retention), the effect of pulling non-migrants out of their origin (creation), and the effect of causing migrants to substitute away from an alternative destination (diversion). An additional dollar of public works and relief spending increased net migration into an area primarily by retaining the existing population and creating new migration into the county. Only a small share of the increase in net migration rate was caused by diversion of people who had already chosen to migrate. AAA spending contributed to net out migration, primarily by creating new out migrants and repelling potential in migrants. A counterfactual analysis suggests that the uneven distribution of New Deal spending explains about twelve percent of the internal migration flows in the United States between 1935 and 1940.

Purpose: The entire radiotherapytreatment planning process, from simulation, target definition, planning, to treatment, requires a collaborative effort from a multidisciplinary team of highly specialized professionals. Although treatment planning is a highly sequential process for an individual patient, professionals are consistently multi‐tasking to support on‐going patient care activities. As a result, treatment planning is a lengthy process, which often results in delay of new treatment start or poor quality treatment plans. Methods: To improve accountability and optimize workflow, a novel electronic messaging solution using event triggering and automatic information processing was designed to improve the effectiveness of collaboration among different professionals for treatment planning. In order to reduce the burden of data entry, we have made efforts to develop software interfaces to other clinical systems, such as the electronic medical record (EMR), integrated scripts executed in the planning system, or Active Directory to obtain planner's information. Professionals receive e‐notice from the system immediately following the completion of the previous step. Results: In our initial deployment of the system clinical wide, the system tracked 2500 planning assignments in the main campus and regional cancer centers with 50+ practicing radiation oncologists and approximately equal numbers of dosimetrists and physicists. The system provided an electronic media to communicate with physicians, dosimetrists, and physicists to improve communication on prescription, dose tolerance, or just simply the timeline for the planning activities. The average simulation‐to‐treatment start time was 3 business days in 50% patients, but IMRT took extra 2 business days to complete. IMRT contouring was completed in one business day in 72% of patients. Workflow bottleneck was identified in certain services for which dominant Monday new starts and rushed plans on Friday were observed. Conclusions: We designed a novel workflow enhancement tool to assist collaboration and process improvement. Research partially supported by Philips Medical Systems

Purpose: The development and testing of a tool for the inclusion of delivery time as a parameter in plan optimization. Methods: We developed an algorithm that estimates the time required for the machine and personnel movements required to deliver a treatment plan on a linear accelerator. We included dose rate, leaf motion, collimator motion, gantry motion, and couch motions (including time to enter the room to rotate the couch safely). Vault-specific parameters to account for time to enter and perform couch angle adjustments were also included. This algorithm works for static, step and shoot IMRT, and VMAT beams photon beams and for fixed electron beams. This was implemented as a script in our treatment planning system. We validated the estimator against actual recorded delivery time from our R and V system as well as recorded times from our IMRT QA delivery. Results: Data was collected (Figure 1) for 12 treatment plans by examining the R and V beam start times, and by manually timing the QA treatment for a reference, but the QA measurements were only significant to the nearest minute. The average difference between the estimated and R and V times was 15%, and 11% when excluding the majormore » outliers. Outliers arose due to respiratory aides and gating techniques which could not be accounted for in the estimator. Conclusion: Non-mechanical factors such as the time a therapist needs to walk in and out of the room to adjust the couch needed to be fine-tuned and cycled back into the algorithm to improve the estimate. The algorithm has been demonstrated to provide reasonable and useful estimates for delivery time. This estimate has provided a useful additional input for clinical decision-making when comparing several potential radiation treatment options.« less

Purpose: To evaluate the dosimetric accuracy for proton therapy patients with metal implants in CT using metal deletion technique (MDT) artifacts reduction. Methods: Proton dose accuracies under CT metal artifacts were first evaluated using a water phantom with cylindrical inserts of different materials (titanium and steel). Ranges and dose profiles along different beam angles were calculated using treatment planning system (Eclipse version 8.9) on uncorrected CT, MDT CT, and manually-corrected CT, where true Hounsfield units (water) were assigned to the streak artifacts. In patient studies, the treatment plans were developed on manually-corrected CTs, then recalculated on MDT and uncorrected CTs. DVH indices were compared between the dose distributions on all the CTs. Results: For water phantom study with 1/2 inch titanium insert, the proton range differences estimated by MDT CT were with 1% for all beam angles, while the range error can be up to 2.6% for uncorrected CT. For the study with 1 inch stainless steel insert, the maximum range error calculated by MDT CT was 1.09% among all the beam angles compared with maximum range error with 4.7% for uncorrected CT. The dose profiles calculated on MDT CTs for both titanium and steel inserts showed very good agreements with the ones calculated on manually-corrected CTs, while large dose discrepancies calculated using uncorrected CTs were observed in the distal end region of the proton beam. The patient study showed similar dose distribution and DVHs for organs near the metal artifacts recalculated on MDT CT compared with the ones calculated on manually-corrected CT, while the differences between uncorrected and corrected CTs were much pronounced. Conclusion: In proton therapy, large dose error could occur due to metal artifact. The MDT CT can be used for proton dose calculation to achieve similar dose accuracy as the current clinical practice using manual correction.

Purpose: The purpose of this work was to evaluate the simulation of setup uncertainty by convolve the dose distribution calculated by the treatment planning system with a Gaussian kernel. Materials and Methods: Setup uncertainty was explicitly simulated by targeting many beams at isocenters that were displaced in such a way that the original isocenter was surrounded symmetrically in R3 space, imitating a patient displacement relative to the position in the original treatment plan. The weighting of the displaced beams was made proportional to a Gaussian probability distribution for several choices of σ. The dose distribution created by multiple beams was compared to the dose distribution created by a Gaussian convolution of the original beam setup using the gamma metric. A commercial radiation treatment planning system (Pinnacle3, Philips Medical Systems, Milpitas CA) was programmed to collect 2,197 beam dose grids for each treatment beam in each of 3 evaluated treatment plans (totaling 32,955 beam dose grids) in order to collect a large sample of displaced isocenters. Subsequent analysis was performed using custom software in MATLAB (The MathWorks, Inc., Natick, MA). Results: For all choices of σ, the gamma values associated with voxels of the plan's regions of interest are almost entirely below 0.4 to 0.5, with only several voxels from many thousands having values from 1.0 to 1.4. Conclusions: The application of a Gaussian convolution is an accurate method of approximating the final dose as it would be delivered by multiple beams randomly displaced from their intended isocenter in the patient, implying that this application is suitable for simulating the effect of setup uncertainty on the treatment plan. This work has been supported in part by a Sponsored Research Agreement with Philips Healthcare.

Purpose: The goal of this work is to automatically collect and organize treatment planning statistics on a large number of patients for retrospective analysis.Method and Materials: A relational database was deigned to include all the metrics associated with treatment planning including: doses, volumes, beams, ROI shapes, prescriptions, IMRT constraints, and patient demographics. An interface was created to automatically populate the database from a commercial radiation treatment planning system (Pinnacle3, Philips Medical Systems, Milpitas CA). Outside of the internal scripting language of the treatment planning system, all essential components operate on open‐source software. Since this was implemented on an open‐standards client‐server database, multiple options are available for data mining. We have currently implemented a web interface to view the database contents and provide analysis tools. Results: A full treatment plan is evaluated and exported within just two minutes. Several major versions of the treatment planning system are supported by the export components of the system. Dozens of plans have been exported into the database, demonstrating full functionality and reliability. Conclusion: Previously, gaining access to certain plan statistics and data required the time‐consuming tasks of manually loading a plan, navigating its contents, and transcribing target information. These tasks can be eliminated by utilizing this database to store radiation treatment plan data. The overall concept and utility of the complete system has generated great interest, benefiting it with enhancements and refinements even prior to a large‐scale deployment. This work has been supported in part by a Sponsored Research Agreement with Philips Healthcare.

To characterize cytochrome P450 (CYP) 3A4 activity in premenopausal and postmenopausal women by evaluating the urinary 6-beta-hydroxycortisol:cortisol ratio.Prospective studyThirteen premenopausal and 13 postmenopausal women who were healthy and not receiving drugs known to affect CYP3A4 activityBeginning on day 2 of menses, premenopausal women collected first morning urine samples every other day for a complete menstrual cycle. Postmenopausal women collected first morning urine every other day for 28 days.Mean weekly 6-beta-hydroxycortisol:cortisol ratios did not differ during the phase (week) of the menstrual cycle. Daily ratios did not differ in postmenopausal women. No difference between premenopausal and postmenopausal women was found on comparing overall median ratios.Cytochrome P450 3A4 activity as measured by 6-beta-hydroxy cortisol:cortisol ratio did not differ by week of menstrual cycle, suggesting no menstrual cycle-related changes. Menopause does not appear to be associated with differences in CYP3A4 activity, compared with premenopause.

Dissatisfaction with the high transaction costs of compensating workers for their injuries led seven states in the 1910s to enact legislation requiring that employers insure their workers' compensation risks through exclusive state insurance funds. This paper traces the political-economic history of the success of compulsory state insurance in three states in the 1910s -- Minnesota, Ohio, and Washington. State insurance gained broad support in these states because a coalition of progressive legislators took control of their respective legislatures, bringing with them the idea that government had the unique ability to correct market imperfections. The political environment in which state insurance thrived in the 1910s provides important insights into the growth of government in the 1930s and 1960s. The major social insurance programs of the New Deal and the Great Society were widely supported at the time because the private market was seen as unable to solve a particular problem, such as unemployment compensation or poverty in old-age. This paper argues that the government's dramatic expansion after the 1932 federal election was not unprecedented; in fact, the ideological roots of New Deal activism were planted during the debates over compulsory state insurance and workers' compensation in the 1910s.

The U.S. Supreme Court has made a number of recent rulings in regard to the death penalty that will likely have the effect of increasing the use of psychiatry during the trial and sentencing process in capital cases. Any such changes are bound to increase the number of ethical dilemmas faced by psychiatrists involved in such work. The rulings affecting psychiatry include: (1) The Eighth Amendment forbids the execution of persons who are mentally incompetent in regard to their ability to appreciate the reasons for punishment. (2) A mentally-ill prisoner may be forcibly given neuroleptics if he presents a danger to himself or others. (3) Forced medication may not be used during the trial and sentencing phase if it has the potential to change the defendant's demeanor significantly enough to affect his defense. (4) Aggravating psychological factors affecting a convictee may be balanced against mitigating factors in considering whether death sentence should be imposed. (5) The psychosocial impact of the crime upon the victim's family may be presented during the sentencing phase as factors relevant to sentencing. (6) Adolescents and retarded individuals are not immune from the death penalty simply by virtue of their age or level of intelligence.

Purpose: To automatically compare dose volume histograms (DVHs) against a set of predetermined goals and constraints to facilitate pre‐treatment plan review. Method and Materials: The internal scripting language of the treatment planning system (Pinnacle3, Philips Medical Systems, Milpitas CA) is used to prepare DVH data for evaluation against a set of constraints identified by ROI name. These settings can specify maximum percent volume by dose, maximum dose for a percent volume, or a maximum point dose. The results are displayed in a dialog box and can also be saved or printed for inclusion in the plan documentation. Results: This program functions as planned, and completes its execution quickly. The dosimetrist's workflow is affected only marginally. Conclusion: The extra information provided by this analysis has been valuable to the staff responsible for plan review. This work has been supported in part by a Sponsored Research Agreement with Philips Healthcare.

Purpose: To investigate the impact of anatomical changes on target coverage and dose to normal tissues during radiotherapy for lungcancer using repeat four‐dimensional computed tomography (4‐DCT) imaging.Methods and Materials: Four patients with approximately 5–10 (average: 8) 4‐DCT imagedata sets acquired weekly during treatment were used for this study. Treatment portals were based on planning tumor volumes (PTV) from the initial data set. The beam arrangements from the initial data sets were transferred onto the 4‐DCT data sets for the subsequent treatment weeks and the dose distributions recalculated. Changes in the dose distributions were evaluated by dose‐volume histograms (DVH) for the internal target volumes (ITV) as well as for normal tissues including total lung,heart and spinal cord. Results: The overall average change in the percentage of volume of PTV and ITV covered by the 95% isodose (V95) between initial and during treatment was −5.2 ± 8.1% and −1.1 ± 1.3%, respectively. The overall average change in the dose to 95% of the PTV and ITV (D95) between initial and during treatment was −6.7 ± 10.1Gy and −0.9 ± 1.3Gy, respectively. Initial normal tissues volumes were comparable to the weekly datasets. Variation between initial vs. mean weekly percent total lung volume exceeding 20Gy (V20), mean total lungdoses, and cord maximum doses were −1.4% ± 1.8%, −0.9Gy ± 1.3Gy and 6.1Gy ± 7.1Gy, respectively. Conclusions: Analysis of serial respiration‐correlated CT scans provided useful information on dosimetric consequences of anatomical changes during treatment. Variation in target and normal tissue volumes were found to be small in average. However, changes were mainly observed in patients with mobile lower lobe lesions; therefore, effort to include image‐guidance based setup or imaging during the course of treatment, should be considered.

This article describes the development of a nontraditional aftercare program set in a predominantly rural area. The program was initiated by a citizen's board concerned with the lack of follow-up services provided to patients discharged from a distant state hospital. The planning format as conceived by representatives of this board is outlined and the steps involved in operationalizing specific services and a research program are described. Lastly, a number of limitations of the program and future directions are enumerated.

The work of psychotherapists who have a cognitive-behavioral orientation and are trained in time-limited, focused psychotherapy has proved to be beneficial in the setting of a comprehensive medical and health maintenance organization. Group interventions that deal with relaxation, social skills, depression, agoraphobia, smoking cessation, problem drinking, weight modification, and Type A behavior, to mention a few, are conducted on an ongoing basis, allowing staff to treat large numbers of people in a time-efficient and cost-effective way. These groups also help the staff to provide a coordinated set of therapeutic and training experiences for patients through their participation in appropriate group treatment during the course of their individual treatment.

In this investigation periodontal destruction was produced by a combination of inflammatory and traumatic factors. After the inflammation was resolved and the trama stopped, a significant amount of alveolar bone regeneration took place. The implications of these findings for the management of advanced periodontal disease are discussed.