Dosimetric Comparison Between High Dose Rate Brachytherapy Boost and Volumetric Arc Therapy Boost in Locally Advanced Cancer cervix

Concurrent chemoradiotherapy is considered the standard treatment for the locally advanced cancer cervix (LACC).Radiotherapy is usually administered by a three-dimensional conformal external beam(3DCRT EBRT) approach to whole pelvis to a minimum dose of 45Gy, followed by a brachytherapy ( BT)boost to give additional dose to the gross tumor within the cervix and parametria. High dose rate (HDR) brachytherapy is commonly administered with intracavitory applicator. HDR BT allows delivery of a high radiation dose to the tumor site with rapid fall off so protect normal tissue. Besides, less target motion compared to EBRT. However, several drawbacks exist including invasive technique, pain, requiring spinal or general anesthesia and operative risks such as uterine perforation, infection, and bleeding. Due to the above risks, we tried to assess the possibility of using high technique  EBRT to replace the BT boost  in patients who are either medically unfit for or refuse a brachytherapy boost. we tried to achieve a similar dose distribution with comparable or improved normal tissue sparing to that seen in previously treated HDR BT plans at our institution. Dosimetric comparison between high technique of external beam radiotherapy volumetric arc therapy (VMAT) and high technique Computer topography (CT) guided HDR BT.Ten patients were selected with LACC, representing typical clinical situations according to initial tumor extension and response after EBRT. A boost was given by intracavitary CT guided HDR BT. High risk clinical target volume (HR CTV), bladder, rectum, sigmoid and small bowel were delineated. Planning was done using Sagi planning system and was manually optimized with respect to organ dose limits. A VMAT planning was created using the variance planning system and a margin of 5mm were added to the CTV to create the target planning target volume (PTV).The inversely planned VMAT was challenged to deliver the highest possible doses to PTVs while respecting D2cc limits from BT, assuming the same fractionation (7 Gy in 3 fractions). When VMAT was limited to D2cc from BT, the D90 for the PTV in VMAT boost was lower than received by the HR CTV in the BT boost (6.3Gy vs. 6.9Gy, p value 0.037). Mean volume of the PTV in VMAT was higher than that of HR CTV in the BT (89 cm3vs 41.7cm3).The dose to the organ at risks (OARs) was comparable.D2cc was higher in VMAT for bladder, sigmoid and rectum (5.6Gy, 0.51, 5.5Gy vs. 4.3Gy, 0.33, 3.9Gy) while D2cc for the small bowel in BT was higher compared to the VMAT (4.1Gy vs. 1.94Gy    ).The VMAT had comparable target coverage and potential for improved sparing of most normal tissues compared to brachytherapy boost. It is an option that exists for patients who refuse BT or can’t tolerate it or in case of non availability of BT or non working machine. However, this is a dosimetric comparison that needs larger number of patients and further application to study the drawbacks that might exist for the VMAT use

Étude du comportement en service de membrures en béton renforcées de barres de PRF

La détérioration des infrastructures au Canada due à la corrosion des armatures est l'un des défis majeurs de l'industrie de la construction. Les progrès récents dans la technologie des polymères ont conduit au développement d'une nouvelle génération de barres d'armature à base de fibres renforcées de polymères (PRF), (en particulier les fibres de verre). Ces barres, résistant à la corrosion, ont montré un grand potentiel d'utilisation pour mieux protéger les infrastructures en béton armé contre les effets dévastateurs de la corrosion. Avec la publication du nouveau code S807-10 "Spécifications pour les polymères renforcés de fibres" et la production de barres en PRF de très haute qualité, celles-ci représentent une alternative réaliste et rentable par rapport à l'armature en acier pour les structures en béton soumises à de sévères conditions environnementales. La conception des éléments en béton armé de barres en PRF est généralement gouvernée par l'état de service plutôt que l'état ultime. Par conséquent, il est nécessaire d'analyser les performances en flexion et le comportement en service en termes de déflexion et de largeur de fissures des éléments en PRF sous charges de service et de vérifier que ces éléments rencontrent les limites des codes. Aussi, de récents développements dans l'industrie des PRF ont conduit à l'introduction des barres en PRF avec des configurations de surface et des propriétés mécaniques différentes. Ces développements sont susceptibles d'affecter leur performance d'adhérence et, par conséquent, la largeur des fissures dans les éléments en PRF. Cependant, les codes de conception et les guidelines de calcul fournissent une valeur unique pour le coefficient d'adhérence (k[indice inférieur b]) en tenant compte des configurations de surface et en négligeant le type de barre en PRF, le diamètre de la barre, et le type de béton et de sa résistance. En outre, le code canadien S807-10 "Spécifications pour les polymères renforcés de fibres" fournit une étape en classant les barres en PRF par rapport à leur module d'élasticité (E[indices inférieurs frp]). Ces classifications ont été divisées en trois classes : Classe I (E[indices inférieurs frp]<50 GPa), Classe II (50 GPa [plus petit ou égal] E[indices inférieurs frp]< 60 GPa) et Classe III (E[indices inférieurs frp] [plus grand ou égal] 60 GPa). Ce programme de recherche vise à étudier expérimentalement le comportement en flexion des éléments en béton en service armé avec différents paramètres sous charges statiques. Le programme expérimental est basé sous plusieurs paramètres, dont les différents ratios de renforcement, différents types de barres (différentes classes comme classifiées par le CAN/CSA S807-10), le diamètre et la surface de la barre, la configuration ainsi que la résistance du béton. De plus, les recommandations actuelles de design pour les valeurs de k[indice inférieur b] et la vérification de la dépendance des valeurs de k[indice inférieur b] sur le type de barres (verre ou carbone), le diamètre des barres et le type de béton et sa résistance ont été étudiées. Le programme expérimental comprenait la fabrication et les essais sur 33 poutres à grande échelle, simplement appuyées et mesurant 4250 mm de long, 200 mm de large et 400 mm de hauteur. Vingt et sept poutres en béton ont été renforcées avec des barres en PRF à base de verre, quatre poutres en béton ont été renforcées avec des barres de PRF à base de carbone, et deux poutres ont été renforcées avec des barres en acier. Toutes les poutres ont été testées en flexion quatre points sur une portée libre de 3750 mm. Les paramètres d'essai étaient: le type de renforcement, le pourcentage d'armature, le diamètre des barres, configurations de surface et la résistance du béton. Les résultats de ces essais ont été présentés et discutés en termes de résistance du béton, de déflection, de la largeur des fissures, de déformations dans le béton et l'armature, de résistance en flexion et de mode de rupture. Dans les trois articles présentés dans cette thèse, le comportement en flexion et la performance des poutres renforcées de barres en PRFV et fabriquées avec un béton normal et un béton à haute performance ont été investigués, ainsi que les différentes classes de barres en PRFV et leurs configurations de surface. Les conclusions des investigations expérimentales et analytiques contribuent à l'évaluation des équations de prédiction de la déflection et des largeurs de fissures dans les codes de béton armé de PRF, pour prédire l'état de service des éléments en béton renforcés de PRF (déflection et largeur de fissures). En outre, à la lumière des résultats expérimentaux de cette étude, les équations de service (déflection et largeur des fissures) incorporées dans les codes et guidelines de design [ACI 440.1R-06, 2006; ISIS Manual No.3, 2007; CAN/CSA-S6.1S1, 2010; CAN/CSA-S806, 2012] ont été optimisées. En outre, les largeurs de fissures mesurées et les déformations ont été utilisées pour évaluer les valeurs courantes de k[indice inférieur b] fournies par les codes et les guidelines de calcul des PRF. En outre, les conclusions ne prennent pas en charge la valeur unique de k[indice inférieur b] pour les barres en PRF de types différents (carbone et verre) avec des configurations de surface similaires et s'est avéré être dépendant du diamètre de la barre

The Effect of Mineral Pigments on Mechanical Properties of Concrete

&nbsp;Pigmented concrete exhibits artesian properties in addition to ordinary concrete properties, explicitly high strength, excellent durability, and weather resistance. However, the influence of several parameters that affect the characteristics of colored concrete should be studied; extensively. In this paper, the impact of the w/b (water/binder) ratio using color pigments on the mechanical properties such as compressive and flexural strengths of colored cement mortar prisms and cubes experimentally investigated. The experimental program included 21 mixes with six cubes and three flexural prisms specimens for assessing compressive and flexural strength, respectively. The blends included different water/binder ratios with values of 0.4, 0.5, and 0.6, in addition to several color pigments as a partial replacement of cement. The percentage of replacements altered between 0, 2.5%, 5% and 7.5% with two different shades of pigments consisting of red iron and green chromium oxide. Based on the experimental results, empirical expressions were generated based on Abram’s law to assess the relationship between the compressive strength of colored concrete and w/b ratio. The results revealed that the compressive and flexural strength of colored concrete is influenced by w/b ratio and partially replacement percentage of cement by color pigment not proportionally direct. Furthermore, the shade of pigments also has a different impact as well

The use of latissimus dorsi mini-flap in partial breast reconstruction

Introduction: The cosmetic drawbacks of breast conserving surgery are asymmetry, nipple or skin retraction, and volume loss with unsatisfactory cosmetic outcome. The principle of Latissimus dorsi mini-flap (LDMF) is to use part of the Latissimus dorsi (LD) muscle as volume replacement to large breast defect up to 20 -30 % of the breast volume. Purpose: To evaluate (LDMF) as a volume replacement to large breast defect after wide local excision in different breast quadrants and the benefit of using this procedure regarding the cosmetic outcomes, patient satisfaction, procedure-related complications. Materials and Methods: The study was carried out at the National Cancer Institute, Cairo University, Egypt, from September 2017 to December 2018. Fifteen patients were selected. Wide local excision with post-resection defects of 20%-30% of breast volume were done. An inferolateral incision was done for both tumor resection and LDMF harvesting without any back scar. The patients were scheduled for regular follow up. Results: All the resection margins were negative. Mean Operative time was 176.6 minutes, the mean hospital stay was 2.47 days. The mean score for sensory preservation was 7.66. The mean of visual analogue score VAS was 8.33 with a score range from 8 to 9. The mean of the surgeon evaluation was 8.53. The median ranged from 8 to 9. Conclusion: LDMF makes BCS possible to a group of patients who are classically required mastectomy. It is particularly benefical to patients that responds poorly to neoadjuvant chemotherapy or with wide spreading DCIS

Assessment of the inhalation technique and adherence to therapy and their effect on disease control in outpatients with asthma

Objectives The objective of this study was to assess correct use of inhaler devices, adherence to inhaler corticosteroid treatment and their effects on asthma control. Methods This study was a prospective, single-centre, observational study conducted between July and February 2016 at Al-Makased Hospital, respiratory outpatient clinic. Inhaler technique of asthma patients using pressurized metered-dose inhalers or dry powder inhalers (Turbuhaler (TH) and Accuhaler DiskusTM (ACC)) were assessed against published inhaler technique checklists. Asthma control variables measured using Asthma Control Test (maximum 25, higher score corresponding to better asthma control) were assessed, and adherence to asthma medications was assessed by Morisky adherence scale. Key findings Two hundred and twenty patients were recruited in the study. The mean age was 42.3 15.2 years and 59.1% were male. One hundred and seventeen (53.2%) were using TH, 60 (27.3%) were using ACC and 43(19.5%) were using MDIs. Only 22 (10%) were smoker and only 48 (21.8%) patients were their asthma controlled (ACT score >20). The devices were used correctly by 79.1% of patients using MDI, 69% of ACC and 55.6% of TH users (P > 0.001). The most common improper step was ‘forceful inhalation’ (65.4%) made by the MDI users, ‘Not exhaling to residual volume’ (58.7%) made by ACC users and ‘Not inhaling deeply enough’ (52.2%) made by TH users. Multivariate analysis showed that the likelihood of having controlled asthma was significantly higher in those with correct inhaler techniques (OR 2.3; 95% CI: 1.08–4.77; P = 0.028), high adherence to medications (OR 2.37; 95% CI: 1.05–4.92; P = 0.03) and having a higher level of education (OR 2.58; 95% CI: 1.19–3.63; P = 0.018). Conclusions It was found that asthma control was better among correct users. Repetitive training about using devices may contribute improving inhaler technique.This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors

Pharmaceutical care for adult asthma patients: A controlled intervention one‐year follow‐up study

Asthma is a clinical problem with social, psychological and economic burdens. To improve patient disease management, different education programmes have been developed. Challenges in asthma management may be partially attributed to nonadherence or improper use of inhalers. This study aimed to implement and assess hospital‐based pharmaceutical care services for asthmatic patients. A 12‐month, single‐ centre, randomized, controlled study was initiated in asthmatic adult patients who had been divided into either a control or intervention group. Patients in the control group received the usual care, and patients in the intervention group received patient counselling per study protocol that covered asthma knowledge, control, adherence to treatment and inhalation techniques. The main variables compared measurements at baseline with those at 6 and 12 months. A total of 192 patients completed the study protocol: 90 in the control group and 102 in the intervention group. The control group included 90 patients, and the intervention group included 102 patients. Over the course of the 12‐month follow‐up period, a significant difference was observed between intervention and control groups with respect to asthma control (38.2% vs 10.0%; P < .001), mean correct inhalation technique (confidence interval [CI]: 8.1, 7.8‐8.5 vs CI: 6.1; 5.6‐6.6; P = .01) and good medication adherence (60.7% vs 50.0%, P = .02). There were 34% and 25% decreases in emergency room visits and hospital admissions, respectively, in the intervention group compared to the control group. This study emphasizes the importance of patient counselling in asthma management and the significant contribution that the pharmacist's intervention can have on asthma control

Activated protein C resistance in Behcet's disease

Abstract Behcet&#8217;s disease is a chronic multi-system disorder of unknown etiology with protean manifestations. Venous thromboembolism is more common than arterial thrombosis, with deep vein thrombosis being the most frequent. Endothelial dysfunction resulting from vascular inflammation is considered to be an important factor of thrombosis, although the endothelial injury itself cannot completely explain the hypercoagulable state of the disease because other vasculitis syndromes do not increase the risk of thrombosis. The aim of this study is to evaluate the prevalence of activated protein C resistance (APC-R) in Egyptian patients with Behcet&#8217;s disease. Also, to detect hyperhomocysteinemia in selected cases (with vascular complications) to assess their relationship with thromboembolic complications. The APC resistance ratio mean in the group of patients with vascular involvement was 2.6&#8201;&#177;&#8201;0.8 which was less than the group with no vascular involvement 2.8&#8201;&#177;&#8201;0.6, with non- significant P-value (0.5). There was more incidence of ocular lesions in the group of patients with high homocysteine level than the group of patients with normal homocytsteine level with significant P-value (0.08).Peer Reviewe

Medical doctors\u27 offline computer-assisted digital education: Systematic review by the digital health education collaboration

Background: The widening gap between innovations in the medical field and the dissemination of such information to doctors may affect the quality of care. Offline computer-based digital education (OCDE) may be a potential solution to overcoming the geographical, financial, and temporal obstacles faced by doctors.Objective: The objectives of this systematic review were to evaluate the effectiveness of OCDE compared with face-to-face learning, no intervention, or other types of digital learning for improving medical doctors\u27 knowledge, cognitive skills, and patient-related outcomes. Secondary objectives were to assess the cost-effectiveness (CE) of OCDE and any adverse effects.Methods: We searched major bibliographic databases from 1990 to August 2017 to identify relevant articles and followed the Cochrane methodology for systematic reviews of intervention.Results: Overall, 27 randomized controlled trials (RCTs), 1 cluster RCT (cRCT), and 1 quasi-RCT were included in this review. The total number of participants was 1690 in addition to the cRCT, which included 24 practices. Due to the heterogeneity of the participants, interventions, and outcomes, meta-analysis was not feasible, and the results were presented as narrative summary. Compared with face-to-face learning, the effect of OCDE on knowledge gain is uncertain (ratio of the means [RM] range 0.95-1.17; 8 studies, 495 participants; very low grade of evidence). From the same comparison, the effect of OCDE on cognitive skill gain is uncertain (RM range 0.1-0.9; 8 studies, 375 participants; very low grade of evidence). OCDE may have little or no effect on patients\u27 outcome compared with face-to-face education (2 studies, 62 participants; low grade of evidence). Compared with no intervention, OCDE may improve knowledge gain (RM range 1.36-0.98; 4 studies, 401 participants; low grade of evidence). From the same comparison, the effect of OCDE on cognitive skill gain is uncertain (RM range 1.1-1.15; 4 trials, 495 participants; very low grade of evidence). One cRCT, involving 24 practices, investigated patients\u27 outcome in this comparison and showed no difference between the 2 groups with low-grade evidence. Compared with text-based learning, the effect of OCDE on cognitive skills gain is uncertain (RM range 0.91-1.46; 3 trials with 4 interventions; 68 participants; very low-grade evidence). No study in this comparison investigated knowledge gain or patients\u27 outcomes. One study assessed the CE and showed that OCDE was cost-effective when compared with face-to-face learning if the cost is less than or equal to Can $200. No trial evaluated the adverse effect of OCDE.Conclusions: The effect of OCDE compared with other methods of education on medical doctors\u27 knowledge and cognitive skill gain is uncertain. OCDE may improve doctors\u27 knowledge compared with no intervention but its effect on doctors\u27 cognitive skills is uncertain. OCDE may have little or no effect in improving patients\u27 outcome

Systematic review and meta-analysis of the effectiveness of pre-pregnancy care for women with diabetes for improving maternal and perinatal outcomes.

BACKGROUND: Pre-gestational diabetes mellitus is associated with increased risk of maternal and perinatal adverse outcomes. This systematic review was conducted to evaluate the effectiveness and safety of pre-conception care (PCC) in improving maternal and perinatal outcomes. METHODS: Databases from MEDLINE, EMBASE, WEB OF SCIENCE, and Cochrane Library were searched, including the CENTRAL register of controlled trials, and CINHAL up until March 2019, without any language restrictions, for any pre-pregnancy care aiming at health promotion, glycemic control, and screening and treatment of diabetes complications in women with type I or type II pre-gestational diabetes. Trials and observational studies were included in the review. Newcastle-Ottawa scale and the Cochrane collaboration methodology for data synthesis and analysis were used, along with the GRADE tool to evaluate the body of evidence. RESULTS: The search identified 8500 potentially relevant citations of which 40 reports of 36 studies were included. The meta-analysis results show that PCC reduced congenital malformations risk by 71%, (Risk ratio (RR) 0.29; 95% CI: 0.21-0.40, 25 studies; 5903 women; high-certainty evidence). The results also show that PCC may lower HbA1c in the first trimester of pregnancy by an average of 1.27% (Mean difference (MD) 1.27; 95% CI: 1.33-1.22; 4927 women; 24 studies, moderate-certainty evidence). Furthermore, the results suggest that PCC may lead to a slight reduction in the risk of preterm delivery of 15%, (RR 0.85; 95% CI: 0.73-0.99; nine studies, 2414 women; moderate-certainty evidence). Moreover, PCC may result in risk reduction of perinatal mortality by 54%, (RR 0.46; 95% CI: 0.30-0.73; ten studies; 3071 women; moderate-certainty evidence). There is uncertainty about the effects of PCC on the early booking for antenatal care (MD 1.31; 95% CI: 1.40-1.23; five studies, 1081 women; very low-certainty evidence) and maternal hypoglycemia in the first trimester, (RR 1.38; 95% CI: 1.07-1.79; three studies; 686 women; very low- certainty evidence). In addition, results of the meta-analysis indicate that PCC may lead to 48% reduction in the risk of small for gestational age (SGA) (RR 0.52; 95% CI: 0.37-0.75; six studies, 2261 women; moderate-certainty evidence). PCC may reduce the risk of neonatal admission to intensive care unit (NICU) by 25% (RR 0.75; 95% CI: 0.67-0.84; four studies; 1322 women; moderate-certainty evidence). However, PCC may have little or no effect in reducing the cesarean section rate (RR 1.02; 95% CI: 0.96-1.07; 14 studies; 3641 women; low-certainty evidence); miscarriage rate (RR 0.86; 95% CI: 0.70-1.06; 11 studies; 2698 women; low-certainty evidence); macrosomia rate (RR 1.06; 95% CI: 0.97-1.15; nine studies; 2787 women, low-certainty evidence); neonatal hypoglycemia (RR 0.93; 95% CI: 0.74-1.18; five studies; 880 women; low-certainty evidence); respiratory distress syndrome (RR 0.78; 95% CI: 0.47-1.29; four studies; 466 women; very low-certainty evidence); or shoulder dystocia (RR 0.28; 95% CI: 0.07-1.12; 2 studies; 530 women; very low-certainty evidence). CONCLUSION: PCC for women with pre-gestational type 1 or type 2 diabetes mellitus is effective in improving rates of congenital malformations. In addition, it may improve the risk of preterm delivery and admission to NICU. PCC probably reduces maternal HbA1C in the first trimester of pregnancy, perinatal mortality and SGA. There is uncertainty regarding the effects of PCC on early booking for antenatal care or maternal hypoglycemia during the first trimester of pregnancy. PCC has little or no effect on other maternal and perinatal outcomes