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This study was designed to evaluate managing problem loans and work out the pinnacle of bank failures in Nigeria. One of the recommendations of the Basel Committee on Banking Supervision was credit risk management which is the optimization of the bank's risk-adjusted rate of return by maintaining credit risk exposure within an acceptable level. Descriptive survey research was used and data were collected via annual reports of the sampled bank within the period of 2011-2016. The population of the research included the Deposit Money Banks. Pearson Coefficient of Correlation was the statistical tool used to analyse the hypotheses and this was done with the aid of Statistical Package for Social Sciences (SPSS). The researcher concluded that there is no significant relationship between credit risk management and bank failure in Nigeria. However, there were traces of weak negative relationships which keen interest should be given to because of the sensitive nature of the banking sector. [ABSTRACT FROM AUTHOR]

NEOM is a new regional development in Saudi Arabia with a strong focus on the environment and sustainable development. In the cultural aspect, NEOM represents an opportunity for urban development that considers the protection of natural heritage assets. The Hismah desert in the northeast part of NEOM is characterised by sandstone and aeolian landscapes which are important in terms of scientific, educational, tourism, archaeological, ecological, and cultural value. This paper aims to assess the geomorphological landscape in the Hismah desert and provides a sustainable development plan for geoconservation and geotourism. The assessment method considers the landscape’s scientific and economic value, mainly derived from fieldwork. Economic value is calculated from ecological, aesthetic, and cultural value. Scientific and economic value for the whole landscape is high. The prolonged weathering and denudation process leads to mesa, butte, pinnacle, scarp, yardang, wadi, and rock pedestal formation. Key aeolian features are nebkha, sand and gravel sheets. The geological features are honeycomb structures, sandstone crossbed, and sedimentary deformation. Historical and cultural features enhance economic value. Considering the United Nations Sustainable Development Goals, geoconservation and geotourism can be developed sustainably to support regional development in an arid region. Therefore, in link with the NEOM Project, this paper proposes Hismah Desert as a geopark for conserving geomorphological landscape, geotourism and regional development. [ABSTRACT FROM AUTHOR]

Background: Although the Pinnacle Acetabular Hip System (DePuy Synthes) has demonstrated excellent survivorship results since it was first introduced in 2003, there have been a growing number of cases indicating that Pinnacle liners may be subject to a higher-than-expected rate of early dissociation failure. Between 2006 and 2020, our Centre received 212 retrieved Pinnacle liners from Western Australian hospitals. Of these, 26 were removed due to liner dissociation. Methods: To better understand the frequency and cause of this complication we assessed all retrieved Pinnacle acetabular components for type, damage modes and patient demographics. The leverage force required to dissociate Pinnacle liners was also measured and compared with another commonly used acetabular system, the Trident (Stryker Orthopaedics). Results: The estimated minimum incidence of liner dissociation from our data was 0.35%. Characterisation of dissociated Pinnacle cases (n = 26) revealed 73% were female with an average age of 59 compared to all retrieved Pinnacle cases (n = 212) where 58% were female with an average age of 66. Retrieval analysis indicated plastic deformation of the liner into an ovoid shape, signs of impingement on the rim postero-superiorly and shearing of the liner's anti-rotation tabs was common. Mechanical testing indicated that the dissociation strength of Pinnacle cups decreases at approximately 6.6 N/year in situ (p = 0.01). Conclusion: The survival rate of Pinnacle acetabular cups is exceptional with only 5% revised at 10 years. However, surgeons should be aware of the clinical symptoms and high-risk demographics when assessing patients with polyethylene Pinnacle liners. [ABSTRACT FROM AUTHOR]

Introduction: The Pinnacle3 Auto-Planning (AP) package is an automated inverse planning tool employing a multi-sequence optimisation algorithm. The nature of the optimisation aims to improve the overall quality of radiotherapy plans but at the same time may produce higher modulation, increasing plan complexity and challenging linear accelerator delivery capability. Methods and materials: Thirty patients previously treated with intensity-modulated radiotherapy (IMRT) to the prostate with or without pelvic lymph node irradiation were replanned with locally developed AP techniques for step-and-shoot IMRT (AP-IMRT) and volumetric-modulated arc therapy (AP-VMAT). Each case was also planned with VMAT using conventional inverse planning. The patient cohort was separated into two groups, those with a single primary target volume (PTV) and those with dual PTVs of differing prescription dose levels. Plan complexity was assessed using the modulation complexity score. Results: Plans produced with AP provided equivalent or better dose coverage to target volumes whilst effectively reducing organ at risk (OAR) doses. For IMRT plans, the use of AP resulted in a mean reduction in bladder V50Gy by 4·2 and 4·7 % (p ≤ 0·01) and V40Gy by 4·8 and 11·3 % (p < 0·01) in the single and dual dose level cohorts, respectively. For the rectum, V70Gy, V60Gy and V40Gy were all reduced in the dual dose level AP-VMAT plans by an average of 2·0, 2·7 and 7·3 % (p < 0·01), respectively. A small increase in plan complexity was observed only in dual dose level AP plans. Findings: The automated nature of AP led to high quality treatment plans with improvement in OAR sparing and minimised the variation in achievable dose planning metrics when compared to the conventional inverse planning approach. [ABSTRACT FROM AUTHOR]

Introduction: Cementless fixation is the standard for acetabular fixation in primary total hip arthroplasty (THA). There are various surface finishes thought to improve osteointegration, although literature regarding the long-term survival of some of these surfaces is limited. Regardless of design, primary stability is essential to allow for osteointegration. Previous studies have suggested an increased rate of radiolucency and compromised short-term functional outcomes using the Tritanium primary acetabular component (Stryker, Mahwah, NJ). The purpose of this study was to compare the primary Tritanium acetabular component to another contemporary acetabular component as a control group with an established clinical record. Methods: 444 consecutive, primary THAs performed by a single surgeon from 2008 to 2012 were reviewed. Patients were included if they had a minimum 1-year follow-up. Implant survivorship and modified Harris Hip Scores (mHHS) were recorded for all patients at final follow-up. Radiographs were evaluated by 2 surgeons at 6 weeks, 1 year, and the most recent follow-up for evidence of radiolucency and migration. Components were considered to have evidence of radiographic lucency if they had radiolucency in 2 or more DeLee zones. Results: 198 patients met criteria for inclusion (96 Pinnacle, 102 Tritanium). Average follow-up was 28 (12–72) months. At final follow-up 6.2% of the Pinnacle cups and 29.4% of the Tritanium cups had radiographic evidence of loosening (p < 0.01). The average mHHS for the Tritanium group was 83.1, and 88.4 for the Pinnacle group (p < 0.01). Radiographic evidence of loosening also correlated with a lower mHHS: 75.5 versus 86.4 (p < 0.01). In patients that received Tritanium cups without screw fixation 44.6% showed radiographic evidence of loosening versus 8% that received screw fixation (p < 0.01). In total, 6 patients in the Tritanium group required revision for aseptic loosening of the acetabular component. Conclusions: The 30% rate of radiographic loosening in the Tritanium group was significantly higher than the Pinnacle group and correlated with an inferior clinical outcome. Interestingly the use of screw augmentation was protective against radiographic evidence of loosening. This suggests that the Tritanium component may be prone to fibrous in-growth because of inadequate primary stability. [ABSTRACT FROM AUTHOR]

Background: The dual antigen iELISA uses two Streptococcus equi subsp equi surface protein antigens composed of N‐terminal portions of SEQ2190 (Antigen A) and SeM (Antigen C). It is currently used to identify animals exposed to S. equi which have developed an immune response to the target antigens. Objectives: To determine the usefulness of the dual antigen iELISA in a population of horses vaccinated with Pinnacle IN. We hypothesised that horses vaccinated for strangles with a live attenuated, non‐encapsulated SeM‐2 strain of S. equi, would seroconvert when tested 5 weeks later by the dual antigen iELISA. Study design: Prospective case‐control study. Methods: Three separate serum samples were obtained from 26 client‐owned horses vaccinated annually with Pinnacle® IN and 26 university‐owned (non‐vaccinates): at annual strangles vaccination (S1), 5‐week post‐vaccination (S2) from vaccinates, and a third (S3) (at 10 weeks) from vaccinates who received a booster. Seropositivity was defined as an OD450 nm value ≥0.5 for one or both antigens. Mixed‐effects ordered logistic regression analysis was used to identify factors associated with a suspect seropositive and seropositive value on the combined Antigen A and Antigen C iELISA. Post hoc pairwise comparisons of linear predictive margins were used to assess the differences in OD450 at a specific time between Antigens A and C. Results: Nineteen of 25 (76%) vaccinates were seropositive at S2 compared to 1 of 26 (4%) non‐vaccinates. When adjusted for sample number, vaccinates were more likely to be seropositive or suspect than non‐vaccinates (OR 14; P =.02, 95% CI 1.62‐122.03). The OD450 value was significantly larger for Antigen C than Antigen A for vaccinates (P <.001; 95% CI 0.13‐0.26) when normalised by age, sex and breed. Main limitations: Guttural pouch sampling for S. equi in seroconverted horses was unavailable. Conclusions: With a high rate of seroconversion to both antigens, the use of the dual antigen iELISA is not recommended in populations vaccinated with Pinnacle® IN. [ABSTRACT FROM AUTHOR]

Purpose/Objective(s): Stereotactic ablative body radiotherapy (SBRT) for vertebral metastases is a challenging treatment process. Planning automation has recently reported the potential to improve plan quality and increase planning efficiency. We performed a dosimetric evaluation of the new Personalized engine implemented in Pinnacle3 for full planning automation of SBRT spine treatments in terms of plan quality, treatment efficiency, and delivery accuracy. Materials/Methods: The Pinnacle3 treatment planning system was used to reoptimize six patients with spinal metastases, employing two separate automated engines. These two automated engines, the existing Autoplanning and the new Personalized, are both template-based algorithms that employ a wishlist to construct planning goals and an iterative technique to replicate the planning procedure performed by skilled planners. The boost tumor volume (BTV) was defined as the macroscopically visible lesion on RM examination, and the planning target volume (PTV) corresponds with the entire vertebra. Dose was prescribed according to simultaneous integrated boost strategy with BTV and PTV irradiated simultaneously over 3 fractions with a dose of 30 and 21 Gy, respectively. Dose-volume histogram (DVH) metrics and conformance indices were used to compare clinically accepted manual plans (MP) with automated plans developed using both Autoplanning (AP) and Personalized engines (Pers). All plans were evaluated for planning efficiency and dose delivery accuracy. Results: For similar spinal cord sparing, automated plans reported a significant improvement of target coverage and dose conformity. On average, Pers plans increased near-minimal dose D98% by 10.4% and 8.9% and target coverage D95% by 8.0% and by 4.6% for BTV and PTV, respectively. Automated plans provided significantly superior dose conformity and dose contrast by 37%–47% and by 4.6%–5.7% compared with manual plans. Overall planning times were dramatically reduced to about 15 and 23 min for Pers and AP plans, respectively. The average beam-on times were found to be within 3 min for all plans. Despite the increased complexity, all plans passed the 2%/2 mm γ-analysis for dose verification. Conclusion: Automated planning for spine SBRT through the new Pinnacle3 Personalized engine provided an overall increase of plan quality in terms of dose conformity and a major increase in efficiency. In this complex anatomical site, Personalized strongly reduce the tradeoff between optimal accurate dosimetry and planning time. [ABSTRACT FROM AUTHOR]

Purpose/Objective(s)Stereotactic ablative body radiotherapy (SBRT) for vertebral metastases is a challenging treatment process. Planning automation has recently reported the potential to improve plan quality and increase planning efficiency. We performed a dosimetric evaluation of the new Personalized engine implemented in Pinnacle3 for full planning automation of SBRT spine treatments in terms of plan quality, treatment efficiency, and delivery accuracy.Materials/MethodsThe Pinnacle3 treatment planning system was used to reoptimize six patients with spinal metastases, employing two separate automated engines. These two automated engines, the existing Autoplanning and the new Personalized, are both template-based algorithms that employ a wishlist to construct planning goals and an iterative technique to replicate the planning procedure performed by skilled planners. The boost tumor volume (BTV) was defined as the macroscopically visible lesion on RM examination, and the planning target volume (PTV) corresponds with the entire vertebra. Dose was prescribed according to simultaneous integrated boost strategy with BTV and PTV irradiated simultaneously over 3 fractions with a dose of 30 and 21 Gy, respectively. Dose-volume histogram (DVH) metrics and conformance indices were used to compare clinically accepted manual plans (MP) with automated plans developed using both Autoplanning (AP) and Personalized engines (Pers). All plans were evaluated for planning efficiency and dose delivery accuracy.ResultsFor similar spinal cord sparing, automated plans reported a significant improvement of target coverage and dose conformity. On average, Pers plans increased near-minimal dose D98% by 10.4% and 8.9% and target coverage D95% by 8.0% and by 4.6% for BTV and PTV, respectively. Automated plans provided significantly superior dose conformity and dose contrast by 37%–47% and by 4.6%–5.7% compared with manual plans. Overall planning times were dramatically reduced to about 15 and 23 min for Pers and AP plans, respectively. The average beam-on times were found to be within 3 min for all plans. Despite the increased complexity, all plans passed the 2%/2 mm γ-analysis for dose verification.ConclusionAutomated planning for spine SBRT through the new Pinnacle3 Personalized engine provided an overall increase of plan quality in terms of dose conformity and a major increase in efficiency. In this complex anatomical site, Personalized strongly reduce the tradeoff between optimal accurate dosimetry and planning time.

BackgroundIn radiation oncology, automation of treatment planning has reported the potential to improve plan quality and increase planning efficiency. We performed a comprehensive dosimetric evaluation of the new Personalized algorithm implemented in Pinnacle3 for full planning automation of VMAT prostate cancer treatments.Material and MethodsThirteen low-risk prostate (without lymph-nodes irradiation) and 13 high-risk prostate (with lymph-nodes irradiation) treatments were retrospectively taken from our clinical database and re-optimized using two different automated engines implemented in the Pinnacle treatment system. These two automated engines, the currently used Autoplanning and the new Personalized are both template-based algorithms that use a wish-list to formulate the planning goals and an iterative approach able to mimic the planning procedure usually adopted by experienced planners. In addition, the new Personalized module integrates a new engine, the Feasibility module, able to generate an “a priori” DVH prediction of the achievability of planning goals. Comparison between clinically accepted manually generated (MP) and automated plans generated with both Autoplanning (AP) and Personalized engines (Pers) were performed using dose-volume histogram metrics and conformity indexes. Three different normal tissue complication probabilities (NTCPs) models were used for rectal toxicity evaluation. The planning efficiency and the accuracy of dose delivery were assessed for all plans.ResultsFor similar targets coverage, Pers plans reported a significant increase of dose conformity and less irradiation of healthy tissue, with significant dose reduction for rectum, bladder, and femurs. On average, Pers plans decreased rectal mean dose by 11.3 and 8.3 Gy for low-risk and high-risk cohorts, respectively. Similarly, the Pers plans decreased the bladder mean doses by 7.3 and 7.6 Gy for low-risk and high-risk cohorts, respectively. The integral dose was reduced by 11–16% with respect to MP plans. Overall planning times were dramatically reduced to about 7 and 15 min for Pers plans. Despite the increased complexity, all plans passed the 3%/2 mm γ-analysis for dose verification.ConclusionsThe Personalized engine provided an overall increase of plan quality, in terms of dose conformity and sparing of normal tissues for prostate cancer patients. The Feasibility “a priori” DVH prediction module provided OARs dose sparing well beyond the clinical objectives. The new Pinnacle Personalized algorithms outperformed the currently used Autoplanning ones as solution for treatment planning automation.

Background: In radiation oncology, automation of treatment planning has reported the potential to improve plan quality and increase planning efficiency. We performed a comprehensive dosimetric evaluation of the new Personalized algorithm implemented in Pinnacle3 for full planning automation of VMAT prostate cancer treatments. Material and Methods: Thirteen low-risk prostate (without lymph-nodes irradiation) and 13 high-risk prostate (with lymph-nodes irradiation) treatments were retrospectively taken from our clinical database and re-optimized using two different automated engines implemented in the Pinnacle treatment system. These two automated engines, the currently used Autoplanning and the new Personalized are both template-based algorithms that use a wish-list to formulate the planning goals and an iterative approach able to mimic the planning procedure usually adopted by experienced planners. In addition, the new Personalized module integrates a new engine, the Feasibility module, able to generate an " a priori " DVH prediction of the achievability of planning goals. Comparison between clinically accepted manually generated (MP) and automated plans generated with both Autoplanning (AP) and Personalized engines (Pers) were performed using dose-volume histogram metrics and conformity indexes. Three different normal tissue complication probabilities (NTCPs) models were used for rectal toxicity evaluation. The planning efficiency and the accuracy of dose delivery were assessed for all plans. Results: For similar targets coverage, Pers plans reported a significant increase of dose conformity and less irradiation of healthy tissue, with significant dose reduction for rectum, bladder, and femurs. On average, Pers plans decreased rectal mean dose by 11.3 and 8.3 Gy for low-risk and high-risk cohorts, respectively. Similarly, the Pers plans decreased the bladder mean doses by 7.3 and 7.6 Gy for low-risk and high-risk cohorts, respectively. The integral dose was reduced by 11–16% with respect to MP plans. Overall planning times were dramatically reduced to about 7 and 15 min for Pers plans. Despite the increased complexity, all plans passed the 3%/2 mm γ-analysis for dose verification. Conclusions: The Personalized engine provided an overall increase of plan quality, in terms of dose conformity and sparing of normal tissues for prostate cancer patients. The Feasibility " a priori " DVH prediction module provided OARs dose sparing well beyond the clinical objectives. The new Pinnacle Personalized algorithms outperformed the currently used Autoplanning ones as solution for treatment planning automation. [ABSTRACT FROM AUTHOR]

Painting is one of the attractive and symbolic arts in Iran and the study of paintings confirms the transfer of significant individual and social concepts of such aforementioned works. Persian poetry and literature are one of the literary artworks that bestows an imperative value in conveying essential human concepts. One of Rumi's main concerns is anthropology and according to him the Quran is considered as the most influential book; the reflection of good and evil is one of such impacts represented in the Quran and on the verses of the Masnavi. This research has been done by "comparative-analytical" method. The research findings indicate that many of the models presented in Masnavi are consistent with Quranic models; the furthermost of these role models are either divine prophets or saints including: divine prophets such as: Adam, Ibrahim, Noah, David, Solomon, Saleh, Younis, Moses, Yusuf, Jesus and Muhammad (PBUH); and divine saints such as: Bayazid Bastami, Mansour Hallaj, Fazil Ayyaz and Shaqiq Balkhi among other figures. In addition; a number of human manifestations in the abyss of the oppressors of history are tyrannical kings and bloodthirsty rulers; including: Cain, Pharaoh, Nimrod, Qarun, Abu Jahl, Abu Lahab, and Hajjaj Yusuf. Rumi has applied such human patterns through symbols and signs and has often made mystical interpretations regarding the figures and events related to their lives; in this regard, his objective was to display what moral virtues or vices each of these patterns partake. In the remaining paintings from the Safavid period, concepts and themes beholding the virtue and significance of human beings can be deliberated upon. Research aims: 1. Scrutinizing the human face in Masnavi and its comparison with the Holy Quran. 2. Examining the pinnacle and depth of the human face in Safavid paintings. Research questions: 1. What is the pinnacle and depth of man from the point of view of Masnavi and Quran? 2. What is the reflection of the human face in Safavid paintings?

There is paucity of data on Atrial Fibrillation (AF) management and associated clinical outcomes among Asian Americans. This study sought to investigate baseline risk factor profiles, racial disparities in clinical management and adverse clinical outcomes among White and Asian Americans. We used National Cardiovascular Data Registry (NCDR®) Practice Innovation and Clinical Excellence (PINNACLE) registry and linked Centers of Medicare and Medicaid Services data to identify Asian and White patients with AF between January 1, 2013–June 30, 2018. We compared rates of baseline risk factors, management strategies (rate versus rhythm control), anticoagulation use and rates of adverse events between racial groups. The two race groups were compared using hierarchical multivariable adjusted regression models to account for site and confounders. In total, 1,359,827 patients (18,793 Asians and 1,341,034 Whites) were included in our analysis. Compared to White Americans, Asian Americans were more likely to use a rate control strategy (Odds Ratio [OR]: 1.20, 95% Confidence Interval [CI]: 1.15–1.25) and lower odds of rhythm control strategy (atrial ablations, cardioversions, or use of antiarrhythmic drugs) (OR: 0.83, 95% CI: 0.80–0.87) in adjusted analysis. Use of oral anticoagulants and direct oral anticoagulants were similar. There were no significant race-based differences in likelihood of all-cause mortality, stroke, and bleeding requiring hospitalization. Analyses performed using propensity score matching were consistent with the main results. Asian Americans with AF have a lower likelihood of being managed with rhythm control strategies. Overall use of OAC and AF related adverse events remain similar between the two racial groups. • Asian and White Americans with atrial fibrillation (AF) have different risk factor profiles. • Asian Americans were less likely to use rhythm control including antiarrhythmics drugs, cardioversion, or atrial ablations. • Rate of anticoagulation use among White and Asian Americans with AF were not statistically different. • There were no differences in AF related adverse events (all-cause mortality, strokes, or bleeding) between the two groups. [ABSTRACT FROM AUTHOR]

In a mixed‐vendor radiation oncology environment, it is advantageous if the department's treatment planning system (TPS) supports the linear accelerators of different vendors. In this publication beam data collection and modeling for the Versa HD linear accelerator in Monaco, Pinnacle, and Eclipse are discussed. In each TPS static field, Intensity‐Modulated Radiation Therapy (IMRT) step and shoot, and Volumetric‐Modulated Arc Therapy (VMAT) plans for flattened and flattening‐filter free photon beams of all available energies were evaluated for field sizes >3 × 3. To compare passing rates, identical beam model validation plans were calculated in each TPS. Eclipse, Monaco, and Pinnacle beam models passed validation measurements in homogeneous materials for a variety of treatment fields, including static, IMRT, and VMAT. In the case of Eclipse, the "dosimetric leaf gap" parameter was found to be critical for passing rates of VMAT plans. The source size parameter plays an important role as well for small fields. In the case of Pinnacle the multileaf collimator offset table needed to be optimized for better VMAT QA results. Each of the investigated treatment planning systems met the criteria to be used clinically in conjunction with Elekta Versa HD linear accelerators. It can be of great advantage to have the option to operate a TPS and linear accelerator from different vendors, as decisions surrounding linear accelerator or TPS purchases are very complicated and not just limited to technical considerations. [ABSTRACT FROM AUTHOR]

Purpose/Objectives: The purpose of this study is to dually evaluate the effectiveness of PlanIQ in predicting the viability and outcome of dosimetric planning in cases of complex re‐irradiation as well as generating an equivalent plan through Pinnacle integration. The study also postulates that a possible strength of PlanIQ lies in mitigating pre‐optimization uncertainties tied directly to dose overlap regions where re‐irradiation is necessary. Methods: A retrospective patient selection (n = 20) included a diverse range of re‐irradiation cases to be planned using Pinnacle auto‐planning with PlanIQ integration. A consistent planning template was developed and applied across all cases. Direct plan comparisons of manual plans against feasibility‐produced plans were performed by physician(s) with dosimetry recording relevant proximal OAR and planning timeline data. Results and Discussion: All re‐irradiation cases were successfully predicted to be achievable per PlanIQ analyses with three cases (3/20) necessitating 95% target coverage conditions, previously exhibited in the manually planned counterparts, and determined acceptable under institutional standards. At the same time, PlanIQ consistently produced plans of equal or greater quality to the previously manually planned re‐irradiation across all (20/20) trials (P = 0.05). Proximal OAR exhibited similar to slightly improved maximum point doses from feasibility‐based planning with the largest advantages gained found within the subset of cranial and spine overlap cases, where improvements upward of 10.9% were observed. Mean doses to proximal tissues were found to be a statistically significant (P < 0.05) 5.0% improvement across the entire study. Documented planning times were markedly less than or equal to the time contributed to manual planning across all cases. Conclusion: Initial findings indicate that PlanIQ effectively provides the user clear feasibility feedback capable of facilitating decision‐making on whether re‐irradiation dose objectives and prescription dose coverage are possible at the onset of treatment planning thus eliminating possible trial and error associated with some manual planning. Introducing model‐based prediction tools into planning of complex re‐irradiation cases yielded positive outcomes on the final treatment plans. [ABSTRACT FROM AUTHOR]

Various scholars have recognized how literary authors use mega-metaphor (scattered metaphorical domain references) to unobtrusively shape their narratives. Corpus analysis proves useful not only in identifying the presence of such metaphorical systems in longform texts but also in assessing their relative prominence across multiple texts. This article will examine 50 randomly selected literary narratives so as to discern the extent to which the relatively uncommon but metaphorically replete word pinnacle contributes surreptitious metaphorical meaning to the literary texts in which it is found. Results of the study confirm that the word "pinnacle," when it is used at all, is nearly always placed so as to highlight climactic scenes or emphasize key turning points in protagonist character development. The fact that metaphorical lines of interpretation relating to certain words and phrases may be detected, not only by way of critical intuition but also through the electronic searching of multiple text corpora, demonstrates the value of cross-textual analysis strategies in certain cases. It also hints that megametaphor, rather than being a rare and idiosyncratic type of literary artifice, may be more prevalent than has been previously acknowledged. [ABSTRACT FROM AUTHOR]

Background: Treatment plans for head and neck (H&N) cancer are highly complex due to multiple dose prescription levels and numerous organs at risk (OARs) close to the target. The plan quality is inter-planner dependent since it is dependent on the skills and experience of the dosimetrist. This study presents a blinded prospective clinical comparison of automatic (AU) and manually (MA) generated H&N VMAT plans made for clinical use. Methods: MA and AU plans were generated for 30 consecutive patients in Pinnacle3 using the IMRT optimisation module and the new Autoplan module, respectively. The plan quality was blindedly compared by three senior oncologists and the best plan was selected for treatment of the patient. Planning time was measured as the active operator time used. The plan quality was analysed with DVH metrics and the dose delivery accuracy validated on the ArcCheck phantom. Results: For twenty-nine out of the thirty patients the AU plan was chosen for treatment. Target doses were more homogenous with the AU plans and the OAR doses were significantly reduced, between 0.5 and 6.5 Gy. The average operator time spent on creating a manual plan was 64 min which was halved by Autoplan. The AU plans were more modulated as illustrated by an increase in MUs, which might cause the slightly lower pass rate of 97.7% in the ArcCheck measurements. Conclusions: Target doses were similar between MA and AU plan, while AU plans spared all OAR considerably better than the MA plans.

Background: Accurate three-dimensional dosimetry is essential in modern radiotherapy techniques such as volumetric-modulated arc therapy (VMAT) and intensity-modulated radiation therapy (IMRT). In this research work, the PRESAGE® dosimeter was used as quality assurance (QA) tool for VMAT planning for head and neck (H&N) cancer. Material and method: Computer tomography (CT) scans of an Image Radiation Oncology Core (IROC) H&N anthropomorphic phantom with both IROC standard insert and PRESAGE® insert were acquired separately. Both CT scans were imported into the Pinnacle (9.4 version) TPS for treatment planning, where the structures [planning target volume (PTV), organs at risk) and thermoluminescent detectors (TLDs) were manually contoured and used to optimise a VMAT plan. Treatment planning was done using VMAT (dual arc: 182°–178°, 178°–182°). Beam profile comparisons and gamma analysis were used to quantify agreement with film, PRESAGE® measurement and treatment planning system (TPS) calculated dose distribution. Results: The average ratio of TLD measured to calculated doses at the four PTV locations in the H&N phantom were between 0·95 to 0·99 for all three VMAT deliveries. Dose profiles were taken along the left–right, the anterior–posterior and superior–inferior axes, and good agreement was found between the PRESAGE® and Pinnacle profile. The mean value of gamma results for three VMAT deliveries in axial and sagittal planes were found to be 94·24 and 93·16% when compared with film and Pinnacle, respectively. The average values comparing the PRESAGE® results and dose values calculated on Pinnacle were observed to be 95·29 and 94·38% in the said planes, respectively, using a 5%/3 mm gamma criteria. Conclusion: The PRESAGE® dose measurements and calculated dose of pinnacle show reasonable agreement in both axial and sagittal planes for complex dual arc VMAT treatment plans. In general, the PRESAGE® dosimeter is found to be a feasible QA tool of VMAT plan for H&N cancer treatment. [ABSTRACT FROM AUTHOR]

This study focused on exploring the relationship between Pareto Principle and levels of Leadership Proposed by inordinate leadership expert J.C Maxwell. Through multistage sampling technique, 213 dyads were nominated to participate in the study. The study was quantitative and data was collected through two structured questionnaires LLAQ (for subordinates) and PPQ (for leaders. The results signposted that, all the five levels positively correlated with the coefficient Pinnacle (r=.46), People Development (r=.37), Production (r=.41), Permission (r=.42), and Position (r=.46). Additional findings were reconnoitred that, People development level has literature support having relationship Pareto Principle with five levels of leadership. [ABSTRACT FROM AUTHOR]

Background: The number of revision hip arthroplasty procedures has been increasing substantially, with the acetabular component requiring component revision in over half of the cases. New porous implant designs attempt to improve outcomes due to improved osseointegration; however, sufficient primary stability is paramount for good osseointegration.Methods: We compared 2 revision cups of the same geometry, yet different surface properties in an in vitro scenario: a porous titanium surface and a conventional sintered-bead titanium surface. These were tested in 10 cadaveric pelvises under a physiologic cyclic partial weight-bearing scenario. Each side was randomly implanted with one of the implants. Relative motion between the bone and cup was measured using an optical measuring device. Statistical evaluation was carried out descriptively using a covariance analysis with repeated measures and a test of fixed effects, with significance determined as P < .05.Results: The conventional cup displayed an average relative motion of 28.02 μm; and the porous implant displayed an average relative motion of 33.42 μm. There was no statistically significant difference between the two with regard to the resultant relative motion (P = .2649). The bone mineral density does have a significant influence on resultant relative motion (P = .0406), with higher bone mineral density correlating with less relative motion in both implants.Conclusion: The porous implant provides similar primary stability to the conventional implant in the tested scenario; the motion of both implants relative to the bone was within safe limits for osseointegration. Bone stock must be considered when choosing implant type and postoperative care. [ABSTRACT FROM AUTHOR]

Purpose Automated treatment planning is a new frontier in radiotherapy. The Auto-Planning module of the Pinnacle 3 treatment planning system (TPS) was evaluated for liver stereotactic body radiation therapy treatments. Methods Ten cases were included in the study. Six plans were generated for each case by four medical physics experts. The first two planned with Pinnacle TPS, both with manual module (MP) and Auto-Planning one (AP). The other two physicists generated two plans with Monaco TPS (VM). Treatment plan comparisons were then carried on the various dosimetric parameters of target and organs at risk, monitor units, number of segments, plan complexity metrics and human resource planning time. The user dependency of Auto-Planning was also tested and the plans were evaluated by a trained physician. Results Statistically significant differences (Anova test) were observed for spinal cord doses, plan average beam irregularity, number of segments, monitor units and human planning time. The Fisher-Hayter test applied to these parameters showed significant statistical differences between AP e MP for spinal cord doses and human planning time; between MP and VM for monitor units, number of segments and plan irregularity; for all those between AP and VM. The two plans created by different planners with AP were similar to each other. Conclusions The plans created with Auto-Planning were comparable to the manually generated plans. The time saved in planning enables the planner to commit more resources to more complex cases. The independence of the planner enables to standardize plan quality. [ABSTRACT FROM AUTHOR]

Cardiovascular diseases have surpassed infectious disorders to become the leading cause of morbidity and mortality in India.1 A national-level registry comprehensively documenting the current-day prevalence of cardiovascular risk factors and disease burden among patients seeking care in the outpatient setting in India is currently non-existent. With a burgeoning urban population, the cardiovascular disease burden in India is set to skyrocket, with an estimated 18 million productive years of life lost by 2030.2 While there are limited quality improvement registries in India, for example, the Kerala acute coronary syndrome and Trivandrum heart failure registries, their focus is on in-patient care quality improvement, while the vast majority of patients with cardiovascular diseases worldwide, including India, interact with the health care system in the outpatient setting.3,4 Recognizing this unmet need, the American College of Cardiology partnered with local stakeholders in India to establish India's first outpatient cardiovascular disease performance measurement initiative in 2011, the PINNACLE (Practice Innovation and Clinical Excellence) India Quality Improvement Program (PIQIP).5 This manuscript discusses the inception of the PIQIP registry, the progress it has made and challenges thus far, and its future direction and the promise it holds for cardiovascular care quality improvement in India.

Little Salt Spring (Sarasota County, FL, USA) is a sinkhole with groundwater vents at ~77 m depth. The entire water column experiences sulfidic (~50 μM) conditions seasonally, resulting in a system poised between oxic and sulfidic conditions. Red pinnacle mats occupy the sediment-water interface in the sunlit upper basin of the sinkhole, and yielded 16S rRNA gene clones affiliated with Cyanobacteria, Chlorobi, and sulfate-reducing clades of Deltaproteobacteria. Nine bacteriochlorophyll e homologues and isorenieratene indicate contributions from Chlorobi, and abundant chlorophyll a and pheophytin a are consistent with the presence of Cyanobacteria. The red pinnacle mat contains hopanoids, including 2-methyl structures that have been interpreted as biomarkers for Cyanobacteria. A single sequence of hpnP, the gene required for methylation of hopanoids at the C-2 position, was recovered in both DNA and cDNA libraries from the red pinnacle mat. The hpnP sequence was most closely related to cyanobacterial hpnP sequences, implying that Cyanobacteria are a source of 2-methyl hopanoids present in the mat. The mats are capable of light-dependent primary productivity as evidenced by 13C-bicarbonate photoassimilation. We also observed 13C-bicarbonate photoassimilation in the presence of DCMU, an inhibitor of electron transfer to Photosystem II. Our results indicate that the mats carry out light-driven primary production in the absence of oxygen production-a mechanism that may have delayed the oxygenation of the Earth's oceans and atmosphere during the Proterozoic Eon. Furthermore, our observations of the production of 2-methyl hopanoids by Cyanobacteria under conditions of low oxygen and low light are consistent with the recovery of these structures from ancient black shales as well as their paucity in modern marine environments. [ABSTRACT FROM AUTHOR]