Development of a multi-layer quality assurance program to evaluate the uncertainty of deformable dose accumulation in adaptive radiotherapy.

PURPOSE: Deformable dose accumulation (DDA) has uncertainties which impede the implementation of DDA-based adaptive radiotherapy (ART) in clinic. The purpose of this study is to develop a multi-layer quality assurance (MLQA) program to evaluate uncertainties in DDA. METHODS: A computer program is developed to generate a pseudo-inverse displacement vector field (DVF) for each deformable image registration (DIR) performed in Accuray's PreciseART. The pseudo-inverse DVF is first used to calculate a pseudo-inverse consistency error (PICE) and then implemented in an energy and mass congruent mapping (EMCM) method to reconstruct a deformed dose. The PICE is taken as a metric to estimate DIR uncertainties. A pseudo-inverse dose agreement rate (PIDAR) is used to evaluate the consequence of the DIR uncertainties in DDA and the principle of energy conservation is used to validate the integrity of dose mappings. The developed MLQA program was tested using the data collected from five representative cancer patients treated with tomotherapy. RESULTS: DIRs were performed in PreciseART to generate primary DVFs for the five patients. The fidelity index and PICE of these DVFs on average are equal to 0.028 mm and 0.169 mm, respectively. With the criteria of 3 mm/3% and 5 mm/5%, the PIDARs of the PreciseART-reconstructed doses are 73.9 ± 4.4% and 87.2 ± 3.3%, respectively. The PreciseART and EMCM-based dose reconstructions have their deposited energy changed by 5.6 ± 3.9% and 2.6 ± 1.5% in five GTVs, and by 9.2 ± 7.8% and 4.7 ± 3.6% in 30 OARs, respectively. CONCLUSIONS: A pseudo-inverse map-based EMCM program has been developed to evaluate DIR and dose mapping uncertainties. This program could also be used as a sanity check tool for DDA-based ART.

Incorporating uncertainty bounds in daily deformable dose accumulation for adaptive radiation therapy of head-and-neck cancer.

BACKGROUND: The widespread use of deformable dose accumulation (DDA) in adaptive radiotherapy (ART) has been limited due to the lack of clinically compatible methods to consider its related uncertainties. PURPOSE: We estimate dose reconstruction uncertainties in daily DDA during CT-guided radiotherapy of head-and-neck cancer (HNC). We project confidence intervals of cumulative dose-volume parameters to the parotids and determine threshold values to guide clinical decision-making in ART. METHODS: Doses from daily images (megavoltage CTs [MVCTs]) of 20 HNC patients treated with tomotherapy were reconstructed and accumulated in the planning CT (PCT) utilizing a commercial DDA algorithm (PreciseART, Accuray, Inc.). For each mapped fraction, we warped the planning contours to the MVCT. Dose-volume histograms (DVHs) calculated in the MVCT (with warped contour and native dose) and the PCT (with native contour and mapped dose) were compared; the observed inconsistencies were associated with dose reconstruction errors. We derived uncertainty bounds for the transferred dose to voxels within the structure of interest in the PCT. The confidence intervals of cumulative dose-volume parameters were mid-treatment projected and evaluated as predictors of the end of treatment cumulative metrics. The need for plan adaptation was tested by comparing the projected uncertainty bounds with the treatment constraint points. RESULTS: Among all cases, the uncertainty in mean values of daily dose distributions mapped to the reference parotid's contours averaged between 2.8% and 3.8% of typical single fraction planning values and less than 1% for the planning target volume (PTV) D95%. These daily inconsistencies were higher in the ipsilateral compared to the contralateral parotid and increased toward the end of treatment. The magnitude of the uncertainty bounds for the cumulative treatment mean dose, D50%, and V20 Gy to the parotids, and PTV D95% were on average 3.5%, 6.6%, 4.6%, and 0.4% of the planned or prescribed values, with confidence intervals of 97.1%-107.0%, 98.2%-110.4%, 95.6%-111.1%, and 98.2%-100.2% respectively. The uncertainty intervals projected at mid-treatment intersected with the end of treatment bounds in 82% of the parotid's metrics; half of them presented an overlapping percentage greater than 60%. In five patients, the cumulative mean doses were projected at mid-treatment to exceed the total treatment constraint point by at least 3%; this threshold was exceeded at the end of treatment in the five cases. Underdosing was projected in only one case; the cumulative PTV D95% at the end of treatment was below the clinical threshold. CONCLUSION: Uncertainty bounds were incorporated into the results of a commercial DDA tool. The cohort's statistics showed that the parotids' cumulative DVH metrics frequently exceeded the planning values if confidence intervals were included. Most of the uncertainty bounds of the PTV metrics were kept within the clinical thresholds. We verified that mid-treatment violation projections led to exceeding the constraint point at the end of the treatment. Based on a 3% threshold, approximately one fourth of the patients are expected to be replanned at mid-treatment for parotids sparing during HNC radiotherapy.

Effect of Supplementary Physical Training on Vertical Jump Height in Professional Ballet Dancers.

Dancers require many specific dance skills of a ballistic nature. The design of supplementary training to improve the strength of the lower limbs and jump height is a relevant area of research. The purpose of this study was (1) to compare the effect of plyometric training versus combined training on countermovement jump (CMJ), squat jump (SJ), and sauté in first position (sauté) height and (2) to observe whether changes in CMJ and SJ were associated with changes in sauté in female and male dancers. Eighty-one classical professional ballet dancers (41 women and 40 men, age = 22.9 [3.7] y, body mass = 59.7 [8.6] kg, height = 167.4 [7.3] cm) were divided into a control group and 2 experimental groups: plyometric training and combined training. All groups followed their common routine of training regarding classes and rehearsal practice, whereas the experimental groups added 2 sessions (1 h per session) for 9 weeks of supplementary training. Significant increases (medium to large effect size) in CMJ, SJ, and sauté height were found in the pretest versus posttest comparisons for both experimental groups. Significant, very large correlations were found between the magnitude of improvement in sauté and the magnitude of improvement in CMJ and SJ. Plyometric and combined training programs are effective ways to improve jumping ability in professional dancers. The improvement in CMJ and SJ has a good transference on sauté `performance. These findings support the use of traditional training methods to improve jump height in specific and nonspecific ballet jumping ability.

The Effect of 16 Weeks of Lower-Limb Strength Training in Jumping Performance of Ballet Dancers.

Jumping ability is considered a determinant of performance success. It is identified as one of the predictors and talent identification in many sports and dance. This study aimed to investigate the effect of 16 weeks of lower-limb strength training on the jumping performance of ballet dancers. A total of 24 participants from the same dance school were randomly selected in the control group [CG; n = 10; aged 13.00 (1.49) years; 43.09 (9.48) kg and 1.53 (0.11) m] and the intervention group [IG; n = 14; aged 12.43 (1.45) years; 38.21 (4.38) kg and 1.51 (0.07) m], evaluated before and after the applied strength training program mainly using the body weight of each participant. Jump performance was assessed using MyJump2, a scientifically validated mobile phone app. Intergroup and intragroup comparisons were assessed, and the magnitude of change was calculated using the effect size (ES). While CG significantly decreased the relative power over time (p < 0.001, ES = -0.29: small), results from the intragroup comparisons suggest that IG significantly increased the countermovement jump (CMJ) height (p < 0.001, ES = 1.21: large), the relative force (p < 0.001, ES = 0.86: moderate), maximal velocity (p < 0.001, ES = 1.15: moderate), and relative power (p < 0.001, ES = 1.37: large). We concluded that a 16-week strength training program of lower limbs is an effective way to improve CMJ height in young dancers. Supplementary strength training appears to be the determinant for the improvement of the jumping performance of ballet dancers.

Individualized Training Based on Force-Velocity Profiling During Jumping in Ballet Dancers.

PURPOSE: Ballet dancers are required to achieve performance feats such as exciting and dramatic elevations. Dancers with a greater jump height can perform a wider range of skills during their flight time and implement more specific technical skills related to the aesthetic components of a dance choreography. New findings suggest the relationship between force and velocity mechanical capabilities (F-V profile) as an important variable for jumping performance. A new field method based on several series of loaded vertical jumps provides information on the theoretical maximal force, theoretical maximal velocity, theoretical maximal power, and the imbalance between force and velocity (F-VIMB). The purpose of this study was to observe the effects of 9 wk of individualized F-V profile-based training during countermovement jumps (CMJs) in female ballet dancers. METHODS: CMJ and mechanical outputs of 46 dancers (age = 18.9 [1.1] y, body mass = 54.8 [6.1] kg, height = 163.7 [8.4] cm) were estimated in a pre-post intervention. The control group (10 participants) continued with the standardized training regimen (no resistance training), whereas the experimental group (36 participants) performed 2 sessions over 9 wk of a training plan based on their F-V profile. RESULTS: The experimental group presented significant differences with large effect sizes in CMJ height (29.3 [3.2] cm vs 33.5 [3.72] cm), theoretical maximal force (24.1 [2.2] N/kg vs 29.9 [2.8] N/kg), and theoretical maximal velocity (4 [0.6] m/s vs 3.2 [0.5] m/s). Significant differences with a very large effect size were found in F-VIMB (43.8% [15.3%] vs 24.9% [8.7%]). CONCLUSION: A training program addressing F-VIMB is an effective way to improve CMJ height in female ballet dancers.

Fitness as mediator between weight status and dimensions of health-related quality of life.

BACKGROUND: There is evidence that overweight and obesity in children is associated with poor Physical Fitness and consequently lower Health-related Quality of Life (HRQoL). However, this linear-causal relationship between Weight Status → Physical Fitness → HRQoL is not enough to fully understand this phenomenon. Therefore, need to know, through mediation analysis, how operate the Physical Fitness between weight status and HRQoL dimensions. PURPOSE: The aim of this study was to determine which HRQoL dimensions are mediated through Physical Fitness in obese (including overweight) and normal weight children. The study also examined the association between Physical Fitness, Body Mass Index (BMI) and HRQoL. METHODS: A total of 233 overweight/obese children and 105 normal-weight children participated in the study. Children were recruited from public educational centers and a public weight loss program. BMI, Physical Fitness (upper limb, central body and lower limb strength; agility and range of motion) and HRQoL (PedsQL and VAS) were measured. Simple mediation analyses by gender, through PROCESS macro developed by Preacher and Hayes, were performed in order to analyze whether Physical Fitness computed as z-score, is a mediator in the relation between weight status (normal weight or overweight/obesity) and HRQoL dimensions. \itionally, unequal-variances t statistics were executed to know differences in BMI, Physical Fitness components and HRQoL dimensions between groups, and correlations to know the associations between weight status, Physical Fitness z-score and HRQoL. RESULTS: Our results, indicated association between the Physical Fitness z-score and HRQoL dimensions in overweight/obese children. Regarding to mediation analysis, the results showed that the negative association between overweight/obesity and HRQoL is softened by the level of Physical Fitness. Therefore Physical Fitness is a mediator in the relationship between overweight/obesity children and the most of dimensions of HRQoL, except the School functioning in boys and the School and Emotional functioning in girls. CONCLUSIONS: The negative effect of overweight or obesity on HRQoL inn children, is mitigated by Physical Fitness. Consequently, the Physical Fitness is a mediator on HRQoL in most dimensions, especially daily living, in schoolchildren.

Experimental HPGe coaxial detector response and efficiency compared to Monte Carlo simulations.

The peak efficiency for photons hitting the frontal surface of a medium volume n-type HPGe coaxial detector is mapped using acutely collimated beams of energies between 31 and 383 keV from a (133)Ba radioactive source. Simulated values obtained with the Monte Carlo radiation transport code penelope, using a model that respected actual detector dimensions and physical constants while varying dead-layer thicknesses, allowed us to fit the experimental results in the detector bulk but not near its rim. The spectra of a (137)Cs source were measured using the detector shielded from the natural background radiation, with and without a broad angle collimator. The corresponding simulated spectra, using the fitted dead-layer thicknesses, underestimate the continuum component of the spectra and overestimate the peak efficiency, by less than ten percent in the broad angle collimator arrangement. The simulated results are sensitive to the photon attenuation coefficients.

Novel strategies for inhibiting PD-1 pathway-mediated immune suppression while simultaneously delivering activating signals to tumor-reactive T cells.

We previously developed cell-based vaccines as therapeutics for metastatic cancers. The vaccines were aimed at activating type I CD4(+)T cells and consisted of tumor cells transfected with genes encoding syngeneic MHC class II and CD80 costimulatory molecules, and lacking the MHC II-associated invariant chain. The vaccines showed some efficacy in mice with sarcoma, melanoma, and breast cancer and activated MHC class II syngeneic T cells from breast, lung, and melanoma patients. During the course of the vaccine studies, we observed that CD80 not only costimulated naïve T cells, but also bound to PD-L1 and prevented tumor cell-expressed PD-L1 from binding to its receptor PD-1 on activated T cells. A soluble form of CD80 (CD80-Fc) had the same effect and sustained IFNγ production by both human and murine PD-1(+) activated T cells in the presence of PD-L1(+) human or mouse tumor cells, respectively. In vitro studies with human tumor cells indicated that CD80-Fc was more effective than antibodies to either PD-1 or PD-L1 in sustaining T cell production of IFNγ. Additionally, in vivo studies with a murine tumor demonstrated that CD80-Fc was more effective than antibodies to PD-L1 in extending survival time. Studies with human T cells blocked for CD28 and with T cells from CD28 knockout mice demonstrated that CD80-Fc simultaneously inhibited PD-L1/PD-1-mediated immune suppression and delivered costimulatory signals to activated T cells, thereby amplifying T cell activation. These results suggest that CD80-Fc may be a useful monotherapy that minimizes PD-1 pathway immune suppression while simultaneously activating tumor-reactive T cells.

Feasibility of spent metalworking fluids as co-substrate for anaerobic co-digestion.

In this paper, anaerobic co-digestion of spent metalworking fluids (SMWF) and pig manure (PM) was evaluated. Three SMWF:PM ratios were tested in order to find the highest process efficiency. The best results (COD removal efficiencies of 74%) were achieved co-digesting a mixture with a SMWF:PM ratio of 1:99, w/w(1) (corresponding to 3.75mL SMWF/Lreactor week), which indicates that SMWF did not affect negatively PM degradation. Furthermore, two different weekly SMWF pulse-frequencies were performed (one reactor received 1 pulse of 3.75mL/Lreactor and the other 3 pulses of 1.25mL/Lreactor) and no differences in COD removal efficiency were observed. Microbiology analysis confirmed that Pseudomonas was the predominant genus when treating anaerobically SMWF and the presence of a higher fraction of Archaea was indicative of good digester performance. This study confirms the feasibility of anaerobic co-digestion as an appropriate technology for treating and valorising SMWF.

Mortalidad en el menor de 5 años: principales factores de riesgo / Mortality in the person younger than 5 years: main risk factors

Hospital Pediátrico Docente Pedro Agustín Pérez de Guantánamo, para identificar los principales factores de riesgo que influyeron en la mortalidad en el menor de 5 años. Se estudian todos los niños egresados fallecidos (n=139) y una muestra sistemática de niños con la misma edad que ingresaron por enfermedades similares, pero que no fallecieron. Se analizaron factores de riesgo biológicos y socioambientales. Como riesgo biológico se encontró la enfermedad asociada al embarazo (anemia y sepsis urinaria. La edad materna fue inferior a 18 años y superior a 35. El peso al nacer inferior a 2 500 gramos, el estado nutricional deficiente y la lactancia materna nula o insuficiente. Entre los factores socioambientales: el estado conyugal soltero o acompañado, la escolaridad de los padres insuficiente, las malas condiciones de vida, el hábito de fumar y la ingestión de bebidas alcohólicas durante el embarazo(AU)

A study of case control is done during 2003 and 2011, at the Teaching Pediatric Hospital Pedro Agustín Pérez of Guantanamo, to identify the main factors of risk that influenced the mortality in the person younger than 5 years. All the deceased gone away (n=139 children) and a systematic children sample with the same age whom were admitted for similar illnesses, but children didn't die. Biological risk factors were analyzed and socioenvironmental too. As biological risk was found the illness associated with the pregnancy (anemia and urinary sepsis. The maternal age was lower than 18 years and superior to 35. The weight on having been born lower than 2 500 grams, the deficient nutritional state and the void or insufficient breast feeding. Socioenvironmental factors such as: the single or accompanied conjugal state, the insufficient schooling of the parents, the bad living conditions, the habit of smoking and the consumption of alcoholic beverages during the pregnancy

Enhanced methane production from pig manure anaerobic digestion using fish and biodiesel wastes as co-substrates.

Co-digestion of pig manure (PM(1)) with fish (FW(2)) and biodiesel waste (BW(3)) was evaluated and compared with sole PM digestion. Results indicated that co-digestion of PM with FW and/or BW is possible as long as ammonium and volatile fatty acids remained under inhibitory levels by adjusting the operating conditions, such as feed composition, organic loading rate (OLR) and hydraulic retention time (HRT). PM and FW co-digestion (90:10 and 95:5, w/w(4)) was possible at OLR of 1-1.5g COD/Ld, resulting in biogas production rates of 0.4-0.6 L/Ld and COD removal efficiencies of 65-70%. Regarding BW, good results (biogas production of 0.9 L/Ld and COD elimination of 85%) were achieved with less than 5% feeding rate. Overall, operating at the same OLR, the biogas production and methane content in the co-digester was higher than in the only PM digester.

Megestrol acetate-induced adrenal insufficiency.

Megestrol acetate is a synthetic progestin that has been used since the 1970s for the treatment of advanced cancer and subsequently to treat anorexia, cachexia and weight loss in AIDS patients. It has been shown that high doses or prolonged treatment with this drug may cause Cushing's syndrome, new-onset diabetes and suppression of plasma ACTH and cortisol levels. Megestrol acetate may cause suppression of the pituitary-adrenal axis due to the affinity of this compound for the glucocorticoid receptor. Recognising the glucocorticoid-like activity of megestrol and its effects at the axis level is important for the diagnosis of sub-clinical adrenal insufficiency. We present the case of a 74-year-old woman with infiltrating ductal breast carcinoma refractory to prolonged hormonal treatment with megestrol acetate, presenting with adrenal insufficiency.

Tumor de Wilms: informe de un caso / Wilms tumor: a case report

Se presenta el caso de un niño de 3 años de edad del municipio Yateras, Guantánamo, con diagnóstico de tumor de Wilms, antecedentes de epilepsia y tratamiento regular con Carbamazepina. Se diagnostica tumor en hipocondrio izquierdo en cuerpo de guardia, notado por la madre cinco días antes. Fue remitido al Hospital Pediátrico Pedro A. Pérez, realizándosele ultrasonido y tomografía axial computarizada confirmando el diagnóstico. Se traslada al Hospital Pediátrico Sur de Santiago de Cuba, confirmándose estadía II e histología desfavorable. Se realizó nefrectomía izquierda, tratamiento quimioterapéutico y radioterapia. La respuesta ha sido favorable, no se evidencia recidivas, tiene seguimiento y como efectos colaterales al tratamiento apareció alopecia e infecciones respiratorias a repetición (AU)

Comportamiento de la mortalidad por infecciones respiratorias agudas / Behavior of the mortality for acute breathing infections

Se realizó un estudio descriptivo transversal, con el objetivo de caracterizar la mortalidad por infecciones respiratorias agudas durante 8 años (1996-2003) en el Hospital Pediátrico Docente “Pedro Agustín Pérez”, de la provincia de Guantánamo. El universo estuvo constituido por los 45 fallecidos que hubo por esta causa durante el período de estudio. El dato primario se obtuvo de la revisión de las historias clínicas mediante el uso de un formulario confeccionado previamente. Las variables estudiadas fueron: mortalidad según edad, sexo, factores asociados, como bajo peso al nacer, atopia, estado nutricional, condiciones de vida, lactancia materna, síntomas y signos al ingreso, y causas básicas de muerte. Se encontró una disminución de la mortalidad en los últimos tres años. Mayormente afectados resultaron los menores de un año, masculinos, con bajo peso al nacer como principal factor asociado. Los síntomas y signos más frecuentes fueron: la tos y la fiebre. La causa básica de muerte que prevaleció fue la neumonía(AU)

Comportamiento clinico-epidemiológico de la glomerulonefritis difusa aguda / Clinical-epidemic behavior of the acute diffuse glomerulonephritis

Se realiza un estudio descriptivo de los pacientes que ingresaron con el diagnóstico de glomerulonefritis difusa aguda post-infecciosa, desde 1999 al 2002, en el Hospital Pediátrico Docente “Pedro A Pérez” de Guantánamo, con el objetivo de realizar un análisis clínico epidemiológico de esta enfermedad en la población infantil. Se valoran diferentes variables tales como: edad, sexo, condiciones socioeconómicas y las enfermedades previas presentadas por los pacientes, además, de los síntomas y signos, las formas clínicas de inicio, y en su conjunto objetivar la magnitud de la enfermedad en los años de estudio. El grupo de edades con más afectados es el de 5-9 años. El sexo masculino representa el 53,7 por ciento del total de los casos estudiados. Se corrobora la influencia de las condiciones socioeconómicas insuficientes. La piodermitis constituye el antecedente previo fundamental en el 59,7 por ciento de los casos. Prevalece la forma clásica de la enfermedad entre las formas clínicas presentadas. El edema y la hematuria resaltan entre los elementos clínicos clásicos de inicio de la enfermedad(AU)

Mortalidad por cardiopatías congénitas en el menor de un año / Mortality by heart defect congenital in smaller than one year

Se realizó un estudio descriptivo transversal con el objetivo de caracterizar la mortalidad por cardiopatías congénitas en el menor de un año en el servicio de neonatología del Hospital General Docente “Dr. Agostinho Neto” y el Hospital “Pedro A Pérez”, en el período enero 1995-diciembre 2000. El universo estuvo constituido por los 57 niños menores de un año que fallecieron por la enfermedad durante el período de estudio. Se revisaron las historias clínicas de los pacientes y se procesaron los datos mediante el programa EPI INFO 6. Se determinaron las tasas de mortalidad proporcionada y la tendencia de la enfermedad. Se analizaron las variables: edad, sexo, peso al nacer, forma de presentación, tipo de cardiopatías, enfermedades asociadas. Se evidenció la mayor tasa de mortalidad proporcionada durante el año 1996, la tendencia fue descendente en el período. El mayor porcentaje de los fallecidos fue de menores de 7 días, del sexo femenino, de más de 2500 gramos de peso al nacer. La forma de presentación más común fue las asociadas y el tipo más frecuente, las cianóticas, entre las cuales predominó la transposición de grandes vasos. La desnutrición proteico–energética y las enfermedades genéticas fueron las principales enfermedades asociadas(AU)

Mortalidad en el menor de 5 años: principales factores de riesgo / Mortality in the smaller than 5 years: main risk factors

Se realizó un estudio de casos y controles, durante los años comprendidos entre 1992-2000, ambos inclusive, en el Hospital Pediátrico "Pedro A. Pérez" de Guantánamo, para identificar los principales factores de riesgo que influyeron en la mortalidad en el menor de 5 años. Se estudiaron todos los niños egresados fallecidos (n=278) (grupo estudio) y una muestra sistemática de niños con la misma edad que ingresaron por enfermedades similares, en el mismo período de tiempo, pero que no fallecieron (grupo control). Se analizaron los principales factores de riesgo biológico y socioambientales. Los principales resultados encontrados fueron: los factores asociados con la mortalidad: como riesgo biológico; enfermedad asociada al embarazo: la anemia y la sepsis urinaria; la edad materna inferior a 18 años y superior a 35, el peso al nacer inferior a 2500 gramos, el estado nutricional deficiente y la lactancia materna nula o insuficiente. Entre los factores socioambientales: el estado conyugal soltera o acompañada; la escolaridad de los padres insuficiente; las malas condiciones de vida, el hábito de fumar y la ingestión de bebidas alcohólicas durante el embarazo(AU)

Estudio clínico-estadístico de la hepatitis viral y su seguimiento

Se revisaron 563 historias clínicas realizándose un estudio de los principales síntomas de la hepatitis viral, desde un punto de vista clínico. Se analizan las pruebas funcionales hepáticas, tanto durante la estancia hopsitalaria como en los distintos seguimientos. La determinación de la bilirrubina es importante durante el período de hospitalización, pero no es los casos egresados y en franca convalecencia. La prueba de la turbidez de timol es de gran valor en el seguimiento(AU)