Organizing a Successful Practice and Considering Tax and Estate Planning.

To care for your family and to do "good" for your alma mater, religious organization, and the other charities you love, you need to do "well," which is to build a successful practice. To achieve a successful practice, following the principles of the dozen A's is helpful: Ability, Availability, Amicability, Approachable, Attuned, Aware, Attentive to patients, Attentive to others, Attentive to details, Apology (ability to apologize and accept apology gracefully), Assimilate, Affordable. Another way to put it is "skills to treat, heart to care at a sensible price."

The design and use of a simple device for the MRI assessment of changes in cardiovascular function by lower-body negative-pressure-simulated reduction of central blood volume.

AIM: To use a locally designed and simple lower-body negative-pressure (LBNP) device and 1.5 T magnetic resonance imaging (MRI) to demonstrate the ability to assess changes in cardiovascular function during preload reduction. These effects were evaluated on ventricular volumes and great vessel flow in healthy volunteers, for which there are limited published data. MATERIAL AND METHODS: After ethical review, 14 volunteers (mean age 33.9 ± 7 years, mean body mass index [BMI] 23.1 ± 2.5) underwent LBNP prospectively at 0, -5, -10, and -20 mmHg pressure, using a locally designed LBNP box. Expiratory breath-hold biventricular volumes, and free-breathing flow imaging of the ascending aorta and main pulmonary artery were acquired at each level of LBNP. RESULTS: At -5 mmHg, there was no change in aortic flow or left ventricular volumes versus baseline. Right ventricular output (p=0.013) and pulmonary net flow (p=0.026) decreased. At -20 mmHg, aortic and pulmonary net flow (p<0.001) decreased, as were left and right ventricular end diastolic volume (p<0.001) and left and right end systolic volumes (p=0.038 and p=0.003 respectively). CONCLUSIONS: Use of a MRI-compatible LBNP device is feasible to measure changes in ventricular volume and great arterial flow in the same experiment. This may enhance further research into the effects of preload reduction by MRI in a wide range of important cardiovascular pathologies.

A pilot image interpretation teaching intervention to improve competence and confidence of radiographers to detect left ventricular thrombus in routine cardiac MRI scans.

INTRODUCTION: Prompt diagnosis of left ventricular (LV) thrombus is clinically important, as it may require immediate anti-coagulation treatment. The aim of this study was to determine if a teaching intervention delivered by cardiovascular magnetic resonance (CMR) physicians would increase the CMR radiographers' ability to detect LV thrombus on a routine CMR scan. METHODS: A cohort of 25 patients (14 with and 11 without LV thrombus) were identified. A multi-parametric CMR protocol had been performed in all patients. Ten radiographers reviewed the 25 randomised anonymised studies on a workstation, documenting the presence/absence of LV thrombus and their confidence level on a 7-point Likert scale. Two senior CMR fellows then delivered a focused teaching programme to the radiographers and all 25 randomised scans were reassessed 1 month after the teaching intervention. RESULTS: Following dedicated training, there was a significant improvement in correct thrombus identification per radiographer (pre-training: 75 ± 6% vs post-training: 85 ± 6%, p = 0.009). The size of the thrombus was not associated with the likelihood of incorrectly identifying LV thrombus size prior to the training session (p = 0.2), but a trend was observed between smaller thrombus size and incorrect identifications post-training (p = 0.06). The radiographers' overall confidence in assessing the cases prior to the teaching session was high (5.6 ± 0.8 out of 7). Following the teaching session, self-reported confidence did not vary significantly (5.9 ± 0.7 out of 7, p = 0.42). When evaluating the teaching session, radiographers provided very positive feedback, rating the usefulness of the teaching intervention as highly educative (8.8 ± 0.4 out of 10). CONCLUSIONS: This is the first study that has explored the ability and confidence of CMR radiographers in detecting LV thrombus on routine CMR scans as a result of the teaching intervention delivered by CMR physicians. IMPLICATIONS FOR PRACTICE: A teaching intervention can improve CMR radiographers' diagnostic skills and diagnostic confidence.

Validation of the Diet Satisfaction Questionnaire: a new measure of satisfaction with diets for weight management.

OBJECTIVE: The Diet Satisfaction Questionnaire was developed to fill the need for a validated measure to evaluate satisfaction with weight-management diets. This paper further develops the questionnaire, examining the factor structure of the original questionnaire, cross-validating a revised version in a second sample and relating diet satisfaction to weight loss during a 1-year trial. METHODS: The 45-item Diet Satisfaction Questionnaire (DSat-45) uses seven scales to assess characteristics that influence diet satisfaction: Healthy Lifestyle, Convenience, Cost, Family Dynamics, Preoccupation with Food, Negative Aspects, and Planning and Preparation. It was administered five times during a 1-year weight-loss trial (n = 186 women) and once as an online survey in a separate sample (n = 510 adults). Confirmatory factor analysis was used to assess and refine the DSat-45 structure, and reliability and validity data were examined in both samples for the revised questionnaire, the DSat-28. Associations were examined between both DSat questionnaires and weight loss in the trial. RESULTS: Internal consistency (reliability) was moderate for the DSat-45. Confirmatory factor analysis showed improved fit for a five-factor structure, resulting in the DSat-28 that retained four of the original scales and a shortened fifth scale. This revised questionnaire was reliable in both samples. Weight loss across the year-long trial was positively related to satisfaction with Healthy Lifestyle, Preoccupation with Food, and Planning and Preparation in both versions of the questionnaire. CONCLUSIONS: Measures of reliability and validity were improved in the more concise DSat-28 compared to the DSat-45. This shorter measure should be used in future work to evaluate satisfaction with weight-management diets.

Application of TWIST MR angiography to aid successful central venous access in challenging patients: initial single-centre experience.

AIM: To investigate whether time-resolved angiography with interleaved stochastic trajectories (TWIST) with GeneRalised Autocalibrating Partially Parallel Acquisitions (GRAPPA) parallel acquisition could be used successfully to non-invasively and efficiently image patients with more complex vascular access issues. MATERIALS AND METHODS: TWIST magnetic resonance angiography (MRA) in the GRAPPA algorithm was performed on 15 patients at our centre using the 1.5 T Siemens Magnetom Avanto MRI system. Images were interpreted by cardiac radiologists. RESULTS: TWIST provided excellent dynamic imaging of the venous system, demonstrating venous occlusion, stenoses, and collaterals, as well as providing good anatomical detail. CONCLUSION: TWIST MRA enables successful identification of candidate sites for central/tunnelled line access, whilst diagnosing complications of long-term access such as venous thrombosis or congenital venous anomalies.

MRI-guided prostate adaptive radiotherapy - A systematic review.

Dose escalated radiotherapy improves outcomes for men with prostate cancer. A plateau for benefit from dose escalation using EBRT may not have been reached for some patients with higher risk disease. The use of increasingly conformal techniques, such as step and shoot IMRT or more recently VMAT, has allowed treatment intensification to be achieved whilst minimising associated increases in toxicity to surrounding normal structures. To support further safe dose escalation, the uncertainties in the treatment target position will need be minimised using optimal planning and image-guided radiotherapy (IGRT). In particular the increasing usage of profoundly hypo-fractionated stereotactic therapy is predicated on the ability to confidently direct treatment precisely to the intended target for the duration of each treatment. This article reviews published studies on the influences of varies types of motion on daily prostate position and how these may be mitigated to improve IGRT in future. In particular the role that MRI has played in the generation of data is discussed and the potential role of the MR-Linac in next-generation IGRT is discussed.

Stress responses to repeated exposure to a combined physical and social evaluative laboratory stressor in young healthy males.

Repeated exposure to homotypic laboratory psychosocial stressors typically instigates rapid habituation in hypothalamic-pituitary-adrenal (HPA) axis-mediated stress responses in humans. However, emerging evidence suggests the combination of physical stress and social evaluative threat may be sufficient to attenuate this response habituation. Neuroendocrine, cardiovascular and subjective stress responses following repeated exposure to a combined physical and social evaluative stress protocol were assessed to examine the habituation response dynamic in this context. The speech task of the Trier social stress test (TSST; Kirschbaum et al., 1993) and the socially evaluated cold pressor task (SECPT; Schwabe et al., 2008) were administered in a combined stressor protocol. Salivary cortisol, cardiovascular and subjective stress responses to a non-stress control and repeat stressor exposure separated by six weeks were examined in males (N=24) in a crossover manner. Stressor exposure resulted in significant elevations in all stress parameters. In contrast to the commonly reported habituation in cortisol response, a comparable post-stress response was demonstrated. Cortisol, heart rate and subjective stress responses were also characterised by a heightened response in anticipation to repeated stress exposure. Blood pressure responses were comparatively uniform across repeated exposures. Findings suggest a combined physical and social evaluative stressor is a potentially useful method for study designs that require repeated presentation of a homotypic stressor.

No effects of ingesting or rinsing sucrose on depleted self-control performance.

Self-control tasks appear to deplete a limited resource resulting in reduced subsequent self-control performance; a state of ego depletion. Evidence of reduced peripheral glucose by exertion of self-control, and attenuation of ego depletion by carbohydrate metabolism underpins the proposition that this macronutrient provides the energetic source of self-control. However, the demonstration of positive, non-metabolic effects on ego depletion when merely sensing carbohydrates orally contradicts this hypothesis. Recent studies have also failed to support both metabolic and non-metabolic accounts. The effects of ingesting or rinsing a carbohydrate (sucrose) and an artificially sweetened (sucralose) solution on capillary blood and interstitial glucose, and depleted self-control performance were examined in older adults. Forty, healthy, adults (50-65years) ingested and rinsed sucrose and sucralose solutions in a 2 (method)×2 (source), fully counterbalanced, repeated measures, crossover design. Capillary blood and interstitial glucose responses were assayed. Depleted self-control performance (induced by the Bakan visual processing task) on an attention switch task was assessed under each study condition. Ego depletion had no consistent effects on peripheral glucose levels and no significant effects of ingesting or rinsing sucrose on self-control were observed. The act of rinsing the solutions, independent of energetic content, resulted in a small, non-significant enhancement of performance on the attention switch task relative to ingesting the same solutions (RT: p=.05; accuracy: p=.09). In conclusion, a metabolic account of self-control was not supported. Whilst a positive effect of rinsing on depleted self-control performance was demonstrated, this was independent of energetic content. Findings suggest glucose is an unlikely physiological analogue for self-control resources.

A low glycaemic load breakfast can attenuate cognitive impairments observed in middle aged obese females with impaired glucose tolerance.

BACKGROUND AND AIMS: There has been no systematic investigation of the individual and combined effects of impaired glucose tolerance (IGT) and obesity on cognitive function in the absence of ageing. The aims were to examine the effects of IGT and increased waist circumference on cognitive function in ostensibly healthy adults, and to investigate whether a low glycaemic load (GL) breakfast can attenuate cognitive impairments in these populations. METHODS AND RESULTS: Sixty five females aged 30-50 years were classified into one of four groups following waist circumference (WC) measurements and an oral glucose tolerance test: NGT/low WC (n = 25), NGT/high WC (n = 22), IGT/low WC (n = 9), IGT/high WC (n = 9). Memory, psychomotor and executive functions were examined 30 and 120 min after consuming low GL, high GL and water breakfasts according to a randomised, crossover, counterbalanced design. IGT was associated with impairment of verbal and spatial memory, and psychomotor function relative to females with NGT, independent of waist circumference. Increased waist circumference was associated with impairment of verbal memory and executive function relative to females with low WC, independent of IGT. Consumption of the LGL breakfast attenuated verbal memory impairment in the IGT/high WC group relative to the HGL breakfast and no energy control. CONCLUSION: Increased central adiposity and abnormalities in glucose tolerance preceding type 2 diabetes can have demonstrable negative effects on cognitive function, even in ostensibly healthy, middle-aged females. The potential for GL manipulations to modulate glycaemic response and cognitive function in type 2 diabetes and obesity merits further investigation.

Psychological benefits of weight loss following behavioural and/or dietary weight loss interventions. A systematic research review.

It is generally accepted that weight loss has significant physiological benefits, such as reduced risk of diabetes, lowered blood pressure and blood lipid levels. However, few behavioural and dietary interventions have investigated psychological benefit as the primary outcome. Hence, systematic review methodology was adopted to evaluate the psychological outcomes of weight loss following participation in a behavioural and/or dietary weight loss intervention in overweight/obese populations. 36 Studies were selected for inclusion and were reviewed. Changes in self-esteem, depressive symptoms, body image and health related quality of life (HRQoL) were evaluated and discussed. Where possible, effect sizes to indicate the magnitude of change pre- to post- intervention were calculated using Hedges' g standardised mean difference. The results demonstrated consistent improvements in psychological outcomes concurrent with and sometimes without weight loss. Improvements in body image and HRQoL (especially vitality) were closely related to changes in weight. Calculated effect sizes varied considerably and reflected the heterogeneous nature of the studies included in the review. Although the quality of the studies reviewed was generally acceptable, only 9 out of 36 studies included a suitable control/comparison group and the content, duration of intervention and measures used to assess psychological outcomes varied considerably. Further research is required to improve the quality of studies assessing the benefits of weight loss to fully elucidate the relationship between weight loss and psychological outcomes.

RTOG 0518: randomized phase III trial to evaluate zoledronic acid for prevention of osteoporosis and associated fractures in prostate cancer patients.

BACKGROUND: RTOG 0518 evaluated the potential benefit of zoledronic acid therapy in preventing bone fractures for patients with high grade and/or locally advanced, non-metastatic prostate adenocarcinoma receiving luteinizing hormone-releasing hormone (LHRH) agonist and radiotherapy (RT). METHODS: Eligible patients with T-scores of the hip (<-1.0, but >-2.5 vs >-1.0) and negative bone scans were prospectively randomized to either zoledronic acid, 4 mg, concurrently with the start of RT and then every six months for a total of 6 infusions (Arm 1) or observation (Arm 2). Vitamin D and calcium supplements were given to all patients. Secondary objectives included quality of life (QOL) and bone mineral density (BMD) changes over a period of three years. RESULTS: Of 109 patients accrued before early closure, 96 were eligible. Median follow-up was 36.3 months for Arm 1 and 34.8 months for Arm 2. Only two patients experienced a bone fracture (one in each arm) resulting in no difference in freedom from any bone fracture (P=0.95), nor in QOL. BMD percent changes from baseline to 36 months were statistically improved with the use of zoledronic acid compared to observation for the lumbar spine (6% vs -5%, P<0.0001), left total hip (1% vs -8%, P=0.0002), and left femoral neck (3% vs -8%, P=0.0007). CONCLUSIONS: For patients with advanced, non-metastatic prostate cancer receiving LHRH agonist and RT, the use of zoledronic acid was associated with statistically improved BMD percent changes. The small number of accrued patients resulted in decreased statistical power to detect any differences in the incidence of bone fractures or QOL.

Experience and acceptability of diets of varying protein content and glycemic index in an obese cohort: results from the Diogenes trial.

BACKGROUND/OBJECTIVES: To investigate acceptability and tolerability of diets of different protein and glycemic index (GI) content aimed at weight maintenance following a phase of rapid weight loss, as part of a large pan-European dietary intervention trial. SUBJECTS/METHODS: The Diogenes study (www.diogenes-eu.org) consisted of an initial 8-week rapid weight-loss phase (800-1000 kcal/day), followed by a 6-month weight maintenance intervention with five different diets varying in protein and GI content. Measurement of a range of outcomes relating to experience of the Diogenes diets in terms of acceptability, experience and mood were recorded via end of day questionnaires throughout the study. RESULTS: Weight change during the initial weight loss phase weakly, but positively correlated with acceptability of the programme (r range=-0.08 to 0.2, P 0.05, n=685 on four of five dimensions). Success at weight maintenance positively correlated with acceptance of the programme (r range=-0.21 to -0.34, P<0.001, n=540 for all five dimensions). The diets with higher protein content were more acceptable than the low protein (LP) diets, however, no differences between the high vs low GI diets were found concerning acceptability and tolerability. CONCLUSIONS: Results suggest that moderately high protein diets, compared with LP diets, are more acceptable diets for weight control in overweight individuals.

Potential benefits of satiety to the consumer: scientific considerations.

Foods and dietary patterns that enhance satiety may provide benefit to consumers. The aim of the present review was to describe, consider and evaluate research on potential benefits of enhanced satiety. The proposal that enhanced satiety could only benefit consumers by a direct effect on food intake should be rejected. Instead, it is proposed that there is a variety of routes through which enhanced satiety could (indirectly) benefit dietary control or weight-management goals. The review highlights specific potential benefits of satiety, including: providing appetite control strategies for consumers generally and for those who are highly responsive to food cues; offering pleasure and satisfaction associated with low-energy/healthier versions of foods without feeling 'deprived'; reducing dysphoric mood associated with hunger especially during energy restriction; and improved compliance with healthy eating or weight-management efforts. There is convincing evidence of short-term satiety benefits, but only probable evidence for longer-term benefits to hunger management, possible evidence of benefits to mood and cognition, inadequate evidence that satiety enhancement can promote weight loss, and no evidence on which consumers would benefit most from satiety enhancement. The appetite-reducing effects of specific foods or diets will be much more subtle than those of pharmaceutical compounds in managing hunger; nevertheless, the experience of pharmacology in producing weight loss via effects on appetite suggests that there is potential benefit of satiety enhancement from foods incorporated into the diet to the consumer.

Study of the use of antidepressants for depression in dementia: the HTA-SADD trial--a multicentre, randomised, double-blind, placebo-controlled trial of the clinical effectiveness and cost-effectiveness of sertraline and mirtazapine.

OBJECTIVE: Depression is common in dementia, causing considerable distress and other negative impacts. Treating it is a clinical priority, but the evidence base is sparse and equivocal. This trial aimed to determine clinical effectiveness of sertraline and mirtazapine in reducing depression 13 weeks post randomisation compared with placebo. DESIGN: Multicentre, parallel-group, double-blind placebo-controlled randomised controlled trial of the clinical effectiveness of sertraline and mirtazapine with 13- and 39-week follow-up. SETTING: Nine English old-age psychiatry services. PARTICIPANTS: A pragmatic trial. Eligibility: probable or possible Alzheimer's disease (AD), depression (4+ weeks) and Cornell Scale for Depression in Dementia (CSDD) score of 8+. EXCLUSIONS: clinically too critical (e.g. suicide risk); contraindication to medication; taking antidepressants; in another trial; and having no carer. INTERVENTIONS: (1) Sertraline; (2) mirtazapine; and (3) placebo, all with normal care. Target doses: 150 mg of sertraline or 45 mg of mirtazapine daily. OUTCOME: CSDD score. Randomisation: Allocated 1 : 1 : 1 through Trials Unit, independently of trial team. Stratified block randomisation by centre, with randomly varying block sizes; computer-generated randomisation. Blinding: Double blind: medication and placebo identical for each antidepressant. Referring clinicians, research workers, participants and pharmacies were blind. Statisticians blind until analyses completed. RESULTS: Numbers randomised: 326 participants randomised (111 placebo, 107 sertraline and 108 mirtazapine). OUTCOME: Differences in CSDD at 13 weeks from an adjusted linear-mixed model: mean difference (95% CI) placebo-sertraline 1.17 (-0.23 to 2.78; p = 0.102); placebo-mirtazapine 0.01 (-1.37 to 1.38; p = 0.991); and mirtazapine-sertraline 1.16 (-0.27 to 2.60; p = 0.112). HARMS: Placebo group had fewer adverse reactions (29/111, 26%) than sertraline (46/107, 43%) or mirtazapine (44/108, 41%; p = 0.017); 39-week mortality equal, five deaths in each group. CONCLUSIONS: This is a trial with negative findings but important clinical implications. The data suggest that the antidepressants tested, given with normal care, are not clinically effective (compared with placebo) for clinically significant depression in AD. This implies a need to change current practice of antidepressants being the first-line treatment of depression in AD. From the data generated we formulated the following recommendations for future work. (1) The secondary analyses presented here suggest that there would be value in carrying out a placebo-controlled trial of the clinical effectiveness and cost-effectiveness of mirtazapine in the management of Behavioural and Psychological Symptoms of Dementia. (2) A conclusion from this study is that it remains both ethical and essential for trials of new medication for depression in dementia to have a placebo arm. (3) Further research is required to evaluate the impact that treatments for depression in people with dementia can have on their carers not only in terms of any impacts on their quality of life, but also the time they spend care-giving. (4) There is a need for research into alternative biological and psychological therapies for depression in dementia. These could include evaluations of new classes of antidepressants (such as venlafaxine) or antidementia medication (e.g. cholinesterase inhibitors). (5) Research is needed to investigate the natural history of depression in dementia in the community when patients are not referred to secondary care services. (6) Further work is needed to investigate the cost modelling results in this rich data set, investigating carer burden and possible moderators to the treatment effects. (7) There is scope for reanalysis of the primary outcome in terms of carer and participant CSDD results.

Impact of postprandial glycaemia on health and prevention of disease.

Postprandial glucose, together with related hyperinsulinemia and lipidaemia, has been implicated in the development of chronic metabolic diseases like obesity, type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD). In this review, available evidence is discussed on postprandial glucose in relation to body weight control, the development of oxidative stress, T2DM, and CVD and in maintaining optimal exercise and cognitive performance. There is mechanistic evidence linking postprandial glycaemia or glycaemic variability to the development of these conditions or in the impairment in cognitive and exercise performance. Nevertheless, postprandial glycaemia is interrelated with many other (risk) factors as well as to fasting glucose. In many studies, meal-related glycaemic response is not sufficiently characterized, or the methodology with respect to the description of food or meal composition, or the duration of the measurement of postprandial glycaemia is limited. It is evident that more randomized controlled dietary intervention trials using effective low vs. high glucose response diets are necessary in order to draw more definite conclusions on the role of postprandial glycaemia in relation to health and disease. Also of importance is the evaluation of the potential role of the time course of postprandial glycaemia.

SU-E-T-579: Dosimetric Benefits of Online Adaptive Replanning for Post-Operative Radiation Therapy of Prostate Bed.

PURPOSE: To demonstrate the dosimetric benefits of using an online adaptive replanning scheme to address interfractional variations in radiotherapy of prostate bed. METHODS: We have previously developed an online adaptive replanning tool (RealART, Prowess Inc.) aiming to address interfractional variations including organ deformation and rotation. Using this tool, we analyzed a total of 102 daily pre-treatment CTs acquired using an in-room CT (CTVision, Siemens) for 10 patients treated with post-operative IMRT of prostate bed. The PTV was assumed to be the volume enclosed by the 95% prescription isodose surface generated for the conventional four field box. On each daily CT set, contours of the PTV, rectum and bladder were generated by populating the planning contours using an auto-segmentation tool based on deformable registration (ABAS, Elekta) with manual editing. Four plans were generated and compared: (1) IGRT (repositioning) plan by copying the original plan with aligning the anterior rectal wall from the daily CT to that of the planning CT, (2) IGRT plan by copying the original plan with aligning the surgical clips, (3) online adaptive plan by tailoring the original plan to conform to the anatomy of the day, and (4) a new plan re- optimized based on the daily anatomy. RESULTS: The adaptive and re- optimization plans are in general superior than the two repositioning plans in terms of both target coverage and critical structure sparing. For example, the averages of dose volume quantities for all daily CTs are: rectum V45Gy 55.7±18.0% (one standard deviation), 57.3±17.5%, 48.2±11.8%, 42.5±9.6%; rectum V60Gy 31.8±20.3%, 34.0±16.6%, 22.6±9.7%, 16.5±7.4%; bladder V45Gy 30.0±11.9%, 39.5±24.2%, 37.6±16.8%, 36.5±16.2%; bladder V60Gy 17.4±9.2%, 25.4±18.1%, 24.7±12.7%, 23.9±12.0%; PTV V100 81.9±16.6%, 88.7±7.9%, 92.9±4.6%, and 94.6±2.4% for the above (1)-(4) plans, respectively. CONCLUSIONS: The online adaptive replanning scheme is effective to account for interfractional variations in post-operative radiotherapy of prostate bed. This work is supported partially by MCW Cancer Center Fotsch Foundation.

SU-E-J-11: Characterization of Interfractioanal Anatomical Variations in Post-Operative Radiation Therapy for Prostate Bed.

PURPOSE: To quantitatively characterize the interfractional anatomic variations in post-operative radiation therapy (RT) for prostate bed, so that appropriate strategy that can fully address these variations can be developed. METHODS: A total of 102 daily pre-treatment CT acquired using an in-room CT (CTVision, Siemens) for 10 patients treated with post-operative IG-IMRT of prostate bed. Prior to each fraction, patients were repositioned to correct for interfractional translational shifts based on the alignment of both anterior rectal wall and surgical clips between the daily CT and the planning CT. The PTV was assumed to be the volume enclosed by the 95% prescription isodose surface generated for the conventional four field box. Contours of the PTV, rectum and bladder on each daily CT were generated by populating the planning contours using an auto-segmentation tool based on deformable registration (ABAS, Elekta) with manual editing. Interfrcational variations in the volumes, shapes and positions of these contours were obtained. The displacement of the center of mass (DCOM) with respect to the isocenter was used to measure interfractional organ motion, and the maximum overlap rate (MOR) was used to measure organ deformation. RESULTS: Interfractional variations in the volumes of rectum and bladder were in the range of 50-270% (average 116±41%) and 30-180% (average 67±26%), respectively. The averages of DCOM for rectum are: - 0.35±0.46cm (lateral, varying from -1.58 to 1.23cm), -0.33±0.99cm (longitudinal, varying from -2.4 to 1.8cm), and -3.41±1.14cm (vertical, varying from -5.56 to -0.99cm). These values for bladder are: -0.20±0.50cm (lateral, varying from -1.48 to 0.61cm), 3.63±1.10cm (longitudinal, varying from -5.7 to 3.1cm), and -0.31±0.97cm (vertical, varying from -1.68 to 2.77cm). CONCLUSIONS: Large interfractional changes in organ volumes, shapes and positions are seen in post-operative RT for prostate bed. These changes cannot be accounted for by the current standard practice of IGRT repositioning. This work is supported partially by MCW Cancer Center Fotsch Foundation.

The surgical technique of minimally invasive transforaminal lumbar interbody fusion.

We aim to describe the minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) technique. The MI-TLIF procedure was developed to achieve the same goal of neural decompression and interbody arthrodesis as the traditional, open TLIF techniques. MI-TLIF has been utilized in the treatment of an array of lumbar pathologies, while offering the advantages of reducing soft tissue trauma, decreasing postoperative pain, and reducing the rate of complication when compared to the open techniques. The surgical technique of MI-TLIF is described in a step-by-step fassion. A technical review of this novel minimally invasive procedure was performed. Additionally, data collected through our experience with this procedure is reported. Data was collected retrospectively from patients between January 2008 and December 2009 who underwent MI-TLIF. The mean preoperative VAS score was 6.12±2.02 compared to 2.11±2.69 postoperatively. The mean ODI score dropped from 38.29±13.19 preoperatively to 16.00 ±16.598 postoperatively. Eighty-four patients who underwent MI-TLIF between October 2007 and December 2010 were divided based on age (over or under 65 years) and intraoperative estimated blood loss (EBL) was compared. The mean EBL for the young age group was 93.37±102.16 mL compared to 100 ±61.24 mL for the older group. Operation times for the MI-TLIF procedure has decreased from 3-4 hours to approximately 2 hours throughout our experience with this technique. The MI-TLIF technique is a safe and effective procedure offering the advantages of less tissue damage, less blood loss, and reduced postoperative hospitalization over the open techniques.

Problems in identifying predictors and correlates of weight loss and maintenance: implications for weight control therapies based on behaviour change.

Weight management is a dynamic process, with a pre-treatment phase, a treatment (including process) phase and post-treatment maintenance, and where relapse is possible during both the treatment and maintenance. Variability in the statistical power of the studies concerned, heterogeneity in the definitions, the complexity of obesity and treatment success, the constructs and measures used to predict weight loss and maintenance, and an appreciation of who and how many people achieve it, make prediction difficult. In models of weight loss or maintenance: (i) predictors explain up to 20-30% of the variance; (ii) many predictors are the sum of several small constituent variables, each accounting for a smaller proportion of the variance; (iii) correlational or predictive relationships differ across study populations; (iv) inter-individual variability in predictors and correlates of outcomes is high and (v) most of the variance remains unexplained. Greater standardization of predictive constructs and outcome measures, in more clearly defined study populations, tracked longitudinally, is needed to better predict who sustains weight loss. Treatments need to develop a more individualized approach that is sensitive to patients' needs and individual differences, which requires measuring and predicting patterns of intra-individual behaviour variations associated weight loss and its maintenance. This information will help people shape behaviour change solutions to their own lifestyle needs.