Electron stream effect in 0.35 Tesla magnetic resonance image guided radiotherapy for breast cancer.

Purpose: This research aimed to analyze electron stream effect (ESE) during magnetic resonance image guided radiotherapy (MRgRT) for breast cancer patients on a MR-Linac (0.35 Tesla, 6MV), with a focus on the prevention of redundant radiation exposure. Materials and methods: RANDO phantom was used with and without the breast attachment in order to represent the patients after breast conserving surgery (BCS) and those received modified radical mastectomy (MRM). The prescription dose is 40.05 Gy in fifteen fractions for whole breast irradiation (WBI) or 20 Gy single shot for partial breast irradiation (PBI). Thirteen different portals of intensity-modulated radiation therapy were created. And then we evaluated dose distribution in five areas (on the skin of the tip of the nose, the chin, the neck, the abdomen and the thyroid.) outside of the irradiated field with and without 0.35 Tesla. In addition, we added a piece of bolus with the thickness of 1cm on the skin in order to compare the ESE difference with and without a bolus. Lastly, we loaded two patients' images for PBI comparison. Results: We found that 0.35 Tesla caused redundant doses to the skin of the chin and the neck as high as 9.79% and 5.59% of the prescription dose in the BCS RANDO model, respectively. For RANDO phantom without the breast accessory (simulating MRM), the maximal dose increase were 8.71% and 4.67% of the prescription dose to the skin of the chin and the neck, respectively. Furthermore, the bolus we added efficiently decrease the unnecessary dose caused by ESE up to 59.8%. Conclusion: We report the first physical investigation on successful avoidance of superfluous doses on a 0.35T MR-Linac for breast cancer patients. Future studies of MRgRT on the individual body shape and its association with ESE influence is warranted.

Adaptive Tomotherapy for locally advanced unresectable pancreatic neuroendocrine tumor: Case report and literature review.

Background: Pancreatic neuroendocrine tumor (NET) is rare, and the majority presents late in their clinical course. Here, we present a huge locally advanced pancreatic NET having Hi-Art helical Tomotherapy that resulted in a 68% reduction in target volume during adaptive image-guided radiotherapy (IGRT). Case summary: A 63-year-old man without any history of systemic disease developed voiding difficulty for several months. Associated symptoms included poor appetite, nausea, distended abdomen, and body weight loss. Further magnetic resonance imaging showed a large multilobulated tumor in the left upper abdomen. Tumor biopsy revealed well-differentiated, grade 2, neuroendocrine tumor. Complete resection was unattainable. Therefore, Lanreotide was prescribed initially. However, tumor progression up to the greatest diameter of 18 cm was noted on computed tomography 5 months later. Thus, he stopped Lanreotide and commenced on concurrent chemoradiotherapy (CCRT). With a total dose of 70 Gy in 35 fractions, we generated two adaptive treatment plans during the whole course. Laparoscopic subtotal pancreatectomy with spleen preservation was performed after neoadjuvant CCRT. It has been more than 3 years after IGRT, and he remains cancer free and reports no side effects during regular follow-ups. Conclusion: Tomotherapy caused tumor size reduction and hence facilitated surgical possibility for this originally unresectable pancreatic NET. Neoadjuvant IGRT incorporated with adaptive treatment planning enhanced delivery accuracy. In this case of pancreatic NET resistant to Lanreotide, inter-fractional tumor regression from 1910 to 605 cc (68%) was documented.

Biomarkers of Favorable vs. Unfavorable Responses in Locally Advanced Rectal Cancer Patients Receiving Neoadjuvant Concurrent Chemoradiotherapy.

Colorectal cancer is the second leading cause of cancer death globally. The gold standard for locally advanced rectal cancer (LARC) nowadays is preoperative concurrent chemoradiation (CCRT). Approximately three quarters of LARC patients do not achieve pathological complete response and hence suffer from relapse, metastases and inevitable death. The exploration of trustworthy and timely biomarkers for CCRT response is urgently called for. This review focused upon a broad spectrum of biomarkers, including circulating tumor cells, DNA, RNA, oncogenes, tumor suppressor genes, epigenetics, impaired DNA mismatch repair, patient-derived xenografts, in vitro tumor organoids, immunity and microbiomes. Utilizing proper biomarkers can assist in categorizing appropriate patients by the most efficient treatment modality with the best outcome and accompanied by minimal side effects. The purpose of this review is to inspect and analyze accessible data in order to fully realize the promise of precision oncology for rectal cancer patients.

Case report and literature review: Conversion surgery for initially unresectable huge retroperitoneal liposarcoma after preoperative radiotherapy.

Background: Retroperitoneal liposarcoma (RPLS) is a rare malignancy that is notorious for recurrence. Surgical resection with clean margin is the current treatment of choice. However, owing to the large retroperitoneal space, RPLSs often grow to significant sizes before being diagnosed. Neoadjuvant and adjuvant therapies have potentials to improve long term treatment outcome. Case presentation: A 55-year-old Han Chinese male presented to the general surgery department with a one-year history of abdominal fullness and a one-week history of palpable right inguinal mass. At first, he was diagnosed with incarcerated inguinal hernia. However, abdominal computer tomography (CT) and biopsy confirmed his final diagnosis to be retroperitoneal well-differentiated liposarcoma, cT2bN0M0, stage IIb. The tumor, which measured 44.5cm in maximum diameter, was too large for primary surgical resection. Neoadjuvant radiotherapy with 70 Gy in 35 fractions was delivered to the tumor, which shrunk the target volume from 6300 cc to 4800 cc, as observed in the middle of the radiotherapy course. The right testicular mass also received 70Gy/35Fx. Conversion surgery was performed after radiotherapy. Unfortunately, due to residual tumor, adjuvant chemotherapy consisting of AIM (ifosfamide, Mesna, and doxorubicin) and MAID (Mesna, doxorubincin, ifosfamide, and dacarbazine) regimens were administered sequentially. Afterward, debulking surgery was conducted, plus another 18 cycles of ifosfamide monotherapy when residual tumor was still seen on CT. Since the completion of ifosfamide chemotherapy, the patient has been cancer free with no evidence of tumor recurrence for more than 26 months. Conclusion: Despite conflicting evidence in the literature, our case supports the use of high dose neoadjuvant radiotherapy and adjuvant chemotherapy in treating large, unresectable RPLSs. It also highlights the importance of using individualized, multidisciplinary approach in achieving cure for large, unresectable rare tumors.

ERCC overexpression associated with a poor response of cT4b colorectal cancer with FOLFOX-based neoadjuvant concurrent chemoradiation.

Colorectal cancer (CRC) of the clinical tumor stage T4b (cT4b) refers to advanced tumors with direct invasion of adjacent structures and the tumors are considered unresectable. Despite advancements in aggressive surgery and combination chemotherapy, the prognosis of cT4b CRC remains poor. Optimizing the therapeutic sequence administered to patients with cT4b CRC to improve clinical outcomes is crucial. In the present study, patients with unresectable cT4b and nodal stage N1-2 CRC were investigated at a single institution. A total of 20 consecutive patients were treated with pre-operative concurrent chemoradiation by using 5-fluorouracil/leucovorin/oxaliplatin (FOLFOX) since February 2015 and were regularly followed up until March 2020. Due to their poor response to concurrent chemoradiation (CCRT) with FOLFOX, the chemotherapy regimen was changed to irinotecan plus 5-fluorouracil/leucovorin (FOLFIRI) as the second-line neoadjuvant treatment. Genetic alterations, such as microsatellite instability (MSI), were documented, and the expression levels of excision repair cross-complementing group 1 (ERCC1) and ERCC2 were examined. Of the 20 patients, the tumors of 14 patients (70%) became resectable after FOLFIRI administration. The median duration between the last date of radiotherapy and surgery was 32.7 weeks (range, 10.1-59.3 weeks). Of note, 4 of the 14 patients with resectable tumors (28.6%) achieved a pathologic complete response. The median overall survival and progression-free survival were 27.5 months (range, 12-39 months) and 27.5 months (range, 8-39 months), respectively. The cancerous specimens of all of the patients (100%) exhibited ERCC2 overexpression and 18 specimens (90%) had ERCC1 overexpression. Only one tumor (5%) exhibited high MSI. The present study indicated that ERCC overexpression associated with the poor response of FOLFOX-based CCRT and FOLFIRI after FOLFOX-based CCRT failure may have a potential role in conversion to resectable tumors by neoadjuvant treatment in cT4b CRC. However, a further prospective study with more patients is required to improve the precision of the conclusions.

Five-year survival outcomes of intensity-modulated radiotherapy with simultaneous integrated boost (IMRT-SIB) using forward IMRT or Tomotherapy for breast cancer.

Intensity-modulated radiotherapy with simultaneous integrated boost (IMRT-SIB) reduces overall treatment duration and results in less radiotherapy (RT)-induced dermatitis. However, the use of traditional sequential approach or IMRT-SIB is still under debate since there is not enough evidence of long-term clinical outcomes. The present study investigated 216 patients who underwent breast conserving surgery (BCS) between 2010 and 2013. The median age was 51 years (range, 21-81 years). All patients received IMRT-SIB, 50.4 Gy at 1.8 Gy per fraction to the whole breast and 60.2 Gy at 2.15 Gy per fraction to the tumor bed by integral boost. Among 216 patients, 175 patients received post-operative RT with forward IMRT and 41 patients had Tomotherapy. The median follow-up was 6.4 years. Forty patients (97.6%) in the Tomotherapy arm and 147 patients (84%) in the IMRT arm developed grade 0-1 skin toxicity (P = 0.021). For the entire cohort, the 5-year and 7-year overall survival (OS) rates were 94.4% and 93.1% respectively. The 7-year distant metastasis-free survival rates were 100% vs 89.1% in the Tomotherapy and IMRT arm respectively (P = 0.028). In conclusion, Tomotherapy improved acute skin toxicity compared with forward IMRT-SIB. Chronic skin complication was 1.9%. IMRT-SIB resulted in good long-term survival.

Brain surgery in combination with tyrosine kinase inhibitor and whole brain radiotherapy for epidermal growth factor receptor-mutant non-small-cell lung cancer with brain metastases.

The role of brain surgery (BS) on the survival of patients with non-small-cell lung cancer (NSCLC) and brain metastases (BM), particularly those with epidermal growth factor receptor (EGFR) mutations under tyrosine kinase inhibitors (TKIs) is yet to be defined. We aimed to investigate whether BS could improve the survival of patients in addition to the combination of TKIs and whole brain radiotherapy (WBRT). A cohort of 1394 NSCLC patients between 2011 and 2016 was retrospectively studied. One hundred patients with BM receiving TKI + RT were enrolled. Forty patients (40%) received TKI + BS + RT, and 60 patients (60%) received TKI + RT. Survival time was calculated from the date of BM diagnoses to the date of death or last follow-up. With a median follow-up of 25.6 months (95% CI, 18.6-35.7), the median survival after BM was 18.2 months (95% CI, 10.8 to 27.4) in the TKI + BS + RT group and 11.8 months (95% CI, 5.2 to18) in the TKI + RT group. Cox proportional hazards regression model for the patients with the largest BM over 1 cm showed that TKI + BS + RT group was associated with improved survival relative to TKI + RT group (HR, 0.49; 95% CI, 0.29 to 0.83; P = 0.008). BS adds significant survival benefits in addition to TKIs and WBRT, especially for patients with EGFR-mutant NSCLC and the largest BM over 1 cm.

Combination of Whole-Brain Radiotherapy with Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors Improves Overall Survival in EGFR-Mutated Non-Small Cell Lung Cancer Patients with Brain Metastases.

Brain metastases (BM) cause morbidity and mortality in patients with non-small cell lung cancer (NSCLC). The use of upfront epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) and withholding of whole-brain radiation therapy (WBRT) is controversial. We aim to investigate the impact of WBRT on overall survival (OS). After screening 1384 patients, a total of 141 EGFR-mutated patients with NSCLC and BM were enrolled. All patients received EGFR-TKIs between 2011 and 2015. Ninety-four patients (66.7 %) were treated with WBRT (TKI + WBRT group). With a median follow-up of 20.3 months (95% confidence interval (CI), 16.9-23.7), the median OS after the diagnosis of BM was 14.3 months (95% CI, 9.5 to 18.3) in the TKI + WBRT group and 2.3 months (95% CI, 2 to 2.6) in the TKI alone group. On multivariate analysis, WBRT (p < 0.001), female, surgery to primary lung tumor, and surgery to BM were associated with improved OS. The 1-year OS rate was longer in the TKI+WBRT group than that in the TKI alone group (81.9% vs 59.6%, p = 0.002). In conclusion, this is the first study to demonstrate the negative survival impact from the omission of WBRT in patients with EGFR-mutant NSCLC.

Randomized double-blind, placebo-controlled trial evaluating oral glutamine on radiation-induced oral mucositis and dermatitis in head and neck cancer patients.

BACKGROUND: Glutamine is the primary fuel for the gastrointestinal epithelium and maintains the mucosal structure. Oncologists frequently encounter oral mucositis, which can cause unplanned breaks in radiotherapy (RT). OBJECTIVES: The aim of this study was to explore the association between oral glutamine and acute toxicities in patients with head and neck cancer undergoing RT. METHODS: This was a parallel, double-blind, randomized, placebo-controlled Phase III trial conducted in a university hospital. A central randomization center used computer-generated tables to allocate interventions to 71 patients with stages I-IV head and neck cancers. The patients, care providers, and investigators were blinded to the group assignment. Eligible patients received either oral glutamine (5 g glutamine and 10 g maltodextrin) or placebo (15 g maltodextrin) 3 times daily from 7 d before RT to 14 d after RT. The primary and secondary endpoints were radiation-induced oral mucositis and neck dermatitis, respectively. These were documented in agreement with the National Cancer Institute Common Terminology Criteria for Adverse Events version 3. RESULTS: The study included 64 patients (placebo n = 33; glutamine n = 31) who completed RT for the completers' analysis. Based on multivariate analysis, glutamine had no significant effect on the severity of oral mucositis (OR: 0.3; 95% CI: 0.05, 1.67; P = 0.169). Only the change in body mass index (BMI) was significant in both multivariate completers (OR: 0.41; 95% CI: 0.20, 0.84; P = 0.015) and per-protocol analysis (OR: 0.40; 95% CI: 0.20, 0.83; P = 0.014). No difference was found in the incidence and severity of neck dermatitis between the two arms. CONCLUSIONS: The decrease in BMI was strongly related to the severity of oral mucositis in the head and neck cancer patients under RT, but not to the use of glutamine. This trial was registered at clinicaltrials.gov as NCT03015077.

Tailoring Magnetoelectric Coupling in BiFeO3 /La0.7 Sr0.3 MnO3 Heterostructure through the Interface Engineering.

Electric field control of magnetism ultimately opens up the possibility of reducing energy consumption of memory and logic devices. Electric control of magnetization and exchange bias are demonstrated in all-oxide heterostructures of BiFeO3 (BFO) and La0.7 Sr0.3 MnO3 (LSMO). However, the role of the polar heterointerface on magnetoelectric (ME) coupling is not fully explored. Here, the ME coupling in BFO/LSMO heterostructures with two types of interfaces, achieved by exploiting the interface engineering at the atomic scale, is investigated. It is shown that both magnetization and exchange bias are reversibly controlled by switching the ferroelectric polarization of BFO. Intriguingly, distinctly different modulation behaviors that depend on the interfacial atomic sequence are observed. These results provide new insights into the underlying physics of ME coupling in the model system. This study highlights that designing interface at the atomic scale is of general importance for functional spintronic devices.

Secondary basal cell carcinoma of scalp after radiotherapy: A case report.

RATIONALE: Radiotherapy (RT) is widely used for both malignant and benign tumors in order to reduce the risk of recurrence, to promote tumor control, and to improve survival. However, there have been studies reported that RT is also a risk factor of secondary cancer. Very few cases of secondary malignancy after RT to high grade brain cancer have been reported due to short survival of this disease, and most RT-induced malignancies presented with sarcomatous histology. Here we present a patient with basal cell carcinoma (BCC) 14 years after RT to his brain. PATIENT CONCERNS: A 28-year-old man without any underlying disease had suffered from left side weakness and clonic-tonic seizures for 12 days. DIAGNOSES: His brain images showed a tumor in the right frontal lobe. The pathologic report confirmed anaplastic astrocytoma (WHO Grade III). INTERVENTIONS: After craniotomy and tumor biopsy, RT was delivered. Fourteen years later, a gray-colored skin papule was noted in the previously irradiated area. The scalp biopsy revealed BCC. The scalp BCC was adequately resected. He then suffered from brain tumor recurrence and received further craniotomy for three times combined with chemotherapy with temozolomide. OUTCOMES: After treatment, follow-up brain images showed that the disease was under control. There was no neurological sequela. For scalp BCC, no skin tumor recurrence has been noted to date after the resection 14 years after initial RT. He has survived for more than 26 years since his initial diagnosis of anaplastic astrocytoma, and more than 12 years from the diagnosis of scalp BCC. LESSONS: Notwithstanding the risk of radiation-induced skin cancer, RT contributed to this patient's survival. The possible late adverse events should be informed to the patients.

Comparison of efficacy and safety of preoperative Chemoradiotherapy in locally advanced upper and middle/lower rectal cancer.

BACKGROUND: We aimed to explore the efficacy and safety profile of preoperative neoadjuvant chemoradiation (NACRT) in locally advanced rectal cancer (LARC) in upper rectum versus middle/lower rectum. METHODS: The study included 173 patients with stage II or III (T2-4b, N0-2b) LARC who underwent NACRT followed by total mesorectal excision (TME) between January 2011 and October 2016. Cox regression, log-rank test, and Kaplan-Meier curves were calculated. RESULTS: Among the 173 patients, 58 had lesions in the upper rectum and 115 patients had lesions in middle/lower rectum. In a median follow-up of 35 months (range, 6-73 months), the 5-year disease-free survival (DFS) and overall survival (OS) were 84% and 88% for the patients with upper rectal cancer and 77% and 68% for those with middle/lower rectal cancer (P = 0.251 and P = 0.058, respectively). The 5-year DFS (P = 0.012) and OS (P = 0.003) were better in the NACRT responders [tumor regression grade (TRG) 0 or 1] compared with nonresponders (TRG 2 or 3). The independent prognostic factor of favorable response to NACRT was the FOLFOX regimen (P = 0.004). CONCLUSIONS: Patients with LARC in the upper rectum who underwent NACRT followed by TME had similar DFS and a trend toward longer OS, compared with those who had middle/lower rectal lesions. Furthermore, FOLFOX may yield superior results than fluoropyrimidine based regimen during NACRT. NACRT might be an alternative option for patients with LARC in the upper rectum as it has a favorable pathological complete response rate and comparable clinical outcomes when compared with patients with LARC in middle/lower rectum.

Comparison of Long-Term Outcomes of Postmastectomy Radiotherapy between Breast Cancer Patients with and without Immediate Flap Reconstruction.

PURPOSE: To compare the long-term clinical outcomes of postmastectomy radiotherapy (PMRT) between breast cancer patients with and without immediate transverse rectus abdominis myocutaneous (TRAM) flap reconstruction. METHODS: The study included 492 patients with stage II or III breast cancer who underwent modified radical mastectomy (MRM) and chemotherapy followed by PMRT between 1997 and 2011. Cox regression model and Kaplan-Meier curves were calculated, and the log-rank test was used to evaluate the differences between overall and disease-free survival rates in the 2 groups. RESULTS: Among 492 patients, 213 patients had immediate TRAM flap reconstruction. The mean follow-up was 7.2 years (range, 11-191 months). The 5-year and 10-year disease free survival rates were 81% and 76% for the TRAM flap group and 78% and 73% for the non-flap group. The 5-year and 10-year overall survival rates were 89% and 73% for the TRAM flap group and 83% and 74% for the non-flap group. CONCLUSIONS: There exists no statistically significant difference in the rates of local recurrence, distant metastasis, disease-free and overall survival when comparing immediate TRAM flap reconstruction with no reconstruction. Our results suggest that immediate TRAM flap reconstruction does not compromise long term clinical outcomes in breast cancer patients requiring PMRT.

Intensity modulated radiotherapy with simultaneous integrated boost vs. conventional radiotherapy with sequential boost for breast cancer - A preliminary result.

PURPOSE: This study was aimed to assess the acute dermatological adverse effect from two distinct RT techniques for breast cancer patients. We compared intensity-modulated radiotherapy with simultaneous integrated boost (IMRT-SIB) and conventional radiotherapy followed by sequential boost (CRT-SB). METHODS: The study population was composed of 126 consecutive female breast cancer patients treated with breast conserving surgery. Sixty-six patients received IMRT-SIB to 2 dose levels simultaneously. They received 50.4 Gy at 1.8 Gy per fraction to the whole breast and 60.2 Gy at 2.15 Gy per fraction to the tumor bed by integral boost. Sixty patients in the CRT-SB group received 50 Gy in 25 fractions to the whole breast followed by a boost irradiation to tumor bed in 5-7 fractions to a total dose of 60-64 Gy. Acute skin toxicities were documented in agreement with the Common Terminology Criteria for Adverse Events version 3 (CTCAE v.3.0). RESULTS: Ninety-eight patients had grade 1 radiation dermatitis while 14 patients had grade 2. Among those with grade 2, there were 3 patients in IMRT-SIB group (4.5%) while 11 in CRT-SB group (18.3%). (P = 0.048) There was no patient with higher than grade 2 toxicity. Three year local control was 99.2%, 3-year disease free survival was 97.5% and 3-year overall survival was 99.2%. CONCLUSIONS: A significant reduction in the severity of acute radiation dermatitis from IMRT-SIB comparing with CRT-SB is demonstrated.

Predicting depressive symptoms from acculturative family distancing: A study of Taiwanese parachute kids in adulthood.

We applied Hwang's (2006a) acculturative family distancing (AFD) theory to Taiwanese "parachute kids," who had immigrated to the United States or Canada as unaccompanied minors and remained in North American as adults. It was hypothesized that each dimension of AFD-communication breakdown and cultural value incongruence-would uniquely predict conflict with participants' family members in Taiwan, which would, in turn, predict their depressive symptoms. In a sample of 68 former parachute kids aged 18 to 36 years, the relation between communication breakdown and depressive symptoms was fully mediated by family conflict. On the other hand, the mediation effect was not found for cultural value incongruence. Moreover, a suppression effect occurred, suggesting the likelihood that an additional, unknown variable accounts for the relation between cultural value incongruence and depressive symptoms. We concluded, from these results, that the 2 AFD dimensions operate differently in this population than in previous AFD research. This conclusion was further supported by the finding that participants reported significantly more communication breakdown than cultural value incongruence with family members residing in Taiwan.

Negotiating therapeutic alliances with a family at impasse.

To bridge the science-practice gap, the APA Presidential Task Force endorsed the publication of evidence-based case studies, but to date, there have been few such investigations of conjoint family therapy. To fill this gap, we studied a successful case of treatment-as-usual in a community agency. Owing to the complexity of the working alliance in conjoint therapy, we examined how an experienced family therapist managed to develop and sustain multiple alliances over time with an estranged couple in crisis. The outcome data showed clinically meaningful changes as well as high satisfaction levels and notable declines in the target complaint discomfort levels of all family members. Alliance indicators showed that the therapist worked diligently over time to connect emotionally with each family member and to foster and maintain safety. Session impact scores showed consistently deep sessions but more variability in smoothness. By working toward the only shared treatment goal-to repair each parent's individual relationship with their very angry daughter-the therapist was able to reduce the effect of the marital estrangement on the child. At the end of the 10 contracted family sessions, the parents agreed to begin working on their relationship in couples therapy, which led shortly thereafter to a reconciliation.

Exploring corrective experiences in a successful case of short-term dynamic psychotherapy.

The concept of corrective emotional experience, originally formulated by psychoanalysts Alexander and French (1946), has been redefined by contemporary researchers to be theoretically nonspecific, that is, as "coming to understand or experience an event or relationship in a different or unexpected way" (Castonguay & Hill, 2011). Using postsession questionnaires, videotapes, and posttermination interviews, we explored whether (and how) a corrective experience occurred in a successful case of short-term dynamic psychotherapy (STDP; Davanloo, 1980). A 35-year-old woman suffering severe panic attacks was seen for 31 sessions by an experienced STDP therapist. The questionnaires and interviews focused on (a) perceived intrapsychic and interpersonal changes, and (b) how these changes came about. At termination, the client reported complete symptom relief, greater self-acceptance, improved relationships, and more emotional flexibility. Her corrective experience was evident in the qualitative themes, which showed that she came to understand and affectively experience her relationships with both parents differently. Moreover, the themes reflected both STDP-specific (e.g., confrontation of defenses) and nonspecific (e.g., rapport, acceptance) mechanisms of change. Conversation analysis (Sacks, 1995) of what the client described as "the 'gentle shove' of questions that make me see what I have been trying to ignore since childhood" showed, on a microlinguistic level, how she overcame resistance to strong emotional experience and expression.

Better versus worse family therapy sessions as reflected in clients' alliance-related behavior.

To be responsive to clients' evaluations of the unfolding therapy process, therapists must first accurately "read" client behavior, a particularly challenging task in conjoint family therapy. In this study, the authors compared client behavior in 28 sessions that one family member and the therapist concurred, on the Session Evaluation Questionnaire (W. B. Stiles & J. S. Snow, 1984), were relatively better or worse than their other sessions. Client behavior was rated from videotapes using the System for Observing Family Therapy Alliances (SOFTA-o; M. L. Friedlander et al., 2006). In contrast to the worse sessions, the better sessions were characterized by significantly greater client Engagement in the Therapeutic Process and Safety within the Therapeutic System. Notably, whereas only the worse sessions had exceptionally poor within-family collaboration, 40% of the better sessions were characterized by mild family conflict. Implications are discussed for building theory on therapist responsiveness and for future research that may benefit practice, training, and supervision.

Hypoglossal schwannoma presenting as hemi-atrophy of the tongue.

Schwannoma of the hypoglossal nerve is extremely rare. We report the clinical manifestations of a patient with Schwannoma of the hypoglossal nerve with hemi-atrophy of the tongue and numbness in the lip. Magnetic resonance image study of the brain showed a lobulated mass at the right posterior fossa with an extension to the right upper neck. Surgical intervention was performed with right occipital craniotomy and a partial resection of C1 and occipital condyle. Pathological studies confirmed a Schwannoma with hemorrhages and necrosis.

Removal of arsenic and humic substances (HSs) by electro-ultrafiltration (EUF).

A laboratory scale electro-ultrafiltration (EUF) system was developed and used to explore the removal of arsenic and humic substances (HSs) from water. As a negatively charged species, arsenate(V) was readily removed after applying voltage to the EUF cell. Arsenite(III) was removed via EUF after the pH of the water had been adjusted. Meanwhile, the rejection of HSs increased due to the presence of an electric field. This study also showed that the removal of arsenite(III) from water relies primarily on electrostatic and non-electrostatic mechanisms. In the presence of HSs, arsenate(V) complexed with the HSs and was then able to be removed by EUF. This study demonstrates that EUF is a highly promising means of removing arsenic from water.